XS
`
`9
`
`THE EFFECT OF FOLIC ACID SUPPLEMENTATION
`ON THE TOXICITY OF LOW-DOSE METHOTREXATE
`IN PATIENTS WITH RHEUMAT_OID ARTHRITIS
`
`SARAH L. MORGAN, JOSEPH E. BAGGOIT, WILLIAM H. VAUGHN, PEGGY K,. YOUNG,
`JANET V. AUSTIN, CARLOS L . .({RUMDIECK, and GRACIELA S. ALARCON
`
`Tblrty·two patients with rheumatoid arthritis
`completed a 24-week, placebo-controlled, double-blind
`trial of foUc acid (FA) supplementation during low-dose
`methotrexate (MTX) therapy. Administration of the
`dally FA supplement slgnlftcantly lowered toxicity
`scores without affecting eftlcacy, as measured by joint
`counts, joint indices, and patient and physician evalua(cid:173)
`tion of disease activity. Fifteen patients experienced
`some sort or toxicity; 67% were In the placebo group,
`and 33% were in the FA supplement group. Four
`patients In the placebo group bad toxicity levels serious
`enough to require discontinuation of the MTX, while no
`patients In the FA supplement group discontinued MTX
`because or toxicity. Low-normal Initial plasma and~
`blood cell f olate levels were predictive or future toxicity
`with MTX therapy, We conclude that a dally supple(cid:173)
`ment of 1 mg of FA during low-dose MTX therapy
`(median dose 7.5 mg.lweek [16.4 pmoles]) is useful In
`lessening toxicity without altering eJBcacy during the
`first 6 months of treatment.
`
`From the Department of Nutrition Sciences and the Divi·
`sion of Clinical Immunology and Rheumatology, Department or
`Medicine, The University of Alabama at Birmingham.
`Supported by NIH grants SPOl-CA-28103·10 and 'POO(cid:173)
`AR-20614. Dr. Morgan is the recipient or a Future Nutrition
`Leader's Award from the International Life Sciences Institute:/
`Nutrition Foundation (1986-1988).
`Sarah L. Morgan, MD, RD, FACP; Joseph E. Baggott,
`PhD; William H. Vaughn, BS; Peggy K. Young, CMA; Janet V.
`Austin, BS; Carlos L. Krwndicck, MD, PhD; Graciela S. Alarc6n,
`MD, MPH, PACP.
`Address reprint requests to Sarah L. Morgan, MD, RD,
`FACP, The University of Alabama at Birmingham, Dcpanment of
`Nutrition Sciences, Webb Building-202, UAB Station, Binning·
`ham, AL 3.5294.
`Submitted for publication May 26, 1989; accepted in revised
`form August 21, 1989.
`
`Arthritfl imd Rheumatism, VoJ. 33, No. 1 (JanlW')' 1990)
`
`The use of the folic acid (FA) antagonist, amin(cid:173)
`opterin, for the treatment of rheumatoid arthritis (RA)
`was first reported by Gubner et al in 1951 (1). Numer·
`ous double-blind, placebo-controlled trials have since
`established the efficacy of N-10-methylaminopterin
`(methotrexate; MTX) in the treatment of RA (2-7). A
`meta-analysis of numerous studies has shown that
`patients receiving MTX for RA have a 26% greater
`improvement in their joint counts and a 39% greater
`improvement in pain scores than do control patients
`receiving nonsteroidal antiinftammatory drugs
`(NSAIDs) with or without prednisone. The major
`factor limiting MTX treatment seems to be its toxicity
`(9,10). Toxic manifestations, such as nausea, stomati(cid:173)
`tis, abnormal liver function, cytopenia, and pulmonary
`toxicity, have generally been reported in 30-60% of
`patients (7-10), and in 1study,90% of patients expe(cid:173)
`rienced toxicity (6).
`The folate status of patients before and during
`MTX therapy has received little attention, even
`though some clinical manifestations of folate defi(cid:173)
`ciency, such as cytopenia, anorexia, stomatitfs, and
`gastrointestinal (GI) intolerance (11,12), are also ob(cid:173)
`served as toxic reactions during low-Oose MTX treat·
`ment for RA. It was therefore postulated that the
`administration of FA would be useful in reducing toxic
`manifestations that occur during long-term treatment
`with low-dose MTX for RA. We report herein the
`results of a double-blind, placebo-controlled study
`designed· to test thi~ hypothesis.
`
`PATIENTS AND METHODS
`Pattents. Thirty-nine patients with RA that fulfilled
`the American Rheumatism Association 1958 criteria for
`
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`

`
`10
`
`MORGAN ET AL
`
`Table I. Baseline clinical and demographic characteristics of the
`rheumatoid arthritis patients studied•
`
`Polate group
`(n = 16)
`
`S2.0 ± 14.6
`3/13
`s
`8.7 ± s.s
`IS
`8.0 ± .s.o
`(2.~20.9)
`3.SS.9 ± 222.8
`(101-539)
`14
`
`Placebo group
`(n = 16)
`
`S0.9 ± 13.S
`3/13
`2
`
`JS.3 ± IJ.O:I:
`16
`
`8.S ± 6.0
`(l.J-23.1)
`361.3 ± 193.4
`(146-m>
`16
`
`9
`
`8
`
`Age
`Males/females
`Previous use of folate-
`containing vitaminst
`Years of disease
`Rheumatoid factor
`positive
`Initial serum folate, ng/ml
`
`Initial RBC folate, ng/ml
`
`Concurrent use of
`NSAIDs/aspirin
`Concurrent ·use of
`prednisone
`Anatomic stage§
`Carpal: metacarpal ratio§
`
`3.6 ± 1.3
`o . .so ± 0.03
`• Values are the mean ± SD or the number or patients. Numbers in
`parentheses are ranges. RBC'"" red blood cell: NSAIDs = nonster(cid:173)
`oidal antiinflammatory drugs.
`t Mean 400 µ.g folate/day.
`tP<O.OS.
`§ For explanation, see refs. 14-16.
`
`3.9 ±I.I
`O.SI ± 0.03
`
`definite or classic disease (13) gave informed consent and
`entered the study, which was approved by the Institutional
`Review Board ofThe University of Alabama at Birmingham.
`Seven patients could not be included in the data analysis: 4
`because of noncompliance with the MTX regimen, 2 because
`of administration of intramuscular MTX, and 1 because of
`self-medication with large amounts of FA. None of these 7
`patients were withdrawn because of the occurrence of toxic
`manifestations. Demographic and clinical characteristics of
`the 32 patients who completed the study arc presented in
`Table 1.
`Criteria for entry into the study included RA of more
`than 6 months duration, with onset after 16 years of age, and
`at least 3 of the following: <:?:3 swollen joints, 2:6 or more
`tender joints, 2:45 minutes of morning stiffness, and a
`Westell!ren erythrocyte sedimentation rate (ESR) of ~28
`mm/hour. Radiographs were read by the project rheumatol(cid:173)
`ogist (GSA) in a blinded manner. The anatomic grading
`criteria of Berens and Lin (14), as modified by Trentham and
`Masi (15), as well as the carpal:metacarpal (C:MC) ratio (15),
`were used to assess the radiographs. These measurements
`had been previously used and validated at our institution and
`had been found to be reliable (16).
`Patients with serious concomitant medical illnesses
`such as cancer. liver or renal disease. liver enzyme levels
`more than twice the upper limit of normal, white blood cell
`CWBC) counts <3,500/mml, or platelet counts <150,000/
`mm> were excluded from the trial. Previous use of MTX
`within the past 6 months and treatment with total lympho(cid:173)
`cyte irradiation were also exclusion criteria. Patients were
`not accepted into the trial until gold salts, D-pcnicillamine,
`
`sulfasalazine, or hydroxycloroquine treatment had been
`discontinued for at least 10 days.
`During the study, each patient remained under the
`care of his or her rheumatologist, abstained from alcohol,
`and continued to receive stable doses of aspirin and/or
`NSAIDs. For those taking prednisone at study entry, the
`dosage was kept stable, not to exceed 10 mg/day. It was
`required that both male and female patients either be prac(cid:173)
`ticing contraception or have no reproductive potential.
`Study design. The study was a double-blind, placebo(cid:173)
`controlled trial of 24 weeks duration. Patients were assigned
`to receive folate (I mg [2.2. µmoles]lday) or placebo. The 2
`groups were matched, by the study statistician, on the basis
`of sex, previous use of folate-containing vitamins, rheuma(cid:173)
`toid factor (RF) serology, and age. Identical FA- and placebo(cid:173)
`containing capsules were prepared by the lnvestigational
`Drug Service of the University of Alabama Hospital, using
`capsules provided. by Capsugel (Warner Lambert, Green(cid:173)
`wood, SC). Folic acid (pteroylglutamic acid) was obtained
`from Lederle Laboratories (Pearl River, NY). Spectropho(cid:173)
`tometric analysis indicated that the mean ± SD folate
`content was 1.03 ± 0.16 mg per capsule.
`Folate-containing vitamin preparations, if previously
`used, were stopped for the duration of the study. Oral MTX
`was begun at a dosage of 2.S-7.5 mg per week, and was
`increased in 2.5-mg increments at the discretion of the
`treating rheumatologist. The weekly dosage of MTX did not
`exceed 15 mg, and the median dosage for both groups was
`7.5 mg/week. The MTX tablets were generally ingested in
`equal numbers on 3 consecutive occasions at 12-hour inter(cid:173)
`vals, always beginning on the same day of the week. Neither
`the investigators, the patients, nor the treating rheumatolo·
`gists were aware of the placebo/folic acid capsule assign(cid:173)
`ments until the study was completed. Patients were with(cid:173)
`drawn from MTX therapy at the discretion of the treating
`rheumatologist.
`Patients were evaluated immediately prior to initia(cid:173)
`tion of MTX (visit I), and after approximately 12 weeks
`(range l(}-14 weeks; visit 2) and 24 weeks (range 22-26
`weeks; visit 3) of MTX therapy. Patients were withdrawn
`from the study if they missed more than 3 weeks of MTX
`treatment for any reason.
`Clinical asseument. Each patient was examined and
`interviewed by the same physician/nutritionist (SLM) and
`rheumatology research assistant (JVA or PKY). Medication
`compliance was determined by direct questioning, and by
`pill counts when possible.
`The following clinical variables (5) were determined
`at each visit: I) the number of joints with swelling (of 58
`diarthrodial joints); 2) the number of joints with tenderness
`on pressure, pain on passive motion, or both (of 60 joints); 3)
`the joint swelling index, expressed as a sum, in which each
`joint was graded for swelling as 0 (none). I (mild), 2
`(moderate), or 3 (severe); 4) the joint tenderness/pain index,
`expressed as a sum with joints also graded on the above
`scale ofO (none) to 3 (severe); S) mean grip strength for both
`hands; 6) the duration of morning stiffness, to the nearest
`hour; 7) the patient's assessment of disease activity, graded
`as 0 (asymptomatic:), l (mild), 2 (moderate), 3 (severe), or 4
`(very severe); 8) the physician's assessment of disease
`activity, graded on the same scale; 9) I-day dietary recall,
`
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`
`FOLIC ACID SUPPLEMENTS IN MTX-TREATED RA
`
`11
`
`using food models, which was coded using the Ohio State
`Nutrient Data Base (Unison Systems Associates, Colum(cid:173)
`bus, OH); 10) current medications and dosages: and 1 I) toxic
`side effects. Before beginning MTX, each patient was coun(cid:173)
`seled by his or her attending rheumatologist with regard to
`possible toxic side effects. The presence of such side effects
`was investigated by asking the question, "Is the MTX
`medication causing you any problems?" Toxicity was also
`noted and recorded every 3 weeks by telephone interview.
`A toxicity score (TS) was determined for each pa(cid:173)
`tient. The scoring system was based on the clinical experi(cid:173)
`ences of the investigators and represents an attempt to
`distinguish mild and marginal toxic symptoms (e.g., alope(cid:173)
`cia) from severe and medically important ones (e.g., cytope(cid:173)
`nias) (10). As shown below, it was designed to increase in
`proportion to the duration of toxic events, their intensity,
`and their clinical significance, and to decrease with the time
`on the protocol at which the toxic manifestations first
`appeared (i.e., ifa toxic reaction occurred early in the course
`of treatment, this would result in a higher toxicity score than
`if the same reaction occurred only after a longer course of
`treatment). The duration of the toxic event was placed in the
`numerator of the toxicity score, in order to quantitatively
`emphasize persistent morbidities while minimizing the con(cid:173)
`tribution of transitory morbidities and spurious abnormal
`laboratory values. The TS was calculated as follows:
`
`(duration of toxic events [weeks)) x (intensity)]
`x (clinical severity factor)
`TS=~ - - - - - - - - - - - - - - -
`[
`weeks on protocol
`where intensity = 1 (mild), 2 (moderate), or 3 (severe); and
`clinical severity factor = J (alopecia, nausea, pruritus,
`anorexia and/or general GI intolerance [pyrosis, cramps,
`etc.)), 2 (vomiting, diarrhea, stomatitis and/or rash), 3 (ele(cid:173)
`vated liver enzyme levels and/or elevated serum creatinine
`level), or 4 (cytopenia, documented infections, and/or pul(cid:173)
`monary toxicity).
`Abnormal results on liver function tests were defined
`as transaminase and/or alkaline phosphatase values > 2 times
`the baseline levels; cytopenia was defined as a WBC count
`<3S,OOO/mm3 or a platelet count <150,000/mm': elevated
`serum creatinine level was defined as >I .S mg/di; and
`pulmonary toxicity was defined as evidence of new intersti(cid:173)
`tial pulmonary infiltrates compared with the baseline chest
`radiograph, with evidence of restrictive changes seen on
`pulmonary function tests (i.e., vital capacity <80% of pre(cid:173)
`dicted, normal expiratory flow rates, normal maximal vol(cid:173)
`untary ventilation, and carbon monoxide diffusing capacity
`<70% of normal [17]). Infection was defined as a docu(cid:173)
`mented viral, bacterial, or fungal infection that compromised
`the patient's condition significantly, require;d hospitaliza(cid:173)
`tion, and/or required administration of systerpic antibiotics
`or antlfungal agents. Any abnormality in transjlminase level,
`alkaline phosphatase level, WBC count, or platelet count,
`documented infection believed to be related 10 the MTX, or
`pulmonary toxicity was given an intensity score of 3
`(severe).
`Overall response to treatment was determined by a
`modification of the criteria developed by the Cooperative
`Systematic Studies of the Rheumatic Diseases group (18,
`
`Table 2. Mean ~ SD cumulative doses of methotrexate (MTX) end
`dietary intake or folete and vitamin 811
`Visit I
`
`Visit 2
`
`Visit 3
`
`Cumulative MTX dose, mg
`Folate group
`Placebo group
`Dietary folatc intake,
`µ.yjday
`Folatc group
`Placebo group
`Dietary vitemin 8 11 intake,
`/q/day
`Folate group
`Placebo group
`
`80 ± 21
`70 ± 2S
`
`183 ± 64
`ISO ± 37
`
`196 :!: 112
`206 :!; 176
`
`274 ~ 189
`150 :t 90
`
`220 ± 135
`131 ± S3
`
`2.1 ± 1.4
`2.2 :t: 1.0
`
`3.2 ± 2.6
`J.5 ::!: 0.9
`
`2.0 ± 1.8
`2.0 ± 1.2
`
`19), as follows. The score on the joint swelling index and the
`joint tenderness/pain index at visit 2 and/or visit 3 was·
`compared with the score at visit 1. Marked improvement
`was defined as a <!:SO% decrease in these scores, moderate
`improvement was defined as a 31-49% decrease in the index,
`no change was defined as a score remaining within 30% of
`the original value, and worsening was defined as a >30%
`increase in the score. Improvement and worsening in the
`physician or patient assessment of disease activity were
`defined as changes of at least 2 integers on the 5-point scales.
`Laboratory assessment. At visit l, the complete blood
`cell count (CBC) including platelet count, Westergren ESR,
`liver enzyme levels (aspartate aminotransferase [AST] and
`alkaline phosphatase), RF titer, and serum creatinine level
`were determined. Followup CBC, creatinine studies, and
`liver function tests were performed at the discretion of each
`patient's rheumatologist and were generally repeated at each
`followup visit. Tests were performed more often ·(usually
`weekly) if an abnormal value was obtained.
`Blochemlcal assessment. At visits l, 2, and 3, blood
`was obtained for a vitamin screen (serum and red blood cell
`[RBC) folate, serum vitamin Bm vitamin C, vitamin A,
`13-tarotene, vitamin B6 , thiamine, and riboflavin) and for
`detennination of the C 1 index, by methods previously de(cid:173)
`scribed (20,21). The C 1 index measures the activity of a
`folate-dependent enzyme system in peripheral blood mono(cid:173)
`nuclear cells by assaying the fonnation of serine from
`glycine end radiolabeled formate.
`StatisUcal analysis. Either Student's t-test or analysis
`of variance followed by the least significant difference test
`was used to compare means of normally distributed data.
`The Wilcoxon signed rank test was used with C 1 index data.
`Speannan's rank correlation test and chi-square analysis
`were used when appropriate (22). P values Jess than or equal
`to O.OS were considered significant.
`
`RESULTS
`Characteristics of the patient groups. Sixteen of
`the 32 patients were in the folate supplement group,
`and 16 were in the placebo group. Findings from pill
`counts and questioning suggested a high degree of
`compliance with the MTX and FA/placebo regimen.
`
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`
`12
`
`MORGAN ET AL
`
`Table J. Patient response to mcthotrcxatc: treatment•
`
`No. of patients
`
`Variable,
`patient group
`
`Marked
`improvement
`
`Moderate
`improvement
`
`Marked or
`moderate
`improvement
`
`No
`change Wonening
`
`6
`s
`7
`3
`
`s
`7
`s
`7
`
`3
`4
`
`8
`3
`
`s
`7
`
`4
`6
`
`3
`2
`
`3
`s
`
`3
`2
`
`s
`J
`
`2
`3
`
`I
`0
`
`4
`1
`
`·Swelling index
`Visit 2
`Folatc
`Placebo
`Visit 3
`Fol ate
`Placebo
`Pain/tenderness Index
`Visit l
`Folate
`Placebo
`Visit 3
`· Folate
`Placebo
`Joint swelling count
`Visit 2
`Folate
`Placebo
`· Visit J
`Folate
`Placebo
`Joint pain/tenderness count
`Visit 2
`Folate
`Placebo
`Visit J
`Folate
`Placebo
`Physician assessment
`Visit 2
`Folate
`Placebo
`Visit 3
`Folate
`Placebo
`Patient assessment
`Visit 2
`Folate
`Placebo
`Visit 3
`Polate
`Placebo
`
`s
`s
`4
`3
`
`s
`2
`
`4
`0
`
`4
`s
`J
`s
`
`6
`2
`
`4
`2
`
`13
`11
`
`11
`10
`
`II
`8
`
`12
`10
`
`0
`2
`
`3
`4
`
`3
`3
`
`2
`2
`
`2
`1
`
`2
`s
`
`3
`3
`
`0
`I
`
`0
`0
`
`0
`2
`
`0
`0
`
`l
`0
`
`2
`0
`
`3
`4
`
`3
`2
`
`• The initial study population consisted of 16 patients in the folate group and 16 in the placebo group.
`Numbers shown total less than 16 for each visit because patients dropped out of tbc study, missed
`visits, or the variable was not determined.
`
`The mean duration of disease was longer in the placebo(cid:173)
`treated group; other baseline demographic and clinical
`characteristics, including disease severity as measured
`by joint counts, anatomic stage, and C:MC ratio, were
`not different between the groups (Table 1). There
`were no statistically significant differences between
`the groups in baseline hemoglobin or hematocrit
`values, mean corpuscular volume (MCV). WBC
`counts, or AST, alkaline phosphatase, or serum ere-
`
`atinine levels. The groups did not differ in their initial
`mean serum and RBC folate levels. In addition, there
`was no significant difference between the groups in
`their mean dietary intake offolate or vitamin B12, or in
`the cumulative MTIC intake at any of the visits (Table
`2). While there was a trend toward higher dietary
`f olate consumption in the folate supplement group, it
`was not biologically important. given the much larger
`amount of FA that these patients received in the form
`
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`

`
`FOLIC ACID SUPPLEMENTS IN MTX-TREATED RA
`
`13
`
`• ....
`
`•
`
`• •
`
`•
`
`0
`
`0
`
`•
`14
`
`s
`
`> ll
`....
`~ 2
`lC
`0
`I- I
`
`0
`
`•
`
`• •
`
`•
`
`- •
`
`A
`
`• •
`
`•
`
`•
`
`15
`10
`PLASMA fOLAT£
`
`B
`
`••
`•
`
`
`• •
`
`•
`
`•
`
`• •
`
`of the supplement. In addition, the patients' mean
`dietary intake of folate was below the recommended
`dietary allowance of 400 µ.g/day (23).
`Efficacy. Table 3 shows a comparison between
`the folate supplement and the placebo groups in their
`degree of response to MTX treatment. Chi-square
`analysis failed to show any statistically significant
`difference between the 2 groups in the degree of
`improvement.
`Toxicity and patient dropout. Fifteen patients
`(47%} experienced some form of toxicity; of these, 10
`(67%) were· in the placebo group, and 5 (33%) were in
`the folate supplement group. The toxic manifestations
`observed and the number of patients experiencing the
`reaction,· in the placebo group and the folate supple(cid:173)
`ment group, respectively, were as follows: nausea 8
`and 5, elevations in liver enzyme levels 3 and 0,
`cytopenia 1 and 1, anorexia 2 and 0, alopecia 0 and 2,
`constipation/bloating 1 and 0, pyrosis I and 0, stomach
`cramps 0 and 1, stomatitis 0 and 1, and transiently
`elevated creatinine levels I and 0.
`
`6
`
`La.I 4
`a::
`0
`0
`(I)
`>-
`....
`u
`x
`0 .... 2
`
`0
`
`•
`
`•
`•
`
`•
`.,
`-.-.r
`.....
`
`y
`
`-·-
`
`•••••••••••
`
`FOL ATE
`PLACEBO
`Ffsare 1. Toxicity scores in the folate supplement and placebo
`groups. Horizontal bars show the mean $COTC3 (0.21 and l.06,
`respectively; P = 0.027). See Patients and Methods for explanation
`of toxicity score calculation.
`
`100
`
`700
`
`100
`
`IOO
`
`zoo
`
`300
`
`400
`500
`RBC FOUTE
`Figure 2. Correlation of toxicity score (TS; see Patients and Meth(cid:173)
`ods) with initial plasma (A) and red blood cell (RBC) (B) rotate levels
`(ngfml) in the placebo group. Speanrum's rank correlation coeffi(cid:173)
`cient was -0.84 (P < 0.01) and -0.66 (P < 0.01) for plasma and
`RBC folate levels, respectively. Normal levels of plasma and RBC
`folate are 2:2 nglml and 2:140 ngfml, respectively.
`
`Five of the patients (16%) dropped out of the
`study before visit 3. Four of these patients were in the
`placebo group; their toxicity scores were 1.0, 2.67,
`3.0, and 5.1. MTX had to be discontinued in these
`patients because of toxicity. The toxic reactions ob(cid:173)
`served in the 4 patients were severe nausea, anorexia,
`constipation, persistently elevated liver enzyme levels
`(2 or more determinations 1 week apart), cytopenia,
`and elevated creatinine levels. Elevated creatinine
`levels were attributed to MTX toxicity since they
`normalized following discontinuation of the drug. In
`the 1 patient in the folate supplement group who was
`withdrawn from the study, MTX treatment was
`stopped, not because of toxicity, but in preparation for
`surgical joint replacement.
`The mean toxiCity score in the folate supple(cid:173)
`ment group was significantly lower than that in the
`placebo group (Figure I). Minor toxicity (i.e., toxicity
`score <0.2) or no toxicity occurred in 12 patients in
`the folate supplement group, whereas only 7 patients
`in the placebo group were in this category.
`
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`

`
`14
`
`·~
`
`10
`
`•
`•
`
`•
`•
`••
`_!..!_. •
`•
`••
`•
`•
`•
`
`> u
`:E 5
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`PLACEBO
`FOL ATE
`Figure 3. Changes in mean corpuscular volume (McV) (in ft) from
`visit 1 to visit 3 in the folate supplement and placebo groups.
`Horizontal ban show the mean changes (1.9 ft (not significant} in the
`folate group and .5.8 ft (P < O.OS) in the placebo group). The mean
`change in the placebo group was significantly higher than that in the
`folatc group (P < 0.01). Mean :t SD MCV values in the folate group
`and the placebo group, respectively, were 86.4 ± 8.8 ft and 84.0 ±
`8.3 ft at visit I, and 89.3 ± 8 . .5 ft and 89.8 ± 6.2 ft at visit 3.
`
`The toxicity scores in the placebo group
`showed significant negative correlation with the initial
`plasma (Figure 2A) and RBC (Figure 2B) folate levels.
`These correlations were not found in the folate sup(cid:173)
`plement group, even though 4 patients in this group
`had low-normal initial plasma folate levels (i.e., <3.5
`ng/ml). Of the 4 patients in the placebo group who
`discontinued MTX treatment, 3 had initial plasma
`folate levels of <3.S ng/ml, while the remaining patient
`had a level of S.3 ng/ml.
`Laboratory findlnp. The mean values for hem(cid:173)
`atocrit, WBC count, platelet count, creatinine, AST,
`and alkaline phosphatase did not differ significantly
`between or within the groups at any of the visits.
`Compared with visit 1, there was a significant increase
`in the MCV at visit 3 in the placebo group (Figure 3).
`
`MORGAN ET AL
`
`A significant increase over time in the mean MCV was
`not seen in the folate supplement group. The increase
`in the mean MCV was significantly higher in the
`placebo group than in the folate supplement group.
`Biochemical analysis. As seen in Table 4, there
`was a decrease over time in the mean C1 index from
`visit 1 in the group of patients as a whole, but this was
`statistically significant only at visit 2. However, when
`the treatment groups were compared, the mean de(cid:173)
`crease in the C 1 index in the placebo group was greater
`than that in the folate supplement group. Thus, the
`drop in the C 1 index reflects not only the expected
`MTX antagonism of folate-requiring pathways, but
`also the partial protection conferred by the simulta(cid:173)
`neous administration of the FA supplement.
`A severe decrease in the mean C1 index was
`associated with moderate toxicity, while minor or no
`toxicity was associated with no change in the C 1 index
`(Table S). In patients with improved swelling and
`improved pain/tenderness indices (i.e., marked im(cid:173)
`provement or moderate improvement), toxicity was
`also associated with a severe drop in the mean C 1
`index, while patients who showed clinical improve(cid:173)
`ment without major toxicity had only a moderate
`decrease in the C1 index. Some degree of suppression
`of the C 1 index was associated with, and may be
`necessary for, efficacy, regardless of toxicity. As
`shown in Table 5, patients with improved pain/
`tenderness indices and patients with improved swell(cid:173)
`ing indices had mean decreases in the C1 index of 31 %
`and 42%, respectively, whereas patients with no im(cid:173)
`provement in these joint indices had little or no sup(cid:173)
`pression of the C1 index.
`
`DISCUSSION
`The efficacy of low-dose methotrexate in the
`treatment of RA was not compromised by supplemen-
`
`-41 (26)t
`-18 (12)
`-6.5 (J4)t
`
`Table 4. Mean percent change in the C1 index, from visit 1•
`Group
`Visit 2
`Visit 3
`-12 (24)
`s (12)
`-34 (12)t
`
`All patients
`Fol ate
`Placebo
`• The C1 index measures the activity or a folatc-dependent enzyme
`system in peripheral blood mononuc:lcar cells (see refs. 20 and 21).
`Sixteen patients in the folatc lf'OUp and 16 patients in the placebo
`group were evaluated at visit 1. Numbers in parentheses are n values
`at visits 2 and 3.
`t P < 0.01 versus visit I.
`f P < 0.0.5 vcnus visit I.
`
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`

`
`FOLIC ACID SUPPLEMENTS IN MTX-TREATED RA
`
`15
`
`Table 5. Mean pen:ent change in the C 1 index from visit I, by
`degree of toxicity or improvement with methotrexate treatment•
`
`Minor or no toxicity
`Moderate toxicity
`
`Swelling index improved.
`Swelling index not improved
`
`Pain and tenderness index improved
`Pain and tenderness index not improved
`
`Swelling index improved/minor or no toxicity
`Swelling index improved/moderate toxicity
`
`Pain and tenderness index Improved/minor or no
`toxicity
`Pain and tenderness index improved/moderate
`toxicity
`
`0 (3-0)
`-54 (20)t
`
`-42 '(28)t
`5 (22)
`
`-31 (25)t
`-23 (25)
`
`-24 (17)
`-60 (1 l)t
`
`-16 (17):t
`
`-51 (8)t
`
`•The C1 index measures the activity ofa folate-dependent enzyme
`system in peripheral blood mononuclear cells (sec refs. 20 and 21).
`Values are the mean from visits 2 and 3 combined. Numbers in
`parentheses are n values used to calculate the mean. Moderate
`toxicity was defined as a toxicity score >0.2 (see Patients and
`Methods). Improvement in joint indices was defined as a decrease of
`> 30% from visit 1.
`t P < 0.01 versus visit I.
`* P < 0.05 versus visit I.
`
`tation with daily FA during the period investigated in
`this trial, i.e., the first 6 months of therapy. Since
`35-40% of the US population uses nonprescribed,
`over-the-counter vitamin supplements (24, 25), and
`FA is among the supplements that are available over
`the counter, this finding of a lack of a detrimental
`effect is useful information for clinicians whose pa(cid:173)
`tients are taking MTX. Our results with folic acid are
`in contrast with those of studies on the effect of folinic
`acid (leucovorin) on MTX efficacy (26-30). In I recent
`study, folinic acid at 45 mg/week (beginning 4 hours
`after MTX administration) lessened GI and other toxic
`manifestations, but completely negated the efficacy of
`the MTX (26). Since folinic acid is a stable reduced
`folate cs~formyl-tetrahydrofolic acid) that bypasses
`dihydrofolate reductase inhibition, dosage levels and
`intervals of administration may be more critical than
`with the fully oxidized (i.e., FA) form of the vitamin (30).
`Supplementation with FA, I mg/day, signifi(cid:173)
`cantly reduced toxic manifestations of treatment with
`low-dose MTX. Although the placebo group had a
`longer mean duration of disease, the 2 study groups
`were comparable in all other paramet~rs m~ured,
`suggesting that longer disease duration could not have
`accounted for the differences observed. The median
`weekly dosage of MTX in the folate supplemept group
`was 7.5 mg. Patients treated with substantially higher
`
`doses of MTX may require supplementation with >I
`mg of FA per day to reduce toxicity.
`There has not been a controlled trial of the
`effect on MTX toxicity with the use of FA supplemen(cid:173)
`tation at higher doses. Some investigators have pre(cid:173)
`scribed FA at > 1 mg/day for MTX-treated RA patients
`(31 ,32), but its use has been controversial because of
`potential effects on disease response (33,34).
`The concurrent administration of a drug and its
`antagonist is not without precedent in RA, as indicated
`by reports of successful 0..penicillamine therapy with
`vitamin B6 supplementation (35,36). It should be
`pointed out that FA is a weaker MTX antagonist than.
`is leucovorin. Therefore, concerns that FA supple(cid:173)
`mentation will cause loss of therapeutic efficacy of
`MTX are not well founded.
`Low-normal initial folate levels in our placebo
`group were correlated with a high probability of even(cid:173)
`tual MTX toxicity, strongly suggesting that MTX
`therapy in a folate-depleted patient predisposes that
`individual to toxicity. A similar correlation between
`initial folate status and MTX toxicity has been ob(cid:173)
`served in patients treated for tumors of the head and
`neck (37). Such a correlation was not found in our
`folate supplement group, because patients with mar(cid:173)
`ginal baseline folate levels in this group underwent
`repletion of their folat.e stores concurrently with MTX
`therapy. Therefore, low-normat folate status should be
`included among ·other well-reqognized factors (38-42)
`as a contraindic~tion for M* treatment in patients
`with RA. This observation tak'es on added importance
`since marginal f E>late nutriture may be fairly common
`in RA (43,44). ·it is also likely that marginal folate
`nutritur.e is an uqrecognized determinant of toxicity in,
`and hence a contraindication for the initiation of MTX
`therapy for' psonasis ( 4.S), asthma ( 46), and a variety
`of other conditions (4.7).
`Ar\~Ysis of laf$er numbers of patients over time
`will help to determine if MTX toxicity is less likely in
`patients with normal '.initial folate status; it is known
`that folat.e stat\Js, be~omes bnpaired with long-term
`administration of MTX (20). The impaired utilization
`of folates· in patients with vitamin 8 12 deficiency (48)
`would su~est that vitamin 8~2 levets should also be
`checked prior to initiation of MTX therapy, although
`the im&>Qrtance of low 8 12 values in RA is not com(cid:173)
`pletely udderstood (49).
`Th~ data in Table 4 suggest that careful adjust(cid:173)
`ment of ihe extent of folate. antagonism and of the
`dosage-of: FA is necessary in order to maintain clinical
`
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`
`Teva – Fresenius
`Exhibit 1023-00007
`
`

`
`16
`
`MORGAN ET AL
`
`response without toxicity. Patient improvement, as
`judged by joint indices, was associated with a decrease
`in .the folate-dependent enzyme activities reflected in
`the·c1 index, whereas those patients with no improve(cid:173)
`ment had a smaller decrease, or even an increase, in
`the C 1 index. J1tis is consistent with the fact that
`sulfasalazine, also an inhibitor of folate-dependent
`enzymes including those involved in the C 1 index, is,
`like MTX, useful in the treatment of RA (5~52). The
`association of severe folate antagonism with toxicity is
`demonstrated by the fact that the C 1 index dropped to
`significantly lower levels in the patients with toxicity,
`versus those with no toxicity. Clinically, this is con(cid:173)
`sistent wi