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Methotrexate-induced pancytopenia: a case series of 46 patients
Sajal Ajmani1, Yogesh Preet Singh1, Shiva Prasad1
1Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
Aim:
Methotrexate (MTX) has the potential to cause serious adverse reactions and even mortality. We analyzed the predisposing factors and outcome in patients with MTX-induced pancytopenia admitted into our unit from 1996 to 2015.
Methods:
Patients were identified by departmental database search. Pancytopenia was defined as white blood cell count (WBC) < 3500 cells/mm3 , hemoglobin (Hb) < 11 g/dL and platelet count < 150 000 cells/mm3 . Severe pancytopenia was defined as WBC < 2000 cells/mm3 , Hb < 10 g/dL and platelet count < 50 000 cells/mm3 .
Results:
Forty-six patients were included in the study (female = 35). Twenty-four had been under the care of either primary care physicians or orthopedic surgeons and presented to us with pancytopenia. Sixteen patients had severe pancytopenia. Disease distribution was as follows: rheumatoid arthritis 33, psoriasis eight, systemic sclerosis two and others three. The median dose of MTX was 10 mg/week and median duration of treatment was 11 months. The median cumulative dose was 750 mg. Symptoms at presentation included: oral mucositis (n = 37); fever (n = 24); diarrhea (n = 12), bleeding gums (n = 5) and purpura (n = 3). The potential risk factors were: hypoalbuminemia (n = 23), renal insufficiency (n = 14), dosing errors (n = 13) and non-supplementation of folates (n = 7). Thirteen patients died. WBC at admission was found to determine survival (P < 0.05).
Conclusion:
In patients on MTX, oral mucositis and fever can herald pancytopenia. MTX-induced pancytopenia is associated with high mortality. WBC at admission is the most important prognostic factor. There is need for increased awareness among physicians to minimize prescribing errors. A national guideline on monitoring of patients on MTX is desirable.
Insights
Methotrexate (MTX)-induced pancytopenia can be fatal, with oral mucositis and fever as early warning signs. Low white blood cell count at admission is critical for predicting survival in these patients.
Area of Science:
- Hematology
- Rheumatology
- Pharmacology
Background:
- Methotrexate (MTX) is a widely used medication with a risk of severe adverse events, including life-threatening pancytopenia.
- Identifying predisposing factors and prognostic indicators for MTX-induced pancytopenia is crucial for patient management.
Purpose of the Study:
- To analyze predisposing factors and outcomes in patients experiencing methotrexate-induced pancytopenia.
- To identify key indicators for predicting survival in patients with MTX-induced pancytopenia.
Main Methods:
- Retrospective analysis of patients admitted with MTX-induced pancytopenia between 1996 and 2015.
- Defined pancytopenia and severe pancytopenia based on specific white blood cell (WBC), hemoglobin (Hb), and platelet counts.
- Evaluated patient demographics, clinical presentation, risk factors, and mortality.
Main Results:
- Forty-six patients were included; 35 were female. Rheumatoid arthritis was the most common indication (33 patients).
- Common presenting symptoms included oral mucositis (37 patients) and fever (24 patients).
- Identified risk factors included hypoalbuminemia (23 patients), renal insufficiency (14 patients), dosing errors (13 patients), and lack of folate supplementation (7 patients). Thirteen patients died, with admission WBC count being a significant predictor of survival.
Conclusions:
- Oral mucositis and fever may precede the development of MTX-induced pancytopenia.
- MTX-induced pancytopenia is associated with a high mortality rate.
- Admission WBC count is the most critical prognostic factor; increased physician awareness and national monitoring guidelines are recommended.
