Methotrexate: the gold standard without standardisation.

Even in the current era of biological targeted therapies, methotrexate (MTX) remains the initial preferred antirheumatic drug and is widely prescribed for patients with rheumatoid arthritis (RA). The combination of its perceived efficacy, acceptable safety profile and low cost, as well as decades of clinical experience with its use that have been accumulated by current and previous generations of rheumatologists, make MTX the cornerstone of treatment for RA and the anchor drug for combination with each of the newer biological agents. Four papers in this journal provide general guidance for the use of MTX, its optimal dose and route of administration and its potential toxicity (see articles on pages 1086, 1094, 1100 and 1105). This ‘‘3E Initiative,’’ supported by an unrestricted educational grant from Abbott, began with an extensive systematic literature review (Evidence) that was discussed by each of 17 national scientific committees (Expertise). These national groups combined to form a broad international panel of experts who shared (Exchange) the individual national recommendations. While acknowledging changes in MTX use over time and in different geographical regions, the authors propose consensus guidelines for the use of MTX to manage patients with RA.