11/13/24, 8\:19 PM Guide | Methotrexate counselling

Methotrexate counselling

Table of contents

Introduction

This article provides a step-by-step approach to counselling patients about methotrexate in an OSCE setting.

Opening the consultation

Wash your hands and don PPE if required.
Introduce yourself including your name and role.
Con
Explain the reason for the consultation\:
“ T o d a y I’ d l i k e t o t a l k t o y o u a b o u t a m e d i c a t i o n c a l l e d m e t h o t r e x a t e , w o u l d t h a t b e
o k a y ?”
It is important to establish good rapport and an open line of communication\:
s o m e t h i n g i s n o t c l e a r , p l e a s e f e e l f r e e t o i n t e r r u p t a n d a s k m e .
”
“ I f y o u h a v e a n y q u e s t i o n s a t a n y p o i n t , o r i f
Make sure to check the patient’s understanding at regular intervals throughout the consultation and provide opportunities to
ask questions (this is often referred to as ‘chunking and checking’).

Ideas, concerns & expectations

A key component of counselling involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE).
Asking about a patient’s ideas, concerns and expectations can provide insight into how a patient currently perceives their
situation, what they are worried about and what they expect from the consultation. It can sometimes be challenging to use the
ICE structure in a way that sounds natural in your consultation, but we have provided some examples for each of the three
areas below.
Ideas
“ H a v e y o u h e a r d o f m e t h o t r e x a t e ?”
“ B e f o r e w e s t a r t , a r e y o u a b l e t o t a k e m e t h r o u gh w h a t y o u k n o w a b o u t m e t h o t r e x a t e a l r e a d y ?”
Concerns
“ D o y o u h a v e a n y p a r t i c u l a r w o r r i e s a b o u t s t a r t i n g m e t h o t r e x a t e ?”
Expectations
“ W h a t w e r e y o u h o p i n g w e w o u l d c o v e r t o d a y r e l a t i n g t o c o n s i d e r i n g a t r i a l o f m e t h o t r e x a t e ?”

History taking

Although the purpose of this station is to counsel the patient, it is a good idea to gather a quick, focused history early in the
consultation.
This should include exploration of the patient’s symptoms and management of their condition including trials of previous
medications including their impact, compliance and adverse e
Understanding the patient’s care so far will help you tailor any advice and personalise the information for their speci
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What is methotrexate and when is it used?

Methotrexate is a disease-modifying anti-rheumatic drug (DMARD), i.e. an immune system suppressant, used as a
treatment for certain autoimmune conditions including rheumatoid arthritis and psoriatic arthritis. 1,2
It can also be used in the
treatment of Crohn's disease and ectopic pregnancies.
3,4
Its mode of action is via blocking the action of the enzyme dihydrofolate reductase, thus inhibiting the reduction of
dihydrofolate into tetrahydrofolate.
4
Without this conversion, there is a decrease in purine synthesis and, therefore, DNA, leading to a decrease in in
cell division.
4
At higher doses, methotrexate can also be used as an anti-neoplastic agent in certain cancer treatment regimens due to its
action on cell division. Common oncological treatment regimens in which it is used include acute lymphoblastic leukaemia,
non-Hodgkin’s lymphoma and lung/breast cancers.
1,3,4
Example
“ M e t h o t r e x a t e i s a m e d i c a t i o n t h a t c a n b e u s e d t o d e c r e a s e i n
s y m p t o m s a s s o c i a t e d w i t h r h e u m a t o i d a r t h r i t i s , e s p e c i a l l y j o i n t p a i n , s w e l l i n g a n d s t i
”

How to take methotrexate

Overview

Methotrexate comes in tablet, liquid and injection forms.
3
Methotrexate tablets are prescribed as a once-weekly dose and are taken on the same day each week.
2,3
Starting doses may vary for di
psoriasis is anywhere between 2.5 mg and 10 mg.
3
To avoid errors with methotrexate prescriptions, it is recommended that only one strength of methotrexate tablet (usually
2.5mg) is prescribed and dispensed. It is good practice to decide with the patient which day of the week they will take their
dose and write this down in full on the prescription.
6
Folic acid should be co-prescribed with methotrexate. It can be taken once weekly on the day after the methotrexate dose, or
it can be taken once daily every day except on the day of the methotrexate dose.
1,2
Folic acid reduces the side e
liver toxicity.
6
Folic acid should never be taken on the same day as methotrexate as it can impair the e
2
Patients and carers should be informed of the potentially fatal risk of overdose if methotrexate is taken more frequently than
once a week, and emphasise that it should never be taken daily. If an overdose does occur, immediate medical attention must
be sought.
6

Taking methotrexate tablets

Patients should swallow the methotrexate tablets whole with a drink of water. The tablets can be taken before or after food.
Advise the patient to wash their hands after touching the tablets.

Taking methotrexate liquid

Advise patients to always use the oral syringe that comes with the methotrexate liquid to accurately measure their dose.
Advise the patient to have a drink of water after swallowing the methotrexate liquid.

Having methotrexate injections

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Advise the patient that they will usually need to go to their GP surgery or a hospital outpatient clinic once a week to have their
methotrexate injection.
Alternatively, some patients may get a pre-
to be taught how to self-administer their medication
competent to do it themselves at home.

Missed doses

Advise the patient that if they forget to take a dose, to take it as soon as they remember the next day or the day after. If the
dose is more than two days late, they must contact their GP or clinic for advice. Patients should be advised to never take two
doses together to make up for a missed dose.
1

Check the patient's understanding

It is important to “chunk and check” with the patient at this point to ensure they understand how to take methotrexate.
Example
“ Y o u s h o u l d t a k e m e t h o t r e x a t e a s p r e s c r i b e d o n t h e s a m e d a y e v e r y w e e k . I t c a n b e t a k e n w i t h o r w i t h o u t f o o d .
”
1
[ a d d d e t a i l s r e l e v a n t t o s p e c i
" F o r e x a m p l e , y o u r p r e s c r i p t i o n w i l l r e a d s o m e t h i n g l i k e \: T a k e m e t h o t r e x a t e 1 2 .5 m g ( 5 x 2 .5 m g t a b l e t s ) O N C E W E E K L Y o n
S U N D A Y S .
"
2 ,5
“ Y o u w i l l b e p r e s c r i b e d a s e c o n d m e d i c a t i o n c a l l e d f o l i c a c i d , w h i c h i s t o b e t a k e n a s p r e s c r i b e d , H o w e v e r , y o u s h o u l d n e v e r t a k e t h e f o l i c a c i d o n t h e s a m e d a y a s y o u r m e t h o t r e x a t e d o s e .
”
n o r m a l l y o n c e a d a y .
“ I t i s i m p o r t a n t t h a t y o u d o n’ t s t o p t a k i n g t h e s e m e d i c a t i o n s w i t h o u t t a l k i n g t o y o u r d o c t o r
y o u a r e o n m e t h o t r e x a t e w h e n i n t e r a c t i n g w i t h h e a l t h c a r e w o r k e r s , a s i t c a n a
e x a m p l e , i f y o u w i s h t o r e c e i v e v a c c i n e s a s p e r t h e s c h e d u l e f o r t h o s e t a k i n g m e t h o t r e x a t e , t h e c o n s u l t a n t m a y n e e d t o
a l t e r / s u s p e n d y o u r d o s e .
”
“ I s t h e r e a n y t h i n g y o u a r e n o t c l e a r o n t h a t y o u w o u l d l i k e m e t o go o v e r a ga i n ? I f n o t , w o u l d y o u b e a b l e t o r e p e a t b a c k t o
m e y o u r u n d e r s t a n d i n g o f m e t h o t r e x a t e a n d h o w y o u s h o u l d t a k e i t ?”

Side e

As with all medications, there are side e
Educating the patient about the signs associated with serious side e
attention should these develop, is an important part of methotrexate counselling.
Patients who are prescribed methotrexate will be issued a treatment booklet to take with them to all appointments and an
alert card to advise healthcare professionals that they are taking methotrexate.
Common side e
1,2,3
Loss of appetite
Nausea
Indigestion
Diarrhoea
Headaches
Tiredness
Hair loss
Rare but serious side e
1,2,3
Liver toxicity\: jaundice
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Pulmonary toxicity\: persistent cough, chest pain, dyspnoea
Renal toxicity\: peripheral oedema, polyuria
Signs of infection\: fever, chills, muscle aches, sore throat
Thrombocytopenia\: bleeding gums, haematuria, unexplained bruising
Stevens-Johnson syndrome\: severe skin rash or blisters on skin, mouth, eyes or genitals

Interactions

Some medicines can a
medications with a healthcare professional.
When NSAIDs (e.g. ibuprofen) are taken with methotrexate there is an increased risk of toxicity.
Trimethoprim or co-trimoxazole (septrin) co-prescribed with methotrexate can be fatal. This is due to an additive e
inhibiting dihydrofolate reductase, which increases the risk of bone marrow suppression. This can occur even with short
courses and low doses, therefore these drugs must never be co-prescribed.
Example
“ T h e r e a r e a n u m b e r o f p o t e n t i a l s i d e e
s i d e e
p o t e n t i a l l y h a i r l o s s .
”
“ I t i s g o o d t o b e a w a r e o f t h e s e s i d e e
i m p o r t a n t t o b e a w a r e o f t h e r a r e , b u t s e r i o u s s i d e e
s h o r t n e s s o f b r e a t h , a b d o m i n a l d i s c o m f o r t , v o m i t i n g o r d a r k -c o l o u r e d u r i n e , r e p o r t t h e m t o y o u r d o c t o r a s s o o n a s t h e y
”
o c c u r .
“ Y o u s h o u l d a s k y o u r d o c t o r o r p h a r m a c i s t b e f o r e t a k i n g a n y o v e r-t h e-c o u n t e r m e d i c a t i o n s a s s o m e o f t h e m c a n i n c r e a s e
y o u r r i s k o f d e v e l o p i n g t h e s e s e v e r e s i d e e
a n a n t i b i o t i c c a l l e d t r i m e t h o p r i m .
”
“ W h e n y o u b e g i n t a k i n g m e t h o t r e x a t e y o u w i l l b e g i v e n a n a l e r t c a r d w h i c h c a n b e u s e d t o i n f o r m h e a l t h c a r e
p r o f e s s i o n a l s t h a t y o u a r e t a k i n g t h i s m e d i c a t i o n a n d t h i s w i l l h e l p i n f o r m t h e i r c l i n i c a l d e c i s i o n s .
”

Monitoring

As mentioned above, there is a risk of bone marrow suppression as well as gastrointestinal, liver and pulmonary toxicity
when a patient is taking methotrexate, therefore it is important to monitor the patient closely.
3
When beginning treatment, full blood count, renal and liver function tests should be carried out every 1-2 weeks until the
therapy is stabilised. Thereafter, patients should be monitored every 2-3 months.
3
In addition, testing for viral hepatitis and tuberculosis before starting methotrexate may be required. These results are
required before commencing further treatment options should methotrexate be ine
In women of childbearing age, pregnancy should be ruled out before commencing methotrexate. In addition, advice on the use
of highly e
contraindicated in pregnancy and breastfeeding due to its risk of teratogenicity. This point should be emphasised to any
young, female patients being counselled about methotrexate.
3
Example
“ W h e n y o u
b l o o d c o u n t , k i d n e y f u n c t i o n a n d l i v e r f u n c t i o n . T h i s i s d o n e t o e n s u r e t h e m e d i c a t i o n d o s e i s c o m p a t i b l e w i t h y o u r b o d y .
"
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" Y o u w i l l n e e d t o h a v e b l o o d t e s t s t a k e n e v e r y 1-2 w e e k s u n t i l w e a r e s u r e t h e b l o o d r e s u l t s r e m a i n s t a b l e . A f t e r t h i s p o i n t ,
y o u w i l l c o n t i n u e t o h a v e b l o o d t e s t s t a k e n e v e r y 2- 3 m o n t h s . M o n i t o r i n g t h e s e b l o o d t e s t s i s e s s e n t i a l t o i d e n t i f y a n y
t o x i c s i d e e
d o c t o r s t r a i g h t a w a y .
”
“ W o u l d y o u b e a b l e t o r e p e a t b a c k t o m e y o u r u n d e r s t a n d i n g o f w h e n a n d h o w o f t e n y o u s h o u l d t a k e y o u r m e t h o t r e x a t e
d o s e a n d t h e s e r i o u s s i d e e
”

Closing the consultation

Close the consultation by summarising what you have discussed. This allows you to emphasise the key points of the
consultation.
Finally, thank the patient for their time and o
Dispose of PPE appropriately and wash your hands.

Reviewer

Emily Skinner
Clinical Pharmacist

References

1. National Health Service. M e t h o t r e x a t e . March 2020. Available from\: [LINK]
2. Health Service Executive (HSE) - Medicines Management Programme. O r a l M e t h o t r e x a t e i n P r i m a r y C a r e . January 2015.
Available from\: [LINK]
3. National Institute for Health and Care Excellence (NICE), British National Formulary (BNF). M e t h o t r e x a t e . Accessed December
2021. Available from\: [LINK]
4. Drugbank Online. M e t h o t r e x a t e . Accessed February 2022. Available from\: [LINK]
5. Medicines Agency. P R A C r e c o m m e n d s n e w m e a s u r e s t o a v o i d d o s i n g e r r o r s w i t h m e t h o t r e x a t e . July Europeans from\: [LINK]
2019. Available
6. British National Formulary. M e t h o t r e x a t e . Available from\: [LINK]
Source\: geekymedics.com
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