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

Introduction

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.
Doses of folic acid may be prescribed at least 24 hours after the dose of Methotrexate. However this is not always necessary in children.
The administration of low dose (10-15mg per M2 ) Methotrexate carries significantly less potential toxicity, compared to the significantly higher doses used in Oncology.
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.
Blood monitoring should be in place according to GGC MTX policy, due to possible effects on Liver and bone marrow function.

Authorised Personnel/Specific Staff Competencies

All medical, nursing and pharmacy staff involved in the care of the child receiving low Dose Methotrexate therapy.
Completed GG&C (RHC/Yorkhill) IV administration of medicines Competency package
Competency in Subcutaneous medication administration.

Equipment/Materials

Procedure (d)

Some patients may require anti emetics medication, ensure administered as prescribed.
Some patients may wish local anaesthetic cream or cold spray to reduce pain on administration
Check dose to be given against prescription chart. Both staff must calculate dose independently (dose rounded to nearest 2.5mg increment).
All in house presentations require a minimum of 24 hours’ notice to be made up.
Ensure procedure explained to family
Wash hands and don disposable gloves and apron

A. subcutaneous route

Gather equipment needed, there are a number of preparations available; NHS GG&C use all most exclusively Metoject branded single use prefilled PEN which has an integrated needle (there are 3 other prefilled devices on the market). These come in 2.5mg doses from 7.5mg to 30mg. In exceptional circumstances in house prefilled syringes (IHPFS) from the aseptic pharmacy may be used. You will require; cotton wool and a spot plaster. For IHPFS syringes you will require an S/C 26g needle.
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 have a small air bubble as standard instruction vidoe on line at https://metoject.co.uk/patient/
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
Spills should be dealt with according to GGC Chemotherapy spill policy (V). Possible spill volumes for syringes are very low (less than 1ml).

B. Intravenous route

If a patient is cannulated administration IV may be more patient friendly route.
Gather equipment needed, for an IV medication, the in house pharmacy IV infusion bag is 50ml of 0.9%NaCl regardless of Methotrexate dose.
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.
All IV infusion bags should be spiked at waste height and in the horizontal plane to reduce risk of medicine spillage and eye contact.
Infusion bags are given over 15 minutes, they can be given over a duration of 5 to 60 mins if required.
Spills should be dealt with according to GGC Chemotherapy spill policy (e). Possible spill volumes for IVI are up to 50ml. Spill kits appropriate to volume should be available.
Ensure all procedural waist disposed as per GG&C policy (g)
Remove PPE and dispose of as per GG&C policy
and dose documented