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Methotrexate in Crohn's disease
  1. D S Rampton
  1. Academic Department of Adult and Paediatric Gastroenterology, St Bartholomew's and the Royal London School of Medicine and Dentistry,Turner St, London E1 2AD, UK
  1. Dr D S Rampton, Department of Gastroenterology, Royal London Hospital, London E11BB, UK. drampton{at}

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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.

Key points

  • 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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