Trexall – Methotrexate

Patient Education Quick Reference Guide Diablo Valley Oncology/Hematology Medical Group Phone Number: 925-677-5041

WARNING

Blood related problems

  • Methotrexate may cause serious decreases in your red blood cell, white blood cell and platelet levels which can cause infections, anemia, bruising and bleeding (see Precautions To Be Aware Of Before Taking This Medication).
  • This medication can cause tumor lysis syndrome (TLS), especially in people who are being treated for aggressive lymphomas or acute leukemias. TLS occurs when chemotherapy medications rapidly kill large numbers of cancer cells and cause abnormal changes in your blood (see Precautions To Be Aware Of Before Taking This Medication).
 

Drug interaction related problems

Serious blood related problems as well as gastrointestinal problems have been reported when methotrexate is given in combination with NSAIDS (see Precautions To Be Aware Of Before Taking This Medication and Medication and Food Interactions).  

Gastrointestinal related problems

Diarrhea and sores on the mouth and lips can occur with methotrexate. You should let your doctor or healthcare provider know right away if you develop either of these symptoms since they can become serious (see Precautions To Be Aware Of Before Taking This Medication).  

Infection related problems

Serious infections can occur with methotrexate treatment (see Precautions To Be Aware Of Before Taking This Medication).

Organ related problems

  • This medication can cause changes in the ability of your liver to work normally (see Precautions To Be Aware Of Before Taking This Medication).
  • This medication can cause changes in the ability of your kidneys to work normally. In addition, this medication is cleared from the body by the kidneys. In patients with severe kidney problems, methotrexate may not be cleared from the body as well (see Precautions To Be Aware Of Before Taking This Medication).
  • This medication can cause lung problems (see Precautions To Be Aware Of Before Taking This Medication).
  • In patients with conditions that cause fluid to accumulate in organs such as the liver (ascites), heart (pericardial effusions) or lung (pleural effusions), methotrexate may not be cleared from the body as well. This can lead to high levels of this medication in the body and a greater chance of side effects.
 

Pregnancy related problems

This medication has been reported to cause fetal harm. Extreme caution needs to be exercised when using this medication in women of child bearing age.  

Radiation related problems

When methotrexate is given together with radiation therapy, you may be more likely to develop a condition called soft tissue necrosis and osteonecrosis. This occurs when an area of the skin or bone becomes damaged and dies.  

Skin related problems

Serious skin reactions have been reported in patients receiving methotrexate (see Precautions To Be Aware Of Before Taking This Medication).  

Uses For This Medication

  • Methotrexate is used in combination with other chemotherapy medications to treat adults with many different types of cancer including breast cancer, certain types of leukemia (acute lymphoblastic leukemia, acute nonlymphocytic leukemia, meningeal leukemia), head and neck cancer, mycosis fungoides, osteosarcoma, bladder cancer, and non-Hodgkin’s lymphoma.
  • Methotrexate is also used in the treatment of non-cancerous conditions, including adult and childhood rheumatoid arthritis and psoriasis.
  • This medication may also be given for other conditions as determined by your doctor.
 

How This Medication Works

Methotrexate is a chemotherapy medication that doesn’t allow cancer cells, also known as tumor cells, to divide and grow normally, which leads to tumor cell death.  

Benefits of This Medication

Methotrexate, given together with other chemotherapy medications, may slow down the growth of the tumor, or cancer. In addition, for some cancers, methotrexate may lengthen how long a person lives.  

Who Should Not Take This Medication

You should not take this medication if you:
  • Are allergic to methotrexate or any of its components.
  • Are pregnant.
  • Are breast feeding.
  • Are an alcoholic, have alcoholic liver disease or other chronic liver disease.
  • Have an immunodeficiency syndrome. Your doctor or healthcare provider will check your blood before starting methotrexate to make sure that it is safe to start this medication.
  • Have very low white blood cell, red blood cell, or platelet levels. Your doctor or healthcare provider will check your blood before starting methotrexate to make sure that it is safe to start this medication.
  Precautions to be Aware of Before Taking This Medication NOTE: Side effects can be mild or severe depending on the doses of methotrexate used.  

Activity related precautions

This medication can cause dizziness and fatigue. Use caution or avoid operating machinery, including driving a car, following treatment with this medication.  

Blood related precautions

  • This medication may temporarily reduce the number of platelets in your blood. This can increase your risk of bleeding. Contact your doctor or healthcare provider if you notice unusual bleeding or bruising, have black or tar-like stools, see blood in your urine, or develop pinpoint red spots on your skin. If your platelet levels become too low, your doctor or healthcare provider may recommend that your treatment be delayed, that you receive a platelet transfusion, and/or that you take medication to help increase the number of platelets in your blood. To lower your chance of bleeding, do not use aspirin, aspirin-containing medications, or aspirin-like medications (for example, ibuprofen, naproxen). Use caution with sharp objects like razors and nail cutters, and avoid activities that can cause cuts, bumps and bruises. You should avoid flossing your teeth if you have been told your platelets are low.
  • This medication may temporarily reduce the number of germ fighting white blood cells in your blood. This can increase your risk of infection. Contact your doctor or healthcare provider promptly if you develop any signs of an infection such as fever, painful urination, chills or a sore throat that doesn’t go away. If your white blood cell levels become too low, your doctor or healthcare provider may recommend that your treatment be delayed and/or you receive medication to increase the number of white cells in your blood. To lower your risk of infection, stay away from crowds and people with colds or other illnesses, wash your hands with soap and water well and often, and brush and floss your teeth daily. If you have low levels of a certain type of white blood cell called neutrophils (neutropenia), your healthcare provider may advise you to avoid flossing your teeth because this could put you at risk for infection and bleeding.
  • This medication may temporarily lower the number of red cells in your blood. This can increase your risk of anemia. If your red blood cell level becomes low, you may feel tired and weak. If your red blood cell level becomes too low, your doctor or healthcare provider may recommend that your treatment be delayed, that you receive a red blood cell transfusion, and/or you receive a medication to help increase the red cells in your blood.
 

Drug interaction related precautions

Significant problems, such as serious decreases in your red blood cell, white blood cell and platelet levels, as well as gastrointestinal toxicity have been reported when methotrexate is given together with NSAIDS [such as ibuprofen (Advil®), naproxen (Aleve®), sulindac (Clinoril®), or ketoprofen (Oruvail®)]. Do not take NSAIDS while you are receiving methotrexate.  

Central nervous system precautions

This medication can cause central nervous system problems, including headache, back pain, paraparesis (weakness in the legs), confusion, irritability, sleepiness, ataxia (problems with coordination), seizures (convulsions), temporary blindness, and coma. If you experience any of these symptoms, contact your doctor or healthcare provider immediately.  

Gastrointestinal related precautions

  • This medication may cause nausea, vomiting, and/or diarrhea which can lead to dehydration. Eat small frequent meals, bland foods (for example bananas, rice, apples, toast), and drink plenty of water and fluids that contain electrolytes (e.g. Gatorade, Pedialyte) to avoid dehydration. Contact your doctor or healthcare provider if you have moderate to severe nausea, vomiting or diarrhea. These side effects can be treated with medications.
  • This medication may cause redness or sores in your mouth, throat or on your lips. Talk with your doctor or healthcare provider about proper mouth and throat care (for example brushing and flossing). Avoid foods and drinks that may irritate your mouth such as citrus fruits and juices, tobacco, and spicy foods. Using a salt and baking soda mouthwash (1 teaspoon salt & 1 teaspoon baking soda dissolved in 1 quart of water) four times a day may be soothing.
  • If you have a history of stomach ulcers or ulcerative colitis, you should let your doctor or healthcare provider know, since methotrexate may worsen these conditions.
 

Infection related precautions

You should not receive methotrexate if you have an active infection. In addition, methotrexate can cause serious infections, such as Pneumocystis carinii pneumonia. If you develop a cough or any other signs of a respiratory infection, you should contact your doctor or healthcare provider immediately.  

Organ related precautions

  • This medication can cause changes in the ability of your liver to work normally. This is more common in people who are taking low dose, oral methotrexate for long periods of time. Your doctor or healthcare provider will check your liver regularly, usually through blood tests, while you are on this medication to make sure that your liver is working properly. If you have any liver problems before starting this medication, make sure that you tell your doctor or healthcare provider so that he or she can watch you carefully for possible problems or side effects. In addition, if you have been taking the oral form of methotrexate for an extended period of time, you should contact your doctor or healthcare provider if you experience flu-like symptoms and/or yellowing of the skin and whites of the eyes, as these may be signs of liver damage.
  • This medication can cause changes in the ability of your kidneys to work normally. In addition, this medication is cleared from the body by the kidneys. In patients with severe kidney problems, methotrexate may not be cleared from the body as well. This can lead to high levels of this medication in the body and a greater chance of side effects. Your doctor or healthcare provider will check your kidneys regularly, usually through blood tests, while you are on this medication to make sure that your kidneys are working properly. If you have any kidney problems before starting this medication, make sure that you tell your doctor or healthcare provider so that he or she can watch you carefully for possible problems or side effects.
  • This medication can cause lung problems. Contact your doctor or healthcare provider if you experience symptoms such as a dry, nonproductive cough or difficulty breathing.
 

Skin related precautions

  • This medication can cause serious skin reactions. If you experience any skin changes, contact your doctor or healthcare provider right away.
  • Your skin may become more sensitive to sunlight while taking this medication. Stay out of direct sunlight, wear protective clothing (for example long pants, long-sleeved shirt, hat) and sunglasses, and apply a sun-block product that has a skin protection factor (SPF) of at least 15 to your skin and lips. Do not use a tanning bed or sunlamp while using this medication.
  • In patients who have prior radiation therapy, the skin or tissue damage from radiation therapy can become red and appear damaged again after receiving methotrexate. Contact your doctor or healthcare provider if your skin gets red in areas where radiation was given.
 

Miscellaneous precautions

  • You should avoid drinking alcohol while receiving this medication since it could increase the risk of liver damage.
  • This medication can cause tumor lysis syndrome (TLS). This occurs when chemotherapy medications rapidly kill large numbers of cancer cells and cause abnormal changes in your blood. Your doctor or healthcare provider will check your blood regularly through blood tests. In addition, if you experience symptoms such as muscle weakness, tingling on the lips, arms or legs, anxiety, cough, wheezing, rapid and irregular heart beats, dizziness, chest tightness (shortness of breath), fatigue, increased nausea and/or vomiting, joint-pain, or a feeling of general discomfort, you should contact your doctor or healthcare provider.
  • Do not receive any immunizations (vaccinations) while on this medication without your doctor or healthcare provider’s approval. This medication can increase your risk of infection. For certain immunizations, you may develop the infection that the immunization is intended to prevent.

Patient specific precautions

  • This medication is safe and effective in children with cancer or polyarticular juvenile arthritis
  • Older patients (older than 65 years of age) receiving methotrexate tend to experience some side effects more frequently than younger patients.
 

Pregnancy and Breastfeeding Precautions

  • This medication may cause fetal harm. When taking this medication, you should use effective birth control to prevent pregnancy. In addition, males should avoid pregnancy for three months after treatment, and women should avoid pregnancy for at least one normal menstrual cycle after treatment. Tell your doctor or healthcare provider right away if you or your spouse/partner becomes pregnant.
  • It is not known whether this medication is found or excreted in breast milk. Since many medications are excreted in breast milk and because this medication can cause serious harmful reactions in infants, breastfeeding should be avoided.
  • Many anti-cancer therapies can cause sterility. Notify your doctor or healthcare provider if you want to have children in the future.
 

Medication and Food Interactions

Before using this medication, tell your doctor or healthcare provider of all prescription or over-the- counter products you are taking, including dietary supplements or vitamins, herbal medicines and homeopathic remedies. Do not start or stop any medication without your doctor or healthcare provider’s approval. Possible interactions can occur with methotrexate and the following medications:
  • Azathioprine
  • Chloramphenicol (Chloromycetin®)
  • Folic acid
  • Medications that can cause kidney problems
  • Mercaptopurine (Purinethol®)
  • NSAIDS such as ibuprofen (Advil®), naproxen (Aleve®), sulindac (Clinoril®), ketoprofen (Oruvail®)
  • Penicillins
  • Phenylbutazone
  • Phenytoin (Dilantin®)
  • Probenecid
  • Retinoids
  • Salicylates
  • Trimethoprim/Sulfamethoxazole (Septra®)
  • Sulfasalazine (Azulfidine®)
  • Sulfonamides
  • Tetracycline
  • Theophylline
NOTE: This list may not include all medications that can have interactions with methotrexate. Side Effects
  • All medications can cause side effects. However, not all patients will experience these side effects. In addition, other side effects not listed can also occur in some patients. You should call your doctor or healthcare provider if you have any questions or concerns while you are on this medication.
  • You should contact your doctor or healthcare provider if you experience any side effect(s) which don’t go away, worsen, are serious in nature, or are worrisome to you.
  • Side effects can occur when methotrexate is given alone or together with other chemotherapy medications. The side effects listed below are those reported in patients who were treated with methotrexate alone.
 

More common side effects

  • Sores on the mouth or lips, nausea, vomiting, diarrhea, stomach pain, loss of appetite
  • Decreased white blood cell levels (see Precautions To Be Aware Of Before Taking This Medication)
  • Dizziness, fatigue, malaise
  • Skin changes in areas previously treated with radiation, increased risk of sunburn (see Precautions To Be Aware Of Before Taking This Medication)
  • Increased liver function blood tests (see Precautions To Be Aware Of Before Taking This Medication)
 

Less common side effects

  • Decreased platelet and/or red blood cell (see Precautions To Be Aware Of Before Taking This Medication)
  • Kidney problems (see Precautions To Be Aware Of Before Taking This Medication)
  • Chemical arachnoiditis, a condition that occurs within 48 hours of intrathecal administration (injection into the spinal cord) of methotrexate. Symptoms include neck stiffness, neck pain, nausea and/or vomiting, headache, fever, and back pain and can last from 1-5 days.
 

Rare side effects

This is not a complete list of the rare side effects reported with methotrexate. For a complete list, please talk with your doctor or healthcare provider about reviewing a copy of the package insert.
  • Liver problems (see Precautions To Be Aware Of Before Taking This Medication) 
  • Lung problems (see Precautions To Be Aware Of Before Taking This Medication) 
  • Hair loss 
  • Rash, itching (see Precautions To Be Aware Of Before Taking This Medication) 
  • Dizziness, blurred vision 
  • Leukoencephalopathy, a brain disease that can cause confusion, irritability, sleepiness, problems with coordination and recognition, seizures (convulsions), and coma.
 

How To Take This Medication

  • This medication is either taken by mouth (orally) or given by injection into a vein (IV) by a healthcare professional. Methotrexate can also be injected into the spinal cord (intrathecally) to help kill any cancer cells found there.
  • This medication can be given in different doses (low, medium, and high) depending on your weight, whether you are receiving IV or oral methotrexate, your type of condition, and whether methotrexate is being given with other chemotherapy medications. If you are taking this medication orally, be sure to take it exactly as directed by your doctor or healthcare provider. If you do not understand these instructions, ask your doctor or healthcare provider to explain them to you.
  • When high doses of methotrexate are used, you may be given a medication called sodium bicarbonate before, during and after methotrexate to help flush your kidneys and protect them from this medication. In addition, a medication called leucovorin may be given to help prevent serious side effects such as serious decreases in your red blood cell, white blood cell and platelet levels as well as mouth sores. If you are given leucovorin it is very important that you do not miss or skip doses; if you are unable to take the leucovorin due to nausea contact your health care provider immediately.
  • Antiemetics, which are medications to help prevent and control nausea and vomiting, may be given before methotrexate either by mouth (orally) or by injection into a vein (IV).
  • In the unlikely event of an overdose of this medication contact your doctor, your local poison control center at 1-800-222-1222, or emergency services immediately.
  Proper Storage
  • If you are receiving the IV form of methotrexate, it is unlikely that you will need to store this medication. However, in the event that you do, the unopened containers should be stored at controlled room temperature. Keep in original package to protect from light.
  • If you are taking the oral form of methotrexate, the tablets should be stored at room temperature.
  • Keep this medication out of the reach of children or pets.
  • Ask your doctor or healthcare provider how to dispose of any medication that you no longer use.