Transient Elastography for Monitoring for Hepatotoxicity in Rheumatoid Arthritis Patients on Long-Term Methotrexate

Stefanie D. Wade, MD; Eric M. Yoshida, MD; Mollie N. Carruthers, MD; Michael E. Weinblatt, MD


J Clin Rheumatol. 2021;27(4):e131-e134. 

In This Article

Abstract and Introduction


To the Editor:

Methotrexate (MTX) is recommended as the first disease-modifying antirheumatic drug for patients with symptomatic early rheumatoid arthritis (RA) and with established RA who have not previously taken a disease-modifying antirheumatic drug.[1,2] The American College of Rheumatology (ACR) guidelines recommend liver biopsies for RA patients on MTX with persistent elevations in aspartate aminotransferase (AST) (5 of 9 results within a 12-month interval above the upper limit of normal) or following a decrease in serum albumin below the reference range.[3] Historically, liver biopsy was the reference standard for diagnosing liver cirrhosis; however, noninvasive measures of assessing for liver fibrosis are a rapidly growing field within hepatology. Transient elastography (TE) (Fibroscan; Echosens, Paris, France) has replaced biopsy for assessment of liver fibrosis in several liver conditions.[4] There has been limited assessment of TE use in RA patients on MTX. Rheumatologists are seeing increasing numbers of RA patients on MTX for more than 20 years. In this report, we identify an RA patient on long-term MTX who underwent noninvasive evaluation for liver fibrosis and discuss the potential role of TE in this patient population.