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Prevent methotrexate dispensing errors

May 1, 2019
Weekly dosing of methotrexate is common.

ACP has recently received concerns about pharmacies incorrectly dispensing oral methotrexate. As is common with methotrexate errors, the medication was dispensed with instructions for daily dosing instead of weekly dosing. Pharmacists and pharmacy technicians are reminded that the weekly dosing of methotrexate is common. As these types of dispending errors can result in serious health outcomes, health care providers and patients must be vigilant whenever methotrexate is used.

The Institute for Safe Medication Practices (ISMP) has issued several alerts about preventing methotrexate errors. ISMP recommendations include the following:

  • defaulting to a weekly dosing schedule in prescriber and pharmacy order entry systems,
  • requiring verification and entry of an appropriate oncologic indication in order entry systems for daily orders,
  • educating patients and providing them with verbal and written instructions that specify the weekly dosing schedule and emphasize the danger with taking daily or extra doses,
  • asking patients to repeat back the instructions for taking oral methotrexate to validate understanding,
  • verifying the dose and frequency of all medication lists and discharge instructions, and
  • limiting the prescription quantity to a 30-day supply (e.g., dispensing just eight 2.5 mg tablets for a 5 mg weekly dose would reduce the risk of a serious overdose).

To learn more, visit the ISMP website.

In addition, when methotrexate is being dispensed to a patient in compliance packaging the best practices outlined on page of the Sep/Oct 2012 ACP News article should be considered.