Pharmacology and therapeutics Considerable variation among Iranian dermatologists in the dosing and monitoring of methotrexate for treating psoriasis Omid Zargari 1 , MD, Somayeh Hejazi 1 , MD, Mohamad Shahidi-Dadras 1 , MD, Shima Younespour 1 , PhD, Reza Robati 1 , MD, Alireza Firooz 2 , MD, Parviz Toosi 1 , MD, and Steven R. Feldman 3 , MD, PhD 1 Skin Research Center, Shohada Hospital, Tehran, Iran, 2 Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran, and 3 Departments of Dermatology, Pathology and Public Health Sciences, Center for Dermatology Research, Wake Forest University School of Medicine, Winston-Salem, NC, USA Correspondence Omid Zargari, MD Pars Clinic Somaye Bldv Golsar, Rasht 41657 Iran E-mail: ozargari@iranderma.com Conflicts of interest: None. Abstract Background Methotrexate (MTX) is a risky medication requiring careful attention to dosing and monitoring. Dosing and monitoring practices are not well characterized. Aims The aim of this study was to assess variation in the dosing and monitoring of methotrexate among Iranian dermatologists. Methods A questionnaire was administered to forty experts in psoriasis concerning the use of MTX. Results Among the 39 responding dermatologists (15 women, 24 men), 54% saw fewer than 10 psoriatic patients per week, 23% 10–20 patients, and 23% more than 20 patients. About half of the dermatologists treat their patients with an initial MTX dose of <7.5 mg/week (range 5–17.5 mg/week), an average dose of <10 mg/week (range 5–25 mg/week), and a maximum dose of <20 mg/week (range 7.5 – 50 mg/week) with 71.8% prescribing the medication orally and 28.2% intramuscularly. Subcutaneous injection was preferred by none of the dermatologists as a usual route of administration. Nearly 5% of the dermatologists believe that liver biopsy should be performed prior to treatment with MTX in all patients, and another 5% consider this procedure prior to treatment only in patients with risk factors. About 44 and 33% of the dermatologists do the liver biopsy after 1.0–1.5 g and 3.54 g total cumulative doses, respectively. Conclusion After more than a half century, there are still noticeable controversies on the manner of using MTX in treating psoriasis among Iranian dermatologists. A national guideline may help standardize treatment practices. Introduction Psoriasis is an inflammatory, chronic, immune-mediated disease with great impact on quality of life affecting approximately 2% of the worldwide population. 1 Metho- trexate (MTX), having anti-inflammatory, antiprolifera- tive, and immunosuppressant actions, is one of the main and relatively safe systemic therapies and has been widely used over 50 years for treating psoriasis. 2,3 Indeed, MTX is still considered as the gold standard drug for the treat- ment of severe psoriasis. 4 In spite of this long history for using MTX, there is still no evidence-based study directly addressing the therapeu- tic strategies (i.e., the questions of starting dose, method of escalation, and route of administration) for MTX in psoriasis, 3–6 and there is evidence of variability among dermatologists in how MTX is administered and moni- tored. 7 The purpose of this study was to assess the variability of dosing and monitoring practices among Iranian derma- tologists in their use of MTX in clinical practice. Materials and methods We conducted a survey among practicing dermatologists in Iran; the majority of them were members of the Iranian Psoriasis Network. A questionnaire was designed by the authors to collect the opinions of experts in psoriasis concerning the use of MTX. The questionnaire con- sisted of both open-ended and closed-ended questions. Open-ended questions were about usual starting, aver- age, and maximum dose of MTX administration. Two types of response scales for the closed-ended questions were used: nominal-polytomous questions were applied in questions about medical practice period, number of visits per week by patients with psoriasis, combination ª 2013 The International Society of Dermatology International Journal of Dermatology 2014, 53, 385–389 385