title: Recommendations for the use of methotrexate in rheumatoid arthritis: up and down scaling of the dose and administration routes.
abstract: OBJECTIVE
  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.
  
  
  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 <10mg/week, preferably orally, but considering the parenteral route as an alternative due to compliance, non effectiveness of treatment or gastrointestinal side effects, polypharmacy, obesity (if required doses are >20mg/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 <7.5mg/week, non effectiveness of the route, poor compliance or gastrointestinal side effects. There should be a rapid dose escalation if inadequate responses occurr up to 15-20 or even 25mg/week in about 8 weeks, with increments of 2.5-5mg. The reduction will be carried out according to the dose the patient had, with decreases of 2.5-5mg every 3-6 months. Patient monitoring should be performed every 1-1.5 months until stability and then every 1-3 months.
  
  
  CONCLUSIONS
  This document pretends to solve some common clinical questions and facilitate decision-making in RA patients treated with methotrexate.
authors.affiliation: Servicio de Reumatología, Hospital de Guadalajara, Guadalajara, España. Electronic address: jtorneromolina@ser.es.
authors.forename: Jesús
authors.initials: J
authors.lastname: Tornero Molina
authors.affiliation: Servicio de Reumatología, Hospital Universitario Central de Asturias, Oviedo, España.
authors.forename: Francisco Javier
authors.initials: FJ
authors.lastname: Ballina García
authors.affiliation: Servicio de Reumatología, Hospital Universitario Sierrallana, Torrelavega, Cantabria, España.
authors.forename: Jaime
authors.initials: J
authors.lastname: Calvo Alén
authors.affiliation: Servicio de Reumatología, Hospital Reina Sofía, Córdoba, España.
authors.forename: Miguel Ángel
authors.initials: MÁ
authors.lastname: Caracuel Ruiz
authors.affiliation: Servicio de Reumatología, Hospital del Mar, Barcelona, España.
authors.forename: Jordi
authors.initials: J
authors.lastname: Carbonell Abelló
authors.affiliation: Servicio de Reumatología, Hospital Gutiérrez Ortega, Valdepeñas, Ciudad Real, España.
authors.forename: Antonio
authors.initials: A
authors.lastname: López Meseguer
authors.affiliation: Servicio de Reumatología, Hospital Vall d'Hebron, Barcelona, España.
authors.forename: José Vicente
authors.initials: JV
authors.lastname: Moreno Muelas
authors.affiliation: Servicio de Reumatología, Complejo Asistencia Universitario de León, León, España.
authors.forename: Trinidad
authors.initials: T
authors.lastname: Pérez Sandoval
authors.affiliation: Servicio de Reumatología, Hospital Virgen del Rocío, Sevilla, España.
authors.forename: Jesús
authors.initials: J
authors.lastname: Quijada Carrera
authors.affiliation: Servicio de Reumatología, Hospital Clínico Universitario de Valencia, Valencia, España.
authors.forename: Pilar
authors.initials: P
authors.lastname: Trenor Larraz
authors.affiliation: Servicio de Reumatología, Hospital Universitario Ramón y Cajal, Madrid, España.
authors.forename: Antonio
authors.initials: A
authors.lastname: Zea Mendoza
mesh_terms: D000284:Administration, Oral; D018501:Antirheumatic Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D016903:Drug Monitoring; D006801:Humans; D007267:Injections; D008727:Methotrexate / Q000008:administration & dosage* / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D018501:Antirheumatic Agents; D008727:Methotrexate
keywords: Artritis reumatoide; Consenso; Consensus; Incremento y reducción de dosis; Methotrexate; Metotrexato; Rheumatoid arthritis; Up and down scaling of the dose