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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.
Confirm the patient’s name and date of birth.
Explain the reason for the consultation: “Today I’d like to talk to you about a medication called methotrexate, would that be okay?”
It is important to establish good rapport and an open line of communication: “If you have any questions at any point, or if something is not clear, please feel free to interrupt and ask me.”
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 and 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
- “Have you heard of methotrexate?”
- “Before we start, are you able to take me through what you know about methotrexate already?”
Concerns
- “Do you have any particular worries about starting methotrexate?”
Expectations
- “What were you hoping we would cover today relating to considering a trial of methotrexate?”
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 effects.
Understanding the patient’s care so far will help you tailor any advice and personalise the information for their specific situation.
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 first-line 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 inflammation and 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
“Methotrexate is a medication that can be used to decrease inflammation. Using this medication will help to reduce the symptoms associated with rheumatoid arthritis, especially joint pain, swelling and stiffness.”
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 different conditions. For example, the starting dose for rheumatoid arthritis is 7.5mg whereas 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 effects of methotrexate. It can decrease mucosal and gastrointestinal side effects and may prevent liver toxicity.6
Folic acid should never be taken on the same day as methotrexate as it can impair the efficacy of the medication.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
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-filled injection pen or syringe for self-administration at home. The patient will need to be taught how to self-administer their medication first by one of the medical or nursing team before they are deemed 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
“You should take methotrexate as prescribed on the same day every week. It can be taken with or without food.” 1
[add details relevant to specific form as described above]
“For example, your prescription will read something like: Take methotrexate 12.5mg (5 x 2.5mg tablets) ONCE WEEKLY on SUNDAYS.” 2,5
“You will be prescribed a second medication called folic acid, which is to be taken as prescribed, normally once a day. However, you should never take the folic acid on the same day as your methotrexate dose.”
“It is important that you don’t stop taking these medications without talking to your doctor first. Be sure to mention that you are on methotrexate when interacting with healthcare workers, as it can affect certain medical decisions. For example, if you wish to receive vaccines as per the schedule for those taking methotrexate, the consultant may need to alter/suspend your dose.”
“Is there anything you are not clear on that you would like me to go over again? If not, would you be able to repeat back to me your understanding of methotrexate and how you should take it?”
Side effects and interactions
As with all medications, there are side effects associated with methotrexate use, some more serious than others.
Educating the patient about the signs associated with serious side effects, and the importance of seeking prompt medical 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 effects of methotrexate include:1,2,3
- Loss of appetite
- Nausea
- Indigestion
- Diarrhoea
- Headaches
- Tiredness
- Hair loss
Rare but serious side effects of methotrexate include:1,2,3
- Liver toxicity: jaundice
- 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 affect the way methotrexate works, therefore it is important to advise patients to discuss new 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 effect of 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
“There are a number of potential side effects that you should be aware of when taking methotrexate. The most common side effects that some patients experience are loss of appetite, nausea and diarrhoea as well as headaches, tiredness and potentially hair loss.”
“It is good to be aware of these side effects, however, they do not occur in everyone who takes methotrexate. It is important to be aware of the rare, but serious side effects. If you notice anything like a sore throat, bruising, mouth ulcers, shortness of breath, abdominal discomfort, vomiting or dark-coloured urine, report them to your doctor as soon as they occur.”
“You should ask your doctor or pharmacist before taking any over-the-counter medications as some of them can increase your risk of developing these severe side effects. You should not take anti-inflammatory medications such as ibuprofen or an antibiotic called trimethoprim.”
“When you begin taking methotrexate you will be given an alert card which can be used to inform healthcare professionals that you are taking this medication and this will help inform their clinical decisions.”
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 ineffective.
In women of childbearing age, pregnancy should be ruled out before commencing methotrexate. In addition, advice on the use of highly effective contraception methods (e.g. long-acting reversible contraceptives) should be given. Methotrexate is 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
“When you first start taking methotrexate, we will want to keep a close eye on certain blood levels including your full blood count, kidney function and liver function. This is done to ensure the medication dose is compatible with your body.”
“You will need to have blood tests taken every 1-2 weeks until we are sure the blood results remain stable. After this point, you will continue to have blood tests taken every 2-3 months. Monitoring these blood tests is essential to identify any toxic side effects early. It is equally important to report any of the signs or symptoms we talked about earlier to your doctor straight away.”
“Would you be able to repeat back to me your understanding of when and how often you should take your methotrexate dose and the serious side effects that you should report to your doctor? If you like, we can go through this again.”
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 offer them a leaflet summarising the key information related to methotrexate.
Dispose of PPE appropriately and wash your hands.
Reviewer
Emily Skinner
Clinical Pharmacist
Editor
Dr Chris Jefferies
References
- National Health Service. Methotrexate. March 2020. Available from: [LINK]
- Health Service Executive (HSE) – Medicines Management Programme. Oral Methotrexate in Primary Care. January 2015. Available from: [LINK]
- National Institute for Health and Care Excellence (NICE), British National Formulary (BNF). Methotrexate. Accessed December 2021. Available from: [LINK]
- Drugbank Online. Methotrexate. Accessed February 2022. Available from: [LINK]
- Europeans Medicines Agency. PRAC recommends new measures to avoid dosing errors with methotrexate. July 2019. Available from: [LINK]
- British National Formulary. Methotrexate. Available from: [LINK]
