Your treating pulmonologist has discussed the use of methotrexate with you. In this leaflet, you will find information about the effects and use of this medication. You will also read what to do if you experience side effects. However, this leaflet is not a substitute for the official package insert. If you have any questions after reading this leaflet, you can ask your treating physician.
What is sarcoidosis and why are you prescribed methotrexate?
In people with sarcoidosis, there is a disorder of the immune system that leads to damage to the body. It arises from an uncontrolled reaction of the immune system to an as yet unknown trigger in patients who are susceptible, leading to accumulations of inflammatory cells, also called granulomas. Because the cause of sarcoidosis is unknown, treatment focuses on suppressing the immune system. This leads to a reduction in the accumulation of inflammatory cells. As a result, symptoms and the risk of complications that may occur with the disease are reduced.
How does methotrexate work?
The exact mechanism of methotrexate in sarcoidosis is unknown. It is known to have anti-inflammatory effects by suppressing inflammatory cells. By preventing the accumulation of inflammatory cells (the granulomas), we try to reduce the symptoms of the disease, such as shortness of breath. Methotrexate works much slower than, for example, prednisone. It can take more than 6 weeks before the medication starts to work. Because the manifestation and severity of the disease vary greatly from person to person, the effect of methotrexate and the body's response to the medication also differ per individual. Unfortunately, not everyone experiences sufficient benefit.
What is the dosage and how do you take methotrexate?
Methotrexate is a medication in the form of tablets of 2.5 mg or 10 mg, or it can also be administered via a subcutaneous injection. You use the tablets or injections only one day per week. Take all tablets on one day. Swallow the tablets during a meal, on the same day each week. You can take the tablets all at once or spread them throughout the day. You can swallow the tablets with food or water, but not with grapefruit (juice). It is important not to break or chew the tablets, but to swallow them whole. If you discover during the day that you usually take methotrexate that you have forgotten to take the tablets, take them the same day or at the latest the next day. If you discover it later in the week, skip your tablets for that week. On the usual 'intake day' of the following week, take the normal amount of tablets again. With methotrexate, folic acid (vitamin B11) is always prescribed to reduce the risk of side effects. This should also be taken once a week, the day after taking methotrexate (about 24 hours later). If you take more than 15 mg methotrexate per week (i.e., 6 tablets of 2.5 mg), the dose of folic acid is sometimes increased to twice a week.
What side effects can occur?
The pharmacy’s package insert lists all side effects of methotrexate that have ever occurred.
The most common are:
- gastrointestinal complaints such as a feeling of fullness, nausea and vomiting, or diarrhea
- skin rash
- hair loss
- headache or dizziness
- inflammations and ulcers in the mucous membranes of the mouth and throat
- liver dysfunction, which you do not notice.
Sometimes:
- disorders in the production of blood cells
- shortness of breath or frequent coughing (this may indicate a lung abnormality due to methotrexate).
If you suspect serious side effects, you should stop taking methotrexate. Therefore, contact your pulmonologist if you experience:
- severe sore throat with fever
- repeated nosebleeds
- easy bruising
- shortness of breath or frequent coughing
- severe dehydration (diarrhea and/or persistent (>1 day) vomiting).
In general, side effects will disappear after lowering the dose or discontinuing methotrexate. After recovery from the side effect, methotrexate can usually be resumed. The use of folic acid reduces the number and severity of side effects. If you continue to have gastrointestinal complaints, you can switch to subcutaneous injections. Discuss this with your pulmonologist.
What monitoring is needed when using methotrexate?
Sometimes liver function and blood cell production are disturbed. To detect this at an early stage, the dose of methotrexate is gradually increased and your treating physician will regularly have your blood tested. The first check-up usually takes place 2 weeks after starting the initial dose of methotrexate. Further, with stable findings, every two weeks after each dose increase. Afterwards, your treating physician will gradually reduce these checks to once every 3 - 4 months.
What monitoring is needed when using methotrexate?
Sometimes liver function and blood cell production are disturbed. To detect this at an early stage, your pulmonologist will regularly have your blood tested. In the initial period, this usually happens every four weeks. After this, the checks take place less frequently.
What is the effect on fertility, pregnancy, and breastfeeding?
As far as is known, methotrexate does not affect the fertility of men and women. It is very important to inform your pulmonologist if you are considering pregnancy or are already pregnant. Methotrexate can cause abnormalities in the unborn child and increase the risk of miscarriage. Therefore, you must not use methotrexate during pregnancy. Women must stop using methotrexate three months before a possible pregnancy. Men who use methotrexate and wish to have children must stop this medication three months before the intended pregnancy of their partner. It is therefore important to use reliable contraception during this period and while using methotrexate. You must also not use methotrexate if you are breastfeeding, as it is not yet known whether methotrexate poses risks to the child. Discuss your situation with your pulmonologist.
Can I use methotrexate with other medications?
You can use methotrexate in combination with almost all medications. Contrary to what is often stated in the package insert or what you are told at the pharmacy, you can use methotrexate together with NSAIDs (anti-inflammatory painkillers). This combination is justified due to the low dose of methotrexate in sarcoidosis. You cannot use methotrexate together with some antibiotics, including cotrimoxazole (brand name Bactrimel®) and trimethoprim. These antibiotics are usually used for lung and bladder infections. Always inform your general practitioner and specialist about which medications you use.
What else should I know?
Be careful with alcohol. In combination with methotrexate, the risk of liver dysfunction is higher. Therefore, do not consume more than one alcoholic drink per day.
During the use of methotrexate, vaccination with live, attenuated viruses and bacteria is discouraged. These include vaccinations against mumps, measles, and rubella (MMR), yellow fever, oral polio vaccine, oral typhoid vaccine, and BCG. A flu shot is allowed. Inform the doctor or nurse who prescribes your vaccinations that you use methotrexate.
Do you need a new prescription?
Methotrexate may only be prescribed by a physician experienced with this medication.
You can request a repeat prescription from your treating specialist during your outpatient visit.
If you need a new prescription earlier, you can request it by
- 'Mijn Dossier' and then 'Medicines'. Click on 'Request repeat prescriptions’.
- you can call the pulmonary medicine outpatient clinic to request a repeat prescription by phone.
- Please do this at least 2 weeks before you need your new prescription. Otherwise, we cannot guarantee that your prescription will be sent to your pharmacy on time.
Do you have any questions?
If you have any questions or doubts, please contact the pulmonary diseases outpatient clinic using the contact options and details known to you.