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Reduced Methotrexate Efficacy: Folic acid supplements, caffeine/theophylline, and some antibiotics affecting gut flora may reduce absorption or effects Other Important Interactions: Live vaccines: contraindicated (risk of severe infection) Ciclosporin: excessive immunosuppression and toxicity Mercaptopurine: increased plasma levels (dose adjustment required) Phenytoin and sodium valproate: reduced efficacy reported, monitoring of phenytoin levels recommended Theophylline: decreased clearance, monitoring of theophylline levels recommended References Methotrexate | Drugs | BNF | NICE Accessed 5/2/26 Methotrexate 10 mg Tablets Summary of Product Characteristics (SmPC) (emc) | 11723 Accessed 5/2/26 Methotrexate | Macmillan Cancer Support Accessed 5/2/26 Methotrexate Sodium (Cancer Treatment) NCI Accessed 5/2/26 Managing interactions with methotrexate NHS SPS Specialist Pharmacy Service The first stop for professional medicines advice Accessed 7/2/26 Using folic acid with methotrexate in rheumatoid arthritis NHS SPS Specialist Pharmacy Service The first stop for professional medicines advice Accessed 7/2/26 Methotrexate once-weekly for autoimmune diseases: new measures to reduce risk of fatal overdose due to inadvertent daily instead of weekly dosing GOV.UK Accessed 7/2/26

Mannucci E, Silverii GA

34,40,41 Ferroptosis, another form of regulated cell death characterized by iron-dependent accumulation of ROS, lipid peroxidation, and oxidative membrane damage, is increasingly recognized as a key contributor to APAP-induced liver injury

For moderate, manageable symptoms try dose delay, extra fluids, smaller meals and ginger