Managing Side Effects of Methotrexate
Managing Side Effects of Methotrexate
Dr Louise McCormack
Outline
COMMON Nausea/GI
SERIOUS Pneumonitis
RARE Cancer risk
Lethargy/headache Pancytopenia
Transaminitis Stomatitis
Interactions with other medications
Neutropenia
Alopecia
Macrocytosis
Lymphopenia
PRACTICAL POINTS Pregnancy and fertility
Vaccines
Infection risk
Alcohol
Methotrexate
? Dihydrofolic acid reductase inhibitor
? Weekly dosing only, takes at least 8 weeks to clinical benefit
? Blocking folic acid reduction prevents effective mitosis in rapidly dividing cells ? leucocytes, hair follicles, mucosal cells
? Folic acid supplementation probably does not reduce efficacy of MTX, and does reduce risk of GI side effects, transaminitis, cessation, maybe stomatitis
Gastro intestinal Side Effects
? Nausea, Vomiting, less commonly diarrhoea ? Generally for up to 72 hours post dose ? Common upon commencement - often abate ? Manage by
? Nocte dosing of MTX ? Increase folic acid dose or frequency ? up to 5mg
6 days per week ? Change to Folinic acid 7.5mg or less 8-12 hours
post MTX (leucovorin)
Lethargy/Headache
? Often in the 72 hours post dose not all week ? Can limit its use ? Folic acid and folinic acid not always helpful
but worth a try ? Reduce dose by 5mg week first ? Discuss cessation with Rheum if severe and
not responding to FA changes
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