Methotrexate is an immunosuppressant drug that helps to reduce inflammation in the body. While it is generally an effective treatment for psoriatic arthritis, it can cause unwanted side effects.
Psoriatic arthritis (PsA) is a type of arthritis. According to an article in JAAD, it affects around 1 in 4 people with the skin condition psoriasis.
PsA is an autoimmune condition that causes chronic inflammation of the skin, joints, and connective tissues. This typically causes symptoms such as pain, stiffness, and swelling.
This article describes how methotrexate works to treat PsA. It also looks at the potential side effects of methotrexate and outlines some alternative treatment options available.
Methotrexate is an immunosuppressant drug, which means it suppresses the activity of the immune system. This helps to reduce inflammation and associated pain and swelling.
Methotrexate has several beneficial effects in the treatment of PsA, including:
- Assisting tissue repair: Methotrexate helps white blood cells to repair damaged tissues.
- Increasing adenosine production: According to the Arthritis Foundation, methotrexate causes cells to release adenosine, which is a molecule that blocks inflammation-promoting chemicals.
- Slowing down the production of cytokines: Cytokines are proteins that promote inflammation. Typically, people with PsA have increased levels of cytokines within their joints. An older study from 2003 suggests that methotrexate helps to inhibit the production of cytokines.
Methotrexate can alleviate the symptoms of PsA while helping to prevent further joint damage.
There is some confusion as to the safety of methotrexate. This is because doctors sometimes prescribe very high doses of methotrexate as a treatment for certain cancers.
The dosages required to treat PsA are much lower, with most people taking between 10 milligrams (mg) and 25 mg per week. These low doses are less likely to cause severe side effects.
In fact, according to the Arthritis Foundation, methotrexate is one of the safest arthritis drugs available.
It is essential to take methotrexate according to the doctor’s instructions. Taking too much methotrexate or taking the medication too often can be dangerous.
Methotrexate can cause side effects in some people. While serious side effects are less common, some of these effects can be life-threatening.
The table below shows the most common side effects of methotrexate and their prevalence among people who take the drug for PsA.
|Side effect||Signs and symptoms||Prevalence|
|up to 65% of users|
|Mouth ulcers or sores||painful bumps or sores on the tongue, palate, gums, or inner cheeks||up to 33% of users|
|Methotrexate “fog” (occurring a day or so after taking a dose of methotrexate)||headaches|
|Hair loss||thinning hair, or bald patches||between 1% and 3% of users|
Methotrexate can also cause severe side effects, but these are much less common.
Use of the drug can potentially lead to inflammation and a buildup of scar tissue in areas such as the liver and lungs. It can also potentially cause drops in white blood cell levels and platelet production.
The table below lists severe side effects and their associated symptoms.
|Blood disorder||vomiting blood|
blood in the urine
increased sensitivity to bruising
|Kidney problems||urinating more or less often, or not at all |
swollen hands or feet
|Liver problems||yellow discoloration of the skin or the whites of the eyes|
|Lung inflammation||difficulty breathing|
persistent, dry cough
|Stevens-Johnson syndrome||severe blisters or rash around the mouth, eyes, or genitals|
|Lymphoma (cancers of the lymphatic system)||chills, fever, loss of appetite, tiredness, unexplained weight loss|
The Arthritis Foundation warn that prolonged use of methotrexate can cause liver damage. Although this risk is low, a doctor may recommend regular blood tests to monitor the health of the liver. Reducing or avoiding alcohol intake may help to protect the liver.
To reduce the risk of side effects, a person can try splitting their usual dose of methotrexate. This will mean taking half the dose in the morning and the other half 12 hours later. A person can also split their dose into three parts, and take them in the morning, afternoon, and evening.
Other ways to manage or reduce the side effects of methotrexate include:
- Taking folic acid: A folic acid supplement may help reduce the risk of digestive problems and mouth ulcers by 79%. A person should ask their doctor for advice on the appropriate dose to take and when to take it. Some people may benefit from taking a daily supplement, while others may need a single weekly dose.
- Taking an anti-nausea medication: If nausea is severe, a doctor may prescribe anti-nausea medication to settle the stomach.
- Taking injectable methotrexate: People who experience nausea can also talk to their doctor about switching to injectable methotrexate. This treatment bypasses the stomach, so it may help prevent nausea.
- Using an analgesic mouthwash: Some mouthwashes contain pain relievers such as lidocaine. These should help to alleviate pain from mouth ulcers and mouth sores.
- Avoiding excess sun exposure: Methotrexate makes the skin more sensitive to sunlight. People can protect their skin by wearing a high-SPF sunscreen and long-sleeved clothing. People should also avoid sun lamps and tanning beds.
Methotrexate is not suitable for the following people:
- women who are pregnant or breastfeeding
- people who are allergic to methotrexate
- People who experience severe side effects in response to taking methotrexate
- people who take medications that may interact with methotrexate
- people with chronic liver disease, alcoholic liver disease, or alcoholism
- people who are immunocompromised
- people with a pre-existing blood disorder, such as:
- significant anemia
- low white blood cell counts (leukopenia)
- low blood platelet levels (thrombocytopenia)
Other PsA treatments are available. As with methotrexate, these treatments aim to:
- reduce pain and swelling
- keep joints mobile
- prevent further damage to the joints
We outline some alternative PsA below. In some cases, a doctor may recommend combining different treatments.
Nonsteroidal anti-inflammatory drugs
Nonsteroidal anti-inflammatory drugs (NSAIDs) are often the first-line treatment for PsA. These drugs help to reduce inflammation and alleviate pain.
- traditional NSAIDs, such as ibuprofen, naproxen, and diclofenac
- COX-2 inhibitors, such as celecoxib, and etoricoxib
It is important to note that using NSAIDs to treat PsA is an off-label use. This means the Food and Drug Administration (FDA) have not approved the drugs for treating PsA, but they may be useful.
Corticosteroids are a class of natural or synthetic hormones that help to reduce inflammation in the body. Corticosteroids are available in both oral and injectable forms.
A doctor may use a corticosteroid injection to treat inflammation in a single joint. The results can last from a few weeks to several months.
Methotrexate is a disease-modifying anti-rheumatic drug (DMARD). These drugs block inflammatory processes in the body, thereby helping to slow the progression of PsA.
Besides methotrexate, other DMARDs include leflunomide and sulfasalazine. Doctors may prescribe either medication as an alternative to methotrexate. Taking DMARDs to treat PsA is also an off-label use.
DMARDs can take several weeks or months to have a noticeable effect.
Biological treatments or “biologics” are a newer class of drugs that a doctor may prescribe to treat PsA. The National Psoriasis Foundation explain that these treatments block the action of specific immune cells or proteins that trigger inflammation in the lining of the joints.
Some examples of biologics include:
- tumor necrosis factor-alpha inhibitors
- interleukin 12 and 23 (IL-12/23) inhibitors
- interleukin 17 (IL-17) inhibitors
- interleukin 23 (IL-23) inhibitors
- T cell inhibitors
A doctor will administer biologics via injection into a vein. Doctors usually recommend an initial 3-month course of biologic treatment. If effective, a person can continue the treatment for longer. If it is not effective, a doctor may recommend switching to a different biologic.
Biologics can increase the risk of infection. As such, they are not suitable for people who have a compromised immune system.
Methotrexate is an immunosuppressant drug. It helps to alleviate the symptoms of PsA and slow the progression of the disease.
Methotrexate is generally safe when taken at doses required to treat PsA. Nonetheless, some people may experience side effects, such as digestive issues, mouth sores, and methotrexate fog.
People who experience side effects can try splitting their methotrexate dose over a 12-hour period.
Methotrexate is not suitable for everyone. Other treatment options for psoriatic arthritis include NSAIDs, corticosteroids, and biologics. Individuals should talk to their doctors about their treatment options.