Looking Back: Managing Methotrexate Adverse Effects (Part 3)

This week we bring you the last in our “Looking Back” series on methotrexate. We continue to look at managing methotrexate adverse effects.

Here is the original post from 2017…

In our last two blogs we discussed the importance of folic acid supplementation while on methotrexate,  and the use of dextromethorphan (DM) to reduce the potential “sick day” phenomenon which some people experience the day after taking methotrexate.  In this blog,  I am addressing strategies to avoid nausea that is associated with methotrexate use in some patients.  Of great importance is the use of folic acid as was mentioned earlier.

In addition, methotrexate can be given as a weekly injectable dose instead of swallowed tablets.  This avoids contact with the stomach and reduces nausea.  The injectable is available in three ways.  1. A vial where patients draw up their dose in a syringe,  2. a pre-filled syringe,  3. an auto-injector device (newly available in Canada).  Currently only the first option is a benefit under government based insurance where the other options may be a benefit under private insurance.  The injectable also provides excellent absorption and may be a more effective treatment than the tablets which aren’t as efficiently absorbed.

For patients using tablets, splitting the dose over the day the methotrexate is taken will reduce stomach upset and allow for better absorption.  The maximum number of tablets that can be absorbed at any time is 6.  Doses higher than this need to be split over the day, even if there is no nausea (ie. if you take 8 tablets weekly; swallow 4 after breakfast and 4 tablets after your evening meal on the same day).

It is important to note that many patients using methotrexate experience no adverse effects.


Carolyn Whiskin is the Pharmacy Manager for Charlton Health.  Carolyn specializes in the treatment of autoimmune diseases, pharmaceutical compounding, women’s health, pain and smoking cessation. Carolyn has won provincial and national awards for her commitment to patient care and public service.

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