Background/Purpose:

MTX is the cornerstone of treatment of RA. A relatively rare side effect is liver fibrosis and cirrhosis, the incidence in patients on long-term therapy is thought to be less than 3%. Neither dose nor duration of MTX are associated with liver fibrosis, and abnormal liver enzymes in RA patients do not accurately detect liver fibrosis, making screening problematic. The gold standard for diagnosing liver fibrosis is by biopsy. Routine biopsy is invasive and associated with risks. Other screening tests include hepascore, aminoaspartate transaminase (AST) to platelet ratio index (APRI) and transient elastography (fibroscan) – which have been validated in patients with liver disease but have not been validated in patients with RA.

Methods:

Patients were recruited from Fiona Stanley Hospital (FSH) outpatient general rheumatology and inflammatory arthritis clinics from July 2017, and is ongoing. A DAS-28 (ESR) was completed, BMI, alcohol intake and dose and duration of MTX noted. FBC, UEC, LFT, ESR, CRP, AST, coagulation profile and hepascore were performed at FSH PathWest. Fibroscan was performed on the same day.

An APRI score of >0.7, hepascore of >0.45 and fibroscan of >7 kPa (=F2 metavir score) were used as cut-offs for significant fibrosis.

Statistical analysis was performed using SPSS with non-parametric statistics for non-normally distributed data and parametric for normally distributed data. Comparison between outcome tools was made using Spearman rank correlation (Rs).

Results:

To the end of February 2018, 17 patients have been recruited, with unexpectedly low recruitment due to exclusions mainly from high BMI and treatment with leflunomide. The age range of patients is 53-74 years old, with 41% female, 59% male and duration of methotrexate ranging from 3-240 months. 1 patient was found to have significant fibrosis based on fibroscan and hepascore, however liver biopsy reported no significant fibrosis. 1 patient was found to have cirrhosis based on fibroscan, hepascore and APRI, awaiting liver biopsy. 6 patients had raised hepascore indicative of significant fibrosis in the absence of correlated fibroscan or APRI scores. Duration of methotrexate ranged from 12-240 months, and was not statistically significant.

4 of 8 patients with raised hepascore had raised inflammatory markers. CRP was shown to be associated with fibrotic hepascore values (Rs 0.557, p=0.028), but not ESR (Rs 0.149, p=0.574) or DAS-28 (Rs -0.136, p=0.645). Fibrosis detected by APRI was highly correlated with fibrosis detected by fibroscan (Rs 0.683, p=0.04), but not hepascore (Rs. 0.258, p=0.334). Hepascore detection of fibrosis did not correlate.

Conclusion:

Results suggest that screening for liver fibrosis in RA patients may be indicated. Fibroscan and APRI correlate and are useful in detecting significant fibrosis in RA patients on methotrexate, however fibroscan may have limited utility in obese patients. Hepascore may be useful in detecting significant fibrosis though may also be falsely elevated in those with raised CRP, therefore limiting its utility in RA patients.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/validation-of-hepatic-fibrosis-markers-in-people-with-rheumatoid-arthritis-on-methotrexate/