Concurrent use of methotrexate and acitretin revisited

Background: According to Food and Drug Administration (FDA)-approved prescribing information, combination therapy with acitretin and methotrexate (MTX) is contraindicated. This is based on company data suggesting increased hepatotoxicity in patients who received concomitant methotrexate and etretinate, the prodrug of acitretin. Methods: We reviewed the clinical data of 18 patients with psoriasis who received methotrexate and acitretin concurrently. Patients received 25 mg of acitretin once daily or alternating days and 7.5-25 mg methotrexate weekly. Baseline metabolic panels, including lipids, and complete blood counts (CBC) were drawn prior to therapy and every 4-12 weeks while on therapy. Results: The average length of treatment was 9 months. Two patients discontinued treatment after refusal to abstain from alcohol. Seven patients discontinued treatment due to a lack of response. Two patients discontinued treatment after clearing. One patient discontinued treatment secondary to hair loss. Six patients are currently continuing therapy. Conclusions: In this series of patients, combination therapy with acitretin and methotrexate was well tolerated and often effective. There were no new or unusual adverse events noted, including significant hepatotoxicity. In patients who would benefit from the use of acitretin, the concomitant use of methotrexate is not an absolute contraindication.