A Prospective Trial of Colchicine and Methotrexate in the Treatment of Primary Biliary Cirrhosis

Transcription

1 GASTROENTEROLOGY 1999;117: A Prospective Trial of Colchicine and Methotrexate in the Treatment of Primary Biliary Cirrhosis MARSHALL M. KAPLAN, CHRISTOPHER SCHMID, DAWN PROVENZALE, ARCHNA SHARMA, GEORGE DICKSTEIN, and AUGUSTA MCKUSICK Divisions of Gastroenterology and Clinical Care Research, Department of Medicine, and Tupper Research Institute, New England Medical Center and Tufts University School of Medicine, Boston, Massachusetts Background & Aims: The aim of this study was to determine if colchicine or methotrexate improves blood test results, symptoms, and/or liver histology in patients with primary biliary cirrhosis. Methods: Patients with histologically confirmed primary biliary cirrhosis whose serum alkaline phosphatase (ALP) levels were at least 2 times above normal and who were not yet candidates for liver transplantation received colchicine or methotrexate and were followed up for 2 years. Results: In patients receiving colchicine (n 43), mean pruritus score decreased from 1.63 to 1.12 (P 0.04), ALP level from 494 to 355 U/L (P ), and alanine aminotransferase (ALT) level from 79 to 61 U/L (P ). In patients receiving methotrexate (n 42), pruritus score decreased from 1.25 to 0.44 (P ), ALP from 478 to 235 U/L (P ), and ALT from 96 to 61 U/L (P ). Methotrexate but not colchicine significantly improved liver histology (P 0.005) and serum immunoglobulin G levels (P ). Methotrexate improved most blood test results more than colchicine. Serum bilirubin levels increased slightly with each drug, and albumin levels decreased slightly. Conclusions: Both colchicine and methotrexate improved biochemical test results and symptoms in primary biliary cirrhosis, but the response to methotrexate was greater. There is still no totally effective treatment for primary biliary cirrhosis (PBC), a chronic progressive cholestatic liver disease characterized by the destruction of small intrahepatic bile ducts. 1 Three drugs, ursodeoxycholic acid (UCDA), colchicine, and methotrexate, improve results of biochemical tests of liver function and may slow the rate of progression. 2 8 However, the disease progresses in most patients and usually results in liver failure and the need for liver transplantation. We found that colchicine improved results of biochemical tests of liver function in PBC and decreased the likelihood of dying of liver failure after 4 years compared with patients receiving placebo. 6 The improvement in blood tests was confirmed by others, 9 11 although colchicine s efficacy was lost after 8 years. 12 We later found that methotrexate also improved results of biochemical tests of liver function in PBC and seemed to improve liver histology. 13,14 We therefore began a prospective double-blind trial to compare methotrexate with colchicine in the treatment of PBC. Several years after we began our trial, UDCA was reported to improve biochemical test results of liver function in PBC and to slow its rate of progression. 15 These results have been confirmed by others. 3 5 The mechanism of action of UDCA differs from that of colchicine and methotrexate, and its effects might be additive to those of either drug. Therefore, we revised our protocol so that each patient who had been in our study for at least 2 years could receive UDCA in addition to colchicine or methotrexate. We now report the results of the first 2 years of this study. Materials and Methods Patient Selection The criteria for entry to the study included a clinical history and biochemical profile consistent with PBC, serum alkaline phosphatase (ALP) level of at least 2 times greater than the upper limit of normal, serum bilirubin level not greater than 10 mg/dl, liver biopsy performed within 12 months of entry consistent with or diagnostic of PBC, and radiological or ultrasonic evidence that the bile ducts were patent. Patients were excluded if they had end-stage liver disease defined as follows: serum bilirubin level of 10 mg/dl (170 µmol/l) or serum albumin level of 3.0 g/dl (30 g/l) on 2 examinations 2 months apart; hepatic encephalopathy; hemorrhage from esophageal varices and/or portal gastropathy; or refractory ascites. Other reasons for exclusion from the study were history of alcohol abuse; administration of drugs associated with chronic liver disease; contemplation of pregnancy (unlikely in this group); other serious medical illnesses, e.g., renal disease or heart disease that might in itself cause liver Abbreviation used in this paper: PBC, primary biliary cirrhosis by the American Gastroenterological Association /99/$10.00

2 1174 KAPLAN ET AL. GASTROENTEROLOGY Vol. 117, No. 5 dysfunction or shorten life expectancy; signs of hypersplenism; hematocrit 30; white blood cell count 2500; and platelet count 100,000. Study Plan Each patient was asked to sign a consent form approved by the Human Investigation Review Committee of Tufts New England Medical Center. Patients were then admitted to the Clinical Study Unit of New England Medical Center where the following tests were performed: complete blood count; urinalysis; and measurement of serum creatinine, blood urea nitrogen, serum bilirubin, ALP, aspartate aminotransferase (AST), alanine aminotransferase (ALT), albumin, immunoglobulin (Ig) M, cholesterol, ceruloplasmin, and antimitochondrial antibody levels and prothrombin time. Percutaneous liver biopsy was performed unless it had been done within the previous 12 months. The liver biopsy slides were fixed in D-5 (mercuric chloride and formaldehyde) and stained with H&E and Gomori trichrome stains. Upper gastrointestinal endoscopy was performed to evaluate the presence and severity of esophageal varices and/or portal gastropathy; endoscopic retrograde cholangiography, computerized tomography scanning, or ultrasonography was performed if the patency of the bile ducts was in question. Patients were then divided into 3 groups on the basis of serum bilirubin level and whether the patients had been receiving colchicine before admission to the study. Group 1 consisted of patients who were currently receiving colchicine and whose serum bilirubin level was 2 mg/dl. Group 2 consisted of newly referred patients who had not received colchicine or immunosuppressive drugs such as prednisone, azathioprine, or cyclosporine and whose serum bilirubin was also 2 mg/dl. Group 3 consisted of patients whose serum bilirubin levels were 2 and 10 mg/dl for at least 3 months before referral. They may have been receiving colchicine or immunosuppressive drugs at the time of referral. Patients were randomly assigned by a single study monitor to receive either methotrexate, 15 mg/wk, taken as 5 mg every 12 hours 3 times, or colchicine, 0.6 mg twice daily. Each patient received 1 active study drug and placebo for the other. Both the patients and investigators were blinded to the treatment assignments. Each patient was then seen at 3-month intervals, at which time all of the above blood tests were performed and clinical observations recorded on a standard data collection form. A complete blood count, platelet count, and serum creatinine level were determined at monthly intervals in all patients either at the New England Medical Center or by the referring physician. Numerical scoring of pruritus and fatigue were recorded at each 12-week visit. Each patient kept a specially prepared symptom score diary and recorded the level of itching and fatigue for each week. Mean 12-week scores were calculated at each visit. Each symptom was rated on a scale from 0 to 4 as follows. For pruritus: 0, none; 1, mild no medication required; 2, pruritus interferes with sleep antihistamines or benzodiazepines are used to aid sleep; 3, cholestyramine or colestipol required; and 4, pruritus not fully controlled with cholestyramine or colestipol up to 6 packets/day. For fatigue: 0, none; 1, fatigued but without limitation of daily activities; 2, can perform most but not all daily activities; 3, can perform many but not most activities or requires more sleep than usual; and 4, cannot perform regular activities or sustain regular employment. Each patient was to remain in the double-blind phase of the study for 6 years or until clear evidence of disease progression or drug toxicity was detected and the treatment was judged a failure. Evidence of progression included (1) an increase in serum bilirubin level of 3 mg/dl to a level exceeding 4 mg/dl maintained for at least 3 months; (2) a decrease in serum albumin level of 0.8 g/dl to a level below 3 g/dl maintained for at least 3 months; and (3) appearance of a serious complication such as hepatic encephalopathy, intractable ascites, or hemorrhage from esophageal varices. Treatment was considered a failure in patients experiencing toxicity attributable to a drug, who were removed from the double-blind portion of the study. Drug toxicity attributable to methotrexate included interstitial pneumonitis and persistent cytopenias that were not caused by hypersplenism determined after patients had undergone bone marrow biopsy. Drug toxicity attributable to colchicine included intractable diarrhea and cytopenias not caused by hypersplenism. Patients with treatment failure were either referred for liver transplantation or crossed over to the other mode of treatment if there was not yet a clinical indication for liver transplantation. Patients who continued in the double-blind study for 2 years were readmitted to the Clinical Study Unit, and complete blood tests, percutaneous liver biopsy, and upper gastrointestinal endoscopy were performed. Patients were then reevaluated to determine if they met the criteria for treatment success. Treatment success had been defined before the start of the trial as sustained reduction in either ALP or serum bilirubin levels by at least 50% from baseline for at least 30 weeks with no worsening of other liver function test results or of liver histology. This definition was stringent enough that no patient in our earlier double-blind trial of colchicine vs. placebo would have been a treatment success. 6 During the course of the study, Poupon et al. 15 reported that UDCA improved results of biochemical tests of liver function and might prolong survival free of liver transplantation. The protocol was therefore revised so that all patients in the study could receive UDCA (kindly provided by Ciba-Geigy Corp., Summit, NJ) after they had been in the study for at least 2 years. This revision was approved by the Human Investigation Committee of Tufts New England Medical Center, and a separate consent form was signed by each patient to enter this phase of the study. UDCA, mg kg body wt 1 day 1, was given to each patient, and all patients remained in the double-blind trial of colchicine vs. methotrexate. Patients continued to be followed up as described above. Colchicine and identical-appearing placebo were provided by Eli Lilly and Co. (Indianapolis, IN), and methotrexate and identical-appearing placebo by Lederle Laboratories (Pearl River, NY).

3 November 1999 COLCHICINE AND METHOTREXATE IN PBC 1175 Statistical Analysis Based on an assessment of the relative efficacy of colchicine and methotrexate in decreasing serum ALP and/or serum bilirubin levels after 2 years of drug therapy, we planned to enroll 60 patients. 6,13 We estimated that it would take 2 years to enroll these patients. ALP and bilirubin levels were chosen because there were few data available on survival, referral for liver transplantation, or effects on liver histology from which to base power calculations. Sixty patients would give a comparison between the 2 treatments having 90% power to detect a difference between a 25% chance of success on colchicine and a 65% chance of success on methotrexate at the 5% significance level based on the definition of success stated above. Enrollment was larger than this and included 87 patients seen during the 2-year randomization period. The biochemical and clinical data collected on the 2 treatment groups at entry were compared to determine the success of randomization. The efficacy of treatment in each patient during the study was assessed by computing the difference between the baseline and 24-month values for each of the observed variables. When 24-month follow-up was unavailable, we used measurements from the last available time point (which had to be at least 3 months after baseline) at which all tests were performed. Because previous work and preliminary analysis has shown that the distribution of values for 6 variables, bilirubin, cholesterol, ALP, ALT, AST, and IgM, tended to be skewed to the right, we calculated the logarithms of the values in an attempt to make the distributions more normally distributed. Results were analyzed separately for all patients and also for patients in groups 1 and 2, excluding patients in group 3 who had serum bilirubin levels of 2 mg/dl and had more advanced disease. The following statistical methods were used. Relative frequencies (percentages) were compared with the Pearson 2 test. For untransformed variables, we calculated the arithmetic mean and standard error of values at baseline and follow-up and for the difference in values between baseline and follow-up. For the logarithmically transformed variables, we calculated the corresponding geometric means and standard errors (called relative standard errors). The differences in means were compared with the t test, and a 95% confidence interval based on the normal distribution was calculated. Statistical significance was determined as a 2-sided P value of Cumulative mortality functions were calculated by the Kaplan Meier method and compared by the log rank test. Histological Analysis Liver biopsy specimens obtained at entry and at 2 years were coded and paired by patient, but the sequence of the biopsy, i.e., first or second, was not known to the physicians (M.M.K. and G.D.) who evaluated the specimens. The histological stage of disease in each specimen was determined according to accepted criteria. 16 In addition, each specimen was scored numerically by a modified Knodell score as described previously. 7 The differences in means were calculated with the t test. Results One hundred thirty patients referred with a diagnosis of PBC were screened. Twenty-eight patients did not meet the eligibility criteria. Ten had end-stage PBC as defined above, 16 had serum ALP levels that were increased less than 2-fold, and 2 did not have PBC. These 2 patients had drug-induced cholestasis that resolved spontaneously. Fifteen other patients met the eligibility criteria but did not want to participate in a double-blind study. Eighty-seven patients fulfilling the requirements for entry were admitted to the clinical study unit for randomization. Two withdrew from the study immediately after randomization before they received any drugs, did not return for follow-up testing, and were not included in the analyses. All of the 19 patients in group 1 had been previously treated with colchicine per study design; 10 received colchicine and 9 methotrexate. None of the 49 patients in group 2 had been treated previously; 25 received colchicine and 24 methotrexate. All 17 patients in group 3 had clinically advanced disease and serum bilirubin level of 2.0 mg/dl. Eight received colchicine and 9 methotrexate. Three had been treated previously with colchicine. Overall, 43 patients were randomized to receive colchicine and 42 methotrexate. Table 1 shows the relative frequencies of relevant clinical findings and biochemical test results at baseline. No significant differences were found between the 2 groups. Twenty-nine percent of the methotrexate group had esophageal varices at baseline compared with 16% of the colchicine group (P 0.16). Fifty-three percent in the colchicine group had cirrhosis (stage IV) compared with 38% receiving methotrexate (P 0.15). Patients were evenly matched with respect to the 2 most clinically relevant biochemical predictors of outcome, serum bilirubin and albumin. There were only 3 male patients in the study; 1 received colchicine and 2 methotrexate. Among the 87 patients randomized to receive treatment, 2 patients were referred for liver transplantation before the first 3-month follow-up visit and 2 dropped out of the study shortly after randomization and never received any drug. Eighty-three patients are included in the biochemical data analysis at 2 years. There were 8 additional liver transplantations and 2 deaths; neither death was liver-related. Seven of the 8 patients who underwent liver transplantation were in group 3. Of the 10 patients who died or who received liver transplants, 3 were receiving colchicine and 7 methotrexate. Figure 1 shows the incidence of death and liver

4 1176 KAPLAN ET AL. GASTROENTEROLOGY Vol. 117, No. 5 Table 1. Clinical and Laboratory Characteristics of Patients With PBC at Entry to the Study According to Treatment Group Normal values Colchicine (N 43) Methotrexate (N 42) P value Age ( yr ) a a 0.92 Female 42 (98%) 40 (95%) 0.54 Antimitochondrial 39 (91%) 38 (90%) 0.97 antibody Asymptomatic 7 (16%) 7 (17%) 0.96 Fatigue Pruritus Hepatomegaly 38 (88%) 31 (74%) 0.09 Splenomegaly 15 (35%) 13 (31%) 0.70 Spider nevi Esophageal varices 7 (16%) 12 (29%) 0.16 Stage IV (cirrhosis) 23 (53%) 16 (38%) 0.15 Serum bilirubin b mg/dl Serum albumin g/dl Serum ALP b 116 IU Serum ALT b 25 U/L Hematocrit White blood cell , count IgM b mg/ml Cholesterol b 220 mg/ml Prothrombin time s AST b 35 U/L NOTE. Sample size is 41 in methotrexate group for IgM and varices. a Mean SE. b Geometric mean and relative SE. transplantation for patients who were randomized to colchicine or methotrexate. No significant differences were found. Data from all patient groups were combined in the biochemical and histological analysis. Data from groups 1 and 2 were analyzed separately and are similar to the Figure 1. Incidence of death or liver transplantation for patients with PBC according to treatment group...., Methotrexate;, colchicine. results of the 3 groups. We present the data from all 3 groups. Table 2 shows the mean relative change (ratio of the last value to the first) for levels of serum bilirubin, cholesterol, ALP, AST, ALT, and IgM. We found significant decreases in serum ALP, AST, and ALT levels in both the colchicine and methotrexate groups. ALP decreased by at least 20% in 31 patients receiving methotrexate and in 26 receiving colchicine, with a mean decrease of 51% in the methotrexate (P ) and 28% in the colchicine (P ) group. ALP level increased by at least 20% in 3 patients in the methotrexate and in 3 patients in the colchicine group. For each of these 3 enzyme tests, the decrease was greater for methotrexate, ALP (P 0.001), AST (P 0.02), and ALT (P 0.12). There was a significant decrease in IgM levels on methotrexate (P ), but not on colchicine (P 0.94). The difference between the 2 was significant (P 0.001). Significant decreases in serum cholesterol level were found for both medications (P 0.04 for colchicine and P for methotrexate). There was no significant difference between the 2 drugs (P 0.66). Mean serum bilirubin levels increased slightly but not significantly in both treatment groups, with no significant difference between the 2 groups (P 0.80). Serum bilirubin levels remained normal in 17 of 21 patients receiving methotrexate and in 19 of 23 receiving colchicine. Serum bilirubin levels increased by at least 20% and became elevated in 4 of 20 patients on methotrexate and in 4 of 23 patients on colchicine. Previously increased serum bilirubin levels increased by at least 20% in 10 patients on methotrexate and 10 on colchicine. Previously elevated serum bilirubin levels decreased by at least 20% in 5 patients on methotrexate and 5 on colchicine. Table 2 also shows the arithmetic mean changes in albumin level, prothrombin time, fatigue, pruritus, and platelet count. There was a slight but significant decrease in serum albumin on both colchicine (P 0.05) and methotrexate (P ) but no difference between the 2 drugs (P 0.23). Serum albumin levels remained normal in 29 patients on methotrexate and 36 on colchicine. They decreased by at least 20% and became abnormal ( 3.5 g/dl in 3 patients on methotrexate and in 2 patients on colchicine). Only 1 patient had an abnormal serum albumin level at baseline, and it was stable. Pruritus decreased significantly during both colchicine and methotrexate treatment (P 0.04 for colchicine and P for methotrexate), but there was no difference between the 2 drugs (P 0.34). We found no significant change in prothrombin time or fatigue for

5 November 1999 COLCHICINE AND METHOTREXATE IN PBC 1177 Table 2. Biochemical Variables in the Treatment Groups at Entry and at 24 Months Entry 24 mo Change Effect P value Mean SE Mean SE Mean SE Mean SE Albumin Colchicine Methotrexate Prothrombin time Colchicine Methotrexate Fatigue Colchicine Methotrexate Pruritus Colchicine Methotrexate Platelet Colchicine Methotrexate Gmean RSE Gmean RSE Gmean RSE b Gmean RSE Bilirubin Colchicine Methotrexate Cholesterol Colchicine Methotrexate ALP Colchicine Methotrexate AST Colchicine Methotrexate ALT Colchicine Methotrexate IgM a Colchicine Methotrexate Gmean, geometric mean; RSE, relative standard error. a One patient from each group missing IgM. b Proportion of baseline value at 2 years. either drug. There was a significant decrease in the platelet count for both colchicine (P 0.002) and methotrexate (P 0.04) but no difference between the 2 drugs (P 0.96). Figure 2 shows the changes in 6 biochemical test results during the 24 months that each patient received colchicine or methotrexate. Based on the definition of success described above (sustained reduction in either ALP or serum bilirubin levels by at least 50% from baseline for at least 30 weeks with no worsening of other liver function test results or of liver histology), there were 3 successes on colchicine and 13 on methotrexate (P 0.005). Mean serum ALP level decreased from 505 to 162 IU in the 16 patients who were successes. All decreases were at least 30%, and the mean decrease was 69%. Mean serum bilirubin levels were unchanged in these 16 patients. In 1 patient serum bilirubin level decreased from 3.4 to 0.8 mg/dl. In 3, bilirubin levels increased slightly from normal to 1.1, 1.2, and 1.4 mg/dl, respectively. Serum albumin levels remained normal in all. Methotrexate but not colchicine improved liver histology (Table 3). The mean Knodell score decreased from 12.0 to 9.8 in patients receiving methotrexate (P 0.005) and decreased slightly for colchicine, (P 0.61). The Knodell score improved more in the methotrexate patients who were treatment successes, (P 0.002). We found only insignificant decreases in histological stage in patients receiving both treatments. The results were unchanged if medians were used. The median Knodell score on methotrexate decreased from 11.8 to 9.5 (P 0.004). Eleven patients receiving methotrexate had a decrease of Knodell score 2 points. Only 2 had an increase 2. Twelve patients

6 1178 KAPLAN ET AL. GASTROENTEROLOGY Vol. 117, No. 5 Figure 2. Changes in biochemical test results over 2 years according to treatment group...., Methotrexate;, colchicine. on colchicine had 2-point decrease in Knodell score but 9 had a 2-point increase. Ten patients dropped out of the study. Three withdrew because of methotrexate pneumonitis; 2 of them became severely dyspneic and required a 1 2-week course of prednisone. Among the others, treatment failed in 4 (3 bled from esophageal varices and 1 had worsening jaundice). One withdrew because of worsening fatigue, 1 because of intercurrent illness unrelated to the PBC or the medications, and 1 because of a code violation. Discussion These results confirm our earlier results that both colchicine and methotrexate improved enzyme test results in PBC but that the effects of methotrexate were Table 3. Liver Histology Scores at 2 Years According to Treatment Group Sample size Entry 24 Months Change Effect P value Knodell score (mean) Colchicine Methotrexate Histological stage (mean) Colchicine Methotrexate Sample size Entry (median 1QR) 24 Months Change Knodell score (median) 0.08 a Colchicine b Methotrexate b IQR, Interquartile range. a Wilcoxon rank sum test. b Signed-rank test.

7 November 1999 COLCHICINE AND METHOTREXATE IN PBC 1179 greater than those of colchicine. 6,7 Pruritus, serum ALP, and cholesterol levels improved significantly in patients receiving both drugs. These are all indicators of chronic cholestasis. Both drugs also decreased the elevated serum AST levels, whereas serum IgM level, also an indicator of chronic cholestasis in PBC, decreased significantly in patients receiving methotrexate. The improvement in liver histology in patients receiving methotrexate reinforces the biochemical evidence that methotrexate improved the course of PBC. The histological stage did not decrease significantly after 2-year therapy of either drug, but neither did it increase. Histological stage usually increases in most untreated PBC patients and was found to increase by more than 1 stage every 2 years in a study of 222 patients. 17 Despite the improvements in some determinants of liver function, neither drug was totally effective. Mean serum bilirubin levels increased slightly and serum albumin levels and platelet counts decreased slightly but significantly in patients receiving both drugs. Serum bilirubin and albumin levels are important predictors of outcome in PBC and are included in most prognostic models in PBC. 18 The results with methotrexate and colchicine in PBC are similar to those with UDCA in some ways and different in others. All 3 drugs improved enzyme test results, but only methotrexate and UDCA decreased serum IgM levels. The decreases in ALP and serum IgM levels in the methotrexate-treated patients were similar to those reported for UDCA in 4 large randomized trials 2 5 : 51% and 27% for methotrexate and 52% and 23% for UDCA. 3 5,15 AST and ALT levels decreased more during UDCA (49% and 42%, respectively) than during methotrexate (33% and 36%) treatment. UDCA was more effective than methotrexate or colchicine in lowering serum bilirubin levels and stabilizing serum albumin levels. Serum bilirubin levels decreased by 14% on UDCA and increased by 14% on methotrexate. Albumin levels did not change on UDCA and decreased by 6% on methotrexate. On the other hand, there was more histological improvement with methotrexate than with UDCA. Histology was not improved in 3 of the 4 large controlled trials of UDCA. 3 5 The fourth study found histological improvement in some patients after a post hoc analysis. 19 However, piecemeal necrosis and lobular inflammation were predictors of a poor histological response to UDCA. 19 These same histological abnormalities seem to be predictors of a good histological response to methotrexate. 20 This observation is supported by our recent finding that methotrexate is beneficial in the treatment of patients with PBC who respond incompletely or not at all to UDCA. 21 The improvements in patients on colchicine treatment were of lesser magnitude than with either UDCA or methotrexate. Overall, our results are encouraging and suggest that the combination of all 3 drugs could be beneficial in some patients with PBC. Another interesting finding was the heterogeneity of the response to treatment. Three patients receiving colchicine and 13 receiving methotrexate responded more completely to treatment than did the other patients and were judged treatment successes. In addition, the histological response to colchicine was quite heterogeneous. Just as many patients had a 2-point increase in Knodell score as had a 2-point decrease. The results with colchicine were not statistically significant because of this. The same heterogeneous response to treatment was observed in our earlier open-label trial of methotrexate 20 and also in a trial of UDCA. 22 The long-term safety of methotrexate in the treatment of PBC has not been established. We reported a 14% incidence of methotrexate-related interstitial pneumonitis in PBC patients in a prospective trial of colchicine and methotrexate. 23 However, we have not seen a case since then. Additionally, pulmonary toxicity has not been observed in a group of 265 patients with PBC followed up for up to 4 years in a prospective trial comparing UDCA to UDCA plus methotrexate. 24 Nevertheless, we believe that interstitial pneumonitis is a potential problem with methotrexate and that its prevalence will be similar to that seen in rheumatoid arthritis, approximately 1% 3%. We have not observed hepatic toxicity caused by methotrexate during the 20 years we have been using it to treat patients with chronic cholestatic liver disease. Hepatic fibrosis or cirrhosis is uncommon in patients treated with long-term, low-dose pulse methotrexate unless they drink alcohol or are morbidly obese. 25,26 Bone marrow suppression is also uncommon with lowdose methotrexate, in contrast to the high doses used to treat malignancy. Other side effects of methotrexate (such as nausea, hair loss, and oral aphthous ulcers) are uncommon and not life-threatening. Several aspects of this study deserve comment. First, there was no placebo group. When we planned the study, we had just published the results of our placebocontrolled trial of colchicine. 6 It showed that colchicine improved biochemical test results of liver function and decreased the likelihood of dying of liver disease after 4 years. We believed that it would have been unethical for us to withhold effective treatment in patients with a progressive disease at a time when there was no other medical treatment. Second, the likelihood of achieving success was diminished because our study included so many patients with cirrhosis and portal hypertension, 39 patients, or 46% of the study population. When the

8 1180 KAPLAN ET AL. GASTROENTEROLOGY Vol. 117, No. 5 study was planned, there were few data on the effect of cirrhosis and portal hypertension on survival or response to treatment. Both are indicators of advanced disease and have now been shown to be predictors of shortened survival. 27,28 Patients with advanced disease are less likely to respond to treatment. 29 Third, the 2-year duration of this interim analysis is too short to allow significant end points such as death or referral for liver transplantation to occur. The continuation of the study beyond 2 years with the introduction of UDCA should provide sufficient follow-up to assess these end points and to determine whether the effects of ursodiol are additive to those of colchicine and methotrexate. References 1. Kaplan MM. Primary biliary cirrhosis (review). N Engl J Med 1996;335: Poupon RE, Poupon R, Balkau B. Ursodiol for the long-term treatment of primary biliary cirrhosis. N Engl J Med 1994;330: Heathcote EJ, Cauch-Dudek K, Walker V, Bailey RJ, Blendis LM, Ghent CN, Michieletti P, Miuuk GY, Pappas SC, Scully LI. The Canadian multicenter double-blind randomized controlled trial of ursodeoxycholic acid in primary biliary cirrhosis. Hepatology 1994;19: Lindor KD, Dickson ER, Baldus WP, Jorgensen RA, Ludwig J, Murtaugh PA, Harrison JM, Wiesner RH, Anderson ML, Lange SM. Ursodeoxycholic acid in the treatment of primary biliary cirrhosis. Gastroenterology 1994;106: Combes B, Carithers RL Jr, Maddrey WC, Lin D, McDonald MF, Wheeler DE, Eigenbrodt EH, Munoz SJ, Rubin R, Garcia-Tsao G. A randomized, double-blind, placebo-controlled trial of ursodeoxycholic acid in primary biliary cirrhosis. Hepatology 1995;22: Kaplan MM, Alling DW, Zimmerman HJ, Wolfe HJ, Sepersky RA, Hirsch GS, Elta GH, Glick KA, Eagen KA. A prospective trial of colchicine for primary biliary cirrhosis. N Engl J Med 1986;315: Kaplan MM, Knox TA. Treatment of primary biliary cirrhosis with low-dose weekly methotrexate. Gastroenterology 1991;101: Bergasa NV, Jones A, Kleiner DE, Rabin L, Park Y, Wells MC, Hoofnagle. Pilot study of low-dose oral methotrexate treatment for primary biliary cirrhosis. Am J Gastroenterol 1996;91: Warnes TW, Smith A, Lee FI, Haboubi NY, Johnson PJ, Hunt L. A controlled trial of colchicine in primary biliary cirrhosis. J Hepatol 1987;5: Bodenheimer H Jr, Schaffner F, Pezzullo J. Evaluation of colchicine therapy in primary biliary cirrhosis. Gastroenterology 1988; 95: Vuoristo M, Farkkila M, Karvonen AL, Leino R, Lehtola J, Makinen J, Mattila J, Friman C, Seppala K, Tuominen J, Miettinen TA. A placebo-controlled trial of primary biliary cirrhosis treatment with colchicine and ursodeoxycholic acid. Gastroenterology 1995;108: Zifroni A, Schaffner F. Long-term follow-up of patients with primary biliary cirrhosis on colchicine therapy. Hepatology 1991;14: Kaplan MM, Knox TA, Arora SA. Primary biliary cirrhosis treated with low-dose oral pulse methotrexate. Ann Intern Med 1988;109: Kaplan MM, Knox TA. Methotrexate for primary biliary cirrhosis (letter). Gastroenterology 1992;102: Poupon RE, Balkau B, Eschwege E, Poupon R. A multicenter, controlled trial of ursodiol for the treatment of primary biliary cirrhosis. N Engl J Med 1991;324: Scheuer PJ. Primary biliary cirrhosis: diagnosis, pathology and pathogenesis. Postgrad Med J 1983;4: Locke GR, Therneau TM, Ludwig J, Dickson ER, Lindor KD. Time course of histological progression in primary biliary cirrhosis. Hepatology 1996;23: Dickson ER, Grambsch PM, Fleming TR, Fisher LD, Langworthy A. Prognosis in primary biliary cirrhosis: model for decision making. Hepatology 1989;10: Degott C, Zafrani ES, Callard P, Balkau B, Poupon RE, Poupon R. Histopathogical study of primary biliary cirhhosis and the effect of ursodeoxycholic acid treatment on histology progression. Hepatology 1999;29: Kaplan M, DeLellis R, Wolfe H. Sustained biochemical and histological remission of primary biliary cirrhosis in response to medical treatment. Ann Intern Med 1997;126: Bonis PAL, Kaplan M. Methotrexate improves biochemical tests in patients with primary biliary cirrhosis who respond incompletely to ursodiol. Gastroenterology 1999;117: Jorgensen RA, Dickson ER, Hofmann AF, Rossi SS, Lindor KD. Characterisation of patients with a complete biochemical response to ursodeoxycholic acid. Gut 1995;36: Sharma A, Provenzale D, McKusick A, Kaplan MM. Interstitial pneumonitis after low-dose methotrexate therapy in primary biliary cirrhosis. Gastroenterology 1994;107: Munoz S, Carithers RL, Emmerson SS, Five N, Combes B, Group ftp. Absence of pulmonary toxicity in primary biliary cirrhosis (PBC) treated with methotrexate and ursodiol (abstr). Hepatology 1998;28: Zachariae H, Sogaard H. Methotrexate-induced liver cirrhosis: a follow-up. Dermatologica 1987;175: Kaplan MM. Methotrexate hepatotoxicity and the premature reporting of Mark Twain s death: both greatly exaggerated. Hepatology 1990;12: Markus BH, Dickson ER, Grambsch PM, Fleming TR, Mazzafero V, Klintmalm GB, Wiesner RH, Van Thiel DH, Starzl TE. Efficiency of liver transplantation in patients with primary biliary cirrhosis. N Engl J Med 1989;320: Goudie BM, Burt AD, Macfarlane GJ, Boyle P, Gillis CR, MacSween RN, Watkinson G. Risk factors and prognosis in primary biliary cirrhosis. Am J Gastroenterol 1989;84: Kaplan MM. New strategies needed for treatment of primary biliary cirrhosis? Gastroenterology 1993;104: Received April 12, Accepted July 12, Address requests for reprints to: Marshall M. Kaplan, M.D., 750 Washington Street, Box 233, Boston, Massachusetts marshall.kaplan@es.nemc.org; fax: (617) Supported in part by National Institutes of Health Center for Research Resources, General Clinical Research Center, grant RR 00054; by GRASP (Gastroenterologic Research in Absorptive and Secretory Processes) Digestive Disease Center grant NIH-NIDDK P30 DK34928; and by a grant from Lederle Laboratories (Pearl River, New York).