Question on folic acid and MTX , I got my injector pens 7.5mg prescription 8 week supply , I don’t start till next Thursday . The nurse at the hospital said folic acid is taken every day except MTX day , but they have given me 8 tablets 5mg each , so I guess that means I take one a week , but which day do I take it on , and is that the correct dose for once a week. Not impressed with how it was explained to me , plus I have never injected myself and have just been given the injector pens to get on with it . I can read the instructions but it’s stressful enough taking this drug let alone being left to your own devices first time you use it . Should I call them or am I being over dramatic . Stressed .
MTX and folic acid : Question on folic acid and MTX , I... - NRAS
MTX and folic acid
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Gaz227
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Sorry to hear of the lack of support you have received from the hospital. You should have been shown and then observed injecting MTX for the first time.Folic acid is normally taken everyday except MTX day, so it sounds as if you have been given 8 days supply.
You are not being over dramatic, a call asking for clarification sounds in order
Thanks for the response , my research found that it is only 1mg for folic acid daily nothing on MTX day , but other info I have found said 5mg once a week , the day after MTX .
in reply to Gaz227
I take 20 mg mtx every Wednesday and 5 mg Folic acid every Saturday. I think you should get back to the them and ask for help with your first injection and clarify the FAcid Don’t stress
1mg is the dose in the States
Don’t think they do that any more . I was pointed to a video to watch .
I've been told to take folic acid once a week but not on mtx day. The fact that some are taking it everyday is confusing me. Hospital say once a week and people on here say everyday.I injected on Saturday and took one yesterday.
Can you please tell me why I should take it every day.
It depends on the severity of your side effects, was how it was explained to me.Once a week if you are managing If you have more side effects they increase the folic acid.
Thanks for that information. I've been on Methotrexate for over 20 years . I take one folic acid on Saturday and 20 mg MTX on Sunday plus daily sulfasalazine of 3 gms .
This is what I started with when RA beckoned . Years later I saw that many people were taking folic acid every day . I wondered why but always forgot to ask my rheumatologist.
My disease has been reasonably well controlled although I've had joint destruction and various joint replacements - despite being seronegative .
Increasing folic acid also helps keep the remaining folic cells in our body healthy, necessary for good skin, hair & nails.
I have been told to take the folic acid the day after MTX 24 hours later . I wonder why I am taking it then and not the day before ? Any ideas
No idea , I'm afraid . Although looking at all the replies you have received here there doesn't appear to be a set time for folic acid or a set number of tablets to take . It very much looks like the personal decisions of various rheumatologists , rather than a medical directive . I shouldn't worry just take it when you've been told to and add this to the long list of questions that you'll be amassing before your next rheumatology visit .
You should have been given a help number to ring to speak to a specialist nurse who will help with any queries . They're usually excellent and really approachable .
With RA , I'm afraid there's a lot to take in but don't worry we've all been there - you'll cope . Keep well .
I've spoken to the nurse , I'll just go with what they have said , take the folic acid tablet 24hours after MTX .
People who are taking it six days a week are usually those who have had side-effects from the mtx. One a week it’s a starting point and if you then get side-effects you can increase it to another day and so on. That’s what happened to me.
My response did not say you should take folic acid every day.
My response said ....They do in Edinburgh, but I guess it is different in different parts of the UK. Daily Folic Acid is also prescribed here too, except for MTX day.
Some , but not all rheumatologist prescribe daily folic acid , MTX day excepted, to try and ameliorate the side effects of MTX.
MTX blocks some of the actions of folic acid (Vit B9) which in some people can lead to side effects such as mouth ulcers, hair loss, anaemia, abdominal pain, diarrhoea amongst others.
There is some evidence (Cochrane review for example) to suggest taking high dosages of Folic Acid can help prevent these side effects. But it does not work for everyone, it didn't for me.
It can be confusing because the advice differs from hospital to hospital and rheumatologist to rheumatologist. So best to follow what your own rheumatologist says. There is no right and wrong answer.
I hope it works for you.
Hi, I inject 25mg on a Wednesday eve, and take 1 folic acid each night except on metho day, it was because my hair was falling out, now it is stable but a lot thinner , I used to take folic acid once a week x
Good morning! No you're not being over dramatic at all. It's understandable that you're stressed about taking the mtx for the first time.And just being left to get on with it doesn't help🙄The folic acid instructions do sound vague. I take mine 5 days a week, one 5 mg tablet per day, but not on the mtx day or the day after. Advice does vary from one health authority to another so it might be worth you checking with them.
I don't have pens- I'm still given tablets , but I do inject my biologic, and once I'd done it a couple of times , it was second nature to me.
Wishing you all the best.
Thanks , I think a phone call is required to clear this up 👍, I might drop in the chemist also to check they didn’t get it wrong and never gave me enough folic . 👍
You're welcome. Yes it does seem like there's a problem with the prescription- an 8 week supply for one a week🤔
Not everyone needs to take it 6 days a week MadBunny, Gaz is starting on a low dose of mtx and the same with folic acid, both can be increased if needs be. No point taking more if you don’t need to 😊
I was on a high dose of mtx from the start , hence the higher dose of folic 🙂
Just wondering if high dose did its job for you?
Of the mtx? I took.it with sulfasalazine for 4 yeas but then it started to become less effective and I was put on a biologic, Cimzia. The dosage of mtx was reduced to 10 mg . I still take it but the nurse was talking about possibly reducing it further. The folic acid seems to have worked.
Thanks, I took 25mg methx for 1st 18 months after diagnosis then asked to come off it as I started a biologic, think I should have stayed on it as I'm struggling 5 months on only taking biologic so I'm asking to have it again.
I started on 25. Once I started the biologic it was gradually reduced to 10. I would have agreed to reduce it more but I've been getting worse over the last few months I've been on the biologic since 2014.
It's such a shame when we think things are working and then we get set backs. Hope we get some relief soon
Yes it is. It happened with me with the sulfasalazine , then the mtx. However, I'm still nowhere as bad as I was before I was put on a biologic- I could hardly use my hands and carry out personal tasks. Maybe your biologic needs more time to work fully🤔 It might be worth discussing with your rheumatologist.
That's true, thanks.
One thing I’m confused about , If I take the MTX injection at say 9pm Thursday night when should I take the folic acid tablet 5mg on a once a week basis ?
I take 7,5mg Methotrexate injections and have always been asked to take 5mg Folic Acid everyday but not the day I inject.
Same here. To be honest I really don't think it matters too much, but we do need to follow our own medics instructions.
I think it matters. Too much folic acid is dangerous as well as too little.
As stated in my response......It doesn't matter how much folic acid you are prescribed , so long as you follow the guidance of your rheumatologist. I doubt very much if rheumatologist would prescribe dangerously high dosages of folic acid. The actual dosages , whether daily or weekly is a highly debatable issue, all available on line.
Follow your rheumatologists advice on meds, their advice will be based on what evidence they have which is better than what an individual thinks.
Folic Acid (Vit B9) may be a B vitamin that may not store in the body (a water vitamin that is released from body) not sure. I think may be B6 might be the B that you have to be careful with???
Vitamin B6 is perfectly safe if taken in therapeutic doses....as are all Vitamins. Similarly all Vitamins can cause issues if taken in excessive doses. Follow the prescribed amount of all prescribed meds / supplements and all will be well.
Would that be the same for B9 too?
Yes, excessive B9 can cause gut and skin issues and in very rare cases confusion and other neurological problems. The doses of B9 given to people on MTX are high and cannot be bought over the counter (lower doses can). B6 can cause similiar gut issues / thirst and skin problems. In rare cases it can cause unsteadiness on your feet and lack of coordination.
Thanks you have good knowledge, like a Nutritionist! Do you think that 5mg folic daily 6 times a week is safe with weekly 15mg MTX??
Your rheumatologist should provide you with the appropriate folic acid medication along with MTX. I could not suggest a prescription level for you.5mgs per day of folic acid is the standard dosage, usually 6 days per week with MTX. But there is variability between countries.
Thanks very much. Will do.
Does it not say on the bottle? I’d give your rheumy nurse a call and ask. You’ll get lots of different answers here as we are all told different. I seem to remember I took it the day after, so the next night but do check for you 😊
I'd take the folic acid the same time the following day. Going back to when I first started injecting I did it in the morning & took my folic acid the morning after, then when I was on 2 a week I took it the morning before too. As long as there is 24 hours between MTX & FA you should be fine. You can always ask for clarification when you ring the nurse about the discrepancy in amount of FA.
Yes you are correct. One 5mg tablet per day (6 days a week) but no folic acid on the day MTX is taken.
You do need to be shown how to inject correctly especially if you have never injected before. I only take one 5mg folic acid once a week so your prescription could be right. I think a phone call to your team is needed …
Hi Gaz. This is what I was given when I was prescribed Metoject (although I was shown by the nurse how to use it anyway). You may have these instructions too but if not, I hope these help. It really is a lot easier than you think, the diagrams are helpful - I was terrified at first but after the initial dose, it was really easy. As regards the Folic Acid, it sounds like she has gotten confused with the 8-week supply of pens so you need to have it clarified. Good luck.
I was shown how to use the Metoject pen but it is very easy so could have managed without tbh. I was originally prescribed 5mg Folic Acid one day a week (the day after Methotrexate) but it was increased to six days a week (not on Methotrexate day) when I had a few side effects. I was on tablets originally which are inclined to cause more side effects but changed to injections when they wanted me to have a higher dose. 7.5mg is a low starting dose so hopefully you'll have no problems; I started on 15mg tablets and am now on 20mg Metoject and it's been great for me. I would definitely ring the nurse for clarification - and reassurance.
How long did the Mtx take for you to notice a marked improvement in your pain etc?I started on 10mgs injection 2 weeks ago and honestly am sick to death of this pain. Its so encouraging to read that Mtx works and I'm praying it's the only drug I'll need.
It's hard to say as I was given a steroid injection to tide me over until the medications (I was also on Hydroxychloroquin) kicked in. It is normal for it to take up to 12 weeks but I was given advice on painkillers, hot and cold compresses and had an appointment with an OT who taught me some exercises, gave me some wrist braces and explained about how to do things without putting too much strain on my joints.
Have you got a follow up appointment booked with the nurse? If not, maybe ring the helpline, explain that you're struggling and ask for some pain management advice. I've come to realise that they'll assume that everything is fine unless I tell them otherwise so there's no point suffering in silence.
Disappointing that you aren't sure about whether the Mtx worked on its own. I've had a steroid but they don't work well anymore. What Im hoping is the Mtx works well on its own or what's the point. I don't want to spend my life taking different pain meds that don't really work.Was hoping the mtx worked for you as you said it was good.
It's worked well for me in combination with Hydroxychloroquin and Sulphasalzine although the consultant and I both suspect that the Hydroxychloroquin isn't doing much so my dose has been lowered with a view to coming off it next year. I noticed a lot of improvement when Sulphasalzine was added so had thought that the Methotrexate wasn't doing much but when I missed a few doses recently my joints really complained so I was very happy to get back on it. Currently I don't take any pain relief, just the DMARDS, I have no joint damage and my inflammation levels are low so I'm very happy 😁
When I started on MTX 10mg I took 1 5mg folic acid tablet the day after taking MTX. 7.5mg is a low dose so it may be they feel that the once a week should cope with the side effects. When I got to 15mg they changed me to folic acid 6 days a week, as my nausea worsened. They do like to treat with lowest dose required, which is why I suspect they have prescribed it weekly. I would try it, and if you suffer side effects discuss increasing it
Shouldn't get nausea with injections.
I don’t get nausea anymore since taking folic acid 6 days a week, even though I’m up to 25mg. So happy to continue with tablets 👍
MTX subcutaneous (SC) injections can reduce or remove nausea in some, but not all people. Many people find little or no improvement in nausea when taking SC MTX (or any of the other side effects) and are offered alternative RA meds as the side effects of MTX whether orally or subcutaneously are too great to deal with even with reduced SC dosages.
That’s not good you haven’t been given enough advice about using your injection. Do ring up and speak to your rheumy nurse about this and ask to be shown if you need it. That dose of folic acid is correct, once a week 😊 you are starting on a low dose of mtx and it is standard to start on folic acid once a week and it can be increased if needs be if you get side effects when you increase your mtx. 🤞🏻 All goes well.
No, you're not being over dramatic, you should really have been shown & then done it yourself in front of the person who demonstrated it to you. I was/did with both my pre filled syringes & pens. As neither was done with you hopefully this video will be of help metoject.co.uk/uk-patients/
You are on the lowest injection dose so in one way it would make sense to start with the least folic acid, although if the prescriber of the folic acid has misinterpreted what the nurse said & it is intended you take it 6 times/wk & not once then you should have been given 48… as you know you’ve only been given enough to take it once a week. I would call, ask for clarification &, if it's as the nurse says, ask for another prescription for 42 & for your repeat to be amended to 48.
As FA is unlicensed for MTX side effects there isn't a specific guideline so Rheumys differ in their choice of days it's taken. I started on MTX dose of 15mg & 5mg FA just once a week, taken the day after MTX. That was then increased to twice, the day before & day after. Since 2013 I’ve taken it 6 days, missing out MTX day. So you see, it's the Rheumy preference. What it does mean though is the more days you take it the more likely any side effects are dealt with (or more tolerable), that any healthy cells are protected & the more likely you'll be able to continue on it, that's the thinking anyway.
In the UK we're prescribed 5mg FA. I would think the 1mg you've read about is from an American website, or any other than UK or European one anyhow. It's always best to keep to UK sites then, as you've proven by happenstance, you have the correct info for where you live. Just end any search with UK & they should list first but best to check just in case.
That is awful ,when I first went mxt I had to go to a nurse who showed me the correct way to use it I went twice ,then I was comfortable doing it at home ,I'm now on biologics as max affected my liver badly ,but I take folic acid every day as my hair is thinning, I would speak to your consultant
Give them a call. You need to be confident that you understand everything. Good luck!
I also was given no instructions until three weeks after I first injected myself, following instructions on YouTube. I receive my injector pens from Sciensus and had a nurse come to my house to teach me the proper injection method, going forward. Make sure they give you a Sharps bin to dispose of your used injector pens (didn’t get one for 12 weeks!). I take 5mg folic acid every day except the MTX injection day. I’d call your RA or RA Nurse to clarify the dosage, for your info and peace of mind. Good luck!
I'd definitely call your RA nurse to clarify dose of FA. Perhaps they can arrange for you to have 1-2-1 instruction on administering the injection. While there is alot of instruction material available out there, you need to feel confident that you can do it yourself.
With regard to the sharps bin , please ensure you know how to handle it. My local council was responsible for collection even though hospital said they would at first.
I began 15mg injections of methotrexate just over two years ago (starting with a specialist nurse appointment to instruct on how to use it which l, as someone else mentioned here, could have done without as l've been injecting various biologics for the last six years - with appointments so scarce these days one would hope that they would be more prudently allocated), and was also told by consultant to take one Folic Acid tablet a week (injection day Friday, so tablet taken on the Tuesday) which l dutifully did for six months before desperation at the weekly tiredness, mouth ulcers and general blah feeling drove me to seek guidance on this very site! With the general concencus on here being that my Folic Acid dosage was quite low and l should contact my rheumatologist specialist nurse, my prescription was upped (every day except injection day) and the nausea and mouth ulcers /sores began to improve and are now, thankfully, quite rare 😁 so definitely do contact your team for clarification. And the very best of luck to you with this, and all your treatments.
Not being over dramatic at all. It's terrifying putting this harsh drug into your body for the first time.I started 2 weeks ago with 10mgs injection. Was told to take 1 x 5mg folic acid once a week but not on the day you do the injection.
Don't be scared of the actual injection. It's like an epipen and you won't see the needle or feel it.
If it's any consolation, so far I've had no side effects except for a bit of an upset tummy yesterday.
Good luck.
Hi they should have told you how to do it Don't be shy and get in touch and ask them .
I had a nurse come to my house and explain
The whole process.
Good luck , you'll soon get use to it .
Thanks everyone for your advice , I have just been contacted by Rheumatology and they have told me to take 5 Mg folic acid 24 hours after the MTX injection , also if I want training it’s available but after watching a video someone kindly sent me a link to it looks pretty straight forward . Thanks again everyone this site is such a great life line when you get stressed with questions and worries about our health issues 👍, wishing you all good health and happiness 🙏
I'm glad that's cleared up. Always check with your Rheumy team, they know you, we don't. Even so, it's exactly how I was told to take folic acid when I first started MTX. I hope all's well from now on.
Glad you’ve got the help you need. When I was first prescribed methotrexate 3 years ago I was told to take one folic acid tablet a week (on any day except injection day). The methotrexate made me feel nauseous so my folic acid was increased to 6 times a week to help combat this and it worked. I am now slowly reducing back down to 1 a week because my body tolerates the methotrexate better… and my aim is to keep well on as little medication as possible.
You’ll find your own way but it sounds as though you have a good supporting rheumatology team …as is mine, I think they are all just a bit stretched, frazzled and under resourced at the moment - the Covid effect 🥺
Well, Gaz227, that dose sounds low - 5mg per week. Even if it were 5mg per week, it would be taken in 1mg daily doses, perhaps
Folic acid is interesting in that there doesn't seem to be any set dose. I asked my rheumy about this many years ago, and she was very relaxed about it, saying the important thing is not to take it on the same day as MTX. The dose is not over important!
I take 5mg daily except the day of the MTX and the day before and after. Others will have different routines. I have 10mg MTX by metoject pen weekly. This routine has been followed for so many years that I've lost count (not the pen, that's fairly new; just the dose)..
As I understand it, from my doctor, any surplus folic doesn't hang about in the body, but is expelled as it is water soluble.
You should be able to get all the information from your rheumy team about what is right for you.
Good Luck!
I take folic acid each day except MTX injection day, so the 8 tablets wil cover you first week.Check with GP what your repeat script is regarding Folic Acid.
Never feel it's a problem calling/speaking with your RA team, took me 2-3 appts to get my head around it all.
All the best 
I started methotrexate in December 2021 my initial dose was 2.5 mg x 2 or 5 mg which was taken once a week on Wednesday. It doesn't matter what day of the week you take it, but once you choose a day you will take on same day each week going forward. Per the instructions provided by the pharmacy you take this dose for two weeks and starting the third week the dose went to 2.5 mg x 4 or 10 mg which was my normal dose going forward but could be adjusted depending on how it is working for you. As for folic acid I was given instructions from the pharmacy to take this drug daily and is 1 mg only I do take it on the same day I take methotrexate. According to my research on folic acid you take this to prevent unwanted side effects from the methotrexate i.e mouth ulcers etc. So far things are working well maybe you should consult your doctor to get his thoughts before you start taking this medication as he may want you to take as you described. I don't know what you are taking with the injector pen, but I started taking Orencia four weeks after I started taking the methotrexate and folic acid as I was taking another biological which I had to stop before using a new biological. I did the Orencia injections of 125 mg once a week, but I DO NOT take on the same day that I take methotrexate so that I'm not taking all of these medications together. After 5 weekly injections of Orencia I will have to stopped taking for two weeks as I will be going into phase two which will be the Orencia infusion program. The infusion program will be administered in doctor's office by nurse and will be done once a month moving forward. I do not know what dose I will be receiving as it depends on your weight. I'm excited about my progress so far with the new medications. And finally, so that you are aware when you take methotrexate, and any biological you doctor will be ordering blood work for you on a monthly basis just to make sure that your numbers are within in range as this is important to your long-term health of using these drugs.
Very sorry it's so stressful, without you having any support. I was on oral MTX for many years & took the Folic Acid (1 x 5mg) once a week throughout (day after taking MTX). Even though I had bad side effect the last few years (& was also put on injections near the end), I didn't know any better and no one ever suggested to me to take more Folic Acid! I've seen on this forum a lot of folk have taken it/ taking it up to 6 days a week. That was never recommended to me in all those years! But once a week sound right for the Folic Acid - and if side effects come on they should increase your dose so you take 5mg on more days than just one. Good Luck!
Been on MTX 25mg for quite a while taken on Wednesday with 10 mg folic acid on thursday - those are the instructions I have been given
20mg metoject on Friday evening and 5mg folic acid every evening, except Friday.
I take MTX 20mgs on Sundays (tablets) and 5mg Folic Acid tablets everyday but Sundays.
I'm taking seven 2.5 mg mtx once a week. Every day I take 1mg folic acid except on the day I take mtx. I'm supposed to be taking ten mtx, but I'm slowly increasing after taking a drug holiday to increase the effectiveness of COVID booster.
I always call my rheumatologist when I have questions, though sometimes I don't like to.
Hiya SIG. Are you in the USA by any chance? I ask as here in the UK we're prescribed 5mg folic acid not 1mg. I take 5mg every day except MTX, 17.5mg injection. I hope your increase in dose of MTX helps control you without issue.
Yes, I'm in u.s. 5 mg sounds like a lot. Do you experience side effects? The rheumatologist did tell me I could take 2 folic acid daily if mouth sores (mtx side effect) were bothering me.
No, not on 30mg. I'm a little more tired & not very hungry the day after but nothing like I am without, or when I increase my MTX dose. I've never had mouth ulcers for example. It's enabled me to stay on MTX for so long.
Hi. You should have a ‘training session’ booked by your Rheumatology team. I was when I had injections (stopped as it totally freaked me out!). Regarding the folic, I started on 5mg per week. I think I took it on the Monday, and the Mtx on a Thurs. Mouth ulcers though, so was increased to 6 days (not Mtx day). I think maybe they just start you on 5mg Folic to see how you go, then increase if necessary.
Sorry that you have been left feeling a little confused. I would say YES get in touch and ask for clarification, and Yes ask for someone to give you a couple of lessons on how to inject yourself ( it's not an easy thing to do for the first time). I can tell you that I take my methotrexate on Sunday, and then my folic acid Monday to Friday, so from what you say you have a weeks supply only. BUT DO RING THEM AND ASK FOR CLARIFICATION they may given you a weeks supply in one tablet who knows.
Hope you get it sorted out. Best of luck.
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