Measurement of full blood count and liver function tests are advisable before and within 4 weeks of starting therapy, then monthly thereafter. Early toxicity from methotrexate is primarily gastrointestinal (nausea, vomiting, diarrhoea, and stomatitis) and may be limited by 5 mg of folic acid the day following MTX injection. Treatment is discontinued in 10-18% of patients because of side effects. The principal concerns are hepatotoxicity and pneumonitis. A study of liver biopsies in IBD patients taking MTX showed mild histological abnormalities despite cumulative doses of up to 5.4 grams. Surveillance liver biopsy is not warranted, but if the transaminases increase to more than twice the upper normal limit, it is sensible to withhold MTX until it returns to normal before a retrial of the drug . The prevalence of pneumonitis has been estimated at 2-3 cases per 100 patient years of exposure, but even large series have not reported any case. The main concern with this drug is its teratogenicity, which limits its use in fertile patients.
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