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How I prescribe Methotrexate step-by-step

How I prescribe Methotrexate step-by-step

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I started a couple of patients on Methotrexate (MTX) today and did so the previous workday. I'm very likely to have to explain the drug tomorrow.

It's our go-to drug in rheumatology due to it's favourable benefit-risk ratio.

MethotrexateI thought it worth giving you some insight into how I go about explaining and prescribing this drug.

Please note that this is my general spiel and that there are many variations by rheumatologists all over the world. I also vary it depending on the actual patient and their other medical issues/medications.

This is the gist of what I say:

  • You may hear/read that Methotrexate is Chemotherapy and this might scare you. It's not chemotherapy & can be used safely. I explain why (see link)
  • We need to discuss the amount of alcohol you drink. I typically don't expect patients to become teetotalers, but I'm not comfortable with more than 1-2 standard drinks 2-3 nights a week (I do appreciate that what a patient admits to drinking & the reality may be different).
  • I use 10mg tablets. Commence Methotrexate at 10mg ONCE A WEEK only at dinner time. If tolerated without any side effects (and patients are asked to contact me if there are any ill effects), the dose will then be increased to 20mg ONCE A WEEK only.
  • The day after the MTX dose, you'll take 5mg of folic acid (ie once weekly to start). This is used to reduce side effects.
  • In about 3.5 weeks, after 4 doses (sooner if I am concerned about other medical issues/medications), the 1st monitoring blood tests will be performed. I usually see the patient 1 month after the commencement of MTX.

Patients contemplating/commencing MTX are emailed links to web-based resources to explain the medication. Where possible, my patients also now come in for further education with our rheumatology care coordinator, Flora (we think/feel/believe that the more education a patient has upfront, the better compliance & hopefully, understanding).

Again, note that my spiel and regime for commencing may be different from other rheumatologists. Some differences may be:

  • Different formulation of Methotrexate. Some rheumatologists prefer or only have access to a 2.5mg tablet (rather than the 10mg tablet).
  • Different preference for starting dose. Some may start MTX at a lower dose, eg 7.5mg once a week (ie 3 x 2.5mg tablets).
  • Different speeds for increasing the dose.
  • Different formulations and regimes for folic acid use, ranging from 0.5mg daily to 5mg once weekly to 5mg daily. I am not aware of any studies suggesting an optimum dose but it's accepted that using some folic acid reduces side effects.
  • Regimes are often tweaked depending on a patient's specific situation i.e individualised therapy.

I continue to write about Methotrexate to demystify and debunk myths. I hope this helps in some way. Please do feel free to share your thoughts.

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