Brand name: methotrexate
Generic name: Emthexate, amethopterin, Rheumatrex, Methoblastin, MTX

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Methotrexate elimination is reduced in patients with impaired renal function, ascites, or pleural effusions. Necrotizing fasciitis resulting in death has been reported in a 54-year-old man with rheumatoid arthritis receiving infliximab every 8 weeks along with intramuscular methotrexate weekly dosage. Alkalinization of urine (with bicarbonate and/or acetazolamide) and intravenous hydration (1000 mL per square meter of body surface area over six hours prior to beginning the methotrexate infusion and 3000 mL per square meter of body surface area per day during the methotrexate infusion and for two days after the infusion is completed) are also important to prevent renal toxicity caused by methotrexate and/or its metabolites. Such patients require especially careful monitoring for toxicity, and require dose reduction or, in some cases, discontinuation of methotrexate administration. It is recommended that duration of leucovorin administration in these patients be based on determination of plasma methotrexate concentrations. However, elderly patients are more likely to have age-related renal function impairment, which may require adjustment of dosage in patients receiving leucovorin as a rescue from the effects of high-dose methotrexate. Leucovorin given at the appropriate time rescues bone marrow and gastrointestinal cells from methotrexate but has no apparent effect on pre-existing methotrexate nephrotoxicity. In patients with psoriatic arthritis, the rate of antibody development in patients receiving Humira monotherapy was comparable to patients with rheumatoid arthritis; however, in patients receiving concomitant methotrexate the rate was 7% compared to 1% in rheumatoid arthritis. Her RA had been treated with methotrexate (10 mg per week) and bucillamine (200 mg per day) for 6 years. Patients treated with concomitant methotrexate had a lower rate of antibody development than patients on Humira monotherapy (1% versus 12%). He was treated for RA with infliximab (3 mg/kg) for 3 years, as well as methotrexate (20 mg/week), and corticosteroids. Methotrexate, especially at higher doses or with prolonged treatment, has been associated with hepatotoxicity including acute hepatitis, chronic fibrosis, necrosis, cirrhosis, and liver enzyme elevations.

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