Methotrexate is a medication for the treatment of rheumatoid arthritis. However, it can cause folic acid deficiencies, so simultaneous methotrexate and folic acid supplementation may be necessary.

Methotrexate reduces the replication of harmful cells and helps to reduce inflammation. It works by reducing folic acid levels in the body, which can lead to side effects, such as nausea, vomiting, and stomach pain.

A person taking the medication for rheumatoid arthritis (RA) takes a folic acid supplement to help reduce these unwanted side effects. The body needs folic acid to maintain a healthy gastrointestinal (GI) tract, support liver function, and promote healthy bones and hair.

In this article, learn more about how methotrexate affects folic acid and the other possible side effects.

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Enzymes in the liver convert folic acid into folate, which plays many essential roles in the body, including helping with cell division and DNA replication.

Methotrexate reduces the amount of folic acid in the body, meaning harmful cells cannot replicate as quickly. The medication also increases the amount of adenosine in inflamed joints, decreasing inflammation.

In addition to RA, people also use methotrexate to treat autoimmune conditions such as psoriasis. Doctors may also recommend high, frequent doses of methotrexate to treat certain cancers.

Learn more about the difference between folic acid and folate here.

Methotrexate and RA

Doctors do not know all the ways that methotrexate works to reduce RA symptoms. According to the Food and Drug Administration (FDA), methotrexate affects immune system function, reducing the body’s immune response that contributes to RA symptoms.

Methotrexate also increases adenosine levels in the joints, which further decreases inflammation. Adenosine is a natural compound that regulates inflammation.

People typically take methotrexate once per week and may see a reduction in swelling, inflammation, and tenderness within 6-8 weeks.

A doctor will recommend how much folic acid to take and when to take it.

According to the Arthritis Foundation, some doctors suggest taking 1 milligram (mg) of folic acid a day. Other research indicates that a once-weekly dose of 5 mg will suffice.

Some people will take the folic acid supplement 24 hours after taking a methotrexate dose.

Because methotrexate also depletes folic acid levels, it can cause a variety of side effects, including:

Taking a folic acid supplement can reduce the risk of these side effects.

Other ways to reduce side effects

In addition to taking folic acid supplements, a person can also reduce the side effects of methotrexate by:

  • Talking with a doctor about dosage. Some people who take methotrexate may experience fewer digestive problems if they take half the dose in the morning and a half at night, both with food.
  • Switching to injectable medication. Sometimes, injectable methotrexate causes fewer GI side effects than the tablet does.
  • Asking a doctor about anti-nausea medications. Taking anti-nausea medications, such as ondansetron (Zofran), may help reduce methotrexate-related side effects.
  • Using mouth rinses to reduce sores. Doctors may sometimes prescribe special mouthwashes, or a person may choose to use a warm saltwater rinse.

A person can also ask their doctor about other ways to reduce methotrexate-related side effects.

Methotrexate can lead to unwanted side effects. It is a good idea to discuss possible side effects with a doctor before taking methotrexate.

In pregnancy

People should not take methotrexate when pregnant or breastfeeding (also known as chestfeeding). The drug can cause serious harm to the pregnant person and their pregnancy.

Taking methotrexate during pregnancy can cause:

  • pregnancy loss
  • fetal malformations

Methotrexate and alcohol

Long term or high dose methotrexate use can damage the liver. As alcohol can also impact liver function, doctors may recommend a person reduce their alcohol intake when taking methotrexate.

However, a combination of low doses of the drug and low alcohol intake is typically safe.

Those with alcohol use disorder should also avoid methotrexate because it increases liver enzymes and can be toxic to the liver.

Other side effects

Other side effects that can occur as a result of taking methotrexate include:

A person should contact a doctor immediately if they experience any of the following side effects:

While some of these side effects are relatively widespread among people who take methotrexate, anyone experiencing them should let their doctor know. A doctor can recommend other interventions for these side effects.

If anyone experiences severe side effects, such as bleeding, they may require hospitalization to check blood levels and for other treatments.

While methotrexate can help treat RA, it can lead to folate deficiency and other side effects. Taking a folic acid supplement can help reduce these side effects.

People should talk with a doctor about how much folic acid to take and when to take it for RA. Following a doctor’s treatment plan can reduce adverse symptoms and help to manage RA effectively.

Methotrexate is an effective medication for the treatment of rheumatoid arthritis. However, taking the medication can lead to a folic acid deficiency and side effects, including mouth sores, nausea, and stomach pain.

Taking folic acid supplements can help to manage these side effects and improve overall treatment outcomes.