Low dose methotrexate: Patient monitoring

Last updated: March 09, 2020

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Patient monitoring is essential to mitigate the risk of acute and chronic toxicity with methotrexate. Although most expert bodies agree on what parameters should be monitored, there is some variation around when blood tests should be conducted.

Sometimes local shared guidance attempts to incorporate these differences, giving different schedules according to the disease state being treated. However, other areas have produced a single timetable for all patients regardless of their condition. In practice once patients are stabilised on methotrexate therapy then their liver, renal and haematological status should be assessed every 2-3 months.

For reference, the NICE Clinical Knowledge Summary on the primary care monitoring requirements for people on methotrexate suggests the following schedule. This is based upon guidance from the British Society of Rheumatology and British Health Professionals in Rheumatology and differs to that given by the British Association for Dermatology and the British Society for Gastroenterology.

Full blood count
Creatinine/calculated GFR
Liver function tests: ALT and/or AST and albumin
Every 2 weeks until dose is stable for 6 weeks. Then monthly for 3 months.
Thereafter, at least every 12 weeks.
More frequent monitoring is appropriate in patients at higher risk of toxicity.
Dose increases: Every 2 weeks until dose is stable for 6 weeks, then revert to previous schedule.

In addition to monitoring these parameters, patients with psoriasis taking methotrexate are at risk of hepatic fibrosis. Since routine liver biopsy is not recommended and liver function tests in isolation are inadequate, procollagen peptide type III (PIIINP) has been developed as a marker. This should be measured at least every 3 months.

Other monitoring may be indicated to assess efficacy. This is outside the scope of this tutorial.

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