“I’ve run out of my methotrexate early — can you just print me another script today?”

An early methotrexate repeat is a PRESCRIBING-SAFETY gate, not a clerical task. Methotrexate for rheumatoid arthritis is a high-risk, narrow-margin drug taken ONCE WEEKLY, and "ran out early" must trigger the question WHY — a dosing error or confusion, taking it more than weekly, hoarding, lost tablets, or diversion. The catastrophic, sometimes FATAL error to exclude is inadvertent DAILY dosing (patient, dispensing or prescribing error): if present, it is a toxic emergency (mucositis, marrow suppression, GI/hepatic toxicity) needing urgent assessment, bloods, folinic acid rescue and specialist input — not another prescription — so always confirm weekly dosing on a named day (MHRA Drug Safety Update, September 2020; NPSA oral methotrexate alert, 2006). Actively screen toxicity red flags: mouth ulcers/stomatitis, sore throat/fever/infection (marrow suppression), new breathlessness or dry cough (methotrexate pneumonitis), nausea/vomiting, abdominal pain or jaundice (hepatotoxicity), and unusual bruising/bleeding — any of which mean hold the drug and escalate. Before re-prescribing under shared care, confirm MONITORING (FBC, LFTs, U&E; BSR csDMARD 2025: about 3-monthly once stable) is current and act on overdue/abnormal results first, because re-prescribing blind bypasses the safety system shared care maintains. Reinforce safety counselling — weekly dosing with folic acid on a different day, avoidance of trimethoprim/co-trimoxazole and caution with NSAIDs/alcohol (dangerous interactions/hepatotoxicity), illness awareness, prompt reporting of toxicity symptoms, and, because it is teratogenic, contraception for women who could conceive (CoSRH: contraception can stop at 55, so at 58 it is unlikely to apply — check rather than assume) — and confirm the monitoring booklet. Resist the "just print it, I’ve a bus" pressure courteously but firmly, explaining the safety rationale, and reach a safe disposition: correct any misunderstanding and issue an appropriate quantity with monitoring confirmed, or escalate urgently if toxicity/daily-dosing is found. Safe care over speed.