Methotrexate induced Mucositis and Pancytopenia: A consequence of medication error in a Psoriasis patient

Raagavi. E

Clinical Pharmacist, Kauvery Hospital, Hosur

Background

Methotrexate (MTX) is a commonly prescribed medication for the treatment of Psoriasis. This study highlights a case of Methotrexate-induced mucositis and pancytopenia resulting from a medication error in a patient with Psoriasis. The 43-year-old patient, recently diagnosed with Psoriasis, was receiving methotrexate therapy. The patient, however, unintentionally ingested an excessive dose of methotrexate because of a communication error that occurred during the medication administration process. She started displaying signs of oral mucositis, characterized by ulcers and oral mucosa inflammation. On examination, the buccal mucosa and tongue displayed numerous ulcerative lesions. Due to the mucositis it was challenging for the patient to eat and perform regular oral hygiene procedures.

Healthcare professionals should ensure proper dosing and monitoring to minimize the risk of medication errors and associated complications. Additionally, patients should be educated about the potential side effects of drugs such as methotrexate, like mucositis, to enable early recognition and timely intervention. In conclusion, this study emphasizes the occurrence of methotrexate-induced mucositis and pancytopenia because of medication administration errors in a patient with Psoriasis. By increasing awareness of this potential complication, healthcare providers can improve patient safety.

Keywords

Methotrexate, Psoriasis, Pancytopenia, Mucositis

Methotrexate

Methotrexate (MTX) in low weekly doses is a first-line therapy for inflammatory diseases, such as moderate to severe psoriasis and rheumatoid arthritis. Severe acute toxicity is rare and presents with mucositis, skin ulceration and Pancytopenia. Low-dose oral MTX therapy, starting at 7.5 mg per week and gradually increasing to a maximum of 25 mg per week for adults, is commonly utilized in clinical practice. Severe adverse effects, including pancytopenia, agranulocytosis, necrotic lesions in mucosal tissues and skin additionally problems with the kidneys, liver, and gastrointestinal tract, can happen even with low-dose Methotrexate therapy.

methotrexate

Case Presentation

A 43-year-old female Patient presented to the emergency department with a chief complaint of decreased appetite for 2 days. She had history of Mouth ulcer, Vomiting, fever and Cough for 1 day.

Clinical Examination: Shows the buccal mucosa and tongue of the patient’s oral cavity displayed numerous ulcerative lesions. She was febrile, and his vital signs showed a blood pressure of 120/80 mmHg, a respiratory rate of 20 breaths per min, and a pulse of 124 beats per min.

 

Past Medical and Medication history

She have past medical history of Psoriasis. She had been administered methotrexate 7.5 mg orally once weekly to treat her Psoriasis. However, the patient had misjudged the two medications Folic acid and Methotrexate. She has taken methotrexate 7.5 mg twice daily for the past 1 month and Folic acid 5mg once weekly. Her history and diagnostic findings were consistent with a methotrexate overdose that caused this acute reaction. The patient was inability to tolerate oral feeding

Lab Investigations

White Blood Cell Count – 940 cells/cumm,

Platelets – 105100cells/cumm,

Elevated Liver enzymes (SGPT) – 58 U/L.

Urine routine analysis and renal function test were normal at the time of presentation.

Management

  1. Parenteral Rehydration was initiated, Antiemetics (intravenous Ondansetron) antiulcer (intravenous Pantoprazole), Filgrastim (Recombinant Human Granulocyte Colony Stimulating factor, Oral analgesic Zytee (Choline Salicylate + Benzalkonium chloride ), Zincovit (Multivitamin and Multi minerals) Folic acid, Mucaine Gel (Oxetacaine + Aluminium Hydroxide + Milk Of Magnesia) and Mylocobal ( Intravenous) were given and Methotrexate was discontinued.
  2. The Patient’s symptoms started improving. Oral nutrition was resumed after two days.
  3. The Patient remained hospitalized for six days, and blood counts (Platelets: 160000 lakhs/cumm), (WBC-2750 cells/cumm) were improving and liver function (SGOT: 25 U/L, SGPT: 40 U/L) recovered, as confirmed by laboratory tests (Table 1).
  4. The patient had been discharged with better overall health, no pain, and healing ulcerations in the mouth; all ulcerations were resolved by a follow-up session one week later.

 

Table 1: Results of laboratory tests during the patients hospitalization

Investigations

Day 1

Day 2

Day 3

Normal
White Blood Cells(Cells/Cumm) 940 1610 2750 400010000
Red Blood Cells 3.61 3.86 4.01 4.56
Platelet (Lakhs/Cumm) 105100 45700 160000 140000400000
Hemoglobin 11.13 11.71 12.31 1215
SGOT (U/L) 27 Nil 25 031
SGPT (U/L) 58 Nil 40 045

Conclusion

Methotrexate has a high prevalence of serious, avoidable medication mistakes, severe precaution is needed to increase patient safety. Whenever it involves the combination of folic acid and methotrexate, healthcare professionals need to be thoroughly informed about the dosage for each medication and the day of administration to reduce the error. Patients should be advised to look for any complications related to their therapy. Patients should monitor blood test periodically.

References

  1. Umuerri EM, Aiwuyo HO. Prevalence and correlates of prehypertension and hypertension among adults in Delta State, Nigeria: a cross-sectional community-based study. Ghana Medical Journal. 2020 Mar 31;54(1):48-57.
  2. Rampon G, Henkin C, Jorge VM, Almeida Jr HL. Methotrexate-induced mucositis with extra-mucosal involvement after acidental overdose. Anais brasileiros de dermatologia. 2018 Jan;93:155-6.
  3. Shrestha R, Ojha SK, Jha SK, Jasraj R, Fauzdar A. Methotrexate-Induced Mucositis: A Consequence of Medication Error in a Rheumatoid Arthritis Patient. Cureus. 2023 Sep 30;15(9).
  4. Bedoui Y, Guillot X, Slambarom J, Guiraud P, Giry C, Jaffar-Bandjee MC, Ralandison S, Gasque P. Methotrexate an old drug with new tricks. International journal of molecular sciences. 2019 Oct 10;20(20):5023.
  5. Gonzalez-Ibarra F, Eivaz-Mohammadi S, Surapaneni S, Alsaadi H, Syed AK, Badin S, Marian V, Elamir M. Methotrexate induced pancytopenia. Case Reports in Rheumatology 2014;2014:679580.
Raagavi

Raagavi. E

Clinical Pharmacist

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