Methotrexate: The Dispensing Safety Checklist

📋 First Dispense Essentials

Mandatory items to issue

• Check the patient has a yellow patient-held monitoring booklet. If not, source one and record the patient's details, dose, and day of the week. Encourage the patient to bring it to every clinical appointment and every time they collect their prescription.¹
• Provide a patient alert card and write the dispensed dose in milligrams, the number of tablets, the once-weekly frequency, and the full day of the week on both the card and the dispensing label. For example: 'Take 4 tablets (10 mg total) on Tuesday only'. Remind the patient to show the alert card to any new healthcare professional, including on hospital admission.
• Confirm that folic acid is prescribed or that an alternative plan has been documented. If folic acid is not on the prescription and no explanation is apparent, check with the prescriber before dispensing.²
• Oral methotrexate should normally be prescribed and dispensed using one tablet strength only, usually 2.5 mg. Do not supply mixed tablet strengths. Query any prescription for 10 mg tablets or any prescription with unclear or 'as directed' dosing before dispensing, in line with local safety policy.¹

Baseline clinical checks

• Confirm the indication is non-oncological (for example, rheumatoid arthritis, psoriasis, or inflammatory bowel disease).²
• Usual dose range is 7.5 to 25 mg once weekly. Confirm any unusually high dose against previous records or specialist instructions.⁴
• Confirm baseline blood tests have been completed before starting treatment: full blood count (FBC), liver function tests (LFTs including ALT), and renal function (creatinine and eGFR).³
• Confirm that patients of reproductive potential, and male patients whose partners are of reproductive potential, are using effective contraception. Methotrexate is highly teratogenic. Female patients should continue contraception for at least 6 months after stopping. Male patients should continue for at least 3 months after stopping.⁴

Key risks and lifestyle traps

• Trimethoprim and co-trimoxazole should generally be avoided with methotrexate. This combination can cause life-threatening bone marrow suppression. Consult the prescriber for an alternative antibiotic.⁵
• Do not start over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen without checking first. Prescribed NSAIDs may be used under specialist supervision. Low-dose aspirin as an antiplatelet can generally be continued.⁵
• Penicillins (including amoxicillin) can reduce methotrexate clearance. Counsel patients to report mouth ulcers, sore throat, bruising, or unusual bleeding.⁵
• Proton pump inhibitors (for example, omeprazole, lansoprazole) may reduce methotrexate clearance, particularly in renal impairment. Ensure routine monitoring remains up to date.⁵
• Renal impairment and dehydration increase the risk of methotrexate toxicity. NSAIDs, penicillins, and PPIs all carry heightened risk in patients with reduced renal function. Advise patients to seek advice promptly during illness causing vomiting, diarrhoea, or reduced fluid intake.^{4, 5}
• Statins, fluconazole, terbinafine, and tamoxifen may increase liver toxicity risk. Ensure routine monitoring remains up to date.⁴
• Folic acid should usually be taken on a different day from methotrexate. Follow the prescribed regimen.²

First dispense script

🔄 Repeat Dispense Screen

Mandatory documentation

• Record the dose, strength, and day of the week on every dispense. Confirm this matches the previous supply.
• Check the prescription for any change to dose, frequency, or day of the week since the last supply. Query prescriptions with 'as directed' wording or quantities inconsistent with once-weekly dosing before dispensing.
• Check whether folic acid is still on the repeat prescription. If it has been removed, query with the prescriber before dispensing. Note the reason if confirmed intentional.
• Record whether monitoring is current and document any interventions if monitoring appears overdue.³

Ongoing clinical checks

• Full blood count (FBC), liver function tests (LFTs), and renal function should be monitored according to the specialist or shared-care protocol. Typically every 1 to 2 weeks when starting or after dose changes, then extended once stable. Most stable patients require monitoring at least every 2 to 3 months.³
• Check for newly prescribed medicines that may interact, particularly trimethoprim, co-trimoxazole, NSAIDs, and penicillins.⁵
• Confirm the day of the week on the label matches the patient's current regimen. Confirm no hospital or specialist instruction has changed the dose or dosing day since the last supply.
• Confirm folic acid is still being taken as prescribed.
• If a compliance aid or monitored dosage system is requested, proceed with caution. Methotrexate in blister packs carries a high risk if weekly doses are not clearly segregated from daily medicines. Consult the prescriber or specialist team before dispensing in this way.

Ask the patient at the counter

• "Have you taken your methotrexate exactly once a week on the correct day? Have you accidentally taken any extra doses?"
• "Have you had any mouth ulcers, sore throat, unusual bruising, or bleeding since your last prescription?"
• "Have you started any new medicines, including antibiotics or anything bought without a prescription?"
• "Are you still taking your folic acid as prescribed?"
• "How many tablets do you take each week, and do you know what dose that is in milligrams?"

Lifestyle and surgical alerts

• Do not start over-the-counter ibuprofen or other non-steroidal anti-inflammatory drugs without checking first.
• Alcohol should be avoided or kept to a minimum. Excess alcohol increases the risk of liver toxicity.
• Both men and women should use effective contraception throughout treatment and for the recommended period after stopping.
• Avoid live vaccines unless specifically advised by the specialist team.
• If you are exposed to chickenpox or shingles, or develop symptoms, seek urgent medical advice the same day, particularly if you are not known to be immune or are taking other immunosuppressive medicines.
• During significant illness, especially with fever, vomiting, or diarrhoea, seek advice from your prescriber about whether methotrexate should be temporarily withheld.

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