The quest for an evidence-based approach to surveillance for methotrexate-related hepatotoxicity: Promise and perils.

We very much appreciate the editors' invitation to comment on the systematic review and meta-analysis by Maybury and colleagues, which examined the risk of histologically-confirmed liver fibrosis attributable to methotrexate (MTX) among patients with psoriasis.The authors identified eight studies, all over a decade old, and based on the subset utilising pre- and post-MTX biopsies reported that methotrexate increases the risk of both any liver fibrosis and cirrhosis; that the risk was not increased when studies utilising either serial biopsies or "significant fibrosis" as an endpoint were assessed; and that the role of potential confounders such as obesity and diabetes remains unclear. Although the authors have clearly invested considerable effort in conducting this study, several shortcomings are noteworthy. This article is protected by copyright. All rights reserved.