Advice for children and young people having Methotrexate injections

Essential Information

• Methotrexate should only be given once a week. It should be given on the same day each week.
• You must attend for regular blood tests. Your team will tell you how often these tests should be.
• Do not have ‘live’ vaccinations while on Methotrexate.
• Before taking any other medication, make sure you tell the prescribing doctor that you are taking Methotrexate.
• People on methotrexate also need to take a folic acid supplement. This should not be given on the same day as your weekly methotrexate.

What is Methotrexate?

Certain conditions cause the immune system to be overactive. This results in inflammation. When joints are inflamed, they can be swollen, painful, hot and red. Methotrexate works by calming the body’s immune system. This reduces inflammation and improves the joint symptoms.

Methotrexate treats the symptoms of your condition. It also reduces the risk of uncontrolled inflammation which could otherwise cause long-term damage to your joints.

The conditions which give rise to these symptoms include juvenile idiopathic arthritis (JIA), uveitis, lupus (SLE), juvenile dermatomyositis, vasculitis and scleroderma.

If you look up methotrexate online, you will see that it is used as a chemotherapy treatment. However, because we use a much lower dose of methotrexate we do not call it chemotherapy.

How is it given?

Methotrexate is given once a week. Methotrexate is available as a tablet, liquid or injection. The injection can lead to better absorption and fewer side effects. It is injected under the skin into the fatty (subcutaneous) tissue in the thighs, abdomen or upper arms. Your paediatric rheumatology team will discuss the best option with you. You will then receive further training on how to take it.

You must always wash your hands before and after handling methotrexate.

How long does it take to work?

Methotrexate can take up to 8-12 weeks to work fully. At the start, you might not feel any benefits but it is likely that methotrexate is working. It is important that you take your treatment every week.

Will Methotrexate stop the pain?

Methotrexate is not a painkilling drug so you may still need to take anti-inflammatory medicines (such as Ibuprofen, Naproxen). Once Methotrexate is working (which may take six to eight weeks) you may find that you can stop the anti-inflammatory medications.

How long do I need to take it for?

You will need to take methotrexate for at least 2 years after the inflammation in your body has settled. Your team will monitor you closely to help decide the right time to stop or reduce the dose.

When and how should Methotrexate be taken?

Methotrexate is taken once a week. It can be injected into the thighs, abdomen or upper arms. The site chosen must change on every dose given. Your paediatric rheumatology nurse specialist will show you how it is given.

Initially the local children’s community nursing team will attend your home to help teach you how it is given and they will continue to visit until the whole family is happy. Learning to self-administer is recommended, as this will promote independence.

Will Methotrexate stop the pain?

Methotrexate is not a painkiller. If you are in pain, keep taking your recommended pain relief.

Blood Monitoring

When you are on methotrexate, you will need to have regular blood tests. At the start, this will be every 2 weeks for the first month. Then it will be monthly. Once your results are stable, it will be every 3 months. This will be decided by your Team. If your dose is changed, you will need more frequent blood tests again.

What are the possible side effects?

Most children and young people on methotrexate cope well, with few (if any) side-effects.

In some patients, methotrexate can cause nausea (feeling sick), vomiting, slight thinning of the hair, mouth ulcers, loss of appetite or diarrhoea. If any of these happen, keep a diary and let your Team know as soon as possible.

Some side effects can be helped. This is done by increasing the amount of folic acid you take. If sickness if a problem, an anti-sickness medicine can be prescribed by your team.

Methotrexate can affect the liver or the bone marrow. This is why it is important to have regular blood tests.

Methotrexate may lower your ability to fight infection. This is more likely if you are also taking oral steroid medication. You should be careful about the risk of infection. Take sensible precautions such as good hand washing and avoiding people who are unwell.

If you have a high temperature (38oC or above), or are feeling generally unwell, stop taking your methotrexate and seek medical advice via your GP, NHS 111 or local hospital’s emergency department. You should also let your Team know.

Sun protection

Methotrexate can make your skin more sensitive to sunlight. We recommend:

• avoid intense sunlight (especially between 11 am and 3 pm)
• avoid UV rays (for example, sunbeds or tanning equipment)
• use a sun protection product with a high protection factor (SPF 50) when exposed to the sun
• wear a hat and clothes that cover your arms and legs when in the sun

Chickenpox and measles

Methotrexate may lower your ability to fight infection. If you have never had chickenpox or measles (nor had a vaccine), you may be at risk of a more severe infection. If you develop symptoms of chickenpox or measles, you should go to your local hospital for treatment.

Before starting methotrexate, we will do a blood test to see if you have had chickenpox or measles in the past. This will check if your body is able to fight these infections (has immunity). If you are not immune, it is important to avoid people who have chickenpox, shingles or measles. We will give you further information about what to do if you have contact with someone with these infections during your training session.

Can I take other medication whilst I am on Methotrexate?

Most medications can be taken safely with methotrexate. Some medications, (e.g. antibiotics – co-trimoxazole (Septrin®) and trimepthoprim), do interact with methotrexate so they are not safe to take.

Always tell your doctor, dentist or pharmacist that you are taking methotrexate. This is to ensure they do not prescribe medicines which could interact. Please let your team know If you wish to take any medications that have not been prescribed, including multivitamins or herbal remedies, please speak to a healthcare professional so that they can then check for any interactions.

Can I have vaccinations?

You should not have live vaccinations while you are taking methotrexate without speaking to your Team first. We will give you a leaflet about vaccines.

The nasal flu spray is a live vaccine, therefore, you should not have this. You should also avoid being in a room where nasal flu vaccines are being given. This is in case you breathe in the vaccine by mistake.

Where do I obtain supplies from?

Methotrexate injections are supplied by a homecare delivery company.

You will receive 8 weeks’ supply of medication and a sharps bin. This is to dispose of the used injections.

The old sharps bin should be collected and replaced with a new one. This will happen with your next methotrexate delivery. Please ask the company for this when you are arranging the delivery.

If you have less than two weeks’ supply left and have not been contacted about a new delivery, please contact your homecare delivery company. If you have any issues that the delivery company cannot help you with, please contact your Team.

If you are on oral (either liquid or tablet) methotrexate, your Team will let you know how you will obtain more supplies of this.

Where should I store my methotrexate?

It should be stored at room temperature (below 25 degrees Celsius). Please keep away from the reach of children. Please check the packaging or speak to your Team if you need further advice (for example for travel).

What will happen if you miss a dose?

If you miss a dose and remember the following day, you can immediately take your usual dose of Methotrexate. If however, you remember more than 48 hours late then miss the Methotrexate that week and start taking it again the following week. Missing one dose does not usually cause symptoms to return.

What happens if I forget to take my Methotrexate?

• If you miss a dose of your weekly methotrexate and remember the next day, you can take your usual dose on that day. If you forget the day after too, then please contact your Team for advice.
• If you are unsure what to do, please contact your Team for advice.
• Missing one week’s dose should not cause symptoms to return.

What should I do if I think I have taken too much methotrexate?

If you think you have taken too much methotrexate, go to A&E and update your Team immediately.

What about my future?

If you are on methotrexate as a teenager, other issues may become important:

• Alcohol intake should be kept to a minimum when taking methotrexate. This is because this combination increases the potential to harm your liver.
• It is important you do not become pregnant while taking methotrexate. Methotrexate can be harmful to an unborn baby. Therefore, reliable contraception is essential. Condoms are also recommended to help prevent sexually transmitted infections.
• Taking low dose methotrexate should not affect your chances of having a baby in the future. If you are thinking about planning for a family, please speak to your Team to help manage your medications.

What happens if I need an operation (surgery?) Do I have to stop treatment?

Talk to your healthcare provider. They will advise you on what to do with your methotrexate.

Let your dentist know that you are taking methotrexate. They will take this into account when they are carrying out any dental treatment

Contact Information

If you have any concerns or questions, please contact the Paediatric Rheumatology Advice Line on 01223 254988 or email PaedRheumatology@nhs.net