Low-Dose Methotrexate and Mucocutaneous Adverse Events: Results of a Systematic Literature Review and Meta-Analysis of Randomized Controlled Trials

Objective Methotrexate (MTX) increases the risk of alopecia and stomatitis, but the prevalence of these adverse events among rheumatic patients takingMTXis poorly defined. We conducted a systematic literature review and meta-analysis to estimate the prevalence of alopecia and stomatitis withMTXin rheumatic diseases. Methods We searched PubMed, The Cochrane Library, andCINAHLdatabases for double-blind randomized controlled trials (RCTs) with anMTXmonotherapy arm. Alopecia, stomatitis, and oral/mouth ulcers data were extracted. The quality of trials was assessed by 2 authors. We included trials published since 1990 that used at least 10 mg ofMTXweekly, coadministered with folic or folinic acid. We estimated the prevalence using random-effects models because heterogeneity was anticipated. Two estimates of prevalence were included; the lower bound estimate included all trials (assuming no alopecia and stomatitis if not mentioned), and the upper bound estimate included only those that specifically described prevalence estimates of alopecia or stomatitis. Results Of 3,954 studies identified, 20RCTs were included, with a total of 24MTXmonotherapy arms, of which 10 reported the prevalence of alopecia (n = 1,113), and 21 reported stomatitis or mouth/oral ulcers (n = 2,056). The prevalence of alopecia was between 1.0% and 4.9%. The prevalence of stomatitis was between 5.7% and 8.0%. Conclusion This meta-analysis gives more precise estimates of mucocutaneous adverse events that occur in rheumatic disease patients takingMTX. These estimates will help inform patient decision-making regardingMTX.