No matter what health conditions you may have, experiencing chest pain or tightness can cause concern. One MyLupusTeam member rushed to the emergency room after having these symptoms, only to be diagnosed with heartburn. “Anyone have experiences to share with heartburn or acid reflux after taking methotrexate?” they asked.

If you’re living with lupus and are taking methotrexate to help treat joint inflammation and pain, you may develop heartburn and acid reflux. Some proton pump inhibitors (PPIs, which are medications used to treat acid reflux) can interfere with the way your body clears methotrexate. This interaction is most important at high methotrexate doses but is less likely at the lower doses used for lupus. If you take methotrexate and need acid reflux treatment, your doctor may recommend an alternative or monitor you more closely.

Read on to learn how you can safely treat acid reflux while taking methotrexate.

Methotrexate and Lupus

Methotrexate belongs to a group of drugs called disease-modifying antirheumatic drugs (DMARDs). DMARDs are immunosuppressive medications used to treat inflammatory conditions such as lupus, rheumatoid arthritis, and psoriasis. Immunosuppressive drugs work by slowing down the immune system’s activity.

In people with lupus, methotrexate is used to reduce inflammation, which can help reduce joint pain. Researchers have found it can be effective in reducing disease activity in systemic lupus erythematosus (SLE), the most common form of lupus.

Many MyLupusTeam members have shared how methotrexate has helped with their joint pain:

• “This past August, I started taking methotrexate. I can say that taking methotrexate so far has worked for me. It helps with my symptoms. Flares are remarkably reduced.”
• “I have been on methotrexate since 2014, and it has helped me a lot. The swelling around the joint areas has gone down.”
• “Life is good! Methotrexate is doing wonders for the joint pain and other lupus symptoms.”

Methotrexate and Acid Reflux

Some people experience gastrointestinal (GI) side effects when taking methotrexate, including:

• Nausea
• Vomiting
• Heartburn
• Acid reflux
• Stomach pain

These symptoms can happen at any dose but may be more noticeable at higher doses.

Methotrexate can also cause complications affecting the GI tract, especially when taken with nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin, including stomach ulcers, bleeding, and black stool.

If you experience methotrexate side effects such as heartburn, reflux, or black stool, tell your doctor right away. These side effects could mean you have stomach ulcers and bleeding that require treatment. You may need to have your dose adjusted — or to stop taking the drug entirely.

Lupus and Acid Reflux

Lupus itself may also cause acid reflux and other digestive symptoms. Inflammation can weaken the muscles of your esophagus, the tube that connects the throat and stomach. When they become too weak, the acid in your stomach can flow back into the esophagus, causing acid reflux. Chronic acid reflux can lead to a condition called gastroesophageal reflux disease (GERD). Some lupus medicines, like steroids or NSAIDs, can also irritate the stomach and worsen reflux.

Symptoms of GERD include:

• Heartburn
• A feeling of something stuck in your throat
• Regurgitation of food from your esophagus into your mouth
• Difficulty with swallowing
• Coughing
• Chest pain
• Hoarseness
• Sore throat

Managing Acid Reflux While on Methotrexate

If you experience acid reflux as a side effect of methotrexate, there are options for feeling better.

Medications and Supplements

Several medications used to treat acid reflux and GERD are available over the counter or by prescription. They include:

• Antacids — These drugs neutralize stomach acid for quick relief. Types of antacids include calcium carbonate (such as Tums and Maalox) and a combination of aluminum hydroxide, magnesium hydroxide, and simethicone (such as Alka-Seltzer Anti-Gas and Phazyme).
• Histamine H2-receptor antagonists — These medications decrease the production of acid in the stomach. Examples include cimetidine (such as Tagamet) and famotidine (including Pepcid).
• Proton pump inhibitors — PPIs are strong acid blockers that help to heal the tissue damaged from acid reflux. Types of PPIs include lansoprazole (such as Prevacid), omeprazole (including Prilosec), and esomeprazole (e.g., Nexium).
• Folic acid supplements (folate) — Folate is a form of vitamin B that methotrexate blocks, leading to some of its GI side effects. Research suggests that folic acid supplements can lower your risk of GI side effects from methotrexate by 79 percent.

Most people improve with lifestyle changes and medication. Surgery to strengthen the valve between the stomach and esophagus is only considered for severe GERD that doesn’t improve with other treatments.

Check With Your Doctor About Drug Interactions

PPIs may interfere with how your body breaks down methotrexate, resulting in higher levels of the drug in your body. This can lead to an increased risk of toxic effects from methotrexate. This risk is primarily for high-dose methotrexate (such as for cancer treatment). At low doses (commonly used for arthritis and other autoimmune conditions), the risk is much lower but may still happen in rare cases. High doses are generally more likely to cause interactions, as low doses are absorbed quickly in your GI tract. Ask your healthcare team if your dose is considered high.

If you’re on a high dose of methotrexate, histamine H2-receptor antagonists instead of PPIs may be a better option.

Always talk with your doctor before starting new drugs — even those that can be purchased over the counter — and never stop taking methotrexate without talking to your rheumatologist first.

Lifestyle Changes

Changing certain daily habits can help you reduce your acid reflux symptoms.

Eat Small, Frequent Meals

Stomach acid is more likely to flow back into your esophagus when there’s a lot of food in your stomach. Eating smaller meals a few times per day instead of three large meals may help with acid reflux and GERD.

Avoid Trigger Foods and Beverages

Avoid eating foods that give you heartburn or symptoms of acid reflux. Certain foods and beverages are more likely to cause reflux, including:

• Onions
• Chocolate
• Mint
• Tomatoes
• Garlic
• Citrus
• Spicy foods
• Fatty foods
• Fried foods
• Coffee and tea
• Carbonated drinks

Stay Upright During and After Meals

Sitting upright while eating and staying upright (sitting or standing) afterward for several hours after meals helps to keep stomach acid down. Finish eating three hours before going to bed to avoid lying down with a full stomach.

Raise the Head of Your Bed

Prop up the head of the bed so you can sleep on an incline. Use bed risers or a foam wedge to make your head higher than your feet so gravity can help keep the acid down.

Exercise — With Care

Exercising yields many health benefits — including potentially helping with GERD symptoms. However, particularly strenuous physical activity can worsen symptoms for some people. Speak with your doctor as to whether any type of exercise is OK for you or if you should stick to lower-impact activities like swimming, brisk walks, yoga, or light weight lifting.

Avoid Products Containing Nicotine

Nicotine, a stimulant found in tobacco and vaping devices, may relax the lower esophageal sphincter, a muscle located at the bottom of the esophagus. This muscle helps keep acid down.

Choose Loose-Fitting Clothing

Clothes that are tight around the waist can squeeze your stomach and push acid up, causing reflux.

Check Your Medications

Certain medications can affect the muscles and tissues in your stomach and esophagus, resulting in acid reflux. Some of these medications include:

• Tricyclic antidepressants
• Anti-inflammatory painkillers
• Certain antibiotics
• Oral bisphosphonates
• Sedatives or tranquilizers

Talk With Others Who Understand

On MyLupusTeam, people share their experiences with lupus, get advice, and find support from others who understand.

Have you experienced acid reflux while taking methotrexate? Let others know in the comments below.