Recommendations for the use of methotrexate in rheumatoid arthritis: up and down scaling of the dose and administration routes.

Abstract Objectives To describe the optimal therapeutic strategy for use of methotrexate in RA patients over the initial dose, route of administration, dose increase and decrease, patient monitoring, and use of folic/folinic acid. Materials and methods Eleven clinical experts proposed some questions to be solved. A systematic literature search was conducted. The contents were selected in a work session and subsequently validated via email to establish the level of agreement. Results The initial dose of methotrexate should not be 20 mg/week), patient preference, very active disease or to avoid administration errors. Changing to a parenteral administration is proposed when the oral route is not effective enough, gastrointestinal toxicity appears, there is non-compliance or due to cost-effectiveness reasons before using more expensive drugs. On the contrary, due to patient preferences, intolerance to injections, dose reduction Conclusions This document pretends to solve some common clinical questions and facilitate decision-making in RA patients treated with methotrexate.