10 Ways to Avoid Fatal Methotrexate Errors

Three recent cases of fatal reactions to low­-dose oral methotrexate due to interactions and dosing errors highlight the need to improve safety measures. Two of the cases involved patients who were taking no more than 20mg of methotrexate weekly, yet they died of severe methotrexate toxic effects due to other risk factors, including drug interactions that increased the serum concentration of methotrexate. The third event was very similar to many other methotrexate errors, with patients taking the medication daily instead of weekly, according to the October 2015 ISMP Community/ Ambulatory Care Medication Safety Alert. The events were originally reported in the Sept. 30 ISPM Canada Safety Bulletin. In 2004, ISMP published a study of methotrexate errors over a four­ year period that resulted in 25 deaths and 48 serious outcomes, many due to daily dosing. As a result, ISMP identified methotrexate as a high­ alert medication in both hospital and community settings, even when used for non­oncologic purposes such as rheumatoid arthritis. ISMP’s tips for hospital, community pharmacists and nurses to avoid methotrexate errors include these 10 tips.  

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