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Current Drug Safety

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ISSN (Print): 1574-8863
ISSN (Online): 2212-3911

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Review Article

Methotrexate-induced Severe Pancytopenia in a Patient with Rheumatoid Arthritis: A Case Report and Review of Literature

Author(s): Elham Hosseini and Foroud Shahbazi*

Volume 19, Issue 2, 2024

Published on: 12 June, 2023

Page: [224 - 235] Pages: 12

DOI: 10.2174/1574886318666230516115737

Price: $65

Abstract

Toxicity associated with low doses of methotrexate (MTX) is low, but it may be fatal. Bone marrow suppression and mucositis are among the common side effects of low dose MTX toxicity. Different risk factors have been reported for toxicities associated with low doses of MTX, including accidental use of higher doses, renal dysfunction, hypoalbuminemia, and polypharmacy. In this paper, we present a female patient who had mistakenly used 7.5 mg of MTX daily instead of the same dose of MTX on Thursday and Friday. She was presented with mucositis and diarrhea to the emergency department. Moreover, we searched the databases Scopus and PubMed for available studies and case reports on toxicities associated with MTX dosing errors. The most frequently observed toxicities included gastrointestinal lesions, nausea, vomiting, skin lesions, and bone marrow suppression. Leucovorin, hydration, and urine alkalinization were among the most frequently used treatments. Finally, we summarize the data on the toxicities of low doses of MTX in different diseases.

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[1]
Cronstein BN, Aune TM. Methotrexate and its mechanisms of action in inflammatory arthritis. Nat Rev Rheumatol 2020; 16(3): 145-54.
[http://dx.doi.org/10.1038/s41584-020-0373-9] [PMID: 32066940]
[2]
Pivovarov K, Zipursky JS. Low-dose methotrexate toxicity. CMAJ 2019; 191(15): E423.
[http://dx.doi.org/10.1503/cmaj.181054] [PMID: 30988043]
[3]
Romão VC, Lima A, Bernardes M, Canhão H, Fonseca JE. Three decades of low-dose methotrexate in rheumatoid arthritis: Can we predict toxicity? Immunol Res 2014; 60(2-3): 289-310.
[http://dx.doi.org/10.1007/s12026-014-8564-6] [PMID: 25391609]
[4]
Solomon DH, Glynn RJ, Karlson EW, et al. Adverse effects of low-dose methotrexate. Ann Intern Med 2020; 172(6): 369-80.
[http://dx.doi.org/10.7326/M19-3369] [PMID: 32066146]
[5]
Mustafa SH, Ahmad T, Balouch M, Iqbal F, Durrani T. Safety profile of methotrexate therapy in patients with rheumatoid arthritis. Cureus 2022; 14(7): e27047.
[http://dx.doi.org/10.7759/cureus.27047] [PMID: 36000142]
[6]
Vanni KMM, Lyu H, Solomon DH. Cytopenias among patients with rheumatic diseases using methotrexate: A meta-analysis of randomized controlled clinical trials. Rheumatology 2020; 59(4): 709-17.
[http://dx.doi.org/10.1093/rheumatology/kez343] [PMID: 31504937]
[7]
Common terminology criteria for adverse events (CTCAE) v50. US Department of Health and Human Services, National Institutes of Health, National Cancer Institute 2017.
[8]
Lim AYN, Gaffney K, Scott DGI. Methotrexate-induced pancytopenia: Serious and under-reported? Our experience of 25 cases in 5 years. Rheumatology 2005; 44(8): 1051-5.
[http://dx.doi.org/10.1093/rheumatology/keh685] [PMID: 15901903]
[9]
Kivity S, Zafrir Y, Loebstein R, Pauzner R, Mouallem M, Mayan H. Clinical characteristics and risk factors for low dose methotrexate toxicity: A cohort of 28 patients. Autoimmun Rev 2014; 13(11): 1109-13.
[http://dx.doi.org/10.1016/j.autrev.2014.08.027] [PMID: 25172240]
[10]
Salliot C, van der Heijde D. Long-term safety of methotrexate monotherapy in patients with rheumatoid arthritis: A systematic literature research. Ann Rheum Dis 2009; 68(7): 1100-4.
[http://dx.doi.org/10.1136/ard.2008.093690] [PMID: 19060002]
[11]
Fragoulis GE, Paterson C, Gilmour A, et al. Neutropaenia in early rheumatoid arthritis: Frequency, predicting factors, natural history and outcome. RMD Open 2018; 4(2): e000739.
[http://dx.doi.org/10.1136/rmdopen-2018-000739] [PMID: 30402267]
[12]
Nakafero G, Grainge MJ, Card T, et al. What is the incidence of methotrexate or leflunomide discontinuation related to cytopenia, liver enzyme elevation or kidney function decline? Rheumatology 2021; 60(12): 5785-94.
[http://dx.doi.org/10.1093/rheumatology/keab254] [PMID: 33725120]
[13]
Mori S, Hidaka M, Kawakita T, et al. Factors associated with myelosuppression related to low-dose methotrexate therapy for inflammatory rheumatic diseases. PLoS One 2016; 11(4): e0154744.
[http://dx.doi.org/10.1371/journal.pone.0154744] [PMID: 27128679]
[14]
Grove ML, Hassell AB, Hay EM, Shadforth MF. Adverse reactions to disease-modifying anti-rheumatic drugs in clinical practice. QJM 2001; 94(6): 309-19.
[http://dx.doi.org/10.1093/qjmed/94.6.309] [PMID: 11391029]
[15]
Gutierrez-Ureña S, Molina JF, García CO, Cuéllar ML, Espinoza LR. Pancytopenia secondary to methotrexate therapy in rheumatoid arthritis. Arthritis Rheum 1996; 39(2): 272-6.
[http://dx.doi.org/10.1002/art.1780390214] [PMID: 8849378]
[16]
Ajmani S, Preet Singh Y, Prasad S, et al. Methotrexate-induced pancytopenia: A case series of 46 patients. Int J Rheum Dis 2017; 20(7): 846-51.
[http://dx.doi.org/10.1111/1756-185X.13004] [PMID: 28261918]
[17]
Cansu DÜ, Teke HÜ, Bodakçi E, Korkmaz C. How should we manage low-dose methotrexate-induced pancytopenia in patients with rheumatoid arthritis? Clin Rheumatol 2018; 37(12): 3419-25.
[http://dx.doi.org/10.1007/s10067-018-4242-8] [PMID: 30056523]
[18]
Moore TJ, Walsh CS, Cohen MR. Reported medication errors associated with methotrexate. Am J Health Syst Pharm 2004; 61(13): 1380-4.
[http://dx.doi.org/10.1093/ajhp/61.13.1380] [PMID: 15287234]
[19]
Vial T, Patat AM, Boels D, et al. Adverse consequences of low-dose methotrexate medication errors: data from French poison control and pharmacovigilance centers. Joint Bone Spine 2019; 86(3): 351-5.
[http://dx.doi.org/10.1016/j.jbspin.2018.09.006] [PMID: 30243781]
[20]
Thompson JA, Love JS, Hendrickson RG. Methotrexate toxicity from unintentional dosing errors: Calls to a poison center and death descriptions. J Am Board Fam Med 2021; 34(6): 1246-8.
[http://dx.doi.org/10.3122/jabfm.2021.06.210120] [PMID: 34772781]
[21]
Moisa A, Fritz P, Benz D, Wehner HD. Iatrogenically-related, fatal methotrexate intoxication: A series of four cases. Forensic Sci Int 2006; 156(2-3): 154-7.
[http://dx.doi.org/10.1016/j.forsciint.2004.12.031] [PMID: 16343832]
[22]
Lee JS, Oh JS, Kim YG, Lee CK, Yoo B, Hong S. Methotrexate-related toxicity in patients with rheumatoid arthritis and renal dysfunction. Rheumatol Int 2020; 40(5): 765-70.
[http://dx.doi.org/10.1007/s00296-020-04547-y] [PMID: 32170389]
[23]
Cairns R, Brown JA, Lynch AM, Robinson J, Wylie C, Buckley NA. A decade of Australian methotrexate dosing errors. Med J Aust 2016; 204(10): 384.
[http://dx.doi.org/10.5694/mja15.01242] [PMID: 27256650]
[24]
Shea B, Swinden MV, Ghogomu ET, et al. Folic acid and folinic acid for reducing side effects in patients receiving methotrexate for rheumatoid arthritis. J Rheumatol 2014; 41(6): 1049-60.
[http://dx.doi.org/10.3899/jrheum.130738] [PMID: 24737913]
[25]
Prey S, Paul C. Effect of folic or folinic acid supplementation on methotrexate-associated safety and efficacy in inflammatory disease: a systematic review. Br J Dermatol 2009; 160(3): 622-8.
[http://dx.doi.org/10.1111/j.1365-2133.2008.08876.x] [PMID: 18945303]
[26]
Kalb RE, Strober B, Weinstein G, Lebwohl M. Methotrexate and psoriasis: 2009 National Psoriasis Foundation Consensus Conference. J Am Acad Dermatol 2009; 60(5): 824-37.
[http://dx.doi.org/10.1016/j.jaad.2008.11.906] [PMID: 19389524]
[27]
Hall JJ, Bolina M, Chatterley T, Jamali F. Interaction between low-dose methotrexate and nonsteroidal anti-inflammatory drugs, penicillins, and proton pump inhibitors. Ann Pharmacother 2017; 51(2): 163-78.
[http://dx.doi.org/10.1177/1060028016672035] [PMID: 27701081]
[28]
Narumi K, Sato Y, Kobayashi M, et al. Effects of proton pump inhibitors and famotidine on elimination of plasma methotrexate: Evaluation of drug-drug interactions mediated by organic anion transporter 3. Biopharm Drug Dispos 2017; 38(9): 501-8.
[http://dx.doi.org/10.1002/bdd.2091] [PMID: 28801980]
[29]
Wang X, Song Y, Wang J, et al. Effect of proton pump inhibitors on high-dose methotrexate elimination: A systematic review and meta-analysis. Int J Clin Pharm 2020; 42(1): 23-30.
[http://dx.doi.org/10.1007/s11096-019-00958-5] [PMID: 31916121]
[30]
Suzuki K, Doki K, Homma M, et al. Co-administration of proton pump inhibitors delays elimination of plasma methotrexate in high-dose methotrexate therapy. Br J Clin Pharmacol 2009; 67(1): 44-9.
[http://dx.doi.org/10.1111/j.1365-2125.2008.03303.x] [PMID: 19076159]
[31]
Boerrigter E, Crul M. A non-interventional retrospective cohort study of the interaction between methotrexate and proton pump inhibitors or aspirin. Ann Pharm Fr 2017; 75(5): 344-8.
[http://dx.doi.org/10.1016/j.pharma.2017.06.002] [PMID: 28705331]
[32]
Ranchon F, Vantard N, Henin E, et al. Delayed methotrexate elimination: Incidence, interaction with antacid drugs, and clinical consequences? Hematol Oncol 2018; 36(2): 399-406.
[http://dx.doi.org/10.1002/hon.2479] [PMID: 28983943]
[33]
Reeves DJ, Moore ES, Bascom D, Rensing B. Retrospective evaluation of methotrexate elimination when co-administered with proton pump inhibitors. Br J Clin Pharmacol 2014; 78(3): 565-71.
[http://dx.doi.org/10.1111/bcp.12384] [PMID: 24646036]
[34]
Vakily M, Amer F, Kukulka MJ, Andhivarothai N. Coadministration of lansoprazole and naproxen does not affect the pharmacokinetic profile of methotrexate in adult patients with rheumatoid arthritis. J Clin Pharmacol 2005; 45(10): 1179-86.
[http://dx.doi.org/10.1177/0091270005280100] [PMID: 16172183]
[35]
Karim A, Tolbert DS, Hunt TL, Hubbard RC, Harper KM, Geis GS. Celecoxib, a specific COX-2 inhibitor, has no significant effect on methotrexate pharmacokinetics in patients with rheumatoid arthritis. J Rheumatol 1999; 26(12): 2539-43.
[PMID: 10606360]
[36]
Pflugbeil S, Böckl K, Pongratz R, Leitner M, Graninger W, Ortner A. Drug interactions in the treatment of rheumatoid arthritis and psoriatic arthritis. Rheumatol Int 2020; 40(4): 511-21.
[http://dx.doi.org/10.1007/s00296-020-04526-3] [PMID: 32052146]
[37]
Kwon OC, Lee JS, Kim YG, Lee CK, Yoo B, Hong S. Safety of the concomitant use of methotrexate and a prophylactic dose of trimethoprim-sulfamethoxazole. Clin Rheumatol 2018; 37(12): 3215-20.
[http://dx.doi.org/10.1007/s10067-018-4005-6] [PMID: 29383453]
[38]
Watts CS, Sciasci JN, Pauley JL, et al. Prophylactic trimethoprim-sulfamethoxazole does not affect pharmacokinetics or pharmacodynamics of methotrexate. J Pediatr Hematol Oncol 2016; 38(6): 449-52.
[http://dx.doi.org/10.1097/MPH.0000000000000606] [PMID: 27322715]
[39]
Sosin M, Handa S. Lesson of the week: Low dose methotrexate and bone marrow suppression. BMJ 2003; 326(7383): 266-7.
[http://dx.doi.org/10.1136/bmj.326.7383.266] [PMID: 12560282]
[40]
Cudmore J, Seftel M, Sisler J, Zarychanski R. Methotrexate and trimethoprim-sulfamethoxazole: Toxicity from this combination continues to occur. Can Fam Physician 2014; 60(1): 53-6.
[PMID: 24452563]
[41]
Hamid M, Lashari B, Ahsan I, Micaily I, Sarwar U, Crocetti J. A deadly prescription: Combination of methotrexate and trimethoprim-sulfamethoxazole. J Community Hosp Intern Med Perspect 2018; 8(3): 149-51.
[http://dx.doi.org/10.1080/20009666.2018.1466598] [PMID: 29915656]
[42]
Carretero G, Puig L, Dehesa L, et al. Guidelines on the use of methotrexate in psoriasis. Actas DermoSifiliogrEnglish Edition 2010; 101(7): 600-13.
[http://dx.doi.org/10.1016/S1578-2190(10)70682-X] [PMID: 28709542]
[43]
Bourré-Tessier J, Haraoui B. Methotrexate drug interactions in the treatment of rheumatoid arthritis: A systematic review. J Rheumatol 2010; 37(7): 1416-21.
[http://dx.doi.org/10.3899/jrheum.090153] [PMID: 20436072]
[44]
Colebatch AN, Marks JL. van der HEIJDE DM, Edwards CJ. Safety of nonsteroidal antiinflammatory drugs and/or paracetamol in people receiving methotrexate for inflammatory arthritis: A Cochrane systematic review. J Rheumatol Suppl 2012; 90(0): 62-73.
[http://dx.doi.org/10.3899/jrheum.120345] [PMID: 22942332]
[45]
Angelis-Stoforidis P, Vajda FJ, Christophidis N. Methotrexate polyglutamate levels in circulating erythrocytes and polymorphs correlate with clinical efficacy in rheumatoid arthritis. Clin Exp Rheumatol 1999; 17(3): 313-20.
[PMID: 10410264]
[46]
Dervieux T, Greenstein N, Kremer J. Pharmacogenomic and metabolic biomarkers in the folate pathway and their association with methotrexate effects during dosage escalation in rheumatoid arthritis. Arthritis Rheum 2006; 54(10): 3095-103.
[http://dx.doi.org/10.1002/art.22129] [PMID: 17009228]
[47]
Stamp LK, O’Donnell JL, Chapman PT, et al. Methotrexate polyglutamate concentrations are not associated with disease control in rheumatoid arthritis patients receiving long-term methotrexate therapy. Arthritis Rheum 2010; 62(2): 359-68.
[http://dx.doi.org/10.1002/art.27201] [PMID: 20112376]
[48]
Mohamed HJ, Sorich MJ, Kowalski SM, et al. The role and utility of measuring red blood cell methotrexate polyglutamate concentrations in inflammatory arthropathies-a systematic review. Eur J Clin Pharmacol 2015; 71(4): 411-23.
[http://dx.doi.org/10.1007/s00228-015-1819-x] [PMID: 25687918]
[49]
Ahmadzadeh A, Zamani N, Hassanian-Moghaddam H, Hadeiy SK, Parhizgar P. Acute versus chronic methotrexate poisoning; A cross-sectional study. BMC Pharmacol Toxicol 2019; 20(1): 39.
[http://dx.doi.org/10.1186/s40360-019-0316-8] [PMID: 31269977]
[50]
Kitchlu A, Shirali AC. High-flux hemodialysis versus glucarpidase for methotrexate-associated acute kidney injury: What’s best? J Onco Nephrol 2019; 3(1): 11-8.
[http://dx.doi.org/10.1177/2399369319827305]
[51]
Conway R, Low C, Coughlan RJ, O’Donnell MJ, Carey JJ. Methotrexate use and risk of lung disease in psoriasis, psoriatic arthritis, and inflammatory bowel disease: Systematic literature review and meta-analysis of randomised controlled trials. BMJ 2015; 350(mar13 17): h1269.
[http://dx.doi.org/ 10.1136/bmj.h1269] [PMID: 25770113]
[52]
Raghavendra S, Khurrana T, Malhotra AK. Yet another case of acute methotrexate toxicity due to accidental overdose. J Assoc Physicians India 2020; 68(1): 69.
[PMID: 31979693]
[53]
Jariwala P, Kumar V, Kothari K, Thakkar S, Umrigar DD. Acute methotrexate toxicity: A fatal condition in two cases of psoriasis. Case Rep Dermatol Med 2014; 2014: 1-3.
[http://dx.doi.org/10.1155/2014/946716] [PMID: 25276442]
[54]
Asghar M, Shoaib H, Kang W, Tariq I, Chatterjee T. Methotrexate toxicity: A simple solution to a complex problem. Cureus 2021; 13(4): e14364.
[http://dx.doi.org/10.7759/cureus.14364] [PMID: 33972915]
[55]
Bidaki R, Kian M, Owliaey H, Babaei Zarch M, Feysal M. Accidental chronic poisoning with methotrexate; report of two cases. Emergency 2017; 5(1): e67.
[PMID: 28894782]
[56]
Kumar RR, Makar N, Singh V, Goyal S, Chhabra R. A iatrogenic accidental overdose of methotrexate. J Clin Rheumatol 2021; 27(6): e248.
[http://dx.doi.org/10.1097/RHU.0000000000001753] [PMID: 34054071]
[57]
Arnet I, Bernhardt V, Hersberger KE. Methotrexate intoxication: The Pharmaceutical Care process reveals a critical error. J Clin Pharm Ther 2012; 37(2): 242-4.
[http://dx.doi.org/10.1111/j.1365-2710.2011.01263.x] [PMID: 21463347]
[58]
Singh A, Handa AC. Medication error: A case report of misadventure with methotrexate. JNMA J Nepal Med Assoc 2018; 56(211): 711-5.
[http://dx.doi.org/10.31729/jnma.3538] [PMID: 30381772]
[59]
Srinivasa BM, Padmini S, Kumar P, et al. A case report on methotrexate overdose induced pancytopenia and mucocutaneous ulcerations. Indian J Phar Pract 2020; 13(4): 359-61.
[http://dx.doi.org/10.5530/ijopp.13.4.61]
[60]
Widemann BC, Adamson PC. Understanding and managing methotrexate nephrotoxicity. Oncologist 2006; 11(6): 694-703.
[http://dx.doi.org/10.1634/theoncologist.11-6-694] [PMID: 16794248]
[61]
Widemann BC, Schwartz S, Jayaprakash N, et al. Efficacy of glucarpidase (carboxypeptidase g2) in patients with acute kidney injury after high-dose methotrexate therapy. Pharmacotherapy 2014; 34(5): 427-39.
[http://dx.doi.org/10.1002/phar.1360] [PMID: 24132809]
[62]
Proudfoot AT, Krenzelok EP, Vale JA. Position paper on urine alkalinization. J Toxicol Clin Toxicol 2004; 42(1): 1-26.
[http://dx.doi.org/10.1081/CLT-120028740] [PMID: 15083932]
[63]
Bleyer WA. The clinical pharmacology of methotrexate.new applications of an old drug. Cancer 1978; 41(1): 36-51.
[http://dx.doi.org/10.1002/1097-0142(197801)41:1<36:AID-CNCR2820410108>3.0.CO;2-I] [PMID: 342086]
[64]
Buchen S, Ngampolo D, Melton RG, et al. Carboxypeptidase G2 rescue in patients with methotrexate intoxication and renal failure. Br J Cancer 2005; 92(3): 480-7.
[http://dx.doi.org/10.1038/sj.bjc.6602337] [PMID: 15668713]
[65]
Perazella MA, Moeckel GW. Nephrotoxicity from chemotherapeutic agents: Clinical manifestations, pathobiology, and prevention/therapy. Semin Nephrol 2010; 30(6): 570-81.
[http://dx.doi.org/10.1016/j.semnephrol.2010.09.005] [PMID: 21146122]
[66]
Relling MV, Fairclough D, Ayers D, et al. Patient characteristics associated with high-risk methotrexate concentrations and toxicity. J Clin Oncol 1994; 12(8): 1667-72.
[http://dx.doi.org/10.1200/JCO.1994.12.8.1667] [PMID: 8040679]
[67]
Shamash J, Earl H, Souhami R. Acetazolamide for alkalinisation of urine in patients receiving high-dose methotrexate. Cancer Chemother Pharmacol 1991; 28(2): 150-1.
[http://dx.doi.org/10.1007/BF00689708] [PMID: 2060085]
[68]
Ackland SP, Schilsky RL. High-dose methotrexate: A critical reappraisal. J Clin Oncol 1987; 5(12): 2017-31.
[http://dx.doi.org/10.1200/JCO.1987.5.12.2017] [PMID: 3316519]
[69]
Fabre I, Fabre G, Goldman ID. Polyglutamylation, an important element in methotrexate cytotoxicity and selectivity in tumor versus murine granulocytic progenitor cells in vitro. Cancer Res 1984; 44(8): 3190-5.
[PMID: 6204743]
[70]
Bookstaver PB, Norris L, Rudisill C, DeWitt T, Aziz S, Fant J. Multiple toxic effects of low-dose methotrexate in a patient treated for psoriasis. Am J Health Syst Pharm 2008; 65(22): 2117-21.
[http://dx.doi.org/10.2146/ajhp070676] [PMID: 18997139]
[71]
Pathirana D, Ormerod AD, Saiag P, et al. European S3-guidelines on the systemic treatment of psoriasis vulgaris. J Eur Acad Dermatol Venereol 2009; 23(S2): 1-70.
[http://dx.doi.org/10.1111/j.1468-3083.2009.03389.x] [PMID: 19712190]
[72]
Ouellette S, Shah R, Razi S, Ashforth G, Wassef C. Fatal low‐dose methotrexate toxicity: A case report and literature review. Dermatol Ther 2022; 35(12): e15945.
[http://dx.doi.org/10.1111/dth.15945] [PMID: 36259229]
[73]
Mitsuboshi S. Risk of haematological events and preventive effect of folic acid in methotrexate users with chronic kidney disease and rheumatoid arthritis: Analysis of the Japanese Adverse Drug Event Report database. Br J Clin Pharmacol 2021; 87(5): 2286-9.
[http://dx.doi.org/10.1111/bcp.14641] [PMID: 33179261]
[74]
Mhaskar R, Clark OAC, Lyman G, Engel Ayer Botrel T, Morganti Paladini L, Djulbegovic B. Colony-stimulating factors for chemotherapy-induced febrile neutropenia. Cochrane Libr 2014; 2022(1): CD003039.
[http://dx.doi.org/10.1002/14651858.CD003039.pub2] [PMID: 25356786]
[75]
Smith TJ, Bohlke K, Lyman GH, et al. Recommendations for the use of WBC growth factors: American society of clinical oncology clinical practice guideline update. J Clin Oncol 2015; 33(28): 3199-212.
[http://dx.doi.org/10.1200/JCO.2015.62.3488] [PMID: 26169616]
[76]
Al-Samkari H, Geredeli C, Arslan C, et al. Two randomized controlled trials of romiplostim for chemotherapy-induced thrombocytopenia in patients with solid tumors. Blood 2022; 140(S1): 11250-2.
[http://dx.doi.org/10.1182/blood-2022-155931]
[77]
Kondo H, Date Y. Benefit of simultaneous rhG-CSF and methylprednisolone ‘pulse’ therapy for methotrexate-induced bone marrow failure in rheumatoid arthritis. Int J Hematol 1997; 65(2): 159-63.
[http://dx.doi.org/10.1016/S0925-5710(96)00549-X] [PMID: 9071820]
[78]
Warren RB, Weatherhead SC, Smith CH, et al. British Association of Dermatologists’ guidelines for the safe and effective prescribing of methotrexate for skin disease 2016. Br J Dermatol 2016; 175(1): 23-44.
[http://dx.doi.org/10.1111/bjd.14816] [PMID: 27484275]
[79]
Knoll K, Anzengruber F, Cozzio A, French LE, Murer C, Navarini AA. Mucocutaneous ulcerations and pancytopenia due to methotrexate overdose. Case Rep Dermatol 2016; 8(3): 287-93.
[http://dx.doi.org/10.1159/000446692] [PMID: 27920680]
[80]
Troeltzsch M, von Blohn G, Kriegelstein S, et al. Oral mucositis in patients receiving low-dose methotrexate therapy for rheumatoid arthritis: Report of 2 cases and literature review. Oral Surg Oral Med Oral Pathol Oral Radiol 2013; 115(5): e28-33.
[http://dx.doi.org/10.1016/j.oooo.2012.12.008] [PMID: 23601229]
[81]
Yélamos O, Català A, Vilarrasa E, Roé E, Puig L. Acute severe methotrexate toxicity in patients with psoriasis: A case series and discussion. Dermatology 2014; 229(4): 306-9.
[http://dx.doi.org/10.1159/000366501] [PMID: 25401478]
[82]
Uce Ozkol H, Toptas T, Calka O, Akdeniz N. The efficiency of granulocyte colony-stimulating factor in hemorrhagic mucositis and febrile neutropenia resulted from methotrexate toxicity. Cutan Ocul Toxicol 2015; 34(2): 173-5.
[http://dx.doi.org/10.3109/15569527.2014.918139] [PMID: 24964172]
[83]
Çaliskan E, Tunca M, Açikgöz G, Arca E, Akar A. Accidental high-dose methotrexate toxicity due to an electronic prescribing error. Indian J Dermatol Venereol Leprol 2014; 80(3): 268-9.
[http://dx.doi.org/10.4103/0378-6323.132264] [PMID: 24823414]

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