Methotrexate Therapy for Inflammatory Arthritis

Introduction to Methotrexate

The American College of Rheumatology recommends starting methotrexate at a dose of 7.5-15 mg once weekly, with potential gradual escalation to 25-30 mg weekly or the highest tolerable dose based on response 1
The optimal dosing strategy involves starting at 15 mg/week orally, escalating by 5 mg/month to 25-30 mg/week as needed, with potential switch to subcutaneous administration if oral response is insufficient 1

Improvement in joint pain and swelling may begin within 3-6 weeks, but full therapeutic effect often takes 12 weeks or longer, with regular monitoring of disease activity every 1-3 months during active disease and every 6-12 months once stabilized 2
If no improvement is seen within 3 months or target response isn't achieved by 6 months, treatment adjustments will be necessary 2

Taking folic acid supplements (typically 1 mg daily except on methotrexate day) can reduce many side effects without compromising efficacy 1
Methotrexate is conditionally recommended for patients with subcutaneous nodules who have moderate-to-high disease activity, according to the European League Against Rheumatism 3, 4
However, if nodules progress or worsen while on methotrexate, switching to a non-methotrexate DMARD may be recommended as methotrexate can occasionally contribute to progressive nodulosis, as suggested by the American College of Rheumatology 3, 4

The goal of treatment is to achieve low disease activity or remission, which may allow for eventual dose reduction (though not complete discontinuation), with gradual reduction preferred over abrupt discontinuation, as recommended by the European League Against Rheumatism 3, 4