- Acute lymphoblastic leukemia
- Osteosarcoma
- Non-Hodgkin's lymphomas
- Non-malignant disorders (eg. psoriasis, rheumatoid arthritis)
THIS MEDICATION IS TO BE ADMINISTERED BY A CHEMO-TRAINED NURSE FOR ALL ONCOLOGY PATIENTS IN ORDER TO ENSURE PROTOCOL VALIDATION AND ONCOLOGY CARE MANAGEMENT. FOR NON-ONCOLOGY PATIENTS, IT CAN BE ADMINISTERED SUBCUTANEOUSLY BY ANY NURSE WHO HAS KNOWLEDGE OF PROPER CYTOTOXIC HANDLING POLICIES AND PROCEDURES. PLEASE CONTACT YOUR EDUCATOR IF YOU HAVE ANY QUESTIONS.
- Store at room temperature
- Available as a 25 mg/mL solution for IV use
- Available as a non-preserved 10 mg/mL for intrathecal injection
- Diluted solutions stable for 24 hours room temperature or 9 days refrigerated
- Intrathecal preparations expire after 8 hours due to concern for sterility
- Protect IV infusions from light. (Use brown biohazard bag; do not have to wrap buretrol or tubing.) Light sensitivity is increased by dilution and combination with sodium bicarbonate.
- Solutions Compatible: D5W, 0.9% NaCl and combinations
- Additive/Above Cassette Compatible: no information
- Y-site Compatible: allopurinol, cytarabine, dexamethasone, diphenhydramine (Benadryl), fludarabine, fluorouracil, furosemide, heparin, hydromorphone, lorazepam, methylprednisolone, metoclopramide, morphine, ondansetron, potassium chloride, ranitidine, sodium bicarbonate
Incompatible: chlorpromazine, droperidol, idarubicin, midazolam, propofol
(For approved routes of administration by nursing personnel, refer to Policy for the Administration of Intravenous Medications.)
| SC | YES |
| IM | YES, alternate limb weekly |
| IV Direct | YES, chemotherapy trained RN only Usual dilution: undiluted (25 mg/mL) into freely running IV solution Infusion time: 2 to 5 minutes |
| IV Intermittent Infusion |
Yes Usual dilution: depends on protocol (usual < 25 mg/mL); up to 500 mg/m2 may be given undiluted via syringe pump Infusion time: depends on protocol; undiluted may be given over 10-15 minutes |
| IV Continuous Infusion | YES Usual dilution: depends on protocol (usual < 25 mg/mL) |
| Intrathecal | YES, physician or Clinical Nurse Specialist in Oncology only |
(For neonatal dosages, refer to Neonatal IV Drug Manual.)
Acute Lymphoblastic Leukemia
- 1-5 g/m2 IV over 24 hours Q 3-4 weeks
- dose decreased by 50% in children with Trisomy 21
Osteosarcoma
- 12 g/m2 IV over 4 hours (Maximum dose is 20 g)
- GFR must be > 60 mL/min/1.73 m2
Intrathecal: Usually dosed according to age
- <1 year old = 6 mg IT
- <2 years old = 8 mg IT
- <3 years old = 10 mg IT
- >3 years old = 12 mg IT
- >9 years old = 15 mg IT (depending on protocol, some will have a 12 mg IT maximum dose)
- Dose must be held for ALT >20 x upper limit of normal
** Dosage may differ according to protocol
Immediate (within a few minutes to hours):
- Nausea, vomiting, (moderately low to moderately high emetogenic potential, dose dependent)
- Diarrhea and abdominal distress (especially with large doses)
- Chills, fever, dizziness
- Seizures with large doses
- Intrathecal - backache, fever, meningismus, headache, seizures
- NON-VESICANT
Intermediate (within a few days)
- Ulcerative stomatitis
- Malaise, undue fatigue
- Elevation of liver enzymes, jaundice
- Nephrotoxicity with high doses - see below
- Dermatologic and sensitivity reactions (rash, skin peeling with large doses)
- Photosensitivity
Delayed (within a few days to weeks)
- Myelosuppression, nadir: 7-13 days
- Immunosuppression
- Alopecia
- Other: allergic pneumonitis, osteoporosis, leukoencephalopathy, stroke-like encepalopathy
*Treatment for unusual side effects are available through the study chair identified on the front page of the protocol and/or pharmacy
- Methotrexate has many clinically significant drug interactions (ie. cotrimoxazole [Septra], NSAIDS, phenytoin, thiazide diuretics, warfarin, ascorbic acid [Vitamin C], omeprazole)
- Careful monitoring of patient's hematological status, liver and renal function is necessary before, during and after treatment
- Use with caution in children with a third space (ascites, effusions, edema)
For patients receiving high dose methotrexate (>1 g/m2):
- Monitor creatinine
- Alkalinize urine with PO/IV sodium bicarbonate (may be added to methotrexate infusion bag), ensure urine pH is greater than 7 for up to 48 hours post-dose
- Maintain hydration prior to, during, and after high-dose administration
- Monitor methotrexate levels after high-dose therapy beginning 24 hours after start of infusion
- For doses requiring leucovorin rescue, make sure total rescue is in stock prior to starting treatment
- Leucovorin rescue required for all doses > 300 mg/m2
- Must use non-preserved solutions for doses > 5 g/m2