Pharmacy — Advice Letter for a Patient Starting Methotrexate
A rheumatology pharmacist writes an advice letter to a 49-year-old woman starting methotrexate for newly diagnosed rheumatoid arthritis. The proficient challenge is selecting the most safety-critical information from a complex set of clinical instructions and explaining it in plain, supportive patient language without losing any item that could cause harm if omitted.
Letter type
Advice
Write to
Patient
Target length
200–230 words
The case notes
Patient: Mrs Nadia Khalil, 49 years old; newly diagnosed rheumatoid arthritis
Methotrexate dose: Methotrexate 7.5 mg once weekly on Sundays; dose may increase to 15–25 mg over months depending on response
Folic acid: Folic acid 5 mg once daily on all days EXCEPT Sunday (i.e., 6 days per week) — reduces side effects
Interactions: Avoid NSAIDs, aspirin, trimethoprim, and alcohol; contact rheumatology pharmacist before taking any new medicine including OTC
Monitoring required: Bloods (FBC, LFTs, renal function) fortnightly for the first 3 months, then monthly once stable; patient must not collect the next week's tablet if bloods are overdue
Warning signs requiring urgent help: Mouth ulcers, new cough or shortness of breath, unusual bruising or bleeding, fever, severe nausea or abdominal pain, jaundice — stop the tablet and call the team immediately
Contraception: Effective contraception required during treatment and for 3 months after stopping; teratogenic drug
MHRA alert card: Yellow MHRA methotrexate alert card given; must be carried and shown to any doctor, nurse, dentist or pharmacist
Not to worry the patient unnecessarily about: The low starting dose (7.5 mg) means side effects are rare early; most patients tolerate methotrexate well when monitored correctly
Task: Write an advice letter to Mrs Khalil explaining how to take her methotrexate safely, what to monitor for, and what to do in an emergency.
Writing task
Write an advice letter to Mrs Khalil explaining how to take her methotrexate safely, what to monitor for, and what to do in an emergency.
What to include, what to cut
The hardest mark to win is selection. The same case notes contain decision-relevant facts and distractors. Here is what an examiner expects to see in a Grade B letter for this scenario, and what should be left out.
Include
-
Once weekly on Sundays only — not daily
The single most dangerous error with methotrexate is daily dosing. Multiple deaths have occurred from this mistake. It must be stated explicitly and emphatically.
-
Folic acid every day except Sunday and why
Folic acid reduces mouth ulcers and other side effects but must not be taken on the methotrexate day. The exception must be explicit or the patient may take it with the methotrexate and reduce efficacy.
-
The warning signs that require stopping and calling the team immediately
Methotrexate toxicity — pulmonary, hepatic, bone marrow suppression — can be life-threatening. The patient must be able to act on warning signs without delay. Every one of the key symptoms belongs in the letter.
-
No new medicine (including OTC) without checking
Trimethoprim and NSAIDs are common and dangerous interactions. A patient who takes a UTI antibiotic or pain relief without checking is at risk.
Leave out
-
Detailed pharmacology of methotrexate's mechanism of action
Wrong register for a patient advice letter. The patient needs to know what to do, not how the drug works. One sentence on what it does ('slows the overactive immune response') is enough.
-
Reassurance about the low starting dose in the letter's opening
Save this for the closing. Opening with reassurance before the safety information sends the wrong signal about what is important. Safety information first; supportive framing last.
Criterion in focus · Content
Methotrexate is a high-risk medication. The OET examiner treats this letter as a patient-safety document, not just a writing exercise. Content marks are lost if any of the following are absent: weekly dosing explicit, folic acid schedule with the exception day, blood monitoring requirement, the warning signs to act on, and the 'no new medicine without checking' instruction. All five must be present.
Now write the letter — and find out what is blocking your Grade B
Write a 200–230 words advice letter from these notes, paste it into the free checker for an instant read, then submit it for a human grade against all six criteria. Dr Mariam's team returns line-by-line feedback, from $12.