Title:  Analysis of adverse effects to Methotrexate in Rheumatology Department

Introduction:  Methotrexate is the cornerstone treatment in inflammatory Arthritis. It modulates cytokines response and it has anti-inflammatory effects, however it may not be tolerable for some patients due to its adverse effects.

Aim: Frequency of adverse effects attributed to Methotrexate use and way of reducing them.

Methodology: 100 Omani patients (89 females vs 11 males) from Rheumatology unit at Al Buraimi Hospital were collected during one year, 01/11/2016 to 01/11/2017. They were on Methotrexate 15-20 mg/week & folic acid 5 mg/ week. They were all assessed for Methotrexate tolerance. Adverse effects were classified into 7 categories:
a.	GIT & sick feeling, b. CNS manifestations, c. hepatotoxicity, d. neutropenia, e. hair loss, f. mouth ulcers, g. allergy.

Result: 32 patients at different age groups developed side effects to Methotrexate. Graph1.
17 patients (53%) were managed to continue Methotrexate either by shifting it to sub-cutaneous injection in 9 patients or modifying the oral dose in 8 patients. The adjustment measure includes: divided the dose at the same day, increasing folic acid dose and symptomatic treatment such as Proton pump inhibitor and anti-emetic at the same day of Methotrexate and the day following it. Despite this regime, 8 patients were shifted to other oral DMARDs and 6 patients were changed to anti-TNF/ Rituximab. The remaining 1 patient stopped it completely without further treatment. Graph2.
Conclusion: 53% of patients with side effects to Methotrexate can be managed by modifying the way of introducing the drug rather than changing it to other DMARDs or anti-TNF.