Why Are We Still Undergoing Liver Biopsies?
from Lynn

Re: She Had a Disastrous Liver Biopsy (Nov-Dec 2005)

Ed: With respect to your response to Sharon S. in the above-referenced correspondence; I’ve been on MTX for 11 years non-stop for an accumulated dosage that’s well over 5 grams. Never had liver biopsy. Have always had blood work every other month with normal liver function results. My understanding is:

• Consensus is that if your liver function tests are normal there’s no reason to do a biopsy. There is a significant correlation between hepatic aspartate aminotransferase (AST) and progression of histologic deterioration in patients with RA receiving chronic weekly MTX.

• Some believe a biopsy is in order when MTX reaches cum 5.0 grams [no longer 1.5g].

• Some believe that since psoriasis patients often insist on remaining on MTX, there’s probably little reason to have the biopsy in the first place.

See: http://www.ccjm.org/PDFFILES/Siegel3_05.pdf [See page 7 of 13] (Requires Adobe Acrobat Reader)

Also see: http://www.jrheum.com/subscribers/02/08/1590.html

My guess is that the guidelines for biopsy at 1.5g of MTX are still in place due to lack of additional evidence to support not having a biopsy. This type of evidence, if I understand correctly, would need to come from those of us that have accumulated <5.0 grams and have consistently normal blood results. Who of us wants a biopsy when all else is normal just to formally change liver biopsy guidelines?

Perhaps you want to edit your message. Thanks. -Lynn

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Ed's Response: Thanks for this, Lynn. Excellent information that I'll post in January. My only quibble is your first bullet: "Consensus is that if your liver function tests are normal there's no reason to do a biopsy." I wouldn't call that a "consensus" so long as there are many derms still prescribing liver biopsies based on cumulative dose of 1.5 mgs or greater. I would call that an "informed argument" that is gaining favor.

I think our healthcare culture often moves so (seemingly) slow because anything less than a formal agreement about how to do things leaves wide open spaces for litigation. In such an environment medicine must progress "by resolution" rather than "by evolution." I overstate, but not by much!

Thanks for sharing your research. It will show up at FlakeHQ, now, whenever anyone searches on "liver biopsy." -Ed

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Lynn Responds: How do you know there are many still prescribing liver biopsies on the basis of cum dose? It may be in the guidelines, but how many physicians are actually following them?

Actually it was a consensus of a group of rheumatologists at a conference, as reported to me by my own rheumatologist, and subsequently reported to me from patients of other rheumatologists.

Granted, studies of MTX hepatotoxicity cover a longer period of time for dermatologists as compared to rheumatologists; the older dermatology patient histories reflect much higher dose MTX than are currently prescribed [which arguably create an unfair comparison to the rheumatologists’ data]. The dermatologists’ data supporting liver biopsies also include blood studies at longer intervals than rheumatologists order.

Consider the following:

Annals of the Rheumatic Diseases 2005;64:ii91-ii92
©2005 by BMJ Publishing Group Ltd & European League Against Rheumatism

Psoriatic arthritis and psoriasis: treatment
Discussion: Treatment of psoriatic arthritis and psoriasis

And this pdf link: http://www.ccjm.org/PDFFILES/Siegel3_05.pdf (search for “methotrexate”) (Requires Adobe Acrobat Reader).

There are countless arguments against the biopsy. If dermatologists are indeed prescribing them in accordance to their seemingly outdated guidelines, it would appear that there is a dire need for revision. -Lynn

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Ed's Response: How do you know there aren't? ...

I'm sure there may be some derms who see things the way more liberated rheumies do, but I doubt there's been a poll taken among licensed U.S. derms to determine if they are still following guidelines (perhaps antiquated) regarding methotrexate therapy for P. The article you cite from the Annals of the Rheumatic Diseases seems to substantiate my argument. I.e., "Menter : The guidelines about monitoring psoriasis patients on methotrexate therapy are quite clear, recently updated in 1998, and based on 30+ years of experience with use of the drug, unlike rheumatology guidelines, which are based on a shorter experience and are quite different. Dermatologists take these guidelines seriously, given the experience on which they are based."

While I certainly wish MTX for P could be administered without liver biopsies unless blood work suggested them, I could not say to any flaker, "Find a doctor who will prescribe MTX but won't make you have a liver biopsy based on accumulated dosage." On the contrary, if I receive email from folks in the U.S. saying they've never had a liver biopsy and they've been on MTX for several years, three questions will come to mind: (1) Was the dose so low they've probably not accumulated 1500 mgs? (2) Does the dermatologist forget or overlook the protocol? Or (3) Is the dermatologist enlightened, keeping close tabs on blood work, and not worried about liability should something disastrous happen?

As the argument for cumulative-dose-guided liver biopsies intensifies, I hope the U.S. dermatology authorities will reconsider, and I hope the evidence presented to them will suggest a change in their recommended protocol is in order. If they're really not necessary, anyone would like to avoid a liver biopsy. -Ed

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Lynn Responds: The only thing I can say to that is that dermatological doses are certainly no higher than rheumatological doses. Further, if there’s any enlightening to be done, it’s with regard to dermatologists, who need to review appropriate data and update their guidelines. And as for this criteria of cumulative doses — it ought to be thrown out altogether. -Lynn

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