원저 : HBsAg 양성인 류마티스 관절염 환자와 HBsAg 음성인 류마티스 관절염 환자의 methotrexate에 대한 간독성의 비교

Objective: To investigate the hepatic safety of methotrexate (MTX) and useful parameters to assess the risk of hepatotoxicity in rheumatoid arthritis (RA) patients with hepatitis B surface antigen (HBsAg). Methods: 19 HBsAg positive (B group) and 54 HBsAg negative (non-B group) RA patients taking MTX were prospectively followed up for 2 years. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were checked at 2-month interval. In B group, HBeAg, HBeAb and levels of hepatitis B virus DNA (HBV DNA) were additionally checked, and liver biopsy was performed in seventeen of 19 patients. Change of AST or ALT to more than 1.5 times the upper limit of normal were considered as a hepatic event. The data were analyzed by stepwise linear and logistic regression method. Results: The findings of liver biopsy in B group were classified as grade I (n=8), II (n=6), and IIIA (n=3) according to the Roenigk Classification Scale. Mean cumulative dose of MTX in B group was 2054mg in cases with hepatic event and 1780mg in cases who stopped taking MTX. The frequency of hepatic event (47.4% vs 7.4%, p=0.0001) and MTX withdrawal (26.3% vs 1.9%, p=0.0008) was higher in B group than in non-B group. HBV DNA (+) group (n=9) showed the increased tendency of hepatic event and MTX withdrawal compared with HBV DNA (-) group (n=10). Baseline HBV DNA was negative in all HBeAg (-) patients (n=14), but HBV DNA was positive during MTX therapy in 7 of 14 HBeAg (-) patients. Serum levels of AST and ALT returned to normal range within 2 months after MTX withdrawal in twelve of 13 patients with hepatic event. Conclusion: The use of MTX in HBsAg positive RA patients requires close monitoring of AST and ALT. HBV DNA seems to be a useful marker to predict hepatic event and viral replication, especially in HBeAg (-) patients.