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甲氨蝶呤在眼科的应用及安全性

Application and safety of methotrexate in ophthalmology

来源期刊: 眼科学报 | 2023年7月 第38卷 第7期 489-496 发布时间: 收稿时间:2023/9/6 16:08:44 阅读量:5888
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关键词:
甲氨蝶呤眼科应用不良反应
methotrexate ophthalmology application adverse reaction
DOI:
10.12419/2305190001
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甲氨蝶呤(Methotrexate,MTX)是一种叶酸类似物,具有抗增殖、抗炎和免疫调节作用。在临床上广泛用于治疗多种疾病,包括恶性肿瘤和自身免疫性疾病。MTX通过眼局部注射或者全身给药用于眼科疾病的治疗,其安全性和有效性均已被证实。其中玻璃体腔注射可以减少糖皮质激素及免疫抑制剂的全身使用,在眼科的应用越来越广泛。MTX在备孕期男性及女性、妊娠期妇女、哺乳期妇女、儿童、青少年及老年人等特殊患者人群中的应用有其特殊性,用药情况因患者而异。低剂量MTX常见不良反应包括胃肠道症状、肝功能异常等,比较少出现严重的不良反应,但仍应做好药学监护。该篇综述总结MTX的临床使用方法及其不良反应,为其在眼科的临床应用提供参考。
Methotrexate (MTX) is a folate analog with anti-proliferative, anti-inflammatory and immunomodulatory effects.It is widely used in clinical practice to treat various diseases, including malignant tumors and autoimmune diseases.MTX is used for treating eye diseases by local injection or whole-body administration. Its safety and efficacy have been confirmed. The intravitreal injection can reduce the whole-body use of glucocorticoids and immunosuppressive agents, so it is applied in ophthalmology increasingly. The specificity of MTX has been found in its application in special patients, such as men and women in pregnancy preparation period, pregnant women, lactating women, children, adolescents and the elderly. The dosage varies from patient to patient. Common adverse reactions to low-dose MTX include gastrointestinal symptoms, liver dysfunction, etc. Serious adverse reactions are relatively rare, but pharmaceutical monitoring is still necessarily needed. This review summaries the usage and adverse reactions of MTX in clinical practice, to provide reference for its application in clinical practice in ophthalmology.
甲氨蝶呤(Methotrexate,MTX)是叶酸的类似物,可阻断外来叶酸转变为四氢叶酸,而四氢叶酸是体内合成嘌呤核苷酸和嘧啶脱氧核苷酸的重要辅酶。MTX使嘌呤核苷酸和嘧啶核苷酸的合成代谢途径受阻,选择性作用于DNA合成期,具有抗增殖、抗炎和免疫调节作用[1-3]。MTX在19世纪40年代后期发展为恶性肿瘤的化学治疗剂之后,于1951年首次用于类风湿关节炎和牛皮癣的治疗[4]。在眼科,MTX也通过全身和(或)局部给药用于多种疾病的治疗。近年文章更加关注其新的临床应用、给药途径以及不良反应的监护。本文将对MTX在眼科的应用做一综述,为临床用药提供参考。

1 MTX在眼科的临床应用

1.1 在眼科疾病中的应用

MTX在治疗非感染性巩膜炎方面具有较好效果,是首选的免疫抑制剂[5-6],也是对局部药物疗效不佳的葡萄膜炎的一线治疗用药[7-8]。作为糖皮质激素(激素)减量治疗时的合并用药,MTX已被广泛用于治疗前、中、后或全葡萄膜炎、巩膜炎和眼黏膜类天疱疮[9],对前葡萄膜炎和巩膜炎的治疗成功率最高[10]。MTX也广泛用于儿童及青少年的葡萄膜炎治疗[11]。近期一项多中心、随机、对照观察性的临床研究也证实在成人非感染性葡萄膜炎中,作为与激素联合维持治疗的吗替麦考酚酯(MMF)与MTX,炎症控制效果类似。但是亚组分析发现,在后部和全葡萄膜炎中MTX的治疗效果比MMF更好[12]。一项关于使用维罗非尼(Vemurafenib)诱发葡萄膜炎的病例研究指出,玻璃体内注射MTX可能是靶向抗肿瘤药物引起的严重葡萄膜炎的有效治疗手段[13]
眼内淋巴瘤(intraocular lymphoma,IOL)是一种罕见的淋巴细胞恶性肿瘤,虽然发生率较低,但预后很差[14-15]。目前,以MTX为基础的全身化学治疗联合眼眶放射治疗,或玻璃体腔内化学治疗联合MTX,可有效控制疾病,疗效显著。这些疗法被广泛用于治疗IOL[16-18]
增殖性玻璃体视网膜病(proliferative vitreoretinopathy, PVR)发生在5%~10%的孔源性视网膜脱离(rhegmatogenous retinal detachment,RRD)病例中,是RRD治疗中手术失败的主要原因[19]。有研究指出,手术期间玻璃体腔内输注MTX可能对那些由于既往PVR史或眼内炎症而处于PVR发展高风险的眼睛有益[20]。近年来的研究已经证明了MTX是一种安全且潜在有效治疗和预防PVR的药物[21-22]
玻璃体内MTX用于复发性内皮植入,对于白内障手术后难治性的内皮植入用MTX治疗有效果[23]。通常,使用抗血管内皮生长因子(anti-vascular endothelial growth factor,anti-VEGF)治疗新生血管性年龄相关性黄斑变性(neovascular age-related macular degeneration,nAMD)可改善预后。但是,部分患者对抗VEGF治疗无效。有证据表明,MTX可以在不同水平上中断血管生成的级联反应[24]。对传统抗VEGF治疗无效的患者,玻璃体腔注射MTX可能会有更好的效果[25]

1.2 给药途径及剂量

1.2.1 全身应用
对于葡萄膜炎的治疗,MTX推荐剂量为每周15 mg /m2,最大剂量不超过每周25 mg/m2。若MTX对治疗葡萄膜炎有效,其在局部炎症控制后应再使用12个月。对某些有预后不良因素如初始视力低下、虹膜后粘连、带状角膜病变、青光眼、白内障和黄斑水肿等的患者,MTX的治疗至少应维持24个月[26]
系统性葡萄膜炎治疗,更推荐使用MTX皮下注射,而不是口服MTX[7]。在用法上,MTX可以每周口服或皮下注射1次,需要用到较高剂量(每周15 mg/m2)时,由于皮下注射生物利用度更高,故首选皮下注射途径[27]。对于有胃肠道症状的患者,皮下注射途径更有优势[28]
对MTX耐受性差,又希望避免注射的患者,可以将每周1次的口服剂量分成2次或3次,以实现更高的生物利用度及减少不良反应[29-30]。但是需要在24 h内服用完,分成多天服用的毒性更大,尤其是对骨髓和黏膜组织中快速分裂的细胞有毒性[31]
1.2.2 局部应用
玻璃体内注射MTX在眼科用于多种疾病,其安全性和有效性均已被证实[32]。玻璃体内注射MTX (400 μg/0.1 mL),联合或不联合全身化学治疗和放射治疗,可有效清除眼内肿瘤细胞,用于治疗原发性眼内淋巴瘤[32-35]。有研究证明眼内淋巴瘤治疗开始后约2个月,玻璃体腔内MTX耐受性良好,大多数患者出现局部疾病好转的反应[36]。玻璃体内MTX注射可以使部分原发性眼内淋巴瘤患者症状缓解。即使肿瘤生长迅速,并且MTX的起效速度较慢,但它仍可延缓眼部疾病的发展[33, 37]。一项研究予患者经过改良的玻璃体内注射MTX (400 μg/0.1 mL) 方案。强化期每周注射1次,持续1个月,巩固期每2周注射1次,持续1个月,然后是维持期,每月1次,持续1个月,共注射7次。结果证实改进的MTX玻璃体内注射方案是诱导原发性中枢神经系统淋巴瘤患者眼内受累临床缓解的有效方法,且并发症很少[38]。MTX通过眼内注射可以达到有效浓度,并且可以减少全身MTX相关的不良反应。因此,尤其是对于单侧的眼部疾病,眼内MTX注射值得尝试。
局部使用MTX对后部非感染性葡萄膜炎有效,尤其对于单侧葡萄膜炎和(或)葡萄膜炎性黄斑囊样水肿(cystoid macular edema,CME)都有作用[39]。Taylor及其同事先后通过2项研究表明,单侧非感染性中、后或全葡萄膜炎和(或)CME患者玻璃体内注射400 μg MTX可有效改善眼部炎症、视力和(或)减少CME,一些患者还可以减少全身免疫抑制药物用量[40-41]
玻璃体内注射MTX可以减少白塞病(Behcet's disease, BD)患者的眼部炎症,改善视敏度,减少与BD相关的眼后段症状,并减少激素和免疫抑制药物的应用[42]。在一项研究中,Khalil等[43]对比了玻璃体内注射MTX与球后注射曲安奈德(triamcinolone acetonide,TA)相比在控制BD患者眼后段受累方面的疗效。结果显示,两组患者前房反应和玻璃体炎症的改善情况相似。然而,接受玻璃体内注射400 μg MTX的患者复发较少。他们认为,与球后TA相比,玻璃体内MTX有更好的效果,可以更好地控制炎症反应。有一项病例研究显示,玻璃体腔注射MTX可减轻Vogt-小柳原田综合征(VKH综合征)患者眼部的炎症、疼痛和黄斑水肿[44]。上述临床研究表明,玻璃体内MTX可以帮助葡萄膜炎相关的眼后段受累患者改善症状,并且减少激素以及免疫抑制剂的全身使用。

2 MTX的安全性

2.1 常见的不良反应

在眼科治疗中,一般所需的MTX剂量较低。低剂量MTX的常见不良反应为胃肠道反应[45],例如恶心、胃部不适、腹泻、口腔炎或口腔溃疡、肝功能异常(通常是肝转氨酶轻度升高)、皮疹(通常发生在四肢,影响肘部和膝盖)、中枢神经系统症状(包括头痛、疲劳、不适或注意力不集中)、脱发、药物热、血液学异常(特别是巨噬细胞增多)。
玻璃体内注射MTX的常见不良反应是角膜上皮毒性。其他有报道的不良反应包括白内障、虹膜睫状体炎、玻璃体积血、视网膜脱离、黄斑病变和眼内炎[46-48]

2.2 潜在的较严重不良反应

虽然低剂量MTX比较少出现严重的不良反应。但也存在一定的发生概率[49]。低剂量MTX治疗的患者很少出现肾毒性、肝脂肪变性、纤维化和肝硬化[50]。高剂量和低剂量治疗均可见MTX的肺毒性,并可能表现为急性或慢性症状,在治疗的第一年更常见[51-52]。低剂量MTX是一种免疫调节剂,但不是明显的免疫抑制剂[1]。在绝大多数接受MTX治疗的患者中,不会增加机会性感染发生率,除非患者也接受大剂量激素、其他免疫抑制剂或生物制剂治疗。但是低剂量的MTX可能影响T淋巴细胞活性[53]。骨髓抑制在接受低剂量治疗的患者中很少见,有分析报告指出在服用低剂量MTX并补充叶酸的类风湿关节炎患者中,血细胞减少症是一种罕见不良反应,发生频率远低于之前的预期[54]。但也有研究指出类风湿关节炎患者使用低剂量MTX治疗时,平均红细胞体积持续升高可能与MTX引起血液毒性有关[55]。为了预防这些并发症,美国风湿病学会的指南建议在治疗的前3个月中,每4周进行1次常规外周全血细胞计数,此后在8~12周再进行1次,具体取决于监测期间发现的异常性质和(或)严重性[56]
2.3 低剂量MTX的药学监护低剂量MTX长期应用的安全性是良好的,但是仍应做好药学监护。使用甲氨蝶呤前应评估可能引发严重不良反应的危险因素。治疗开始时可每1.0~1.5个月监测血常规、肝功能、肾功能,用药剂量稳定后可逐渐延长监测时间至每3个月1次。肥胖、糖尿病、病毒性肝炎或酒精性肝病患者使用MTX有加重肝脏疾病的危险。肌酐清除率低于79 mL/min时,MTX骨髓抑制及肝毒性的发生率增加。因此对严重肝肾功能受损、酗酒或药物滥用、已有骨髓抑制、乙型肝炎病毒或丙型肝炎病毒感染活动期的患者,应避免使用MTX[57]
MTX的相关不良反应以胃肠道不适、转氨酶轻度升高和胃炎较常见,与剂量和使用频率相关,在减量或中止治疗后往往可逆。转氨酶升高常呈一过性,MTX相关的纤维化或肝硬化罕见。若谷丙转氨酶或谷草转氨酶水平持续高于正常上限3倍以上,则需停用MTX。推荐在MTX应用24 h后补充叶酸5 mg,在MTX剂量更大时,可考虑适当增加叶酸的剂量[57]

2.4 在特殊人群中的应用

研究表明,服用MTX治疗风湿性疾病的剂量(每周1次最多30 mg)并未降低男性的生育力[58-59]。受孕时父亲暴露于MTX似乎对妊娠结局没有不利影响。在一项113例孕妇的队列中,在受孕期间父亲曾接受低剂量MTX(每周1次,每次30 mg)的治疗,主要先天缺陷或自然流产的发生率均未增加,两组的分娩时胎龄和出生体重均相近[60-62]。但是,一项针对15万名孕妇和准父亲的队列研究,共有50例父亲在受孕前3个月服用了MTX,其中2例孩子出生时患有口面缺陷[63]。在另一项研究中,包括49例在怀孕时服用MTX治疗炎性关节炎的父亲,其后代中未发现先天性异常的风险增加[64]。国外的指南认为父亲可以使用低剂量的MTX[65-66]
MTX是脂溶性低分子药物,在妊娠期间很容易通过胎盘膜转移,影响胎儿[67],并且还需要更长的时间才能从胎儿组织中消除[68],这就使MTX具有致畸性和流产作用。孕期MTX暴露可引起多种先天性畸形,例如唇裂、脑积水、无脑、脑膜膨出、先天性管状长骨狭窄、面部特征异常(低位耳朵,棘皮症)和骨化延迟[69-70]。MTX广泛分布在母体组织中,并且在暴露后可以在肝脏中可持续存在达4个月。然而,在一项研究中,与一般人群相比,有136名受孕前(3个月以内)服用MTX妇女的胎儿先天性异常风险没有高于预期,而188名受孕后暴露的女性,胎儿先天性异常发生率升高[71]。有一项回顾分析,证明小头畸形、颅缝早闭、法洛四联症、肺动脉瓣闭锁、肢体减少缺陷和并指畸形这些先天性异常是胎儿MTX综合征的一部分[72]。因此仍然建议在怀孕前1~3个月停用MTX,在这段时间和整个怀孕期间应继续补充叶酸。
MTX以低浓度排泄到母乳中,数据表明,母乳喂养的婴儿接受的剂量不到母亲剂量1%[73]。虽然它以低浓度排泄到母乳中,但会在新生儿组织中蓄积[74]。所以指南建议在母乳喂养期间应避免MTX[75-76]
皮下注射MTX广泛用于治疗小儿风湿性疾病。一项前瞻性队列研究纳入了41例年龄4~17岁的风湿病患者每周接受皮下注射MTX(25 mg/mL)至少4周。研究结果表明,61%的参与者均曾出现至少一种不良反应,其中恶心(56%)和呕吐(34%)是报告的最常见症状。研究还表明皮下注射MTX与轻度疼痛相关,不良反应出现可能会放大感知疼痛的程度。药师在向患者或家庭成员提供有关MTX的用药咨询时需要注意这一点[77]。有一项研究是3例患有RRD并发PVR的患儿,在基础特应性皮炎和(或)葡萄膜炎的情况下接受了玻璃体视网膜手术和术中玻璃体内注射MTX(40 mg)的组合治疗,随后至少注射了1次 200 μg MTX 进入充满硅油的玻璃体腔。此外,患者还接受了全身性短期免疫抑制剂(每周口服或皮下注射 20 mg MTX,持续12周)和(或)激素。结果显示单次手术后所有眼均实现了视网膜复位并改善了视力,并一直保持到脱离硅油后的最终随访检查。没有观察到眼内或全身注射MTX的不良反应[78]
老年患者需要更加关注MTX在肝肾功能方面的影响。由于MTX主要经肾脏清除,80%~90%以原型随尿液排出。因此,肾脏排泄功能受损时使用MTX及其引起的药物暴露时间延长,会增加骨髓抑制和其他毒性的风险。使用MTX治疗时可能出现危及生命的肝毒性、肺损伤和骨髓抑制,而肾毒性一般是高剂量治疗时才会出现,低剂量治疗出现肾毒性的情况很罕见。但也有研究指出风湿性疾病患者长期(超过24个月)每周使用低剂量MTX(口服7.5 mg)时,患者的肾清除率和肌酐清除率均有下降[79]。所以建议老年患者要根据肾功能调整剂量,治疗期间要定期检测肾功能。低剂量MTX也很容易引起肝毒性,常见转氨酶轻度升高,偶尔会发生肝脂肪变、肝纤维化和肝硬化[80]。不过,采取合适的预防和监测策略可降低肝毒性风险。例如对患者要调查病史和筛查肝炎病毒等体检,以及补充叶酸、减少饮酒等措施。但仍需持续监测并在转氨酶升高时适当调整MTX剂量。

3 小结

MTX作为一种可替代激素的免疫抑制剂,在需要长期使用免疫抑制剂的几种自身免疫疾病中是首选的治疗方法[81]。低剂量MTX通过增加细胞内和细胞外腺苷的水平而具有抗炎和免疫调节特性[82],是最常用于治疗眼部炎症的免疫抑制剂。在眼科,MTX治疗一般选择口服、皮下注射或玻璃体腔注射的方式,其安全性和有效性均已被证实。MTX全身治疗的推荐给药方案是每周1次,起始剂量为7.5 mg,必要时每4~8周调整剂量到25~30 mg/周[83-84]。对于有胃肠道症状、生物利用度较差或剂量> 15 mg/m2的患者,更推荐使用皮下注射的方式。玻璃体腔内注射MTX的推荐剂量为400 μg/0.1 mL。这种方式可以减少激素及免疫抑制剂的全身使用,在眼科的应用越来越广泛。但是MTX在眼科的应用多属于超说明书用药,需要向患者做好用药知情说明以及做好用药监护。大量研究已证明MTX是耐受性良好、安全、有效的一线治疗药物。因此,临床医师无需因为MTX“抗癌药”的最初身份而过分担忧,应该在合适的情况下切实做到合理应用。相信关于MTX的适应证和给药途径将会逐步拓宽,造福更多患者。

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