Article Text

Long-term safety of methotrexate monotherapy in patients with rheumatoid arthritis: a systematic literature research
  1. C Salliot1,
  2. D van der Heijde2
  1. 1
    Paris Descartes University, Medicine Faculty, Rheumatology B Department, Cochin Hospital, Paris, France
  2. 2
    Rheumatology Department, Leiden University Medical Centre, Leiden, The Netherlands
  1. Dr C Salliot, Hôpital Cochin, service de Rhumatologie B, rue du faubourg Saint-Jacques, 75014 Paris, France; carinesalliot{at}


Objective: To perform a systematic literature review of the long-term safety of methotrexate (MTX) monotherapy in rheumatoid arthritis (RA).

Methods: A search was performed in Medline, Cochrane and EMBASE. Adults with RA who had received MTX monotherapy for more than 2 years were studied.

Results: 88 published studies were included. Over 12 years of treatment, the termination rate of MTX due to toxicity was less than for sulfasalazine, gold, d-penicillamine and higher than for hydroxychloroquine (level of evidence 2a–2b). Long-term use of MTX does not appear to be a risk factor for serious infections, including herpes zoster (2b–4), and could provide a survival benefit by reducing cardiovascular mortality (2b). The prevalence of raised liver enzymes (more than twice the upper limit of normal) is close to 13% of patients; 3.7% of patients stopped MTX permanently owing to liver toxicity (2b). Data on the risk for liver fibrosis/cirrhosis are conflicting: a meta-analysis showed an incidence of fibrosis of 2.7% after 4 years of MTX (2a). However, two other studies on sequential liver biopsies did not show evidence for developing severe damage (2b). Insufficient data are available to fully assess the risk of lymphoma and malignancies, although there is no strong evidence of increased risk (2b–4).

Conclusion: This systematic literature search on MTX monotherapy with relatively low-dose use during at least 2 years shows favourable long-term safety.

View Full Text

Statistics from

Supplementary materials


  • Additional tables, figure and references are published online only at

  • Funding: This work was supported by Abbott with an unrestricted educational grant.

  • Competing interests: None.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Linked Articles