Methotrexate Warning

There is a central concern that methotrexate is a high risk drug with unusual dosing. The drug list displays high risk items in red font with a shaded red background. High Risk! Precedes the drug name:

You are similarly warned if you select penicillamine (125mg and 250mg), mercaptamine (50mg and 150 mg), mecaptopurine 50 mg tabs and 150 mg, co-proxamol sf susp 32.5mg + 325mg and co-proxamol tabs 32.5mg + 325mg, and dextropropoxyphene HCl with paracetamol tabs.

When you select the item, an additional message associated with the selected drug eg:

"This is a NPSA High Risk process Caution!

methotroxate tablets 10mg - Usually prescribed weekly. Patients require regular monitoring & blood tests

Proceed / Do not Proceed

If Proceed is selected, the prescribing will continue.

If Do not Proceed is selected, you are returned to the screen prior to the secondary alert."

If you prescribe Methotrexate with a dosage frequency that is not weekly, you will be prompted with the following warning: Warning! The current dosage does not match any of the recommended dosages. You are recommended to record clinical evidence to support this dosage regime..

For Scotland and Northern Ireland, Vision will not allow you to continue unless "Weekly" appears in the dosage field. You will also be warned if you change the text of a recommended dosage. Methotrexate AS DIR is not a valid dosage.

Dosages for Methotrexate can be selected from a dosage pick list on Therapy Add:

Methotrexate tablets 2.5mg: (standard dosage in bold)	Methotrexate tablets 10mg: (Standard dosage in bold)
2.5mg (one tablet) to be taken weekly	10mg (one tablet) to be taken weekly
5mg (two tablets) to be taken weekly	20mg (two tablets) to be taken weekly
7.5mg (three tablets) to be taken weekly	No dose greater than 20mg will be presented for the 10mg dose
10mg (four tablets) to be taken weekly
12.5mg (five tablets) to be taken weekly
15mg (six tablets) to be taken weekly
17.5mg (seven tablets) to be taken weekly
20mg (eight tablets) to be taken weekly
22.5mg (nine tablets) to be taken weekly
25mg (ten tablets) to be taken weekly

Some local prescribing has been restricted to using 2.5 mg tablets only, and sometimes doses are required above the maximum 3 x 2.5 mg contained in the NPSA (National Patient Safety Agency) specification.

The current maximum licensed dose for weekly administration in arthritis (including psoriatic arthritis) is 25mg. You can also overtype the Dosage if prescribing the 10mg tabs, but prescribing above 20mg will alert you in the same way.

You may override these dose options to prescribe greater multiples of 2.5mg, and if you do so, it is recommended that you record clinical evidence of any overridden dosages and a message reminds you of this: Warning! The current dosage does not match any of the recommended dosages. You are recommended to record clinical evidence to support this dosage regime. Are you sure you wish to continue? Proceed / Do not proceed

If you select Proceed, the prescribing continues.

If you select Do not proceed, you are returned to the Therapy Add screen.

For patients that are taking more than 7.5 mg (3 x 2.5mg), or more than 20 mg (2 x 10mg), and there are no 10 mg tabs available, you are prompted to record clinical evidence to support overriding the maximum 3 x 2.5mg dosage or 2 x 10mg dosage.

Switch on drug doubling checks - We recommend that you switch on drug doubling checks to avoid prescribing two forms of methotrexate simultaneously (Consultation - Options - Setup - Drug Check - Doubling - Same Ingredient or Same Drug). This will ensure that if a patient has been prescribed 2.5 mg tablets and in the future, within six months, they are prescribed the 10mg tablets, then a warning displays.