甲氨蝶呤(MTX)毒性可影响多器官系统,表现为肾毒性,骨髓抑制,肝毒性,粘膜炎,和肠胃不适。服用小剂量甲氨蝶呤的患者很少发生严重不良事件。我们介绍了一例86岁女性,每周口服12.5mgMTX治疗类风湿关节炎,在使用万古霉素和哌拉西林-他唑巴坦进行骨髓炎的门诊抗菌治疗(OPAT)期间出现牙龈疼痛和口腔出血。她患有急性肾损伤(AKI),血清MTX水平升高,血小板减少症,中性粒细胞减少症,万古霉素水平是治疗浓度的三倍。怀疑MTX毒性是由万古霉素和哌拉西林-他唑巴坦引起的,引起AKI和MTX的肾清除率受损,而MTX本身具有肾毒性。病人接受了亚叶酸治疗,碱化静脉输液,在2周内注射非格司汀。在5周的门诊随访中,她的肾功能继续下降,远远落后于其他毒性标志物正常化。此案例证明了考虑潜在药物-药物相互作用的重要性,以及在某些组中对OPAT进行严格监测的必要性。
Methotrexate (MTX) toxicity can affect multiple organ systems, manifesting as nephrotoxicity, myelosuppression, hepatotoxicity, mucositis, and gastrointestinal upset. Serious adverse events are rare in patients prescribed low-dose methotrexate. We present a
case of an 86-year-old female on a weekly dose of oral MTX 12.5 mg for rheumatoid arthritis presenting with painful gingiva and oral bleeding during outpatient antimicrobial therapy (OPAT) for osteomyelitis with vancomycin and piperacillin-tazobactam. She had acute kidney injury (AKI), elevated serum MTX levels, thrombocytopenia, neutropenia, and a vancomycin level three times therapeutic concentration. MTX toxicity was suspected to have been triggered by vancomycin and piperacillin-tazobactam causing AKI and impaired renal clearance of MTX which itself is nephrotoxic. The patient was managed with leucovorin, alkalinized intravenous fluids, and filgrastim injections over a 2-week period. Her renal function continued to be reduced at 5-week outpatient follow-up, far after other markers of toxicity normalized. This
case demonstrates the importance of considering potential drug-drug interactions and the need for robust monitoring for OPAT in select groups.