Systemic lupus erythematosus

Prescribing Notes:

• Risks/benefits of disease modifying antirheumatic drugs (DMARDs) should be discussed with patients before commencing using a written information sheet available from Versus Arthritis.
• DMARDs are appropriate for shared care arrangements to facilitate the seamless transfer of individual patient care from secondary care to general practice.
• The MHRA has received reports of prescription and dispensing errors for methotrexate that have resulted in serious and fatal adverse reactions. Methotrexate tablets should be prescribed in 2.5mg strength only. The 10mg strength should not be used since they may be confused with the 2.5mg tablets.
• Patients who have a partial response to or intolerance of oral methotrexate may be switched to subcutaneous methotrexate under the guidance of a rheumatologist.
• Providing monitoring procedure is followed, NSAIDs may be prescribed with methotrexate.
• Subcutaneous methotrexate is available in a variety of brands and formulations. The brand used currently (April 2022) in rheumatology is Metoject pre-filled pen.
• Folic acid 5mg should be prescribed weekly, 24 hours after methotrexate to reduce toxicity. This can be increased to daily (apart from day of methotrexate) if side effects are troublesome. This option could be considered routinely to avoid the risk of nausea / mouth ulcers and the patient stopping the drug.
• The use of oral methotrexate for non-malignant conditions such as rheumatoid arthritis has been highlighted nationally as a potential risk for fatal medication errors. New measures have been implemented to prompt healthcare professionals to record the day of the week for intake and to remind patients of the dosing schedule and the risks of overdose due to continued reports of inadvertent overdose. For further advice see MHRA Drug Safety Update September 2020.