METHOTREXATE SHOULD BE USED ONLY BY PHYSICIANS WHOSE KNOWLEDGE AND EXPERIENCE INCLUDE THE USE OF ANTIMETABOLITE THERAPY. BECAUSE OF THE POSSIBILITY OF SERIOUS TOXIC REACTIONS (WHICH CAN BE FATAL)
METHOTREXATE SHOULD BE USED ONLY IN LIFE THREATENING NEOPLASTIC DISEASES, OR IN PATIENTS WITH PSORIASIS OR RHEUMATOID ARTHRITIS WITH SEVERE, RECALCITRANT, DISABLING DISEASE WHICH IS NOT ADEQUATELY RESPONSIVE TO OTHER FORMS OF THERAPY.DEATHS HAVE BEEN REPORTED WITH THE USE OF METHOTREXATE IN THE TREATMENT OF MALIGNANCY, PSORIASIS, AND RHEUMATOID ARTHRITIS. PATIENTS SHOULD BE CLOSELY MONITORED FOR BONE MARROW, LIVER, LUNG AND KIDNEY TOXICITIES. (See PRECAUTIONS) PATIENTS SHOULD BE INFORMED BY THEIR PHYSICIAN OF THE RISKS INVOLVED AND BE UNDER A PHYSICIAN’S CARE THROUGHOUT THERAPY. THE USE OF METHOTREXATE HIGH DOSE REGIMENS RECOMMENDED FOR OSTEOSARCOMA REQUIRES METICULOUS CARE. (See DOSAGE AND ADMINISTRATION) HIGH DOSE REGIMENS FOR OTHER NEOPLASTIC DISEASES ARE INVESTIGATIONAL AND A THERAPEUTIC ADVANTAGE HAS NOT BEEN ESTABLISHED. METHOTREXATE FORMULATIONS AND DILUENTS CONTAINING PRESERVATIVES MUST NOT BE USED FOR INTRATHECAL OR HIGH DOSE METHOTREXATE THERAPY.
- Methotrexate has been reported to cause fetal death and/or congenital anomalies. Therefore, it is not recommended for women of childbearing potential unless there is clear medical evidence that the benefits can be expected to outweigh the considered risks. Pregnant women with psoriasis or rheumatoid arthritis should not receive methotrexate. (See CONTRAINDICATIONS).
- Methotrexate elimination is reduced in patients with impaired renal functions, ascites, or pleural effusions. Such patients require especially careful monitoring for toxicity, and require dose reduction or, in some cases, discontinuation of methotrexate administration.
- Unexpectedly severe (sometimes fatal) bone marrow suppression, aplastic anemia, and gastrointestinal toxicity have been reported with concomitant administration of methotrexate (usually in high dosage) along with some nonsteroidal anti-inflammatory drugs (NSAIDs). (See PRECAUTIONS
- Methotrexate causes hepatotoxicity, fibrosis and cirrhosis, but generally only after prolonged use. Acutely, liver enzyme elevations are frequently seen. These are usually transient and asymptomatic, and also do not appear predictive of subsequent hepatic disease. Liver biopsy after sustained use often shows histologic changes, and fibrosis and cirrhosis have been reported; these latter lesions may not be preceded by symptoms or abnormal liver function tests in the psoriasis population. For this reason, periodic liver biopsies are usually recommended for psoriatic patients who are under long-term treatment. Persistent abnormalities in liver function tests may precede appearance of fibrosis or cirrhosis in the rheumatoid arthritis population. (See PRECAUTIONS, Organ System Toxicity, Hepatic).
- Methotrexate-induced lung disease, including acute or chronic interstitial pneumonitis, is a potentially dangerous lesion, which may occur acutely at any time during therapy and has been reported at low doses. It is not always fully reversible and fatalities have been reported. Pulmonary symptoms (especially a dry, nonproductive cough) may require interruption of treatment and careful investigation.
- Diarrhea and ulcerative stomatitis require interruption of therapy: otherwise, hemorrhagic enteritis and death from intestinal perforation may occur.
- Malignant lymphomas, which may regress following withdrawal of methotrexate, may occur in patients receiving low-dose methotrexate and, thus, may not require cytotoxic treatment. Discontinue methotrexate first and, if the lymphoma does not regress, appropriate treatment should be instituted.
- Like other cytotoxic drugs, methotrexate may induce "tumor lysis syndrome" in patients with rapidly growing tumors. Appropriate supportive and pharmacologic measures may prevent or alleviate this complication.
- Severe, occasionally fatal, skin reactions have been reported following single or multiple doses of methotrexate. Reactions have occurred within days of oral, intramuscular, intravenous, or intrathecal methotrexate administration. Recovery has been reported with discontinuation of therapy. (See PRECAUTIONS, Organ System Toxicity, Skin.)
- Potentially fatal opportunistic infections, especially pneumonia, may occur with methotrexate therapy.
- Methotrexate given concomitantly with radiotherapy may increase the risk of soft tissue necrosis and osteonecrosis.
Methotrexate (formerly Amethopterin) is an antimetabolite used in the treatment of certain neoplastic diseases, severe psoriasis, and adult rheumatoid arthritis.
Methotrexate is indicated in the treatment of gestational choriocarcinoma, chorioadenoma destruens and hydatidiform mole.
In acute lymphocytic leukemia, methotrexate is indicated in the prophylaxis of meningeal leukemia and is used in maintenance therapy in combination with other chemotherapeutic agents. Methotrexate is also indicated in the treatment of meningeal leukemia.
Methotrexate is used alone or in combination with other anticancer agents in the treatment of breast cancer, epidermoid cancers of the head and neck, advanced mycosis fungoides (cutaneous T cell lymphoma), and lung cancer, particularly squamous cell and small cell types. Methotrexate is also used in combination with other chemotherapeutic agents in the treatment of advanced stage non-Hodgkins lymphomas.
Methotrexate in high doses followed by leucovorin rescue in combination with other chemotherapeutic agents is effective in prolonging relapse-free survival in patients with non-metastatic osteosarcoma who have undergone surgical resection or amputation for the primary tumor.
Methotrexate is indicated in the symptomatic control of severe, recalcitrant, disabling psoriasis that is not adequately responsive to other forms of therapy, but only when the diagnosis has been established, as by biopsy and/or after dermatologic consultation. It is important to ensure that a psoriasis "flare" is not due to an undiagnosed concomitant disease affecting immune responses.
Rheumatoid Arthritis including Polyarticular-Course Juvenile Rheumatoid Arthritis
Methotrexate is indicated in the management of selected adults with severe, active rheumatoid arthritis (ACR criteria), or children with active polyarticular-course juvenile rheumatoid arthritis, who have had an insufficient therapeutic response to, or are intolerant of, an adequate trial of first-line therapy including full dose non-steroidal anti-inflammatory agents (NSAIDs).
Aspirin, (NSAIDs), and/or low dose steroids may be continued, although the possibility of increased toxicity with concomitant use of NSAIDs including salicylates has not been fully explored. (See
PRECAUTIONS, Drug Interactions.) Steroids may be reduced gradually in patients who respond to methotrexate. Combined use of methotrexate with gold, penicillamine, hydroxychloroquine, sulfasalazine, or cytotoxic agents, has not been studied and may increase the incidence of adverse effects. Rest and physiotherapy as indicated should be continued.
Media Articles Related to Methotrexate
Methotrexate Greatly Underprescribed for U.S. RA Patients (CME/CE)
Source: MedPageToday.com - medical news plus CME for physicians [2016.12.02]
(MedPage Today) -- The staple DMARD should be utilized longer, at higher doses, and via subcutaneous delivery, researchers say
Methotrexate ‘Dramatically’ Underused for RA
Source: Medscape Orthopaedics Headlines [2016.12.01]
Methotrexate, the "anchor" drug for rheumatoid arthritis (RA), is "dramatically underutilized in clinical practice," researchers report.
Reuters Health Information
Rheumatoid arthritis: Myth-busting methotrexate
Source: Arthritis / Rheumatology News From Medical News Today [2016.11.14]
Medical professionals are being urged to openly discuss methotrexate for the treatment of rheumatoid arthritis (RA) to allay patient concerns and myths about its toxicity, according to the authors...
Adalimumab plus methotrexate effective for rheumatoid arthritis
Source: The Doctors Lounge - Rheumatology
Adalimumab and methotrexate is about five times more effective than methotrexate alone, according to a new systematic review of studies.
Make the Diagnosis: Nerve Concern
Source: MedPage Today Rheumatology [2016.11.21]
(MedPage Today) -- Case Findings: A 63-year-old left-handed male patient presents with tingling in both hands, particularly the left hand. He has struggled to sleep for the past week; after laying down to read, his hand begins to tingle. He reports the tingling only while lying down, he has no symptoms when sitting or standing, and the symptoms resolve quickly once he sits up. He reports symptoms across the whole hand (front and back), but more on the palm than the fingers. The tingling involves all fingers, but is less pronounced on the thumb. There is no muscle weakness, coolness, or discoloration. He reports no swelling or muscle atrophy. The patient's history includes rheumatoid arthritis, for which he has been taking methotrexate for a year, and new onset diabetes mellitus. He also reports feeling tingling in his legs when he bicycles for a long time.
On exam, the patient reports onset of mild symptoms with his arms raised overhead. There were no neurological findings, and a negative Tinel's sign.
What is your diagnosis?
Published Studies Related to Methotrexate
A randomized, double-blind, and placebo-controlled multicenter clinical trial of
a novel cytotoxic T-lymphocyte antigen-4 fusion protein, Leining, in Chinese
active rheumatoid arthritis patients with an inadequate response to methotrexate. 
To assess the clinical efficacy as well as safety profiles of Leining, a novel
cytotoxic T-lymphocyte antigen-4 fusion protein, versus placebo in the treatment
of Chinese active rheumatoid arthritis (RA) patients with an inadequate clinical
response to methotrexate (MTX)... Administration of Leining in combination with MTX for 24 weeks was well
Remission induction comparing infliximab and high-dose intravenous steroid,
followed by treat-to-target: a double-blind, randomised, controlled trial in
new-onset, treatment-naive, rheumatoid arthritis (the IDEA study). 
infliximab (IFX) with MTX and intravenous corticosteroid for remission induction... CONCLUSIONS: In DMARD-naive early RA patients, initial therapy with MTX+high-dose
Safety and efficacy of combination therapy of iguratimod with methotrexate for
patients with active rheumatoid arthritis with an inadequate response to
methotrexate: an open-label extension of a randomized, double-blind,
placebo-controlled trial. 
with active rheumatoid arthritis (RA)... CONCLUSION: Efficacy and tolerance of iguratimod + MTX therapy was maintained to
Weekly low-dose methotrexate for reduction of Global Initiative for Asthma Step 5
treatment in severe refractory asthma: study protocol for a randomized controlled
BACKGROUND: Patients with chronic severe asthma (CSA) have a crippling disease
and current available treatments are not satisfactory... Improvement in several
indicators of asthma severity and control will be also investigated.
Long-term efficacy and safety of certolizumab pegol in Japanese rheumatoid
arthritis patients with an inadequate response to methotrexate: 52-week results
from an open-label extension of the J-RAPID study. 
an inadequate response to methotrexate... CONCLUSIONS: Continued CZP administration with methotrexate maintained efficacy
Clinical Trials Related to Methotrexate
A Study to Evaluate the Effect of Multiple Doses of Isavuconazole on the Pharmacokinetics of Methotrexate [Completed]
The purpose of this study is to assess the effect of multiple doses of isavuconazole on the
pharmacokinetics of a single dose of methotrexate. Safety and tolerability of isavuconazole
will be assessed alone and in combination with methotrexate.
Assessment of Safety and Pharmacokinetics of a Low Dose of Methotrexate in Healthy Adult Male Kenyan Volunteers [Completed]
Previous investigations indicate that methotrexate, an old anticancer drug, could be used at
low doses to treat malaria. This is a phase I evaluation to assess the safety and
pharmacokinetic profile of this drug in healthy adult male Kenyan volunteers.
Co-Administration Of Methotrexate And CP-690,550 [Completed]
This study was designed to estimate the effects of methotrexate (MTX) on the
pharmacokinetics (PK) of CP-690,550 when administered to subjects with rheumatoid arthritis
(RA), to estimate the effects of CP-690,550 on the PK of MTX and to evaluate the short-term
safety and tolerability of co-administration of CP-690,550 and MTX.
Treatment of Early RA: Minocycline in Combination With Methotrexate vs Methotrexate Alone [Completed]
The purpose of this study is to determine if a combination of methotrexate and minocycline
works better than methotrexate alone in early Rheumatoid Arthritis
The Effects of mETHotrexate Therapy on ST Segment Elevation MYocardial InfarctionS (TETHYS Trial) [Not yet recruiting]
Experimental studies suggest that anti-inflammatory and immunomodulatory drugs could reduce
the inflammatory profile in acute ischemic disease and reduce the area of ischemia.
Methotrexate is a drug that has shown promise in ischemic disease in animal studies.
Reports of Suspected Methotrexate Side Effects
Dyspnoea (109), more >>
PATIENT REVIEWS / RATINGS / COMMENTS
Based on a total of 18 ratings/reviews, Methotrexate has an overall score of 7.22. The effectiveness score is 8.56 and the side effect score is 6.78. The scores are on ten point scale: 10 - best, 1 - worst. Below are selected reviews: the highest, the median and the lowest rated.
Methotrexate review by 64 year old female patient
|Overall rating:|| || |
|Effectiveness:|| || Considerably Effective|
|Side effects:|| || No Side Effects|
|Condition / reason:|| || Rheumatoid Arthritis|
|Dosage & duration:|| || 20 mg. taken 1 x week for the period of 2 years to present|
|Other conditions:|| || none|
|Other drugs taken:|| || Remicade|
|Benefits:|| || The combination of weekly 20mg. Methotrexate with an infusion (at the doctor's office) of Remicade has almost completely controlled my rheumatoid arthritis.
I have had no further joint damage, and the initial symptoms of extreme fatigue and pain in the small joints of my hands, wrists, feet and ankles has abated.|
|Side effects:|| || None that I am aware of|
|Comments:|| || I was diagnosed with rheumatoid arthritis about two years ago and began treatment with a combination of Remicade (infused once every eight weeks over a period of about 2 hours in my doctor's office) and Methotrexate 20 mg. once a week. I take 8 tablets every Friday, 2.r mg. each. I have had no negative side effects from either medication. |
Methotrexate review by 39 year old female patient
|Overall rating:|| || |
|Effectiveness:|| || Considerably Effective|
|Side effects:|| || Moderate Side Effects|
|Condition / reason:|| || Rhematory Arthritis|
|Dosage & duration:|| || 1 cc (dosage frequency: weekly injection) for the period of 2 years|
|Other conditions:|| || Uticaria|
|Other drugs taken:|| || None|
|Benefits:|| || This drug definitely helped control flares and joint stiffness. It also helped defeat the incredible amount of hives. Hives were completely controlled.|
|Side effects:|| || Unfortunately, there were many side effects such as diarrhea, nausea, occasional vomiting, extreme fatigue, foggy mind. Bruising at the injection site was also very common.|
|Comments:|| || One injection every week.|
Methotrexate review by 58 year old female patient
|Overall rating:|| || |
|Effectiveness:|| || Considerably Effective|
|Side effects:|| || Severe Side Effects|
|Condition / reason:|| || psoraitic arthritis|
|Dosage & duration:|| || 6 tabs taken daily for the period of 4 years|
|Other conditions:|| || psoriasis|
|Other drugs taken:|| || none|
|Benefits:|| || the treatment masked the psoriasis and what was considered arthritis|
|Side effects:|| || increasing all over body pain|
|Comments:|| || I started with 4 tabs and increased to 6 as the all over body pain increased and then they were going to put me on prednisone. I opted to turn to homeopathic treatment and weaned off the methotrexate. The all over body pain went completely away but the psoriasis was exacerbated. I'd rather have that than not be able to walk or move.|
Page last updated: 2016-12-02