Methotrexate overdose induced acute kidney injury and pancytopenia: a case report
Abstract
Introduction: Methotrexate is a folic acid antagonist. Dose of methotrexate is ranging from 7.5 mg–30 mg per week. In rheumatoid arthritis (RA), a low dose of methotrexate is used.
Case presentation: A 48-year-old female patient suffering from RA, was admitted to a tertiary care hospital. The patient was taking methotrexate 15 mg daily instead of once weekly dosing schedule mistakenly (cumulative dose of 105 mg). The patient presented with a diffuse ecchymotic rash over both extremities with oral mucositis associated with dysphagia. Upon investigation, pancytopenia (TLC= 3400 /µL, RBC= 1.85 Lac/µL, Platelets= 6000/µL) with microcytic hypochromic anemia (Hb= 4.3 g/dl) with acute kidney injury (Urea= 78 mg/dl, Creatinine= 2.26 mg/dl) was found. Elevated C-reactive protein (9.8 mg/dl) and dyslipidemia (Triglyceride= 218 mg/dl) were also evident. The case was suspected to be methotrexate toxicity and reported in the suspected Adverse Drug Reaction (ADR) form(v1.4).
Management: The patient was advised to stop methotrexate and manage with injectable folinic acid (25 mg thrice Daily for 3 days) and clotrimazole mouth paint locally (thrice daily for two weeks). ADR was assessed as Probable/Likely (WHO-UMC scale), Probable (Naranjo scale), Severe (Modified Hartwig's Severity scale), and Preventable (Schumock and Thronton scale).
Conclusion: Such case report being the first line of evidence for recognizing unexperienced ADR, should be reported for 'signal detection' to improve patient care and safety. Prescription Audit Guidelines (under National Health Mission) should be followed for drug dispensing.
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