1. About methotrexate
Methotrexate is a type of medicine called an immunosuppressant. It slows down your body's immune system and helps reduce inflammation.
It is used to treat inflammatory conditions, including:
It can also be prescribed for other autoimmune conditions such as sarcoidosis.
Methotrexate is available on prescription only.
It comes as tablets, a liquid that you drink, and pre-filled injection pens or syringes that you inject into your skin. Your specialist doctor may recommend injections if the tablets or liquid are not working for you.
It can also be given as an injection to treat some types of cancer. This is usually done in hospital.
NHS coronavirus advice
As long as you have no symptoms of coronavirus infection, keep taking your prescribed immunosuppressant medicine as usual.
If you develop any coronavirus symptoms, talk to your specialist doctor urgently. They will tell you if you need to stop treatment until these symptoms get better.
Updated: 20 March 2020
2. Key facts
- For conditions such as psoriasis, rheumatoid arthritis and Crohn's disease, you'll usually take methotrexate once a week. It's important to take it on the same day each week.
- You'll get a patient card to record the details of your weekly dose and the day you take it. Keep this with you and show it to any healthcare staff involved in your care.
- Before and during treatment, you'll have blood tests to check your blood, liver and kidneys.
- You may also have a chest X-ray and a breathing test to check your lungs before starting treatment.
- It's important to record how much methotrexate you take and the results of your blood tests. You'll usually get a booklet for this.
3. Who can and cannot take methotrexate
Methotrexate can be used by adults and children.
Methotrexate is not suitable for some people. Tell your doctor before taking methotrexate if you:
- have ever had an allergic reaction to methotrexate or any other medicine
- are pregnant, trying to get pregnant or are breastfeeding
- have severe liver, kidney, or blood disease
- have an infection
- have mouth ulcers, or have been diagnosed with a stomach ulcer or duodenal ulcer
- are due to have a "live" vaccine (this includes the live flu vaccine usually given to children)
4. How and when to take methotrexate
If you take methotrexate once a week, take it on the same day each week. There's usually a reminder on your pill packet and patient card, telling you which day to take your medicine.
Doses for inflammatory conditions
For inflammatory conditions such as psoriasis, rheumatoid arthritis and Crohn's disease, the dose will vary. This depends on your condition and blood test results. Always follow the instructions from your doctor.
For rheumatoid arthritis, the usual starting dose is 7.5mg, taken once a week. This can be slowly increased up to 20mg (tablets) or 25mg (pre-filled injection pen or syringe) once a week.
For psoriasis, the usual starting dose is 2.5mg to 10mg, taken once a week. It can be slowly increased up to 30mg once a week.
For Crohn's disease, the usual dose to prevent flare-ups is 10mg to 25mg, taken once a week. This is often called a "maintenance" dose.
If your child is prescribed methotrexate, the doctor will use their height and weight to work out the right dose.
Taking methotrexate tablets
Swallow the tablets whole with a drink of water. You can take your tablets before or after food. Wash your hands after touching the tablets.
Your doctor will tell you how many tablets to take each time. You may have to take up to 10 tablets to make up your dose.
Taking methotrexate liquid
Always use the oral syringe that comes with your medicine to measure your dose. It's important to use this syringe so that you get the right amount.
It's a good idea to have a drink of water after taking your medicine.
Having methotrexate injections
You will usually go to your GP surgery or a hospital outpatient clinic once a week to have your injection.
Alternatively, you may get a pre-filled injection pen or syringe for you to use at home. Your doctor or nurse will show you how to use this.
Methotrexate treatment for cancer
If you're having methotrexate treatment for cancer, a doctor or nurse will usually give you an injection. You may need to have treatment more than once a week and this will be done in hospital.
What if I take too much?
Taking too much methotrexate can cause serious side effects. In some cases it can be fatal.
Store your weekly methotrexate separately, away from any other medicines that you take daily.
If you need to go to A&E, do not drive yourself. Get someone else to drive you or call for an ambulance.
Take the methotrexate packet, or the leaflet inside it, plus any remaining medicine with you.
Taking folic acid
You may be prescribed folic acid tablets while you're taking methotrexate. This is a man-made version of vitamin B9 (also called folate).
Folic acid helps protect the healthy cells in your body and reduces some of the side effects of methotrexate. It can make you less likely to be sick (vomit) or get diarrhoea.
Your doctor will usually start you on one 5mg folic acid tablet, taken once a week. Take it the day after your methotrexate.
If you are still bothered by side effects, your doctor may increase the dose of folic acid. You may need to take 1 tablet 6 times a week, starting the day after you take your methotrexate.
Do not take folic acid on the same day as your methotrexate. It can stop your medicine from working properly.
Tests during treatment
When you first start treatment, you'll have a check-up and blood tests every 1 to 2 weeks. This is to check if the methotrexate is working and if it's causing any side effects.
Your doctor may increase or decrease your methotrexate dose, depending on the results of your tests.
It's important to record how much methotrexate you take and the results of your blood tests. You'll usually get a booklet for this.
Once you and your doctor have found the right dose and your treatment is working well, you'll have a check-up and blood tests every 2 to 3 months.
What if I forget to take it?
If you forget to take a dose, take it as soon as you remember the next day or the day after.
If your dose is more than 2 days late, contact your doctor or the clinic for advice about what to do.
Never take 2 doses together to make up for a missed dose.
5. Side effects
Like all medicines, methotrexate can cause side effects, although not everyone gets them.
Common side effects
Common side effects may happen in more than 1 in 100 people.
Speak to your doctor if these side effects bother you or do not go away:
- loss of appetite, feeling or being sick, stomach ache or indigestion
- feeling tired or drowsy
- hair loss
Serious side effects
Serious side effects are rare and happen in less than 1 in 10,000 people.
Tell your doctor immediately if you get:
- yellowing of your skin and whites of your eyes – these may be signs of liver problems
- a persistent cough, chest pain, difficulty breathing, or you become breathless – these may be signs of inflammation of your lungs
- swollen hands, ankles or feet, changes to how often you pee or not peeing at all – these may be signs of kidney problems
- a high temperature, chills, muscle aches, sore throat – these may be signs of an infection
- bleeding gums, blood in your pee, vomiting blood or unexplained bruising – these may be signs of a blood disorder
- severe skin rash or blisters on your skin, mouth, eyes or genitals – these may be signs of Stevens-Johnson syndrome
Serious allergic reaction
In rare cases, it's possible to have a serious allergic reaction (anaphylaxis) to methotrexate.
Immediate action required: Call 999 or go to A&E now if:
- you get a skin rash that may include itchy, red, swollen, blistered or peeling skin
- you're wheezing
- you get tightness in the chest or throat
- you have trouble breathing or talking
- your mouth, face, lips, tongue or throat start swelling
You could be having a serious allergic reaction and may need immediate treatment in hospital.
These are not all the side effects of methotrexate. For a full list see the leaflet inside your medicines packet.
You can report any suspected side effect using the Yellow Card safety scheme.
6. How to cope with side effects of methotrexate
What to do about:
- loss of appetite, feeling or being sick, stomach ache or indigestion – eat simple meals and do not eat rich or spicy food. It can help to eat and drink slowly and have smaller, more frequent meals. If you're being sick, try taking small, frequent sips of water to avoid dehydration. For stomach ache, putting a heat pad or covered hot water bottle on your stomach may help.
- diarrhoea – drink lots of fluids, such as water or squash, to avoid dehydration. Signs of dehydration include peeing less than usual or having dark strong-smelling pee. Do not take any other medicines to treat diarrhoea without speaking to a pharmacist or doctor.
- headaches, feeling tired or drowsy – rest and drink plenty of water. Do not take non-steroidal anti-inflammatories (NSAIDs), such as ibuprofen. You can try a painkiller such as paracetamol. Do not drink too much alcohol. Do not drive, cycle or use machinery if you feel tired or drowsy. Speak to your doctor if this does not get better.
- hair loss – this is unlikely to be permanent. If hair loss bothers you, talk to your doctor. They may be able to lower your dose or recommend a different medicine.
7. Pregnancy and breastfeeding
Methotrexate and pregnancy
Methotrexate is not recommended in pregnancy.
If you are taking methotrexate and planning a pregnancy in the future, speak to your doctor. They will discuss whether you need to switch to a different medicine before stopping your contraception. Methotrexate can stay in your body for some time, so you need to stop taking methotrexate at least 6 months before trying for a baby.
If you become pregnant while taking methotrexate, do not stop taking your medicine and speak to your doctor as soon as possible. They’ll review your treatment and help you decide what to do next. Your doctor will only prescribe methotrexate for you while you're pregnant if the benefits of the medicine outweigh the chances of it being harmful.
Methotrexate and breastfeeding
Methotrexate passes into breast milk in very small amounts.
If your weekly dose of methotrexate is 25mg or less, it may be possible to breastfeed. However, you must not breastfeed for 24 hours after taking your medicine. Your midwife or health visitor can give you advice about how to feed your baby while you wait 24 hours.
If your weekly dose is more than 25mg, your doctor will talk to you about what’s best for you and your baby. You may still be able to breastfeed if your doctor says it is OK. However it depends on your dose of methotrexate and any other medicines you are taking.
If you breastfeed while taking methotrexate, your baby will have blood tests to check for any side effects.
If you notice that your baby isn't feeding as well as usual, or if you have any other concerns about your baby, talk to your health visitor, midwife or doctor as soon as possible.
Non-urgent advice: Tell your doctor if you're:
- trying to get pregnant
For more information about how this medicine could affect you and your baby, read the leaflet on methotrexate on the Best Use of Medicines in Pregnancy (BUMPs) website.
8. Cautions with other medicines
There are many medicines that affect the way methotrexate works.
Children taking methotrexate must not have a "live" flu vaccine (this usually applies to children aged 2 to 17 years). Adults are given an "inactivated" flu vaccine and this usually does not cause problems with methotrexate.
Tell your doctor if you're taking these medicines before you start methotrexate:
- non-steroidal anti-inflammatories (NSAIDs) like ibuprofen, or cough and cold remedies containing NSAIDs
- co-trimoxazole, trimethoprim or other antibiotics for bacterial infections
- medicines that make you pee more (diuretics), such as indapamide and bendroflumethiazide
- epilepsy medicines such as phenytoin or levetiracetam
- theophylline, a medicine used to treat asthma
- medicines used to treat indigestion, such as omeprazole
- folic acid or vitamin supplements that contain folic acid (or folate) – this is because your doctor may prescribe folic acid to take with your methotrexate
These are not all the medicines that may affect methotrexate.
Mixing methotrexate with herbal remedies and supplements
Do not take vitamin and mineral supplements or any other products that contain folic acid (folate) if you are already taking folic acid prescribed by your doctor. Check the ingredients on the labels of any supplements.
There is not enough information to say whether it's safe to take other herbal remedies or supplements together with methotrexate. They are not tested in the same way as medicines.
Tell your doctor or pharmacist if you're taking any other medicines, including herbal medicines, vitamins or supplements.
9. Common questions about methotrexate
How does methotrexate work?
Methotrexate calms your immune system, to help stop it attacking your body's cells. This helps reduce the inflammation that causes swollen and stiff joints in rheumatoid arthritis, thickened skin in psoriasis or damage to your bowel in Crohn's disease.
Methotrexate is not a painkiller. However, by reducing the inflammation caused by the condition, you may notice a reduction in pain as your symptoms improve.
When used in cancer treatments, methotrexate stops cancer cells reproducing. This helps prevent them growing and spreading in your body.
How long does it take to work?
Once your dose of methotrexate has been increased to a full dose, it may take up to 12 weeks before you notice any benefits.
It's important to keep taking methotrexate. The medicine is working, even if you do not feel any different for a few months.
How long will I take it for?
If methotrexate works for you, you may need to take it for several years to control your symptoms.
Is it safe to take long-term?
Methotrexate may increase the risk of problems with your liver or lungs, especially if you take a high dose.
However, your doctor will monitor you very closely while you're taking methotrexate. Any concerns or problems will be found during routine check-ups.
Speak to your doctor or specialist nurse if you are worried about taking methotrexate.
Does methotrexate increase the risk of cervical cancer?
There is no evidence that methotrexate increases the risk of developing cervical cancer.
Can you get more than a week's supply at a time?
When you start your treatment, your hospital consultant will usually give you the first few prescriptions for methotrexate. You will get 1 week's supply at a time.
They will monitor you closely to make sure that the medicine is working properly, the dose is at the correct level and not giving you too many side effects.
Once the dose is right and your condition is stable, the consultant may ask your GP to continue your treatment. Your GP will also decide where you'll go for blood tests and how often.
Once this is agreed, and if your blood results are OK, your GP will usually give you 1 month's supply of methotrexate at a time (or 4 doses).
Do I need to avoid people with viruses while I'm taking it?
Methotrexate may lower the number of white cells in your blood. This can make you more likely to get an infection.
It's important to reduce your risk of getting an infection. When possible, avoid close contact with people who you know are unwell.
Tell your doctor if you think you are getting a sore throat or if you have a high temperature.
Are there other treatments for inflammatory conditions?
There are several different treatments that can help the symptoms of inflammatory conditions. These include medicines, other types of therapy and even surgery.
Your doctor will be able to recommend the best treatment for you, based on your condition and your symptoms.
Treatments for rheumatoid arthritis
- medicines such as methotrexate, biological medicines (made from proteins and other substances produced by the body) and steroids
- painkillers, including non-steroidal anti-inflammatory drugs (NSAIDs)
- supportive treatments, including physiotherapy
- surgery, including joint replacement
- complementary therapies, such as acupuncture
Treatments for psoriasis
- creams and ointments that you apply to your skin
- ultraviolet light (phototherapy)
- tablets or injections, including methotrexate, that work throughout your entire body
Treatments for Crohn's disease
Can I drink alcohol with it?
It's usually OK to drink alcohol if you take a low weekly dose of methotrexate (25mg or less) for the long-term treatment of an inflammatory condition.
If you are taking high doses of methotrexate, ask your doctor for advice about drinking alcohol.
Are there foods and drinks I need to avoid?
There are no specific foods that you need to avoid while taking methotrexate. However, methotrexate may reduce your ability to fight infection. Therefore, it's best to avoid unpasteurised milk and soft cheeses.
It's also best to avoid having too much caffeine (contained in coffee, tea, some soft drinks and chocolate). This is because caffeine can stop methotrexate from working as well as it should.
Will it affect my contraception?
However, if methotrexate makes you sick (vomit) or have severe diarrhoea for more than 24 hours, your contraceptive pills may not protect you from pregnancy. Look on the pill packet to find out what to do.
Will it affect my fertility?
Methotrexate is not recommended in pregnancy or while trying for a baby.
This medicine can stay in a woman's body for 6 months after they stop taking it.
For men, there is a risk that methotrexate can damage sperm. This can affect the way a baby develops during pregnancy.
Women and men wanting to try for a baby need to stop taking methotrexate at least 6 months before trying to conceive.
Ask your doctor about changing to a different medicine before you stop using contraception.
Can I drive or ride a bike?
Methotrexate may sometimes make you feel tired, or dizzy and light-headed.
If you are feeling tired or dizzy, do not drive, ride a bike or use tools or machinery until you feel better.