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Zlatal 7.5 mg solution for injection in pre-filled syringe

1 ml of solution contains 25 mg methotrexate (as methotrexate disodium).
1 pre-filled syringe of 0.3 ml contains 7.5 mg methotrexate.
Contains less than 1 mmol (23 mg) sodium per dose, i.e. essentially 'sodiumfree'.
For the full list of excipients, see section 6.1.


Solution for injection in pre-filled syringe.
Clear, yellow solution with a pH of 8.0 - 9.0 and an osmolality of
approximately 300 mOsm/kg


Therapeutic indications
Zlatal is indicated for the treatment of
-active rheumatoid arthritis in adult patients,
-polyarthritic forms of severe, active juvenile idiopathic arthritis, when the response
to nonsteroidal anti- inflammatory drugs (NSAIDs) has been inadequate,
-severe recalcitrant disabling psoriasis, which is not adequately responsive to other
forms of therapy such as phototherapy, PUVA, and retinoids, and severe psoriatic
arthritis in adult patients.

- mild to moderate Crohn's disease either alone or in combination with
corticosteroids in adult patients refractory or intolerant to thiopurines.


Posology and method of administration
Important warning with reference to the dosing of methotrexate:
Methotrexate for the therapy of rheumatic diseases or diseases of the skin must only
be used once weekly.
Faulty dosing of methotrexate may lead to serious adverse effects including fatal
course. Please read this paragraph of the SmPC very carefully.
Zlatal should only be prescribed by physicians with experience in the various
properties of the medicinal product and its mode of action. Zlatal is injected once
It must be explicitly pointed out to the patient that Zlatal is applied only once a
It is recommended to specify a certain day of the week as “day for injection”.
Dosage in adult patients with rheumatoid arthritis:
The recommended initial dose is 7.5 mg of methotrexate once weekly, administered
either subcutaneously or intramuscularly. Depending on the individual activity of the
disease and patient tolerability, the initial dose may be increased. A weekly dose of
25 mg should in general not be exceeded. However, doses exceeding 20 mg/week can
be associated with significant increase in toxicity, especially bone marrow
suppression. Response to treatment can be expected after approximately 4 – 8 weeks.
Once the desired therapeutic result has been achieved, the dose should be reduced
gradually to the lowest possible effective maintenance dose.
Dosage in children and adolescents below 16 years with polyarthritic forms of
juvenile idiopathic arthritis: The recommended dose is 10-15 mg/m² body surface
area (BSA)/week. In therapy-refractory cases the weekly dose may be increased up to
20mg/m² body surface area/week. However, an increased monitoring frequency is
indicated if the dose is increased.
Parenteral administration is limited to subcutaneous and intramuscular injection.
Patients with JIA should always be referred to a rheumatology unit specializing in the
treatment of children/adolescents.
Use in children < 3 years of age is not recommended as insufficient data on efficacy
and safety are available for this population. (see section 4.4).
Dosage in patients with psoriasis vulgaris and psoriatic arthritis:
It is recommended that a test dose of 5 - 10 mg be parenterally administered one week
prior to initiation of therapy, in order to detect idiosyncratic adverse effects. The
recommended initial dose is 7.5 mg methotrexate once weekly, administered
subcutaneously or intramuscularly. The dose is to be increased gradually but should

not, in general, exceed a weekly dose of 25 mg of methotrexate. Doses exceeding 20
mg per week can be associated with significant increase in toxicity, especially bone
marrow suppression.. Response to treatment can generally be expected after
approximately 2 – 6 weeks. Once the desired therapeutic result has been achieved,
dose should be reduced gradually to the lowest possible effective maintenance dose.
The dose should be increased as necessary but should in general not exceed the
maximum recommended weekly dose of 25 mg. In a few exceptional cases a higher
dose might be clinically justified, but should not exceed a maximum weekly dose of
30 mg of methotrexate as toxicity will markedly increase.
Dosage in adult patients with Crohn's Disease:
• Induction treatment:
25 mg/week administered either subcutaneously or intramuscularly.
Response to treatment can be expected after approximately 8 to 12 weeks.
• Maintenance treatment:
15 mg/week administered either subcutaneously or intramuscularly.
This product is not indicated for paediatric patients with Crohn’s disease (see section
Patients with renal impairment:

Methotrexate should be used with caution in patients with impaired renal function.
The dose should be adjusted as follows:

Creatinine clearance (ml/min)
> 50
20 – 50
< 20

100 %
50 %
Zlatal must not be used

Patients with hepatic impairment:
Methotrexate should be administered with great caution, if at all, to patients with
significant current or previous liver disease, especially when caused by alcohol.
Methotrexate is contraindicated if bilirubin values are >5 mg/dl (85.5 µmol/L)
For a full list of contraindications, see section 4.3.
Use in elderly patients:
Dose reduction should be considered in elderly patients due to reduced liver and
kidney function as well as lower folate reserves which occur with increased age.
Use in patient with a third distribution space (pleural effusions, ascitis):
As the half-life of Methotrexate can be prolonged to 4 times the normal length in
patients who possess a third distribution space dose reduction or, in some cases,

discontinuation of methotrexate administration may be required (see section 5.2 and
Duration and method of administration:
The medicinal product is for single use only.
Zlatal can be injected via the intramuscular or subcutaneous route.
Please also refer to section 6.6.
The overall duration of treatment is decided by the doctor.
The solution is to be visually inspected prior to use.
Only clear solutions practically free from particles should be used.
Any contact of methotrexate with skin and mucosa is to be avoided! In case of
contamination, the affected parts are to be rinsed immediately with plenty of water!
See section 6.6.
Methotrexate 25 mg/ml treatment of rheumatoid arthritis, juvenile idiopathic arthritis,
severe psoriasis vulgaris and psoriatic arthritis represents long-term treatment.
Rheumatoid arthritis
Treatment response in patients with rheumatoid arthritis can be expected after 4-8
weeks. Symptoms may return after treatment discontinuation.
Severe forms of psoriasis vulgaris and psoriatic arthritis
Response to treatment can generally be expected after 2-6 weeks. Depending on the
clinical picture and the changes of laboratory parameters, the therapy is then
continued or discontinued.
Crohn's Disease:
Response to treatment can be expected after approximately 8 to 12 weeks.
When switching from oral use to parenteral use, a reduction in the dose may be
required, due to the variable bioavailability of methotrexate after oral administration.
Folic acid or folinic acid supplementation may be considered in accordance with
current therapeutic guidelines.


Zlatal is contraindicated in:



hypersensitivity to the active substanceor to any of the excipients listed in
section 6.1,


severe hepatic impairment, if serum if bilirubin is > 5 mg/dl (85.5 µmol/l)
(see also section 4.2),


alcohol abuse,


severe renal impairment (creatinine clearance less than 20 ml/min., see also
sections 4.2 and 4.4 ),


pre-existing blood dyscrasias, such as bone marrow hypoplasia, leukopenia,
thrombocytopenia or significant anaemia,




serious, acute or chronic infections such as tuberculosis and HIV,


stomatitis, ulcers of the oral cavity and known active gastrointestinal ulcer


pregnancy, breast-feeding (see also section 4.6),


concurrent vaccination with live vaccines.

Special warnings and precautions for use
Patients must be clearly advised that the therapy is to be administered once a week,
and not every day. Incorrect intake of methotrexate can lead to severe, including
potentially lethal, side effects. Health personnel and patients should be clearly
Patients receiving therapy should be appropriately monitored, so that signs of possible
toxic effects or adverse reactions can be recognised and assessed without delay.
Hence, methotrexate should be only administered by, or under the supervision of,
doctors whose knowledge and experience include the use of antimetabolite therapy.
Due to the risk of severe or even fatal toxic reactions, the patients should be
thoroughly informed by the doctor about the risks (including early signs and
symptoms of toxicity) and recommended safety measures. They are to be informed
about the necessity to immediately consult the physician if symptoms of intoxication
occur as well as about the subsequent necessary monitoring of symptoms of
intoxication (including regular laboratory tests).
Doses exceeding 20 mg/week can be associated with significant increase in toxicity,
especially bone marrow suppression.
Methotrexate has been reported to cause impairment of fertility, oligospermia,
menstrual dysfunction and amenorrhoea in humans, during and for a short period
after cessation of therapy. In addition, methotrexate causes embryotoxicity, abortion
and foetal defects in humans. Therefore the possible risks of effects on reproduction
should be discussed with male and female patients of childbearing potential (see
section 4.6). Men treated with methotrexate are recommended not to father a child
during treatment and at least 6 months thereafter. Since treatment with methotrexate
can lead to severe and possibly irreversible disorders in spermatogenesis, men should
seek advice about the possibility of sperm preservation before starting therapy.

Skin and mucosal contacts with methotrexate are to be avoided. In the case of
contamination, the parts concerned should be rinsed with plenty of water.

Recommended examinations and safety measures
Before initiating therapy or upon resuming therapy after a rest period:
Complete blood count with differential blood count and platelets, liver enzymes,
bilirubin, serum albumin, chest X-ray and renal function tests. If clinically indicated,
exclude tuberculosis and hepatitis.
During therapy (in the first two weeks weekly, then every two weeks for the next
month; afterwards, depending on leukocyte count and stability of the patient at least
once monthly during the next six months and at least every three months thereafter):
Increased monitoring frequency should also be considered when increasing the dose.
Particularly elderly patients should be examined for early signs of toxicity in short
1. Examination of the oral cavity and throat for mucosal changes.
2. Complete blood count with differential blood count and platelets.
Haematopoietic suppression induced by methotrexate may occur abruptly and at
apparently safe doses. In the event of any significant drop in leukocytes or platelets,
treatment must be discontinued immediately and appropriate supportive therapy
instituted. Patients must be instructed to report all signs and symptoms suggestive of
infection. In patients concomitantly taking haematotoxic medications (e.g.
leflunomide), the blood count and platelets should be closely monitored.
During longer-term therapy with methotrexate bone marrow biopsies are to be
3. Liver function tests:
Particular attention should be paid to the onset of liver toxicity. Treatment should not
be initiated or should be discontinued if there are any abnormalities in liver function
tests or liver biopsies, or if these develop during therapy. Such abnormalities should
return to normal within two weeks; after which, treatment may be resumed at the
discretion of the doctor.
Temporary increases in transaminases to twice or three times of the upper limit of
normal have been reported by patients at a frequency of 13 – 20 %. Persistent
anomalies of liver-related enzymes and/or decrease in serum albumin may be
indicative for severe hepatotoxicity.
Enzyme diagnostics does not allow any reliable prediction of the development of a
morphologically detectable hepatotoxicity, i.e. even in case of normal transaminases,
hepatic fibrosis only histologically identifiable or, more rarely, also hepatocirrhosis
may be present.

In rheumatological indications, there is no evidence to support use of liver biopsies in
monitoring hepatotoxicity. For psoriasis patients the need of a liver biopsy prior to
and during therapy is controversial. Further research is needed to establish whether
serial liver chemistry tests or propeptide of type III collagen can detect hepatotoxicity
sufficiently.This assessment should differentiate between patients without any risk
factors and patients with risk factors, e.g. excessive prior alcohol consumption,
persistent elevation of liver enzymes, history of liver disease, family history of
hereditary liver disorders, diabetes mellitus, obesity and previous contact with
hepatotoxic drugs or chemicals and prolonged methotrexate treatment or cumulative
doses of 1.5 g or more.
In the event of a constant increase in liver-related enzymes, consideration should be
given to reducing the dose or discontinuing therapy.
Due to the potentially toxic effect on the liver, additional hepatotoxic medications
should not be given during treatment with methotrexate unless clearly necessary and
alcohol consumption should be avoided or greatly reduced (see section 4.5). Closer
monitoring of liver enzymes should be undertaken in patients concomitantly taking
other hepatotoxic medications (e.g. leflunomide). The same should also be taken into
consideration if haematotoxic medications are co-administered.
Increased caution should generally be exercised in patients with insulin-dependent
diabetes mellitus, as during methotrexate therapy hepatocirrhosis developed in
isolated cases without intermittent increase in transaminases.
4. Renal function should be monitored via renal function tests and urinanalysis (see
sections 4.2 and 4.3).
If serum creatinine is increased, the dose should be reduced. In serum creatinine
values above 2 mg/dl, no treatment with methotrexate should be done.
As methotrexate is predominantly excreted via the renal route, increased
concentrations can be expected in cases of renal impairment, which may result in
severe adverse reactions.
In cases of possible renal impairment (e.g. in elderly patients), closer monitoring is
required. This
particularly applies to the co-administration of medicinal products which affect
methotrexate excretion, cause kidney damage (e.g. non-steroidal anti-inflammatory
drugs) or which can
potentially lead to haematopoietic disorders. In the presence of risk factors, such as –
even borderline
– impaired renal function, concomitant administration of non-steroidal antiphlogistics
is not recommended. Dehydration may also potentiate the toxicity of methotrexate.
5. Assessment of respiratory system:
Questioning the patient with regard to possible pulmonary dysfunctions, if necessary
lung function test.

Acute or chronic interstitial pneumonitis, often associated with blood eosinophilia,
may occur and
deaths have been reported. Symptoms typically include dyspnoea, cough (especially a
dry non- productive cough), thoracic pain and fever for which patients should be
monitored at each follow-up visit. Patients should be informed of the risk of
pneumonitis and advised to contact their doctor immediately should they develop
persistent cough or dyspnoea.
Methotrexate should be withdrawn from patients with pulmonary symptoms and a
thorough investigation (including chest x-ray) should be made to exclude infection
and tumours. If methotrexate induced lung disease is suspected treatment with
corticosteroids should be initiated and treatment with methotrexate should not be
Pulmonary diseases induced by methotrexate were not always completely reversible
Pulmonary symptoms require a quick diagnosis and discontinuation of methotrexate
therapy. Pulmonary diseases induced by methotrexate, like pneumonitis, can occur
acutely at any time of therapy, were not always completely reversible and have been
reported already at all doses (inclusive low doses of 7.5 mg/week).
During methotrexate therapy, opportunistic infection can occur including
pneumocystis carinii pneumonia, which may take a lethal course. If a patient presents
with pulmonary symptoms, the possibility of pneumocystis carinii pneumonia should
be taken into account.
Special caution is required in patients with impaired pulmonary function.
Particular caution should be exercised in the presence of inactive, chronic infections
(e.g. herpes zoster, tuberculosis, hepatitis B or C), due to possible activation.
6. Methotrexate may, due to its effect on the immune system, impair the response to
vaccinations and interfere with the result of immunological tests.
Concurrent vaccination using live vaccines must not be carried out.
Malignant lymphomas may occur in patients receiving low-dose methotrexate; in
which case, methotrexate must be discontinued. If lymphomas should fail to regress
spontaneously, initiation of cytotoxic therapy is required.
In patients with pathological accumulation of liquid in body cavities (“third space”),
such as ascites or pleural effusions, the plasma elimination half-life of methotrexate is
Pleural effusions and ascites should be drained prior to initiation of methotrexate

Conditions leading to dehydration such as emesis, diarrhoea, stomatitis, can increase
the toxicity of methotrexate due to elevated agent levels. In these cases use of
methotrexate should be interrupted until the symptoms cease
It is important to identify patients with possibly elevated methotrexate levels within
48 hours after therapy, as otherwise methotrexate toxicity may be irreversible.
Diarrhoea and ulcerative stomatitis can be toxic effects and require interruption of
therapy, otherwise haemorrhagic enteritis and death from intestinal perforation may
If haematemesis, black discoloration of the stool or blood in stool occur, therapy is to
be interrupted.
Vitamin preparations or other products containing folic acid, folinic acid or their
derivatives may decrease the effectiveness of methotrexate.
Use in children < 3 years of age is not recommended as insufficient data on efficacy
and safety are available for this population. (see section 4.2).
Radiation induced dermatitis and sun-burn can reappear under methotrexate therapy
(recall- reaction). Psoriatic lesions can exacerbate during UV-irradiation and
simultaneous administration of methotrexate.
This medicinal product contains less than 1 mmol (23 mg) sodium per dose and is i.e.
The absence of pregnancy should be confirmed before Zlatal is administered.
Methotrexate causes embryotoxicity, abortion and foetal defects in humans.
Methotrexate affects spermatogenesis and oogenesis during the period of its
administration which may result in decreased fertility. These effects appear to be
reversible on discontinuing therapy. Effective contraception in men and women
should be performed during treatment and for at least six months thereafter. The
possible risks of effects on reproduction should be discussed with patients of
childbearing potential and their partners should be advised appropriately (see section

Interaction with other medicinal products and other forms of
In animal experiments non-steroidal anti-inflammatory drugs (NSAIDs)
including salicylic acid caused reduction of tubular methotrexate secretion
and consequently increased its toxic effects. However, in clinical studies,
where NSAIDs and salicylic acid were given as concomitant medication to

patients with rheumatoid arthritis, no increase of adverse reactions was
observed. Treatment of rheumatoid arthritis with such drugs can be continued
during low-dose methotrexate therapy but only under close medical
Regular alcohol consumption and administration of additional hepatotoxic
medicinal products increase the probability of hepatotoxic effects of
Patients taking potentially hepatotoxic and haematoxic medicinal products
during methotrexate therapy (e.g.
leflunomide, azathioprine, sulphasalazine, and retinoids) should be closely
monitored for possibly increased hepatotoxicity. Alcohol consumption should
be avoided during treatment with Methotrexate 25 mg/ml.
Administration of additional haematotoxic medicinal products (e.g.
metamizole) increase the probability of severe haematoxic effects of
Be aware of pharmacokinetic interactions between methotrexate,
anticonvulsant drugs (reduced methotrexate blood levels), and 5- fluorouracil
(increased t½ of 5-fluorouracil).
Salicylates, phenylbutazone, phenytoin, barbiturates, tranquillisers, oral
contraceptives, tetracyclines, amidopyrine derivatives, sulfonamides and paminobenzoic acid displace methotrexate from serum albumin binding and
thus increase bioavailability (indirect dose increase).
Probenecid and mild organic acids may also reduce tubular methotrexate
secretion, and thus cause indirect
dose elevations, too.
Antibiotics, like penicillines, glycopeptides, sulfonamides, ciprofloxacin and
cefalotin can, in individual cases, reduce the renal clearance of methotrexate,
so that increased serum concentrations of methotrexate with simultaneous
haematological and gastro-intestinal toxicity may occur.
Oral antibiotics such as tetracyclines, chloramphenicol and non-absorbable
broad-spectrum antibiotics may reduce intestinal methotrexate absorption or
interfere with the enterohepatic circulation, due to inhibition of the intestinal
flora or suppression of bacterial metabolism.
Under (pre-)treatment with substances that may have adverse effects on the
bone marrow (e.g. sulphonamides, trimethoprim-sulphamethoxazole,
chloramphenicol, pyrimethamine), the possibility of marked haematopoietic
disorders should be considered.
Co-administration of medications which cause folate deficiency (e.g.
sulphonamides, trimethoprim- sulphamethoxazole) can lead to increased
methotrexate toxicity. Particular caution should therefore also be exercised in
the presence of existing folic acid deficiency.

On the other hand, concomitant administration of folinic acid containing
drugs or of vitamin preparations, which contain folic acid or derivatives, may
impair methotrexate efficacy.
A rise in the toxicity of methotrexate is generally not anticipated when
Methotrexate 25 mg/ml is used concomitantly with other antirheumatic
agents (e.g. gold compounds, penicillamine, hydroxychloroquine,
sulfasalazine, azathioprine, cyclosporin).
Though the combination of methotrexate and sulfasalazine may enhance
methotrexate efficacy by sulfasalazine related inhibition of folic acid
synthesis, and thus may lead to an increased risk of side effects, these were
only observed in single patients within several trials.
Co-administration of proton-pump inhibitors such as omeprazole or
pantoprazole can lead to interactions:
Concomitant administration of methotrexate and omeprazole has led to a
delay in the renal elimination of methotrexate. In combination with
pantoprazole, inhibited renal elimination of the 7-hydroxymethotrexate
metabolite, with myalgia and shivering, was reported in one case.
Methotrexate may reduce theophylline clearance. Therefore, theophylline
blood levels should be monitored under concomitant methotrexate
Excessive consumption of beverages containing caffeine or theophylline
(coffee, soft drinks containing caffeine, black tea) should be avoided during
methotrexate therapy since the efficacy of methotrexate may be reduced due
to possible interaction between methotrexate and methylxanthines at
adenosine receptors.
The combined use of methotrexate and leflunomide may increase the risk for
pancytopenia. Methotrexate leads to increased plasma levels of
mercaptopurines. Therefore, the combination of these may require dose
Particularly in the case of orthopaedic surgery where susceptibility to
infection is high, a combination of methotrexate with immune-modulating
agents must be used with caution.
Anaesthetics on nitric oxide base potentiate the effect of methotrexate on the
folic acid metabolism and lead to severe unpredictable myelosuppression and
stomatitis. This can be reduced by administering calcium folinate.
Colestyramine can increase the non-renal elimination of methotrexate by
interrupting the enterohepatic circulation.

Delayed methotrexate clearance should be considered in combination with
other cytostatic agents. Radiotherapy during use of methotrexate can increase
the risk of soft tissue or bone necrosis
On account of its possible effect on the immune system, methotrexate can
falsify vaccinal and test results
(immunological procedures to record the immune reaction). During
methotrexate therapy concurrent vaccination with live vaccines must not be
carried out (see section 4.3 and 4.4).


Fertility, Pregnancy and lactation
Methotrexate 25 mg/ml is contraindicated during pregnancy (see section
4.3). In animal studies, methotrexate has shown reproductive toxicity,
especially during the first trimester (see section 5.3). Methotrexate has
been shown to have a teratogenic effect in humans; it has been reported to
cause foetal death and/or congenital abnormalities. Exposure of a limited
number of pregnant women (42) resulted in an increased incidence (1:14)
of malformations (cranial, cardiovascular and extremity-related). When
methotrexate was discontinued prior to conception, normal pregnancies
have been reported. In women of child-bearing age, any existing
pregnancy must be excluded with certainty by taking appropriate
measures, e.g. a pregnancy test, prior to initiating therapy. Women must
not get pregnant during methotrexate therapy and patients of a sexually
mature age (women and men) must use effective contraception during
treatment with Methotrexate 25 mg/ml and at least 6 months thereafter
(see section 4.4). If, nevertheless, pregnancy occurs during this period,
medical advice should be given regarding the risk of harmful effects on the
child associated with treatment.
As methotrexate can be genotoxic, all women who wish to become
pregnant are advised to consult a genetic councelling centre, if possible,
already prior to therapy, and men should seek advice about the possibility
of sperm preservation before starting therapy.
Breast - feeding:
As methotrexate passes into breast milk and may cause toxicity in nursing
infants, treatment is contraindicated during the lactation period (see section
4.3). If use during the lactation period should become necessary, breastfeeding is to be stopped prior to treatment.


Effects on ability to drive and use machines
CNS symptoms, such as fatigue and confusion, can occur during treatment.
Methotrexate 25 mg/ml has minor or moderate influence on the ability to
drive and use machines.


Undesirable effects

Occurrence and severity of undesirable effects depend on dose level and frequency of
Methotrexate 25 mg/ml administration. However, as severe adverse reactions may
occur even at lower doses, it is indispensable that the doctor monitors patients
regularly at short intervals.
Most undesirable effects are reversible if recognised early. If such adverse reactions
occur, dose should be reduced or therapy be interrupted and appropriate
countermeasures should be taken (see section 4.9). Methotrexate therapy should only
be resumed with caution, under close assessment of the necessity for treatment and
with increased alertness for possible reoccurrence of toxicity.
Frequencies in this table are defined using the following convention:
very common (≥ 1/10) common (≥ 1/100 to < 1/10), uncommon (≥ 1/1,000 to <
1/100), rare (≥ 1/10,000 to < 1/1,000), very rare (< 1/10,000), not known (cannot be
estimated from the available data).
Further details are given in the following table. Within each frequency grouping,
undesirable effects are presented in order of decreasing seriousness
The following adverse reactions may occur:

Very common




Infections and

Sepsis, infections (incl.
reactivation of inactive
chronic infection) may
be fatal in some cases


Blood and

Metabolism and

Eye disorders

Very rare/ not known



Severe courses of
bone marrow
depression, aplastic
disorders (partly
eosinophilia and
First signs for these
complications may be:
fever, sore throat,
ulcerations of oral
mucosa, flu-like
complaints, strong
exhaustion, epistaxis
and dermatorrhagia.
Use of methotrexate
should be interrupted
immediately if the
number of blood cells
significantly declines

Allergic reactions,
anaphylactic shock
Diabetes mellitus

Headache, fatigue,

Vertigo, seizures


Severe visual

Pain, muscular asthenia
or paresthesia of the
extremities, changes in
sense of taste (metallic
taste), acute aseptic
meningitis with
meningism (paralysis,
Not known:

Ear and
malignant and
(incl cysts and

Individual cases of
lymphoma, which
abated in a number
of cases once
treatment had been
discontinued. In a
recent study, it was
not possible to
establish that
therapy increases
the incidence of



thoracic and


Loss of appetite,
nausea, vomiting,
abdominal pain,
inflammation and
ulcerations of the
mucous membrane
of mouth and throat
(especially during
the first 24-48 hours
after administration
of Methotrexate 25
mg/ml). Stomatitis,

Pulmonary fibrosis Pharyngitis,
apnoea, bronchial
complications due to
reactions with
and related deaths
cough, dyspnoe
(independent of dose
and pathological
and duration of
findings in the
lung function test
treatment). Typical
symptoms may be:
general illness; dry,
irritating cough;
shortness of breath
progressing to rest
dyspnoea, chest pain,

Pneumocystis carinii
pneumonia and other
pulmonary infections,
chronic obstructive
pulmonary disease.
Pleural effusion

Diarrhoea (especially
during the first 24-48
hours after
administration of
Methotrexate 25

toxic megacolon

ulcers and



Skin and
tissue disorders

connective tissue
and bone
Renal and

Increase in liverrelated enzymes
phosphatase and

erythema, itching

Development of
liver fattening,
fibrosis and
cirrhosis (occurs
frequently despite
monitored, normal
values of liver
enzymes); drop of
serum albumin.
pigmentation of the
skin, hair loss,
increase of
rheumatic nodules,
herpes zoster,
painful lesions of
psoriatic plaque
(Psoriatic lesions
can exacerbate due
to UV radiation
during concomitant
treatment with
methotrexate (also
see section 4.4);
severe toxic
eruption of the
skin, StevensJohnson syndrome,
toxic epidermal
necrolysis (Lyell’s

Inflammation and
ulceration of the
urinary bladder
(possibly with

Acute hepatitis

Hepatic failure

changes of nails,
acne, petechiae,

acute paronychia,

Stress fracture



disorders and
site conditions

Fever, Subcutaneous
administration of
methotrexate shows
good local tolerance.
Only mild local skin
reactions, the number
of which decreased in
the course of
treatment, have been
observed so far.

intramuscular use
of methotrexate,
local adverse
reactions (burning
sensation) or
damage (sterile
formation of
destruction of
fatty tissue) can
occur at the site
of injection,
disturbed wound

Inflammation and
ulceration of the

system and
breast disorders


Loss of libido,
impotence, vaginal
discharge, infertility

The appearance and degree of severity of undesirable effects depends on the dosage
level and the frequency of administration. However, as severe undesirable effects can
occur even at lower doses, it is indispensable that patients are monitored regularly by
the doctor at short intervals.
When methotrexate is given by the intramuscular route, local undesirable effects
(burning sensation) or damage (formation of sterile abscess, destruction of fatty
tissue) at the site of injection can occur commonly. Subcutaneous application of
methotrexate is locally well tolerated. Only mild local skin reactions were observed,
decreasing during therapy.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorization of the medicinal product is
important. It allows continued monitoring of the benefit/risk balance of the medicinal
products. Healthcare professionals are asked to report any suspected adverse reactions
via the Yellow Card Scheme at:


a) Symptoms of overdose
The adverse toxic effects of methotrexate mainly affect the haematopoietic and
gastrointestinal system. Symptoms include leukocytopenia, thrombocytopenia,
anaemia, pancytopenia, neutropenia, bone marrow depression, mucositis,
stomatitis, oral ulceration, nausea, vomiting, gastrointestinal ulceration and
gastrointestinal bleeding. Some patients showed no signs of overdose.
There are reports of death due to sepsis, septic shock, renal failure and aplastic

b ) Treatment of overdose
Calcium folinate is the specific antidote for neutralising the adverse toxic effects
of methotrexate. In the event of accidental overdose, a dose of calcium folinate
equal to or higher than the offending dose of methotrexate should be administered
intravenously or intramuscularly within 1 hour, and dosing continued until serum
levels of methotrexate are below 10-7 mol/L.
In the event of a massive overdose, hydration and urinary alkalisation may be
required to prevent precipitation of methotrexate and/or its metabolites within the
renal tubules. Neither haemodialysis nor peritoneal dialysis has been shown to
improve methotrexate elimination. Effective methotrexate clearance has been
reported with acute, intermittent haemodialysis using a high-flux dialyser.
In patients with rheumatoid arthritis, polyarticular juvenile idiopathic arthritis,
psoriasis arthritis or psoriasis vulgaris, administration of folic or folinic acid may
reduce methotrexate toxicity (gastrointestinal symptoms, inflammation of oral
mucosa, hair loss and increase of liver enzymes), see section 4.5. Prior to using
folic acid products, monitoring of vitamin B12 levels is recommended, since folic
acid may mask an existing vitamin B12 deficiency, particularly in adults over 50
years of age.




Pharmacodynamic properties
Pharmacotherapeutic group: Antineoplastic and immunomodulating agents, other
immunosuppressants. ATC-code: L04AX03
Methotrexate is a folic acid antagonist which belongs to the class of cytotoxic agents
known as antimetabolites. It acts by the competitive inhibition of the enzyme
dihydrofolate reductase and thus inhibits DNA synthesis. It has not yet been clarified,
as to whether the efficacy of methotrexate, in the management of psoriasis, psoriasis
arthritis and chronic polyarthritis, is due to an anti-inflammatory or
immunosuppressive effect and to which extent a methotrexate-induced increase in
extracellular adenosine concentration at inflamed sites contributes to these effects.


Pharmacokinetic properties
After oral application, methotrexate is absorbed from the gastrointestinal tract.
When administered in low doses (7.5mg/m2 to 80mg/m2 body surface area),
methotrexate has a mean bioavailability of approximately 70%, although
considerable inter- and intra-subject variations are possible (25-100%). Plasma
peak concentrations are attained within 1-2 hours. Subcutaneous, intravenous and
intramuscular administration demonstrated similar bioavailability.


Approximately 50% of methotrexate is bound to serum proteins. Upon being
distributed into body tissues, high concentrations particularly in liver, kidneys and
spleen in form of polyglutamates can be found, which can be retained for weeks or
months. When administered in small doses, methotrexate passes into the liquor in
minimal amounts; under high doses (300mg/kg body weight), concentrations
between 4 and 7 µg/ml have been measured in the liquor. Average terminal halflife is 6-7 hours and demonstrates considerable variation (3-17 hours). Half-life
may be prolonged to 4 times the
normal length in patients with third spaces (pleural effusion, ascites).
Approximately 10% of the administered methotrexate is metabolised
intrahepatically. The major metabolite is 7-hydroxymethotrexate.
Excretion takes place, mainly in unchanged form, primarily renal via glomerular
filtration and active secretion in the proximal tubulus. Approx. 5-20% of
methotrexate and 1-5% of 7-hydroxymethotrexate are eliminated via the bile.
Pronounced enterohepatic blood flow exists.
In case of renal insufficiency, elimination is delayed significantly. Impaired
elimination in presence of hepatic insufficiency is not known.
Methotrexate passes the placental barrier in rats and monkeys.


Preclinical safety data
Chronic toxicity
Chronic toxicity studies in mice, rats and dogs showed toxic effects in the form of
gastrointestinal lesions, myelosuppression and hepatotoxicity.
Mutagenic and carcinogenic potential
Long-term studies in rats, mice and hamsters did not show any evidence of a
tumorigenic potential of methotrexate..Methotrexate induces gene and chromosome
mutations both in vitro and in vivo. A mutagenic effect is suspected in humans.
Reproductive toxicology
Teratogenic effects have been identified in four species (rats, mice, rabbits, cats). In
rhesus monkeys, no malformations comparable to humans occurred.




List of excipients
Sodium chloride
Sodium hydroxide (for pH adjustment)
Water for injections


In the absence of compatibility studies, this medicinal product must not be mixed
with other medicinal products.


Shelf life
24 months


Special precautions for storage
Store below 25°C.
Keep the syringe in the outer carton in order to protect from light.
Do not freeze.


Nature and contents of container
Nature of container:
Pre-filled syringes of colourless glass (type I) of 1 ml capacity with attached injection
needle and with a safety device to prevent needlestick injury and re-use. Plunger
stoppers of chlorobutyl rubber.
Pack sizes:
Pre-filled syringes containing 7.5 mg (in 0.3 ml), 10 mg (in 0.4 ml), 12.5 mg (in 0.5
ml), 15 mg (in 0.6 ml), 17.5 mg (in 0.7 ml), 20 mg (in 0.8 ml), 22.5 mg (in 0.9 ml)
and 25 mg (1.0 ml) methotrexate in solution for injection in packs of 1, 4, 6 and 24.
Packs of 1, 4, 6 and 24 pre-filled syringes contain 2, 8, 12 and 48 alcohol swabs,
Not all pack sizes may be marketed.


Special precautions for disposal
Handling and disposal must be consistent with that of other cytotoxic preparations in
accordance with local requirements. Pregnant health care personnel should not handle
and/or administer methotrexate 25 mg/ml.
Methotrexate should not come into contact with the skin or mucosa. In the event of
contamination, the affected area must be rinsed immediately with ample amount of
For single use only. Any unused solution should be discarded.
Any unused product or waste material should be disposed of in accordance with local
requirements for cytotoxic agents.


Nordic Group B.V.
Siriusdreef 22
2132WT Hoofddorp
The Netherlands


PL 40621/0012





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Source: Medicines and Healthcare Products Regulatory Agency

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