Techniques for managing methotrexate toxicity

It was recently suggested [Reactions 141: 4, 12 Apr 1986j, that patients with methotrexate (MTX) toxicity should be treated immediately with folinic acid. Various other salvage methods were attemped in 5 patients aged 7-71 years with blood methotrexate concentrations of 10 - 44 ILmoljL who had received folinic acid. Exchange transfusion was used in 1 patient only and proved to be an effective treatment. Plasma exchange was tried in patients but was not as effective as the charcoal haemoperfusion used in 3 patients nor was it as safe (sudden cardiac death occurred in 1 patient). Further, the administration of aspirin, to prevent rebound blood methotrexate levels, decreased the removal of methotrexate during plasma exchange while it had no such effect on charcoal haemoperfusion (also did not obviously prevent rebound during haemoperfusion). Haemodialysis was also of little value in decreasing blood methotrexate.

Thus, 'unless metabolic emergencies require haemodialysis, we would advise the use of charcoal haemofiltration. This technique is simple, safe, cheap and highly effective at any MTX blood level'. Bouttet E, Frappaz D. Laville M. Finaz J. Pinkerton CR. et at. Lancet 1. 1497, 28 Jun 1986

0157-7271/86/0726-0003/0$01.00/0 © ADIS Press Reactions@ 26 July 1986 3