Methotrexate (low dose)

Methotrexate is a medication used in children to treat autoimmune conditions. Examples include:

• Juvenile idiopathic arthritis
• Systemic lupus erythematosus (SLE) or lupus
• Dermatomyositis
• Vasculitis
• Crohn’s disease and Ulcerative colitis
• Psoriasis
• Eczema

The doses used to treat these conditions are considered low dose and are therefore NOT chemotherapy.

Low dose methotrexate works to slow down your child’s overly active immune system to reduce symptoms of their disease.

While using this medicine – Always remember

• Wash your hands with soap and water before and after giving methotrexate tablets or injections.
• You do not need to do anything special when handling body waste (child’s urine, bowel motions and vomit) including changing nappies unless you are pregnant or breastfeeding.
• If you are pregnant, breastfeeding or family planning, it is recommended that you avoid handling methotrexate. If you are unable to avoid giving methotrexate medication, it is recommended that you wear disposable gloves when handling the medicine, product packaging and body waste.
• Suitable gloves can be supplied by the QCH specialist unit/department looking after your child. Pregnant women do not need to avoid social contact with patients who are taking low dose methotrexate for an autoimmune condition.
• Ensure your child does not have long exposure in the sun whilst taking methotrexate. Always use sun-protective clothing and SPF50+ sunscreen.
• Your child will need regular blood tests while taking methotrexate.
• Before having any immunisations, speak with your doctor.
• If your child becomes unwell or has any signs of an infection, please contact your GP for medical advice.
• Contact the specialist unit/department if your child comes into contact with someone who has chicken pox, shingles or measles.

Giving my child methotrexate

Methotrexate can be given enterally (by mouth or feeding tube) or by injection under the skin (subcutaneous).

When and how should I give methotrexate?

Low dose Methotrexate is usually given once a week on the same day each week.

Enteral doses (given by mouth or feeding tube)

It is ok to give tablets either with or without food.

Do NOT crush the tablets.

Tablets may be cut in half or quarters using a tablet cutter (used for methotrexate ONLY) inside a clear snap lock (zip lock) bag.

If your child cannot swallow tablets, they can be dispersed (mixed) in water using an oral or enfit dispenser.

You can do this by:

• Removing the plunger from the oral/enfit dispenser
• Put the required number of tablets in the dispenser and replace the plunger
• Draw up a small amount of water (e.g. 5 mL). Close off the end by placing index finger over the tip of the syringe and gently shake. The tablet may take a few minutes to disperse properly.
• Once dispersed, give the dose straight away
• Dispose of the oral/enfit dispenser in the general waste
• Only make the dose in the dispenser immediately before giving it.

Doses given by subcutaneous injection (under the skin)

Prefilled syringes with attached needles must be immediately placed into a cytotoxic sharp’s container after use. Avoid recapping the needle at any time.

Close the sharps container when it is almost full and either take it with you to your next specialist appointment at QCH or with prior arrangement, return it to a participating pharmacy.

It is unlikely that you will get an accidental needle-stick injury but if you do happen to prick yourself with the needle while preparing the injection or disposing of the syringe, you should:

1. apply gentle pressure to the puncture site to make it bleed a little
2. wash the area well under a running tap
3. dry and cover the puncture with a Band-Aid

What to do if a dose is missed or my child vomits

Never give a double dose of the medicine to catch up a missed dose.

If you forgot to give a dose and remember any time over the next two days, give the missed dose. For example, if you usually give methotrexate on a Monday, you can give it on a Tuesday or Wednesday. If you remember after this, do NOT give the missed dose.

If your child vomits less than 30 minutes after having a dose of oral/enteral methotrexate, give them the same dose again. If it is subcutaneous do not readminister.

If your child vomits more than 30 minutes after having a dose of either oral or subcutaneous methotrexate, do NOT give them another dose. Wait until the next normal dose.

Avoid stopping methotrexate without discussing with your child’s specialist team.

What to do if I give too much Methotrexate

If you think your child has had too much methotrexate, call the Poisons Information Centre on 13 11 26, even if your child shows no effects.

What about using other medicines with Methotrexate?

Tell your doctor or pharmacist about any other medicines or products your child takes before starting methotrexate. This includes prescription, over the counter medicines, vitamins, supplements, herbal or complementary medicines that you buy from a pharmacy, supermarket, health food shop or online.

You can give your child medicines that contain paracetamol or ibuprofen (anti-inflammatories) to treat pain and fever unless your doctor has told you not to.

Possible side effects – what other effects can occur?

Side effects to be aware of include upset stomach, nausea, vomiting, diarrhea, loss of appetite, mouth ulcers, skin sensitivity to the sun, rash, skin itch, and elevated liver enzymes in the blood.

Folic acid may be prescribed to reduce the likelihood of experiencing side effects of methotrexate. It should be taken on a different day(s) from the methotrexate, normally the day before and/or after taking methotrexate.

Regular blood tests are important for monitoring liver enzyme levels.

General medicine advice

Only give this medicine to your child who was prescribed it. Never give it to anyone else, even if their condition appears to be the same, as this could do harm. Contact Poisons Information Centre on 13 11 26 if another person takes this medicine.

Always have valid prescriptions and enough supply of methotrexate. Methotrexate injections for subcutaneous use (under the skin) may need to be collected from your local hospital pharmacy. Methotrexate tablets should be collected from your local community pharmacy.

Methotrexate prefilled syringes and tablets are usually stored at room temperature. This means in a cool dry place (such as a cupboard) away from heat, direct sunlight and moisture, and kept below 25^oC. Prefilled syringes can be stored in the refrigerator (2-8^oC) if required, without affecting potency. Storage recommendations can change over time so always check storage information provided by the manufacturer.

Store all medicines out of sight and where children cannot reach them. Always keep medicine in the container or box that it came in.

Dispose of expired medicines or medicines you no longer need to your pharmacy.

For more information

This fact sheet is about using this medicine in children and young people. Some information may be different from the manufacturer’s Consumer Medicine Information (CMI). Talk to your doctor, nurse or pharmacist if you have any questions or concerns.

Contact us

In an emergency, always contact 000 for immediate assistance

Pharmacy Department
Level 2, Queensland Children’s Hospital
501 Stanley Street, South Brisbane 4101
t: 07 3068 1901 (9am – 5pm Mon – Fri)
(9am – 12pm Sat – Sun/public holidays)

Outpatient Speciality Clinics (9am – 5pm Mon – Fri)
Rheumatology
t: 07 3068 2389
Dermatology
t: 07 3068 5893
Gastroenterology
t: 07 3068 4325

Endorsed by Queensland Children’s Hospital Medication Safety Committee and developed by 2023 with input from parents and carers.

Updated: 06/01/2023, v1.0.

Contact CHQMedicationSafety@health.qld.gov.au for sources used to create this Fact Sheet.

Disclaimer: We take great care to make sure the information in this Fact Sheet is correct, up-to-date and reflects current use in Australia. However, medicines can be used in different ways for different patients. It is important that you ask the advice of your doctor or pharmacist if you are not sure about something.

This Fact Sheet is to be used as an aid, rather than a substitute for a discussion with your doctor or pharmacist. Children’s Health Queensland Hospital and Health Service accepts no responsibility for any inaccuracies, omissions, reliance placed, or the success of any treatment regimens detailed in this Fact Sheet.