The efficacy of methotrexate for maintaining remission in inflammatory bowel disease

Background: The management of patients with inflammatory bowel disease who are resistant to or intolerant of azathioprine remains a challenge. Low-dose methotrexate has been shown to be effective in inducing remission in Crohn's disease. Aim: This review was conducted because there are limited long-term follow-up data during and after stopping treatment. There arc also limited data on the use of methotrexate in ulcerative colitis. Methods: The study was a retrospective review of clinical notes. Remission was defined as minimal bowel symptoms without the need for oral steroids for 3 months. Relapse was defined as bowel symptoms that required steroid treatment or surgery. Results: Seventy patients were reviewed: 48 had Crohn's disease and 22 had ulcerative colitis. The mean duration of treatment was 17.1 months: the mean maintenance dose was 20 mg weekly. Remission was achieved in 34 of 5 5 patients who completed more than 3 months of treatment (62%). Life-table analysis showed that the chances of remaining in remission at 12, 24 and 36 months (if treatment was continued) were 90%, 73%, and 51%, respectively. The chances of remaining in remission after stopping treatment at 6, 12 and 18 months were 42%, 21% and 16%, respectively. The dose of methotrexate (mg/kg) was associated with the induction of remission (P=0.02). Treatment was equally effective for Crohn's disease and ulcerative colitis. Conclusions: Maintenance methotrexate treatment gives acceptable remission rates for treatment periods up to 3 years. After stopping treatment, relapse is frequent and occurs early (usually within 1 year).