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A minority of patients with Crohn's have disease refractory to or dependent on corticosteroids who are inappropriate for surgery; most will also have failed to respond to aminosalicylates, antibiotics, and/or a liquid formula diet. Firstline immunomodulatory therapy, given to initiate and maintain remission and allow tapering of steroid therapy, is usually azathioprine or 6-mercaptopurine. Unfortunately, approximately 20% of patients are resistant to or intolerant of thiopurines, and their management provides a difficult therapeutic challenge. The possible benefits of mycophenolate mofetil are unconfirmed, while infliximab is expensive and unproved in its long term efficacy and safety.
Methotrexate given intramuscularly can be used to achieve (25 mg/week) and maintain (15 mg/week) remission in patients with steroid refractory or steroid dependent Crohn's disease.
Potential side effects include bone marrow depression, infections, teratogenicity, hepatic fibrosis, and pneumonitis.
Contraindications to methotrexate include liver and renal disease, alcohol, obesity, diabetes, infections, actual or possible pregnancy, and malignancy.
Patients given methotrexate require careful follow up and monitoring, including full blood count and liver function tests every 1–2 months.
Further trials are needed to clarify the indications, dose, route, and duration of therapy with methotrexate.
Methotrexate is of proven value in psoriasis and rheumatoid arthritis.1 2 Since its effects in Crohn's disease were first reported …
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