Methotrexate is one of the most commonly prescribed — and most effective — disease-modifying antirheumatic drugs for treating rheumatoid arthritis (RA). Occasionally, people taking methotrexate for RA may experience side effects. Several members of myRAteam have expressed concerns about various side effects, and some have asked whether methotrexate can cause nosebleeds and sinus infections (also known as sinusitis).

“This is kind of gross,” wrote one member, “but ever since I started methotrexate, I get blood clots when I blow my nose and occasional nosebleeds. I’ve never had a nosebleed or clots prior to this medication.”

Another member reported that they were “diagnosed with both ears infected, as well as a sinus infection … Anyone else go through problems such as this?” “Yes,” replied another, “I seem to have issues with infections every time I try immunosuppressant drugs.”

Here is what you need to know about methotrexate, sinus infections, and nosebleeds. Your rheumatologist is the best resource for managing the side effects of your rheumatoid arthritis treatments. They can provide medical advice based on your RA symptoms and your other medical conditions.

How Can Methotrexate Cause Sinus Infections or Nosebleeds?

Methotrexate is a type of drug known as a disease-modifying antirheumatic drug. It works by suppressing the immune system in order to manage RA symptoms, reduce joint inflammation, and prevent disease flare-ups.

Although methotrexate is effective for treating inflammatory conditions like RA, a suppressed immune system means that the body may be more susceptible to disease-causing bacteria and viruses. Research studies have shown that taking methotrexate is associated with an increased risk of developing infections.

Methotrexate also can affect bone marrow — the spongy tissue found in most bones that creates different blood cells like white blood cells, which help fight infections. Additionally, methotrexate can affect platelets, which help the blood to clot. When production of these cells is affected, the body may have a more difficult time fighting off infections.

Because methotrexate suppresses both the immune system and the production of infection-fighting blood cells, people taking methotrexate are at a higher risk of contracting infections — including sinus infections — and may also bruise, bleed, or develop nosebleeds more easily than the average person.

According to the Mayo Clinic, methotrexate side effects that may suggest an infection include:

• Bloody nose
• Ringing, buzzing, or other noise in the ears
• Cough or hoarseness
• Ear congestion
• Loss of hearing
• Stuffy or runny nose
• Sneezing

These side effects occur in about 10 percent of people taking methotrexate.

Managing Sinus Infections and Nosebleeds on Methotrexate

Dealing with a sinus infection or nosebleeds combined with RA symptoms like joint pain can be an added stressor. If you develop these side effects while taking methotrexate, talk to your rheumatologist or health care professional.

Nosebleeds are usually harmless and can be treated at home. However, if you start getting nosebleeds shortly after starting methotrexate, or if you develop symptoms like shortness of breath, weakness, or pale skin, talk to your doctor. They will want to monitor your symptoms and how often you experience them because frequent nosebleeds can lead to conditions like anemia.

If you show symptoms of a sinus infection while on methotrexate, make an appointment with your doctor as soon as you can. Because methotrexate lowers your immune system’s capacity, your doctor must know of any infections and side effects you are having while taking methotrexate. If left untreated, sinus infections can lead to more serious infections.

Stopping or Changing Methotrexate Dosage

If your doctor determines that methotrexate is causing sinus infections or nosebleeds, they may recommend lowering your dosage or changing medications. They will be able to find the drug or dose that successfully treats your RA while minimizing adverse side effects. It is important to never stop taking your RA medication or change the amount you take without first consulting your rheumatology specialist.

Folic Acid Supplements

Methotrexate blocks cells from accessing folate, which can lead to several of the drug’s side effects. Taking folic acid — a synthetic form of folate — can lower the risk of side effects from methotrexate without affecting the effectiveness of the drug in treating RA. Your doctor will recommend the dosage and how often to take the supplement.

Regular Blood Testing

It’s important to get regular blood tests while taking methotrexate. Experts recommend undergoing blood tests once a month to check your platelet count and other potential abnormalities in your blood. You can discuss testing frequency with your doctor to determine the best schedule.

Infection Prevention

If you are taking methotrexate, it’s important to lower your risk of contracting infections. The Association for Professionals in Infection Control and Epidemiology offers a list of ten ways to prevent infections. Some include:

• Wash your hands frequently.
• Cover your mouth when coughing or sneezing.
• Avoid sharing personal items, such as toothbrushes, razors, or towels.
• Use safe cooking practices, including refrigerating foods two hours after preparation.
• Get vaccinated, but of course, ask your doctor first.

Wearing a mask in public spaces can also prevent you from getting or spreading an infection.

Treating Sinus Infections

If you develop a sinus infection while taking methotrexate, your doctor may recommend different treatments or combinations of treatments based on the severity of the infection. If symptoms are mild, a doctor may monitor your symptoms for several days and see if they improve on their own. If they don’t, there are several treatment options.

Mild sinus infections may be treated by using saline nasal sprays, decongestants, and drinking plenty of fluids.

Sinus infections that last longer than 10 days may be treated with prescription medications, including:

• Antibiotics
• Topical or oral decongestants
• Corticosteroids (steroid nasal sprays)

Chronic (long-lasting) sinus infections may be treated with:

• Steroid nasal sprays
• Medicated saline nasal rinses
• Oral antihistamines (allergy medication) or topical antihistamine sprays

If you take methotrexate and think you might have a sinus infection, talk to your doctor. They’ll take stock of your symptoms, your overall health status, and other medications you’re taking to determine the best treatment for you.

When To Seek Medical Attention for a Nosebleed

Although most nosebleeds are not serious, there are some situations when you should seek medical attention:

• Having a severe nosebleed, or one that actively bleeds for longer than 30 minutes or causes more than one cup of blood
• Having difficulty breathing
• Vomiting due to swallowing large amounts of blood
• Having a nosebleed that was a result of a serious injury like a major fall or car accident

In these situations, call your doctor (or 911), or have someone drive you to an urgent care center or emergency room. Do not drive yourself anywhere — attempting to drive with a nosebleed can cause distractions and be dangerous.

Find Your Team

If you or a loved one is living with RA, consider joining myRAteam today. Here, you can ask and answer questions, share stories, join ongoing conversations, and connect with more than 193,000 members from around the world who understand life with rheumatoid arthritis.

Have you developed sinus infections or nosebleeds while taking methotrexate? Do you have any suggestions for managing these side effects? Share your story or thoughts in the comments below or by posting on myRAteam.