POS0561 Pan-European study on prescription patterns of methotrexate in patients with rheumatoid arthritis

Abstract

Background: According to the EULAR recommendations [1], methotrexate (MTX) is recommended as first-line therapy for patients with rheumatoid arthritis (RA) due to its proven efficacy, safety and cost-effectiveness. Despite its use as an anchor drug for decades, prescription patterns vary highly among physicians and across different countries, which could impact treatment strategies within individual patients. Objective(s): To identify differences in MTX prescription practices by rheumatologists treating RA patients across Europe in daily clinical care. Method(s): A web-based survey of 33 questions was designed to collect information on MTX, including starting and target dose, titration schemes, route of administration, and co-treatment. The survey was disseminated at the 2024 EULAR conference, social media and via email, targeting MTX prescribers across different countries and health care settings. Responses were collected anonymously from June to December 2024. Answers were reported as total percentage (%), mean (+/- standard deviation SD), median (interquartile range), or weighted average (WA). Result(s): A total of 499 responses were collected of which 127 did not answer all questions on MTX prescription and 372 (65.6% women) from 29 different European countries (51.3% Eastern, 48.7% Western Europe) were used for further analyses (Figure 1). The respondents came from different healthcare settings (48.7% university hospitals; 32.2% non-university hospitals, 17.8% non-hospital setting), majority having practiced rheumatology for more than 10 years (60.3%). On average, MTX is prescribed as first-line treatment in 84.3% of DMARD naive RA patients. The most common reasons for not using MTX as first-line are contraindications (WA=3.5) and patient concerns (WA=2.3; Table 1). Around half of the physicians at least sometimes combine MTX with other csDMARDs in treatment naive patients, on average in 17% of cases. Nearly everyone (99.7%) uses concomitant glucocorticoid therapy. Reason for combination and co-treatment are displayed in Table 1. Local policies require MTX-failure before the prescription of b/tsDMARD in 47.8% or of other csDMARDs in 25.8%. Around 8% start MTX with the full target dose. Only 51% use ascending dose in all patients, while 18% in less than a half of their patients. MTX is initiated with a median dose of 10 (10;15) mg/week (w), targeting a median maintenance dose of 20 (20;20) mg/w. Only 17.5% aim for target dose of 25 mg/w, reaching it within 6.8 (+/- 4.3) w. MTX target dose is established considering liver (WA=4.4) and kidney functions (WA=4.2), Table 1. Approximately 44% never recommend splitting the MTX dose, while 10.5% always do (84% preferring to split it on the same day). The guidance on MTX intake on any particular time of the day was quite evenly distributed. Respondents start directly on subcutaneous MTX in 42.3% of patients and 39.6% of patients are switched from oral to subcutaneous MTX over their disease course, mainly due to gastrointestinal side effects (77.2%) or insufficient bioavailability (60.8%). Safety laboratory assessments are performed in median intervals of 3 w after MTX initiation, 4 w after dose increase and every 12 w for stable MTX doses. Patients' initial clinical response to MTX is assessed after 9.1 w on average; 45.1% of respondents assess 3 months after MTX start. Folic acid is supplied with median doses of 5 mg/w for MTX = 15 mg/w, after a minimal median time interval of 24 hours after MTX administration. Conclusion(s): The study reveals the main differences in MTX real world prescription patterns across Europe. Only a minority of respondents targets the MTX dose of 25 mg/w. Half of the participants prefer to start with subcutaneous MTX, whereas less than a half of the patients are switched to subcutaneous MTX over their disease course. These patterns can impact clinical response to MTX and show potential for optimisation of MTX prescription strategies. REFERENCES: [1] Smolen JS et al. Ann Rheum Dis 2023; 82 (1): 3-18. [Figure presented] [Table presented] Acknowledgements: On behalf of the Squeeze consortium. Disclosure of Interests: None declared. © The Authors 2025. This abstract is an open access article published in Annals of Rheumatic Diseases under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Neither EULAR nor the publisher make any representation as to the accuracy of the content. The authors are solely responsible for the content in their abstract including accuracy of the facts, statements, results, conclusion, citing resources etc. Copyright © 2025 © Author(s) (or their employer(s)) 2025. No commercial re-use. See rights and permissions. Published by Elsevier Inc.