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Drug interactions may be important risk factors for methotrexate neurotoxicity, particularly in pediatric leukemia patients

Lookup NU author(s): Dr Frederik van DelftORCiD, Professor Roderick Skinner



This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0).


Methotrexate administration is associated with frequent adverse neurological events during treatment for childhood acute lymphoblastic leukemia. Here, we present evidence to support the role of common drug interactions and low vitamin B-12 levels in potentiating methotrexate neurotoxicity.We review the published evidence and highlight key potential drug interactions as well as present clinical evidence of severe methotrexate neurotoxicity in conjunction with nitrous oxide anesthesia and measurements of vitamin B-12 levels among pediatric leukemia patients during therapy.We describe a very plausible mechanism for methotrexate neurotoxicity in pediatric leukemia patients involving reduction in methionine and consequential disruption of myelin production. We provide evidence that a number of commonly prescribed drugs in pediatric leukemia management interact with the same folate biosynthetic pathways and/or reduce functional vitamin B-12 levels and hence are likely to increase the toxicity of methotrexate in these patients. We also present a brief case study supporting out hypothesis that nitrous oxide contributes to methotrexate neurotoxicity and a nutritional study, showing that vitamin B-12 deficiency is common in pediatric leukemia patients.Use of nitrous oxide in pediatric leukemia patients at the same time as methotrexate use should be avoided especially as many suitable alternative anesthetic agents exist. Clinicians should consider monitoring levels of vitamin B-12 in patients suspected of having methotrexate-induced neurotoxic effects.

Publication metadata

Author(s): Forster VJ, van Delft FW, Baird SF, Mair S, Skinner R, Halsey C

Publication type: Article

Publication status: Published

Journal: Cancer Chemotherapy and Pharmacology

Year: 2016

Volume: 78

Issue: 5

Pages: 1093-1096

Print publication date: 01/11/2016

Online publication date: 22/09/2016

Acceptance date: 02/09/2016

Date deposited: 06/01/2017

ISSN (print): 0344-5704

ISSN (electronic): 1432-0843

Publisher: Springer


DOI: 10.1007/s00280-016-3153-0


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