Methotrexate and folic acid

I do hope this latest setback is stabilised soon and you begin to feel better. God knows you've been through the mill! Regards, tina

I'm sending you a link in a pm which you might find interesting. Have they considered you might be one of the people who doesn't absorb pred well? Might you do better with injections I wonder?

I can empathise with the feeling of frustration - I've just been sent back up to 15mg pred after nearly 2 years at 5mg. After 12 years of PMR - I'm a trifle p-eed off...

Hope you feel better soon.

I have had PMR for over 2 years. Like most I started on 20 mg of Prednisone. During the first 4-5 months, I seemed to be getting regular flares and my rheumatologist recommended I start with a supplement of Methotrexate (MTX), and after taking MTX at the same time as prednisone, I had less flares and much less intensity of the flare that did occur. DMARDs such as methotrexate ‘dampen’ down the underlying disease process rather than simply treating symptoms.

My rheumatologist strongly required that I take a regular amount of folic acid (1 mg per day) but not on the day of the week that I take my MTX dose. She indicated that 1 mg of folic acid per day was adequate for a male – females may need slightly more.

MTX suppresses cells which are metabolically active. One of the ways it does this is to antagonize an enzyme involved in the metabolism of folic acid. The enzyme is essential for cells to go about their business, and methotrexate in effect stops them doing this. This is fine when you're hoping to control the action of cells involved in inflammation but an unwanted spin-off is that it affects other active cells such as in the immune system, the stomach, the hair and the ovaries. In fact the drug suppresses any tissue which is ‘active’, that is, has metabolically active cells in it. Now, because of its action on the enzyme involved in the metabolism of folic acid, giving relatively large doses of folic acid acts as an antidote to the drug. If you were to take the folic acid on the same day as the methotrexate it would undoubtedly reduce the effectiveness of the methotrexate. But giving the folic acid on the other days of the week avoids this reduction in effectiveness and also prevents some of the side-effects. Traditionally folic acid has been given on each of the six non-methotrexate days but there are some rheumatology departments now using folic acid only three times a week, or even only once a week. My rheumatologist still thinks that six days a week is the best.

It took almost 2 months before the MTX seemed to become active. I have been taking my ‘once-a-week’ 25mg weekly dose on Mondays and daily Folic Acid for almost 2 years and I have not had any apparent side effects other than the regular ‘fatigue’ that I think occurs with or without MTX. Alcohol significantly increases the risk for liver damage while taking methotrexate, so alcohol should be avoided while on this medication.

It is important to avoid caffeine (coffee, tea, some sodas) around the time you take methotrexate, as the methotrexate may not work as well.

My prednisone taper is actively being reduced and I’m currently at 4mg pred. I think that there is some significant benefit from using a DMARD. My rheumatologist has now recommended that I start a slow MTX reduction (to 20 mg per week) following success with my prednisone taper program.

All the best,

Dave