Download Administration Side Effects Preparations available Drug Interactions

SHARED CARE PROTOCOL
for SOUTH EAST ESSEX
Drug Name
METHOTREXATE
Clinical Indication: Rheumatoid Arthritis and Psoriasis; psoriatic arthritis, connective tissue diseases, juvenile idiopathic arthritis.
Date approved: December 2014
Due for review: December 2016
Author(s)/Originator(s): Esther Trillo-Gallo / Dr W M Wong
Administration
Side Effects
Oral or parenteral
Methotrexate is available as 2.5mg and 10mg tablets. Care needs to be taken if switching between 10mg
and 2.5mg tablets.
Subcutaneous injection is preferred route in children. Consider sc injection in adults with inefficacy or
intolerance of the oral preparation.
Folic acid supplementation should be co-prescribed. Local recommendation is folic acid 5mg/day on 6 days
per week.
Nausea, alopecia, skin rash & diarrhoea. May resolve with reduction in the dose or increasing the
dose of folic acid. Stop the treatment if does not resolve and inform the specialist team.
Pulmonary Symptoms: A small minority of patients develop symptoms of interstitial pneumonitis
soon after starting treatment indicated by persistent dry coughs /shortness of breath. Stop the
methotrexate and refer to the specialist team or Casualty urgently.
Significant reduction in cellular count in blood (Cytopaenia): Withdraw methotrexate and inform the
specialist team or a haematologist. Consider Folinic acid rescue.
Preparations available
Methotrexate tablets 2.5mg and 10mg.
Metoject pre-filled PENs 50mg/ml, 0.15ml (7.5mg); 0.2ml (10mg); 0.25ml (12.5mg); 0.3ml (15mg); 0.35ml
(17.5mg); 0.4ml (20mg); 0.45ml (22.5mg); 0.5ml (25mg); 0.55ml (27.5mg); 0.6ml (30mg).
Drug Interactions
For full information on Drug Interactions, go to Methotrexate List of Drug Interactions
Reduced excretion with NSAIDs and salicylates (at the doses of methotrexate used these interactions
are not clinically significant). Increased toxicity with cyclosporin. Bone marrow depression with
trimethoprim and co-trimoxazole. Probenecid increases serum methotrexate levels and dose
reduction is needed.
Contra-indications
Hepatic impairment, pregnancy, breast feeding, active infection and immune deficiency syndromes.
Precautions
Blood disorders, renal impairment, peptic ulceration, ulcerative stomatitis.
Alcohol: Generally advised to stay well within national limits, 21 Units/week for men, 14 Units/week for women.
Pregnancy & Breast Feeding: Men & Women of childbearing age should not plan to conceive whilst on methotrexate. All female patients should be advised against conception and pregnancy. A reliable form of
contraception should be advised to all patients during methotrexate therapy as well as for at least 3 months after discontinuation of treatment. In case of accidental pregnancy stop methotrexate and discuss with
the specialist team.
Elective Surgery: Drug can be continued (stop if any active infection, consider withdrawal with GU or lower GI surgery).
Immunisations: All live immunisations should be avoided. Pneumococcal vaccination is recommended, revaccination is not recommended (see BNF). Flu vaccines should be given annually. Passive immunisation
should be carried out using VZIg in non-immune patents if exposed to Chicken pox or shingles, 1 gram im (adults 15+ yr) as soon as possible after exposure, and within 10 days.
Patient Information
Patients should report all symptoms and signs suggestive of infection, especially sore throat
Aspirin and NSAID: Patients should be advised to avoid self-medication with over-the-counter aspirin or ibuprofen.
Methotrexate. For full prescribing information refer to the latest BNF and SPC
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Criteria for shared care. Prescribing responsibility will only be transferred when:
 Treatment is for a specified indication.
 Treatment has been initiated and established by the secondary care specialist.
 The patient’s initial reaction to and progress on the drug is satisfactory.
 The patient’s general physical, mental and social circumstances are such that he/she would benefit from shared care arrangements.
Responsibilities of initiating specialist
 Initiation of treatment
 3 month worth of treatment will be supplied or until patient is stable and does not require blood tests for three months.
 Monitor tests as required before and during treatment as agreed in Summary of Monitoring and Responsibilities document.
 Discussion with the patient regarding benefits and side effects of treatment
 Prompt communication with the GP of any changes in treatment (including dose adjustments) and assessments of adverse events
 Advice to GPs about all aspects of treatment
 Report adverse events to the CSM
 Ensure clear arrangements for back-up, advice and support.
Responsibilities of the GP
 To prescribe on going therapy to patients after treatment has been established in Secondary Care, usually three months.
 To report any adverse events to the consultant.
 Prompt referral to specialist if there is any change in patient’s status.
 Reporting to and seeking advice from the specialist on any aspect of patient care which is of concern to the GP and may affect treatment.
 To monitor overall health and wellbeing of the patient.
 To review that blood tests are performed within the last 3 months before issuing a new prescription. For best practice it is recommended that GPs check that blood tests’ results are in
range and contact specialist as detailed in Summary of Monitoring and Responsibilities document or as below.
Results that require specialist team input:
Liver enzymes elevated or transaminase
WCC
Significant reduction in renal function
MCV Increased > 105
> 2 times upper normal limit
9
< 3.5 x 10 /l
Neutrophils
Platelets
9
< 2 x 10 /l
9
< 100 x 10 /l
Check for other causes (B12, folate and alcohol consumption). A high MCV is not an indication to stop treatment.
Flu-like symptoms, sore throat, infection, rash, ulceration, bruising
Secondary Care contact information
If stopping medication or needing advice please contact:
Dr / nurse
Contact number:
Department
Patient’s named Consultant or Clinical Nurse Specialist team in Rheumatology
01702 385128 Nurse specialist live telephone service Mon, Tues, Wed, Fri 9am – 11am. . Alternatively Rheumatology secretaries on 01702 435555, extension
numbers 5616 or 6721 or Email: [email protected].
Rheumatology
Methotrexate. For full prescribing information refer to the latest BNF and SPC
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