Methotrexate in Rheumatoid (RA) and Psoriatic arthritis (PsA)
Methotrexate is one of the most commonly used drug in arthritis. It is the one of the most important in many rheumatology diseases. Methotrexate in most patients causes no side effects and is a very good drug. However, methotrexate can cause severe nausea or sickness, abdominal pain or even diarrhoea, in many patients. Many patients stop taking methotrexate due to this, which is not good, because taking methotrexate is very important for many types of arthritis.
There are very few drug options to treat RA, which are as low-cost and as good as methotrexate. Biologicals are often next line drugs in such cases. They are very good drugs, but they can be very costly and have more risk of infections than methotrexate.
There are steps which you or your doctor can take to decrease methotrexate sickness. Here, are they.
Steps one can take to decrease methotrexate sickness or vomiting sensation in Rheumatoid, psoriatic and other arthritis
1) Start methotrexate at lower dose and increase it slowly
Most doctors, in most countries, start methotrexate at 10mg once a week dose in patients with Rheumatoid arthritis. Sometimes, the 10mg dose can cause severe sickness and is too much for the body to cope with. In India, or most other countries methotrexate is available in 2.5 mg strength. You can start with 2.5 mg a week and gradually increase by 2.5 mg every week. The body or stomach gets time to adjust to methotrexate.
Another, common technique we use in daily practice is to split the doses. Methotrexate dose could be split in two or four parts. For example, if you are taking 10mg once a week on Sunday, you can split it in four doses like this :
2.5 mg morning and evening, after meals, on Saturday
2.5 mg morning and night after meals, on Sunday
Sometimes, leaving a day or two day’s gap between also helps. For example, you can take tablets as above on Saturday and Tuesday.
2) Using more folic acid tablets or having foods rich in folic acid – may prevent methotrexate nausea and hair loss
If you are on methotrexate, your doctor must have already given you folic acid 5mg once a week. Folic acid prevents the side effects of methotrexate. Increasing folic acid helps avoid sickness may also help prevent hair loss. Depending on one’s own response, folic acid can be increased from two days a week to six days a week. Do not take it on methotrexate days.
Methotrexate avoids folic acid to do its normal work in body & stomach, which is one reason for its side effects. Thus, we give more folic acid, so that there is enough to work for the body.
Also, one can improve folic acid intake in the diet. The good healthy foods are rich source of folic acid. These foods control inflammation in Rheumatoid arthritis too. E.g. : Nuts (almonds, walnut, cashews etc) , dark green veggies (broccoli, spinach, lettuce etc), legumes (dals), avocado ; fruits like papaya, citrus, grapes, banana etc.
3) Have more caffeine on days around methotrexate
Recently, Dr Malaviya from India, published a study, where 55% of patients had relief from methotrexate sickness, by just increasing their caffeine intake. If you are not a coffee drinker, you have another option : dark chocolate. Since dark chocolate has caffeine related compound, it also works.
The ideal way to take increased caffeine is around methotrexate day, as follows : Take 1 cup coffee or 2 small squares of dark chocolate (like Bourneville or Lindt) morning and evening, on the day before, on the day and on the day after taking methotrexate. (So if you are taking methotrexate on Sunday, start consuming coffee or chocolate from Saturday and have it till Monday evening).
Your doctor or nurse can also suggest ways or prescribe medicines, to reduce methotrexate sickness in rheumatoid arthritis
4) Stomach or acidity tablets can prevent feeling sick with methotrexate
Stomach tablets like pantoprazole or omeprazole or lansoprazole etc, decrease stomach acidity and help avoid methotrexate sickness.
In some countries, like India, we have above drugs combined with domperidone (eg : Pan D). Domperidone helps forward motion in stomach and intestines and may suppress vomiting sensation.
5) Anti-vomit tablet
An anti-vomit tablet like granisetron or ondansetron suppresses your vomiting sensation in brain, so that you don’t feel sick. Granisetron is easy to take as it is taken once a day only.
You can take these medicines, on day before, on the day and day after methotrexate.
6) Take methotrexate injections, instead of tablets may reduce its vomiting and bloating sensation
In western countries, methotrexate injections are commonly used in patients who feel sick due to tablets. Methotrexate injections do not irritate the stomach and hence, cause less sickness or bloating sensation. Like insulin, methotrexate injections pens are available, which patient can easily use without help.
7) To take folinic acid, a big brother of folic acid
As described above, sometimes methotrexate causes side effects on body by not allowing folic acid to work properly. Folinic acid, a stronger version of folic acid, could help in some patients (This is based on practice, there is no definite research to make this statement). 1-2 tablets of folinic acid a week may avoid methotrexate side effects and allow its good effect.
These are the most common methods. But this is not the end of list. There are some other things which seem to help some people :
- Take methotrexate at night, you may sleep over the sickness 🙂 .
- Some people feel taking peppermint, ginger or green tea helps to soothe.
I recommend most patients to try more than one method at a time. For example, in a patient feeling sick with methotrexate, I first increase folic acid, give them stomach tablets and ask them to increase caffeine around methotrexate days. If it doesn’t work, I consider them to shift to methotrexate injections.
Do you feel very sick with methotrexate ? Try these methods and let us know.
Have you tried any other method to stop methotrexate sickness ? Or have you already stopped taking methotrexate due to sickness ? Did you try any of the above methods before stopping it ? Let us know. It might be helpful for other patients.
Do you have any query with regards to rheumatoid or any other arthritis you a have ? Contact us. We will get back within 72 hours.
Author: Dr Nilesh Nolkha, Rheumatologist
Dr Nilesh Nolkha is a young and dynamic rheumatologist who keeps patients interests at forefront of everything he does.