No matter what health conditions you may have, experiencing chest pain or tightness can be terrifying. 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 (Rheumatrex, Trexall) to help treat joint inflammation and pain, you may develop heartburn and acid reflux, which can be uncomfortable and difficult to manage. Some medications used to treat acid reflux can affect the way your body processes methotrexate and may not be safe options for people with lupus.

Read on to learn how you can safely and effectively manage 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 dampening the immune system’s activity. Methotrexate is also used at high doses in cancer therapy to slow the growth of cancer cells.

In people with lupus, methotrexate is used to reduce inflammation of the joints and skin and the pain associated with these symptoms. It is effective in reducing lupus disease activity and may allow some people with lupus to lower their supplemental corticosteroid dosage.

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

In some cases, methotrexate can cause gastrointestinal (GI) side effects, including nausea, vomiting, heartburn, and acid reflux. Higher doses of the drug appear more likely to cause these symptoms.

Methotrexate can also cause side effects affecting the GI tract, especially when taken with NSAIDs or aspirin, including stomach ulcers and bleeding and black stool.

If you experience methotrexate side effects such as heartburn, reflux, or black stool, tell your doctor right away. They may indicate the presence of 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 reflux 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 (ongoing) acid reflux can lead to a condition called gastroesophageal reflux disease (GERD).

Symptoms of GERD include:

• Heartburn
• A feeling of something stuck in your throat
• Food coming back from your esophagus into your mouth
• Difficulty swallowing
• Coughing
• Chest pain
• Hoarseness
• Sore throat

Managing Acid Reflux While on Methotrexate

If you experience acid reflux or GERD but need to take methotrexate to treat joint pain and swelling caused by lupus, treatment and management options are available.

Medical Interventions

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

• Antacids — These drugs neutralize stomach acid for quick relief. Types of antacids include calcium carbonate (such as Tums and Rolaids) and a combination of aluminum hydroxide, magnesium hydroxide, and simethicone (Mylanta).
• Histamine H2-receptor antagonists — These medications decrease the production of acid in the stomach for up to 12 hours. Medications in this category include cimetidine (Tagamet) and famotidine (Pepcid AC).
• Proton pump inhibitors (PPIs) — These drugs are strong acid blockers that help to heal the esophageal tissue damaged from acid reflux long term, though they usually require a few days to become fully effective. Types of PPIs include lansoprazole (Prevacid), omeprazole (including Prilosec), and esomeprazole (including Nexium).

If medications prove ineffective, your doctor may recommend surgery to repair the valve between your stomach and esophagus.

Check With Your Doctor About Drug Interactions

Importantly, 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. Using histamine H2-receptor antagonists in place of PPIs has been shown to be safe and effective for treating acid reflux and GERD.

Many types of medications other than PPIs also can interact with methotrexate, leading to toxic effects. It’s important to talk to your rheumatologist before adding any new drugs to your regimen if you’re living with lupus.

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 remaining upright (sitting and/or standing) for about 45 to 60 minutes 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 the feet so gravity can help keep the acid down.

Maintain a Healthy Weight

Researchers have found that people with a body mass index (BMI) of 25 or higher are more likely to experience GERD-related symptoms. BMI is a ratio of a person’s weight to their height, and a BMI of 25 or higher is clinically considered overweight.

BMI in and of itself isn’t a reliable way to determine if you have a healthy weight, though, so speak with your doctor for guidance.

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.

Stop Using 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 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, such as amitriptyline (e.g., Amitid, Elavil) and doxepin (Sinequan)
• Anti-inflammatory painkillers, including ibuprofen (e.g., Advil, Motrin) and aspirin
• Certain antibiotics, including tetracycline (Achromycin V) and clindamycin (Cleocin)
• Oral bisphosphonates (osteoporosis medications), including alendronate (e.g., Binosto, Fosamax), ibandronate (Boniva), and risedronate (Actonel, Atelvia)
• Sedatives or tranquilizers, including benzodiazepines such as diazepam (e.g., Valium) and temazepam (Restoril)

If you are being treated for lupus symptoms with methotrexate and have heartburn, acid reflux, or GERD, talk to your doctor about ways to manage the reflux symptoms. Your doctor may suggest alternative acid-reducing medications and recommend nonmedication ways to prevent reflux.

As with other medications, 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.

Talk With Others Who Understand

MyLupusTeam is the social network for people with lupus and their loved ones. On MyLupusTeam, more than 223,000 members come together to ask questions, give advice, and share their stories with others who understand life with lupus.

Have you had acid reflux while on methotrexate? Share your experience in the comments below, or start a conversation by posting on MyLupusTeam.