Methotrexate therapy

Through a variety of mechanisms including folate independent pathways, once weekly low-dose methotrexate, either oral or parenteral, has been demonstrated to exert immune-modifying effects. The currently published data shows the efficacy of methotrexate in Crohn disease while convincing data for ulcerative colitis is lacking. While there is robust prospective data in adult Crohn disease, the current data in pediatric patients is largely retrospective. However, there is strongly favorable data in juvenile rheumatoid arthritis patients. Until there is prospective, long-term efficacy and safety data on methotrexate in pediatric IBD, it is reasonable to consider the thiopurines to be the first line immunomodulators in this setting. The teratogenicity of methotrexate stands out as a distinguishing toxicity concern. Accordingly, for patients who are not of child-bearing potential and who do not respond or who cannot tolerate the thiopurines, methotrexate is a promising second line immunomodulator.