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Medication Error- A Case Report of Misadventure with Methotrexate
Anup Singh1, Aru Chhabra Handa1
1Department of Otorhinolaryngology and Head & Neck Surgery, Medanta- The Medicity, Gurugram, Haryana, India.
JNMA; Journal of the Nepal Medical Association
|November 2, 2018
Summary
Methotrexate (MTX) toxicity can arise from prescription errors, leading to severe side effects like mucositis and organ damage. This case highlights the importance of careful prescribing to prevent MTX overdose and associated complications.
Area of Science:
- Pharmacology
- Oncology
- Toxicology
Background:
- Methotrexate (MTX) is a vital antimetabolite drug with antineoplastic and immunomodulatory uses in treating various cancers.
- MTX toxicity, manifesting as mucositis or organ damage (bone marrow, renal, hepatic), can result from overdose or prescription errors.
Observation:
- Acute high-dose MTX ingestion does not typically cause toxicity due to saturable absorption.
- A case of MTX toxicity is presented, stemming from a prescription error involving daily dosing in a patient with multiple comorbidities.
Findings:
- The presented case illustrates MTX toxicity due to a prescription error leading to daily dosing, not acute overdose.
- Management challenges were encountered in a patient with multiple comorbidities.
Implications:
- Prescribers must exercise caution to prevent MTX toxicity, particularly in patients with comorbidities.
- Implementing measures to avoid prescription errors is crucial for patient safety and preventing MTX-related adverse events.
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