methotrexate once daily

[mipharmd]

I just had a doctor adamantly tell me that he wants methotrexate 2.5 once daily except sunday #30 with 3 refills. He said that he has been practicing for 54 years, He is an internist, and He went to medical school and that if I did not want to fill his prescription to give it back to the patient and have them go to another pharmacy. So I gave the script back to the patient.

I tried researching on it, but the few things I found say once a day dosing should not be used and causes increase risk (higher than weekly dosing) for hepatic toxicity.

Anyone have any ideas or have had patients take it once a day-

---

Members don't see this ad.

 

[PharmdA07]

What is the indication? Is it R.A.?

 

[farmadiazepine]

In retail, I don't think you should be filling a once daily methotrexate Rx. What you should be seeing outpatient wise in a retail pharmacy is once weekly, twice weekly, 3 times weekly, or 3 doses per week kind of Rx's. That's all I'm comfortable filling. If the MD gives you an attitude like that, you give back the Rx bc there is no reasoning with an a**hole like that. What I like to do is, after me trying to research and come up with nothing, I say to them if they want to prescribe it then they have to fax me over the article with the dosing regimen they want to use. As long as it is in some journal article somewhere and they can show me literature, then I will fill it accordingly after reviewing it myself. That's the only way you should practice medicine in my opinion.

 

[npage148]

Wouldn't fill it full stop. No reason to dose it like that in an non cancer setting. (And probably none for a cancer setting either)

 

[StellargalS]

I just had a doctor adamantly tell me that he wants methotrexate 2.5 once daily except sunday #30 with 3 refills. He said that he has been practicing for 54 years, He is an internist, and He went to medical school and that if I did not want to fill his prescription to give it back to the patient and have them go to another pharmacy. So I gave the script back to the patient.

I tried researching on it, but the few things I found say once a day dosing should not be used and causes increase risk (higher than weekly dosing) for hepatic toxicity.

Anyone have any ideas or have had patients take it once a day-

First I needed this review so thank you. Likewise I found what you did. I tried a couple of different search strategies in PubMed and finally got annoyed and googled. Sometimes there isn't enough time to hold out for the best evidence. Like you I just seek to reassure my assertion the best I can and then document my actions in the case of a dispense. Too bad Dr. Dick was on the job. When I can't find a rational explanation to off label high risk prescribing I approach the call in terms of documenting due diligence and then go from there. Most make a change.

I pasted the citation and snip its to what I was able to uncover on this topic.

R. Rau, G. Herborn. Benefit and risk of methotrexate treatment in rheumatoid arthritis. Clin Exp Rheumatol. 2004; 22 (Suppl. 35): S83-S94.
(page S-87)

Liver Toxicity
Among patients with psoriasis, liver fibrosis and cirrhosis developed with
increasing cumulative doses in up to 24% of patients treated with daily MTX.
Risk factors for liver toxicity, in addition to daily dosing, included high alcohol consumption, obesity, and diabetes. Weekly dosing was found to be better tolerated than daily dosing. Awareness of potential liver side effects in the long-term treatment with MTX is necessary, although hepatotoxicity has not been a substantial problem with weekly low-dose MTX in patients with RA. There are proposals to change the guidelines for monitoring liver function tests
(145).

(page S-89)
Tolerability can often be improved by administering the drug in the evening
or in two equal doses in the morning and evening of the same day, by changing the route of administration (parenteral versus oral), reducing the dose, or by supplementation with folic acid.​

This last snippet I included just to show that discussion about the practice of splitting is confined to the wake time on the day the weekly dose is scheduled.

 

[rxlea]

What did the patient (or doctor) tell you it was for?

 

[Protongenic]

Wouldn't fill it full stop. No reason to dose it like that in an non cancer setting. (And probably none for a cancer setting either)

I concur; and no cancer settings that I'm aware of either for daily PO regimens.

Liver Toxicity

Agreed; and well-documented fatal accumulations, too. Definitely high risk.

http://www.ismp.org/newsletters/acutecare/articles/20020403.asp

 

[mipharmd]

I did not even get to say a word, I left a message with the nurse/receptionist who kept rereading the script to me and said the dr was with patients. She said the dr wrote that so i should dispense it. So i told her that have the DR call me so I can verify the rx and diagnosis with him. She didnt have the diagnosis. The dr called and it was a one sided conversation, he would not let me ask or say anything. Everytime I started to talk he reiterated his point of him being the internist, etc. So not sure, but the patient picked it up and went someplace else.

 

[PharMed2016]

I did not even get to say a word, I left a message with the nurse/receptionist who kept rereading the script to me and said the dr was with patients. She said the dr wrote that so i should dispense it. So i told her that have the DR call me so I can verify the rx and diagnosis with him. She didnt have the diagnosis. The dr called and it was a one sided conversation, he would not let me ask or say anything. Everytime I started to talk he reiterated his point of him being the internist, etc. So not sure, but the patient picked it up and went someplace else.

Perhaps the patient has dermatomyositis or polymyositis where the target dose is 10mg-25mg/weekly, titrating to effect. Even then, I would be hesitant. Did he prescribe concomitant folate?

 

[Hope1974]

I've seen it. Methotrexate once a day except for one or two days. I thought it's not possible, but it is on a low dose, say 1 tablet a day, 2.5mg. So, it is possible. Never seen it retail though, but up here in the hospital yes. It was for RA I believe.

 

[Amicable Angora]

I just had a doctor adamantly tell me that he wants methotrexate 2.5 once daily except sunday #30 with 3 refills. He said that he has been practicing for 54 years, He is an internist, and He went to medical school and that if I did not want to fill his prescription to give it back to the patient and have them go to another pharmacy. So I gave the script back to the patient.

I tried researching on it, but the few things I found say once a day dosing should not be used and causes increase risk (higher than weekly dosing) for hepatic toxicity.

Anyone have any ideas or have had patients take it once a day-

My pharmcy professors told me it's almost always given once a week not once a day.

 

[Hope1974]

My pharmcy professors told me it's almost always given once a week not once a day.

You'll find that a lot of things your professors said don't hold true in real world pharmacy.

 

[StellargalS]

The fact remains that the OP attempted to do his due diligence but was thwarted and undermined by the reprehensible behavior of that Dr.

My ability to contribute constructively to the physicians plan of care was the direct result of my daily interaction with a core group of physicians. Their tolerance for my inexperience in an area and their willingness to share with me their expertise instilled in me a loyalty for them. In the end I became for each of them a reliable and trusted resource that unloaded a ****storm of utilization management burdens.

Relationships are hard to cultivate in the big box setting and this sets the stage for these unfortunate interactions.

 

[BeLikeBueller]

I've seen it. Methotrexate once a day except for one or two days. I thought it's not possible, but it is on a low dose, say 1 tablet a day, 2.5mg. So, it is possible. Never seen it retail though, but up here in the hospital yes. It was for RA I believe.

Student here, so let's make this a teaching moment...do you not have to supplement with folinic acid in this case? My understanding was that folinic acid can't be given w/in 24 hours of MTX, so the only alternative I could see would be to give high doses on the day off?