I’m sure this topic has been discussed previously but to save me searching I would like to ask whether anyone has been given advice around withholding MTX before having a Covid vaccine.
I have already had six vaccinations and have never been given advice to withhold MTX before having it.
A friend recently told me that he was advised to stop his MTX for a week before vaccination but this is news to me.
In the event that the immunocompromised community will be offered another spring booster (hopefully!) I would like to make sure I am getting maximum protection so any advice would be appreciated.
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Hightower62
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Hiya Elwin. I did for the first time when I had my 3rd booster (6th vaccination) last December, I’ve continued on it for the previous vacinnations, including my annual flu jab. I regretted it, I had my first flare in ages & shan't do the same when I have my Spring booster. I decided to try after the BRS suggested pausing MTX for a fortnight post booster, not by recommendation of my own Rheumy. Even if it had been I still wouldn't do it again.
I should mention I’ve been on MTX 14 years later this year, the first year oral & ever since subcut.
We are each different of course, you may be that much better controlled & find you don't miss your MTX so it's best you seek advice, not that it will make any difference if you're advised to pause it & you do flare.
I’ve not stopped mine and my rheumy agreed I shouldn’t because I flare easily if it’s stopped. Not worth the risk to me, but that’s me. I’d just do what you did the last 6 times or contact your rheumy nurse. 😊
A study was published last year that tested whether patients with autoimmune rheumatic diseases who are taking methotrexate had a better immune response (measured by antibody levels) if methotrexate was skipped for a variety of time periods, before and after vaccination. They concluded that the best approach, as a balance between flaring and immune response, was to take at least a 10 day break after vaccination. They also found that age was an important factor, so older people are more likely to benefit from a methotrexate break.
I think this has started to feed into practice because at my last appointment in the summer my rheumatologist recommended that I skip methotrexate for two weeks after my autumn booster. My RA is reasonably well controlled at the moment so it wasn't likely to cause a flare for me. This would be a very important factor in the decision of whether to take a break though!
Oh, also, the study was also specific to the COVID vaccine(s), I can't remember which ones but it'll say in the paper.
The study was done, though, because there was a small study about methotrexate and flu vaccines a few years ago that also found that a break in methotrexate can help boost the immune response. I'll add the link to that one if I can find it Edit: This study is also open access and available at: ard.bmj.com/content/77/6/89...
The flu study was quite small, and so the results are less reliable than if it had involved more patients. I suspect that more research would be required before there would enough evidence to change the mtx recommendations.
I stopped mxt for 2 weeks before and 2 weeks after vaccine. It was a mistake as I had a bad flare afterwards. I think next time I would just leave 2 weeks after vaccine to give it chance to be effective. This is just my decision and you should check with your rheumatologist.
it was only prior to the last booster number 6, that advice changed. A study found that antibody numbers were around 22,750 in those who omitted MTX for 2 weeks, and just over 10,000 in those who didn’t.
Here’s the research that was done. I did have a flare, but would still do again, as I’m on 5 immunosuppressants, so need all the help I can get.
I’ve had 6 vaccinations too, and after I’d had my first dose I had a telephone consultation with my rheumatologist. I asked if I should stop mtx around the time of the next vaccination, and her response was that if my RA was stable I could stop the mtx from the week before the vaccination date, but for me she wouldn’t advise stopping it because I would go into a massive flare.
There seems to be a single study suggesting a stronger protective response to the vaccine if you cease MTX. The conclusion of the study is that suspending MTX "could potentially translate to increased vaccine efficacy." This is based on lab tests of antibody response, not measured statistical protection of patients. i.e. The results indicate better protection in theory, not in practice as yet. This constitutes weak evidence which has to be weighed against Covid risk in your own case versus the impact of a potential flare-up.
As others have said, I think it is a decision that depends on your individual circumstances. I didn't stop mtx after the first 2 jabs. I did an antibody test after the 2nd and had a very low antibody level. So after the third, I stopped for 2 weeks. Did an antibody test and had a hugely increased antibody level. Which may or may not affect my actual covid risk, of course. Our rheumatology department (Torbay and South Devon) now recommend that everyone stops for 2 weeks, unless their disease is poorly managed. My PsA is very much under control at the moment, so the only side effect of stopping the mtx has been very minor pain and stiffness in my hands after about 11 or 12 days, and that has lasted for a week or two each time.
You will have many replies to this post, so this is just one more!
From the start, I was told by rheumatology that it was not necessary to stop my weekly 10mg injections of methotrexate before covid vaccinations. I've been taking methotrexate since 1998, and the only vaccine I've been warned against is the one for shingles. No "live" vaccines should be taken with methotrexate, I was told.
I've now had 6 covid vaccines and will probably be up for another soon. You should be advised by your rheumatology team - I'm sure the team is well aware of patients who are just as concerned as yourself.
It may well have to do with dosage - but it's not difficult to find out.
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Edit: This study is also open access and available at: 
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