Methotrexate in Rheumatology – Complete patient info

Methotrexate is usually given in the form of tablets in once or twice weekly dose. We usually start with the dose of 7.5 mg once a week and gradually increase to a maximum of 20-25 mg per week.

Please make sure that you have understood the dose of your methotrexate tablet. One should not take the same on a daily basis or take a higher dose by mistake.

Besides tablets, methotrexate can be given in the form of a weekly injection. It is given as a subcutaneous injection like an insulin. In a subcutaneous injection we give injection in the layer of the fat under the skin. This is given with a very small needle like insulin and causes very little discomfort. It can be usually taken by patients themselves at home. Patients can be easily taught how to take it. Methotrexate injections can be a better mode for patients who feel vomiting like with tablets (please see side effects below). Injections might also be a option for those who are not responding well to tablets.

Methotrexate is a long term treatment. It works slowly and its good effects are usually seen after 3-12 weeks of treatment. It doesn’t work immediately. Your doctors might give you some Non-steroidal anti-inflammatory drugs (NSAIDS) or some doses of steroids (eg : prednisolone) at start. This is so that patients have relief before the effect of methotrexate is seen. Once methotrexate or other DMARD starts working, we stop or taper steroids and NSAIDS. ( Please note that NSAIDS are commonly known as pain-killers in India, but they also help to control inflammation.).

In which rheumatology diseases do we use methotrexate ?

Methotrexate is a very useful drug in many autoimmune or rheumatic conditions.

It is commonly used in following diseases

Rheumatoid arthritis
Psoriatic arthritis
Juvenile idiopathic arthritis
Vasculitis
SLE (lupus) etc

As with all medications, methotrexate can cause some side effects. The side effects can vary from person to person. Discuss side effects with doctor. They will suggest measures to minimise or tackle them. If you still have issues with your specialist doctor can give you other options.

The more common side effects with methotrexate are nausea (feeling sick or vomiting like) and abdominal pain. These usually happen on the day of taking methotrexate tablet or the day after.

Read more on how to prevent nausea and sickness associated with methotrexate in following article 7 ways to decrease methotrexate sickness or nausea in Rheumatoid & Psoriatic arthritis

People with methotrexate can also have oral ulcers and mild to moderate hair loss. We can decrease these side effects by giving patients folic acid. Folic acid is a vitamin that prevents or decreases the side effects of methotrexate. Hence all patients in methotrexate are also prescribed folic acid tablets.

If the patient has lot of vomiting like sensation on the day of methotrexate, doctors can give them some anti-vomit tablets or acidity tablets. There is some evidence that taking dark chocolate or coffee on methotrexate day might help avoid vomiting sensation. The body might also get adjusted to methotrexate after a while. The patient may not have much issues after taking few doses of methotrexate.

Methotrexate can sometimes lower the blood counts and can sometimes increase the liver enzymes. Your rheumatologist or treating doctor should regularly do blood tests. They make sure that you are not developing any problems with methotrexate.

Methotrexate has been used in Rheumatoid arthritis for more than 30 years now. Many patients take it throughout life without any major issues. A specialist doctor will always monitor patients on methotrexate closely. They will stop or change the drug if there are any issues.

The doctors need to regularly check patient’s blood counts, liver and renal function. Routine blood tests are advised to be done every 2-3 weeks as we start methotrexate. Once the patient is on long term stable methotrexate we can do blood tests once every 3 months or so.

Some special situations to inform your doctor when you are on methotrexate

You should always tell any doctor if you are on methotrexate even if you go to doctor for other issues.. Also inform your rheumatology (specialist) doctor or your local family physician if you develop any of the following while taking methotrexate ;

Any infection like sore throat cough fever or diarrhoea etc Any sudden onset breathlessness Any unexplained bleeding Any yellowing of the skin or eyes jaundice Any new symptoms that concerns you

If you are really unwell with something, you should hold your methotrexate. You should also contact your doctor as soon as possible.

You should also show your doctor if you develop any chicken pox or shingles.

Rheumatic diseases are diseases with overactive immunity. Drugs that control the immunity are very important for controlling such diseases. Methotrexate does help in controlling this overactive immunity. When we give such drugs there is always a risk that immunity might be slightly lowered. This might increase risk of infections.

However, methotrexate used in rheumatic diseases is known as low dose methotrexate (LD-Mtx). It is reasonably safe. There is decent evidence that it does not increase the risk of major infections. Some infections might become more severe while patients are on methotrexate. That is why we ask patients to inform if they have any infections. We also use vaccines to decrease infection risk in patients (see vaccination section below).

Methotrexate helps to control your rheumatoid arthritis or other rheumatic diseases. Steroids are very strong suppressors of immune system and can increase risk of infections. Methotrexate helps to control disease by avoiding steroids.

You should always inform any doctor you are showing that you are on methotrexate.

There are some medications where methotrexate can interact with.

Don’t take any ayurvedic remedies or herbal remedies along with methotrexate or other rheumatic disease medications. Please inform your doctor if you are planning to do same. This may otherwise lead to side effects to major organs like liver and kidneys.

Usually most antibiotics are safe to be taken while one is taking methotrexate. If a doctor prescribes you an antibiotic called septran (which contains trimethoprim) it can lead to some issues. So always tell your doctor that you are taking methotrexate and they can give you medications accordingly.

Medications like anti-fit (or convulsion) medication and anti-asthma medication (Deriphylline) can interact with methotrexate. Doctor should take caution while prescribing you the same. Please discuss any medication you are taking with your specialist doctor or rheumatologist.

Vaccines help to prevent diseases. There are many vaccines which can be given to adults besides vaccine given to children. Some vaccines have live bacteria. We don’t advise people to take vaccines with live bacteria while they are on methotrexate. Always discuss any vaccine you are taking with your doctor. For example, yellow fever vaccine is not given in patients on methotrexate. Yellow fever vaccine is given when you are travelling to certain parts of Africa.

It’s is safe to take vaccines not containing live bacteria in patients on methotrexate. Your doctor may advise you some vaccines to decrease the risk of some infections. Usually vaccines against pneumonia bacteria and influenza are advised to rheumatic patients. It will vary for each patient and doctor.
Alcohol in patients on methotrexate for rheumatology diseases
Taking small quantity of alcohol while one is on methotrexate is safe. One should not exceed 14 units of alcohol per week. Also, one should avoid alcohol binges while on methotrexate.
Fertility breastfeeding and pregnancy planning – issues with methotrexate for rheumatoid arthritis
All rheumatic diseases patients with uncompleted families should discuss pregnancy plans with their doctors in the first few visits itself.

Methotrexate does not decrease the chance of fertility or getting pregnant in either males or females.

Methotrexate can cause potential damage to babies in the womb if a pregnant lady takes methotrexate. Thus, females should avoid pregnancy while on methotrexate. They should plan it with their specialist doctor. They will give the patient other options and hold methotrexate.

For more information on pregnancy management in rheumatic diseases one can read the following article :Rheumatoid, psoriatic arthritis & pregnancy : All queries answered
Instead of methotrexate, doctors can use other medications which are safe in pregnancy (can read more in above article). Methotrexate takes time to clear from body after stopping. It is thus advised to avoid pregnancy for at least 3 months after we stop methotrexate. Thereafter the patient can plan pregnancy. The outcomes of pregnancy doesn’t change in patients who have taken methotrexate in the past.

Women on methotrexate should avoid pregnancy and strictly use contraceptive measures. The type of contraceptive measures (condoms, pills etc.) can be decided after consultation with your obstetrician and rheumatologist.

There is good research to show that methotrexate does not affect the semen or sperm quality. Male partners taking methotrexate does not cause any problems in pregnancy. So there is no need to stop methotrexate for a male person planning pregnancy.

The methotrexate drug can pass into the breast milk and effect on child are not known. Methotrexate should not be given to breastfeeding mother and specialist doctor will provide alternative solutions to her.

• Methotrexate controls the overactive immune system in rheumatic diseases and helps control inflammation. This helps to prevent joint and organ damage.
• Methotrexate is not a pain killer or steroid. It is a disease modifying anti-rheumatic drug (DMARD).
• Methotrexate used in rheumatic diseases is low dose (LD-MTX) and is not chemotherapy. It is very different drug from high doses (HD-MTX) used in chemotherapy.
• Methotrexate may take 3-12 weeks to show it’s good effects of controlling disease.
• Methotrexate in rheumatology is given as once or twice weekly tablets. It can also be given as a weekly insulin like injection with little discomfort.
• Methotrexate used in rheumatology may cause nausea (vomiting like feeling), abdominal discomfort, oral ulcers and hair loss Folic acid vitamin help prevent these side effects and is given to all patients on methotrexate. The patient’s body might get adjusted to methotrexate after few weeks with minimal issues.
• The specialist doctor will advise routine blood monitoring (every 1-3 months) while one is on methotrexate.
• Rheumatoid diseases itself can involve lungs. Methotrexate causing lung issues is very rare. Inform your specialist doctor if you have new onset breathing issues.
• One should always inform any doctor (if showing for other health issues) if they are taking methotrexate. This will help the doctor to give medicines which do not interact with methotrexate.
• Inform your doctor if you have any infections. If one is very unwell with any illness (other than their rheumatic disease), they should hold their next methotrexate dose They should then show their specialist doctor as soon as possible and they can advise when to restart the same.
• One can have alcohol in limited quantities while on methotrexate.
• Some vaccines with live bacteria are not given in patients on methotrexate. It is safe to have vaccines with inactive bacteria or their subunits in patients on methotrexate.
• Females should avoid pregnancy while on methotrexate. Those desiring pregnancy should always plan it with their doctor. They will need to hold methotrexate for at least three months. Male patients on methotrexate do not need to stop drugs even if they are planning pregnancy.
• Methotrexate is not given to breast-feeding mothers.

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