Pancytopenia after accidental overdose of methotrexate A complication of low‐dose therapy for rheumatoid arthritis

Brown, M A; Corrigan, A. B.

doi:10.5694/j.1326-5377.1991.tb93850.x

Cited by 29 publications

(9 citation statements)

References 10 publications

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“…6,8 Pancytopenia, which is usually transient after MTX discontinuation, occurred in 1.4%-3% of treated patients with RA. 13 Although the safety profile of MTX is generally good, several studies have shown greater toxicity in elderly patients. [13][14][15] The age of our patient was 64 years similar to many of other reported cases.…”

Section: Discussionmentioning

confidence: 99%

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Early-onset pancytopenia and skin ulcer following low-dose methotrexate therapy

et al. 2008

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Pancytopenia is a rare but serious adverse effect of low-dose methotrexate (MTX) sodium therapy, and this case report describes a very early-onset of pancytopenia and cutaneous lesions after three days of ingestion. A 64-year-old man was presented to Emergency Department with weakness, fever, poor appetite, nausea, and vomiting after he had had accidentally ingested MTX tablets (2.5 mg) twice a day for the last three days. On initial examination, several painful lesions in his oral mucosa and a cutaneous ulceration on his right foot were also observed. He had severe pancytopenia, poor kidney functions, and abnormal coagulation parameters. The blood level of MTX was found to be within therapeutic range. He was treated with leucovorine, intravenous antibiotics, and appropriate blood transfusions; he was discharged from hospital without any sequela. Pancytopenia associated with low-dose (cumulative dose of 15 mg in 3 days) MTX therapy had not been reported previously. The Naranjo probability scale showed pancytopenia and skin ulcer associated with low-dose MTX therapy as probable adverse reactions. Risk factors for pancytopenia such as renal insufficiency, hypoalbuminemia, low folate levels, concomitant infections, concomitant use of drugs, and folate supplementation were not identified in our patient. Although pancytopenia associated with low-dose MTX therapy is not expected as early as 3 days after initiation of the therapy, physicians should also be aware of this life threatening adverse effect during the very first days of MTX therapy for rheumatoid arthritis patients.

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Section: Discussionmentioning

confidence: 99%

“…13 Although the safety profile of MTX is generally good, several studies have shown greater toxicity in elderly patients. [13][14][15] The age of our patient was 64 years similar to many of other reported cases. On the contrary, other studies have shown that low-dose MTX treatment in elderly patients appears safe.…”

Section: Discussionmentioning

confidence: 99%

Early-onset pancytopenia and skin ulcer following low-dose methotrexate therapy

et al. 2008

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“…Other causes included a wrong prescription (written for daily instead of weekly), verbal miscommunication when the order was phoned into the pharmacy, and wrong instructions on the pharmacy vial dispensed to the patient . The medical literature reports additional cases involving patient misunderstanding; pill boxes filled incorrectly; patients confusing methotrexate pills with other pills that are used daily; lack of knowledge by caregivers; prescriber errors, especially among nonspecialist clinicians; transcription errors; and pharmacy labeling errors …”

Section: Discussionmentioning

confidence: 99%

Development of an algorithm to detect methotrexate wrong frequency error using computerized health care data

Herrinton

Woodworth

Eworuke

et al. 2019

Pharmacoepidemiology and Drug

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Purpose We validated an algorithm to detect frequency errors in computerized healthcare data and estimated the incidence of these errors in an integrated healthcare system. Methods We applied Sentinel System analytic tools on the electronic health records of Kaiser Permanente, Northern California, January 1, 2010, through May 30, 2015,to identify rheumatoid arthritis (RA) patients with new use of methotrexate (365‐day baseline period). We identified potential methotrexate frequency errors using ICD‐9 code 995.20 (adverse drug event), Current Procedural Terminology (CPT) code 96409 for injection of leucovorin and prescription refill patterns. We performed chart review to confirm the frequency errors, assessed performance for detecting frequency errors, and estimated the incidence of chart‐confirmed errors. Results The study included 24,529 methotrexate dispensings among 3,668 RA patients. Among these, 722 (3%) had one dispensing and 23,807 (97.1%) had ≥2 dispensings during 1‐year follow‐up period. We flagged 653 (2.7%) with a potential medication error (46 with one dispensing and 607 with ≥2 dispensings). We sampled 94 for chart review, and confirmed three methotrexate errors. All three confirmed frequency errors involved a first methotrexate dispensing followed by injected rescue therapy, leucovorin, (positive predictive value, 60%; 95% confidence interval [CI], 15‐95%). No potential errors were found among patients with ≥2 dispensings. We estimated the frequency error incidence among one methotrexate dispensing to be 0.4% (95%CI, 0.1% to 1.2%). Conclusion Rescue therapy is a specific indicator of methotrexate overdose among first methotrexate dispensings. This method is generalizable to other medications with serious adverse events treated with antidotes.

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“…In addition, some medications should not be transferred to controlled dosage systems due to the potential instability of the medication, 9 and the National Pharmaceutical Association has found that dosettes are ‘time consuming, fiddly, and expensive’ 10 . A filling error can turn a sporadic usage error into a daily one; one such error with methotrexate had a near fatal result 11 …”

Section: Introductionmentioning

confidence: 99%

“…10 A filling error can turn a sporadic usage error into a daily one; one such error with methotrexate had a near fatal result. 11 To better understand the problems associated with the use of dosettes, it was decided to identify and analyse dosette-related events among the first 12 000 incidents reported on Part B of the generic incident reporting form used in all South Australian, and some Victorian public hospitals, and by a domiciliary nursing service in South Australia. This incident form is the reporting instrument for the Australian Incident Monitoring Study (AIMS), 12 and Part B is the voluntary, anonymous component, completed at the workplace but coded at the Australian Patient Safety Foundation (APSF), using a specially developed classification for adverse events, the Generic Occurrence Classification (GOC).…”

Section: Introductionmentioning

confidence: 99%

Towards the safer use of dosettes

1999

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Patient compliance has long been recognized to be a problem associated with drug treatment. Dosettes constitute a compliance aid; their aim is to maintain patient independence, while facilitating patient compliance. However, those patients most in need of such devices are the least likely to be able to manage them. It was therefore decided to examine incidents in which problems involving dosettes had been identified; 52 such incidents were found. Half the incidents involved filling errors, and most of these involved nurses; some incidents were potentially dangerous systematic errors. A second type of incident involved a problem with use, mainly caused by hurried or confused patients; these sporadic errors were less dangerous than filling errors. The remainder of the incidents involved patients taking medication in addition to the medication in the dosette. Recommendations include objectively assessing that a dosette is appropriate for the individual patient, and education about the need for compliance, meticulous care and checking when filling, and regular checks to confirm correct use.

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Pancytopenia after accidental overdose of methotrexate A complication of low‐dose therapy for rheumatoid arthritis

Cited by 29 publications

References 10 publications

Early-onset pancytopenia and skin ulcer following low-dose methotrexate therapy

Early-onset pancytopenia and skin ulcer following low-dose methotrexate therapy

Development of an algorithm to detect methotrexate wrong frequency error using computerized health care data

Towards the safer use of dosettes

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