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WARNING: SEVERE TOXIC REACTIONS, INCLUDING EMBRYO-FETAL TOXICITY
See full Prescribing Information for complete boxed warning.
Methotrexate can cause the following severe or fatal adverse reactions.
Monitor closely and modify dose or discontinue methotrexate as appropriate.
Bone marrow suppression [see Warnings and Precautions (5.1)]
Serious infections [see Warnings and Precautions (5.2) ]
Renal toxicity and increased toxicity with renal impairment [see Warnings and Precautions (5.3)]
Gastrointestinal toxicity [see Warnings and Precautions (5.4)]
Hepatic toxicity [see Warnings and Precautions (5.5)]
Pulmonary toxicity [see Warnings and Precautions (5.6)]
Hypersensitivity and dermatologic reactions [see Warnings and Precautions (5.7)]
Methotrexate can cause embryo-fetal toxicity, including fetal death. Use in pJIA is contraindicated
in pregnancy. Consider the benefits and risks of XATMEP and risks to the fetus when prescribing
XATMEP to a pregnant patient with a neoplastic disease. Advise females and males of reproductive
potential to use effective contraception during and after treatment with XATMEP [see Contraindications
(4), Warnings and Precautions (5.9), Use in Specific Populations (8.1, 8.3)].
INDICATIONS
Xatmep is a folate analog metabolic inhibitor indicated for the:
treatment of pediatric patients with acute lymphoblastic leukemia (ALL) as part of a multi-phase, combination chemotherapy
maintenance regimen
management of pediatric patients with active polyarticular juvenile idiopathic arthritis (pJIA) who have had
an insufficient therapeutic response to, or are intolerant of, an adequate trial of first-line therapy including
full dose non-steroidal anti-inflammatory agents (NSAIDs).
ADDITIONAL IMPORTANT SAFETY INFORMATION
Contraindications:
Xatmep is contraindicated in pregnant patients with non-malignant disease and in patients with severe
hypersensitivity to methotrexate.
Xatmep suppresses hematopoiesis and can cause severe and life-threatening pancytopenia, anemia, leukopenia,
neutropenia, and thrombocytopenia. Obtain blood counts at baseline and periodically; monitor patients for
complications of bone marrow suppression.
Patients treated with Xatmep are at increased risk for developing life-threatening or fatal bacterial, fungal, or viral
infections, including Pneumocystis jiroveci pneumonia, invasive fungal infections, hepatitis B reactivation,
tuberculosis (primary or reactivation), disseminated Herpes zoster and cytomegalovirus infections.
Renal toxicity and increased toxicity with renal impairment, including acute renal failure. Consider administration
of glucarpidase in patients with toxic plasma methotrexate concentrations (>1 micromole/liter) and delayed
clearance due to impaired renal function.
Xatmep can cause diarrhea, stomatitis, vomiting, hemorrhagic enteritis, and fatal intestinal perforation. Patients
with peptic ulcer disease and ulcerative colitis are at increased risk for severe gastrointestinal adverse reactions.
Unexpected severe and fatal gastrointestinal toxicity can occur with concomitant use of NSAIDs.
Hepatic toxicity: severe and potentially irreversible hepatotoxicity, including fibrosis, cirrhosis, and fatal liver failure
can occur. Avoid use of Xatmep in patients with chronic liver disease.
Pulmonary toxicity: acute or chronic interstitial pneumonitis and irreversible or fatal cases can occur at all
dose levels.
Hypersensitivity: anaphylaxis or other serious hypersensitivity reactions. Discontinue methotrexate.
Severe, including fatal, dermatologic reactions such as toxic epidermal necrolysis, Stevens-Johnson
syndrome, exfoliative dermatitis, skin necrosis, erythema multiforme can occur. Radiation dermatitis and
sunburn may be “recalled.”
Secondary malignancies can occur at all dose levels. Lymphoproliferative disease has been reported with
low-dose oral methotrexate which regressed when methotrexate is withdrawn.
Methotrexate can cause embryo-fetal toxicity and fetal death when administered during pregnancy. Consider the
risks and benefits of Xatmep and risks to the fetus when prescribing to a pregnant patient with a neoplastic
disease. Effective contraception should be practiced by patients of reproductive potential while receiving Xatmep
therapy, and for 3 and 6 months afterwards for males and females, respectively. Xatmep is contraindicated in
non-neoplastic disease.
Effects on reproduction: Methotrexate can cause impairment of fertility, oligospermia, and menstrual dysfunction.
It is unknown if the infertility is reversible in affected patients.
Increased toxicity in third-space accumulation. Evacuate significant third-space accumulation prior
to methotrexate administration.
Immunizations may be ineffective when given during Xatmep therapy.
Immunization with live virus vaccines is not recommended during Xatmep therapy.
Concomitant radiation therapy increases the risk of soft tissue necrosis and osteonecrosis associated
with methotrexate.
Closely monitor laboratory parameters for hematology, renal function, and liver function. Increase monitoring
during initial dosing, dose changes, and during periods of increased risk of elevated methotrexate blood levels
(e.g., dehydration).
Pulmonary function tests may be useful if methotrexate-induced lung disease is suspected, especially
if baseline measurements are available.
Risk of improper dosing: Once-weekly dosing is appropriate. Fatal toxicity has been reported with daily dosing.
An accurate milliliter measuring device should be used. Inform patients that a household teaspoon is not an
accurate measuring device and could lead to overdosage.
Advise women not to breastfeed during Xatmep therapy.
Most common adverse reactions are ulcerative stomatitis, leukopenia, nausea, abdominal distress, and elevated
liver function tests.
Other frequently reported reactions are malaise, fatigue, chills and fever, dizziness, and decreased resistance
to infection.
The approximate incidences of adverse reactions reported in pediatric patients with JIA treated with oral, weekly
doses of methotrexate (5 to 20 mg/m2/week or 0.1 to 0.65 mg/kg/week) were as follows (virtually all patients
were receiving concomitant nonsteroidal anti-inflammatory drugs, and some also were taking low doses of
corticosteroids): elevated liver function tests, 14%; gastrointestinal reactions (e.g., nausea, vomiting, diarrhea),
11%; stomatitis, 2%; leukopenia, 2%; headache, 1.2%; alopecia, 0.5%; dizziness, 0.2%; and rash, 0.2%. Although
there is experience with dosing up to 30 mg/m2/week in JIA, the published data for doses above 20 mg/m2/week
are too limited to provide reliable estimates of adverse reaction rates.
Drug Interactions:
Penicillins may reduce the clearance of methotrexate; increased serum concentrations of methotrexate
with concomitant hematologic and gastrointestinal toxicity have been observed with methotrexate. Monitor
patients accordingly.
Trimethoprim/sulfamethoxazole has been reported to increase bone marrow suppression in patients receiving
methotrexate. Monitor patients accordingly.
Hepatotoxins: May increase hepatotoxicity. Monitor patients receiving concomitant hepatotoxins for signs
of hepatotoxicity.
Probenecid may reduce renal elimination of methotrexate; consider alternative drugs.
Theophylline: May decrease theophylline clearance. Monitor theophylline levels.
