Part 6: Checklist for Moderating Methotrexate Side Effects in Rheumatoid Arthritis

What can be done to help methotrexate side effects?

13 Things to consider before flushing methotrexate

Methotrexate is an important drug for Rheumatoid Arthritis treatment. Many patients give up on it before fully considering their options. If a physician has recommended you discontinue methotrexate either due to liver toxicity or kidney malfunction, then you must do so. Also, you can never take methotrexate if you are pregnant or drink alcohol heavily.  For the rest of us (most Rheumatoid Arthritis patients), here are a few things to consider which may moderate methotrexate side effects.

  1. Are you taking your folic acid regularly? Is it the dose the doctor prescribed? Did you tell her all of your side effects? Sometimes the folic acid dose can be increased to alleviate methotrexate side effects. Some RA patients also take some combination of folic acid and folinic acid (leucovorin).
  2. Several companies manufacture generic methotrexate. Sometimes, it can be important to make sure that you are getting the same generic methotrexate with each refill. You can tell by the color of the tablets, or you can ask the pharmacist. Patients have reported a distinct difference in effectiveness if their brands are switched.
  3. Methotrexate doses can be decreased to reduce side effects and then built up slowly again because the body can learn to tolerate the drug.
  4. Methotrexate can be dosed as either a once a week or spread out over a few days. Perhaps if one has not worked well, switching methods will work better.
  5. Methotrexate can be administered either orally or by injection. The injection provides a stronger dose simply because absorption is closer to 100% (none is lost in the digestive process.) Injections are an option if there are digestive issues or a higher dose of methotrexate is required.
  6. Digestive issues with methotrexate are often prevented by a daily regimen of omeprazole magnesium (generic for Prilosec) or a similar medication which blocks histamine receptors in the stomach. Taking some type of acid inhibitor is also recommended by many doctors for prevention of damage from NSAIDs.
  7. Pink bismuth tablets (generic for Pepto-Bismol in the US) also provide effective relief for digestive symptoms due to methotrexate and are generally considered very safe.
  8. Many people find that certain foods help alleviate side effects of oral methotrexate dosing. For example,  oatmeal eaten directly before the pills are swallowed prevents stomach upset for some.
  9. I have personally found that sucking hard peppermint candy helps so much with the “metallic taste” side effect that comes with long term use of methotrexate. Peppermint has a long list of beneficial properties and works in a few seconds. It also relieves nausea naturally.
  10.  It is well known that grapefruit is a food which has the opposite effect to oatmeal. It increases absorption of medication. So, if you are worried about trouble with methotrexate, don’t eat grapefruit.
  11.  I read a book written by a physician who suggested taking methotrexate at bedtime so that you can sleep through lots of the side effects which are worst during the first day. I know people who even take their dose on a certain day with a plan to take it easy one day every week.
  12.  Check for drug interactions. Perhaps the methotrexate alone is not what is causing the problem, but the combination of drugs. Ask a pharmacist to give you advice. It’s also pretty easy to research drug interactions on Google. Type “interaction” and then the name of each drug in quotes. If you find something, ask your doctor about it. Never change your medicine without talking to the doctor.
  13.  Since the body can become accustomed to drugs, side effects often resolve with no change in treatment. I call this “pushing through it” because if you endure, often your tolerance of a medication will improve. A rheumatologist once told me that most patients who give up methotrexate do it too soon and against doctor advice because they do not know that the side effects may not be permanent.

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