Psoriasis: Recommendations for methotrexate

  • Severe, recalcitrant, disabling psoriasis that is not adequately responsive to other forms of therapy  
Absolute contraindications
  • Pregnancy
  • Nursing mothers
  • Alcoholism
  • Alcoholic liver disease or other chronic liver disease
  • Immunodeficiency syndromes
  • Bone-marrow hypoplasia, leukopenia, thrombocytopenia, or significant anemia
  • Hypersensitivity to methotrexate
Relative contraindications
  • Abnormalities in renal function may require a marked reduction in the dose as 85% of methotrexate is renally excreted
  • Abnormalities in liver function-LFT results should be followed up and all elevations require careful monitoring
  • Hepatitis, active or recurrent
  • Greater than moderate alcohol consumption-although there are few data to support specific limits on alcohol consumption, some physicians require patients to completely refrain from alcohol whereas others allow daily alcohol intake; a history of alcoholism is particularly worrisome if there is baseline liver damage
  • Concomitant use of hepatotoxic drugs-more frequent monitoring of LFT results should be considered
  • Active infectious disease, particularly chronic infections that are likely to be worsened by immunosuppressive effects of methotrexate (eg, active untreated tuberculosis or acquired immunodeficiency syndrome); methotrexate should be withheld during acute infections
  • Current use of other immunosuppressive agents
  • Conception should be avoided during methotrexate treatment and afterward for at least 3 mo in men and 3 ovulatory cycles in women
  • Recent vaccination with a live vaccine
  • Obesity (body mass index>30)
  • Diabetes mellitus
  • Unreliable patient

 Strength of Recommendation: B Level of Evidence: II

Navigate section 4 of the psoriasis guideline: Systemic agents

Citation note

When referencing this guideline in a publication, please use the following citation: Menter A, Korman NJ, Elmets CA, Feldman SR, Gelfand JM, Gordon KB, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 4. Guidelines of care for the management and treatment of psoriasis with traditional systemic agents. J Am Acad Dermatol. 2009 Sep;61(3):451-85. 

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