What is your approach to monitoring for hepatic fibrosis in chronic methotrexate use?

Historically, in lower-risk patients (e.g. rheumatoid arthritis patients who are less likely to have metabolic syndrome and are treated with lower doses), guidance has been to proceed with liver biopsy if repeated tests show elevated liver enzymes or hypoalbuminemia. In higher risk patients, (e.g. p...

Historically, dermatologists have routinely ordered liver biopsies in psoriatic patients receiving MTX. It was part of their guidelines. Rheumatologists have not for the most part. Psoriatic patients for whatever reason tend to develop more liver disease from MTX. Other factors that enhance MTX hepa...