Methotrexate for Rheumatology Patients

Important information about methotrexate for the rheumatology patient:

Methotrexate is a treatment for juvenile arthritis and other autoimmune conditions such as dermatomyositis, lupus, psoriasis, uveitis, and vasculitis. This medicine can also be used for many other non-rheumatic diseases, often at much higher doses.

The medicine reduces inflammation throughout the body, including in the eyes, skin, and blood vessels. As a result, the pain and stiffness caused by inflammation can be improved.

Methotrexate can be given as an injection under the skin (SQ, subcutaneously) or as a tablet or liquid given by mouth (orally). Your healthcare provider will discuss which option is best for your child. It is given once a week.

Side effects of methotrexate include:

• Feeling more tired than usual the day after taking the medicine.

• Upset stomach or nausea the day after taking the medicine

• Increased risk of infection

• Irritation to the liver (which can most often be reversed if identified early)

• Decreased blood counts

• Hair thinning and mouth sores are possible but rare with the doses used for rheumatologic disease

• Rare risk of pneumonitis, which is an inflammation of the lungs

Folic acid may help reduce the side effects. Your provider may recommend a multivitamin containing 400-1000 mcg (1mg) of folic acid. If the multivitamin does not reduce the side effects, your provider may give you a prescription for folic acid which is taken daily, or leucovorin which is taken once weekly. If symptoms continue, your healthcare team may prescribe a medicine for nausea.

Patient instructions:

• Give methotrexate once a week, on the same day. If you miss a dose, please call your healthcare provider. Rotate injection sites weekly if taking methotrexate subcutaneously.

• Do not give this medicine with food. Take one hour before or 2 hours after eating food.

• Do not give methotrexate if your child has a fever.

• If your child has a fever, call your rheumatology provider. They may ask you to stop giving the methotrexate until the fever is gone. You should also take your child to your primary care provider if they have a fever.

• Let your primary care provider know that your child is taking methotrexate. Your child should not receive live vaccines while taking methotrexate. Live vaccines include: MMR, varicella and the nasal flu mist. Your child should receive the flu shot, which does not contain live virus. The COVID vaccine is also recommended. Talk to your provider about when and how often your child should get this vaccine. When possible, your child should avoid contact with people who are sick

• Call your rheumatology provider if your child has been exposed to chicken pox or shingles (varicella).

• Some antibiotics cannot be taken with methotrexate. Check with your rheumatology provider before giving your child any antibiotics

• Patients should not drink alcohol while taking methotrexate.

• Your child will need regular blood tests to check that the medicine is not causing problems with blood cells or their liver, also called medicine toxicity. Your team cannot refill your child's methotrexate prescription unless their blood tests are up to date. This is a common schedule for blood testing:

  • One month, or 4 doses, after starting the medicine

  • If the results are normal, test again every 3 to 4 months

  • When your child is due to have medicine toxicity labs drawn; they should be done at least 5 days after the weekly injection

Methotrexate injection usually comes in a vial. Learn more about how to give medicine from a vial.

Sometimes it can be prescribed as an autoinjector. 

• Otrexup™ autoinjector

• Rasuvo® autoinjector

Safety:

• Wash your hands after handling this medicine.

• Methotrexate can harm an unborn baby. Patients should not get pregnant while taking methotrexate. Do not handle or administer methotrexate if you are pregnant or breastfeeding.

• Keep this medicine away from other children and animals.

Instructions for storage and disposal:

• Store methotrexate in a cool, dark, dry place. Room temperature or below is recommended. Do not store it in the bathroom.

• Contact your local refuse department to learn the rules for needle and syringe disposal in your area. We cannot accept used syringes in our office. More information about this can also be found at www.safeneedledisposal.org.

Call your CHOP healthcare team with questions, concerns or if your child:

• Has a fever of 101° or more on the day the day they usually take methotrexate. Your team will help you to determine when to take it next

• Has yellow coloring of the skin or eyes

• Feels very tired or weak after taking a dose of this medicine

• Has a fever or illness and the primary care provider is unsure of what next steps to take

• Has swelling or pain at an injection site that does not go away after 2-3 days

• Has signs of an allergic reaction soon after taking the methotrexate such as swelling of the face, lips, tongue or throat; trouble breathing, wheezing or chest tightness

• Has been given too much medicine

Call 911 if your child has signs of an allergic reaction such as swelling of the face, lips, tongue or throat; trouble breathing, wheezing or chest tightness. If you are concerned the reaction is related to methotrexate, call your healthcare team after symptoms resolve to discuss a plan moving forward.

Division of Rheumatology

215-590-2547

Reviewed on March 24, 2023, by Kirsten Spichiger, DNP, CRNP; Melissa A. Lerman, MD, PhD, MSCE; Hannah Gustafson, PharmD