Methotrexate

About Methotrexate

Methotrexate is a dihydrofolate reductase inhibitor: by blocking that enzyme it interferes with DNA synthesis, repair and cell replication. The generic tablet, Trexall and Jylamvo labels cover adults and children with acute lymphoblastic leukemia (ALL) as part of combination maintenance chemotherapy, adults with mycosis fungoides or with relapsed or refractory non-Hodgkin lymphoma, adults with rheumatoid arthritis, children with polyarticular juvenile idiopathic arthritis (pJIA) and adults with severe psoriasis. Xatmep is labeled for children with ALL, or with active pJIA when first-line therapy, including full-dose NSAIDs, was not enough or not tolerated. Rasuvo is labeled, under that same first-line condition, for selected adults with severe, active rheumatoid arthritis and children with active pJIA, and for adults with severe, recalcitrant, disabling psoriasis not adequately responsive to other therapy; it is not for cancer. The tablet labels start rheumatoid arthritis at 7.5 mg once weekly, raised for an optimal response, pJIA at 10 mg/m2 once weekly and psoriasis at 10 to 25 mg once weekly; some cancer regimens use other schedules.

The boxed warning on the tablet and Jylamvo labels says methotrexate can cause embryo-fetal toxicity, including fetal death, so it must not be used in pregnancy for non-cancer conditions; that it must not be taken after a severe hypersensitivity reaction to it, including anaphylaxis; and that serious adverse reactions, including death, have occurred, so the bone marrow, gastrointestinal tract, liver, lungs, skin and kidneys are closely monitored. The tablet and Xatmep boxed warnings add that oral methotrexate taken once daily by mistake has resulted in death, and Jylamvo’s warnings section covers fatal medication errors. Blood counts, liver tests and kidney function are checked at baseline and periodically. Other warnings cover serious infections, neurotoxicity, secondary cancers, tumor lysis syndrome and impaired fertility, and heavy alcohol use raises the risk of liver damage. Mouth ulcers, low white blood cell counts, nausea and abdominal distress are common side effects.

The tablet and Jylamvo labels handle folic acid this way: for rheumatoid arthritis, pJIA and psoriasis, folate deficiency may increase methotrexate’s adverse reactions, and folic acid or folinic acid is given; for cancer, products containing folic acid or its derivatives may make methotrexate less effective and are taken only if the prescriber directs. The tablet labels advise contraception during treatment and for 6 months after the last dose for females and 3 months for males with female partners, and no breastfeeding until 1 week after the last dose. Live vaccines are not recommended during treatment. Rasuvo comes only in doses from 7.5 to 30 mg; other doses or routes need another methotrexate product. Drugs@FDA lists every Otrexup and RediTrex strength as discontinued.

Taking Methotrexate

How to take it

Exactly as prescribed: for arthritis and psoriasis, one time each week on the same day of the week, never every day. Measure the oral solutions with an accurate milliliter measuring device, not a household teaspoon. Inject Rasuvo under the skin of the abdomen or thigh. If you take too much, call your prescriber or go to an emergency room right away.

If you miss a dose

Call your prescriber right away for instructions about when to take the next dose, and do not take a double dose to make up for a missed one.

Storage

Keep tablets at room temperature in a tightly closed container, away from light, excess heat and moisture, out of reach of children. Xatmep may be kept in the refrigerator or at room temperature, and is thrown away after 60 days at room temperature; throw away Jylamvo 3 months after first opening. Keep Rasuvo at room temperature, protected from light.

Interactions to know about

Aspirin and other NSAIDs, proton pump inhibitors, penicillins, sulfonamides and some other oral antibiotics, probenecid, and antifolates such as dapsone and pyrimethamine can increase methotrexate exposure, as can drugs that harm the liver or kidneys; nitrous oxide anesthesia is avoided.

This summarizes the official prescribing information. Your prescriber’s and pharmacist’s instructions, and the leaflet that comes with your medicine, take priority.

Why the cash price for Methotrexate differs from pharmacy to pharmacy

Generic tablets come in 2.5 mg, so a weekly dose of 7.5 mg or more takes several tablets, and quotes for the same supply differ by each pharmacy’s fee and markup and by whether methotrexate is on its flat-price generic list.

Trexall, Xatmep, Jylamvo and Rasuvo have no rated generics, so each is filled as written; a pharmacist does not replace Trexall with generic tablets, or a solution with tablets, without the prescriber.

Ways to pay less for Methotrexate without insurance

• Ask whether methotrexate tablets are on the pharmacy’s flat-price generic list, and compare more than one pharmacy.
• If Trexall is prescribed, ask the prescriber whether the same weekly dose could be written as generic 2.5 mg tablets.
• If a solution or Rasuvo is prescribed, ask the prescriber whether tablets would suit you, and ask the maker whether a savings program applies to someone paying cash.
• Once your weekly dose is stable, ask for a ninety-day supply.
• Upload the prescription to Script Unlock so licensed pharmacies can quote their cash price. You pay the pharmacy directly.

Questions to ask your pharmacist about Methotrexate

1. 1.Which day of the week is my dose, and does my label say once weekly?
2. 2.Should I take folic acid or folinic acid, and on which days?
3. 3.Which blood tests do I need, and how often?
4. 4.Do my pain relievers, acid reducers or antibiotics interact with it?

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