Methotrexate

Methotrexate is an immunosuppressant medication used to reduce reliance on steroids in various inflammatory and autoimmune conditions affecting the visual system.

Common Uses

• Giant cell arteritis (steroid-sparing)
• Optic perineuritis (recurrent or steroid-dependent)
• Inflammatory eye disease (uveitis, scleritis)
• Thyroid eye disease (in some cases)
• Orbital inflammation (idiopathic orbital inflammatory disease)
• Sarcoidosis affecting vision
• Various autoimmune conditions affecting the visual system

How It Works

• Inhibits folic acid metabolism
• Reduces immune cell activity
• Anti-inflammatory effects
• Effects build over weeks to months

Dosing

Important

• Once weekly dosing (NOT daily)
• Starting: 7.5-15 mg weekly
• May increase to 25 mg weekly
• Oral or injectable

Folic Acid

• Take folic acid daily (except methotrexate day)
• Reduces side effects
• Usually 1 mg daily

Side Effects

Common

• Nausea (especially on dosing day)
• Fatigue
• Mouth sores
• Hair thinning

Serious

• Liver damage
• Bone marrow suppression
• Lung problems
• Infection risk

Precautions

Pregnancy

• Absolutely contraindicated
• Causes birth defects and miscarriage
• Stop 3+ months before conception
• Both men and women

Alcohol

• Avoid or minimize
• Increases liver toxicity risk

Immunizations

• Avoid live vaccines
• Get flu and pneumonia vaccines

Monitoring

• Blood counts regularly (CBC)
• Liver function tests (LFTs)
• Kidney function (creatinine)
• Symptoms of infection or toxicity
• Visual acuity and exam to monitor disease activity

Related Medications

• Prednisone—often used initially, methotrexate allows tapering
• Mycophenolate mofetil—alternative steroid-sparing agent
• Azathioprine—another option for immunosuppression

When to Contact Your Doctor

• Fever or signs of infection
• Severe nausea or vomiting
• Mouth sores that don't heal
• Unusual bruising or bleeding
• Vision changes or new eye pain
• Shortness of breath or persistent cough