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Is Folic Acid Necessary?

My son (age 6) has just been put on Trexall (oral methotrexate) once a week for his colitis. He is also on Prednisone (start weaning off tomorrow) and VSL. I am very nervous about this new med, as Evan is only 39 lbs and I am worried he will have a bad reaction to such a strong med. I had read that people take folic acid with the methotrexate to help combat side effects, so had asked his GI's office last week if I needed to also include that with the trexall. Well, Friday they told me he didn't need it. I went ahead and ordered some anyway. BUT, today, the day after his dose of 7.5 mg, he is getting slightly flushed and I noticed his cheeks look swollen this morning. He also has a round red spot on his neck, near his collarbone, which kind of looks like a hickey.

For those of you who have experience with this med, do you find it necessary to take Folic Acid along with it? Does it help combat side effects? Should I call the dr and tell them about his flushing, small spot of rash and swollen cheeks? He is otherwise acting OK, although a little tired, and is eating well... even has a bit more of an appetite than usual.

Thank you for any and all advice!


Staff member
New York, USA
Although I have never taken methotrexate, I would call the doctor about the possible side effects, especially since you said his cheeks are swollen..

I do know some medications deplete or inhibit the absorption of folic acid...not sure if supplementing would do any harm.

My understanding is that folic acid is a have to while on Methotrexate. I would talk to the pharmacist that dispensed it to you and have them explain all the details, especially if your dr. is saying your kiddo doesn't need it. (I work as a pharmacy tech for a large children's hospital...I would highly recommend conferring with a pharmacist on this.) :) Since your kiddo is taking it orally, there is probably an administration schedule that you follow. Hope you find the answers you need!


Well-known member
I have never heard of Mtx without Folic acid. Mtx is a folic acid antagonist. Best to double check. Also, I would call on the flush, swollen cheeks and the red spot. I hope My Little Penguin sees this as she is the allergy expert around these parts.

my little penguin

Staff member
The folic acid needs to be started typically prior to the Mtx .
Some skip the day of Mtx injection others don't.
Again something to ask your pharm or Gi.
Red hickey like spots sound like hives
Swollen face as well.
I would talk to your Gi doc ASAP .
Allergic reactions can be mild but others can progress.
Signs of Anaphylaxis1

Skin: Flushing; itching; hives; swelling; rash; itching of lips, tongue and palate; swelling of lips, tongue and back of throat (uvula); itching around eyes; redness and swelling of eyes; and tearing of eyes.

Respiratory: Itching and tightness of the throat; difficulty swallowing; change in voice; hoarseness; dry cough; harsh high-pitched breathing (stridor); itching in the outer ear canals; shortness of breath; chest tightness; cough and wheezing; itching of the nose; runny nose; congestion; and sneezing.

Gastrointestinal: Nausea; cramping abdominal pain; vomiting; and diarrhea.

Cardiovascular: Decreased blood pressure; feeling faint; fainting; not acting normally; chest pain; and heart rhythm abnormalities.

Other: Uterine cramping in women; and an aura of impending doom.

( not a doc just a mom so call your doc. ;) )
OK. I'm so confused. The GI is saying Evan isn't a "candidate" who needs Folic Acid supplements while on the methotrexate, claiming that it is only needed when there is a liver dysfunction in the patient. ??? He also believes the swelling is from the Prednisone, which I am almost inclined to believe however I didn't notice the swollen cheeks until the morning after his Trexall dose? Coincidence, maybe. But I'm scared of doing something wrong here, which may hurt my baby instead of helping him. :(
Found this from 2013, Edinburgh, regimen of methotrexate injection for crohn's;http://www.ljf.scot.nhs.uk/SharedCareProtocols/SCP/scp/methotrexate (Crohn's child).pdf
"Methotrexate is an antifolate drug, which inhibits dihydrofolate reductase, essential for the synthesis of purines and pyrimidines. Methotrexate interferes with the supply of folic acid to the body so small doses of folic acid should be prescribed 24 hours after the dose of methotrexate to help minimise gastrointestinal side effects."
"24 hours after Methotrexate each patient should receive a single oral dose of folic acid 5mg each week"


from Boston Children's Hospital http://childrenshospital.org/clinicalservices/Site1966/mainpageS1966P92.html
"Methotrexate is a maintenance medication. It is used to help keep patients with Crohn’s disease feeling well and off steroids..............You will also need to take a supplement called Folic Acid while taking this medication.

When did your child start methotrexate?
want to add that there may be different thoughts on the necessity of folate supplementation --I'm not sure. A quick search found that in 2005 doctors differed in their opinion as to whether all patients with Rheumatoid arthritis getting methotrexate should get folate or should wait for side effects.
Thank you for those links xmdmom.

Evan just now had fecal and urinary incontinence. He has fecal incontinence when flaring, but never urinary.... Bms should be normalizing 2 weeks into prednisone treatment, so I don't understand where this is coming from. :(
Our 13 year old is on MTX and takes 1MG of folic acid daily. Our doctor believes you always supplement with folic acid while on MTX. I would get a second opinion if your doctor thinks otherwise.


Definite YES on the folic acid. Claire was first on MTX at age 4 and the Rheumatologist had her on folic acid then too. Same scenario with different doc (GI) and different diagnosis years later. MTX = Folic Acid :)

Keep us posted on the reaction!

Thank you all. His gi still insists Evan won't need it. Hmm.
He did ok his multivitamin, which has 400 mcg of folic acid, daily. I have been giving him 800 mcg during the week too, but skipping the weekend so as not to interfere with the med.
His reaction - the swelling in face - is the prednisone. I checked photos I took of him the week before starting the trexall. So far, he's had the mtx for 3
weeks and no complaints of nausea or other side effects. **knock on wood**
I've never heard of anyone saying folic acid is not required when on methotrexate either, and as it's water soluble, as far as I'm aware there's little risk of taking too much, as the excess will be expelled in urine anyway, there's just the possible interaction on the day of the methotrexate dose.

It's somewhat academic, but for those interested, at the last gastroenterology conference I was at one of the prominent gastros who presented a paper on mtx was asked by a colleague whether it was really necessary to skip the day of the dose. He responded that it was irrelevant when used as an immunosuppressant as the reasons for skipping had something to do with the specific mechanisms of action for cancer treatment (I forget the exact details sorry) but that it wouldn't do any harm to skip the day of the dose anyway.

All that said, we've discovered through trial and error that I need 10mg/week of folic acid, so I just take 5mg both the day before & after, which seems to work quite well.