NSAIDs: Should not be administered prior to or concomitantly with high doses of Trexall, such as used in the treatment of osteosarcoma

Salicylates, Phenylbutazone, Phenytoin and Sulfonamides: Toxicity may be increased Penicillin, Theophylline, Probenecid, Azathioprine, Retinoids,

Sulfasalazine: Should be closely monitored for possible increased risk of hepatotoxicity

Cisplatin: Caution must be exercised if high-dose Trexall is administered in combination

Mercaptopurine: Trexall increases the plasma levels of mercaptopurine

Tetracycline, Chloramphenicol and Nonabsorbable Broad Spectrum Antibiotics: May decrease intestinal absorption of Trexall

Vitamin preparations containing folic acid or its derivatives: Decreases responses to systemically administered Trexall

Trimethoprim/Sulfamethoxazole: Rarely increases bone marrow suppression

Contraindications

Alcoholism, alcoholic liver disease or other chronic liver disease

Immunodeficiency syndromes

Pre-existing blood dyscrasias, such as bone marrow hypoplasia, leukopenia, thrombocytopenia, or significant anemia

Hypersensitivity to methotrexate

Pregnant women with psoriasis or rheumatoid arthritis

Women of childbearing potential

Nursing mothers

Pregnancy should be avoided if either partner is receiving methotrexate; during and for a minimum of three months after therapy for male patients, and during and for at least one ovulatory cycle after therapy for female patients

Neoplastic Diseases-

Choriocarcinoma and similar trophoblastic diseases: Orally or intramuscularly in doses of 15 to 30 mg daily for a five-day course. The courses are usually repeated for 3 to 5 times as required, with rest periods of one or more weeks interposed between courses, until any manifesting toxic symptoms subside. Since hydatidiform mole may precede choriocarcinoma, prophylactic chemotherapy with methotrexate has been recommended. Chorioadenoma destruens is considered to be an invasive form of hydatidiform mole. Methotrexate is administered in these disease states in doses similar to those recommended for choriocarcinoma

Acute Lymphoblastic Leukemia

Induction dose: 3.3 mg/m2 in combination with prednisone 60 mg/m2 daily for 4 to 6 weeks

Maintenance dose: Orally or IM administration 2 times a week in total weekly doses of 30 mg/m2

Alternate maintenance dose: 2.5 mg/kg IV every 14 days. If and when relapse does occur, reinduction of remission can again usually be obtained by repeating the initial induction regimen

Lymphoma

Burkitt's tumor Stages I to II: 10 to 25 mg once a day for 4 to 8 days

Burkitt's tumor Stage III: Methotrexate is commonly given concomitantly with other antitumor agents

Duration of therapy: All stages usually require several courses of therapy interposed with 7 to 10 day rest periods

Lymphosarcoma Stage III: 0.625 to 2.5 mg/kg daily as a part of combination chemotherapy

Mycosis Fungoides: Early stage dosing: 5 to 50 mg once a week; alternatively, 15 to 37.5 mg 2 times a week may be used in patients who have responded poorly to weekly therapy

Breast Cancer: 40 mg/m 2 intravenously on the 1 st and 8 th day every 4 weeks in combination with cyclophosphamide and fluoracil for 6-12 cycles

Head and Neck Cancer: 40 mg/m2 IV weekly until disease progression or unacceptable toxicity (3 weeks equals one cycle; goal is to complete at least six cycles).

Adult Rheumatoid Arthritis: Single doses of 7.5 mg once per week, Maximum dose: 20 mg/week in adults

Polyarticular-Course Juvenile Rheumatoid Arthritis: 10 mg/m2 once weekly

Psoriasis: Single dose: 10 to 25 mg once per week, maximum dose: 30 mg/week

The most frequently reported adverse reactions include ulcerative stomatitis, leukopenia, nausea and abdominal distress

Other frequently reported adverse effects are malaise, undue fatigue, chills and fever, dizziness and decreased resistance to infection

Trexall has been reported to cause impairment of fertility, oligospermia and menstrual dysfunction in humans, during and for a short period after cessation of therapy

US FDA Pregnancy Category X. Methotrexate should be used in the treatment of neoplastic diseases only when the potential benefit outweighs the risk to the fetus. It is contraindicated in nursing mothers.

Trexall formulations and diluents containing preservatives must not be used for intrathecal or high dose Trexall therapy

It is necessary to follow patients on Trexall closely for toxic effects

If adverse reactions occur, the drug should be reduced in dosage or discontinued and appropriate corrective measures should be taken. If necessary, this could include the use of leucovorin calcium

If Trexall therapy is reinstituted, it should be carried out with caution, with adequate consideration of further need for the drug and increased alertness as to possible recurrence of toxicity

Persistent liver function test abnormalities, &/or depression of serum albumin may be indicators of serious liver toxicity & require evaluation

Folate deficiency: May increase Trexall toxicity

Use in Special Populations

Pediatric patients: Benefits should be weighed against the potential risk before using Trexall alone or in combination with other drugs, especially in pediatric patients or young adults.

Geriatric patients: Elderly patients should be closely monitored for early signs of hepatic, bone marrow and renal toxicity.

Leucovorin is indicated to diminish the toxicity and counteract the effect of inadvertently administered overdosages of Trexall and its administration should begin as promptly as possible.

Store at a temperature not exceeding 30°C in a dry place. Protect from light & moisture.