Methotrexate

• Solution for injection vials 5mg/2ml, 50mg/2ml, 500mg/20ml, 1g/10ml
• Solution for infusion vials 5g in 50ml
• Tablets 2.5mg (£1.64 = 28 tablets)
• Metoject PEN solution for injection pre-filled pen (£12.87 - £16.56 per syringe)
  • 0.15ml (7.5mg), 0.2ml (10mg), 0.25ml (12.5mg), 0.3ml (15mg), 0.35ml (17.5mg), 0.4ml (20mg), 0.45ml (22.5mg), 0.5ml (25mg), 0.55ml (27.5mg), 0.6ml (30mg) (for South Devon patients this is provided by specialist services at Torbay Hospital)

Notes

1. West Devon: refer to individual shared care guidelines for use in Gastroenterology, Rheumatology, and Dermatology conditions
   1. West Devon oral methotrexate dermatology guideline
   2. West Devon subcutaneous methotrexate dermatology guideline
2. South Devon: refer to individual shared care guidelines for use in Gastroenterology, Rheumatology, or Dermatology conditions
   1. South Devon oral methotrexate dermatology guideline
   2. Prescribing and monitoring of subcutaneous methotrexate (Metoject) is undertaken by specialist services at Torbay Hospital
3. Methotrexate dose should be taken once weekly.
4. To avoid confusion for patients due to differences between injection devices, subcutaneous methotrexate should be prescribed by brand
5. To avoid errors it is recommended that:
   1. The patient is carefully advised of the dose and frequency and the reason for taking methotrexate and any other prescribed medicine (eg. folic acid)
   2. The prescription and the dispensing label clearly show the dose and frequency of administration, for example: 'methotrexate 2.5mg tablets: (number of tablets) to be taken as a single dose ONCE A WEEK on XXXDAY'
   3. Only one strength of methotrexate tablet (2.5mg) should be prescribed and dispensed
   4. Staff that encounter methotrexate prescriptions must ensure the correct dosing interval is given.
   5. Methotrexate treatment booklets should be issued where appropriate.
   6. The patient is warned to report immediately the onset of any feature of blood disorders (eg. sore throat, bruising and mouth ulcers), liver toxicity (eg. nausea, vomiting, abdominal discomfort and dark urine), and respiratory effects (e.g. shortness of breath)
   7. Patients should be co-prescribed folic acid to prevent methotrexate-induced side-effects (off-label use). Prescribe 5mg at least once weekly (more frequent dosing is often routinely recommended, refer to individual shared care guidelines / specialist advice). Folic acid should be taken at least 24 hours after previous methotrexate administration. Be aware that methotrexate and folic acid tablets look alike.
   8. Methotrexate and NSAIDs: if aspirin or other NSAIDs are given concurrently the dose of methotrexate should be carefully monitored. Patients should be advised to avoid self-medication with over-the-counter aspirin or ibuprofen.
6. MHRA Drug Safety Update (September 2020): Methotrexate once-weekly for autoimmune diseases: new measures to reduce risk of fatal overdose due to inadvertent daily instead of weekly dosing. Advice for prescribers: 
   1. Before prescribing methotrexate, make sure that the patient is able to understand and comply with once-weekly dosing  
   2. Consider the patient’s overall polypharmacy burden when deciding which formulation to prescribe, especially for a patient with a high pill burden  
   3. Decide with the patient which day of the week they will take their methotrexate and note this day down in full on the prescription  
   4. Inform the patient and their caregivers of the potentially fatal risk of accidental overdose if methotrexate is taken more frequently than once a week; specifically, that it should not be taken daily  
   5. Advise patients of the need to promptly seek medical advice if they think they have taken too much
7. MHRA Drug Safety Update (August 2023): Methotrexate: advise patients to take precautions in the sun to avoid photosensitivity reactions 
   1. Photosensitivity reactions are known side effects of methotrexate treatment and can occur with both low-dose and high-dose treatment. 
   2. Reactions manifest as severe sunburn such as rashes with papules or blistering, with some patients reporting swelling; rarely, photosensitivity reactions have contributed to deaths from secondary infections. 
   3. Healthcare professionals, including those prescribing and dispensing methotrexate, should remind patients to take precautions to protect themselves from the sun and UV rays.
   4. Refer to the safety update for advice to give to patients.

Pemetrexed

• Powder for solution for infusion vials 100mg, 500mg, 1g
• Solution for infusion vials 100mg/4ml, 500mg/20ml, 850mg/34ml, 1g/40ml

Notes

1. NICE TA124: Pemetrexed is not recommended for the treatment of locally advanced or metastatic non-small cell lung cancer (August 2007).
2. NICE TA181: Pemetrexed in combination with cisplatin is recommended as an option for the first-line treatment of patients with locally advanced or metastatic non-small-cell lung cancer (NSCLC) only if the histology of the tumour has been confirmed as adenocarcinoma or large-cell carcinoma (September 2009).
3. NICE TA402: Pemetrexed (Alimta) is recommended as an option for the maintenance treatment of locally advanced or metastatic non-squamous non-small-cell lung cancer in adults (August 2016), when
   1. their disease has not progressed immediately after 4 cycles of pemetrexed and cisplatin induction therapy
   2. their Eastern Cooperative Oncology Group (ECOG) performance status is 0 or 1 at the start of maintenance treatment and
   3. the company provides the drug according to the terms of the commercial access agreement as agreed with NHS England.
   4. Refer to TA402 for additional considerations regarding performance status score.
4. NICE TA190: Pemetrexed (Alimta) is recommended as an option for the maintenance treatment of people with locally advanced or metastatic non-small-cell lung cancer other than predominantly squamous cell histology if disease has not progressed immediately following platinum-based chemotherapy in combination with gemcitabine, paclitaxel or docetaxel (August 2017).
5. NICE TA135: Pemetrexed is recommended as a treatment option for malignant pleural mesothelioma only in people who have a World Health Organization (WHO) performance status of 0 or 1, who are considered to have advanced disease and for whom surgical resection is considered inappropriate (January 2008).

Raltitrexed

• Powder for solution for infusion vials 2mg