Methotrexate for chronic inflammatory conditions 

Methotrexate is a medicine that has been used to treat chronic inflammatory conditions such as juvenile idiopathic arthritis, juvenile dermatomyositis, systemic lupus erythematosus, vasculitis and severe psoriasis for many years.This information sheet from Great Ormond Street Hospital (GOSH) explains about the use of methotrexate in such conditions. 

Methotrexate is also used in the treatment of cancer but in much higher doses. In rheumatological conditions, lower doses are used. Methotrexate has been used in children, young people and adults for many years with good effect.

Methotrexate is not a cure but it should help your child’s condition by reducing the symptoms and the need for other medicines. The usual practice is to remain on methotrexate until your child is in remission (no active inflammation) – this may be for several years. You and your child will have a more detailed teaching session before starting this medication.

How is it given?

Methotrexate comes in several forms, either as syrup, tablets, or as an injection under the skin (subcutaneous). It is given only once a week. It is important to take methotrexate on the same day each week.Methotrexate does not work immediately. It may be 6 to 12 weeks before any benefit is noticed.

The doctor may suggest changing to injectable methotrexate if your child is unable to tolerate the tablets/syrup or if the inflammation fails to respond to the oral methotrexate.

Who should not take methotrexate?

People with the following conditions should discuss taking methotrexate with their doctor:

  • „„hypersensitivity to methotrexate or any of its ingredients
  • „„pregnant, could be pregnant, trying to become pregnant or breastfeeding
  • „„existing severe blood disorders
  • existing breathing problems
  • „„existing kidney problems

What are the side effects?

  • „„Nausea or stomach upset – This is quite common and is usually managed by taking the dose with or after food. Taking the medicine on Friday nights means that school is not missed if there is some stomach upset the next day. Please speak to your doctor or nurse if nausea or vomiting is becoming a problem.
  • „„Mouth ulcers.
  • „„Thinning of the hair – not usually a noticeable problem.
  • „„Generally feeling unwell, including fatigue and loss of appetite - we will prescribe folic acid, which can help to prevent or minimise this and other side effects. 
  • „„Effects on the blood count – monitored carefully with regular blood tests.
  • „„Inflammation of the liver – monitored carefully with regular blood tests. Alcohol should not be taken with methotrexate as it may upset liver function.
  • „„Skin rashes – uncommon.
  • „„Cough and breathing problems – incredibly rare in children and young people.

„„Methotrexate must not be given to patients who may be pregnant or are likely to become pregnant in the near future. If your daughter is over 12 years old, we will ask her about her periods and any possibility that she could be pregnant. If the young person is sexually active, they must use contraception.

Methotrexate and other medicines

Some medicines can react with methotrexate. Always check with your doctor or pharmacist before giving your child any other medicine, including medicines on prescription from your family doctor (GP), medicines bought from a pharmacy (chemist) or any herbal or complementary medicines.

Regular monitoring

Your child must have regular blood tests every two to eight weeks. Most children do not have any problems but if they do occur, the methotrexate can be briefly stopped or the dose reduced, Children treated with methotrexate will be given a card to record the results of these blood tests.

Important information

„„Methotrexate should never be given more than once a week.

„„Your child’s immunity to chicken pox should be checked with a blood test prior to starting methotrexate and the result should be recorded on the parent-held blood monitoring card.

„„If your child is on methotrexate and has not had chicken pox and comes into contact with someone who has chicken pox or shingles (either face to face or longer than 15 minutes in the same room), you should report to your local doctor immediately as your child may be at risk of developing a more severe form of the infection and may need treatment.

„„If your child gets chicken pox or shingles you should also report to your local doctor immediately for aciclovir to be given „„

Your child should NOT have any live vaccinations such as inhaled influenza/flu, MMR, oral polio, chicken pox, yellow fever or BCG while taking methotrexate. Inactivated or killed vaccines such as the injectable influenza/flu, meningitis C, pneumococcal, hepatitis, Hib, tetanus, diphtheria, whooping cough/pertussis and the killed version of the polio immunisation are permitted if the patient is stable on treatment.

„„Keep all medicines in a safe place where children cannot reach or see them.

„„You should handle these drugs with care. Avoid touching the methotrexate wherever possible.

„„Methotrexate should be stored at room temperature.

„„Methotrexate tablets are made in two different strengths – 2.5mg and 10mg. They are different shapes but a similar colour so always check you have been given the correct strength by your doctor or pharmacist. Do not take the tablets if you think you have the wrong strength. Check with your doctor or pharmacist first.

„„Methotrexate is also available in liquid form. It is important to check with your doctor or pharmacist that you are giving the correct volume.

„„Methotrexate should always be taken as directed by your doctor, nurse or pharmacist.

„„If you forget to give your child their dose on your normal day, you can give it as soon as you remember on the following day or the day after that, but never give double the dose.

„„If the doctor decides to stop treatment, return any remaining medicine to the pharmacist. Do not flush or throw them away.

Compiled by: 
The Pharmacy department and Rheumatology CNS team in collaboration with the Child and Family Information Group Each person reacts differently to medicines so your child will not necessarily have any of the side effects mentioned.
Last review date: 
November 2015
Ref: 
2015F0673

Disclaimer

Please read this information sheet from GOSH alongside the patient information leaflet (PIL) provided by the manufacturer. If you do not have a copy of the manufacturer’s patient information leaflet please talk to your pharmacist. A few products do not have a marketing authorisation (licence) as a medicine and therefore there is no PIL.

For children in particular, there may be conflicts of information between the manufacturer’s patient information leaflet (PIL) and guidance provided by GOSH and other healthcare providers. For example, some manufacturers may recommend, in the patient information leaflet, that a medicine is not given to children aged under 12 years. In most cases, this is because the manufacturer will recruit adults to clinical trials in the first instance and therefore the initial marketing authorisation (licence) only covers adults and older children.  

For new medicines, the manufacturer then has to recruit children and newborns into trials (unless the medicine is not going to be used in children and newborns) and subsequently amend the PIL with the approved information. Older medicines may have been used effectively for many years in children without problems but the manufacturer has not been required to collect data and amend the licence. This does not mean that it is unsafe for children and young people to be prescribed such a medicine ‘off-licence/off-label’. However, if you are concerned about any conflicts of information, please discuss with your doctor, nurse or pharmacist.