Methotrexate

Why Do I Need This Treatment?

In conditions such as rheumatoid arthritis, psoriatic arthritis, systemic lupus erythematosus (SLE), and uveitis, the immune system becomes overactive.
Instead of protecting you, your white blood cells attack your own joints, skin, eyes, and other tissues, leading to pain, swelling, and long-term damage.

To prevent this, doctors use immune-suppressing medicines. Methotrexate is the most commonly used of these drugs.

What is Methotrexate and How Does It Work?

Methotrexate is a disease-modifying antirheumatic drug (DMARD).
It calms the immune system, reduces inflammation, and prevents further joint and organ damage.
It is usually taken once weekly. In some cases, based on your rheumatologist’s advice, it may be given twice weekly in divided doses.
You may take it as a tablet or a small injection under the skin.

Methotrexate Dosing in Sri Lanka

In Sri Lanka, methotrexate is available in 2.5 mg tablets. ( if getting tablets from overseas please check tablet strength)
Treatment usually starts with 3–4 tablets (7.5–10 mg) taken once a week, as advised by your rheumatologist.
The dose is then gradually increased after reviewing blood reports every 3–4 weeks.
The maximum usual dose is about 8–10 tablets (20–25 mg per week)- this may be split over 2 consecutive days for maximum benefit and to reduce side effects.

When Will I Notice Benefits?

Methotrexate takes time to work – usually 6 to 12 weeks (up to 3 months) before symptoms start to improve.
During this waiting period, your doctor may give you steroids (e.g. prednisolone) to control inflammation and prevent joint damage until methotrexate becomes effective.
Once methotrexate is working, steroids are usually reduced and stopped.

Expanded Benefits

Methotrexate not only reduces inflammation and prevents joint damage — it has also been shown to:
- Reduce the risk of heart disease in rheumatoid arthritis.
- Prolong life expectancy in patients with inflammatory arthritis.
These long-term benefits are best achieved with regular and consistent treatment.

Avoiding Treatment Gaps

It is important to take methotrexate regularly as prescribed.
If methotrexate is stopped for several weeks, your disease may flare.
Never restart methotrexate on your own after a break — always consult your rheumatologist and repeat the necessary blood tests before resuming treatment.

The Importance of Blood Checks

When you are on methotrexate, regular blood tests are absolutely essential.
These blood checks are done to:
- Ensure you are not developing side effects (by monitoring blood counts, liver, and kidney function).
- Ensure the medicine is working effectively (by checking that your disease activity is adequately controlled).
Without both of these, there are risks:
- If monitoring is missed, dangerous side effects may go unnoticed.
- If disease activity is not checked, joint damage can continue silently.

Never continue methotrexate without regular blood tests and follow-up with your rheumatologist.

Taking Methotrexate Safely

Take methotrexate once or twice weekly (on consecutive days) , exactly as recommended by your rheumatologist.
Folic acid is prescribed alongside methotrexate to reduce side effects such as mouth ulcers and stomach upset.
Always show your methotrexate prescription to any doctor or pharmacist before starting new medicines.

Possible Side Effects

Common but Usually Mild:

Nausea or stomach upset
Mouth ulcers or sore throat
Tiredness, headaches
Mild hair thinning

Less Common but Important:

Infections may occur (fever, cough, ,urine infections).
Lung irritation (persistent cough, breathlessness).
Skin rash or severe mouth ulcers.

If you notice mouth sores, fever, persistent cough, severe tiredness, or breathing problems — STOP methotrexate and contact your doctor immediately.

Long-Term Treatment and Follow-Up

Methotrexate is safe and effective for long-term use, often continued for many years.
Regular rheumatology follow-ups and blood monitoring are essential to ensure safety and effectiveness.
Do not stop suddenly — ongoing treatment helps keep the disease under control and prevents joint damage.

Drugs that Can Be Combined Safely with Methotrexate

Your rheumatologist may prescribe methotrexate together with other medicines to improve outcomes. These may include:

Other DMARDs (e.g. leflunomide, sulfasalazine, hydroxychloroquine)
Biologic DMARDs (e.g. TNF inhibitors, IL-6 blockers)
Steroids (e.g. prednisolone tablets or injections)
NSAIDs (e.g. naproxen, ibuprofen)
Folic acid supplements to reduce side effects

Key Reminders

Once or twice weekly (consecutive days) as prescribed — never daily.
In Sri Lanka: start with 7.5–10 mg (3–4 tablets), gradually increasing up to 20–25 mg (8–10 tablets) per week.
Take folic acid to reduce side effects.
It may take 3 months to work – steroids may be needed in the meantime.
Do not restart methotrexate on your own after a break — consult your doctor and repeat blood tests.
Blood tests are essential — they keep you safe and confirm the drug is working.
Continue long-term with regular monitoring and rheumatology follow-up.
Both men and women must stop methotrexate 3 months before pregnancy and consult their doctor.

Further Information

For more detailed guidance, refer to the Australian Rheumatology Association (ARA) patient leaflet on methotrexate:

Methotrexate is a safe and effective medicine for long-term control of autoimmune diseases when used carefully. It reduces inflammation, prevents permanent joint damage, lowers heart disease risk, and helps you maintain a better quality of life — but only if taken with proper blood monitoring and regular follow-up.