Administering methorexate

Mercy Hospitals
Learning Package in
Administering Methotrexate
1

© Published by Mercy Hospitals Victoria Ltd.
Authors:
Contributors:
Reviewed by:
Nicole Whiting, Peri-operative Nursing Educator
John Caluza, Clinical Nurse Educator
Natalie Hackett, Clinical Nurse Educator
Caroline Cooper-Blair,
Program Lead
Version: April 2017 / V1.0 Date: April 2017 Review:
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contents of this document may be altered and / or revised without prior notice; no responsibility is taken
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This document is bound by copyright and has been produced for the intended use of Mercy Hospitals,
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For more information, please contact:
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2

Table of Contents
Glossary of Terms 4
What is Methotrexate? 5
Mode of action
5
Indications 5
Precaution and Contraindications 6
How is Methotrexate administered?
a. Intramuscularly
b. Orally
Special considerations 7
6-7
Management and Precaution in administering Methotrexate
a. Health & safety
b. Extravasation
c. Cleaning a spill
d. Staff Decontamination and reporting
7-10
VII. Patient Education of Cytotoxic Drug 11
References 12
3

Glossary of Terms
Competency
Standards
Competent
Not Competent
Key Sites
Key Parts
Industry benchmark for training and assessment which specify the scope of
knowledge and skill sets to be covered in a training package
The learner has achieved required outcomes and can function efficiently and
independently and does not require cues and / or prompting. They can relate
theory to practice commensurate with the level of knowledge and skill
The learner has not achieved required outcomes and cannot function
efficiently and requires assistance. They cannot to relate theory to practice
commensurate with the level of knowledge and skill
The part of the patient that is accessed during an invasive procedure
A part of the equipment that must remain sterile and can only come into
contact with other key parts or key sites.
4

What is Methotrexate?
Methotrexate is a folic acid antagonist that interferes with DNA synthesis in actively proliferating tissues
such as trophoblastic tissue. It interferes with the growth of certain cells of the body, especially cells that
reproduce quickly, such as cancer cells, bone marrow cells, and skin cells.
Methotrexate is also used to treat certain types of cancer of the breast, skin, head and neck, or lung. It can
be used to treat severe psoriasis and rheumatoid arthritis with precaution as per doctors advice. This type
of medicine is usually given after other medications have been tried without successful treatment of
symptoms.
There are many reports in the medical literature of the successful treatment of non-ruptured ectopic
pregnancy with methotrexate administration. Potential side effects of methotrexate use include nausea,
diarrhoea, alopecia, stomatitis, abdominal pain, and serious effects such as pneumonitis, leucopoenia and
hepato/nephrotoxicity.
II. Mode of action
Methotrexate is an antimetabolite that interferes with DNA synthesis, repair, and cellular replication by
inhibiting dihydrofolate reductase. Tissues with high rates of cellular proliferation such as neoplasms, bone
marrow, fetal cells, buccal and intestinal mucosa, and cells of the urinary bladder are generally more
sensitive to the effects of methotrexate than most normal tissues.
III. Indications
According to treatment protocol, it is indicated to the following type of illness:
Breast cancer,
Bladder cancer,
Squamous cell cancer of head and neck,
Gestational trophoblastic disease,
Acute leukaemias,
Non-Hodgkin lymphomas,
Osteosarcoma, \
Brain tumours,
Graft-versus-host disease
Psoriasis
Rheumatoid arthritis
Crohn’s disease
Ectopic pregnancy
Polymyositis, dermatomyositis

IV. Precaution and Contraindications
Immunodeficiency syndromes—additive immunosuppression.
GI ulceration—may worsen.
Third space fluid collection, eg pleural effusion, ascites—may delay excretion of methotrexate and increase
toxicity; drain before treatment or provide folinic acid rescue.
Contraindications to systemic methotrexate include blood dyscrasias, renal disease, hepatic dysfunction
and active peptic ulcer disease, and pre-treatment exclusion of these conditions is recommended.
V. How is Methotrexate administered?
Methotrexate may cause very serious, life-threatening side effects therefore not only the patients who are
taking the medications need to take precautions but also the staff who handled the drugs and patient’s
bodily fluid, such as the nurses, psa, and other multidisciplinary team.
a. Intramuscularly
This will usually be performed by Nursing Staff, following a
Lap/D&C and if ordered by the doctor. It is local injection
indicated for the ectopic gestational mass and systemic
administration. Systemic administration has been proven
to be more affective in cases of tubal pregnancy. Two
protocols exist for the use of systemic methotrexate –
Single dose (50mg/m2 IMI) and multiple-dose (1mg/kg
IMI days 1, 3, 5 and 7, with folic acid rescue days 2, 4, 6
and 8).
As compared with the multiple-dose protocol, single-dose
methotrexate is less expensive, has fewer side effects,
does not require folic acid and rescue therapy and is more
readily accepted by patients.
The criteria to consider methotrexate treatment of ectopic pregnancy include a low initial hCG (

. Orally
Tablets are taken strictly as directed. It should only be
taken once a week on the same day each week; it must not
be taken every day unless otherwise indicated such as BMT,
Breast Ca treatment. Since these medications decrease
your immune system, it may increase your chances of
getting an infection. Nurses should report to the doctor any
signs and symptoms of cough, difficulty breathing or signs
of infection.
The pharmacist or nurses must obtain drug history before
administering this medication because some medications
together with methotrexate may lead to toxicity.
Staff training and education is needed in order to be competent in giving the medication.
Neoplastic indications: take tablets on an empty stomach with a glass of water, 1 hour before, or 2 hours
after, food.
Eg. Doses of methotrexate
tab, 2.5 mg, 30, Methoblastin, PBS
tab, 10 mg (scored), 15, 50, Methoblastin
VI. Special considerations:
This medicine may also cause bruising and bleeding
secondary to low platelet count (thrombocytopenia).
Avoid excessive or prolonged sun exposure, wear
protective clothing and use sunscreen. A follow up
appointment will be required as further blood test may be
required to determine the effectiveness of the
Methotrexate.
For gynae patients: The follow-up regarding repeat blood
tests performed after 4 days and 7 days to measure the
pregnancy hormone level. If the treatment is effective, the
patient will need to have a blood test to measure the
pregnancy hormone level every week until the result is
zero.
VII. Management and Precaution in administering Methotrexate
Methotrexate is a cytotoxic drug and precautions need to be taken when
administering this agent. Pregnant staff and those breast feeding should avoid
contact with cytotoxic agents. Some mutagenic cytotoxic agents may pose a
greater risk to male staff if there is continuous low-level exposure. For this
reason, guidelines have been drawn up recommending basic safety
procedures and administration techniques, to promote an awareness of the
potential hazards involved and ensure safe practice.

legislative requirements for health and safety
legislative requirements for waste management
the risk management process
occupational hazards of exposure to cytotoxic drugs and waste
control measures and work practices to be adopted when handling cytotoxic drugs and waste
maintenance of equipment
correct selection, use, cleaning and disposal of personal protective equipment
procedures to be adopted in the event of an accident, injury or spill
access to first aid resources
storage, transport, treatment and disposal of cytotoxic waste
Please refer to - Pharmacy Procedure -Safe Handling of Cytotoxic Drugs Mercy Health 2011
Nursing staff who administer Methotrexate needs to complete an annual competency to ensure both
patient & staff safety when giving and disposing of this drug. The staff who have completed the Cytotoxic
Management Module in EVIQ (https://education.eviq.org.au/courses/antineoplastic-drug-administrationfor-the-non-can)
are also a valuable resource when giving
methotrexate in business hours.
When giving methotrexate it is the responsibility of the
registered nurse caring for the patient to ensure that all OH&S
safety requirements are in place prior to giving the drug. The
registered nurse should also be well informed of the route &
side effects of methotrexate prior to its administration. It is
the responsibility of all registered nurses at Mercy Health to
complete their online competencies annually.
a. Health & safety
unless ¾ full.
The greatest risk of occupational exposure to cytotoxic
drugs is during drug manufacture and preparation because
of the concentrations and quantities used. Personal
protective equipment (PPE) must be worn when handling
contaminated waste. This includes closed footwear, nitrile
gloves, non-permeable long sleeved gown and protective
goggles if there is a risk of splashing it is recommended to
use N95 mask -airborne. Use only leurlock or interlink
fittings and connections. All PPE equipment worn while
administering methotrexate, as well as sharps &
ampoules’, should be placed in the purple sharps bin for
disposal. This should be sealed after use but not replaced
The personal protective equipment box must be in placed near the patient’s room, with the purple sharps
bin and contains the relevant protective equipment required to administer cytotoxic drugs. In operating
theatre the equipment is located in the recovery room. The purple sharps bin is required for safe disposal
of sharps used in cytotoxic therapy.

As with the administration of all drugs, the Medication, Double Checking, Drugs, administration Procedure
2011 –Mercy Health should be adhered to.
REMEMBER THE 7 R’S OF SAFE MEDICATION ADMINISTRATION
Right Dose
Right Drug
Right Patient
Right Time
Right Route
Right Documentation
Right reason
ALWAYS CHECK ALLERGIES/ SENSITIVIES
Please refer to Procedure - Medication, Double Checking, Drugs, and administration Procedure 2011 –
Mercy Health.
b. Extravasation
Extravasion is indicated by the presence of an erratic flow rate, absence of flow, erythema, blister
formation, streaking of the vein and/or pain. If this occurs, it is imperative that extravasation is detected
and managed quickly and efficiently to prevent necrosis and/or functional loss of the limb and tissue
concerned .The Extravasation kit is located in DPU and should be present when giving any cytotoxic drug
intravenously. If methotrexate is given intramuscularly or orally, all staff must be aware of this term & the
location of the kit available.
▪ Please refer to the Procedure -Management of Extravasation: Cytotoxic Drugs Mercy Health 2011 for
further information.
c. Cleaning a spill
Minor spills (cytotoxic spills less than 50mls or spills of body fluids containing cytotoxic agents) Spills
during agent administration, patient care and transport
• Isolate area and place signs if required
• Allocate responsibility for managing the spill staff contaminated by the agent should refer
to Personal Contamination another staff member should be allocated responsibility for
managing the spill
• Wear personal protective equipment; gown, gloves, eyewear, and mask; refer to Personal
Protective Equipment and spill Kit
• Contain and soak up the spill using dry absorbent material wash area with copious amounts
of alkaline detergent rinse area thoroughly with water dry area with absorbent materials
discard all waste into purple cytotoxic waste container remove personal protective
equipment, discard into purple cytotoxic waste.
• Wash hands thoroughly with soap and water complete an incident report
Major spills (cytotoxic spills greater than 50 mls)
• Isolate area and place signs
• Allocate responsibility for managing the spill

Staff contaminated by the agent should ask another staff member should be
allocated responsibility for managing the spill
• Access the nearest spill kit
• Put on gown, mask, protective eyewear, shoe coverings and double gloves (inner latex
glove and outer heavy utility glove) contained in the spill kit.
• Contain and cover the spill using appropriate absorbent material (absorbent side facing
down and plastic backed side up) provided in the spill kit.
• Use spill towels (in spills kit on ward) to wash area with alkaline detergent
• Use spill towels to rinse area thoroughly with water and to dry area fully.
• Discard all waste into large blue poly bag
• Remove shoe coverings and outer utility gloves and discard into blue poly bag
• Wearing inner gloves, seal blue poly bag and place into chemotherapy waste poly bag along
with gown, mask and protective eyewear
• Remove inner gloves and seal chemotherapy waste poly bag
• Place entire bag into purple cytotoxic waste bucket
• Wash hands thoroughly with soap and water
• Complete an incident report form
The spill kit
• A spill kit is available in Day Procedure Unit Nurses Station. Any spills or personnel contamination
must be reported as soon as possible to the director or deputy director of pharmacy. An incident
report must be completed detailing the type of incident, action taken to manage the spill and
action taken to prevent future occurrences.
• The Baxter spill kit is required to clean & contain a spill. This kit contains specific equipment and
signage to contain spills with minimal risk of exposure to others. If the kit is used Pharmacy need to
be advised so it can be replaced. All the waste from the spill is to be placed in the purple bag
provided in the Baxter Kit & sent for disposal.
d. Staff Decontamination and reporting
In the event of spillage of cytotoxic agents onto unprotected skin or into the eye, immediate
action should be taken to wash the material away with large volumes of water or sodium
chloride 0.9%.
In the event of a staff member and their clothing being contaminated by spillage of cytotoxic
agents the staff member should proceed immediately to shower and change contaminated
clothes. Contact the AHC and complete a VHIMS. Further medical attention as advised.

The Staff should notify the nurse in charge or the after-hours coordinator, who is responsible
for area at time and report to Medical Team if needed it is advised to be checked in ED. Staff
will complete an incident report.
VII.
Patient Education of Cytotoxic Drugs
It is important that patient and patient families are well educated if a cytotoxic drug has been given. Mercy
Health has a specific instruction sheet for patients on Methotrexate for the treatment and should be given
and explained prior to discharge. This process will occur on the ward prior to discharge.
Discharge instruction sheet will outline this information, as well as safety requirements regarding toilet
flushing etc. Staff will provide this to the patient & explained to them, prior to leaving the hospital.

References:
https://www.petermac.org/services/treatment/medical-oncology/chemotherapy/chemotherapy-drugsand-safety
https://www.petermac.org/sites/default/files/mediauploads/Late%20Effects%20Guidelines%20for%20GPs.pdf
Lipscomb GH, Stovall Tg, Lin FW. Nonsurgical Treatment of ectopic pregnancy. NEJM 2000; 343:1325-1329.
Fylstra DL. Tubal Pregnancy: A review OF Current Diagnosis and Treatment. Obs Gyn Survey 1998; 53:320-
328
Draycott T Read M. The managed care of early pregnancy problems. Current opinion Obs Gyn 1997; 9:262-
266
Sauer MV, Gorrill MJ et al. Nonsurgical management of unruptured ectopic pregnancy: an extended clinical
trial. Fertil Steril 1987; 48:752-755
Lipscomb GH, McCord ML et al. Predictors of Success of Methotrexate Treatment in Women with Tubal
Ectopic Pregnancies. NEJM 1999; 341:1974-1978
Sowter MC, Farquhar CM et al. A randomized trial comparing single dose systemic methotrexate and
laparoscopic surgery for the treatment of unruptured tubal pregnancy. BJOG 2001; 108:192-203.
Hajenius PJ, Engelsbel S et al. Randomized tiral of systemic methotrexate versus laparoscopic salpingostomy
in tubal pregnancy. Lancet 1997; 350:774-779.
▪ Morlock RJ, Lafata JE, Einstein D. Cost-Effectiveness of Single-Dose Methotrexate Compared with
Laparoscopic Treatment of Ectopic Pregnancy. Obstet Gynaecol 2000; 95:407-412
▪ Cytotoxic Agents – Safe Handling and administration.
CLINICAL PRACTICE GUIDELINE - Mercy Health
▪ Procedure - Medication, Double Checking, Drugs, administration Procedure 2011 –Mercy Health .
▪ Pharmacy Procedure -Safe Handling of Cytotoxic Drugs Mercy Health 2011
▪ Procedure -Management of Extravasation: Cytotoxic Drugs Mercy Health
2011