Methotrexate (MTX) remains the first-line pharmacotherapy for rheumatoid arthritis (RA), yet gastrointestinal (GI) adverse events (AEs) are frequently reported. This systematic review and meta-analysis aimed to estimate the prevalence of GI AEs among RA patients treated with MTX. A comprehensive search of PubMed, Scopus, and Cochrane databases was conducted, including observational and interventional studies reporting GI AEs in adult RA patients receiving MTX. Risk of bias was assessed using the Newcastle–Ottawa Scale, JBI Critical Appraisal Tool, and Cochrane RoB 2 as appropriate. Pooled prevalence estimates with 95% confidence intervals (CIs) were calculated using a random-effects model. Thirty-seven studies involving 19,986 participants were included. Nausea and abdominal pain were the most frequently reported AEs, with pooled prevalence of 24.3% (95% CI: 16.7–34.0) and 19.6% (95% CI: 13.9–26.9), respectively. Substantial heterogeneity was observed across studies and persisted after stratification by MTX route or study design. Nine studies reported discontinuation due to GI AEs, with rates ranging from 1.7% to 23.4% and a pooled prevalence of 8.5% (95% CI: 5.0–14.3). Gastrointestinal AEs affect approximately one-fifth of RA patients receiving MTX, with nausea and abdominal pain being the most common symptoms. GI events leading to treatment discontinuation were relatively uncommon. Clinician awareness and timely management of GI AEs are important to prevent nonadherence and optimize MTX therapy. © The Author(s), under exclusive licence to International League of Associations for Rheumatology (ILAR) 2026.