Drug Facts
Composition & Profile
Identifiers & Packaging
16 HOW SUPPLIED/STORAGE AND HANDLING XATMEP is a clear yellow to orange oral solution that contains 2.5 mg of methotrexate per milliliter (equivalent to 2.74 mg of methotrexate sodium/mL). It is packaged in a high-density polyethylene (HDPE) bottle with a child-resistant cap and tamper-evident seal. XATMEP is available in bottles of 60 mL (NDC 52652-2001-6) and 120 mL (NDC 52652-2001-1). Store XATMEP refrigerated (2°C to 8°C/36°F to 46°F) tightly closed in the original container prior to dispensing. Once dispensed, patients may store XATMEP either refrigerated (2°C to 8°C/36°F to 46°F) or at room temperature (20°C to 25°C/68°F to 77°F) with excursions permitted to 15°C to 30°C/59°F to 86°F [see USP Controlled Room Temperature]. If stored at room temperature, discard after 60 days. Avoid freezing and excessive heat.; PRINCIPAL DISPLAY PANEL - 120 mL Bottle Label NDC 52652-2001-1 Xatmep ® (methotrexate) Oral Solution 2.5 mg/mL For Oral Use Only CAUTION: Cytotoxic agent 120 mL azurity pharmaceuticals Rx Only Each 1 mL contains 2.5 mg methotrexate (equivalent to 2.74 mg methotrexate sodium). Usual Dose: See prescribing information. KEEP THIS AND ALL MEDICATIONS OUT OF THE REACH OF CHILDREN Store refrigerated 2° - 8°C (36° - 46°F) Patients may store Xatmep either refrigerated or at room temperature (20° - 25°C/68° - 77°F). If stored at room temperature, discard after 60 days. Discard on _____/_____/_____ Manufactured for: Azurity Pharmaceuticals, Inc. Wilmington, MA 01887 USA Lot: Exp: Principal Display Panel - 120 mL Bottle Label
- 16 HOW SUPPLIED/STORAGE AND HANDLING XATMEP is a clear yellow to orange oral solution that contains 2.5 mg of methotrexate per milliliter (equivalent to 2.74 mg of methotrexate sodium/mL). It is packaged in a high-density polyethylene (HDPE) bottle with a child-resistant cap and tamper-evident seal. XATMEP is available in bottles of 60 mL (NDC 52652-2001-6) and 120 mL (NDC 52652-2001-1). Store XATMEP refrigerated (2°C to 8°C/36°F to 46°F) tightly closed in the original container prior to dispensing. Once dispensed, patients may store XATMEP either refrigerated (2°C to 8°C/36°F to 46°F) or at room temperature (20°C to 25°C/68°F to 77°F) with excursions permitted to 15°C to 30°C/59°F to 86°F [see USP Controlled Room Temperature]. If stored at room temperature, discard after 60 days. Avoid freezing and excessive heat.
- PRINCIPAL DISPLAY PANEL - 120 mL Bottle Label NDC 52652-2001-1 Xatmep ® (methotrexate) Oral Solution 2.5 mg/mL For Oral Use Only CAUTION: Cytotoxic agent 120 mL azurity pharmaceuticals Rx Only Each 1 mL contains 2.5 mg methotrexate (equivalent to 2.74 mg methotrexate sodium). Usual Dose: See prescribing information. KEEP THIS AND ALL MEDICATIONS OUT OF THE REACH OF CHILDREN Store refrigerated 2° - 8°C (36° - 46°F) Patients may store Xatmep either refrigerated or at room temperature (20° - 25°C/68° - 77°F). If stored at room temperature, discard after 60 days. Discard on _____/_____/_____ Manufactured for: Azurity Pharmaceuticals, Inc. Wilmington, MA 01887 USA Lot: Exp: Principal Display Panel - 120 mL Bottle Label
Overview
XATMEP contains methotrexate, a folate analog metabolic inhibitor. Chemically methotrexate is N-[4-[[(2,4-diamino-6-pteridinyl)methyl]methylamino]-benzoyl]-L-glutamic acid. The structural formula is: XATMEP is a clear yellow to orange oral solution that contains 2.5 mg of methotrexate per milliliter (equivalent to 2.74 mg of methotrexate sodium/mL). Inactive ingredients include purified water, sodium citrate, citric acid, methylparaben sodium, propylparaben sodium, and sucralose. It may also contain sodium hydroxide or hydrochloric acid for pH adjustment. Structural Formula
Indications & Usage
XATMEP is a folate analog metabolic inhibitor indicated for the: Treatment of pediatric patients with acute lymphoblastic leukemia (ALL) as a component of a combination chemotherapy maintenance regimen ( 1.1 ). Management of pediatric patients with active polyarticular juvenile idiopathic arthritis (pJIA) who are intolerant of or had an inadequate response to first-line therapy ( 1.2 ). 1.1 Acute Lymphoblastic Leukemia XATMEP is indicated for the treatment of pediatric patients with acute lymphoblastic leukemia (ALL) as part of a multi-phase, combination chemotherapy maintenance regimen. 1.2 Polyarticular Juvenile Idiopathic Arthritis XATMEP is indicated in the management of pediatric patients with active polyarticular juvenile idiopathic arthritis (pJIA) who have had an insufficient therapeutic response to, or are intolerant of, an adequate trial of first-line therapy including full dose non-steroidal anti-inflammatory agents (NSAIDs).
Dosage & Administration
Use another formulation of methotrexate for patients requiring dosing via routes of administration other than oral ( 2.1 ). Measure with an accurate measuring device ( 2.1 ). Recommended Dosage: ALL: 20 mg/m 2 one time weekly ( 2.2 ). pJIA: Starting dose of 10 mg/m 2 one time weekly ( 2.3 ). 2.1 Important Administration Information XATMEP is intended for oral use only. Use another formulation of methotrexate for alternative dosing in patients who require dosing via other routes of administration. Instruct patients and caregivers that the recommended dose should be taken weekly, as directed, and that mistaken daily use of the recommended dose has led to fatal toxicity [see Warnings and Precautions ( 5.15 ), Overdosage ( 10 )]. It is important that XATMEP be measured with an accurate measuring device [see Warnings and Precautions ( 5.15 ), Patient Counseling Information ( 17 )] . A household teaspoon is not an accurate measuring device. A pharmacist can provide an appropriate device and can provide instructions for measuring the correct dose. 2.2 Acute Lymphoblastic Leukemia The recommended starting dose of XATMEP, in multi-agent combination chemotherapy maintenance regimens, is 20 mg/m 2 given one time weekly. After initiating XATMEP, continuation of appropriate dosing requires periodic monitoring of absolute neutrophil count (ANC) and platelet count to assure sufficient drug exposure (that is to maintain ANC at a desirable level) and to adjust for excessive hematological toxicity. 2.3 Polyarticular Juvenile Idiopathic Arthritis The recommended starting dose of XATMEP is 10 mg/m 2 given one time weekly. Dosages should be tailored to the individual patient and adjusted gradually to achieve an optimal response. Although there is experience with doses up to 30 mg/m 2 /week in pediatric patients, doses greater than 20 mg/m 2 /week may result in a significant increase in the incidence and severity of serious toxic reactions, especially bone marrow suppression. Doses between 20 and 30 mg/m 2 /week (0.65 to 1 mg/kg/week) may have better absorption and fewer gastrointestinal side effects if methotrexate is administered by an alternative route using another formulation. Therapeutic response usually begins within 3 to 6 weeks and the patient may continue to improve for another 12 weeks or more. Certain side effects such as mouth sores may be reduced by folate supplementation with methotrexate in pJIA. 2.4 Evaluations Prior to Starting Methotrexate Assess hematologic, hepatic, and renal function before beginning, as well as periodically during and before reinstituting, therapy with XATMEP [see Warnings and Precautions ( 5.1 , 5.3 , 5.5 , 5.7 , 5.14 )] . Exclude pregnancy in females of reproductive potential before starting XATMEP [see Contraindications ( 4 ), Warnings and Precautions ( 5.9 ), Use in Specific Populations ( 8.1 , 8.3 )] . 2.5 Handling Information XATMEP is a cytotoxic drug. Follow applicable special handling and disposal procedures. 1
Warnings & Precautions
Secondary malignancies can occur. In case of immunosuppression-associated lymphoma, discontinue methotrexate before starting treatment for lymphoma ( 5.8 ). Immunizations may be ineffective ( 5.10 ). Effects on reproduction: May cause impairment of fertility, oligospermia and menstrual dysfunction ( 5.11 , 8.3 ). 5.1 Bone Marrow Suppression XATMEP suppresses hematopoiesis and can cause severe and life-threatening pancytopenia, anemia, leukopenia, neutropenia, and thrombocytopenia. Obtain blood counts at baseline and periodically during treatment. Monitor patients for possible clinical complications of bone marrow suppression. Provide supportive care and modify dose or discontinue XATMEP as needed. 5.2 Serious Infections Patients treated with XATMEP are at increased risk for developing life-threatening or fatal bacterial, fungal, or viral infections including opportunistic infections such as Pneumocystis jiroveci pneumonia, invasive fungal infections, hepatitis B reactivation, tuberculosis primary infection or reactivation, and disseminated Herpes zoster and cytomegalovirus infections. Monitor patients for the signs and symptoms of infection during and after treatment with XATMEP and treat promptly. Consider dose modification or discontinuation of XATMEP in patients who develop serious infections [see Warnings and Precautions ( 5.1 )] . 5.3 Renal Toxicity and Increased Toxicity with Renal Impairment XATMEP can cause renal damage including acute renal failure. Monitor renal function to decrease the risk of renal injury and mitigate renal toxicity. Consider administration of glucarpidase in patients with toxic plasma methotrexate concentrations (> 1 micromole per liter) and delayed clearance due to impaired renal function [see glucarpidase Prescribing Information] . 5.4 Gastrointestinal Toxicity XATMEP can cause diarrhea, vomiting, stomatitis, hemorrhagic enteritis, and fatal intestinal perforation. Patients with peptic ulcer disease or ulcerative colitis are at a greater risk of developing severe gastrointestinal adverse reactions. Interrupt or discontinue XATMEP and institute appropriate supportive care as needed. Unexpectedly severe and fatal gastrointestinal toxicity can occur with concomitant administration of XATMEP (primarily at high dosage) and nonsteroidal anti-inflammatory drugs (NSAIDs) [see Drug Interactions ( 7.1 )] . 5.5 Hepatic Toxicity XATMEP can cause severe and potentially irreversible hepatotoxicity including fibrosis, cirrhosis, and fatal liver failure. Avoid use of XATMEP in patients with chronic liver disease. Assess liver function prior to initiating XATMEP and monitor liver function tests during treatment. Interrupt or discontinue XATMEP as appropriate. Transient asymptomatic acute liver enzyme elevations are common and are not predictive of subsequent hepatic disease. Persistent abnormalities in liver function tests may precede appearance of fibrosis or cirrhosis. Other risk factors for hepatotoxicity include alcoholism, obesity, diabetes, hyperlipidemia, previous significant exposure to liver toxins, history of liver disease, family history of inheritable liver disease, persistent abnormal liver chemistry findings, duration of therapy, and advanced age. 5.6 Pulmonary Toxicity Methotrexate-induced pulmonary toxicity including acute or chronic interstitial pneumonitis and irreversible or fatal cases can occur at all dose levels. Monitor patients for signs of pulmonary toxicity and interrupt or discontinue XATMEP as appropriate. 5.7 Hypersensitivity and Dermatologic Reactions Severe, including fatal, dermatologic reactions, such as toxic epidermal necrolysis, Stevens-Johnson syndrome, exfoliative dermatitis, skin necrosis, erythema multiforme, can occur with methotrexate. Discontinue XATMEP if severe dermatologic reactions occur. Anaphylaxis can occur with methotrexate. If anaphylaxis or any other serious hypersensitivity reaction occurs, immediately discontinue methotrexate and institute appropriate therapy. Methotrexate is contraindicated for use in patients with a history of severe hypersensitivity. Radiation dermatitis and sunburn may be “recalled” by the use of methotrexate. 5.8 Secondary Malignancies Secondary malignancies can occur at all dose levels of methotrexate. There have been instances of lymphoproliferative disease associated with low-dose oral methotrexate which have regressed completely following withdrawal of methotrexate without institution of antineoplastic therapy. Discontinue XATMEP first and institute appropriate treatment if the lymphoma does not regress. 5.9 Embryo-Fetal Toxicity Based on published reports and methotrexate’s mechanism of action, methotrexate can cause embryo-fetal toxicity and fetal death when administered to a pregnant woman. In pregnant women with non-malignant diseases, methotrexate is contraindicated. Consider the benefits and risks of XATMEP and risks to the fetus when prescribing XATMEP to a pregnant patient with a neoplastic disease. Advise females of reproductive potential to use effective contraception during therapy and for 6 months after the final dose. Advise males of reproductive potential to use effective contraception during and for at least 3 months after the final methotrexate dose [see Contraindications ( 4 ), Use in Specific Populations ( 8.1 , 8.3 ), Clinical Pharmacology ( 12.1 )] . 5.10 Ineffective Immunization and Risks Associated with Live Vaccines Immunization may be ineffective when given during XATMEP therapy. Immunization with live virus vaccines is not recommended. There have been reports of disseminated vaccinia infections after smallpox immunization in patients receiving methotrexate therapy. 5.11 Effects on Reproduction Based on published reports, methotrexate can cause impairment of fertility, oligospermia, and menstrual dysfunction. It is not known if the infertility is reversible in affected patients. Discuss the risk of effects on reproduction with female and male patients [see Use in Specific Populations ( 8.3 )] . 5.12 Increased Toxicity Due to Third-Space Accumulation Methotrexate can exit slowly from third‑space accumulations resulting in prolonged terminal plasma half-life and toxicity. Evacuate significant third-space accumulations prior to methotrexate administration [see Clinical Pharmacology ( 12.3 )] . 5.13 Soft Tissue and Bone Toxicity with Radiation Therapy Concomitant radiation therapy increases the risk of soft tissue necrosis and osteonecrosis associated with methotrexate. 5.14 Laboratory Tests Closely monitor patients undergoing XATMEP therapy so that toxic effects are detected promptly. In general, monitoring of the following parameters is recommended: hematology at least monthly, renal function and liver function every 1 to 2 months [see Warnings and Precautions ( 5.1 , 5.3 , 5.5 )] . Increase monitoring frequency during initial dosing, dose changes, or during periods of increased risk of elevated methotrexate blood levels (e.g., dehydration). Liver Function Tests Transient liver function test abnormalities are observed frequently after methotrexate administration and are usually not cause for modification of methotrexate therapy. Persistent liver function test abnormalities, and/or depression of serum albumin may be indicators of serious liver toxicity and require evaluation [see Warnings and Precautions ( 5.5 )] . Pulmonary Function Tests Pulmonary function tests may be useful if methotrexate-induced lung disease is suspected, especially if baseline measurements are available [see Warnings and Precautions ( 5.6 )] . 5.15 Risk of Improper Dosing Both the physician and pharmacist should emphasize to the patient that the recommended dose is taken one time weekly, as directed, and that mistaken daily use of the recommended dose has led to fatal toxicity [see Dosage and Administration ( 2.1 ), Overdosage ( 10 )] . Advise patients to measure XATMEP with an accurate milliliter measuring device. Inform patients that a household teaspoon is not an accurate measuring device and could lead to overdosage, which can result in serious adverse reactions [see Overdosage ( 10 )] . Advise patients to ask their pharmacist to recommend an appropriate measuring device and for instructions for measuring the correct dose [see Dosage and Administration ( 2.1 ), Patient Counseling Information ( 17 )] .
Boxed Warning
SEVERE TOXIC REACTIONS, INCLUDING EMBRYO-FETAL TOXICITY Methotrexate can cause the following severe or fatal adverse reactions. Monitor closely and modify dose or discontinue methotrexate as appropriate. Bone marrow suppression [see Warnings and Precautions ( 5.1 )] Serious infections [see Warnings and Precautions ( 5.2 )] Renal toxicity and increased toxicity with renal impairment [see Warnings and Precautions ( 5.3 )] Gastrointestinal toxicity [see Warnings and Precautions ( 5.4 )] Hepatic toxicity [see Warnings and Precautions ( 5.5 )] Pulmonary toxicity [see Warnings and Precautions ( 5.6 )] Hypersensitivity and dermatologic reactions [see Warnings and Precautions ( 5.7 )] Methotrexate can cause embryo-fetal toxicity, including fetal death. Use in pJIA is contraindicated in pregnancy. Consider the benefits and risks of XATMEP and risks to the fetus when prescribing XATMEP to a pregnant patient with a neoplastic disease. Advise females and males of reproductive potential to use effective contraception during and after treatment with XATMEP [see Contraindications ( 4 ), Warnings and Precautions ( 5.9 ), Use in Specific Populations ( 8.1 , 8.3 )]. WARNING: SEVERE TOXIC REACTIONS, INCLUDING EMBRYO-FETAL TOXICITY See full prescribing information for complete boxed warning. Methotrexate can cause severe or fatal toxicities. Monitor closely and modify dose or discontinue for the following toxicities: bone marrow suppression ( 5.1 ), infection ( 5.2 ), renal ( 5.3 ), gastrointestinal ( 5.4 ), hepatic ( 5.5 ), pulmonary ( 5.6 ), hypersensitivity and dermatologic ( 5.7 ). Methotrexate can cause embryo-fetal toxicity and fetal death. Use in polyarticular juvenile idiopathic arthritis is contraindicated in pregnancy ( 4 ). Consider the benefits and risks of XATMEP and risks to the fetus when prescribing XATMEP to a pregnant patient with a neoplastic disease. Advise patients to use effective contraception during and after treatment with XATMEP ( 5.9 , 8.1 , 8.3 ).
Contraindications
XATMEP is contraindicated in the following: Pregnancy in patients with non-malignant diseases. XATMEP can cause embryo-fetal toxicity and fetal death when administered during pregnancy [see Warnings and Precautions ( 5.9 ), Use in Specific Populations ( 8.1 )] . Patients with severe hypersensitivity to methotrexate [see Warnings and Precautions ( 5.7 ), Adverse Reactions ( 6.1 , 6.2 )] . Pregnancy (patients with pJIA) ( 4 ). Severe hypersensitivity to methotrexate ( 4 ).
Adverse Reactions
The following adverse reactions are discussed in more detail in other sections of the labeling. Bone Marrow Suppression [see Warnings and Precautions ( 5.1 )] Serious Infections [see Warnings and Precautions ( 5.2 )] Renal Toxicity and Increased Toxicity with Renal Impairment [see Warnings and Precautions ( 5.3 )] Gastrointestinal Toxicity [see Warnings and Precautions ( 5.4 )] Hepatic Toxicity [see Warnings and Precautions ( 5.5 )] Pulmonary Toxicity [see Warnings and Precautions ( 5.6 )] Hypersensitivity and Dermatologic Reactions [see Warnings and Precautions ( 5.7 )] Secondary Malignancies [see Warnings and Precautions ( 5.8 )] Ineffective Immunization and Risks Associated with Live Vaccines [see Warnings and Precautions ( 5.10 )] Infertility [see Warnings and Precautions ( 5.11 )] Increased Toxicity Due to Third‑Space Accumulation [see Warnings and Precautions ( 5.12 )] Soft Tissue and Bone Toxicity with Radiation Therapy [see Warnings and Precautions ( 5.13 )] Most common adverse reactions are: ulcerative stomatitis, leukopenia, nausea, abdominal distress, and elevated liver function tests. Other frequently reported adverse reactions are malaise, fatigue, chills and fever, dizziness and decreased resistance to infection ( 6 ). To report SUSPECTED ADVERSE REACTIONS, contact Azurity Pharmaceuticals, Inc., at 1-855-379-0383 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. 6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug, and may not reflect the rates observed in practice. The most frequently reported adverse reactions include ulcerative stomatitis, leukopenia, nausea, and abdominal distress. Other frequently reported adverse reactions are malaise, fatigue, chills, fever, dizziness, and decreased resistance to infection. Folate deficiency states may increase methotrexate toxicity. Polyarticular Juvenile Idiopathic Arthritis The approximate incidences of adverse reactions reported in pediatric patients with JIA treated with oral, weekly doses of methotrexate (5 to 20 mg/m 2 /week or 0.1 to 0.65 mg/kg/week) were as follows (virtually all patients were receiving concomitant nonsteroidal anti-inflammatory drugs, and some also were taking low doses of corticosteroids): elevated liver function tests, 14%; gastrointestinal reactions (e.g., nausea, vomiting, diarrhea), 11%; stomatitis, 2%; leukopenia, 2%; headache, 1.2%; alopecia, 0.5%; dizziness, 0.2%; and rash, 0.2%. Although there is experience with dosing up to 30 mg/m 2 /week in JIA, the published data for doses above 20 mg/m 2 /week are too limited to provide reliable estimates of adverse reaction rates. 6.2 Postmarketing Experience Additional adverse reactions which have been identified during postmarketing use of methotrexate are listed below by organ system. Blood and Lymphatic System Disorders: Suppressed hematopoiesis causing anemia, aplastic anemia, pancytopenia, leukopenia, neutropenia, thrombocytopenia, lymphadenopathy, lymphoproliferative disorders (including reversible), hypogammaglobulinemia Cardiovascular: Thromboembolic events (including arterial thrombosis, cerebral thrombosis, deep vein thrombosis, retinal vein thrombosis, thrombophlebitis, and pulmonary embolus), pericarditis, pericardial effusion, hypotension Eye Disorders: Optic neuropathy, transient blindness, blurred vision, ocular irritation, conjunctivitis, xerophthalmia Gastrointestinal Disorders: Gingivitis, pharyngitis, stomatitis, anorexia, nausea, vomiting, diarrhea, hematemesis, melena, gastrointestinal ulceration and bleeding, enteritis, pancreatitis Hepatobiliary Disorders: Hepatotoxicity, acute hepatitis, chronic fibrosis and cirrhosis, decreased serum albumin, liver enzyme elevations Immune System Disorders: Vasculitis, lymphomas, and anaphylactoid reactions Infections: Fatal opportunistic infections (most commonly Pneumocystis jiroveci pneumonia). There have also been reports of other infections, pneumonia, sepsis, nocardiosis, histoplasmosis, cryptococcosis, Herpes zoster , Herpes simplex hepatitis, and disseminated Herpes simplex Metabolism: Hyperglycemia and tumor lysis syndrome Musculoskeletal System: Stress fracture, soft tissue necrosis, osteonecrosis, arthralgia, myalgia, osteoporosis Nervous System Disorders: Headaches, drowsiness, blurred vision, transient blindness, speech impairment (including dysarthria and aphasia), hemiparesis, paresis and convulsions have also occurred following administration of methotrexate. Following low doses, there have been reports of transient subtle cognitive dysfunction, mood alteration, unusual cranial sensations, leukoencephalopathy, or encephalopathy. Renal Disorders: Azotemia, hematuria, proteinuria, cystitis Reproductive Disorders: Defective oogenesis or spermatogenesis, menstrual dysfunction, loss of libido, impotence, vaginal discharge, gynecomastia Respiratory Disorders: Pulmonary fibrosis, respiratory failure, chronic interstitial obstructive pulmonary disease, pleuritic pain and thickening alveolitis Skin Disorders: Erythematous rashes, pruritus, urticaria, photosensitivity, pigmentary changes, alopecia, ecchymosis, telangiectasia, acne, furunculosis, erythema multiforme, toxic epidermal necrolysis, Stevens-Johnson syndrome, skin necrosis, skin ulceration, accelerated nodulosis, and exfoliative dermatitis.
Drug Interactions
Oral Antibiotics: May increase hematologic and gastrointestinal toxicity. Monitor patients accordingly ( 7.1 ). Nitrous Oxide: May increase the risk of toxicity ( 7.1 ). NSAIDs, Aspirin, and Steroids: May elevate and prolong serum methotrexate levels and increase gastrointestinal toxicity. Monitor patients accordingly ( 7.1 ). 7.1 Effect of Other Drugs on XATMEP Oral Antibiotics Penicillins may reduce the renal clearance of methotrexate; increased serum concentrations of methotrexate with concomitant hematologic and gastrointestinal toxicity have been observed with methotrexate. Monitor patients accordingly [see Warnings and Precautions ( 5.1 , 5.4 )] . Trimethoprim/sulfamethoxazole has been reported to increase bone marrow suppression in patients receiving methotrexate. Monitor patients accordingly [see Warnings and Precautions ( 5.1 )] . Hepatotoxins The potential for increased hepatotoxicity when methotrexate is administered with other hepatotoxic agents has not been evaluated; however, hepatotoxicity has been reported in such cases. Monitor patients receiving XATMEP with other potential hepatotoxins (e.g., azathioprine, retinoids, and sulfasalazine) for possible signs of hepatotoxicity. Probenecid Probenecid may reduce renal elimination of methotrexate. Consider alternative drugs. Nitrous Oxide The use of nitrous oxide anesthesia potentiates the effect of methotrexate on folate-dependent metabolic pathways, resulting in the potential for increase toxicity. Avoid the simultaneous use of nitrous oxide and methotrexate. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs), Aspirin, and Steroids Concomitant administration of some NSAIDs with high dose methotrexate therapy has been reported to elevate and prolong serum methotrexate levels, resulting in deaths from severe hematologic and gastrointestinal toxicity. Caution should be used when NSAIDs and salicylates are administered concomitantly with lower doses of methotrexate, including XATMEP. These drugs have been reported to reduce the tubular secretion of methotrexate in an animal model and may enhance its toxicity. Despite the potential interactions, studies of methotrexate in patients with rheumatoid arthritis, including patients with polyarticular juvenile idiopathic arthritis (pJIA), have usually included concurrent use of constant dosage regimens of NSAIDs, without apparent problems. It should be appreciated, however, that the doses used in pJIA (10 mg/m 2 /week as starting dose) are somewhat lower than those used in acute lymphoblastic leukemia and that larger doses could lead to unexpected toxicity. Aspirin, NSAIDs, and/or low dose steroids may be continued, although the possibility of increased toxicity with concomitant use of NSAIDs including salicylates has not been fully explored. Steroids may be reduced gradually in patients who respond to methotrexate. 7.2 Effect of XATMEP on Other Drugs Theophylline Methotrexate may decrease the clearance of theophylline. Monitor theophylline levels when coadministered with XATMEP.
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