Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology
Case reportSevere stomatitis caused by misuse of methotrexate in an elderly patient with chronic rheumatoid arthritis
Introduction
Methotrexate (MTX), commonly used in treatment of various malignancies, is also used as a first-line therapy for treatment of rheumatoid arthritis (RA). In Japan, MTX is recommended for use in RA patients who no longer respond to normal amounts of other disease-modifying anti-rheumatic drugs (DMARDs). A dose of 5–35 mg MTX is typically administered once per week. The most common adverse effects of MTX treatment are gastrointestinal and bone marrow toxicities. Moreover, these adverse effects are dose-dependent and can be potentially fatal; therefore, when they develop, MTX treatment is reduced or stopped, and folic acid is administered. Although stomatitis is a common adverse effect of MTX therapy during treatment of malignant disease, it is uncommon in MTX therapy for treatment of RA [1,2]. Here, we report a case of an elderly patient who exhibited severe stomatitis accompanied by febrile neutropenia; this stomatitis was caused by misuse of MTX during treatment of RA. Elderly patients with chronic diseases are often treated with multiple medications; thus, they are at great risk for drug misuse, especially in cases of dementia. Therefore, dental practitioners should be mindful of the potential risk for drug misuse, as oral manifestations may provide an initial sign of drug misuse symptoms.
Section snippets
Case report
An 83-year-old female patient was referred to our hospital in 2016 with a chief complaint of oral mucosal pain, accompanied with extreme fatigue. The patient had experienced those symptoms for approximately 1 week prior to her first visit to our department; she had been treated with vidarabine ointment, steroid ointment, rebamipide and acetaminophen, as directed by her primary physician. However, those symptoms had worsened, so she was referred to our department. On initial assessment, she was
Discussion
The estimated prevalence of RA has been estimated at 1.0% of the Japanese population; a large portion (27%) of these RA patients are treated with MTX [3].
MTX inhibit the nucleic acid synthesis by inhibiting activation of folic acid, and is therefore effective for treatment of RA [4]; for this purpose, MTX is usually administered once per week, and the typical worldwide dose range is 7.5–25 mg/week [5].
Toxicity of MTX is reported to be dose-dependent; thus, it is more frequently observed when
Conflict of interests
The authors declare that they have no conflict of interests.
Funding
The authors received no funding for the writing of this manuscript.
Consent for publication
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Ethics approval and consent to participate
Because this report involves no experiment, ethics approval is waived.
Acknowledgements
The authors would like to thank the patient for giving consent.
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