Methotrexate


Concise Prescribing Info
Indications/Uses
Listed in Dosage.
Dosage/Direction for Use
Adult : PO Burkitt's lymphoma 10-25 mg/day for 4-8 days, repeat after 7-10 days. Choriocarcinoma 15-30 mg/day for 5 days, repeat after an interval of at least 1 wk for 3-5 courses. Mycosis fungoides 2.5-10 mg/day to induce remission. Rheumatoid arthritis 7.5 mg once wkly, adjust if needed. Up to 20 mg/wk. Crohn's disease 12.5-22.5 mg once wkly for up to 1 yr. PO/IV/IM Psoriasis 10-25 mg once wkly, adjust subsequent doses if needed. IV Osteosarcoma 12-15 g/m2 as infusion, followed by folinic acid. Breast cancer 10-60 mg/m2 often w/ cyclophosphamide and fluorouracil. Advanced lymphosarcoma Up to 30 mg/kg, followed by folinic acid rescue. Acute lymphoblastic leukaemia Maintenance: 2.5 mg/kg every 14 days. PO/IM Acute lymphoblastic leukaemia Maintenance: 15 mg/m2 1-2 times/wk w/ other agents. IM Choriocarcinoma 15-30 mg/day for 5 days. Repeat after at least 1 wk for 3-5 courses. Mycosis fungoides 50 mg/wk in 1-2 divided doses. Crohn's disease 25 mg once wkly for 16 wk. Maintenance: 15 mg/wk. Intrathecal Meningeal leukaemia 12 mg/m2 (Max: 15 mg) once wkly for 2-3 wk, then once mthly.
Dosage Details
Intramuscular
Choriocarcinoma
Adult: 15-30 mg daily for 5 days. Repeat after at least 1 wk for 3-5 courses. Alternatively, 0.25-1 mg/kg (max: 60 mg) every 48 hr for 4 doses followed by folinic acid rescue, repeat at intervals of 7 days for 4 or more courses.

Intramuscular
Mycosis fungoides
Adult: 50 mg wkly as a single dose or 2 divided doses.

Intramuscular
Acute lymphoblastic leukaemia
Adult: Maintenance: 15 mg/m2 once or twice wkly, with other agents.

Intramuscular
Crohn's disease
Adult: 25 mg once wkly for 16 wk. Maintenance: 15 mg wkly.

Intrathecal
Meningeal leukaemia
Adult: 12 mg/m2 (max 15 mg) once wkly for 2-3 wk, then once mthly. Alternatively, 200-500 mcg/kg every 2-5 day until CSF cell count is normalised.
Child: <1 yr: 6 mg, 1 yr: 8 mg, 2 yr: 10 mg, >3 yr: 12 mg. Patients <3 yr should be treated in accordance with combination chemotherapy protocols. Admin is at wkly intervals and repeated until the CSF cell count is normal.

Intravenous
Osteosarcoma
Adult: Initial recommended dose: 12 g/m2 as a 4-hr infusion, followed by folinic acid, as part of combined therapy. May increase dose to 15 g/m2 in subsequent treatments if initial dosage is insufficient to achieve peak serum methotrexate levels of 454 mcg/mL at the end of the infusion. Methotrexate infusion is administered on postoperative wk 4, 5, 6, 7, 11, 12, 15, 16, 29, 30, 44 and 45; in combination with other chemotherapy agents. Folinic acid can be given orally, IM or IV inj starting 24 hr after the beginning of the methotrexate infusion. Give via parenteral routes If patient experiences GI toxicity (e.g., nausea, vomiting). Usual dosage of folinic acid: 15 mg every 6 hr for a total of 60 hr or a total of 10 doses.

Intravenous
Breast cancer
Adult: 10-60 mg/m2 often with cyclophosphamide and fluorouracil.

Intravenous
Advanced lymphosarcoma
Adult: Up to 30 mg/kg, followed by folinic acid rescue.

Intravenous
Acute lymphoblastic leukaemia
Adult: Maintenance: 2.5 mg/kg every 14 days.

Oral
Choriocarcinoma
Adult: 15-30 mg daily for 5 days, repeat after an interval of ≥1 wk for 3-5 courses.

Oral
Acute lymphoblastic leukaemia
Adult: Maintenance: 15 mg/m2 once or twice wkly, with other agents.

Oral
Burkitt's lymphoma
Adult: 10-25 mg daily for 4-8 days, repeated after 7-10 days.

Oral
Psoriasis
Adult: 10-25 mg wkly as a single dose, adjust subsequent doses based on response.

Oral
Rheumatoid arthritis
Adult: 7.5 mg once wkly, adjust by response. Not more than 20 mg/wk.

Oral
Mycosis fungoides
Adult: 2.5-10 mg daily to induce remission.

Oral
Crohn's disease
Adult: 12.5-22.5 mg once wkly for up to 1 yr.

Parenteral
Psoriasis
Adult: 10-25 mg wkly as a single dose. Adjust subsequent doses based on response. May be given via IV/IM admin.
Renal Impairment
CrCl Dosage
<10 Avoid use
10-50 30-50% of dose
51-60 70% of dose
61-80 75% of dose
Hepatic Impairment
Bilirubin 3.1-5 mg/dl: Administer 75% of dose; Bilirubin >5 mg/dl: Avoid use.
Administration
Should be taken on an empty stomach. Best taken on an empty stomach. May be taken w/ meals to reduce GI discomfort. Avoid taking w/ milk-rich products.
Reconstitution
Intramuscular:
Dilute powder with D5W or normal saline to a concentration ≤25 mg/ml (20 mg and 50 mg vials) and 50 mg/ml (1 g vial).
Intrathecal:
Reconstitute to 2.5-5 mg/ml with normal saline, D5W, lactated Ringer's, or Elliott's B solution. Use preservative-free preparations.
Intravenous:
Dilute powder with D5W or normal saline to a concentration ≤25 mg/ml (20 mg and 50 mg vials) and 50 mg/ml (1 g vial).
Parenteral:
Dilute powder with D5W or normal saline to a concentration ≤25 mg/ml (20 mg and 50 mg vials) and 50 mg/ml (1 g vial).
Incompatibility
Intramuscular:
Y-site incompatibility: Chlorpromazine, gemcitabine, nalbuphine, promethazine, propofol, idarubicin, ifosfamide, midazolam. Syringe incompatibility: Droperidol. Admixture incompatibility: Bleomycin.
Intravenous:
Y-site incompatibility: Chlorpromazine, gemcitabine, nalbuphine, promethazine, propofol, idarubicin, ifosfamide, midazolam. Syringe incompatibility: Droperidol. Admixture incompatibility: Bleomycin.
Parenteral:
Y-site incompatibility: Chlorpromazine, gemcitabine, nalbuphine, promethazine, propofol, idarubicin, ifosfamide, midazolam. Syringe incompatibility: Droperidol. Admixture incompatibility: Bleomycin.
Contraindications
Severe renal or hepatic impairment, pre-existing profound bone marrow suppression in patients with psoriasis or rheumatoid arthritis, alcoholic liver disease, AIDS, pre-existing blood dyscrasias, pregnancy (in patients with psoriasis or rheumatoid arthritis), breast-feeding.
Special Precautions
Hepatic or renal impairment, bone marrow depression, elderly, neonates. Ulcerative disorders of the GI tract. Monitor haematological, renal and hepatic function, and GI toxicity regularly.
Adverse Reactions
Ulceration of the mouth and GI disturbances (e.g. stomatitis and diarrhoea), bone marrow depression, hepatotoxicity, renal failure, skin reactions, alopecia, ocular irritation, arachnoiditis in intrathecal use, megaloblastic anaemia, osteoporosis, precipitation of diabetes, arthralgias, necrosis of soft tissue and bone, anaphylaxis, impaired fertility.
Potentially Fatal: Pulmonary reactions (e.g. interstitial lung disease); neurotoxicity (e.g. leukoencephalopathy, paresis, demyelination) with intrathecal use; foetal deaths.
IM/Intra-arterial/IV/Parenteral/PO/SC: X
Overdosage
Nausea, vomiting, alopecia, melena, and renal failure.
Drug Interactions
Decreased effectiveness with folic acid and its derivatives.
Potentially Fatal: Increased toxicity with NSAIDs and salicylates; probenecid; some penicillins; aminoglycosides neomycin and paromomycin; sulfonamides such as sulfafurazole and sulfamethoxazole; co-trimoxazole or trimethoprim; nephrotoxic agents (e.g. cisplatin); ciclosporin; etretinate. Synergistic enhancement of effects with fluorouracil. Increased bioavailability of mercaptopurine. Reduces serum-valproate concentrations. Reduced serum concentrations with colestyramine. Increased serum concentrations with omeprazole.
Food Interaction
May be given with meals to minimise GI discomfort. Serum levels may be decreased if taken with food. Decreased absorption in milk-rich food, decreased drug response with folate. Avoid ethanol (may be associated with increased liver injury). Avoid echinacea (has immunostimulant properties).
Action
Description: Methotrexate is a folic acid antagonist that inhibits DNA synthesis. It irreversibly binds to dihydrofolate reductase, inhibiting the formation of reduced folates, and thymidylate synthetase, resulting in inhibition of purine and thymidylic acid synthesis.
Pharmacokinetics:
Absorption: Rapidly absorbed from the GI tract at low doses, higher doses are less well absorbed. Rapidly and completely absorbed after IM doses. Peak plasma concentrations after 1-2 hr (oral), 30-60 min (IM).
Distribution: Tissues and extracellular fluids; crosses the blood-brain barrier and placenta; enters breast milk. Small amounts in saliva and breastmilk. 50% bound to plasma proteins. Bound as polyglutamate conjugates, bound drug may remain in the body for several mth, particularly in the liver .
Metabolism: Partly by intestinal flora. Does not undergo significant metabolism at low dose therapy; 7-hydroxy metabolite is detected at high-doses.
Excretion: Primarily via urine; small amounts in bile, faeces. Some evidence of enterohepatic recirculation. Interindividual variation exists, patients with delayed clearance are at an increased risk of toxicity.
Storage
Intramuscular:
Store intact vials at room temperature (15-25°C). Protect from light. Solutions diluted in D5W or normal saline are stable at room temperature (21-25°C) for 24 hr. Reconstituted solutions with a preservative may be stored under refrigeration for up to 3 mth, and up to 4 wk at room temperature.
Intrathecal:
Store intact vials at room temperature (15-25°C). Protect from light. Solutions diluted in D5W or normal saline are stable at room temperature (21-25°C) for 24 hr. Reconstituted solutions with a preservative may be stored under refrigeration for up to 3 mth, and up to 4 wk at room temperature. Dilutions are stable for 7 days at room temperature, but are recommended to be used within 4-8 hr.
Intravenous:
Store intact vials at room temperature (15-25°C). Protect from light. Solutions diluted in D5W or normal saline are stable at room temperature (21-25°C) for 24 hr. Reconstituted solutions with a preservative may be stored under refrigeration for up to 3 mth, and up to 4 wk at room temperature.
Oral:
Store tablets at room temperature (15-25°C). Protect from light.
Parenteral:
Store intact vials at room temperature (15-25°C). Protect from light. Solutions diluted in D5W or normal saline are stable at room temperature (21-25°C) for 24 hr. Reconstituted solutions with a preservative may be stored under refrigeration for up to 3 mth, and up to 4 wk at room temperature.
Disclaimer: This information is independently developed by MIMS based on Methotrexate from various references and is provided for your reference only. Therapeutic uses, prescribing information and product availability may vary between countries. Please refer to MIMS Product Monographs for specific and locally approved prescribing information. Although great effort has been made to ensure content accuracy, MIMS shall not be held responsible or liable for any claims or damages arising from the use or misuse of the information contained herein, its contents or omissions, or otherwise. Copyright © 2020 MIMS. All rights reserved. Powered by MIMS.com
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