Researchers evaluate a new non-invasive test, NASH Fibrosure, to evaluate the potential of nonalcoholic fatty liver disease damage in psoriasis patients using methotrexate.
Psoriasis is an autoimmune disease characterized by patches of dry, red, itchy, and scaly skin. Since the 1970s, Methotrexate (originally used as a cancer drug) has been approved as a treatment for severe psoriasis. As with all therapeutics, common side effects and complications associated with the long-term use of treatments includes nonalcoholic fatty liver disease, which results in liver damage in individuals who are not alcoholic but is typically indistinguishable from alcoholic hepatitis. Another common complication is liver fibrosis, which is excessive scar tissue accumulated in the liver as a result of ongoing inflammation in the liver which can lead to liver cirrhosis. However, the long-term implications of chemical-driven liver damage in psoriasis patients receiving methotrexate remain unclear.
Green and colleagues recently investigated the use of a noninvasive test, NASH FibroSure, as a potential alternative to liver biopsies. Their aim was to evaluate whether this NASH FibroSure test could be used for determining psoriasis patients’ eligibility for methotrexate treatment, monitor the development of hepatotoxic effects induced by methotrexate and also monitoring of liver fibrosis progression whilst undergoing methotrexate treatment. Their results were published in JAMA Dermatology.
This retrospective analysis included 129 patients who had psoriasis and were undergoing methotrexate treatment at a single institution. Of these 129 participants, 107 patients (57 women and 50 men) with an average age of 83 years old, underwent NASH FibroSure testing whilst taking treatment. Among these individuals a positive correlation between the cumulative methotrexate dose and an increase in NASH FibroSure score for liver fibrosis in women, but not in men, was observed. Also, of the 129 participants, 69 patients underwent testing prior to starting treatment, with 19 patients showing elevated fibrosis test scores and 54 patients with elevated steatosis scores. All patients included in this study with the exception of 2 individuals did not undergo a liver biopsy for treatment management.
Several limitations for this study are noted by the authors, including the risk scores generated by the NASH FibroSure are mathematical models and not an actual measure of fibrosis and of the 129 participants, only 2 underwent liver biopsies to validate their fibrosis scores. Furthermore, given that the cohort of patients were not in a controlled environment, the changes in fibrosis scores or progression of nonalcoholic fatty liver disease for psoriasis patients remains unknown. Finally, as all participants self-identified as non-Hispanic white, the data is limited and unable to generalize the results to other races. Further investigations which are multi-institutional, include psoriasis patients receiving methotrexate vs alternative treatments and includes men and women with different racial and ethnic backgrounds is necessary.
The results of this study indicated that when using the NASH FibroSure test, psoriasis patients had a high prevalence of elevated scores for liver fibrosis. The elevated liver fibrosis scores observed suggest patients could potentially need to change to an alternative psoriasis treatment. Although the results do not suggest a liver biopsy can be entirely replaced by this noninvasive test, the NASH FibroSure test could be used as an alternative to reduce the number of liver biopsies required, particularly for women, to monitor changes in nonalcoholic fatty liver disease and liver fibrosis in psoriasis patients undergoing methotrexate treatment.
Written by Lacey Hizartzidis, PhD
Bauer B, Chyou PH, Stratman EJ, Green C. Noninvasive Testing for Nonalcoholic Steatohepatitis and Hepatic Fibrosis in Patients With Psoriasis Receiving Long-term Methotrexate Sodium Therapy. JAMA Dermatol. 2017 Aug 23. doi:10.1001/jamadermatol.2017.2083.
Psoriasis Treatments, Systemic Medications: Methotrexate, National Psoriasis Foundation website https://www.psoriasis.org/about-psoriasis/treatments/systemics/methotrexate. Accessed September 1st, 2017.