Methotrexate’s effect on the body
· Methotrexate is an antimetabolite-type cytotoxic agent. It has been used to treat various malignant diseases.
· In low dosages it can reduce inflammation, and related disease progression. 
· This drug acts by interfering with folic acid synthesis, and many of the adverse effects can be avoided by use of folic acid (5 mg per day)
· It does not lead to remission in all cases
· Beware of potential serious side-effects on the body. Careful monitoring essential.

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Who can benefit from methotrexate?
· Some people with rheumatoid arthritis not responding sufficiently to non-drug measures and NSAID’s.

When and how do I take methotrexate?
Methotrexate in tablet form should be taken:
· once a week on the same day of the week,
· with food. 
· It should be swallowed whole and not chewed or crushed.
· It can also be injected once a week, either under the skin or into the muscle.

What dose do I take?
· Methotrexate tablets, available in 2.5 mg and 10 mg doses, look so similar that you should always check that you take the correct dose.
· Your doctor will usually start you off with 7,5 mg – 10 mg per week, and then increase the weekly dose by 2,5 mg for 2 –4 weeks till the optimal response is achieved.
· The maximum dose is usually 20 mg per week.
· Add a folate supplement of 5 mg per day

How long will methotrexate take to work?
Methotrexate is regarded as rapid-acting, but it does not work immediately. It may take 3 to 12 weeks before you feel better.

What are the potential side-effects?
· The adverse effects are minimal with low dose therapy.
· In some people methotrexate can affect the gastro-intestinal tract and can cause diarrhoea and/or nausea,
· It may cause mouth ulcers, hair loss and skin rashes, pigmentary changes

· It may suppress bone marrow function. With fewer blood cells produced, the likelihood of infections increases.
· It may damage the liver and/or kidneys
· In some cases it may cause hypersensitivity pneumonitis (inflammation of the lung) with breathlessness. If you become breathless, you should see your doctor immediately.
· RED ALERT: a person on methotrexate with a sore throat and high fever, should be admitted to hospital very urgently. If you develop a sore throat, or other infection, or a fever, or unexplained bruising or bleeding, or any new symptoms after starting methotrexate, you should see your doctor urgently.
· If you have not had chicken-pox but come into contact with someone with chicken-pox or shingles, or if you develop shingles or chicken-pox while taking methotrexate, you should see your doctor immediately. You may need special treatment.
· 5 mg of folic acid per day can reduce the likelihood of side-effects.

Do I need any special monitoring while on methotrexate?
Yes.
· Your blood count (including hemoglobin, white cell count and platelets) should be monitored.
· Your liver function should be monitored carefully and regularly prior to and during the treatment. 
Can I take other medication while on methotrexate?
Some drugs will interact with methotrexate and should be avoided or used with great care. 
· Aspirin and non-steroidal anti-inflammatory drugs inhibits the kidneys’ ability to metabolize the drug and the risk of renal damage increases
· Phenytoin, trimethoprim, cotrimoxazole and triamterene may increase the risk of methotrexate toxicity.
· Methotrexate may increase uric acid blood concentrations – person may need more allopurinol, the medication prescribed to reduced elevated blood uric acid levels.
· Monitor the use of anti-clotting agents carefully as methotrexate may interfere with the synthesis of clotting factors.
· No vaccination with live virus vaccines. Thus no vaccination against polio, rubella (German Masles) or yellow fever. Flu vaccines are safe.
· Avoid sulphonamide antibiotics

What about methotrexate and pregnancy and breastfeeding?
It can reduce fertility and is likely to harm the unborn baby.
Take contraceptive precautions while taking methotrexate and even for 6 months after methotrexate is stopped. Inform your doctor immediately if you fall pregnant while on methotrexate.
Do not use while pregnant or breastfeeding. 

What about alcohol while taking methotrexate?
Alcohol enhances the risk of liver damage, and must be avoided.

Read more:
Assess your symptoms of arthritis - part 1
Assess your symtoms of arthritis - part 2

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