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Formulary and Stocking Status of Glucarpidase for High-Dose Methotrexate Toxicity at a Pediatric Academic Medical Center

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Formulary and Stocking Status of Glucarpidase for High-Dose Methotrexate Toxicity at a Pediatric Academic Medical Center

Background

•Methotrexate, a folate antimetabolite, is widely used for treating pediatric malignancies

•High-dose methotrexate can cause acute nephrotoxicity during administration leading to delayed elimination and excessive accumulation of methotrexate
 
•Leucovorin, a reduced form of folic acid, is routinely used as rescue after high-dose methotrexate administration, although it is unclear whether leucovorin rescue alone prevents toxicity from prolonged high levels of methotrexate
 
•Glucarpidase, a recombinant enzyme that rapidly hydrolyzes methotrexate to inactive metabolites, may be employed to rapidly reduce toxic methotrexate  concentrations independent of renal function
 
•Addition of glucarpidase to the hospital formulary was denied and vials are not stocked due to cost, short expiration dating, and rapid availability from a specialty pharmacy
 
•An institutional policy exists to guide appropriate non-formulary use and procurement
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