Misinterpretation of Prescription Leading to Acute Methotrexate Toxicity: An avoidable Accident

Low-dose oral methotrexate (MTX), as used for several dermatological and rheumatological indications, is generally a safe medication. Overdose of MTX may cause acute toxicity, which results in oral mucositis, skin ulceration, and pancytopenia. A 40-year-old man presented with a 3-day history of or...

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Bibliographic Details
Main Authors: Farhana Quyum, M.A. Bashar, Mashfiqul-Hasan
Format: Article
Language:English
Published: Liaquat National Hospital and Medical College 2025-02-01
Series:Liaquat National Journal of Primary Care
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Online Access:https://journals.lnh.edu.pk/lnjpc/pdf/54167155-e211-47cb-a695-40f4edc48394.pdf
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Summary:Low-dose oral methotrexate (MTX), as used for several dermatological and rheumatological indications, is generally a safe medication. Overdose of MTX may cause acute toxicity, which results in oral mucositis, skin ulceration, and pancytopenia. A 40-year-old man presented with a 3-day history of oral mucosal ulceration along with pustular eruption, painful bullae, and skin erosion. He also had a passage of black, tarry stool for 2 days. Another patient, A 50-year-old female presented with oral mucosal ulceration and per-rectal bleeding. Both were recently started on low-dose oral MTX for seronegative arthritis. Misinterpreting the physician’s prescription, they took MTX daily instead of weekly. Their blood count revealed a variable degree of pancytopenia. They were treated with intravenous or oral Leucovorin, along with other supportive therapy. Patients started responding within a few days after treatment and were discharged after a week. Proper education of the patient regarding the dosage is fundamental for prescribing MTX and reducing the chance of developing toxicities. MTX-induced acute toxicity is a medical emergency requiring prompt and proper intervention.
ISSN:2707-3521
2708-9134