Skip to main content

Advertisement

Molecular action of methotrexate in inflammatory diseases

Arthritis Research & Therapy volume 4, Article number: 266 (2002) Cite this article

Article metrics

Abstract

Despite the recent introduction of biological response modifiers and potent new small-molecule antirheumatic drugs, the efficacy of methotrexate is nearly unsurpassed in the treatment of inflammatory arthritis. Although methotrexate was first introduced as an antiproliferative agent that inhibits the synthesis of purines and pyrimidines for the therapy of malignancies, it is now clear that many of the anti-inflammatory effects of methotrexate are mediated by adenosine. This nucleoside, acting at one or more of its receptors, is a potent endogenous anti-inflammatory mediator. In confirmation of this mechanism of action, recent studies in both animals and patients suggest that adenosine-receptor antagonists, among which is caffeine, reverse or prevent the anti-inflammatory effects of methotrexate.

Introduction

The demonstration in 1985 that low-dose, intermittent methotrexate is a potent and effective therapy for rheumatoid arthritis (RA) [1] led to a dramatic change in the way that patients with RA are treated. Indeed, methotrexate is no less efficacious than specific anti-tumor-necrosis-factor (anti-TNF) therapy for the relief of symptomatic joint inflammation in early RA, and the difference between methotrexate and etanercept with respect to protection from structural injury in RA is probably not biologically significant [2]. Thus, methotrexate remains the cornerstone of therapy for RA, and understanding the mechanism(s) responsible for the therapeutic efficacy of this agent may lead to the development of new therapies.

History and clinical pharmacology

Methotrexate was first developed in the 1940s as a specific antagonist of folic acid. This drug inhibits the proliferation of malignant cells, primarily by inhibiting the de novo synthesis of purines and pyrimidines. Because administration of high doses of reduced folic acid (folinic acid) or even folic acid itself can reverse the antiproliferative effects of methotrexate, it is clear that methotrexate does act as an antifolate agent. Interestingly, although not originally designed as such, methotrexate appears to be a 'pro-drug', i.e. a compound that is converted to the active agent after uptake. Methotrexate is taken up by cells via the reduced folate carrier and then is converted within the cells to polyglutamates [3]. Methotrexate polyglutamates are long-lived metabolites that retain some of the antifolate activities of the parent compound, although the potency for inhibition of various folate-dependent enzymes is shifted [3–6].

Proposed mechanisms of action of methotrexate

Low-dose methotrexate was introduced for the treatment of RA because of its presumed antiproliferative properties, although it was unclear how inhibiting proliferation of the lymphocytes thought to be responsible for synovial inflammation in RA for one day a week might lead to effective suppression of disease activity. However, it soon became clear that inhibition of folic acid metabolism could not be completely responsible for the anti-inflammatory effect of methotrexate. During the past 15 years, it has become clear that administration of folic acid in doses of 1–5 mg per day helps to prevent much of the toxicity of methotrexate without interfering with the anti-inflammatory efficacy of the drug, whereas very high doses of folinic acid also prevent methotrexate toxicity but may interfere with its efficacy [7–20]. There are two potential explanations for the capacity of high doses of folinic acid to reverse the therapeutic effects: first, folinic acid may bypass the effects of methotrexate on reduction of folic acid and thereby bypass the therapeutic effects of the drug; alternatively, folinic acid but not folic acid may compete with methotrexate for a single transport site into the cell (Fig. 1) and may thus interfere with cellular uptake of methotrexate [21]. Moreover, the expected inhibition of cellular proliferation is manifested as bone marrow suppression, and oral and gastrointestinal ulcers, and may require lowering the dose of the drug and, usually, the efficacy of the therapy, suggesting that inhibition of cellular proliferation alone is not responsible for the anti-inflammatory effects of methotrexate. Thus, folate antagonism appears to play, at most, a minimal role in the anti-inflammatory mechanism of methotrexate.

Figure 1
figure1

Methotrexate-induced metabolic changes lead to increased extra-cellular adenosine. ADA = adenosine deaminase; AICAR = aminoimidazolecarboxamidoribonucleotide; AICAside = aminoimidazolecarboxamidoribonucleoside; AK = adenosine kinase; AMPDA = AMP deaminase; DHF = dihydrofolate; DHFglu = dihydrofolate polyglutamate; ecto-5'NT = ecto-5'nucleotidase; FAICAR = formyl-AICAR; IMP = inosine monophosphate; MTX = methotrexate; MTXglu = methotrexate polyglutamate; RFC1 = reduced folate carrier 1.

Full size image

Another potential mechanism by which methotrexate may diminish inflammation in the joint is by diminishing cytokine production. Numerous studies have demonstrated diminished levels of inflammatory cytokines in the serum of patients. The adenosine A2A receptor agonist CGS-21680 is a potent inhibitor of neutrophil leukotriene synthesis in vitro, and, similarly, methotrexate therapy leads to diminished production of leukotriene B4 by neutrophils stimulated ex vivo[22, 23]. The mechanism by which methotrexate diminishes these cytokine levels remains unexplained and it is difficult to determine from these studies whether the effects of methotrexate therapy on production of inflammatory mediators results in diminished inflammation or is secondary to other anti-inflammatory events.

Similarly, methotrexate-mediated effects on T-cell function, either in vivo or in vitro, have been demonstrated. Indeed, Genestier and colleagues have reported that methotrexate diminishes antigen-stimulated T-cell proliferation both in vitro and in T cells taken from patients taking methotrexate [24]. That the effects of methotrexate on T-cell function are completely reversed by folic acid and that the effects of therapy on T cells studied ex vivo are present for only 48 hours a week would strongly suggest that this cannot be responsible for the bulk of the anti-inflammatory effects of the drug.

A third proposed mechanism of action is based upon the observation that polyamines accumulate in the synovium of patients with RA and that metabolism of these polyamines by macrophages leads to the production of toxic oxygen products that diminish stimulated T-cell function [25–27]. Indeed, methotrexate therapy does diminish polyamine levels in the joints of patients with RA [28–30], but this effect, like that of methotrexate on T-cell proliferation, is reversed by folic acid. Moreover, there are more than enough toxic oxygen metabolites being generated in the rheumatoid synovium to mediate the tissue damage present in this disease; another source of toxic agents would add relatively little.

Methotrexate induces adenosine release

Our laboratory originally proposed the hypothesis that the beneficial effects of methotrexate result from the intracellular accumulation of intermediates in purine biosynthesis that, by a mechanism that has not been completely worked out, leads to increased concentrations of adenosine in the extracellular space [31]. This hypothesis sprang from the prior demonstration that intracellular accumulation of specific intermediates in the de novo synthesis of purines leads to adenosine release [32] and from our interest in the anti-inflammatory effects of adenosine, which are mediated by specific receptors on inflammatory cells. Prior work had demonstrated that methotrexate polyglutamates inhibit the enzyme aminoimidazolecarboxamidoadenosineribonucleotide (AICAR) transformylase more potently than the other enzymes involved in purine biosynthesis [4, 5, 33]. This inhibition occurred at pharmacologically relevant concentrations of methotrexate and might be expected to occur more readily with infrequent loading with methotrexate, since methotrexate polyglutamates are long-lived metabolites (persisting for weeks). The presence of increased concentrations of AICAR metabolites in the urine of RA patients treated with methotrexate supports these findings [34, 35]. The accumulation of AICAR and its metabolites has a direct inhibitory effect on at least two key enzymes, adenosine deaminase and AMP deaminase, with the end result of increased concentrations of adenosine and adenine nucleotides intracellularly [4]. Methotrexate in doses similar to that used in the treatment of RA has been known to cause the accumulation of AICAR in animal models of RA, and this accumulation is associated with an elevation in adenosine concentration in the extracellular space [32, 36]. The exact mechanisms by which the elevation of extracellular adenosine arises are not fully understood, but dephosphorylation of adenine nucleotides is likely to be a major contributor, partly because of the ubiquitous nature of ATP in tissues and partly because of the widespread existence of ecto-5'-nucleotidase, an enzyme that catalyzes the dephosphorylation of AMP to adenosine [37].

All this evidence points to adenosine as a key mediator in the anti-inflammatory actions of methotrexate. In vivo experiments support this contention. The nonselective adenosine receptor antagonist 8-phenyl theophylline potentiated inflammatory responses in a hamster-cheek-pouch model [38]. Infusion of adenosine directly into the knee in rats inhibited the development of adjuvant-induced arthritis, and an adenosine receptor antagonist effectively reduced the severity of joint inflammation in a collagen-induced arthritis model in mice [39, 40]. We have previously shown that the anti-inflammatory effects of methotrexate in carrageenan induced mouse air pouch inflammation is reversed by an antagonist to the adenosine A2A receptor, or by the addition of adenosine deaminase, an adenosine-metabolizing enzyme, suggesting that adenosine is indeed responsible for the anti-inflammatory effects of methotrexate in vivo[36]. An interesting study by Silke et al. showed that ingestion of caffeine, a nonselective antagonist of adenosine receptors, in coffee correlates with poor clinical response to methotrexate, and patients with a high caffeine intake are more likely to discontinue methotrexate than those with a low caffeine intake [41].

To better appreciate how adenosine influences biological responses in the network of events taking place in an inflammatory milieu, something must be said about this autocoid and the cellular receptors with which it interacts to produce these physiological responses. Adenosine receptors, or P1 receptors, fall into four known subclasses: A1, A2A, A2B, and A3. These are members of the large, seven-transmembrane-receptor family of receptors that influence cell signaling mechanisms by coupling to G proteins. The receptor sequences have been characterized and, with the exception of the A3 receptor, they are highly conserved during evolution. Adenosine receptors modulate a vast array of physiological functions, from heart rate to the state of wakefulness. Adenosine, acting on P1 receptors, exerts a number of actions on a variety of cell types relevant to the anti-inflammatory effect of methotrexate.

Cellular effects

Neutrophils

Neutrophils, a hallmark of acute inflammation, are among the first cells recruited into the inflammatory site. The limitation of neutrophilic-mediated damage relies in part on the modification of the adhesive capacity and ability to generate chemical damage, properties under purinergic influence. The resting neutrophil has a number of mechanisms that, once activated, can damage tissues. One of these is latent nicotinamide adenine dinucleotide phosphate (NADPH) oxidase, a multimolecular complex that is assembled at the plasma membrane upon activation of the neutrophil and that generates oxygen radicals [42]. The first in the chain of these oxygen radicals is superoxide anion, and it was the discovery in 1983 that superoxide generation, as stimulated by a variety of agents including the chemoattractant N-formyl-leucyl-phenylalanine (f MLP), the complement component C5a, and the calcium ionophore A23187, was inhibited by adenosine that sparked an interest in the anti-inflammatory properties of adenosine [43, 44]. This physiological action of adenosine has subsequently been ascribed to its action on the adenosine A2A receptor, which is present on the neutrophilic surface membrane [45]. An important second messenger to adenosine-A2A-receptor signaling in this respect appears to be 3',5'-cyclic adenosine monophosphate (cAMP), the intracellular concentration of which increases with neutrophilic adenosine A2A receptor stimulation. cAMP further activates protein kinase A downstream and inhibition of protein kinase A reverses the effects of cAMP analogues but not of adenosine receptor agonists on stimulated neutrophilic superoxide anion generation [46]. The cAMP-protein-kinase-A-dependent adenosine inhibition of neutrophil oxidative activity is mediated via the adenosine A2A receptor [47]. One direct consequence of the interruption of superoxide anion formation and respiratory burst reactions is the protection of vascular endothelial cells from neutrophil-mediated injury [48].

The adenosine-A2A-receptor-mediated effects on neutrophil function are dose-related. At concentrations similar to those required to inhibit the release of superoxide anions, adenosine, acting through A2A receptors, inhibits adherence to endothelial cells by stimulated neutrophils [49]. This may be related in part to dose-related preferential recruitment of receptor subtype, since the adenosine A1 receptor exhibits many opposing physiological functions to those mediated by the A2A receptor, including stimulation of neutrophil adherence to endothelial cells. Adenosine also inhibits the release of vascular endothelial growth factor from neutrophils, thereby enhancing vascular permeability [50]. The dose-dependent response in adenosine action is also seen with Fc-gamma-receptor-mediated neutrophil phagocytosis, which is enhanced by A1 receptor stimulation but inhibited via A2 receptors [51]. In addition, adenosine also inhibits the TNF-induced generation of elastase by neutrophils [52].

Expression of adhesive molecules is an important event that guides neutrophil recruitment into an inflammatory site through adhesion to the vascular endothelium. Adenosine has been known to be a modulator of the expression or function of adhesive molecules including β2-integrin, L-selectin, and CD11b/CD18 [49, 53, 54]. The activity of adenosine in the modulation of neutrophil adhesion again demonstrates the opposing roles of A1 and A2 receptors [49].

Macrophages

Cells of the monocyte-macrophage series are abundant in the rheumatoid synovium and pannus and contribute significantly to the tissue damage seen in both acute and chronic disease, as recently reviewed by Kinne and colleagues [55]. Macrophages, the differentiated tissue form, are also critical producers of cytokines that play a prominent role in promoting proinflammatory responses that culminate in tissue damage. Like neutrophils, their capacity to phagocytose opsonized particles and to generate super-oxide anions plays a major role in eliciting tissue damage. Inhibition of Fc-gamma-receptor phagocytic activity in cultured monocytes is exhibited by adenosine at high concentrations such as that seen with tissue damage and is a function mediated via adenosine A2 receptors, while low concentrations of adenosine have the opposite effect on Fc-gamma-receptor phagocytic activity mediated via adenosine A1 receptors [56]. Similarly, adenosine inhibits the generation of superoxide anions by monocytes stimulated with N-formyl-leucyl phenylalanine [57].

One of the well known though uncommon side effects of methotrexate treatment is the formation of subcutaneous nodules, often similar in histological appearance though not in distribution to those found in rheumatoid disease. A hallmark of these subcutaneous nodules is the existence of the multinucleated giant cell, formed by fusion of macrophages. The fusion of macrophages into multinucleated giant cells is enhanced by stimulation of the adenosine A1 receptor and is inhibited by activation of the A2 receptor [58, 59].

The recent success of anti-TNF therapy highlights the role of cytokines as important mediators of inflammatory activity. Not surprisingly, methotrexate, still one of the most effective disease-modifying antirheumatic drugs for the treatment of RA, acting through the release of adenosine, also inhibits the production of TNF-α, although the adenosine receptor involved in this action remains controversial [60–63]. Modulation of cytokine production by adenosine extends far beyond TNF-α and includes observable effects on IL-6, IL-8, IL-10, IL-12, and macrophage inflammatory protein-1α (MIP-1α) [40, 64, 65]. Cytokines themselves can regulate the expression of adenosine receptors on monocytic cells and thereby modulate adenosine-mediated responses, as we and others have recently shown [66, 67]. Macrophage production of nitric oxide and nitric oxide synthase is also inhibited by adenosine, probably via A2B receptors [65, 67].

Endothelial cells

Endothelial cells are effective transit barriers between vessels and tissue and as such are notable in inflammation not only because of their expression of adhesive molecules, which allow leukocytes their access to inflammatory sites. The effectiveness of this barrier function relies in part on the preservation of impermeability to circulating cells homing in to take part in inflammatory reactions in the tissues. Adenosine enhances this barrier function by decreasing enthothelial permeability via A2B receptor and helps limit potential tissue damage [68, 69]. Production of inflammatory cytokines such as IL-6 and IL-8 and expression of adhesive molecules such as intercellular adhesion molecule-1 (ICAM-1) and E-selectin by endothelial cells are also suppressed by adenosine [70]. Another important aspect of inflammation lies in the proliferation and migration of endothelial cells in the process of angiogenesis, which is enhanced by the presence of adenosine, probably acting through A2 receptors [71–73]. Adenosine may also induce apoptosis of endothelial cells, thus potentially enhancing the extravasation of inflammatory fluids [74].

Humoral and cellular immune responses

Rheumatoid factor, or autoantibodies directed against the Fc portion of IgG, is a hallmark of RA, although its exact role in the pathogenesis of the disease has been debated. The effect of methotrexate on the levels of circulating IgM rheumatoid factors has also been controversial. While some workers have reported no suppression of serum rheumatoid factor levels with methotrexate treatment, Alarcon et al. observed significant drops in the levels of both IgM and IgA rheumatoid factors in methotrexate-treated patients, and particularly of the concentration of IgM rheumatoid factor in those who showed clinical improvement [75]. These findings were confirmed by other groups in studies done both in vivo and ex vivo[76–80], although it is unclear whether this is a primary or secondary effect of adenosine.

T lymphocytes have received much attention in relation to the pathogenesis of RA and opinions differ in their contribution to the causation of the disease. The presence of these cells in the affected synovium and the strong ethnicity-dependent HLA-DR associations implicate T lymphocytes as key players in the disease process. One possible explanation of the beneficial actions of methotrexate in RA is the diminution of both the size and reactivity of the T-lymphocyte population. There are suggestions that this may be accomplished by the induction of apoptosis in activated T cells [24]. This suggestion is consistent with the observations of reductions in peripheral blood T and B lymphocyte populations after short-term methotrexate treatment [81], and methotrexate induction of apoptosis in inflammatory cells may be relevant to its antirheumatic actions in vivo[82]. In contrast, significant increases in the CD3- and CD4-positive peripheral blood cells and enhancement of stimulated lymphocyte proliferation have been observed after long-term treatment with methotrexate [83], and adenosine, acting through and A2A A2B receptors, may play a role in T-cell deactivation [84, 85]. Nonetheless, the role of these shifts in T-cell function and trafficking in the pathogenesis of RA is unclear.

Phlogistic responses

Cytokines are messengers with major roles in inflammatory and immune responses and have been targets of interest in recent therapeutic developments in chronic arthritis, with TNF-α and IL-1 as the focus of interest [86]. In animal models of chronic arthritis, methotrexate was thought to be useful in reducing the production of IL-1 [87, 88]. In support of these findings, clinical studies of RA patients receiving methotrexate treatment have documented reductions in monocytic IL-1 production but not serum concentrations of IL-1 [89]. Others have disputed this view and suggested that alterations in IL-1 responses were related to diminutions in the ability of cells to respond to IL-1 rather than to direct inhibition of its production, perhaps through dose-dependent ligand binding [90–92].

Methotrexate is also known to suppress TNF activity by suppressing TNF-induced nuclear factor-κB activation in vitro, in part related to a reduction in the degradation and inactivation of an inhibitor of this factor, IκBα, and probably related to the release of adenosine [93]. The generation of TNF-α by peripheral blood mononuclear cells is suppressed by an adenosine kinase inhibitor, by virtue of its ability to limit adenosine uptake and metabolism and thereby enhance extracellular adenosine concentration [94]. TNF-α synthesis in T cells and macrophages is suppressed [95]. In the murine collagen-induced arthritis model, in vivo intraperitoneal methotrexate treatment reduced TNF serum levels and diminished TNF production by splenic T cells and macrophages [96]. Methotrexate suppresses the production of both TNF and IFN-γ by T-cell-receptor-primed T lymphocytes from both healthy human donors and RA patients [97]. In early RA, in which the disease duration is less than 6 months, methotrexate treatment is associated with a significant decrease of TNF-α-positive CD4+ T cells, while the number of T cells expressing the anti-inflammatory cytokine IL-10 increased [98]. Methotrexate is also known to suppress the IL-6-induced generation of reactive oxygen species in the synoviocytes of RA patients [99]. Serum IL-6 levels have also declined after methotrexate treatment in RA patients in some studies [100]. Constantin et al. reported that ex vivo treatment of peripheral blood monocytes with methotrexate increased expression of IL-4 and IL-10 while IL-2 and interferon-γ expression were decreased, suggesting that the immunoregulatory role of methotrexate is also targeted at adjusting the balance between Th1 proinflammatory and Th2 anti-inflammatory cytokines [101]. Again, the molecular mechanism of these changes is unclear.

Conclusion

Our search for mechanisms governing the inflammatory response has uncovered many facets relevant to the pathogenesis of arthitic diseases. The success of methotrexate as an antirheumatic agent rests on its many actions that affect a wide variety of pathogenic mechanisms, many of which are mediated by the release of adenosine. The molecular mechanism for many of these phenomena is related to the enhanced release of adenosine into the extracellular space, where it can activate its receptors on relevant cell types. In this respect, methotrexate is an excellent example of how knowledge and continuing research in molecular biology and pharmacology can be employed in the refinement of existing medications originally used on an observational basis. Such understanding will form the basis for the development of new and more effective therapy for the treatment of rheumatic diseases.

Abbreviations

AICAR:

= aminoimidazolecarboxamidoribonucleotide

Fc:

= crystallizable fragment (of antibody)

IFN:

= interferon

IL:

= interleukin

RA:

= rheumatoid arthritis

Th:

= T helper (cells)

TNF:

= tumor necrosis factor.

References

  1. 1.

    Weinblatt ME, Coblyn JS, Fox DA, Fraser PA, Holdsworth DE, Glass DN, Trentham DE: Efficacy of low-dose methotrexate in rheumatoid arthritis. N Engl J Med. 1985, 312: 818-822.

  2. 2.

    Bathon JM, Martin RW, Fleischmann RM, Tesser JR, Schiff MH, Keystone EC, Genovese MC, Wasko MC, Moreland LW, Weaver AL, Markenson J, Finck BK: A comparison of etanercept and methotrexate in patients with early rheumatoid arthritis. N Engl J Med. 2000, 343: 1586-1593. 10.1056/NEJM200011303432201.

  3. 3.

    Chabner BA, Allegra CJ, Curt GA, Clendeninn NJ, Baram J, Koizumi S, Drake JC, Jolivet J: Polyglutamation of methotrexate. Is methotrexate a prodrug?. J Clin Invest. 1985, 76: 907-912.

  4. 4.

    Baggott JE, Vaughn WH, Hudson BB: Inhibition of 5-aminoimidazole-4-carboxamide ribotide transformylase, adenosine deaminase and 5-adenylate deaminase by polyglutamates of methotrexate and oxidized folates and by 5-aminoimidazole-4-carboxamide riboside and ribotide. Biochem J. 1986, 236: 193-200.

  5. 5.

    Allegra CJ, Drake JC, Jolivet J, Chabner BA: Inhibition of phosphoribosylaminoimidazolecarboxamide transformylase by methotrexate and dihydrofolic acid polyglutamates. Proc Natl Acad Sci U S A. 1985, 82: 4881-4885.

  6. 6.

    Chabner BA, Myers CE: Clinical Pharmacology of Cancer Chemotherapy. In Cancer: Principles and Practice of Oncology. Edited by: DeVita VT, Hellman S, Rosenberg SA. 1989, Philadelphia: JB Lippincott, 349-395.

  7. 7.

    Ortiz Z, Shea B, Suarez-Almazor M, Moher D, Wells G, Tugwell P: Folic acid and folinic acid for reducing side effects in patients receiving methotrexate for rheumatoid arthritis. Cochrane Database Syst Rev 2. 2000

  8. 8.

    Suarez-Almazor ME, Belseck E, Shea B, Wells G, Tugwell P: Methotrexate for rheumatoid arthritis. Cochrane Database Syst Rev 2. 2000

  9. 9.

    Ravelli A, Migliavacca D, Viola S, Ruperto N, Pistorio A, Martini A: Efficacy of folinic acid in reducing methotrexate toxicity in juvenile idiopathic arthritis. Clin Exp Rheumatol. 1999, 17: 625-627.

  10. 10.

    Pincus T: Folic and folinic acid supplementation reduces methotrexate gastrointestinal side effects in rheumatoid arthritis. Clin Exp Rheumatol. 1998, 16: 667-668.

  11. 11.

    Morgan SL, Baggott JE, Lee JY, Alarcon GS: Folic acid supplementation prevents deficient blood folate levels and hyperhomocysteinemia during longterm, low dose methotrexate therapy for rheumatoid arthritis: implications for cardiovascular disease prevention. J Rheumatol. 1998, 25: 441-446.

  12. 12.

    Ortiz Z, Shea B, Suarez-Almazor ME, Moher D, Wells GA, Tugwell P: The efficacy of folic acid and folinic acid in reducing methotrexate gastrointestinal toxicity in rheumatoid arthritis. A metaanalysis of randomized controlled trials. J Rheumatol. 1998, 25: 36-43.

  13. 13.

    Hunt PG, Rose CD, McIlvain-Simpson G, Tejani S: The effects of daily intake of folic acid on the efficacy of methotrexate therapy in children with juvenile rheumatoid arthritis. A controlled study. J Rheumatol. 1997, 24: 2230-2232.

  14. 14.

    Shiroky JB: The use of folates concomitantly with low-dose pulse methotrexate. Rheum Dis Clin North Am. 1997, 23: 969-980.

  15. 15.

    Shiroky JB: Ann Intern Med. 1996, 124: 73-74.

  16. 16.

    Kavanaugh A, Kavanaugh D: Folic acid and methotrexate in rheumatoid arthritis. Ann Intern Med. 1996, 124: 73-74.

  17. 17.

    Cooper BA: Folic acid and methotrexate in rheumatoid arthritis. Ann Intern Med. 1996, 124: 73-74.

  18. 18.

    Dijkmans BA: Folate supplementation and methotrexate. Br J Rheumatol. 1995, 34: 1172-1174.

  19. 19.

    van Ede AE, Laan RF, Rood MJ, Huizinga TW, van de Laar MA, van Denderen CJ, Westgeest TA, Romme TC, de Rooij DJ, Jacobs MJ, X de Boo TM, van der Wilt GJ, Severens JL, Hartman M, Krabbe PF, Dijkmans BA, Breedveld FC, van de Putte LB: Effect of folic or folinic acid supplementation on the toxicity and efficacy of methotrexate in rheumatoid arthritis: a fortyeight week, multicenter, randomized, double-blind, placebocontrolled study. Arthritis Rheum. 2001, 44: 1515-1524. 10.1002/1529-0131(200107)44:7<1515::AID-ART273>3.0.CO;2-7.

  20. 20.

    Endresen GK, Husby G: Folate supplementation during methotrexate treatment of patients with rheumatoid arthritis. An update and proposals for guidelines. Scand J Rheumatol. 2001, 30: 129-134. 10.1080/030097401300162888.

  21. 21.

    Matherly LH, Czajkowski CA, Angeles SM: Identification of a highly glycosylated methotrexate membrane carrier in K562 human erythroleukemia cells up-regulated for tetrahydrofolate cofactor and methotrexate transport. Cancer Res. 1991, 51: 3420-3426.

  22. 22.

    Sperling RL, Benincaso AI, Anderson RJ, Coblyn JS, Austen KF, Weinblatt ME: Acute and chronic suppression of leukotriene B4 synthesis ex vivo in neutrophils from patients with rheumatoid arthritis beginning treatment with methotrexate. Arthritis Rheum. 1992, 35: 376-384.

  23. 23.

    Surette ME, Krump E, Picard S, Borgeat P: Activation of leukotriene synthesis in human neutrophils by exogenous arachidonic acid: inhibition by adenosine A[2a] receptor agonists and crucial role of autocrine activation by leukotriene B[4]. Mol Pharmacol. 1999, 56: 1055-1062.

  24. 24.

    Genestier L, Paillot R, Fournel S, Ferraro C, Miossec P, Revillard JP: Immunosuppressive properties of methotrexate: apoptosis and clonal deletion of activated peripheral T cells. J Clin Invest. 1998, 102: 322-328.

  25. 25.

    Flescher E, Bowlin TL, Ballester A, Houk R, Talal N: Increased polyamines may downregulate interleukin 2 production in rheumatoid arthritis. J Clin Invest. 1989, 83: 1356-1362.

  26. 26.

    Flescher E, Bowlin TL, Talal N: Regulation of IL-2 production by mononuclear cells from rheumatoid arthritis synovial fluids. Clin Exp Immunol. 1992, 87: 435-437.

  27. 27.

    Yukioka K, Wakitani S, Yukioka M, Furumitsu Y, Shichikawa K, Ochi T, Goto H, Matsui-Yuasa I, Otani S, Nishizawa Y: Polyamine levels in synovial tissues and synovial fluids of patients with rheumatoid arthritis. J Rheumatol. 1992, 19: 689-692.

  28. 28.

    Furumitsu Y, Yukioka K, Kojima A, Yukioka M, Shichikawa K, Ochi T, Matsui-Yuasa I, Otani S, Nishizawa Y, Morii H: Levels of urinary polyamines in patients with rheumatoid arthritis. J Rheumatol. 1993, 20: 1661-1665.

  29. 29.

    Nesher G, Osborn TG, Moore TL: In vitro effects of methotrexate on polyamine levels in lymphocytes from rheumatoid arthritis patients. Clin Exp Rheumatol. 1996, 14: 395-399.

  30. 30.

    Nesher G, Moore TL: The in vitro effects of methotrexate on peripheral blood mononuclear cells. Modulation by methyl donors and spermidine. Arthritis Rheum. 1990, 33: 954-959.

  31. 31.

    Cronstein BN, Eberle MA, Gruber HE, Levin RI: Methotrexate inhibits neutrophil function by stimulating adenosine release from connective tissue cells. Proc Natl Acad Sci U S A. 1991, 88: 2441-2445.

  32. 32.

    Gruber HE, Hoffer ME, McAllister DR, Laikind PK, Lane TA, Schmid-Schoenbein GW, Engler RL: Increased adenosine concentration in blood from ischemic myocardium by AICA riboside: effects on flow, granulocytes and injury. Circulation. 1989, 80: 1400-1411.

  33. 33.

    Allegra CJ, Hoang K, Yeh GC, Drake JC, Baram J: Evidence for direct inhibition of de novo purine synthesis in human MCF-7 breast cells as a principal mode of metabolic inhibition by methotrexate. J Biol Chem. 1987, 262: 13520-13526.

  34. 34.

    Baggott JE, Morgan SL, Koopman WJ: The effect of methotrexate and 7-hydroxymethotrexate on rat adjuvant arthritis and on urinary aminoimidazole carboxamide excretion. Arthritis Rheum. 1998, 41: 1407-1410. 10.1002/1529-0131(199808)41:8<1407::AID-ART9>3.0.CO;2-H.

  35. 35.

    Luhby AL, Cooperman JH: Aminoimidazole carboxamide excretion in vitamin B12 and folic acid deficiencies. Lancet. 1962, 2: 1381-1382.

  36. 36.

    Cronstein BN, Naime D, Ostad E: The antiinflammatory mechanism of methotrexate: increased adenosine release at inflamed sites diminishes leukocyte accumulation in an in vivo model of inflammation. J Clin Invest. 1993, 92: 2675-2682.

  37. 37.

    Morabito L, Montesinos MC, Schreibman DM, Balter L, Thompson LF, Resta R, Carlin G, Huie MA, Cronstein BN: Methotrexate and sulfasalazine promote adenosine release by a mechanism that requires ecto-5'-nucleotidase-mediated conversion of adenine nucleotides. J Clin Invest. 1998, 101: 295-300.

  38. 38.

    Rosengren S, Arfors KE, Proctor KG: Potentiation of leukotriene B4-mediated inflammatory response by the adenosine antagonist, 8-phenyl theophylline. Int J Microcirc: Clin Exp. 1991, 10: 345-357.

  39. 39.

    Green PG, Basbaum AI, Helms C, Levine JD: Purinergic regulation of bradykinin-induced plasma extravasation and adjuvant-induced arthritis in the rat. Proc Natl Acad Sci U S A. 1991, 88: 4162-4165.

  40. 40.

    Szabo C, Scott GS, Virag L, Egnaczyk G, Salzman AL, Shanley TP, Hasko G: Suppression of macrophage inflammatory protein [MIP]-1 alpha production and collagen-induced arthritis by adenosine receptor agonists. Br J Pharmacol. 1998, 125: 379-387.

  41. 41.

    Silke C, Murphy MS, Buckley T, Busteed S, Molloy MG, Phelan M: The effects of caffeine ingestion on the efficacy of methotrexate. Rheumatology [Oxford]. 2001, 40 (suppl1): S34-

  42. 42.

    Halliwell B, Hoult JR, Blake DR: Oxidants, inflammation, and anti-inflammatory drugs. FASEB J. 1988, 2: 2867-2873.

  43. 43.

    Cronstein BN, Kramer SB, Weissmann G, Hirschhorn R: Adenosine: a physiological modulator of superoxide anion generation by human neutrophils. J Exp Med. 1983, 158: 1160-1177.

  44. 44.

    Cronstein BN, Kramer SB, Weissmann G, Hirschhorn R: A new physiological function for adenosine: regulation of superoxide anion production. Trans Assoc Am Physicians. 1983, 96: 384-391.

  45. 45.

    Cronstein BN, Rosenstein ED, Kramer SB, Weissmann G, Hirschhorn R: Adenosine; a physiologic modulator of superoxide anion generation by human neutrophils. Adenosine acts via an A2 receptor on human neutrophils. J Immunol. 1985, 135: 1366-1371.

  46. 46.

    Cronstein BN, Haines KA, Kolasinski SL, Reibman J: Occupancy of G alpha s-linked receptors uncouples chemoattractant receptors from their stimulus-transduction mechanisms in the neutrophil. Blood. 1992, 80: 1052-1057.

  47. 47.

    Sullivan GW, Rieger JM, Scheld WM, Macdonald TL, Linden J: Cyclic AMP-dependent inhibition of human neutrophil oxidative activity by substituted 2-propynylcyclohexyl adenosine A[2A] receptor agonists. Br J Pharmacol. 1992, 132: 1017-1026.

  48. 48.

    Cronstein BN, Levin RI, Belanoff J, Weissmann G, Hirschhorn R: Adenosine: an endogenous inhibitor of neutrophil-mediated injury to endothelial cells. J Clin Invest. 1986, 78: 760-770.

  49. 49.

    Cronstein BN, Levin RI, Philips MR, Hirschhorn R, Abramson SB, Weissmann G: Neutrophil adherence to endothelium is enhanced via adenosine A1 receptors and inhibited via adenosine A2 receptors. J Immunol. 1992, 148: 2201-2206.

  50. 50.

    Wakai A, Wang JH, Winter DC, Street JT, O'Sullivan RG, Redmond HP: Adenosine inhibits neutrophil vascular endothelial growth factor release and transendothelial migration via A2B receptor activation. Shock. 2001, 15: 297-301.

  51. 51.

    Salmon JE, Cronstein BN: Fcgamma receptor-mediated functions in neutrophils are modulated by adenosine receptor occupancy: A1 receptors are stimulatory and A2 receptors are inhibitory. J Immunol. 1990, 145: 2235-2240.

  52. 52.

    Ottonello L, Amelotti M, Barbera P, Dapino P, Mancini M, Tortolina G, Dallegri F: Chemoattractant-induced release of elastase by tumor necrosis factor- primed human neutrophils: auto-regulation by endogenous adenosine. Inflamm Res. 1999, 48: 637-642. 10.1007/s000110050515.

  53. 53.

    Firestein GS, Bullough DA, Erion MD, Jimenez R, Ramirez-Wein-house M, Barankiewicz J, Smith CW, Gruber E, Mullane KM: Inhibition of neutrophil adhesion by adenosine and an adenosine kinase inhibitor: the role of selectins. J Immunol. 1995, 154: 326-334.

  54. 54.

    Wollner A, Wollner S, Smith JB: Acting via A2 receptors, adenosine inhibits the upregulation of Mac-1 [CD11b/CD18] expression on FMLP-stimulated neutrophils. Am J Resp Cell Mol Biol. 1993, 9: 179-185.

  55. 55.

    Kinne RW, Brauer R, Stuhlmuller B, Palombo-Kinne E, Burmester GR: Macrophages in rheumatoid arthritis. Arthritis Res. 2000, 2: 189-202. 10.1186/ar86.

  56. 56.

    Salmon JE, Brogle N, Brownlie C, Edberg JC, Kimberly RP, Chen BX, Erlanger BF: Human mononuclear phagocytes express adenosine A1 receptors. A novel mechanism for differential regulation of Fc gamma receptor function. J Immunol. 1993, 151: 2775-2785.

  57. 57.

    Leonard EJ, Shenai A, Skeel A: Dynamics of chemotactic peptide-induced superoxide generation by human monocytes. Inflammation. 1987, 11: 229-240.

  58. 58.

    Merrill JT, Shen C, Schreibman D, Coffey D, Zakharenko O, Fisher R, Lahita J, Salmon RG, Cronstein BN: Adenosine A1 receptor promotion of multinucleated giant cell formation by human monocytes: a mechanism for methotrexate-induced nodulosis in rheumatoid arthritis. Arthritis Rheum. 1997, 40: 1308-1315.

  59. 59.

    Merrill TJ, Shen C, Schreibman D, Coffey D, Zakharenko O, Fisher R, Lahita RG, Salmon J, Cronstein BN: Adenosine A1 receptor promotion of multinucleated giant cell formation by human monocytes, a mechanism for methotrexate-induced nodulosis in rheumatoid arthritis. Arthritis Rheum. 1995, 38 (Suppl): S157-

  60. 60.

    Eigler A, Greten TF, Sinha B, Haslberger C, Sullivan GW, Endres S: Endogenous adenosine curtails lipopolysaccharide-stimulated tumour necrosis factor synthesis. Scand J Immunol. 1997, 45: 132-139. 10.1046/j.1365-3083.1997.d01-377.x.

  61. 61.

    Prabhakar U, Brooks DP, Lipshlitz D, Esser KM: Inhibition of LPS-induced TNF alpha production in human monocytes by adenosine [A2] receptor selective agonists. Int J Pharmacol. 1995, 17: 221-224. 10.1016/0192-0561(94)00096-7.

  62. 62.

    Sajjadi FG, Takabayashi K, Foster AC, Domingo RC, Firestein GS: Inhibition of TNF-alpha expression by adenosine: role of A3 adenosine receptors. J Immunol. 1996, 156: 3435-3442.

  63. 63.

    McWhinney CD, Dudley MW, Bowlin TL, Peet NP, Schook L, Bradshaw M, De M, Borcherding DR, Edwards CK: Activation of adenosine A3 receptors on macrophages inhibits tumor necrosis factor-alpha. Eur J Pharmacol. 1996, 310: 209-216. 10.1016/0014-2999(96)00272-5.

  64. 64.

    Bouma MG, Stad RK, van den Wildenberg FA, Buurman WA: Differential regulatory effects of adenosine on cytokine release by activated human monocytes. J Immunol. 1994, 153: 4159-4168.

  65. 65.

    Hasko G, Szabo C, Nemeth ZH, Kvetan V, Pastores SM, Vizi ES: Adenosine receptor agonists differentially regulate IL-10, TNF-alpha, and nitric oxide production in RAW 264.7 macrophages and in endotoxemic mice. J Immunol. 1996, 157: 4634-4640.

  66. 66.

    Khoa ND, Montesinos MC, Reiss AB, Delano D, Awadallah N, Cronstein BN: Inflammatory cytokines regulate function and expression of adenosine A2A receptors in human monocytoid THP-1 cells. J Immunol. 2001, 167: 4026-4032.

  67. 67.

    Xaus J, Mirabet M, Lloberas J, Soler C, Lluis C, Franco R, Celada A: IFN-gamma up-regulates the A2B adenosine receptor expression in macrophages: a mechanism of macrophage deactivation. J Immunol. 1999, 162: 3607-3614.

  68. 68.

    Lennon PF, Taylor CT, Stahl GL, Colgan SP: Neutrophil-derived 5'-adenosine monophosphate promotes endothelial barrier function via CD73-mediated conversion to adenosine and endothelial A2B receptor activation. J Exp Med. 1998, 188: 1433-1443. 10.1084/jem.188.8.1433.

  69. 69.

    Richard LF, Dahms TE, Webster RO: Adenosine prevents permeability increase in oxidant-injured endothelial monolayers. Am J Physiol. 1998, 274: H35-H42.

  70. 70.

    Bouma MG, van den Wildenberg FAJM, Buurman WA: Adenosine inhibits cytokine release and expression of adhesion molecules by activated human endothelial cells. Am J Physiol. 1996, 39: C522-C529.

  71. 71.

    Grant MB, Tarnuzzer RW, Caballero S, Ozeck MJ, Davis MI, Spoerri PE, Feoktistov I, Biaggioni I, Shryock JC, Belardinelli L: Adenosine receptor activation induces vascular endothelial growth factor in human retinal endothelial cells. Circ Res. 1999, 85: 699-706.

  72. 72.

    Ethier MF, Chander V, Dobson JG: Adenosine stimulates proliferation of human endothelial cells in culture. Am J Physiol. 1993, 265: H131-H138.

  73. 73.

    Sexl V, Mancusi G, Baumgartner-Parzer S, Schutz W, Freissmuth M: Stimulation of human umbilical vein endothelial cell proliferation by A2-adenosine and beta 2-adrenoceptors. Br J Pharmacol. 1995, 114: 1577-1586.

  74. 74.

    Harrington EO, Smeglin A, Newton J, Ballard G, Rounds S: Protein tyrosine phosphatase-dependent proteolysis of focal adhesion complexes in endothelial cell apoptosis. Am J Physiol Lung Cell Mol Physiol. 2001, 280: L342-L353.

  75. 75.

    Alarcon GS, Schrohenloher RE, Bartolucci AA, Ward JR, Williams HJ, Koopman WJ: Suppression of rheumatoid factor production by methotrexate in patients with rheumatoid arthritis. Arthritis Rheum. 1990, 33: 1156-1161.

  76. 76.

    Spadaro A, Riccieri V, Sili Scavalli A, Taccari E, Zoppini A: One year treatment with low dose methotrexate in rheumatoid arthritis: effect on class specific rheumatoid factors. Clin Rheumatol. 1993, 12: 357-360.

  77. 77.

    Olsen NJ, Teal GP, Brooks RH: IgM-rheumatoid factor and responses to second-line drugs in rheumatoid arthritis. Agents Actions. 1991, 34: 169-171.

  78. 78.

    Moore S, Ruska K, Peters L, Olsen NJ: Associations of IgA and IgA-rheumatoid factor with disease features in patients with rheumatoid arthritis. Immunol Invest. 1994, 23: 355-365.

  79. 79.

    Olsen NJ, Callahan LF, Pincus T: Immunologic studies of rheumatoid arthritis patients treated with methotrexate. Arthritis Rheum. 1987, 30: 481-488.

  80. 80.

    Olsen NJ, Murray LM: Antiproliferative effects of methotrexate on peripheral blood mononuclear cells. Arthritis Rheum. 1989, 32: 378-385.

  81. 81.

    Wascher TC, Hermann J, Brezinschek HP, Brezinschek R, Wilders-Truschnig M, Rainer F, Krejs GJ: Cell-type specific response of peripheral blood lymphocytes to methotrexate in the treatment of rheumatoid arthritis. Clin Invest. 1994, 72: 535-540.

  82. 82.

    Nakazawa F, Matsuno H, Yudoh K, Katayama R, Sawai T, Uzuki M, Kimura T: Methotrexate inhibits rheumatoid synovitis by inducing apoptosis. J Rheumatol. 2001, 28: 1800-1808.

  83. 83.

    Weinblatt ME, Trentham DE, Fraser PA, Holdsworth DE, Falchuk KR, Weissman BN, Coblyn JS: Long-term prospective trial of low-dose methotrexate in rheumatoid arthritis. Arthritis Rheum. 1988, 31: 167-175.

  84. 84.

    Mirabet M, Herrera C, Cordero OJ, Mallol J, Lluis C, Franco R: Expression of A2B adenosine receptors in human lymphocytes: their role in T cell activation. J Cell Sci. 1999, 112: 491-502.

  85. 85.

    Dong RP, Kameoka J, Hegen M, Tanaka T, Xu Y, Schlossman SF, Morimoto C: Characterization of adenosine deaminase binding to human CD26 on T cells and its biologic role in immune response. J Immunol. 1996, 156: 1349-1355.

  86. 86.

    van den Berg WB: Anti-cytokine therapy in chronic destructive arthritis. Arthritis Res. 2001, 3: 18-26. 10.1186/ar136.

  87. 87.

    DiMartino MJ, Johnson WJ, Votta B, Hanna N: Effect of antiarthritic drugs on the enhanced interleukin-1 [IL-1] production by macrophages from adjuvant-induced arthritic [AA] rats. Agents Actions. 1987, 21: 348-350.

  88. 88.

    Novaes GS, Mello SB, Laurindo IM, Cossermelli W: Low dose methotrexate decreases intraarticular prostaglandin and interleukin 1 levels in antigen induced arthritis in rabbits. J Rheumatol. 1996, 23: 2092-2097.

  89. 89.

    Chang DM, Weinblatt ME, Schur PH: The effects of methotrexate on interleukin 1 in patients with rheumatoid arthritis. J Rheumatol. 1992, 19: 1678-1682.

  90. 90.

    Segal R, Mozes E, Yaron M, Tartakovsky B: The effects of methotrexate on the production and activity of Il-1. Arth Rheum. 1989, 32: 370-377.

  91. 91.

    Chang DM, Baptiste P, Schur PH: The effect of antirheumatic drugs on interleukin 1 [IL-1] activity and IL-1 and IL-1 inhibitor production by human monocytes. J Rheumatol. 1990, 17: 1148-1157.

  92. 92.

    Brody M, Bohm I, Bauer R: Mechanism of action of methotrexate: experimental evidence that methotrexate blocks the binding of interleukin 1 beta to the interleukin 1 receptor on target cells. Eur J Clin Chem Clin Biochem. 1993, 31: 667-674.

  93. 93.

    Majumdar S, Aggarwal BB: Methotrexate suppresses Nf-kappaB activation through inhibition of IkappaBalpha phosphorylation and degradation. J Immunol. 2001, 167: 2911-2920.

  94. 94.

    Eigler A, Matschke V, Hartmann G, Erhardt S, Boyle D, Firestein GS, Endres S: Suppression of TNF-alpha production in human mononuclear cells by an adenosine kinase inhibitor. J Leukoc Biol. 2000, 68: 97-103.

  95. 95.

    Becker C, Barbulescu K, Hildner K, Meyer zum Buschenfelde KH, Neurath MF: Activation and methotrexate-mediated suppression of the TNF alpha promoter in T cells and macrophages. Ann N Y Acad Sci. 1998, 859: 311-314.

  96. 96.

    Neurath MF, Hildner K, Becker C, Schlaak JF, Barbulescu K, Germann T, Schmitt E, Schirmacher P, Haralambous S, Pasparakis M, Meyer Zum Buschenfelde KH, Kollias G, Marker-Hermann E: Methotrexate specifically modulates cytokine production by T cells and macrophages in murine collagen-induced arthritis [CIA]: a mechanism for methotrexate-mediated immunosuppression. Clin Exp Immunol. 1999, 115: 42-55. 10.1046/j.1365-2249.1999.00753.x.

  97. 97.

    Hildner K, Finotto S, Becker C, Schlaak J, Schirmacher P, Galle PR, Marker-Hermann E, Neurath MF: Tumour necrosis factor [TNF] production by T cell receptor-primed T lymphocytes is a target for low dose methotrexate in rheumatoid arthritis. Clin Exp Immunol. 1999, 118: 137-146. 10.1046/j.1365-2249.1999.01022.x.

  98. 98.

    Rudwaleit M, Yin Z, Siegert S, Grolms M, Radbruch A, Braun J, Sieper J: Response to methotrexate in early rheumatoid arthritis is associated with a decrease of T cell derived tumour necrosis factor alpha, increase of interleukin 10, and predicted by the initial concentration of interleukin 4. Ann Rheum Dis. 2000, 59: 311-314. 10.1136/ard.59.4.311.

  99. 99.

    Sung JY, Hong JH, Kang HS, Choi I, Lim SD, Lee JK, Seok JH, Lee JH, Hur GM: Methotrexate suppresses the interleukin-6 induced generation of reactive oxygen species in the synoviocytes of rheumatoid arthritis. Immunopharmacology. 2000, 47: 35-44. 10.1016/S0162-3109(99)00185-X.

  100. 100.

    Spadaro A, Taccari E, Riccieri V, Sensi F, Sili Scavalli A, Zoppini A: Relationship of soluble interleukin-2-receptor and interleukin-6 with class-specific rheumatoid factors during low-dose methotrexate treatment in rheumatoid arthritis. Rev Rhum Engl Ed. 1997, 64: 89-94.

  101. 101.

    Constantin A, Loubet-Lescoulie P, Lambert N, Yassine-Diab B, Abbal M, Mazieres B, de Preval C, Cantagrel A: Antiinflammatory and immunoregulatory action of methotrexate in the treatment of rheumatoid arthritis: evidence of increased interleukin-4 and interleukin-10 gene expression demonstrated in vitro by competitive reverse transcriptase-polymerase chain reaction. Arthritis Rheum. 1998, 41: 48-57. 10.1002/1529-0131(199801)41:1<48::AID-ART7>3.3.CO;2-B.

Download references

Acknowledgements

This work was supported by grants from the National Institutes of Health (AR41911, GM56268), Medco Research, Inc., and the General Clinical Research Center (M01RR00096) and by the Kaplan Cancer Center.

Author information

Affiliations

  1. Division of Clinical Pharmacology, NYU School of Medicine, New York, NY, USA

    • Edwin SL Chan
    •  & Bruce N Cronstein

Authors

  1. Search for Edwin SL Chan in:

  2. Search for Bruce N Cronstein in:

Corresponding author

Correspondence to Bruce N Cronstein.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Chan, E.S., Cronstein, B.N. Molecular action of methotrexate in inflammatory diseases. Arthritis Res Ther 4, 266 (2002) doi:10.1186/ar419

Download citation

Keywords

  • adenosine receptor
  • inflammation
  • methotrexate
  • rheumatoid arthritis

Arthritis Research & Therapy

ISSN: 1478-6362

Contact us