Methotrexate in Crohn's disease and ulcerative colitis

• Crohn's disease
  • methotrexate has been used effectively with azathioprine unresponsive Crohn's disease - including fistulating Crohn's disease (1)
  • treatment with methotrexate in low dosage offers an effective alternative to thiopurine maintenance in patients with Crohn's disease (2)

In patients who have failed to respond to steroids, or who are intolerant of azathioprine or 6-mercaptopurine, methotrexate has been shown to induce remission of inflammatory bowel disease in 40 per cent of patients (3)

• a review suggests there is no evidence for the use of lower-dose oral methotrexate (4)
• methotrexate is as efficacious in inducing remission as azathioprine, it does not appear to work any faster (3)

NICE state with respect to use of methotrexate in Crohn's disease (5):

• Add-on treatment in Crohn's disease Maintenance treatment for those who choose this option
  • methotrexate
    • consider addtion of methotrexate to a conventional glucocorticosteroid or budesonide to induce remission in people who cannot tolerate azathioprine or mercaptopurine, or in whom TPMT activity is deficient, if:
      • there are two or more inflammatory exacerbations in a 12-month period, or
      • the glucocorticosteroid dose cannot be tapered
        
        
  • only consider methotrexate to maintain remission in people who:
    • needed methotrexate to induce remission, or
    • have tried but did not tolerate azathioprine ormercaptopurine for maintenance or
    • have contraindications to azathioprine or mercaptopurine (for example, deficient TPMT activity or previous episodes of pancreatitis)

Reference:

1. Feagan BG et al (1995). Methotrexate for the treatment of Crohn's disease. The North American Crohn's Study Group Investigators. NEJM; 332: 292-7.
2. Drugs and Therapeutics Bulletin (2002); 39 (12): 91-95.
3. Prescriber (2004), 15 (5)
4. Alfadhli AAF, McDonald JWD, Feagan BG. Methotrexate for induction of remission in refractory Crohn's disease (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester: John Wiley & Sons, Ltd.
5. NICE (May 2019). Crohn's disease Management in adults, children and young people