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MTX Pancytopenia Emergency — SCE Dermatology MCQ

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EasyDermatopharmacologyMTX Pancytopenia EmergencySCE Dermatology

A 55-year-old man with chronic plaque psoriasis has been on Methotrexate and has developed mucositis. His FBC shows pancytopenia (WCC 1.2, Hb 68, Plt 35). What is the emergency management?

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Correct answer: C — Stop Methotrexate immediately; administer IV Folinic acid (Calcium folinate) rescue; supportive care with transfusion, antibiotics, and G-CSF as needed; urgent haematology input

Methotrexate-induced pancytopenia is a medical emergency with significant mortality. Immediate management: (1) STOP Methotrexate; (2) IV Folinic acid (Calcium folinate — NOT folic acid; folinic acid bypasses the Methotrexate block, directly providing active folate for DNA synthesis); (3) Supportive care: blood/platelet transfusion, broad-spectrum antibiotics for febrile neutropenia, G-CSF consideration; (4) Urgent haematology input; (5) Monitor renal function (impaired renal clearance may have precipitated toxicity). Folic acid is NOT adequate rescue — folinic acid specifically is required. Common precipitants of MTX toxicity include: renal impairment, drug interactions (NSAIDs, Trimethoprim, Penicillins), overdose (daily instead of weekly dosing errors), and infection.

Reference: BAD 2016 MTX; NPSA; BNF