From the Guidelines
When taking methotrexate, the recommended daily folate supplement is 1 mg, except for the days methotrexate is given, to minimize adverse effects while preserving the medication's efficacy. This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of folate supplementation in reducing the rate of adverse effects associated with methotrexate therapy 1. The study suggests that folate is typically given daily, except for the days in which methotrexate is given, to avoid influencing efficacy.
Key Considerations
- Folate supplementation is crucial when on methotrexate to decrease the rate of adverse effects, including hepatic laboratory abnormalities and GI adverse effects 1.
- The choice between folic acid and folinic acid does not affect efficacy, but folic acid is less expensive 1.
- It is essential to avoid taking folate on the same day as methotrexate, as this may reduce the medication's effectiveness.
- The specific dosage of folate should be determined by a healthcare provider based on individual needs and the methotrexate regimen.
Evidence-Based Decision
The recommendation for a daily folate supplement of 1 mg is supported by the joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management of psoriasis with systemic nonbiologic therapies 1. Although another study suggests that at least 5 mg of folic acid per week is recommended, the most recent and highest quality study prioritizes daily supplementation except on methotrexate administration days 1.
Clinical Implications
In real-life clinical practice, it is vital to prioritize the patient's safety and minimize potential adverse effects while ensuring the efficacy of methotrexate. Therefore, a daily folate supplement of 1 mg, except on methotrexate administration days, is the recommended approach. This strategy is supported by the latest evidence and expert consensus, aiming to optimize the balance between minimizing side effects and preserving the therapeutic benefits of methotrexate 1.
From the Research
Folate Supplementation with Methotrexate
- The daily dose of folate supplement that can be taken with methotrexate is not explicitly stated in the provided studies, but the studies suggest that folate supplementation can be taken daily to ameliorate side effects without compromising methotrexate efficacy 2, 3, 4.
- Folic acid is recommended as a daily supplement to reduce methotrexate toxicity, with a suggested dose of 5 mg given on the morning following the day of methotrexate administration 5.
- However, a more recent study suggests that weekly folic acid supplementation may be a convenient and well-tolerated alternative to daily dosing in pediatric patients with inflammatory bowel disease on methotrexate, with a dose of 800 mcg taken weekly 6.
- It is essential to note that the dosing and frequency of folate supplementation may vary depending on individual patient needs and the specific condition being treated.
Types of Folate Supplementation
- Folic acid and folinic acid are both effective in reducing methotrexate toxicity, but folic acid is more cost-effective and easier to handle 3, 4.
- Folinic acid should only be used for methotrexate toxicity, as dosing close to methotrexate administration may hinder methotrexate efficacy 2.
Benefits of Folate Supplementation
- Folate supplementation reduces the incidence of hepatotoxicity and gastrointestinal intolerance associated with methotrexate therapy 4, 5.
- Folate supplements do not appear to significantly reduce the effectiveness of methotrexate in the treatment of rheumatoid arthritis or psoriasis 3, 4, 5.
- Folic acid supplementation may also reduce the risk of cardiovascular disease by offsetting the elevation in plasma homocysteine associated with methotrexate use 5.