Methotrexate polyglutamation in relation to infliximab pharmacokinetics in rheumatoid arthritis

Ann Rheum Dis. 2013 Jun;72(6):908-10. doi: 10.1136/annrheumdis-2012-202591. Epub 2012 Nov 17.


Objective: The combination of methotrexate (MTX) with infliximab can modify infliximab pharmacokinetics and lower the incidence of antibodies against infliximab (ATIs). We hypothesised that the pharmacokinetic interaction between MTX and infliximab is related to activation of MTX to immunosuppressive MTX polyglutamates (MTXPGs).

Methods: Adult patients with rheumatoid arthritis receiving weekly MTX with infliximab for more than 3 months were enrolled in a cross-sectional study. Blood was collected at trough before the infusion of infliximab. Red blood cell (RBC) MTXPGs were measured using liquid chromatography, and circulating levels of infliximab were measured using a cell-based assay. ATIs were measured using enzyme immunoassays. Statistical analyses consisted of multiple regression and Wilcoxon tests.

Results: In the 61 patients enrolled in the study, ATIs were detected in 11 (18%). Regression analyses revealed that lower infliximab levels (median 3.3 µg/ml) were associated with the presence of ATIs and lower RBC MTXPG levels (median 28 nmol/l) (p<0.05). Logistic regression revealed that RBC MTXPG levels above 25 nmol/l were associated with a 4.7-fold lower likelihood of having ATIs (OR=4.7; 95% CI 1.1 to 20.8; p=0.02). None of the 12 patients with RBC MTXPG levels above 50 nmol/l tested positive for ATIs.

Conclusions: These hypothesis-generating data indicate that MTXPGs are associated with infliximab pharmacokinetics and ATI formation.

Keywords: Anti-TNF; Methotrexate; Pharmacokinetics; Rheumatoid Arthritis.

Publication types

  • Clinical Trial
  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Antibodies, Monoclonal / immunology
  • Antibodies, Monoclonal / pharmacokinetics*
  • Antibodies, Neutralizing / immunology*
  • Antirheumatic Agents / immunology
  • Antirheumatic Agents / pharmacokinetics*
  • Arthritis, Rheumatoid / drug therapy
  • Arthritis, Rheumatoid / metabolism*
  • Chromatography, Liquid
  • Cross-Sectional Studies
  • Drug Interactions / immunology
  • Drug Therapy, Combination
  • Erythrocytes / chemistry
  • Erythrocytes / immunology
  • Female
  • Humans
  • Infliximab
  • Male
  • Methotrexate / analogs & derivatives*
  • Methotrexate / pharmacokinetics*
  • Middle Aged
  • Polyglutamic Acid / analogs & derivatives*
  • Polyglutamic Acid / pharmacokinetics


  • Antibodies, Monoclonal
  • Antibodies, Neutralizing
  • Antirheumatic Agents
  • Polyglutamic Acid
  • methotrexate polyglutamate
  • Infliximab
  • Methotrexate