Taking low-dose methotrexate daily instead of weekly causes mucositis, cytopenias and deaths every year, and the error usually happens at the point of dispensing or when a patient is admitted. Write the dose once weekly with the named day of the week on the prescription, prescribe folic acid on a different day, and tell the patient in plain words never to take it daily. Check full blood count, liver tests and creatinine before starting and regularly thereafter, and stop it while a patient has an acute infection or acute kidney injury.
- Write 'once weekly' and the named day on every methotrexate prescription.
- Prescribe folic acid on a different day of the week.
- Check blood count, liver tests and creatinine before starting and at regular intervals.
- Tell patients and carers in plain words that daily dosing is dangerous.
Why it matters
Methotrexate stays first-line in early RA, and dosing errors remain a preventable cause of serious harm.
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