What Are Common Side Effects Of Methotrexate
Most people can take methotrexate comfortably, but all medications can cause side effects. Three of the most common ones for methotrexate are:
- Nausea and vomiting
- Mouth sores and ulcers
- Methotrexate fog
To prevent or relieve side effects, your provider may recommend one or more of these steps:
- Taking half of your dose in the morning and the other half in the evening on the day you would normally take your full dose
- Taking a folic acid supplement
- Switching from tablets to the injection form of methotrexate
- Taking an anti-nausea medication for severe nausea
Some rare but serious side effects you should be aware of include:
- Liver disease: If youve had liver disease before, methotrexate can increase your chances of getting liver damage. Alcohol can also increase this risk. Do not drink alcohol while taking methotrexate.
- Aplastic anemia: This is a condition where your body isnt making enough new red blood cells. If it happens, it usually develops over weeks or months, and may cause weakness and fatigue.
- Lung disease: In very rare cases, methotrexate has been linked to lung disease. Be sure to let your provider know if you start to notice a dry cough or difficulty breathing.
This is not a complete list of side effects for methotrexate. Always take your prescription as instructed, follow up with your provider at your scheduled appointments, and reach out if you have any questions or concerns.
Is Methotrexate Safe If Im Pregnant Or Planning To Be
Methotrexate can cause birth defects. It can also increase the risk of infertility in men who take it. If you arent taking methotrexate yet and are planning to be pregnant, let your doctor know. They will likely recommend that you hold off on starting methotrexate. However, if you are already taking it, you may be asked to stop and wait 1 to 3 months before trying to conceive.
How It Makes You Feel
The correct dose of methotrexate will reduce inflammation and alleviate the condition its prescribed for, whether thats rheumatoid arthritis, psoriasis, inflammatory bowel disease, and so on. But it can take one to two months to work.
The most common side effects include nausea and mouth ulcers, due to the drugs inhibition of folate. This is because inhibiting folate targets rapidly dividing cells of the gastrointestinal tract.
Folic acid supplementation is used to prevent side effects associated with low-dose methotrexate therapy. Preferably, folic acid is not taken on the same day methotrexate is taken. Many studies have shown that folic acid supplements do not hinder the effectiveness of methotrexate.
If methotrexate is taken too frequently daily instead of weekly, for instance it can suppress bone marrow, reducing blood cell production and impairing the immune system. This can make the body susceptible to infections and, in the worst-case scenario, result in death.
In rare cases, this suppression of blood cell production can also occur at normal doses. This risk is higher in the elderly and in patients with reduced kidney function or dehydration.
Other severe side effects include lung and liver damage with long-term usage. People prescribed methotrexate will be closely monitored by their doctor for these effects.
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Methotrexate Initially Not A Drug For Ra
Although methotrexate has been proven as a great treatment option for RA, that isnt why this drug was created. In fact, methotrexate was initially introduced in the 1940s as a cancer treatment drug. Doctors prescribed it to provide relief for patients with different types of cancers, such as non-hodgkin lymphoma and breast cancer.
Methotrexate works by interfering with cancer cells ability to absorb and use folate. Folate is a form of vitamin B thats necessary for cell survival, but methotrexate has the effect of partially inhibiting dihydrofolate reductase within the cancerous cells.
Then in the 1970s, the Food and Drug Administration approved methotrexate for psoriasis according to the National Psoriasis Foundation. Psoriasis afflicts roughly 7.5 million people and involves itchy, inflamed skin. Fortunately for its sufferers, numerous studies have backed using methotrexate as a suitable psoriasis treatment option. For example, one 26-year retrospective study found that low-dose MTX is an effective therapy for severe forms of psoriasis.
Not only is methotrexate beneficial for people with psoriasis, its also helpful for those diagnosed with psoriatic arthritis. This type of arthritis is different than RA in that psoriasis generally precedes issues in the joints. In some cases though, no psoriasis-type symptoms exist at all.
A Similar Reduced Immune Response Can Occur With Flu Vaccine
One of the reasons doctors and patients have been concerned about methotrexate is because the drug has previously been shown to reduce immune response to the influenza vaccine in some patients.
We dont know the mechanism by which methotrexate lowers antibody response to the flu vaccine, Haberman says. The reason for the drop in COVID-19 response is similarly unclear.
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But it does point out that not everyone is the same when it comes to armoring up against COVID-19. It is imperative to know where the gaps exist so that we can address them and ensure that all of our patients are properly protected, she says.
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Myth: You Should Stop Non
The scary things you may read about the dangers of combining NSAIDs and methotrexate are primarily aimed at people taking high-dose methotrexate to treat cancer. Methotrexate is eliminated from the body by the kidneys, and if your kidney function is impaired , then methotrexate levels may increase to dangerous amounts resulting in severe consequences such as bone marrow and liver damage, says Bryant England, MD, assistant professor in the division of rheumatology and immunology at the University of Nebraska Medical Center in Omaha.
On low-dose methotrexate you wont be forbidden from using NSAIDs. However, regular blood work to monitor for these complications is essential while on methotrexate and may need to be more frequent when NSAIDs are also used, says Dr. England.
You may also find that you dont need NSAIDs as much as you used to before you started methotrexate. Patients and providers should regularly evaluate whether there is an ongoing need for NSAIDs or if alternative medications or non-drug therapies for pain relief could be substituted, Dr. England says.
How Does Methotrexate Work To Treat Rheumatoid Arthritis
Methotrexate belongs to a group of medications known as nonbiologic DMARDs . Examples of other nonbiologic DMARDs used to treat RA include , , and .
We dont know exactly how methotrexate works to treat RA yet, but researchers agree that it has an effect on the immune system. Methotrexate is thought to prevent your body from mounting immune and inflammatory responses. One way researchers think it does this is by blocking the effects of folic acid, a chemical that supports the production of new cells. Methotrexate may also ramp up processes in your body that counteract inflammation.
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Myth: Methotrexate Has Horrible Side Effects For Everyone
Theres no getting around the fact that methotrexate can cause a variety of side effects. These can include: gastrointestinal problems, such as nausea, stomach upset, and loose stool mouth ulcers hair loss and liver problems.
The good news is that not everyone experiences all or most of these side effects, and many people find them to be mild.
Most people tolerate methotrexate fairly well at the doses recommended for the treatment of RA, and most of the side effects improve or are better tolerated over time, says Dr. Makol.
Speak up about any possible drug-related symptoms you develop, because there are a lot of things you can do to ease or prevent methotrexate side effects. Your doctor may be able to adjust your dosage or switch you to subcutaneous shots of methotrexate instead of pills, which may be easier on your stomach.
You can also take folic acid supplements, which you can buy over the counter, along with methotrexate. These B vitamins help reduce side effects like mouth sores, sun sensitivity, hair loss and stomach upset.
Myth: You Have To Stop Drinking Alcohol When You Take Methotrexate
Not necessarily. There are reasons to be concerned about this alcohol/drug combo, but you may not have to become a teetotaler if you enjoy an occasional beer, cocktail, or glass of wine.
Alcohol doesnt make methotrexate less effective. The problem is that methotrexate can be toxic to the liver and has the potential to accelerate toxicity when mixed with alcohol, which is also metabolized by the liver. We ask our patients to limit the amount of alcohol they drink, but it doesnt have to be zero. If you drink, dont miss your lab tests so any liver abnormalities can be caught early. If there is any question about liver issues, then further testing with imaging and possible biopsy can be very informative, says Rebecca L. Manno, MD, MHS, assistant professor of medicine in the Johns Hopkins Arthritis Center in Baltimore.
Your doctor can advise on whether drinking any alcohol while on methotrexate is safe for you. Read more about alcohol and methotrexate.
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How Is Methotrexate Used
Methotrexate is usually taken in tablet form once a week. Sometimes it is taken as an injection, also once a week. A doctor will usually prescribe a very low dose at first, which will be gradually increased. Once the methotrexate is working well, the dose will be adjusted to the lowest level capable of maintaining the improvement that has been achieved.
People taking methotrexate will have regular blood tests – usually carried out by Dermatology Nurses, or by their own GP – to monitor possible effects of the treatment. These are required weekly at first, or when the dose is being altered, but once the dose of methotrexate is stable, monitoring tests are carried out every 2-3 months. People taking methotrexate should have an annual flu vaccination, but should check with a doctor or nurse before having any other vaccinations or taking other medication.
Methotrexate is often used on its own to treat psoriasis or psoriatic arthritis, however it is sometimes used in conjunction with other medications, in order to help the other medication work more effectively by preventing the body from building up antibodies.
What This New Information Means For People With Inflammatory Arthritis
Already, recommendations by the American College of Rheumatology call for holding the dosing of methotrexate for one week after each vaccine dose for those with well-controlled disease. People with RA who are on this medication should work with their physician to discuss their specific drug regimen.
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Can I Drink Alcohol While Taking Methotrexate
Methotrexate can affect liver function, which is why doctors will monitor your liver health closely while you take it. Methotrexate isnt recommended for people who already have chronic liver disease or who are heavy drinkers and have alcohol-related liver damage. Because there is potential for liver damage in people taking MTX, they shouldnt consume alcohol excessively.
For occasional drinkers, Dr. Feldman says the rules about how much alcohol is safe to drink while taking methotrexate depends on the rheumatologist. Some doctors insist on no alcohol at all, he explains. He tends to be a little looser with his patients. I tell my patients you can have a few drinks per week, just not all at once.
And dont have the alcohol two days before you get your blood drawn at the office, he adds, because the alcohol can mess up the liver function test and confuse your doctor. But he thinks a drink here and there is not dangerous for patients without any liver issues.
Can You Get The Covid
The answer is generally yes. The American College of Rheumatology encourages people with rheumatic diseases to get vaccinated against COVID-19. We want patients to get a COVID-19 vaccine hard stop, says rheumatologist Jeffrey Curtis, MD, MPH, a Professor of Medicine at the University of Alabama at Birmingham who led the task force that created the ACR COVID-19 vaccine guidance.
Beyond known allergies to vaccine components, there are no known additional contraindications to COVID-19 vaccination for people with rheumatic diseases, the guidance states. This means that simply having an autoimmune or inflammatory rheumatic disease or taking medication like methotrexate to treat it is not a reason to not get a COVID-19 vaccine.
The general consensus for most immunosuppressed patients based on what is known about how COVID-19 vaccines work is that COVID-19 vaccines should be safe for people on immunosuppressant therapy but may be some degree less effective.
Concerns have largely stemmed from the fact that people who take medications like methotrexate or other medications that affect immune system function were not included in the clinical trials that led to the vaccines authorization.
Similarly, a small study just published in the journal Annals of the Rheumatic Diseasesfound that about one-third of people with inflammatory arthritis or related conditions taking methotrexate had a reduced response to the COVID-19 vaccine.
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Methotrexate Once Weekly Dosing
- Patients can find the dose schedule for methotrexate taken for rheumatoid arthritis and psoriasis confusing
- Check regularly that your patients understand how to take methotrexate correctly.
- Specify on every prescription, and the dispensed medicine label, the day of the week the dose is to be taken.
- It is important to regularly monitor renal and liver function tests, full blood count and respiratory symptoms in all patients taking methotrexate.
Methotrexate is used to treat cancer and, in lower doses, to treat rheumatoid arthritis and psoriasis. Methotrexate interferes with folic acid metabolism and folic acid tablets are used to reduce adverse effect such as nausea or stomatitis1.
The Best Ways To Minimize Methotrexate Side Effects
Some side effects from this drug result from a drop in folic acid levels in the body. To reduce these effects, doctors generally prescribe folic acid supplements along with the drug.
Many people find taking the oral medicine with food can prevent stomach upset, Tenpas says.
Some recommend splitting the dose, by taking half in the morning and the other half 12 hours later to ease these gastrointestinal side effects. If that doesnt help, talk to your doctor about switching from the oral to the injectable version of the drug.
To deal with mouth sores, the the Arthritis Foundation suggests using a saltwater rinse or special mouthwash containing a lidocaine pain reliever. If nausea is an issue, you can request a prescription for anti-nausea medicine.
Not all of the negative effects of the drug cause symptoms. This is why routine blood tests are regularly performed for people taking this medication.
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Path To Improved Health
Methotrexate is usually taken by mouth as a tablet. Sometimes it is given as an injection . The dosage and how often you take it depends on why youre taking it. Some people take it on a rotating schedule of alternating days. People with RA or psoriasis often take it once a week. Its a strong medicine, so its important to take it exactly as your doctor tells you. Some people have mistakenly taken it once a day instead of once a week. They experienced very serious side effects, including death. NEVER change the amount you take or the time of day you take this medicine.
If you forget a dose, talk to your doctor before you take another dose. It can take weeks or months before you feel the full effects of methotrexate. Dont take more of it to try to speed up the process. Taking too much can cause harmful side effects.
Always talk to your doctor before stopping methotrexate.
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Methotrexate may cause side effects. The most common include:
- Swollen, tender gums.
- Thinning hair.
Be sure to tell your doctor about any side effects you have. Some side effects of methotrexate can be serious. Call your doctor right away if you have:
- A fever or feel as if you have the flu.
- Any unusual bruising or bleeding .
- Blurred vision or loss of vision.
- Weakness or difficulty moving one or both sides of your body.
What Else Should I Know About Taking Methotrexate
- Its important to keep every appointment with your doctor. He or she will need to watch the medicines effect on your body. They will also order blood tests to check your kidneys, liver, and blood production.
- Dont drink any alcohol, not even beer or wine. Drinking alcohol while youre taking methotrexate can cause serious liver problems.
- Dont take medicine for pain or inflammation unless your doctor tells you its okay. This includes over-the-counter pain medicine such as NSAIDs. Examples of NSAIDS are ibuprofen or naproxen . Pain medicines can increase the effects of methotrexate, which can be bad for you.
- Dont take any vitamins, supplements, or herbal products without talking to your doctor first. These can cause serious damage to your body.
- Dont get any vaccines while youre taking methotrexate. If youve stopped taking methotrexate, talk to your doctor to make sure that its okay to get a vaccine.
- Taking methotrexate can make it easier for you to get an infection. Try to avoid people who are sick.
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Optimal Methotrexate Dose For Rheumatoid Arthritis
The usual adult dose of methotrexate for rheumatoid arthritis is, as mentioned above, 7.5 milligrams as a single weekly dose. It can be taken as a divided dose: 2.5 milligrams taken orally every 12 hours for 3 divided doses over 36 hours once a week. The usual maximum weekly adult dose for oral methotrexate is 20 milligrams . The usual oral pediatric dose of methotrexate for rheumatoid arthritis is 5 to 15 milligrams once weekly.
According to research, the optimal evidence-based dose recommendation for adults with rheumatoid arthritis involves a starting dose of 15 milligrams of oral methotrexate once a week. That dose may be gradually increased to 25-30 milligrams per week or the highest tolerable dose. A switch to injectable methotrexate can be made by people with rheumatoid arthritis who achieve an insufficient response with oral methotrexate or for those who cannot tolerate the oral formulation. No matter what adjustments are made, it must remain as a weekly dose.