Methotrexate for non oncology conditions subcutaneously or intravenously (SOP for adminstration)

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Audience

Authorised Personnel/Specific Staff Competencies

  1. All medical, nursing and pharmacy staff involved in the care of the child receiving low Dose Methotrexate therapy.
  2. Completed GG&C (RHC/Yorkhill) IV administration of medicines Competency package
  3. Competency in Subcutaneous medication administration
Introduction
  1. Methotrexate is a disease modifying anti-rheumatic drug (DMARD), which inhibits dihydrofolate reductase, essential for the synthesis of purines and pyrimidines. Methotrexate interferes with the supply of folic acid to the body.
  2. Doses of folic acid may be prescribed at least 24 hours after the dose of Methotrexate. However this is not always necessary in children.
  3. The administration of low dose (10-15mg per M2 ) Methotrexate carries significantly less potential toxicity, compared to the significantly higher doses used in Oncology.
  4. Due to its teratogenic effects pregnancy is absolutely contra indicated in patients receiving MTX, advice and contraception should be in place for sexually active individuals. If there is risk of pregnancy the MTX should be stopped immediately and advice sought for the health of the foetus, and advice on its potential viability.
  5. Blood monitoring should be in place according to GGC MTX policy, due to possible effects on Liver and bone marrow function.
Equipment/Materials
  1. Case notes or electronic patient record
  2. Drug kardex
  3. Appropriate Personal Protective Equipment (gloves and apron)
  4. Spillage kit
Procedure
  1. Some patients may require anti emetics medication, ensure administered as prescribed. 
  2. Check dose to be given against prescription chart adhering to medicines policy.
  3. Both registered nurses must calculate dose independently (dose rounded to nearest 2.5mg increment).
  4. All in house presentations require ordered with 24 hours notice.

A. Subcutaneous route

  1. Gather equipment needed, there are currently 2 preparations available; Metoject branded single use prefilled PEN which have an integrated needle. These come in 2.5mg doses from 7.5mg to 30mg and should be used in preference to the alternative presentation of house prefilled syringes (IHPFS) from the aseptic pharmacy. You will require; cotton wool and a spot plaster. For IHPFS syringes you will require an S/C 26g needle.
  2. IHPFS come without air bubbles, no attempt to prime the needle should be made to reduce the chance of medicine leak to the environment. Metoject PENS come with an instructional video on line at www.metoject.com
  3. The S/C injection should be given at a 90 degree angle into the skin. Areas usually used at the upper deltoid of the arm, anterior & lateral aspect of the mid thigh and the abdomen. Sites are rotated weekly 
  4. Spills should be dealt with according to GGC Chemotherapy spill policy. Possible spill volumes for syringes are very low (less than 1ml).   

B. Intravenous route 

  1. If a patient is cannulated administration IV may be more patient friendly route. 
  2. Gather equipment needed, there are currently 2 preparations available; an in house prefilled syringes (IHPFS) and in house pharmacy IV infusion bag (50ml of 0.9%NaCl) both from aseptic pharmacy. 
  3. No attempt to remove air bubbles or to prime the needles/syringes should be made to reduce the chance of medicine leak to the environment.
  4. All IV infusion bags should be spiked at waste height and in the horizontal plane to reduce risk of medicine spillage and eye contact (GG&C IV medicine policy).
  5. Bolus low dose Methotrexate can be given over 2 to 5 minutes.
  6. Infusion bags can be given over the same time scale, but are more usually give over 15 minutes, due to volume.
  7. Spills should be dealt with according to GGC Chemotherapy spill policy. Possible spill volumes for syringes are under 0.5ml, for IVI volumes can be up to 50ml. Spill kits appropriate to volume should be available.
References

RCN Guidance: Administering subcutaneous Methotrexate for inflammatory arthritis

BNF for Children 2012-2013

Braun J & Rau R (2009) An update on Methotrexate. Current Opinion in Rheumatology 21:216–223

Editorial Information

Last reviewed: 01 September 2015

Next review: 01 September 2017

Author(s): D Fell

Approved By: Clinical Effectiveness