Group Warns of Methotrexate Overdosing Dangers

December 4, 2002

1 hour, 28 minutes ago

By Pallarito

NEW YORK (Reuters Health) - Clinicians should take special care to guard

against accidental overdoses in prescribing or administering oral

methotrexate, the Institute for Safe Medication Practices (ISMP) warned on

Tuesday.

Methotrexate is generally given in low weekly or twice-a-week doses for

treating conditions like rheumatoid arthritis, asthma and psoriasis, but is

given in much higher, daily doses for fighting cancer. Mistakes occur all

too frequently when the drug is accidentally administered daily, when weekly

dosing was intended, the ISMP observed.

The nonprofit ISMP, an independent reviewer of medication errors, issued a

special " Medication Safety Alert " after learning of two new cases of

methotrexate mix-ups in the past month, resulting in one fatality and one

permanent disability.

Over the years, ISMP has repeatedly warned about the potential for errors

with oral methotrexate. " Because of the number of fatalities...clinicians

should consider it a higher alert medication regardless of the indication, "

the group cautioned.

Recently, an 86-year-old patient who was supposed to receive 2.5 milligrams

(mg) of the hair re-growth treatment minoxidil four times a day actually

received methotrexate. In another case, a 79-year-old patient died after

receiving nine doses of 15-mg methotrexate daily instead of weekly.

" We're just very concerned...and it isn't just methotrexate, " said ISMP

President Cohen. " The docs and the pharmacists are just so used to

one tablet daily, " he said. " If they're not really focusing on what they're

doing, they do it almost automatically. "

The outcome can be tragic, particularly for elderly patients, but it's also

a mistake that is easily preventable in most cases, Cohen told Reuters

Health.

The group's Safety Alert identifies several safeguards to help reduce the

risk of methotrexate errors. For one, doctors should indicate within the

prescription the reason why the drug is being prescribed, it advises. It

also recommends building alerts into electronic prescribing systems and

pharmacy computers to check the indication and dosing frequency. Other steps

include counseling patients, providing written information on weekly dosing

and advising of the dangers of extra doses.

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