Start with informed consent, and informed means informed. Patient empowerment is vital to ensure a safe methotrexate journey. Ensure the patient is aware of the risks and benefits of methotrexate. Have you documented this? Did you have this conversation once, many moons ago, or is it a regular discussion? What about a footnote to the methotrexate script: this could advise of the signs and symptoms of methotrexate toxicity, and the need to act urgently should these arise. A computer-generated template makes this fast and easy. Recommend that 2.5mg tablets only are to be dispensed, and how many to take; also, specify the day of the week.
Regular blood tests
Link patient blood testing to prescribing. This ensures a robust system to ensure regular monitoring. No test, no script, no exceptions. The BNF has recommendations about the recommended blood testing intervals.6
We have developed a simple patient alert leaflet. We print it on bright yellow A4 paper for instant recognition. It folds nicely to a credit card size for ease of storage and retrieval by the patient.
Patients taking immunosuppressants are immunocompromised! Consider the uptake of flu and pneumococcal vaccines. The next edition of the national immunisation guidelines will specifically address the area of immunosuppressed patients.
Assess alcohol intake
Methotrexate and alcohol are both effective hepatotoxins. Patient education, including assessment of alcohol intake, is part of the recommended clinical assessment for methotrexate toxicity.7 Have you had that discussion yet?
We are all responsible
Methotrexate toxicity represents a real and ongoing threat to our patients, and we all have a role in addressing this. A shared responsibility exists to address our responsibilities to patients and patient empowerment is central to the safe use of methotrexate. Once you start down this road you might subsequently consider lithium, warfarin, DMARDs, to name a few.
Start today and build a safe methotrexate culture in your practice. It is good for patients and good for doctors... a win-win situation.