METHOTREXATE 25 MG/ML INJECTION

Active substance: METHOTREXATE ANHYDROUS

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SUMMARY OF PRODUCT CHARACTERISTICS

1

NAME OF THE MEDICINAL PRODUCT
Methotrexate 25 mg/ml Injection.

2

QUALITATIVE AND QUANTITATIVE COMPOSITION
Each 1 ml contains methotrexate (present in solution as methotrexate sodium)
equivalent to 25 mg anhydrous methotrexate.
For excipients, see 6.1.

3

PHARMACEUTICAL FORM
Sterile solution for injection or infusion.

4

CLINICAL PARTICULARS

4.1

Therapeutic indications
Methotrexate is used for the treatment of neoplastic disease.

4.2

Posology and method of administration
Routes of administration: For intramuscular, intravenous (bolus injection or
infusion), intrathecal, and intra-arterial use.
Methotrexate should only be administered by or under the direct supervision
of a physician experienced in cytotoxic chemistry.
Adults and Children
Dosages are based on a patients bodyweight or surface area except when
administering by the intrathecal routes when a maximum dose of 15 mg is
recommended. If the patient has hepatic or renal impairment, or
haematological deficiency, then the dosage should be reduced. When giving
larger doses (more than 100 mg), the intravenous route is usually used with

infusion over a period of up to 24 hours; part of the dosage may be given as an
initial rapid intravenous infusion.
Methotrexate has been used with beneficial effects in a wide variety of
neoplastic diseases, alone and in combination with other cytotoxic agents,
hormones, radiotherapy or surgery. Dosage schedules therefore vary
considerably, depending on the clinical use, particularly when intermittent
high-dose regimens are followed by the administration of calcium folinate to
rescue normal cells from toxic effects.
Elderly
Due to diminished hepatic and renal function and decreased folate stores,
methotrexate should be used with extreme caution in elderly patients. A
reduction in dosage should be considered and these patients should be closely
monitored for early signs of toxicity.
The following are examples of dosage regimes that have been used for
particular indications.
Choriocarcinoma and other trophoblastic tumours:
Intramuscular
administration of 0.25 - 1 mg/kg to a maximum of 60 mg per dose every 48
hours (with calcium folinate rescue) for 4 doses. Repeated courses at 7 day
intervals should be given until urinary chorionic gonadotrophin levels have
returned to normal. This usually requires at least four courses of treatment. If
patients have complications such as extensive metastases, they may be treated
with combinations of other cytotoxic drugs and methotrexate. Similar doses
are used for the treatment of hydatidiform mole and chorioadenoma destruens.
Leukaemia in children: To induce remissions in acute lymphocytic leukaemia,
the use of a combination of other cytotoxic drugs and corticosteroids is
reported to be best.
Methotrexate 15 mg/m2, given parenterally or orally once weekly, in
combination with other drugs appears to be the treatment of choice for
maintenance of drug-induced remissions.
Meningeal Leukaemia in children: Doses of up to 15 mg, intrathecally, at
weekly intervals, until the CSF appears to be normal (usually 2-3 weeks) have
been found useful for the treatment of meningeal leukaemia.
Although intravenous doses of the order of 50 mg/m2 of methotrexate do not
appreciably penetrate the CSF, larger doses of the order of 500 mg/m2 or
greater do produce cytotoxic levels of methotrexate in the CSF. This type of
therapy has been used in short courses, followed by administration of calcium
folinate, as initial maintenance therapy to prevent leukaemic invasion of the

central nervous system in children with poor prognosis lymphocytic
leukaemia.
Lymphoma: Non-Hodgkin’s lymphoma, e.g. childhood lymphosarcoma, has
recently been treated with 3-30mg/kg (approximately 90-900 mg/m2) of
methotrexate given by intravenous injection and infusion followed by
administration of calcium folinate with the higher doses. Some cases of
Burkitt’s lymphoma, when treated in the early stages with courses of 15
mg/m2 daily for five days, have shown prolonged remissions.
Combination chemotherapy is also commonly used in all stages of the disease.
Breast Cancer: In advanced breast cancer, methotrexate is often given in
cyclical combinations with other cytotoxic drugs. The methotrexate is given in
intravenous doses of 10 - 60 mg/m2. Adjuvant therapy in early cases following
mastectomy and/or radiotherapy has used similar dosage regimes.
Osteogenic Sarcoma: Adjuvant therapy to primary surgical treatment of
osteosarcoma has recently included methotrexate either alone or in cyclical
combination with other drugs. Doses have been from 20 - 300 mg/kg
(approximately 600 - 9000 mg/m2) methotrexate given intravenously and
followed by calcium folinate rescue. Treatment of metastatic cases of
osteosarcoma has also employed the sole use of methotrexate.
Bladder Carcinoma: Doses of up to 100 mg of methotrexate intravenously
every one or two weeks are reported to have given encouraging results for
bladder carcinoma. The results vary from symptomatic relief to complete
regressions, although these are unsustained. It is also reported that high dosage
methotrexate with calcium folinate rescue is being evaluated.
Head and Neck Cancer: Pre-operative adjuvant therapy and the treatment of
advanced tumours have used doses of 240 - 1080 mg/m2 methotrexate, given
by intravenous infusions followed by calcium folinate rescue. Methotrexate is
also reported to have been given by intra-arterial infusions in the treatment of
head and neck cancers.
Bronchogenic Carcinoma: 20 - 100 mg/m2 methotrexate given by intravenous
infusion has been used in cyclical combinations for the treatment of advanced
tumours. High doses of methotrexate, followed by calcium folinate rescue
have also been used as the sole treatment.

4.3

Contraindications
Profound impairment of renal or hepatic function or haematological
impairment.

Alcoholism. Liver disease including alcoholic liver disease, fibrosis, cirrhosis,
recent or active hepatitis; active infectious disease; and overt or laboratory
evidence of immunodeficiency syndrome(s).
Pre-existing blood dyscrasias, such as bone marrow hypoplasia, anaemia,
leucopenia or thrombocytopenia. Methotrexate is contra-indicated in pregnant
patients. Because of the potential for serious adverse reactions from
methotrexate in breast fed infants, breast-feeding is contra-indicated in women
taking methotrexate.
Patients with a known allergic hypersensitivity to methotrexate or any of the
excipients in the formulation should not receive methotrexate.
Diluents containing preservatives must not be used for intrathecal or high dose
methotrexate therapy.

4.4

Special warnings and precautions for use
WARNINGS
Methotrexate must be used only by physicians experienced in antimetabolite
chemotherapy.
Because of the possibility of fatal or severe toxic reactions, the patient should be fully
informed by the physician of the risks involved and be under his constant supervision.
Acute or chronic interstitial pneumonitis, often associated with blood eosinophilia, may
occur and deaths have been reported.
Potentially fatal opportunistic infections, including Pneumocystis carinii pneumonia,
may occur with methotrexate therapy. When a patient presents with pulmonary
symptoms, the possibility of Pneumocystis carinii pneumonia should be considered.
Pulmonary signs and symptoms, e.g. a dry non-reproductive cough, fever, cough, chest
pain, dyspnoea, hypoxemia and an infiltrate on chest x-ray, or a non-specific
pneumonitis may also be indicative of a potentially dangerous lesion and require
interruption of treatment and careful investigation. Pulmonary lesions can occur at all
dosages. Methotrexate induced lung disease may occur acutely at any time during
therapy and has been reported at doses as low as 7.5 mg/week. It is not always fully
reversible. Infection (including pneumonia) needs to be excluded.

Patients should be monitored for pulmonary signs and symptoms at each follow up visit.
Patients should be informed of the risk of pneumonitis and advised to contact their
doctor immediately should they develop a persistent cough or dyspnoea.
Methotrexate should be withdrawn from patients with pulmonary symptoms and a
thorough investigation should be made to exclude infection. If methotrexate induced
lung disease is suspected, treatment with corticosteroids should be initiated and
treatment with methotrexate should not be restarted.
Deaths have been reported with the use of methotrexate in the treatment of malignancy,
therefore it should only be used in life threatening neoplastic diseases.
Full blood counts should be closely monitored before, during and after treatment. Any
profound drop in white-cell or platelet counts should result in immediate withdrawal of
the drug and appropriate supportive therapy (see section 4.8). Patients should be advised
to report all signs and symptoms suggestive of infection.
Methotrexate may be hepatotoxic, particularly at high dosage or with prolonged
therapy. Liver atrophy, necrosis, cirrhosis, fatty changes, and periportal fibrosis have
been reported. Since changes may occur without previous signs of gastrointestinal or
haematological toxicity, it is imperative that hepatic function be determined prior to
initiation of treatment and monitored regularly throughout therapy. If substantial
hepatic function abnormalities develop, methotrexate dosing should be suspended for
at least 2 weeks. Special caution is indicated in the presence of pre-existing liver
damage or impaired hepatic function. Concomitant use of other drugs with
hepatotoxic potential (including alcohol) should be avoided.
Methotrexate has been shown to be teratogenic; it has caused foetal death and/or
congenital anomalies. Therefore it is not recommended in women of childbearing
potential unless there is appropriate medical evidence that the benefits can be
expected to outweigh the considered risks. Pregnant psoriatic patients should not
receive methotrexate.
Renal function should be closely monitored before, during and after treatment.
Caution should be exercised if significant renal impairment is disclosed. Reduce dose
of methotrexate in patients with renal impairment. High doses may cause the
precipitation of methotrexate or its metabolites in the renal tubules. A high fluid
throughput and alkalinisation of the urine to pH 6.5 – 7.0, by oral or intravenous
administration of sodium bicarbonate (5 x 625 mg tablets every three hours) or
acetazolamide (500 mg orally four times a day) is recommended as a preventative
measure. Methotrexate is excreted primarily by the kidneys. Its use in the presence of
impaired renal function may result in accumulation of toxic amounts or even
additional renal damage.
Symptoms of gastro-intestinal toxicity, usually first manifested by diarrhoea and
ulcerative stomatitis, necessitate interruption of therapy otherwise haemorrhagic enteritis
and death from intestinal perforation may occur.

Methotrexate affects gametogenesis during the period of its administration and may
result in decreased fertility which is thought to be reversible on discontinuation of
therapy. Conception should be avoided during the period of methotrexate
administration and for at least 6 months thereafter. Patients and their partners should
be advised to this effect.
The immunological response to concurrent vaccination could be decreased, as
methotrexate has some immunosuppressive activity. A severe reaction could result from
the concomitant use of a live vaccine, and it is therefore not generally recommended.
There have been reports of disseminated vaccinia infections after smallpox
immunisation in patients receiving methotrexate therapy.
Patients with pleural effusions or ascites should have these drained if appropriate before
treatment and their plasma methotrexate levels monitored, or treatment should be
withdrawn. The reason being that methotrexate exits slowly from third party
compartments (e.g. pleural effusions, ascites). This results in a prolonged terminal halflife and unexpected toxicity.
Deaths have been reported with the use of methotrexate. Serious adverse reactions
including deaths have been reported with concomitant administration of methotrexate
(usually in high doses) along with some non-steroidal anti-inflammatory drugs
(NSAIDs).
Concomitant administration of folate antagonists such as
rimethoprim/sulphamethoxazole has been reported to cause an acute megaloblastic
pancytopenia in rare instances.
Systemic toxicity may occur following intrathecal administration. Blood counts
should be monitored closely.
A chest X-ray is recommended prior to initiation of methotrexate therapy.
If acute methotrexate toxicity occurs, patients may require folinic acid.
Folate deficiency states may increase methotrexate toxicity.
PRECAUTIONS
Methotrexate has a high potential toxicity, usually dose related, and should be used
only by physicians experienced in antimetabolite chemotherapy, in patients under
their constant supervision. The physician should be familiar with the various
characteristics of the drug and its established clinical usage.

Before beginning methotrexate therapy or reinstituting methotrexate after a rest period, a
chest x-ray, assessment of renal function, liver function and blood elements should be
made by history, physical examination and laboratory tests. Patients undergoing therapy
should be subject to appropriate supervision every 2-3 months so that signs of possible
toxic effects or adverse reactions may be detected and evaluated with minimal delay.
Renal function and full blood counts should be closely monitored before, during and
after treatment.
It should be noted that intrathecal doses are transported into the cardiovascular system
and may give rise to systemic toxicity. Systemic toxicity of methotrexate may also be
enhanced in patients with renal dysfunction, ascites or other effusions due to
prolongation of serum half-life.
Carcinogenesis, mutagenesis and impairment of fertility: Animal carcinogenicity studies
have demonstrated methotrexate to be free of carcinogenic potential. Although
methotrexate has been reported to cause chromosomal damage to animal somatic cells
and bone marrow cells in humans, these effects are transient and reversible. In patients
treated with methotrexate, evidence is insufficient to permit conclusive evaluation of any
increased risk of neoplasia. Methotrexate has been reported to cause impairment of
fertility, oligospermia, menstrual dysfunction and amenorrhoea in humans, during and
for a short period after cessation.
In addition, methotrexate causes embryotoxicity, abortion and foetal defects in humans.
Therefore, the possible risks of effects on reproduction should be discussed with patients
of child-bearing potential (see ‘warnings’).
Methotrexate can suppress haematopoiesis and cause anaemia, aplastic anaemia,
pancytopenia, leucopenia, neutropenia and/or thrombocytopenia. Haematopoietic
suppression caused by methotrexate may occur abruptly and with apparently safe
dosages. Methotrexate should be used with caution, if at all in patients with malignancy
and pre-existing haematopoietic impairment. In the treatment of neoplastic diseases,
methotrexate should be continued only if the potential benefit outweighs the risk of
severe myelosuppression.
It is essential that the following
months) in the clinical evaluation
complete haematological analysis,
chest X-ray and, when high doses
methotrexate.

laboratory tests are included regularly (every 2-3
and monitoring of patients receiving methotrexate:
urinalysis, renal function tests, liver function tests,
are administered, determination of plasma levels of

The purpose is to determine any existing organ dysfunction or system impairment.
The tests should be performed prior to therapy, at appropriate periods during therapy
and after termination of therapy.
Liver biopsy may be considered after cumulative doses>1.5 g have been given, if
hepatic impairment is suspected.

Methotrexate is bound in part to serum albumin after absorption, and toxicity may be
increased because of displacement by certain drugs such as salicylates,
sulphonamides, phenytoin, and some antibacterials such as tetracycline,
chloramphenicol and para-aminobenzoic acid. These drugs, especially salicylates and
sulphonamides, whether antibacterial, hypoglycaemic or diuretic, should not be given
concurrently until the significance of these findings is established.
Vitamin preparations containing folic acid or its derivatives may alter response to
methotrexate.
Methotrexate should be used with extreme caution in patients with the presence of
infection, haematological depression, renal impairment, peptic ulcer, ulcerative colitis,
ulcerative stomatitis, diarrhoea, debility, and also in young children and the elderly. If
profound leukopenia occurs during therapy, bacterial infection may occur or become
a threat. Cessation of the drug and appropriate antibiotic therapy is usually indicated.
In severe bone marrow depression, blood or platelet transfusions may be necessary.
Methotrexate therapy in patients with impaired renal function should be undertaken with
extreme caution, and at reduced dosages because impairment of renal function will
decrease methotrexate elimination.
Since it is reported that methotrexate may have an immunosuppressive action, this
factor must be taken into consideration in evaluating the use of the drug where
immune responses in a patient may be important or essential.
In all instances where the use of methotrexate is considered for chemotherapy, the
physician must evaluate the need and usefulness of the drug against the risks of toxic
effects or adverse reactions. Toxic effects may be related in frequency and severity to
dose or frequency of administration, but has been seen at all doses and can occur at any
time during therapy. Most adverse reactions are reversible if detected early. When such
reactions do occur, the dosage should be reduced or discontinued and appropriate
corrective measures should be taken. If methotrexate therapy is reinstituted, it should be
carried out with caution, with adequate consideration of further need for the drug, and
with increased alertness as to possible recurrence of toxicity.
Methotrexate given concomitantly with radiotherapy may increase the risk of soft tissue
necrosis and osteonecrosis.
If vomiting resulting in dehydration happens, methotrexate should be discontinued until
recovery occurs.
Like other cytotoxic drugs, methotrexate may induce “tumour lysis syndrome” in
patients with rapidly growing tumours. Appropriate supportive and pharmacologic
measures may prevent or alleviate this condition.

Severe, occasionally fatal, skin reactions such as Stevens-Johnson Syndrome, toxic
epidermal necrolysis (Lyell’s syndrome) and erythema multiforme have been reported
within days of administering single or multiple doses of methotrexate.
Acutely, liver enzyme elevations are frequently seen. These are usually transient and
asymptomatic, and do not appear predictive of subsequent hepatic disease. Persistent
liver abnormalities and/or decrease of serum albumin may be indicators of serious liver
toxicity. Liver biopsy after sustained use often shows histological changes, and fibrosis
and cirrhosis have been reported.
Malignant lymphomas may occur in patients receiving low-dose methotrexate, in which
case therapy must be discontinued. Failure of the lymphoma to show signs of
spontaneous regression requires the initiation of other cytotoxic therapy.
The use of methotrexate high-dose regimens recommended for osteosarcoma requires
meticulous care. High dosage regimens for other neoplastic diseases are investigational
and a therapeutic advantage has not been established.
Methotrexate may cause renal damage that may lead to acute renal failure. Close
attention to renal function including adequate hydration, urine alkalinisation, and
measurement of serum methotrexate and renal function are recommended.

4.5

Interaction with other medicinal products and other forms of interaction
Drugs such as salicylates, sulphonamides, tetracyclines, chloramphenicol, diuretics, paminobenzoic
acid,
acidic
anti-inflammatory drugs,
diphenylhydantoins,
hypoglycaemics may displace methotrexate, which is extensively protein bound,
increasing the potential for toxicity when given concurrently. Concomitant use of other
drugs with nephrotoxic or hepatotoxic potential (including alcohol) should generally be
avoided, unless considered clinically justified, in which case the patient should be
closely monitored.
The response to methotrexate may be altered if vitamin preparations which contain folic
acid or its derivatives are also being taken. High doses of calcium folinate may reduce
the efficacy of intrathecally administered methotrexate.
If methotrexate is given prior to or concomitantly with NSAID’s, including salicylates,
extreme caution should be exercised as there have been reports of severe methotrexate
toxicity and even death due to reduced methotrexate excretion. These drugs have been
reported to reduce the tubular secretion of methotrexate in an animal model and thereby
may enhance its toxicity. It is recommended that methotrexate dosage be carefully
controlled during treatment with NSAIDs.
However, patients using constant dosage regimens of NSAIDs have received
concurrent doses of methotrexate without problems observed.

Renal tubular transport is also diminished by probenecid, penicillins, and omeprazole,
which may result in potentially toxic methotrexate levels. The use of methotrexate with
these drugs should be carefully monitored. Haematologic and gastrointestinal toxicity
have been observed in combination with high and low dose methotrexate.
It has been reported rarely that the use of folate antagonists e.g. trimethoprim, cotrimoxazole, when given concomitantly with methotrexate may cause bone marrow
depression, acute megaloblastic pancytopenia. Methotrexate-induced stomatitis and
other toxic effects may be increased by the use of nitrous oxide. Methotrexate should
be used with caution in patients taking drugs with an anti-folate potential.
The potential for increased hepatotoxicity when methotrexate is administered with other
hepatotoxic agents has not been evaluated. However, hepatotoxicity has been reported
in such cases. Therefore, patients receiving concomitant therapy with methotrexate and
other potential hepatotoxic agents (e.g. alcohol, leflunomide, azathioprine, sulfasalazine,
retinoids) should generally be avoided, unless clinically justified, in which case the
patient should be closely monitored for possible increased risk of hepatotoxicity.
Enhancement of nephrotoxicity may be seen when high-dose methotrexate is
administered in combination with a potentially nephrotoxic chemotherapeutic agent (e.g.
cisplatin).

Existing data suggests that etretinate is formed from acitretin after ingestion of alcoholic
beverages. However, the formation of etretinate without concurrent alcohol intake
cannot be excluded. Methotrexate serum levels may be increased by etretinate (acitretin
metabolite) and severe hepatitis has been reported following concomitant use.
Consequently, the concomitant use of methotrexate and acitretin should be avoided.
Oral antibiotics, such as tetracycline, chloramphenicol, and non-absorbable
broad spectrum antibiotics, may decrease intestinal absorption of methotrexate or
interfere with the enterohepatic circulation by inhibiting bowel flora and suppressing
metabolism of methotrexate by bacteria.
Methotrexate may decrease the clearance of theophylline; theophylline levels
should be monitored when used concurrently with methotrexate.

4.6

Pregnancy and lactation

Abortion, foetal death, and/or congenital anomalies have occurred in pregnant women
receiving methotrexate, especially during the first trimester of pregnancy. Therefore it
is not recommended in women of childbearing potential unless the benefits can be
expected to outweigh the considered risks. Women of childbearing potential should not
be started on methotrexate until pregnancy is excluded. If the drug is used during
pregnancy for antineoplastic indications, or if the patient becomes pregnant while taking
this drug, the patient should be informed of the potential hazard to the foetus.
Methotrexate affects spermatogenesis and oogenesis during the period of its
administration which may result in decreased fertility.
Defective oogenesis or
spermatogenesis, transient oligospermia, menstrual dysfunction have been reported in
patients receiving methotrexate. To date, this effect appears to be reversible on
discontinuing therapy. Conception should be avoided for at least 3 months after
treatment with methotrexate has ceased. Patients receiving methotrexate and their
partners should be advised appropriately.
Methotrexate has been detected in human breast milk and is contra-indicated during
breast-feeding.

4.7

Effects on ability to drive and use machines
Not applicable.

4.8

Undesirable effects
The most common adverse reactions include ulcerative stomatitis, leucopenia, nausea
and abdominal distress. Although very rare, anaphylactic reactions to methotrexate
have occurred. Others reported are eye-irritation, malaise, undue fatigue, vasculitis,
sepsis, arthralgia/myalgia, chills and fever, dizziness, loss of libido/impotence and
decreased resistance to infection. In general, the incidence and severity of sideeffects are considered to be dose-related.
Opportunistic infections (sometimes fatal) have been reported in patients receiving
methotrexate therapy for neoplastic and non-neoplastic diseases, Pneumocystis carinii
pneumonia being the most common. Other reported infections include pneumonia,
nocardiosis, histoplasmosis, cryptococcosis, Herpes zoster, Herpes simplex hepatitis
and disseminated Herpes simplex.
Conjunctivitis and serious visual changes of unknown etiology have been reported.
Additional reactions related to or attributed to the use of methotrexate such as
osteoporosis, stress fractures, nodulosis, reversible lymphomas, tumour lysis
syndrome, abnormal (usually megaloblastic) red cell morphology, precipitation of
diabetes, other metabolic changes, anaphylactoid reactions and sudden death have
been reported.

Adverse reactions for the various systems are as follows:
Skin: Stevens-Johnson Syndrome, toxic epidermal necrolysis (Lyell’s Syndrome),
erythematous rashes, pruritus, urticaria, photosensitivity, pigmentary changes,
alopecia, ecchymosis, telangiectasia, acne, furunculosis, erythema multiforme.
Lesions of psoriasis may be aggravated by concomitant exposure to ultraviolet
radiation. Skin ulceration in psoriatic patients and rarely painful erosion of psoriatic
plaques have been reported. The recall phenomenon has been reported in both
radiation and solar damaged skin.
Blood: Bone marrow depression is a common effect of methotrexate therapy and can
occur abruptly, resulting in thrombocytopenia, anaemia or leucopenia. Infection (e.g.
pneumonia) or septicaemia and haemorrhage from various sites may result. Aplastic
anaemia, pancytopenia and neutropenia, lymphadenopathy, lymphoproliferative
disorders (including reversible) have been reported, as has hypogammaglobulinaemia.
Alimentary System: Gingivitis, pharyngitis, stomatitis, anorexia, vomiting, diarrhoea,
haematemesis, melaena, gastrointestinal ulceration and bleeding, enteritis, hepatic
toxicity resulting in active liver atrophy, necrosis, fatty metamorphosis, periportal
fibrosis, or hepatic cirrhosis. In rare cases the effect of methotrexate on the intestinal
mucosa has led to malabsorption or toxic megacolon. In rare cases the effect of
methotrexate on the intestinal mucosa has led to malabsorption or toxic megacolon.
Hepatic: Hepatic toxicity resulting in significant elevations of liver enzymes, decrease
in serum albumin, acute liver atrophy, necrosis, acute hepatitis, fatty metamorphosis,
periportal fibrosis or cirrhosis or death may occur, usually following chronic
administration.
Urogenital system: High dose methotrexate therapy may result in renal failure and
uraemia. Other reactions reported to occur include cystitis, azotemia, dysuria, severe
nephropathy, haematuria, defective oogenesis or spermatogenesis, transient
oligospermia, menstrual dysfunction, infertility, abortion, foetal defects. Vaginitis,
vaginal discharge, nephropathy and vaginal ulcers.
Pulmonary system: Acute or chronic interstitial pneumonitis, often associated with
blood eosinophilia, may occur and deaths have been reported (see Section 4.4
Warnings and Precautions for Use). After oral and intrathecal use, acute pulmonary
oedema has been reported. Pulmonary fibrosis, respiratory failure and chronic
interstitial pulmonary disease have been reported. After high doses, pleuritic pain and
pleural thickening have been reported.
Central nervous system: Observed effects include headaches, blurred vision and
drowsiness. Occasionally after low doses it is reported that short lived subtle
cognitive dysfunction, alterations in moods and unusual cranial sensations may be
observed. Higher doses occasionally result in hemiparesis, paresis, speech impairment
including dysarthria and aphasia, and convulsions. Following high intravenous doses
or low doses of methotrexate following cranial-spinal radiation, leucoencephalopathy

has been reported. Convulsion, paresis, Guillain-Barre syndrome and increased
cerebrospinal fluid pressure have followed intrathecal administration.
Other reactions related to, or attributed to the use of methotrexate such as
pneumonitis, metabolic changes, precipitation of diabetes, osteoporotic effects,
abnormal changes in tissue cells and even sudden death have been reported.
Serious neurotoxicity, frequently manifested as generalised or focal seizures has been
reported with unexpectedly increased frequency among paediatric patients with acute
lymphoblastic leukaemia who were treated with intermediate-dose intravenous
methotrexate (1gm/m2).
Symptomatic patients were commonly noted to have leucoencephalopathy and/or
microangiopathic calcifications on diagnostic imaging studies. Chronic
leucoencephalopathy has also been reported in patients who received repeated doses
of high-dose methotrexate with calcium folinate rescue even without cranial
irradiation. Discontinuation of methotrexate does not always result in complete
recovery.
A transient acute neurological syndrome has been observed in patients treated with
high dosage regimens. Manifestations of this neurological syndrome may include
behavioural abnormalities, focal sensorimotor signs, including transient blindness or
vision loss, and abnormal reflexes. The exact cause is unknown.
Cardiac: Pericarditis, pericardial effusion, hypotension, and thromboembolic events
including arterial thrombosis, cerebral thrombosis, thrombophlebitis, deep vein
thrombosis, retinal vein thrombosis and pulmonary embolus.
Adverse reactions following intrathecal methotrexate are generally classified into
three groups; acute, subacute and chronic. The acute form is a chemical arachnoiditis
manifested by headache, back or shoulder pain, nuchal rigidity, and fever. The
subacute form may include paresis, usually transient, paraparesis/paraplegia
associated with involvement with one or more spinal nerve roots, nerve palsies, and
cerebellar dysfunction. The chronic form is a leucoencephalopathy manifested by
irritability, confusion, ataxia, spasticity, occasionally convulsions, dementia,
somnolence, coma and rarely, death. This central nervous system toxicity can be
progressive. There is evidence that the combined use of cranial radiation and
intrathecal methotrexate increased the incidence of leucoencephalopathy. Signs of
neurotoxicity (meningeal irritation, transient or permanent paresis, encephalopathy)
should be monitored following intrathecal administration of methotrexate.
Additional reactions related to or attributed to the use of methotrexate such as
osteoporosis, abnormal (usually 'megaloblastic') red cell morphology, precipitation of
diabetes, other metabolic changes, and sudden death have been reported.

4.9

Overdose

In post-marketing experience, overdose with methotrexate has generally occurred
with oral and intrathecal administration, although intravenous and intramuscular
overdosage have also been reported.
Symptoms of intrathecal overdose are generally CNS symptoms, including headache,
nausea and vomiting, seizure or convulsion, and acute toxic encephalopathy. In some
cases, no symptoms were reported. There have been reports of death following
intrathecal overdose. In these cases, cerebellar herniation associated with increased
intracranial pressure, and acute toxic encephalopathy have been reported.
Calcium folinate is the antidote for neutralising the immediate toxic effects of
methotrexate on the haematopoietic system. Where large doses or overdoses are
given, calcium folinate may be administered by intravenous infusion in doses up to 75
mg within 12 hours, followed by 12 mg intramuscularly every 6 hours for 4 doses.
Where average doses of methotrexate appear to have an adverse effect 6-12 mg of
calcium folinate may be given intramuscularly every 6 hours for 4 doses. In general,
where overdosage is suspected, the dose of calcium folinate should be equal to or
higher than, the offending dose of methotrexate and should be administered as soon
as possible; preferably within the first hour and certainly within 4 hours after which it
may not be effective.
Other supporting therapy such as blood transfusion and renal dialysis may be
required. Calcium folinate administration should begin as promptly as possible. As
the time interval between methotrexate administration and calcium folinate initiation
increases, the effectiveness of calcium folinate in counteracting toxicity decreases.
Monitoring of the serum methotrexate concentration is essential in determining the
optimal dose and duration of treatment with calcium folinate.
In cases of massive overdose, hydration and urinary alkalisation may be necessary to
prevent precipitation of methotrexate and/or its metabolites in the renal tubules.
Neither haemodialysis nor peritoneal dialysis has been shown to improve
methotrexate elimination. Effective clearance of methotrexate has been reported with
acute, intermittent haemodialysis using a high flux dialyser.
Following intrathecal overdose, CSF drainage may remove up to 95% of the dose if
commenced within 15 minutes of administration, although this falls to 20% after 2
hours. For intrathecal doses over 100 mg, ventriculolumbar perfusion should
accompany CSF drainage. In addition, high dose systemic calcium folinate or
alkaline diuresis may be required.

5

PHARMACOLOGICAL PROPERTIES

5.1

Pharmacodynamic properties
ATC Code: LO1B A01 Folic acid analogues
Methotrexate, a derivative of folic acid, belongs to the class of cytotoxic
agents known as antimetabolites. It acts principally during the “S” phase of

cell division, by the competitive inhibition of the enzyme dihydrofolate
reductase, thus preventing the reduction of dihydrofolate to tetrahydrofolate, a
necessary step in the process of DNA synthesis and cellular replication.

5.2

Pharmacokinetic properties
Methotrexate distributes rapidly following a bolus intravenous injection; its
disappearance from the plasma compartment is a triphasic: t½ (alpha) = 0.250.7 hour; t½ (beta) = 2.0-3.5 hours; t½ (gamma) = 10-15 hours. The initial
plasma half-life value is often obscured because methotrexate is infused over 2
to 12 hours periods.
Methotrexate metabolites account for less than 10% of the total dose if the
drug is given intravenously at 30 mg/m2. The two major metabolites are 2,4diamino-N10-methylpteroic acid (DAMPA) and 7-hydroxy-methotrexate (7OH MTX). Both metabolites are biologically inactive. The 7-OH MT in the
kidney tubules may contribute to nephrotoxicity especially with high-dose
therapy.
Under conditions of normal renal function, drug clearance from plasma is 103
ml/min/m2. Young children are able to tolerate considerably more systemic
methotrexate, presumably because of improved renal clearance.
Methotrexate is concentrated in the liver and the bile, and can reach
bile:plasma ratios as high as 200:1. However, the actual amount of
methotrexate excreted by this route has been reported to be only 6.3% because
most biliary methotrexate is reabsorbed from the GI tract.
With intrathecal administration, the slow rate of release of methotrexate from
the CSF is rate controlling, therefore the elimination from the body is delayed,
t½ (beta) for methotrexate following intrathecal administration is 5.2-7.8
hours. The terminal elimination phase is greatly prolonged (t½ (gamma) - 5278 hours).
Methotrexate is distributed mainly in the extracellular spaces but a proportion
penetrates cell membranes and is strongly bound to dihydrofolate reductase.
About 50% is bound to plasma proteins. Bound methotrexate may be retained
in the body for many months.

5.3

Preclinical safety data
Preclinical information has not been included because the safety profile of
methotrexate has been established after many years of clinical use. Please refer
to section 4.

6

PHARMACEUTICAL PARTICULARS

6.1

List of excipients
Sodium chloride
Sodium hydroxide
Hydrochloric acid (1:20)
Water for injection.

6.2

Incompatibilities
Mixed injections should be avoided.

6.3

Shelf life
36 months.

6.4

Special precautions for storage
Store below 25ºC in the original package.

6.5

Nature and contents of container
Clear Type 1 glass ampoules in 1 ml or 2 ml sizes (in a pack of 5), or Clear
Type 1 glass vials with elastomeric closures in 2 ml, 4 ml, 8 ml, 20 ml & 40
ml sizes.
Not all pack sizes may be marketed.

6.6

Special precautions for disposal
Methotrexate may be diluted with the following infusion fluids: 0.9% sodium
chloride, glucose, sodium chloride and glucose. Solutions are stable for up to
24 hours when stored at 2 - 8°C.
Discard any unused solution.
Other drugs should not be mixed with methotrexate in the same infusion
container.

As with all cytotoxic preparations, special precautions should be taken for safe
handling and disposal and only trained personnel should prepare the drug.
Preparation should be performed in a designated area ideally in a vertical
laminar flow hood, with the work surface covered with disposable plasticbacked absorbent paper.
In the event of contact with either the eyes or skin, wash thoroughly with
water and seek medical advice. Seek immediate medical attention if the drug is
ingested, or if there is a danger of systemic absorption of significant quantities
of methotrexate, by any route, as leucovorin cover will be required.
Adequate protective clothing should be worn, such as PVC gloves, safety
glasses, disposable gowns and masks. It is recommended that luer lock fittings
are used in the assembly of syringes and giving sets to avoid leakage.
All used material, needles, syringes, vials and other items which have come
into contact with cytotoxic drugs should be incinerated. Excreta should be
similarly treated.
Pregnant staff should not be involved in the handling of cytotoxic
preparations.

7

MARKETING AUTHORISATION HOLDER
Teva UK Limited
Eastbourne
BN22 9AG

8

MARKETING AUTHORISATION NUMBER(S)
PL 00289/0466

9

DATE OF FIRST AUTHORISATION/RENEWAL OF THE
AUTHORISATION
27/05/03

10

DATE OF REVISION OF THE TEXT

25/04/2012

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Source: Medicines and Healthcare Products Regulatory Agency

Disclaimer: Every effort has been made to ensure that the information provided here is accurate, up-to-date and complete, but no guarantee is made to that effect. Drug information contained herein may be time sensitive. This information has been compiled for use by healthcare practitioners and consumers in the United States. The absence of a warning for a given drug or combination thereof in no way should be construed to indicate that the drug or combination is safe, effective or appropriate for any given patient. If you have questions about the substances you are taking, check with your doctor, nurse or pharmacist.

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