What is the importance for a patient taking methotrexate (a chemotherapy agent and immune system suppressant) to be aware of in terms of monitoring and management?

From the Guidelines

The correct answer is A. having routine renal and hepatic function tests. When teaching a patient taking methotrexate, the nurse should emphasize the importance of regular monitoring of kidney and liver function. Methotrexate is metabolized by the liver and excreted by the kidneys, so it can potentially cause hepatotoxicity and nephrotoxicity. Regular blood tests to assess liver enzymes (AST, ALT) and kidney function (creatinine, BUN) are essential to detect any early signs of organ damage, as recommended by the 2021 American College of Rheumatology guideline 1. This monitoring allows healthcare providers to adjust dosing or discontinue the medication if necessary to prevent serious complications.

Some key points to consider when monitoring patients on methotrexate include:

• Regular laboratory monitoring (CBC and liver function tests) should be performed every 3 to 6 months, assuming no abnormalities in laboratory test results, as suggested by the joint American Academy of Dermatology-National Psoriasis Foundation guidelines 1.
• Patients with risk factors for developing complications, such as decreased kidney function, should be closely monitored, and a test dose should be considered in these patients 1.
• Methotrexate can be continued only if the risk of cirrhosis is low, and annual GI/hepatology referral or vibration-controlled transient elastography, or both, should be performed if methotrexate is continued despite abnormal baseline liver fibrosis laboratory results 1.
• Patients on methotrexate actually need adequate folic acid supplementation to reduce side effects, as recommended by the 2021 American College of Rheumatology guideline 1.

Unlike option B, limiting folic acid consumption is not recommended, as folic acid supplementation can help reduce side effects. Option C mentions reporting alopecia and rash, which are potential side effects but not the primary teaching focus. Option D is incorrect because methotrexate is typically not taken daily but rather weekly for most conditions to minimize toxicity, as suggested by the British Association of Dermatologists' guidelines 1.

From the FDA Drug Label

Patients should be informed of the early signs and symptoms of toxicity, of the need to see their physician promptly if they occur, and the need for close follow-up, including periodic laboratory tests to monitor toxicity Laboratory Tests Patients undergoing methotrexate therapy should be closely monitored so that toxic effects are detected promptly. Baseline assessment should include a complete blood count with differential and platelet counts, hepatic enzymes, renal function tests and a chest X-ray During therapy of rheumatoid arthritis and psoriasis, monitoring of these parameters is recommended: hematology at least monthly, renal function and liver function every 1 to 2 months.

The nurse will teach the patient the importance of having routine renal and hepatic function tests 2. This is crucial for monitoring toxicity and detecting potential adverse effects early on. The patient should also be informed of the need for close follow-up and periodic laboratory tests to ensure safe treatment with methotrexate. Key points to emphasize include:

• Baseline assessment: complete blood count, hepatic enzymes, renal function tests, and chest X-ray
• Monitoring parameters: hematology, renal function, and liver function
• Frequency of monitoring: at least monthly for hematology, every 1 to 2 months for renal and liver function

From the Research

Importance of Patient Education for Methotrexate Therapy

The nurse will teach the patient the importance of:

• Having routine renal and hepatic function tests 3, 4, 5
• Reporting alopecia and rash, as these can be signs of toxic effects 3
• Understanding the potential for major toxic effects, such as hepatic, pulmonary, renal, and bone marrow abnormalities, and the importance of monitoring for these effects 3, 6, 4
• Not taking the medication on a daily basis, as methotrexate should be administered once weekly as a single dose or in divided doses given over a 24-hour period to reduce the incidence of major toxic effects 3
• Limiting interactions with other medications, such as salicylates and nonsteroidal anti-inflammatory drugs, which can increase the risk of toxic effects 3 Note that limiting folic acid consumption is not recommended, as folic acid supplementation can help reduce minor toxic effects, such as stomatitis, malaise, nausea, diarrhea, headaches, and mild alopecia 3, 5