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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Methotrexate, ciclosporin and retinoid monitoring

Dermatology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Overdose, organ toxicity or pregnancy exposure

Daily methotrexate error, mucositis with fever or bleeding, severe cytopenia, new hypoxic lung disease, hypertensive crisis or acute kidney injury on ciclosporin, pancreatitis with extreme triglycerides, severe hepatitis, or pregnancy during methotrexate or acitretin exposure requires urgent action.

Action: Withhold the implicated medicine, document dose and last administration, arrange same-day hospital and specialist assessment with FBC, renal, liver and other cause-directed tests, treat sepsis or organ failure, and obtain urgent toxicology, dermatology, renal, respiratory or fetal-medicine advice.

Synopsis

Select and monitor methotrexate, ciclosporin and oral retinoids for severe skin disease, prevent weekly-dose and interaction errors, interpret trends in marrow, liver, kidney, blood pressure and lipids, and apply reproductive safeguards.

  • Methotrexate for inflammatory skin disease is taken once weekly on one named day, never daily; tablet strength, folic-acid day and monitoring owner must remain unambiguous.
  • Methotrexate suppresses folate-dependent nucleotide synthesis and immune proliferation; marrow, liver, lung and renal-clearance toxicity make trends as important as absolute thresholds.
  • Ciclosporin blocks calcineurin signalling and acts rapidly, but vasoconstrictive nephrotoxicity, hypertension, electrolyte disturbance, infection and interactions limit continuous use.
  • Acitretin normalises keratinocyte differentiation and is not conventionally immunosuppressive, but dryness, liver and lipid toxicity and exceptionally prolonged teratogenic risk dominate monitoring.
  • Baseline methotrexate assessment includes FBC, renal and liver function, hepatitis and HIV risk assessment, pregnancy status, vaccination, alcohol, lung history and interacting medicines.
  • Before ciclosporin, obtain at least two creatinine and blood-pressure measurements and assess potassium, magnesium, lipids, urate, infection, cancer and interacting CYP3A medicines.

Key red flags

Fever, mouth ulceration, sore throat, bruising, bleeding, new breathlessness, jaundice, severe headache, very high blood pressure, falling urine output, rising creatinine, severe abdominal pain, visual change, pregnancy or a dosing discrepancy must interrupt routine prescribing and trigger prompt assessment.

Methotrexate marrow toxicity

Mouth ulcers, sore throat, fever, bruising and bleeding with falling counts can progress rapidly, especially after daily dosing, renal decline or trimethoprim exposure.

Investigation priorities

01
Methotrexate baseline panelFirst step

Identify marrow, liver, renal, infection, lung and reproductive contraindications.

Management branches

First-line safe initiationBuild the baseline before the first dose

A conventional systemic dermatology medicine has been selected.

  1. Confirm disease indication, previous therapy, infection and cancer history, vaccination, pregnancy plans, alcohol, comorbidity and every interacting prescription and non-prescription product.
  2. Obtain the medicine-specific baseline and agree exact dose, administration, laboratory interval, symptom actions and which clinician owns each result and prescription.
  3. Give a written medicine card: one named weekly day for methotrexate, blood-pressure and interaction precautions for ciclosporin, or pregnancy and alcohol restrictions for acitretin.

Key medicines

MethotrexateFor systemic-treatment-eligible psoriasis, NICE uses incremental initiation such as 5–10 mg orally once weekly, increasing to the lowest effective dose up to 25 mg once weekly; assess response after 3 months at target dose.Never daily. Use one named weekday and one tablet strength, co-prescribe folic acid on another day, avoid pregnancy and trimethoprim or co-trimoxazole, adjust for renal function and monitor marrow, liver, lung and infection toxicity.
Folic acid with methotrexatePrescribe at least 5 mg orally once weekly on a day different from methotrexate; a specialist may increase the amount or number of non-methotrexate days for adverse effects.Do not place routinely on the methotrexate day unless a specialist protocol says so, and do not confuse ordinary folic acid supplementation with folinic-acid rescue for overdose.
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Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE psoriasis systemic-treatment recommendationsSelection, dosing, response and place of methotrexate, ciclosporin and acitretin.
  • SPS methotrexate monitoringDermatology baseline, monitoring intervals, action thresholds and trend interpretation.
  • MHRA once-weekly methotrexate safetyPrevention of fatal daily-dose errors and named-weekday safeguards.
  • Neoral ciclosporin SmPCWeight-based dosing, baseline-relative creatinine, blood pressure, interactions and duration cautions.
  • Acitretin SmPCDose, liver and lipid monitoring, alcohol, interactions and teratogenic restrictions.
  • MHRA oral retinoid pregnancy preventionCurrent contraception, testing, donation and educational-material requirements.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem ·

Before acitretin, document liver, fasting lipids, glucose risk and pregnancy-prevention eligibility; where pregnancy is possible, prevention and testing continue for three years after the last dose.
  • Trimethoprim or co-trimoxazole with methotrexate can cause profound marrow toxicity, while macrolides, azoles, grapefruit and many other agents can raise ciclosporin exposure.
  • A creatinine rise above 30% from the patient's pretreatment baseline on ciclosporin is clinically important even if the laboratory value still lies inside its population reference range.
  • Do not renew from a normal latest result alone: falling neutrophils, rising transaminases, increasing creatinine or blood pressure and missed monitoring require response before the next supply.
    • Content changes
    Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom