When should I stop Methotrexate because of side effects?

Question

Hello doctor,

My Methotrexate dosage is 15 mg/week. I have been taking this drug for almost five months now, as a treatment for rheumatoid arthritis. It was working well initially, until my CRP levels went down from 24 mg/L to 9 mg/L.

However, I am now dealing with constant nausea on the day of my injection, much more hair loss than usual, and my last blood test showed an ALT level of 62 U/L, which my rheumatologist said needs to be monitored.

At what point is enough enough?
Can Methotrexate at the age of 38 cause side effects that are significant enough to justify stopping treatment?
Do I just have to keep pushing through them?

Kindly help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I have read your query and understood your concern.

We usually try to continue Methotrexate for as long as possible because it is a cornerstone treatment for rheumatoid arthritis (RA), and many other conventional medications are generally less effective.

However, if you can no longer tolerate the side effects, then the treatment is no longer helping you as it should, and it may be time to consider a change.

I would first suggest reducing the Methotrexate dose to 12.5 mg once a week and seeing whether your nausea and other side effects improve. If you still have persistent nausea and your liver enzyme levels do not improve after one to two weeks of the lower dose, then Methotrexate may need to be stopped.

In cases of Methotrexate intolerance, we often switch to Leflunomide 20 mg once daily, as it is generally associated with very few gastrointestinal side effects. However, Leflunomide can also cause elevated liver enzymes, so if this happens as well, the next step would usually be biologic therapy.

I suggest you follow this treatment plan:

Reduce Methotrexate to 12.5 mg once weekly.
Increase Folic acid to 10 mg once weekly instead of 5 mg.
Repeat your liver enzyme tests after two weeks and follow up with the results.

I hope you are satisfied with my answer. For further queries, you can consult me at iCliniq.

Thank you.