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Methotrexate is a well-established and effective treatment for a range of rheumatic diseases. Methotrexate is known as a disease-modifying anti-rheumatic drug (DMARD) which dampens down the inflammation in the joints and reduces the activity of your child’s immune system.

When and how to take?

Methotrexate may be taken in tablet or liquid form but is also frequently administered as a subcutaneous injection. Injection may be a more appropriate method of administration of methotrexate even at the onset of JIA and the new metoject pen preparation is now available making it much easier for children to cope with the injections.  Your rheumatology team will advise you about the most suitable preparation for your child.

Methotrexate should be taken once a week on the same day whether in the form of a tablet, liquid or injection. If a dose is missed or forgotten, then it can be given within 48 hours of the usual day. If the dose is more than 48 hours, please contact your rheumatology nurse for advice. Tablets should not be crushed.

Methotrexate subcutaneous injection may be used for several reasons e.g. when oral medication is poorly absorbed or tolerated and therefore does not work as well as it should. In some children the use methotrexate injections offers the best chance of getting their disease under control. It is important to remember that it may take up to 12 weeks before Methotrexate starts to work.

What are the possible side effects?

Most children and young people manage to take methotrexate without any side effects. The most commonly reported problems are tummy upsets and tiredness the day after taking the medication. Side effects may be lessened by taking folic acid the day after the dose of methotrexate, but unlike in adults this is not routinely prescribed in kids from the outset of treatment. Please contact your rheumatology nurse if your child has on-going problems taking their methotrexate.

The following side effects are very rare but you should contact your doctor or rheumatology nurse immediately if your child develops any of the following symptoms: unexplained rash or bruising, fever, sore throat, mouth ulcers, chicken pox or anything else that may concern you. It is also advised that your child should not be given any live vaccines.

Blood Monitoring

Methotrexate affects the immune system and it is also important to make sure the medication is working properly. Bloods must be checked either at your G.P surgery or local hospital prior to starting Methotrexate and if levels are normal ongoing monitoring will be between 4 -12 weeks. It is useful to keep a diary of all blood monitoring appointments. Your consultant or nurse will advise of the intervals in between blood tests. Do not miss appointments, and if so contact your rheumatology nurse.

Subcutaneous injections

No one really likes injections but it is important to ask yourself whether your child understands what is involved in their injection. From a young age it is important to encourage your child to become familiar with their treatment and to understand what it does and how it helps them. Parents know their child best so use information appropriate to their level of understanding. If parents adopt a positive attitude and are encouraging it can make a lot of difference. If your child is very anxious around getting their injection then distraction techniques can be useful as this can take your child’s mind off the procedure and fear associated with the injection. Any activity that takes their mind off the procedure is worth trying, such as, deep breathing, reading a book, singing songs, or watching a video. It can also be helpful to agree and activity after injection. You might have to try various things to find out what works best for your child. Your rheumatology team will be able to help you with any problems around injections & anxiety so please ask if you need help. If you going to be giving your child injections then you will be shown in detail the process around preparing equipment, syringes used and disposal by the nurse in order for you to administer Methotrexate safely and effectively at home. This is now much easier with the new metoject pen type of injection.

NOTE: In the event of a spillage of Methotrexate always wash your hands thoroughly after dealing with a spillage and if further advice is required contact your rheumatology team or if out of hours, NHS 24.

Travel Advice

Storage of methotrexate will vary according to local policy and manufacturer’s guidelines. Caution should be taken when in hot climates though, discuss with the rheumatology nurse, consultant or pharmacist. If flying, oral liquid and methotrexate injections should be held in hand luggage, separate sundries such as spare needles, sharps boxes cotton wool etc can be stored in check-in luggage. Due to heightened security measures at airports it is recommended you inform your travel company that you will be travelling with methotrexate and to get a supporting letter from your G.P or rheumatology department.

Other options to consider include taking tablets instead of injections or injection given just before going on holiday and then as soon as you return from holiday. Again discuss this first with your rheumatology nurse. If vaccinations are required for travel abroad see your practice nurse or G.P in good time before travel, however your child should not be given any LIVE vaccines.

If your child becomes unwell with diarrhoea and/or vomiting while on holiday, withhold methotrexate and seek medical advice.

Pregnancy

It important that mothers who are pregnant, trying to conceive or breast feeding are informed by consultant or nurse of the potential risks of handling Methotrexate due to its effects on the unborn child. Although there is little evidence regarding this and it is personal choice, best practice advocates parents should not administer Methotrexate in these circumstances. Young adults who are sexually active should use effective contraception as Methotrexate can harm a developing baby. If planning a pregnancy Methotrexate must be discontinued for at least 3 months before and if a young person discovers that they are pregnant they should seek urgent advice from their nurse, G.P or local health clinic.

Please remember that if your rheumatology team are available to help you with any problems or issues you or your child may have with taking medications so please don’t be afraid to ask.

Methotrexate Injections

The new metoject pen preparation has made giving methotrexate injections much easier for many children.  Information on methotrexate is available on the SNAC site and if giving your child injections you will have received detailed instruction from your rheumatology team.

However, here are a few reminders before administering subcutaneous Methotrexate injections;

  • Ensure it is the correct dose and within the expiry date.
  • Choose a clean area which has a flat surface.
  • Wear disposable gloves (children who administer their own medication do not require gloves)
  • Choose a different injection site each week, common used sites are the upper outer quadrant of the thigh, alternate leg used each week.
  • Give at a 90 degree, ensuring the needle is fully inserted before administering Methotrexate.
  • Dispose in a cytotoxic sharps bin.

In the event of a spillage (of either oral liquid or injection solution) always use disposable gloves.

NOTE: In the event of a spillage of Methotrexate always wash your hands thoroughly after dealing with a spillage and if further advice is required contact your rheumatology team or if out of hours, NHS 24.

Work surfaces or floor

  • Blot the spillage with absorbent paper
  • Wash the area thoroughly with soap and water
  • Dispose of paper/cloths in the cytotoxic sharps bin and close over

Skin

  • Do not scrub the skin
  • Wash with plenty of soap and water, dry thoroughly

Clothing

  • Blot dry
  • Remove clothing and wash separately from other clothing

Eyes

  • Wash your eye(s) with copious amount of water for at least 5 minutes
  • Seek medical advice