Methotrexate 2.5 Mg Tablets
SUMMARY OF PRODUCT CHARACTERISTICS
1 NAME OF THE MEDICINAL PRODUCT
Methotrexate 2.5 mg Tablets
2 QUALITATIVE AND QUANTITATIVE COMPOSITION
Each tablet contains 2.5mg of methotrexate.
Excipients: 11.88 mg lactose (as lactose monohydrate).
For a full list of excipients, see section 6.1.
3 PHARMACEUTICAL FORM
Tablet.
Yellow, circular, biconvex, uncoated tablets plain on both sides, 4.50mm in diameter.
4 CLINICAL PARTICULARS
4.1 Therapeutic indications
- Active rheumatoid arthritis in adult patients.
- Severe forms of psoriasis vulgaris, particularly of the plaque type, which cannot be sufficiently treated with conventional therapy such as phototherapy, PUVA, and retinoids, and severe psoriatic arthritis.
4.2 Posology and method of administration
For doses not realisable/practicable with this strength another strength of this medicinal product is available.
• This medicine should be taken once a week.
• The prescriber may specify the day of intake on the prescription.
Rheumatoid arthritis
The usual dose is 7.5 - 15 mg once weekly. The planned weekly dose may be administered in three divided doses over 36 hours. The schedule may be adjusted gradually to achieve an optimal response but should not exceed a total weekly dose of 20 mg. Thereafter the dose should be reduced to the lowest possible effective dose which in most cases is achieved within 6 weeks.
Psoriasis
Before starting treatment it is advisable to give the patient a test dose of 2.5-5.0 mg to exclude unexpected toxic effects. If, one week later, appropriate laboratory tests are normal, treatment may be initiated. The usual dose is 7.5-15 mg taken once weekly.
The planned weekly dose administered as three divided doses over 24 hours. As necessary, the total weekly dose can be increased up to 25 mg. Thereafter the dose should be reduced to the lowest effective dose according to therapeutic response which in most cases is achieved within 4 to 8 weeks.
The patient should be fully informed of the risks involved and the clinician should pay particular attention to the appearance of liver toxicity by carrying out liver function tests before starting methotrexate treatment, and repeating these at 2 to 4 month intervals during therapy. The aim of therapy should be to reduce the dose to the lowest possible level with the longest possible rest period. The use of methotrexate may permit the return to conventional topical therapy which should be encouraged.
Use in elderly
Methotrexate should be used with extreme caution in elderly patients, a dose reduction should be considered due to reduced liver and kidney function as well as lower folate reserves which occurs with increased age.
Patients with hepatic impairment
Methotrexate should be administered with great caution, if at all, to patients with significant current or previous liver disease, especially if due to alcohol.
4.3 Contraindications
Methotrexate is contra-indicated in the presence of severe/significant renal or significant hepatic impairment, liver disease including fibrosis, cirrhosis, recent or active hepatitis; active infectious disease; and overt or laboratory evidence of immunodeficiency syndrome(s) and serious anaemia, leucopoenia or thrombocytopenia. Methotrexate Tablets should not be used concomitantly with drugs with antifolate properties (see section 4.5, Interactions with other Medicinal Products and other forms of Interaction). Methotrexate is teratogenic and should not be given during pregnancy or to mothers who are breast feeding (see Section 4.6., Pregnancy and Lactation).
Following administration to a man or woman conception should be avoided by using an effective contraceptive method for at least 3 months after using Methotrexate 2.5mg Tablets (see Section 4.4, Special Warnings and Special Precautions for Use).
Patients with a known allergic hypersensitivity to methotrexate or any of the excipients should not receive methotrexate.
4.4 Special warnings and precautions for use
The prescriber may specify the day of intake on the prescription.
Patients should be aware of importance of adhering to the once weekly intakes.
Methotrexate should be used with extreme caution in patients with haematological depression, renal impairment, diarrhoea, and ulcerative disorders of the GI tract and psychiatric disorders. Hepatic toxicity has been observed, usually associated with chronic hepatic disease. The administration of low doses of methotrexate for prolonged periods may give rise, in particular, to hepatic toxicity. Liver function should be closely monitored. If hepatic function abnormalities develop, methotrexate dosing should be suspended for at least two weeks. It is only appropriate to restart methotrexate provided the abnormalities return to normal and the re-exposure is deemed appropriate.
Particular care and possible cessation of treatment are indicated if stomatitis or GI toxicity occurs as haemorrhagic enteritis and intestinal perforation may result.
Reversible eosinophilic pulmonary reactions and treatment resistant, interstitial fibrosis may occur, particularly after long-term treatment.
Renal lesions may develop if the urinary flow is impeded and urinary pH is low, especially if large doses have been administered. Renal function should be closely monitored before, during and after treatment. Reduce dose of methotrexate in patients with renal impairment. High doses may cause the precipitation of methotrexate or its metabolites in the renal tubules. A high fluid throughput and alkalinisation of the urine to pH 6.5 - 7 by oral or intravenous administration of sodium bicarbonate (5x625mg tablets every three hours) is recommended as a preventative measure.
Haematopoietic suppression caused by Methotrexate may occur abruptly and with apparently safe dosages. Full blood counts should be closely monitored before, during and after treatment. If a clinically significant drop in white cell or platelet count develops, methotrexate therapy should be withdrawn immediately and appropriate supportive therapy given (see Undesirable Effects section). Patients should be advised to report all symptoms or signs suggestive of infection.
Malignant lymphomas may occur in patients receiving low dose methotrexate, in which case therapy must be discontinued. Failure of the lymphoma to show signs of spontaneous regression requires the initiation of cytotoxic therapy.
Methotrexate has been shown to be teratogenic; it has been reported to cause foetal death and/or congenital abnormalities. Therefore, it is not recommended in women of childbearing potential unless the benefits can be expected to outweigh the considered risks. If this drug is used during pregnancy for antineoplastic indications, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the foetus.
Following administration to a man or woman conception should be avoided by using an effective contraceptive method for at least 3 months after using Methotrexate 2.5mg Tablets (see section 4.3, Contraindications).
Methotrexate has some immunosuppressive activity and therefore the immunological response to concurrent vaccination may be decreased. In addition, concomitant use of a live vaccine could cause severe antigenic reaction.
Methotrexate should only be used by clinicians that are familiar with the various characteristics of the drug and its mode of action.
Before beginning Methotrexate therapy or reinstituting Methotrexate after a rest period, a chest x-ray, assessment of renal function, liver function and blood elements should be made by history, physical examination and laboratory tests. This will include a routine examination of lymph nodes and patients should report any unusual swelling to the doctor.
Patients receiving low-dose methotrexate should:
• Have a full blood count and renal and liver function tests before starting treatment. These should be repeated weekly until therapy is stabilised, thereafter patients should be monitored every 2-3 months throughout treatment.
• Patients should report all symptoms and signs suggestive of infection, especially sore throat.
If acute methotrexate toxicity occurs, patients may require treatment with folinic acid.
The disappearance of methotrexate from plasma should be monitored, if possible.
This is recommended in particular when high, or very high doses are administered in order to permit calculation of an adequate dose of leucovorin (folinic acid) rescue.
Patients with pleural effusions and ascites should be drained prior to initiation of methotrexate therapy or treatment should be withdrawn.
When to perform a liver biopsy in rheumatoid arthritis patients has not been established either in terms of a cumulative Methotrexate dose or duration of therapy.
Pleuropulmonary manifestation of rheumatoid arthritis has been reported in the literature. In patients with rheumatoid arthritis, the physician should be specifically alerted to the potential for Methotrexate induced adverse effects in the pulmonary system.
Patients should be advised to contact their physicians immediately should they develop a cough or dyspnoea (see Undesirable Effects section).
Methotrexate given concomitantly with radiotherapy may increase the risk of soft tissue necrosis and osteonecrosis.
Acute or chronic interstitial pneumonitis, often associated with blood eosinophilia, may occur and deaths have been reported. Symptoms typically include dyspnoea, cough (especially a dry nonproductive cough) and fever for which patients should be monitored at each follow-up visit. Patients should be informed of the risk of pneumonitis and advised to contact their doctor immediately should they develop persistent cough or dyspnoea.
Methotrexate should be withdrawn from patient’s pulmonary symptoms, and a thorough investigation should be made to exclude infection. If methotrexate induced lung disease is suspected, treatment with corticosteroids should be initiated and treatment with methotrexate should not be restarted.
Lung manifestations of RA and other connective tissue disorders are recognised to occur. In patients with RA, the physician should be specifically alerted to the potential for methotrexate induced adverse effects on the pulmonary system.
Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.
4.5 Interaction with other medicinal products and other forms of interaction
Methotrexate is immunosuppressive and may therefore reduce immunological response to concurrent vaccination. Severe antigenic reactions may occur if a live vaccine is given concurrently.
Methotrexate is extensively protein bound and may displace, or be displaced by, other acidic drugs. The concurrent administration of agents such as p-aminobenzoic acid, chloramphenicol, penicillins, ciprofloxacin, diphenyl hydantoins, phenytoin, acidic anti-inflammatory agents, salicylates, sulphonamides, tetracyclines, thiazide diuretics, probenecid, sulfinpyrazone or oral hypoglycaemics will decrease the methotrexate transport function of renal tubules, thereby reducing excretion and almost certainly increasing methotrexate toxicity. Methotrexate dosage should be monitored if concomitant treatment with aspirin, ibuprofen or indometacin (NSAIDs) is commenced, as concomitant use of NSAID's has been associated with fatal methotrexate toxicity. Concomitant administration of folate antagonists such as trimethoprim, co-trimoxazole and nitrous oxide should be avoided. Hepatic and nephrotoxic drugs should be avoided.
Acitretin (a treatment for psoriasis) is metabolised to etretinate. Methotrexate levels may be increased by etretinate and severe hepatitis has been reported following concomitant use.
Vitamin preparations containing folic acid or its derivatives may alter response to methotrexate.
4.6 Fertility, pregnancy and lactation
Methotrexate is contra-indicated in pregnancy. Methotrexate affects spermatogenesis and oogenesis and may therefore decrease fertility. This effect appears to be reversible after discontinuation of therapy. Patients and their partners should be advised to avoid pregnancy until 3 months after cessation of methotrexate therapy.
Patients should not breast feed whilst taking methotrexate.
Methotrexate causes embryotoxicity, abortion and foetal defects in humans. Therefore, the possible risks of effects on reproduction should be discussed with patients of child bearing potential (see section 4.4, Special Warnings and Special Precautions for Use and section 4.3, Contraindications).
4.7 Effects on ability to drive and use machines
None known.
4.8 Undesirable effects
In general, the incidence and severity of side effects are considered to be dose-related. Adverse reactions for the various systems are as follows:
Skin:
Stevens - Johnson syndrome, epidermal necrolysis, erythaematous rashes, pruritus, urticaria, photosensitivity, pigmentary changes, alopecia, ecchymosis, telangiectasia, acne, furunculosis. Lesions of psoriasis may be aggravated by concomitant exposure to ultraviolet radiation. Skin ulceration in psoriatic patients and rarely painful erosion of psoriatic plaques has been reported. The recall phenomenon has been reported in both radiation and solar damaged skin.
Haematopoietic:
Bone marrow depression is most frequently manifested by leucopoenia, thrombocytopenia (which are usually reversible) and anaemia, or any combination may occur. Infection or hypogammaglobulinaemia has been reported.
Alimentary System:
Mucositis (most frequently stomatitis although gingivitis, pharyngitis and even enteritis, intestinal ulceration and bleeding) may occur. In rare cases the effect of Methotrexate on the intestinal mucosa has led to malabsorption or toxic megacolon. Nausea, anorexia and vomiting and/or diarrhoea may also occur.
Hepatic:
Hepatic toxicity resulting in significant elevations of liver enzymes, acute liver atrophy, necrosis, fatty metamorphosis, periportal fibrosis or cirrhosis or death may occur, usually following chronic administration.
Urogenital System:
Renal failure and uraemia may follow methotrexate administration, particularly after high doses or prolonged administration. Vaginitis, vaginal ulcers, cystitis, haematuria and nephropathy have also been reported. Methotrexate can decrease fertility. This effect appears to be reversible after discontinuation of therapy (see section 4.6, Pregnancy and Lactation).
Pulmonary System:
Infrequently an acute or chronic interstitial pneumonitis, often associated with blood eosinophilia, may occur and deaths have been reported. Acute pulmonary oedema has also been reported after oral and intrathecal use. Pulmonary fibrosis is rare. A syndrome consisting of pleuritic pain and pleural thickening has been reported following high doses.
In the treatment of rheumatoid arthritis, methotrexate induced lung disease is a potentially serious adverse drug reaction which may occur acutely at any time during therapy. It is not always fully reversible. Pulmonary symptoms (especially a dry, non productive cough) may require interruption of treatment and careful investigation.
Central Nervous System:
Headaches, drowsiness, ataxia and blurred vision have occurred following low doses of methotrexate, transient subtle cognitive dysfunction, mood alteration, or unusual cranial sensations have been reported occasionally. Aphasia, paresis, hemiparesis, and convulsions have also occurred following administration of higher doses.
There have been reports of leukoencephalopathy following intravenous methotrexate in high doses, or low doses following cranial-spinal radiation.
Other reports include eye irritation, malaise, undue fatigue, vasculitis, sepsis, arthralgia/myalgia, chills and fever, dizziness, loss of libido/impotence and decreased resistance to infection. Also opportunistic infections such as herpes zoster. Osteoporosis, abnormal (usually "megaloblastic") red cell morphology, precipitation of diabetes, other metabolic changes, and sudden death in relation to or attributed to the use of methotrexate.
Although very rare, anaphylactic reactions to methotrexate have been reported.
Acute or chronic interstitial pneumonitis, often associated with blood eosinophilia, may occur and deaths have been reported (see Section 4.4, Special Warnings and Special Precautions for Use).
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard
4.9 Overdose
Leucovorin is a specific antidote for methotrexate and, following accidental overdosage, should be administered within one hour at a dosage equal to, or greater than, the methotrexate dose. It may be administered by i.v. bolus or infusion. Further doses may be required. The patient should be observed carefully and blood transfusions, renal dialysis and reverse barrier nursing may be necessary.
In cases of massive overdose, hydration and urinary alkalisation may be necessary to prevent precipitation of methotrexate and/or its metabolites in the renal tubules. Neither haemodialysis nor peritoneal dialysis has been shown to improve methotrexate elimination. Effective clearance of methotrexate has been reported with acute, intermittent haemodialysis using a high flux dialyser.
Cases of overdose, sometimes fatal, due to erroneous daily intake instead of weekly intake of oral methotrexate have been reported. In these cases, symptoms that have been commonly reported are haematological and gastrointestinal reactions.
5 PHARMACOLOGICAL PROPERTIES
5.1 Pharmacodynamic properties
Methotrexate is a folic acid antagonist and its major site of action is the enzyme dihydrofolate reductase. Its main effect is inhibition of DNA synthesis but it also acts directly both on RNA and protein synthesis. Methotrexate is a phase specific substance, the main effect being directed during the S-phase of cell division.
The inhibition of dihydrofolate reductase can be circumvented by the use of leucovorin (folinic acid; citrovorum factor) and protection of normal tissues can be carried out by properly timed administration of leucovorin calcium.
5.2 Pharmacokinetic properties
When given in low doses, methotrexate is rapidly absorbed from the GI tract giving plasma concentrations equivalent to those achieved after i.v. administration. Higher doses are less well absorbed. About 50% has been shown to be protein bound. Biphasic and triphasic plasma clearance has been shown. The majority of the dose is excreted within 24 hours in the urine mainly as unchanged drug.
5.3 Preclinical safety data
No further preclinical safety data are available.
6 PHARMACEUTICAL PARTICULARS
6.1 List of excipients
Anhydrous Calcium Hydrogen Phosphate
Lactose Monohydrate Sodium starch glycolate Cellulose, microcrystalline Purified Talc Magnesium stearate
6.2 Incompatibilities
Not applicable.
6.3 Shelf life
24 months.
6.4 Special precautions for storage
This medicine has no special storage temperature requirements. Store in the original container to protect from light
6.5 Nature and contents of container
Amber colour PVC /Aluminium blister- Blister packs of 7, 10, 14, 20, 24, 28, 30, 56, 60, 84, 90, 100 and 112 film coated tablets.
Not all pack sizes may be marketed
6.6 Special precautions for disposal
Any unused product or waste material should be disposed of in accordance with local requirements
7 MARKETING AUTHORISATION HOLDER
Morningside Healthcare Ltd 115 Narborough Road Leicester LE30PA United Kingdom
8 MARKETING AUTHORISATION NUMBER(S)
PL 20117/0163
9 DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION 22/12/2011
10 DATE OF REVISION OF THE TEXT
10/03/2015