Trexall is a brand-name prescription medication that’s used to treat certain types of rheumatoid arthritis (RA), psoriasis, and cancer.

Trexall contains the active drug methotrexate, which is a kind of drug called an antimetabolite. Trexall is a chemotherapy medication for cancer. It’s also FDA-approved to treat arthritis and psoriasis, but in much lower doses than are used for cancer. In arthritis treatment, Trexall is known as a disease-modifying antirheumatic drug (DMARD).

Trexall comes as a tablet that you swallow. It’s available in four different strengths: 5 mg, 7.5 mg, 10 mg, and 15 mg.

What it does

Trexall is FDA-approved to treat the following conditions:

  • RA in adults that’s severe and active.* RA is a disease that occurs when your immune system mistakenly starts attacking your joints. “Active” means that you currently have symptoms.
  • Polyarticular juvenile RA that’s active.* This type of arthritis occurs in children. And “polyarticular” means that the disease affects more than one joint.
  • Psoriasis in adults that’s severe.* With psoriasis, your immune system mistakenly starts attacking healthy skin cells. This causes thick, scaly patches to build up on your skin.
  • Certain kinds of cancers. These cancers include:
    • epidermoid cancers of the head and neck (cancers that start in cells lining the moist surfaces inside the mouth, throat, nose, or sinuses)
    • a type of skin cancer called advanced mycosis fungoides (also called cutaneous T-cell lymphoma). “Advanced” means that the cancer affects much of the skin and may have spread to other organs.
    • advanced non-Hodgkin lymphoma (a group of cancers that begin in certain kinds of white blood cells). “Advanced” means that the cancer has spread to multiple lymph nodes or one or more other organs.
    • pregnancy-related cancers of the uterus (womb), including gestational choriocarcinoma, chorioadenoma destruens, and hydatidiform mole**

* For these conditions, Trexall is used after someone has tried other treatments that either didn’t work for them or that they couldn’t tolerate.

** Trexall has a boxed warning for harm in pregnancy. A boxed warning is the most serious warning from the Food and Drug Administration (FDA). For more information, see “FDA warnings” at the beginning of this article.

Effectiveness

Methotrexate (the active drug in Trexall) is a well-accepted and effective treatment for cancer, RA, and psoriasis. Methotrexate is included in treatment guidelines for all these conditions. It’s also been in widespread use since the Food and Drug Administration (FDA) first approved the medication in the 1950s.

For more information about the effectiveness of Trexall, please see the “Trexall uses” section below.

Trexall is available as a brand-name medication, and it contains the active drug methotrexate. (As the active drug, methotrexate is the ingredient that makes Trexall work.) Generic forms of methotrexate tablets are available, but these come in a lower strength (2.5 mg) than Trexall.

A generic drug is an exact copy of the active drug in a brand-name medication. The generic is considered to be just as safe and effective as the original drug. Generics also tend to cost less than brand-name drugs.

Methotrexate is also available as:

  • an oral liquid (Xatmep) that you swallow
  • a liquid solution (Rasuvo, Otrexup, and RediTrex) that you inject subcutaneously, which means that it’s given as an injection just under your skin
  • an intravenous injection (given as an injection into your vein)

Trexall can cause mild or serious side effects. The following lists contain some of the key side effects that may occur while taking Trexall. These lists don’t include all possible side effects. Side effects are more likely when Trexall is used in high doses to treat cancer.

For more information on the possible side effects of Trexall, talk with your doctor or pharmacist. They can give you tips on how to deal with any side effects that may be bothersome.

Note: The Food and Drug Administration (FDA) tracks side effects of drugs they have approved. If you would like to report to the FDA a side effect you’ve had with Trexall, you can do so through MedWatch.

Mild side effects

The mild side effects of Trexall that are more common can include:

Most of these side effects may go away within a few days or a couple of weeks. But if they become more severe or don’t go away, talk with your doctor or pharmacist.

* Trexall has boxed warnings for digestive system problems and infections. A boxed warning is the most serious warning from the Food and Drug Administration (FDA). For more information, see “FDA warnings” at the beginning of this article.

Serious side effects

Serious side effects from Trexall aren’t common, but they can occur. Call your doctor right away if you have serious side effects. Call 911 if your symptoms feel life threatening or if you think you’re having a medical emergency.

Serious side effects and their symptoms can include:

  • Serious infections, such as Pneumocystis carinii (now called Pneumocystis jirovecii) pneumonia, which affects your lungs.* Symptoms can include:
    • cough
    • fever
    • shortness of breath
  • Lung problems, such as stiffening or inflammation (swelling) in the lungs,* particularly in people with rheumatoid arthritis (RA). Symptoms can include:
    • dry cough without mucus
    • shortness of breath
    • trouble breathing
    • fever
  • Kidney problems, such as kidneys not working well or kidney failure. Symptoms can include:
    • producing less urine or urinating less often than usual
    • blood in your urine
    • sudden weight gain
  • Ulcers (sores) or bleeding in your digestive system.* Symptoms can include:
    • blood in your stools
    • vomiting blood or what looks like coffee grounds
  • Lymphoma (cancer in the lymph nodes, which are part of your immune system and are found near your neck and armpit, among other spots).* Symptoms can include:
    • tiredness
    • fever
    • weight loss
    • loss of appetite
    • itching
  • Severe skin reactions, such as Stevens-Johnsons syndrome.* Symptoms can include:
    • rash
    • redness
    • swelling
    • blisters
    • peeling
    • itching
  • Tumor lysis syndrome (a serious condition caused by the breakdown of cancer cells), especially in people with rapidly growing cancers.* Symptoms can include:
    • fast or irregular heart rate
    • tiredness
    • muscle weakness or cramps
    • passing out
    • upset stomach, vomiting, or lack of appetite
    • trouble urinating
    • loose stools

Other serious side effects, explained in more detail below in “Side effect details,” include:

* Trexall has boxed warnings for these side effects. A boxed warning is the most serious warning from the Food and Drug Administration (FDA). For more information, see “FDA warnings” at the beginning of this article.

Side effects in children

Side effects of Trexall in children are similar to those in adults. Clinical studies looked at children who took methotrexate for polyarticular juvenile RA. (Methotrexate is the active drug in Trexall.) Researchers found the following:

  • Ulcerative stomatitis (sores or painful areas in your mouth called ulcers)* occurred in 2% of children.
  • Nausea, vomiting, and diarrhea* occurred in 11% of children.
  • Leukopenia (low white blood cell count)* occurred in 2% of children.
  • Liver enzyme levels that were higher than normal occurred in 14% of children. Enzymes are proteins that aid chemical changes in your body. And higher levels of liver enzymes can be a sign of damage to your liver.*

* Trexall has a boxed warning for these side effects. A boxed warning is the most serious warning from the FDA. For more information, see “FDA warnings” at the beginning of this article.

Side effect details

You may wonder how often certain side effects occur with this drug. Here’s some detail on several of the side effects this drug may cause.

Boxed warnings

Trexall has several boxed warnings about possible risks of taking the medication. A boxed warning is the most serious warning from the FDA. For more information, see “FDA warnings” at the beginning of this article.

Allergic reaction

As with most drugs, some people can have an allergic reaction after taking Trexall. However, it’s not known how often people using Trexall have allergic reactions. Symptoms of a mild allergic reaction can include:

  • skin rash
  • itchiness
  • flushing (warmth and redness in your skin)

A more severe allergic reaction is rare but possible. Symptoms of a severe allergic reaction can include:

  • swelling under your skin, typically in your eyelids, lips, hands, or feet
  • swelling of your tongue, mouth, or throat
  • trouble breathing

Call your doctor right away if you have a severe allergic reaction to Trexall. Call 911 if your symptoms feel life threatening or if you think you’re having a medical emergency.

Stomatitis

Sores or painful areas in your mouth called ulcers may occur with Trexall.* This is called ulcerative stomatitis.

In clinical studies, stomatitis occurred in about 3% to 10% of adults who took methotrexate (the active drug in Trexall) for RA or psoriasis.

Stomatitis can be one of the first symptoms of more serious side effects in your digestive system, such as ulcers or bleeding. If you develop sores or ulcers in your mouth while taking Trexall, tell your doctor right away. Don’t take another dose until you’ve seen your doctor. You may need to stop taking Trexall to avoid developing serious problems, such as bleeding or tearing in your intestines.

To help prevent stomatitis, your doctor will usually recommend that you take folic acid. And they may increase your folic acid dose to help ease stomatitis.

* Trexall has a boxed warning for digestive system problems. A boxed warning is the most serious warning from the FDA. For more information, see “FDA warnings” at the beginning of this article.

Nausea

Trexall commonly causes nausea. In clinical studies, nausea and vomiting occurred in about 10% of adults who took methotrexate for RA or psoriasis.

If you feel nauseous during your Trexall treatment, try taking your doses with food or at bedtime. If you take Trexall for RA or psoriasis, it may also help to take your weekly dose as a course of three doses, rather than taking it as one dose. Discuss this with your doctor. Don’t make any changes to your doses without talking to your doctor first.

Your doctor will likely recommend that you take folic acid with Trexall to help ease side effects, including nausea. But if your nausea is bothersome, your doctor may increase your dose of folic acid. Or they may recommend switching to an injected form of methotrexate. You can also talk with your doctor about taking an anti-nausea medication.

And if you’re taking Trexall for cancer, your doctor will usually prescribe an anti-nausea medication to take as well.

Blood disorders

Trexall can sometimes cause problems with your blood cell counts. These may include anemia (low red blood cell count), leukopenia (low white blood cell count), and thrombocytopenia (low platelet count).

In clinical studies of RA and psoriasis, about 3% to 10% of adults who took methotrexate had thrombocytopenia. And about 1% to 3% had leukopenia or pancytopenia (a drop in the levels of all blood cells).

Types of blood cells explained

Red blood cells carry oxygen around your body. If your red blood cell count falls, this can lead to a condition called anemia. It can make you feel weak and tired.

White blood cells are part of your immune system. They help your body fight germs that can cause infections. If your white blood cell count falls, this weakens your immune system and raises your risk for developing infections.* Some infections can be serious or life threatening.

Platelets help your blood clot if you injure yourself, for example. And if your platelet count falls, this can lead to easy bruising or bleeding.

Preventing infections

Try to reduce your exposure to germs while taking Trexall to help prevent infections. Wash your hands often. And if possible, try to avoid crowds and people who are sick, especially those with chickenpox. Also, talk with your doctor about making sure your vaccines are up to date before you start taking Trexall. (For more above vaccines, see the “Common questions about Trexall” section below.)

See your doctor right away if you have symptoms of blood cell problems while you take Trexall. These can include:

  • fever
  • chills
  • other signs of infection, such as:
    • sore throat
    • shortness of breath
    • cough
    • skin sores
    • wounds that won’t heal
    • a burning feeling when you urinate
  • unusual or unexplained bruising or bleeding
  • fatigue

You’ll need regular blood tests to check your blood cell levels while you take Trexall.

* Trexall has a boxed warning for infections. A boxed warning is the most serious warning from the FDA. For more information, see “FDA warnings” at the beginning of this article.

Liver problems

Trexall can sometimes cause liver problems.* These include fibrosis (stiffening) and cirrhosis (scarring), both of which affect how well your liver can work.

In clinical studies of RA and psoriasis, about 15% of adults who took methotrexate had liver enzyme levels that were higher than normal. Enzymes are proteins that aid chemical changes in your body. And higher levels of liver enzymes can be a sign of damage to your liver.

Liver problems are more likely to develop after long-term use of Trexall.

You’ll need regular blood tests to check how well your liver is working while you take Trexall. These are called liver function tests. You may also need to have a liver biopsy if you take Trexall for longer than a few months. A liver biopsy is a procedure in which your doctor removes a small amount of tissue from your liver, usually with a needle. The liver tissue will be examined for signs of fibrosis or cirrhosis.

Symptoms of liver problems

See your doctor if you have symptoms of liver problems while taking Trexall. These may include:

  • dark urine
  • pale stools
  • vomiting
  • belly pain
  • yellowing of your skin or the whites of your eyes
  • tiredness
  • lack of appetite
  • itchy skin

If you develop problems with your liver, you may need to stop taking Trexall.

* Trexall has a boxed warning for liver problems. A boxed warning is the most serious warning from the FDA. For more information, see “FDA warnings” at the beginning of this article.

The Trexall dosage your doctor prescribes will depend on several factors. These include:

  • the type and severity of the condition you’re using Trexall to treat
  • your age
  • your weight and height
  • other medical conditions you have
  • other medications you’re taking
  • how your body responds to the drug

With psoriasis and rheumatoid arthritis (RA), your doctor will typically start you on a low dosage. Then they’ll adjust it over time to reach the amount that’s right for you. Your doctor will ultimately prescribe the smallest dosage that provides the desired effect.

The following information describes dosages that are commonly used or recommended. However, be sure to take the dosage your doctor prescribes for you. Your doctor will determine the best dosage to fit your needs.

Drug forms and strengths

Trexall comes as a tablet that you swallow. It’s available in four different strengths: 5 mg, 7.5 mg, 10 mg, and 15 mg.

Dosage for psoriasis

You’ll take Trexall once a week to treat psoriasis. The usual starting dosage for adults is 10 mg to 25 mg as a single dose, once a week. You’ll take Trexall on the same day each week.

Another dosage option is 2.5 mg every 12 hours for three doses. This is taken once a week. Your doctor may prescribe the generic form of Trexall (methotrexate) if you take this dosage.

If your psoriasis symptoms don’t ease much after 12 weeks, your doctor may gradually increase your weekly dose. However, higher doses come with an increased risk of side effects. (See the “Trexall side effects” section above to learn more.) But once your skin has cleared up, your doctor will gradually reduce your dose to the lowest level that keeps your psoriasis under control. Some people continue treatment at a low dose. Others may take a break from treatment and then restart if their psoriasis gets worse again.

Dosage for rheumatoid arthritis

The usual starting dose for RA in adults is 7.5 mg as a single dose, once a week. You’ll take Trexall on the same day each week.

Another dosage option is 2.5 mg every 12 hours for three doses. This is taken once a week. Your doctor may prescribe the generic form of Trexall (methotrexate) if you take this dosage.

If your RA symptoms don’t ease much after 12 weeks, your doctor may gradually increase your weekly dose. However, higher doses come with an increased risk of side effects. (See the “Trexall side effects” section above to learn more.)

Dosage for juvenile rheumatoid arthritis

Trexall can be used for polyarticular juvenile RA in children ages 2 years and older.

The recommended starting dosage is 10 mg per meter squared (m2) of body surface area, once a week. The dose should be taken on the same day each week. (Your child’s doctor will determine the body surface area by using your child’s weight and height.)

If your child’s arthritis symptoms don’t improve much after 12 weeks, their doctor may gradually increase their weekly dose. However, higher doses come with an increased risk of side effects. (See the “Trexall side effects” section above to learn more.)

Dosage for cancer

The Trexall dosage that your doctor prescribes will depend on your type of cancer, what other treatments you’re having, along with several other factors. Always follow your doctor’s instructions.Talk with your doctor if you have questions about how much Trexall you should take.

Dosage for pregnancy-related cancers of the uterus

Pregnancy-related cancers of the uterus include choriocarcinoma and trophoblastic diseases. A typical dosage for choriocarcinoma and similar trophoblastic diseases is 15 mg to 30 mg a day for 5 days. After this, you’ll usually have a break from treatment for 1 or more weeks to allow any side effects to ease.

You’ll typically repeat the 5-day course of treatment three to five times as needed, with a break of 1 or more weeks between each course.

Always follow your doctor’s instructions.

Dosage for leukemia

Trexall is a type of chemotherapy medication. It’s typically used with other chemotherapy drugs as well as drugs called corticosteroids to treat certain forms of leukemia, including acute lymphoblastic leukemia. The dosage your doctor prescribes will depend on the type of leukemia you have, what other medications you’re taking, as well as your weight and height. Always follow the instructions that your doctor gives you.

When you start treatment, it’s usual to take Trexall every day. Or you may take the drug in cycles where you take Trexall every day for a few days, followed by a few days where you don’t take the drug. This break allows healthy cells to recover from the treatment before the next cycle.

This first phase of treatment is called induction. It aims to achieve remission, which is when cancer cells can no longer be detected in the blood or bone marrow, and numbers of healthy blood cells return to normal. (Bone marrow is where your blood cells are made.)

Once the leukemia is in remission, you may take Trexall either twice a week or once every two weeks as a maintenance treatment. This helps stop any cancer cells remaining in your body from increasing in numbers again. (The increase is called a relapse.)

Dosage for lymphomas

Trexall may be used on its own or with other chemotherapy medications to treat lymphomas. The dosage your doctor prescribes will depend on the type of lymphoma you have, what other medications you’re taking, as well as your body weight. Always follow the instructions your doctor gives you.

It’s usual to take Trexall in cycles, where you take a dose every day for a few days, followed by a few days where you don’t take the drug. The break allows healthy cells to recover from the treatment before the next cycle. You may need several cycles of treatment.

Dosage for mycosis fungoides

Mycosis fungoides is a type of skin cancer, and it’s also called cutaneous T-cell lymphoma.

A typical dosage for treating this type of skin cancer is 5 mg to 50 mg, once a week. You’ll take Trexall on the same day each week. Your doctor may reduce your weekly dose if your blood cell counts fall too low. And if your cancer doesn’t respond well to the treatment, your doctor may increase your dose to 15 mg to 37.5 mg, twice a week.

Take Trexall for as long as your doctor recommends.

Pediatric dosage

Trexall is used to treat polyarticular juvenile RA and certain cancers, such as leukemia, in children. For information about the pediatric dosage for polyarticular juvenile RA, see the “Dosage for juvenile rheumatoid arthritis” section above.

The pediatric dosage for treating cancer depends on several different factors. Always follow the instructions that your child’s cancer specialist gives.

What if I miss a dose?

It depends how often you take Trexall and how long it’s been since you missed your dose. If you miss a dose, call your doctor to find out whether you should take the missed dose. Never take a double dose to make up for missing a dose.

To help make sure that you don’t miss a dose, try setting a reminder on your phone. A medication timer may be useful, too.

Will I need to use this drug long term?

For RA and psoriasis, Trexall is meant to be used as a long-term treatment. If you and your doctor determine that Trexall is safe and effective for you, you’ll likely take it long term.

For cancer, you may take Trexall as several courses or cycles over a few months. A course or cycle of treatment is where you take a dose every day for a few days, followed by a few days where you don’t take the drug. This will depend on the type of cancer being treated and whether Trexall is safe and effective for you.

The Food and Drug Administration (FDA) approves prescription drugs such as Trexall to treat certain conditions. Trexall may also be used off-label for other conditions. Off-label use is when a drug that’s approved to treat one condition is used to treat a different condition.

Trexall for rheumatoid arthritis

Trexall is FDA-approved to treat rheumatoid arthritis (RA) that’s active and severe. “Active” means that you currently have symptoms. Trexall is used when first-line drugs, including nonsteroidal anti-inflammatory drugs (NSAIDs), haven’t worked well enough or caused bothersome side effects. First-line drugs are the first medications prescribed by your doctor for your RA.

RA causes inflammation (swelling) in your joints. RA is called an autoimmune disease because your immune system mistakenly starts attacking your joints. Trexall helps stop this from occurring. The drug helps reduce swelling, pain, and stiffness in your joints. When used for arthritis, Trexall is known as a disease-modifying antirheumatic drug (DMARD).

Effectiveness

Methotrexate, the active drug in Trexall, is well accepted as an effective treatment for RA. The drug has been used to treat RA in adults since the 1980s. It’s one of the most effective and commonly used medications for RA. In current guidelines from the American College of Rheumatology, methotrexate is recommended as a first-line DMARD for treating RA.

Trexall for juvenile rheumatoid arthritis

Trexall is FDA-approved to treat polyarticular juvenile RA that’s active. This is a form of RA that affects children. And “polyarticular” means that the disease affects more than one joint.

Trexall is used when first-line drugs, including NSAIDs, haven’t worked well enough or have caused bothersome side effects.

Juvenile RA is an autoimmune disease that occurs when your immune system mistakenly starts attacking your joints. Trexall helps stop this from occurring. The drug helps reduce swelling, pain, and stiffness in children’s joints.

Effectiveness

Methotrexate is well accepted as an effective treatment for juvenile RA. The drug has been used to treat childhood arthritis since the 1990s. Methotrexate is one of the most effective and commonly used medications for RA. In current guidelines from the American College of Rheumatology, the drug is recommended as a first-line DMARD for treating juvenile RA.

Trexall for psoriasis

Trexall is FDA-approved to treat psoriasis in adults that’s severe, hard to treat, and significantly affects your day-to-day life. The drug is used when psoriasis hasn’t eased enough with other treatments, such as topical (applied to the skin) treatments or light therapy.

Psoriasis is an autoimmune disease that occurs when your immune system mistakenly starts attacking healthy skin cells. This causes your skin cells to be replaced much faster than usual. Red or silver plaques (thick, scaly patches) then build up on your skin. Trexall helps stop this occurring.

Effectiveness

Methotrexate has been FDA-approved for treating psoriasis since the 1970s. It’s an effective treatment option for severe psoriasis, and is recommended in current guidelines from the American Academy of Dermatology.

According to these guidelines, clinical studies found that methotrexate eased psoriasis symptoms by at least 75% in about 50% to 60% of people who took the drug.

Trexall for cancer

Trexall is FDA-approved to treat neoplastic diseases, which are cancers of various types, such as:

  • breast cancer
  • epidermoid cancers of the head and neck (cancers that start in cells lining the moist surfaces inside the mouth, throat, nose, or sinuses)
  • lung cancer
  • a type of skin cancer called advanced mycosis fungoides (also called cutaneous T-cell lymphoma). “Advanced” means that the cancer affects much of the skin and may have spread to other organs.
  • advanced non-Hodgkin lymphoma (a group of cancers that begin in certain kinds of white blood cells). “Advanced” means that the cancer has spread to multiple lymph nodes or one or more other organs.
  • certain forms of leukemia, such as acute lymphoblastic leukemia (a type of blood cancer)
  • pregnancy-related cancers of the uterus (womb), including gestational choriocarcinoma, chorioadenoma destruens, and hydatidiform mole*

Trexall is used in high doses for cancer, and in these cases it’s known as a chemotherapy drug.

* Trexall has a boxed warning for harm in pregnancy. A boxed warning is the most serious warning from the Food and Drug Administration (FDA). For more information, see “FDA warnings” at the beginning of this article.

Effectiveness

Methotrexate is a well accepted and effective form of chemotherapy. The drug has been widely used to treat cancer since it was first approved by the FDA in the 1950s. Methotrexate is typically used with other chemotherapy drugs. It’s a treatment option included in guidelines for several types of cancer, including:

Off-label uses for Trexall

In addition to the uses listed above, Trexall has several off-label uses. Off-label drug use is when a drug that’s approved for one use is used for a different one that’s not approved. Here are a few of the more common off-label uses.

Ectopic pregnancy

An ectopic pregnancy occurs when an embryo (fertilized egg) implants somewhere outside of the womb, typically in one of the fallopian tubes. With an ectopic pregnancy, the embryo can’t develop properly. So the embryo must be removed because it can be harmful to the mother.

Trexall isn’t FDA-approved to treat ectopic pregnancy. However, methotrexate is commonly used for this purpose. The drug is usually given by injection. Methotrexate stops the embryo developing further and causes a miscarriage.

Crohn’s disease

Crohn’s disease is a form of inflammatory bowel disease. It’s partly caused by your immune system attacking the cells lining your bowel. Methotrexate can be effective in preventing your immune system from causing inflammation (swelling) in your bowel.

Trexall isn’t FDA-approved to treat Crohn’s disease. However, the drug may be used off-label for this condition. Methotrexate is a treatment option recommended in current guidelines for managing Crohn’s disease.

Lupus

Lupus, the short name for systemic lupus erythematosus, is a long-term autoimmune condition. It’s caused by your immune system attacking healthy tissue throughout your body. Methotrexate can help stop this from occurring.

Trexall isn’t FDA-approved to treat lupus. However, the drug may be used off-label for this condition. Methotrexate is a treatment option recommended in current guidelines for managing lupus. The drug may help reduce the need for corticosteroids (medications that reduce inflammation).

Trexall and children

Trexall is FDA-approved to treat polyarticular juvenile RA and cancers in children. See the “Trexall for juvenile rheumatoid arthritis” and “Trexall for cancer” sections above.

Trexall may also be used off-label for certain conditions in children. In particular, it may be used to treat Crohn’s disease and psoriasis in children.

Drinking alcohol with Trexall raises your risk for liver-related side effects.* (See the “Trexall side effects” section above to learn more.) You should avoid drinking alcohol while you’re taking Trexall.

Studies have found that people with psoriasis have a greater risk of liver damage if they have alcohol use disorder. Avoiding drinking excess alcohol may also reduce your risk for worsening psoriasis.

* Trexall has a boxed warning for liver problems. A boxed warning is the most serious warning from the Food and Drug Administration (FDA). For more information, see “FDA warnings” at the beginning of this article.

Trexall can interact with several other medications. It can also interact with certain supplements.

Different interactions can cause different effects. For instance, some interactions can interfere with how well a drug works. Other interactions can increase the number of side effects or make them more severe.

Trexall and other medications

Below is a list of medications that can interact with Trexall. This list doesn’t contain all drugs that may interact with Trexall.

Before taking Trexall, talk with your doctor and pharmacist. Tell them about all prescription, over-the-counter (OTC), and other drugs you take. Also tell them about any vitamins, herbs, and supplements you use. Sharing this information can help you avoid potential interactions.

If you have questions about drug interactions that may affect you, ask your doctor or pharmacist.

Trexall and NSAIDs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are drugs that reduce inflammation (swelling) and relieve pain.

Taking NSAIDs with Trexall can cause Trexall to build up in your body. This can increase your risk for side effects related to your blood cells, stomach, and intestines.* (For more about side effects, see the “Trexall side effects” section above.) These problems can sometimes be severe and potentially fatal, particularly if you take a high dose of Trexall.

Don’t take NSAID medications with Trexall unless your doctor has prescribed them to you. For example, if you have rheumatoid arthritis (RA), your doctor may prescribe Trexall with an NSAID. However, your doctor will monitor you closely and adjust your treatment if needed.

Examples of NSAID medications to avoid unless prescribed by your doctor include:

Some of these medications are ingredients in many OTC pain-relievers or cold and flu remedies. So be sure to check the ingredients of any medications you buy without a prescription before you take them with Trexall.

* Trexall has a boxed warning for an increased risk of side effects with certain medications. A boxed warning is the most serious warning from the Food and Drug Administration (FDA). For more information, see “FDA warnings” at the beginning of this article.

Trexall and certain antibiotics

Don’t take the antibiotics trimethoprim/sulfamethoxazole (Bactrim, Septra) with Trexall. When taken with Trexall, these antibiotics raise your risk for side effects related to your blood cells. (For more about side effects, see the “Trexall side effects” section above.)

And taking certain other antibiotics with Trexall can cause the drug to build up in your body. This can raise your risk for Trexall side effects.

Examples of antibiotics that can raise the risk for side effects with Trexall include:

If you need to take one these antibiotics, your doctor may lower your Trexall dosage for a time. You may also need some extra monitoring.

Trexall and probenecid

Probenecid (Probalan) is a treatment for gout. Taking Trexall with probenecid can cause Trexall to build up in your body. This can increase your risk for side effects with Trexall. (For more about side effects, see the “Trexall side effects” section above.) If you take these drugs together, your doctor will monitor you closely and adjust your doses if needed.

Trexall and drugs that affect your liver or blood cells

Taking Trexall with other drugs that can affect your liver or blood cells may raise your risk for side effects related to your liver* or blood cells. (For more about side effects, see the “Trexall side effects” section above.)

Examples of these drugs include the following:

  • azathioprine (Azasan, Imuran)
  • retinoids such as acitretin (Soriatane) and tretinoin (Retin-A)
  • sulfasalazine (Azulfidine)

If you take one of these drugs with Trexall, your doctor will monitor you closely for side effects.

* Trexall has a boxed warning for liver problems. A boxed warning is the most serious warning from the Food and Drug Administration (FDA). For more information, see “FDA warnings” at the beginning of this article.

Trexall and theophylline

Taking Trexall with theophylline (Theo-24, Theocron, Elixophyllin) can cause theophylline to build up in your body. This can raise your risk for side effects from theophylline.

If you take Trexall with theophylline, you may need extra blood tests to check the level of theophylline in your blood. Your doctor may reduce your theophylline dose if your blood level becomes too high.

Trexall and vaccines

You shouldn’t get live vaccines while you’re taking Trexall. Live vaccines contain live but weakened forms of bacteria or viruses. They normally don’t cause infections in people with healthy immune systems. However, they could cause infections* if your immune system is weakened by taking Trexall.

While you’re taking Trexall, you shouldn’t get live vaccines such as:

It’s safe to get inactive (not live) vaccines, such as the flu shot or pneumococcal vaccine, while you’re taking Trexall. However, inactive vaccines might be less effective than usual while you’re taking Trexall. Talk with your doctor about getting your vaccines up to date before you start your Trexall treatment.

* Trexall has a boxed warning for infections. A boxed warning is the most serious warning from the Food and Drug Administration (FDA). For more information, see “FDA warnings” at the beginning of this article.

Trexall and herbs and supplements

Your doctor will usually want you to take folic acid while you’re taking Trexall. Folic acid may help reduce some of the side effects of this drug. (For more about side effects, see the “Trexall side effects” section above.)

However, don’t take extra folic acid without checking with your doctor first. An example of this would be a multivitamin supplement that contains folic acid. Taking too much folic acid could make Trexall less effective for you.

There aren’t any other supplements or herbs that have been specifically reported to interact with Trexall. However, you should still check with your doctor or pharmacist before using any of these products while taking Trexall.

Your doctor will usually ask you to take folic acid while you’re taking Trexall. Folic acid may help reduce some of the side effects of Trexall. (For more about side effects, see the “Trexall side effects” section above.) Take folic acid as directed by your doctor while you use Trexall.

If you take Trexall weekly for psoriasis or rheumatoid arthritis (RA), you should take your folic acid on a different day than your Trexall dose.

If you take a high dose of Trexall to treat cancer, you’ll usually take folic acid after each course or cycle of Trexall. (A course or cycle of treatment is when you take a dose every day for a few days, followed by a few days where you don’t take the drug.) This helps healthy cells recover from the treatment and helps reduce the risk of side effects.

Trexall may be used with other drugs to treat RA, psoriasis, or cancer. Some drug combinations work better than taking Trexall on its own. Your doctor will let you know if you need to take other drugs with Trexall to treat your condition.

As with all medications, the cost of Trexall can vary.

The actual price you’ll pay depends on your insurance plan, your location, and the pharmacy you use.

It’s important to note that you may have to get Trexall at a specialty pharmacy. This type of pharmacy is authorized to carry specialty medications. These are drugs that may be expensive or may require help from healthcare professionals to be used safely and effectively.

Your insurance plan may require you to get prior authorization before approving coverage for Trexall. This means that your doctor and insurance company will need to communicate about your prescription before the insurance company will cover the drug. The insurance company will review the request and let you and your doctor know if your plan will cover Trexall.

If you’re not sure if you’ll need to get prior authorization for Trexall, contact your insurance plan.

Financial assistance

If you need financial support to pay for Trexall, help is available. NeedyMeds lists programs that may aid you in lowering the cost of Trexall. For more information and to find out if you’re eligible for support, visit the program website.

Other drugs are available that can treat your condition. Some may be a better fit for you than others. If you’re interested in finding an alternative to Trexall, talk with your doctor. They can tell you about other medications that may work well for you.

Note: Some of the drugs listed here are used off-label to treat these specific conditions. Off-label use is when a drug that’s approved to treat one condition is used to treat a different condition.

Alternatives for psoriasis

Examples of other drugs that may be used to treat severe psoriasis include:

Alternatives for rheumatoid arthritis

Examples of other drugs that may be used to treat rheumatoid arthritis (RA) include:

  • corticosteroids, such as prednisone (Rayos)
  • sulfasalazine (Azulfidine)
  • azathioprine (Azasan, Imuran)
  • hydroxychloroquine (Plaquenil)
  • leflunomide (Arava)
  • certolizumab pegol (Cimzia)
  • etanercept (Enbrel)
  • golimumab (Simponi)
  • adalimumab (Humira)
  • infliximab (Remicade)
  • anakinra (Kineret)
  • abatacept (Orencia)
  • rituximab (Rituxan)
  • tofacitinib (Xeljanz, Xeljanz XR)
  • tocilizumab (Actemra)

Alternatives for juvenile rheumatoid arthritis

Examples of other drugs that may be used to treat juvenile RA include:

  • corticosteroids, such as prednisone (Rayos)
  • sulfasalazine (Azulfidine)
  • hydroxychloroquine (Plaquenil)
  • leflunomide (Arava)
  • etanercept (Enbrel)
  • golimumab (Simponi)
  • adalimumab (Humira)
  • infliximab (Remicade)
  • abatacept (Orencia)
  • rituximab (Rituxan)
  • tocilizumab (Actemra)

Alternatives for cancer

There are many alternative drugs that may be used to treat cancer. Depending on the type of cancer you have, alternatives may include other chemotherapy drugs and targeted therapies.

Targeted therapies are drugs that work by targeting specific features of cancer cells. These therapies typically affect fewer healthy cells than traditional chemotherapy, so they tend to cause fewer side effects. In recent years, many new targeted therapies have been developed for many different types of cancer.

Talk with your doctor if you want to know more about alternative treatment options for your cancer.

You may wonder how Trexall compares with other medications that are prescribed for similar uses. Here we look at how Trexall and Enbrel are alike and different.

Ingredients

Trexall contains the active drug methotrexate. Enbrel contains the active drug etanercept.

Uses

The Food and Drug Administration (FDA) has approved Trexall to treat the following conditions:

  • RA in adults that’s severe and active.* RA is a disease that occurs when your immune system mistakenly starts attacking your joints. “Active” means that you currently have symptoms.
  • Polyarticular juvenile RA that’s active.* This type of arthritis occurs in children. And “polyarticular” means that the disease affects more than one joint.
  • Psoriasis in adults that’s severe.* With psoriasis, your immune system mistakenly starts attacking healthy skin cells. This causes thick, scaly patches to build up on your skin.
  • Certain kinds of cancers. These cancers include:
    • epidermoid cancers of the head and neck (cancers that start in cells lining the moist surfaces inside the mouth, throat, nose, or sinuses)
    • a type of skin cancer called advanced mycosis fungoides (also called cutaneous T-cell lymphoma). “Advanced” means that the cancer affects much of the skin and may have spread to other organs.
    • advanced non-Hodgkin lymphoma (a group of cancers that begin in certain kinds of white blood cells). “Advanced” means that the cancer has spread to multiple lymph nodes or one or more other organs.
    • pregnancy-related cancers of the uterus (womb), including gestational choriocarcinoma, chorioadenoma destruens, and hydatidiform mole**

* For these conditions, Trexall is used after someone has tried other treatments that either didn’t work for them or that they couldn’t tolerate.

** Trexall has a boxed warning for harm in pregnancy. A boxed warning is the most serious warning from the Food and Drug Administration (FDA). For more information, see “FDA warnings” at the beginning of this article.

Enbrel is FDA-approved to treat:

  • RA in adults that’s moderate to severe and active
  • polyarticular juvenile RA in children ages 2 years and older that’s moderate to severe
  • psoriatic arthritis (a type of joint swelling that can sometimes occur in people with psoriasis)
  • ankylosing spondylitis (a kind of joint swelling that affects the spine)
  • plaque psoriasis in adults and children ages 4 years and older that’s moderate to severe

Drug forms and administration

Trexall comes as a tablet that you swallow.

Enbrel is given subcutaneously (as an injection just under the skin). The drug is available in four forms:

  • a prefilled syringe
  • a prefilled autoinjector
  • a prefilled cartridge for use with a reusable autoinjector
  • a vial

Side effects and risks

Trexall and Enbrel can cause some similar and some different side effects. Below are examples of these side effects.

Mild side effects

These lists contain examples of mild side effects that can occur with Trexall or with Enbrel.

* Trexall has boxed warnings for digestive system problems. A boxed warning is the most serious warning from the FDA. For more information, see “FDA warnings” at the beginning of this article.

Serious side effects

These lists contain examples of serious side effects that can occur with Trexall, with Enbrel, or with both drugs (when taken individually).

* Trexall has boxed warnings for these side effects. A boxed warning is the most serious warning from the FDA. For more information, see “FDA warnings” at the beginning of this article.

** Enbrel has a boxed warning for cancer.

*** Both Trexall and Enbrel have boxed warnings for these side effects.

Effectiveness

Trexall and Enbrel have different FDA-approved uses, but they’re both used to treat the following conditions:

  • severe plaque psoriasis in adults
  • severe RA in adults
  • juvenile polyarticular RA

These drugs haven’t been directly compared for these conditions in clinical studies. However, studies have found both Trexall and Enbrel to be effective for treating all three conditions.

Both Trexall and Enbrel are recommended in current guidelines for treating psoriasis, RA, and juvenile RA. Enbrel is typically used if Trexall or other standard therapies haven’t worked well enough or aren’t suitable. The guidelines also recommend using these drugs together to improve effectiveness.

Costs

Trexall and Enbrel are both brand-name drugs. There are currently no generic forms of either drug. Brand-name medications usually cost more than generics.

However, generic forms of the active drug in Trexall (methotrexate) are available, but these tablets come in a lower strength than Trexall.

Methotrexate is also available as:

  • an oral liquid (Xatmep) that you swallow
  • a liquid solution (Rasuvo, Otrexup, RediTrex) that you inject subcutaneously, which means that it’s given as an injection just under your skin
  • an intravenous injection (given as an injection into your vein)

According to estimates on GoodRx.com, Trexall tablets cost significantly less than the injected forms of Enbrel. The actual price you’ll pay for either drug depends on your insurance plan, your location, and the pharmacy you use.

Like Enbrel (above), the drug cyclophosphamide has uses similar to those of Trexall. Here’s a comparison of how Trexall and cyclophosphamide are alike and different.

Ingredients

Trexall contains the active drug methotrexate. Cyclosphosphamide contains the active drug cyclosphosphamide.

Uses

The Food and Drug Administration (FDA) has approved Trexall to treat the following conditions:

  • RA in adults that’s severe and active.* RA is a disease that occurs when your immune system mistakenly starts attacking your joints. “Active” means that you currently have symptoms.
  • Polyarticular juvenile RA that’s active.* This type of arthritis occurs in children. And “polyarticular” means that the disease affects more than one joint.
  • Psoriasis in adults that’s severe.* With psoriasis, your immune system mistakenly starts attacking healthy skin cells. This causes thick, scaly patches to build up on your skin.
  • Certain kinds of cancers. These cancers include:
    • epidermoid cancers of the head and neck (cancers that start in cells lining the moist surfaces inside the mouth, throat, nose, or sinuses)
    • a type of skin cancer called advanced mycosis fungoides (also called cutaneous T-cell lymphoma). “Advanced” means that the cancer affects much of the skin and may have spread to other organs.
    • advanced non-Hodgkin lymphoma (a group of cancers that begin in certain kinds of white blood cells). “Advanced” means that the cancer has spread to multiple lymph nodes or one or more other organs.
    • pregnancy-related cancers of the uterus (womb), including gestational choriocarcinoma, chorioadenoma destruens, and hydatidiform mole**

* For these conditions, Trexall is used after someone has tried other treatments that either didn’t work for them or that they couldn’t tolerate.

** Trexall has a boxed warning for harm in pregnancy. A boxed warning is the most serious warning from the Food and Drug Administration (FDA). For more information, see “FDA warnings” at the beginning of this article.

Cyclophosphamide is FDA-approved to treat:

* Trexall has a boxed warning for harm in pregnancy. A boxed warning is the most serious warning from the Food and Drug Administration (FDA). For more information, see “FDA warnings” at the beginning of this article.

Drug forms and administration

Trexall comes as a tablet that you swallow. Cyclophosphamide is available in two forms. One is a capsule that you swallow. The other is a powder that’s mixed with a liquid solution for injection.

Side effects and risks

Trexall and cyclophosphamide are both chemotherapy drugs. These medications can cause some similar and some different side effects. Below are examples of these side effects.

Mild side effects

These lists contain examples of mild side effects that can occur with Trexall, with cyclophosphamide, or with both drugs (when taken individually).

* Trexall has a boxed warning for digestive system problems. A boxed warning is the most serious warning from the Food and Drug Administration (FDA). For more information, see “FDA warnings” at the beginning of this article.

Serious side effects

These lists contain examples of serious side effects that can occur with Trexall, with cyclophosphamide, or with both drugs (when taken individually).

* Trexall has boxed warnings for these side effects. A boxed warning is the most serious warning from FDA. For more information, see “FDA warnings” at the beginning of this article.

Effectiveness

Trexall and cyclophosphamide have different FDA-approved uses, but they’re both used to treat the following types of cancer:

  • advanced mycosis fungoides
  • non-Hodgkin lymphoma
  • breast cancer
  • acute lymphoblastic leukemia

Both these drugs are effective for treating cancer. The choice of which to use very much depends on individual factors. These include the particular form and stage of your cancer, what other treatments you’re having, and any other conditions you have.

Trexall and cyclophosphamide are both included in guidelines for treating the following:

These two drugs are often used together to treat cancer.

Costs

Trexall is a brand-name drug. It’s not currently available in generic form. However, generic forms of the active drug in Trexall (methotrexate) are available, but these tablets come in a lower strength than Trexall. Cyclophosphamide is a generic drug. Brand-name medications usually cost more than generics.

Methotrexate is also available as:

  • an oral liquid (Xatmep) that you swallow
  • a liquid solution (Rasuvo, Otrexup, RediTrex) that you inject subcutaneously, which means that it’s given as an injection just under your skin
  • an intravenous injection (given as an injection into your vein)

The dosage of Trexall and cyclophosphamide will vary depending on several factors, including the condition that’s being treated and what other drugs you’re taking. Therefore, it’s hard to compare the costs of the two drugs. To get an idea of the drug prices, you can talk with your pharmacist or visit GoodRx.com. Keep in mind that what you’ll pay for either drug also depends on your insurance plan, your location, and the pharmacy you use.

You should take Trexall according to your doctor’s or healthcare provider’s instructions.

When to take

It doesn’t matter what time of day you take your Trexall dose. However, it’s very important that you understand how often your doctor wants you to take it. Accidentally taking Trexall once a day instead of once a week may cause serious side effects and can be fatal. (For more about side effects, see the “Trexall side effects” section above.)

For rheumatoid arthritis (RA) or psoriasis, you’ll take Trexall every week. You’ll either take it as one dose, on the same day each week. Or you may take it as three doses, 12 hours apart, starting on the same day each week.

For cancer, always follow your doctor’s instructions for when to take Trexall.

To help make sure that you don’t miss a dose, try setting a reminder on your phone. A medication timer may be useful, too.

Taking Trexall with food

You can take Trexall either with or without food.

Can Trexall be crushed, split, or chewed?

No. You should swallow Trexall tablets whole with a drink such as water. Don’t crush, split, or chew the tablets unless your doctor tells you to. And try to handle them as little as possible.

Trexall is a type of drug called an antimetabolite. It stops cells from making new DNA (genetic material). This stops the cells from multiplying.

Methotrexate has most effect on cells that are multiplying rapidly, such as cancer cells, blood cells, and cells lining the mouth and intestine.

In rheumatoid arthritis

RA is a disease that causes inflammation (swelling) in your joints. It’s an autoimmune condition that occurs when your immune system mistakenly starts attacking your joints.

Trexall works by slowing down the production of blood cells that make up part of your immune system. This stops your immune system from attacking your joints and eases swelling, pain, and stiffness in your joints. Reducing the inflammation also helps prevent long-term damage to your joints.

When used for arthritis, Trexall is known as a disease-modifying antirheumatic drug (DMARD).

In psoriasis

Psoriasis is also an autoimmune disease. It occurs when your immune system mistakenly starts attacking healthy skin cells. Your skin responds by replacing your skin cells much faster than usual, without the skin cells shedding off normally. This leads to red or silver plaques (thick, scaly patches) building up on your skin.

Trexall works by slowing down the production of blood cells that make up part of your immune system. This stops your immune system attacking your skin cells. The drug helps restore the normal turnover rate of skin cells and stops plaques from forming.

In cancer

Cancer forms when certain cells in your body develop an abnormality that make them multiply much faster than usual. Trexall works by stopping the cancerous cells from multiplying. This helps slow the cancer’s growth or gets rid of cancer cells entirely.

How long does it take to work?

With RA, Trexall starts to reduce joint swelling, pain, and stiffness within 3 to 6 weeks. However, it can take up to 12 weeks for the drug to have its full effect.

With psoriasis, Trexall starts to improve your skin within 3 to 6 weeks. However, it can take 3 to 6 months for the drug to have its full effect.

Cancers usually start to respond to Trexall within a few weeks, but you may not be able to notice this. Your doctor will monitor how well your cancer is responding with various tests.

Trexall can cause birth defects and miscarriage if taken during pregnancy.* If you’re pregnant or plan to get pregnant, you shouldn’t take Trexall to treat psoriasis or rheumatoid arthritis.

If you’re able to get pregnant, your doctor will want you to have a pregnancy test before you start treatment. See your doctor right away if you think you could be pregnant while taking Trexall.

And you should wait at least one full menstrual cycle after you stop taking Trexall before trying to become pregnant.

* Trexall has a boxed warning for harm in pregnancy. A boxed warning is the most serious warning from the Food and Drug Administration (FDA). For more information, see “FDA warnings” at the beginning of this article.

Trexall can harm an unborn baby if taken during pregnancy.* Trexall can also affect sperm. Both men and women should use effective birth control to prevent pregnancy while taking Trexall.

If you’re sexually active and you or your partner can become pregnant, talk with your doctor about your birth control needs while you’re using Trexall.

Men should use birth control during treatment and for 3 months after they stop taking Trexall.

Women should use birth control during treatment and for at least one menstrual cycle after they stop taking Trexall.

* Trexall has a boxed warning for harm in pregnancy. A boxed warning is the most serious warning from the Food and Drug Administration (FDA). For more information, see “FDA warnings” at the beginning of this article.

Methotrexate (the active drug in Trexall) passes into breast milk. This could cause serious side effects in a nursing child, so you shouldn’t breastfeed while you’re taking Trexall. If you have questions about the best way to feed your child during your treatment, talk with your doctor.

Here are answers to some frequently asked questions about Trexall.

Is Trexall chemotherapy?

Yes, Trexall is a type of chemotherapy that’s used to treat cancer. However, when used for rheumatoid arthritis (RA) and psoriasis, the drug is used in much lower doses than those used for chemotherapy.

When used to treat RA, Trexall is called a disease-modifying antirheumatic drug (DMARD).

Do I need to take folic acid with Trexall?

Yes, most likely. Taking folic acid may help reduce some of the side effects of Trexall, such as mouth sores.* (For more about side effects, see the “Trexall side effects” section above.) Folic acid may also help prevent liver problems, such as cirrhosis (scarring).* Take folic acid as directed by your doctor while you use Trexall.

If you take Trexall weekly for psoriasis or RA, you’ll usually take folic acid on a different day of the week than your Trexall dose.

If you take a high dose of Trexall to treat cancer, you’ll usually take folic acid after each course or cycle of Trexall. (A course or cycle of treatment is where you take a dose every day for a few days, followed by a few days where you don’t take the drug.) The folic acid is often given in an injected form called leucovorin. The folic acid helps healthy cells recover from the treatment and helps reduce the risk of side effects.

* Trexall has boxed warnings for digestive system and liver problems. A boxed warning is the most serious warning from the Food and Drug Administration (FDA). For more information, see “FDA warnings” at the beginning of this article.

Why does Trexall have so many boxed warnings?

Boxed warnings alert doctors and patients about drug side effects that can be dangerous. Trexall has so many warnings because it contains a very toxic drug that can affect several different parts of your body. Boxed warnings help make sure that doctors and patients know what problems to look out for when using potentially dangerous treatments. This helps lessen any risks.

The serious side effects of Trexall are more likely to occur with high doses that are used for chemotherapy. (For more about side effects, see the “Trexall side effects” section above.) These side effects are less likely with low doses that are used for RA or psoriasis.

Should I avoid getting certain vaccines while taking Trexall?

Yes. You shouldn’t get live vaccines while you’re taking Trexall. Live vaccines contain live but weakened forms of bacteria or viruses. They usually don’t cause infections in people with healthy immune systems. However, they could cause infections* if your immune system is weakened by taking Trexall.

For more details about vaccines and Trexall, see the “Trexall and vaccines” section under “Trexall interactions” above.

* Trexall has a boxed warning for infections. A boxed warning is the most serious warning from the Food and Drug Administration (FDA). For more information, see “FDA warnings” at the beginning of this article.

Can Trexall cure my condition?

It’s not currently possible to cure RA or psoriasis. However, taking Trexall may help keep these conditions under long-term control.

It may be possible for Trexall to cure certain cancers. It depends on the type and stage of the cancer, along with what other treatments you’re having or had. Talk with your doctor about whether Trexall is likely to be able to cure your cancer.

This drug comes with several precautions.

FDA warnings

This drug has boxed warnings. A boxed warning is the most serious warning from the Food and Drug Administration (FDA). It alerts doctors and patients about drug effects that may be dangerous.

  • Drug toxicity. Trexall can cause serious side effects that can sometimes be fatal. Because of the risk of serious side effects, Trexall should be given only by doctors who have prescribed this drug or similar drugs in the past. While you take this drug, it’s important that you stay under the care of your doctor and follow all their instructions. Your doctor will closely monitor you to help prevent serious problems. Trexall should be used only for tumors that are life threatening or for psoriasis or rheumatoid arthritis (RA) that’s severe and hard to treat, and that has a significant impact on your day-to-day life.
  • Harm in pregnancy. Trexall may cause birth defects and miscarriage if taken during pregnancy. Don’t take the drug to treat psoriasis or RA if you’re pregnant. See your doctor right away if you’re taking Trexall and think you could be pregnant. For more information, please see the “Trexall and pregnancy” section above.
  • Harmful buildup with certain conditions. Trexall may build up in your body if you have a condition called ascites (fluid in your belly) or pleural effusion (fluid around your lungs), or if your kidneys don’t work well. This buildup may raise your risk for side effects. (To learn more, see the “Trexall side effects” section above.) If you have any of these conditions, your doctor will closely monitor you while you take Trexall. If you have certain side effects, your doctor may need to lower your dose or stop your treatment.
  • Increased risk of side effects with certain other treatments. Having radiation therapy with Trexall may increase your risk for damage to bone or soft tissue such as muscles. And taking nonsteroidal anti-inflammatory drugs (NSAIDs) with Trexall may raise your risk for severe side effects affecting your digestive system and bone marrow (where your blood cells are made). These problems can sometimes be fatal. Examples of NSAIDs include aspirin, ibuprofen (Advil, others), and naproxen (Aleve, others). For more information, please see the “Trexall interactions” section above.
  • Infections. Trexall may weaken your immune system and increase your risk for infections such as Pneumocystis carinii (now called Pneumocystis jirovecii) pneumonia, which affects your lungs. These infections may be serious and even fatal. If you have an active infection (meaning that you currently have symptoms), it may need to be treated before you start taking Trexall. For more information, please see the “Trexall side effects” section above.
  • Liver problems. Trexall may cause liver damage, such as fibrosis or cirrhosis, particularly with long-term use. You’ll have regular blood tests to check your liver function while you take Trexall. If you take the drug for a long time, you may also need to have liver biopsies to check for any problems. (A liver biopsy is a procedure in which your doctor removes and tests a small sample of your liver.) For more information, please see the “Trexall side effects” section above.
  • Lung problems. Trexall may sometimes cause a type of lung disease. While taking the drug, see your doctor right away if you have a dry cough without mucus, trouble breathing, or shortness of breath. Stopping Trexall treatment may not always make this lung problem go away.
  • Digestive system problems. Trexall can sometimes cause diarrhea or ulcerative stomatitis (sores or painful areas in your mouth called ulcers). If you have these side effects while taking the drug, see your doctor right away. Don’t take another dose until you’ve seen your doctor. You may need to stop using Trexall to avoid serious and possibly fatal problems such as bleeding or tearing in your intestines.
  • Lymphomas. Low doses of Trexall may increase your risk for a type of cancer called lymphoma, which affects the lymph nodes. (Lymph nodes, which are part of your immune system, are found on either side of your neck and beneath your armpits, among other spots.) If you develop lymphoma while taking Trexall, it may go away when you stop using the drug. But if the lymphoma doesn’t go away, you may need treatment for the condition.
  • Tumor lysis syndrome. If you take Trexall to treat a fast-growing cancer, you may develop a side effect called tumor lysis syndrome (TLS). This can occur when lots of cancer cells break down quickly. If your kidneys can’t remove the chemicals from the broken-down cells fast enough, the chemicals can build up in your blood. TLS can quickly become life threatening. You’ll have regular blood tests to check for this problem while you take Trexall. And it’s important to drink plenty of fluids during your treatment to help your kidneys work well.
  • Skin reactions. One or more doses of Trexall may cause skin reactions such as Stevens-Johnsons syndrome. These skin reactions may be serious and even fatal. See your doctor right away if you have a skin rash, redness, itching, peeling, or blistering while taking Trexall. They may have you stop taking the drug. In some cases, this side effect has gone away after people stopped taking the drug.

Other precautions

Before taking Trexall, talk with your doctor about your health history. Trexall may not be right for you if you have certain medical conditions or other factors affecting your health. These include:

  • Peptic ulcers. Trexall can cause serious side effects in your digestive system. If you have a peptic ulcer (sore) in your stomach or intestines, talk with your doctor about whether Trexall is right for you.
  • Ulcerative colitis. Trexall can cause serious side effects in your digestive system. If you have ulcerative colitis, talk with your doctor about whether Trexall is an option for you.
  • Kidney problems. Trexall can cause or worsen kidney problems such as kidney failure. The drug can also build up in your body if you have kidney problems.If your kidneys don’t work well, ask your doctor whether Trexall is right for you.
  • Dehydration. Becoming dehydrated (losing too much fluid from your body) raises your risk for kidney problems with Trexall. If you lose a lot of fluids while you take Trexall, you should call your doctor for advice on what to do. You can lose fluids and become dehydrated through vomiting, diarrhea, fever, or sweating a lot without drinking enough fluids.
  • Liver problems. Trexall can cause and worsen liver problems such as cirrhosis. If you have a long-term liver disease, you shouldn’t take Trexall for RA or psoriasis. If you have any problem with your liver, talk with your doctor about whether Trexall is right for you.
  • Alcohol use disorder or alcoholic liver disease. You have an increased risk for liver problems if you drink alcohol with Trexall. If you have a history of alcohol use disorder or alcohol-related liver disease, you shouldn’t take Trexall for RA or psoriasis. Ask your doctor about other treatment options.
  • Blood disorders. Trexall can cause anemia (low red blood cell count), leukopenia (low white blood cell count), and thrombocytopenia (low platelet count). You’ll have regular blood tests to check your blood cells while you take Trexall. You shouldn’t take the drug to treat RA or psoriasis if you already have problems with your blood cells or bone marrow. Talk with your doctor about other possible treatments.
  • Weak immune system. Trexall can weaken your immune system and make it harder to fight infections. If you already have a weak immune system (due to an immunodeficiency syndrome, for example), you shouldn’t take Trexall for RA or psoriasis. Ask your doctor what other treatments are better choices for you.
  • Allergic reaction. If you’re allergic to Trexall or any of its ingredients, you shouldn’t take Trexall. Talk with your doctor about a different treatment.
  • Breastfeeding. Don’t take Trexall if you’re breastfeeding. For more information, please see the “Trexall and breastfeeding” section above.

Note: For more information about the potential negative effects of Trexall, see the “Trexall side effects” section above.

Using more than the recommended dosage of Trexall can lead to serious side effects and can be fatal. Make sure you know how often to take Trexall and for how long. Most cases of overdose occur when Trexall is accidentally taken every day instead of every week.

Don’t use more Trexall than your doctor recommends.

Overdose symptoms

Symptoms of an overdose can include worsening Trexall side effects. These may include the following:

  • drop in blood cell counts, which can result in fever, bruising or bleeding easily, and fatigue (lack of energy)
  • painful areas in your mouth called ulcers*
  • sore mouth
  • nausea and vomiting
  • diarrhea*
  • ulcers (sores) or bleeding in your digestive system, which can cause belly pain, vomiting blood, or passing tarry or black stools

* Trexall has a boxed warning for digestive system problems. A boxed warning is the most serious warning from the Food and Drug Administration (FDA). For more information, see “FDA warnings” at the beginning of this article.

What to do in case of overdose

If you think you’ve taken too much of this drug, call your doctor. You can also call the American Association of Poison Control Centers at 800-222-1222 or use their online tool. But if your symptoms are severe, call 911 or go to the nearest emergency room right away.

When you get Trexall from the pharmacy, the pharmacist will add an expiration date to the label on the bottle. This date is typically 1 year from the date they dispensed the medication.

The expiration date helps guarantee that the medication is effective during this time. The current stance of the Food and Drug Administration (FDA) is to avoid using expired medications. If you have unused medication that has gone past the expiration date, talk with your pharmacist about whether you might still be able to use it.

Storage

How long a medication remains good can depend on many factors, including how and where you store the medication.

You should store Trexall tablets at room temperature (68°F to 77°F/20°C to 25°C) in a tightly sealed container away from light. Avoid keeping this medication in areas where it could get damp or wet, such as in bathrooms.

Disposal

If you no longer need to take Trexall and have leftover medication, it’s important to dispose of it safely. This helps prevent others, including children and pets, from taking the drug by accident. It also helps keep the drug from harming the environment.

The FDA website provides several useful tips on medication disposal. You can also ask your pharmacist for information on how to dispose of your medication.

The following information is provided for clinicians and other healthcare professionals.

Indications

Trexall is approved for:

Mechanism of action

Trexall contains the active drug methotrexate, an antimetabolite drug that works by inhibiting the enzyme dihydrofolic acid reductase. Blocking this enzyme interferes with the production of nucleotides required for DNA repair and synthesis, stopping cell multiplication.

Rapidly dividing cells are most susceptible to the effects of Trexall. These include malignant cells and cells in the bone marrow. Methotrexate reduces inflammation in autoimmune diseases through its suppressant effects on the immune system.

Pharmacokinetics and metabolism

The absorption of methotrexate from Trexall tablets is dose-dependent. In adults, bioavailability is approximately 60% at doses of 30 mg/m2 or less. With doses higher than 80 mg/m2, bioavailability is much lower than this. Maximum serum concentration is reached within 1 to 2 hours of dosing.

In children taking Trexall for leukemia, absorption varies greatly, and bioavailability can range from 23% to 95%. Doses higher than 40 mg/m2 are absorbed less well. After a 15 mg/m2 dose, the time to reach maximum serum concentration can vary from 0.67 hours to 4 hours. Food can delay Trexall absorption and reduce Cmax.

Methotrexate is about 50% bound to plasma proteins.

Methotrexate is metabolized to active metabolites in the liver and through intracellular mechanisms. It’s primarily excreted renally.

With low doses of methotrexate (less than 30 mg/m2) for psoriasis, RA, or neoplastic diseases, the terminal half-life is between 3 and 10 hours. The terminal half-life is 8 to 15 hours with high doses of methotrexate.

Renal impairment increases serum methotrexate levels due to reduced and delayed renal clearance.

Contraindications

Trexall is contraindicated in:

  • breastfeeding
  • people with known hypersensitivity to methotrexate
  • people with psoriasis or RA who:
    • are pregnant
    • have alcohol use disorder or alcoholic liver disease
    • have chronic liver disease
    • have immunodeficiency syndromes

Storage

Trexall should be stored at room temperature (68°F to 77°F/20°C to 25°C).

Disclaimer: Medical News Today has made every effort to make certain that all information is factually correct, comprehensive, and up to date. However, this article should not be used as a substitute for the knowledge and expertise of a licensed healthcare professional. You should always consult your doctor or other healthcare professional before taking any medication. The drug information contained herein is subject to change and is not intended to cover all possible uses, directions, precautions, warnings, drug interactions, allergic reactions, or adverse effects. The absence of warnings or other information for a given drug does not indicate that the drug or drug combination is safe, effective, or appropriate for all patients or all specific uses.