Methotrexate Sodium Prescribing Information
• Methotrexate Tablets can cause embryo-fetal toxicity, including fetal death. For non-neoplastic diseases, Methotrexate Tablets are contraindicated in pregnancy. For neoplastic diseases, advise females and males of reproductive potential to use effective contraception[see Contraindications (.), Warnings and Precautions (4 CONTRAINDICATIONSMethotrexate Tablets are contraindicated in:
• Pregnant women receiving Methotrexate Tablets for treatment of non-neoplastic diseases[see Warnings and Precautions (5.1), and Use in Specific Populations ].• Patients with a history of severe hypersensitivity reactions, including anaphylaxis, to methotrexate[see Warnings and Precautions ].
• In pregnancy for non-neoplastic diseases• History of severe hypersensitivity to methotrexate
), Use in Specific Populations (5.1 Embryo-Fetal ToxicityBased on published reports and its mechanism of action, Methotrexate Tablets can cause fetal harm, including fetal death, when administered to a pregnant woman. Methotrexate Tablets is contraindicated for use in pregnant women receiving Methotrexate Tablets for the treatment of non-malignant diseases. Advise pregnant women with neoplastic diseases of the potential risk to a fetus. Advise females of reproductive potential to use effective contraception during treatment with Methotrexate Tablets and for 6 months after the final dose. Advise males with female partners of reproductive potential to use effective contraception during Methotrexate Tablets treatment and for 3 months after the final dose
[seeContraindications , Use in Specific Populations ].,8 USE IN SPECIFIC POPULATIONSLactation:Instruct not to breastfeed.8.1 PregnancyRisk SummaryMethotrexate Tablets are contraindicated in pregnant women with non-neoplastic diseases
[see Contraindications ].Based on published reports and its mechanism of action
[see Clinical Pharmacology ], methotrexate can cause embryo-fetal toxicity and fetal death when administered to a pregnant woman. There are no animal data that meet current standards for nonclinical developmental toxicity studies. Advise pregnant women with neoplastic diseases of the potential risk to a fetus.In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.
DataHuman DataPublished data from case reports, literature reviews, and observational studies report that methotrexate exposure during pregnancy is associated with an increased risk of embryo-fetal toxicity and fetal death. Methotrexate exposure during the first trimester of pregnancy is associated with an increased incidence of spontaneous abortions and multiple adverse developmental outcomes, including skull anomalies, facial dysmorphism, central nervous system abnormalities, limb abnormalities, and sometimes cardiac anomalies and intellectual impairment. Adverse outcomes associated with exposure during second and third trimesters of pregnancy include intrauterine growth restriction and functional abnormalities. Because methotrexate is widely distributed and persists in the body for a prolonged period, there is a potential risk to the fetus from preconception methotrexate exposure.
A prospective multicenter study evaluated pregnancy outcomes in women taking methotrexate less than or equal to 30 mg/week after conception. The rate of spontaneous abortion and miscarriage in pregnant women exposed to methotrexate was 42% (95% confidence interval [95% CI] 29, 59), which was higher than in unexposed patients with autoimmune disease (22%; 95% CI: 17, 30) and unexposed patients with nonautoimmune disease (17%; 95% CI: 13, 23). Of the live births, the rate of major birth defects in pregnant women exposed to methotrexate after conception was higher than in unexposed patients with autoimmune disease (adjusted odds ratio (OR) 1.8 [95% CI: 0.6, 6]) and unexposed patients with non-autoimmune disease (adjusted OR 3.1 [95% CI: 1, 10]) (2.9%). Major birth defects associated with pregnancies exposed to methotrexate after conception were not always consistent with methotrexate-associated adverse developmental outcomes.
8.2 LactationRisk SummaryLimited published literature report the presence of methotrexate in human milk in low amounts, with the highest breast milk to plasma concentration ratio reported to be 0.08:1. There are no data on the effects of methotrexate or its metabolites on the breastfed child or their effects on milk production. Because of the potential for serious adverse reactions in a breastfed child, instruct women not to breastfeed during treatment with Methotrexate Tablets and for 1 week after the final dose.
8.3 Females and Males of Reproductive PotentialMethotrexate can cause malformations and fetal death at doses less than or equal to the recommended clinical doses
[Use in Specific Populations ].Pregnancy TestingVerify the pregnancy status of females of reproductive potential prior to initiating Methotrexate Tablets
[see Contraindications , Use in Specific Populations ].ContraceptionFemalesAdvise females of reproductive potential to use effective contraception during treatment with Methotrexate Tablets and for 6 months after the final dose.
MalesMethotrexate can cause chromosomal damage to sperm cells. Advise males with female partners of reproductive potential to use effective contraception during treatment with Methotrexate Tablets and for 3 months after the final dose.
InfertilityFemalesBased on published reports of female infertility after methotrexate, advise females of reproductive potential that methotrexate can cause impairment of fertility and menstrual dysfunction during treatment with Methotrexate Tablets and after the final dose. It is not known if the infertility may be reversed in all affected females.
MalesBased on published reports of male infertility after methotrexate, advise males that methotrexate can cause oligospermia or infertility during treatment with Methotrexate Tablets and after the final dose. It is not known if the infertility may be reversed in all affected males.
8.4 Pediatric UseThe safety and effectiveness of Methotrexate Tablets in pediatric patients have been established for the treatment of ALL as part of the combination chemotherapy maintenance regimen and the treatment of pJIA
[see Indications and Usage , Dosage and Administration ]. No new safety signals have been observed in pediatric patients in clinical studies[see Adverse Reactions ].The safety and effectiveness of Methotrexate Tablets have not been established in pediatric patients for the other indications
[see Indications and Usage ]. Patients with renal impairment are at increased risk for methotrexate adverse reactions. Closely monitor patients with renal impairment [creatinine clearance (CLcr) less than 90 mL/min, Cockcroft-Gault] for adverse reactions. Reduce the dosage or discontinue Methotrexate Tablets as appropriate[see Warnings and Precautions ].8.7 Hepatic ImpairmentThe pharmacokinetics and safety of methotrexate in patients with hepatic impairment is unknown. Patients with hepatic impairment may be at increased risk for methotrexate adverse reactions based on the elimination characteristics of methotrexate
[see Clinical Pharmacology ].Closely monitor patients with hepatic impairment for adverse reactions. Reduce the dosage or discontinue Methotrexate Tablets as appropriate[see Warnings and Precautions ].)]8.3 Females and Males of Reproductive PotentialMethotrexate can cause malformations and fetal death at doses less than or equal to the recommended clinical doses
[Use in Specific Populations ].Pregnancy TestingVerify the pregnancy status of females of reproductive potential prior to initiating Methotrexate Tablets
[see Contraindications , Use in Specific Populations ].ContraceptionFemalesAdvise females of reproductive potential to use effective contraception during treatment with Methotrexate Tablets and for 6 months after the final dose.
MalesMethotrexate can cause chromosomal damage to sperm cells. Advise males with female partners of reproductive potential to use effective contraception during treatment with Methotrexate Tablets and for 3 months after the final dose.
InfertilityFemalesBased on published reports of female infertility after methotrexate, advise females of reproductive potential that methotrexate can cause impairment of fertility and menstrual dysfunction during treatment with Methotrexate Tablets and after the final dose. It is not known if the infertility may be reversed in all affected females.
MalesBased on published reports of male infertility after methotrexate, advise males that methotrexate can cause oligospermia or infertility during treatment with Methotrexate Tablets and after the final dose. It is not known if the infertility may be reversed in all affected males.
• Methotrexate Tablets are contraindicated in patients with a history of severe hypersensitivity reactions to methotrexate, including anaphylaxis[Contraindications (), Warnings and Precautions (4 CONTRAINDICATIONSMethotrexate Tablets are contraindicated in:
• Pregnant women receiving Methotrexate Tablets for treatment of non-neoplastic diseases[see Warnings and Precautions (5.1), and Use in Specific Populations ].• Patients with a history of severe hypersensitivity reactions, including anaphylaxis, to methotrexate[see Warnings and Precautions ].
• In pregnancy for non-neoplastic diseases• History of severe hypersensitivity to methotrexate
)].5.2 Hypersensitivity ReactionsHypersensitivity reactions, including anaphylaxis, can occur with methotrexate
[see Contraindications , AdverseReactions ].If anaphylaxis or other serious hypersensitivity reaction occurs, immediately and permanently discontinue Methotrexate Tablets
[see Dosage and Administration ].• Serious adverse reactions, including death, have been reported with methotrexate. Closely monitor for adverse reactions of the bone marrow, gastrointestinal tract, liver, lungs, skin, and kidneys. Withhold or discontinue Methotrexate Tablets as appropriate[Warnings and Precautions (,5.3 MyelosuppressionMethotrexate suppresses hematopoiesis and can cause severe and life-threatening pancytopenia, anemia, leukopenia, neutropenia, and thrombocytopenia
[see Adverse Reactions ].Obtain blood counts at baseline, periodically during treatment, and as clinically indicated. Monitor patients for clinical complications of myelosuppression. Withhold, dose reduce, or discontinue Methotrexate Tablets taking into account the importance of Methotrexate Tablet treatment in the context of the severity of the disease being treated, the severity of the adverse drug reaction, and availability of alternative therapy
[see Dosage and Administration ].,5.4 Gastrointestinal ToxicityDiarrhea, vomiting, nausea, and stomatitis occurred in up to 10% of patients receiving methotrexate for treatment of non-neoplastic diseases. Hemorrhagic enteritis and fatal intestinal perforation have been reported
[see Adverse Reactions ].Patients with peptic ulcer disease or ulcerative colitis are at a greater risk of developing severe gastrointestinal adverse reactions[see Drug Interactions ].Withhold or discontinue Methotrexate Tablets for severe gastrointestinal toxicity taking into account the importance of Methotrexate Tablet treatment in the context of the severity of the disease being treated, the severity of the adverse drug reaction, and availability of alternative therapy
[see Dosage and Administration ].,5.5 HepatotoxicityMethotrexate can cause severe and potentially irreversible hepatotoxicity, including fibrosis, cirrhosis, and fatal liver failure
[see Adverse Reactions ].The safety of Methotrexate Tablets in patients with hepatic disease is unknown.The risk of hepatotoxicity is increased with heavy alcohol consumption. In patients with psoriasis, fibrosis or cirrhosis may occur in the absence of symptoms or abnormal liver tests; the risk of hepatotoxicity appears to increase with total cumulative dose and generally occurs after receipt of a total cumulative dose of 1.5 g or more.
Monitor liver tests at baseline, periodically during treatment and as clinically indicated. Withhold or discontinue Methotrexate Tablets taking into account the importance of Methotrexate Tablet treatment in the context of the severity of the disease being treated, the severity of the adverse drug reaction, and availability of alternative therapy
[see Dosage andAdministration ].,5.6 Pulmonary ToxicityPulmonary toxicity, including acute or chronic interstitial pneumonitis and irreversible or fatal cases, can occur with methotrexate
[see Adverse Reactions ].Monitor patients for pulmonary toxicity and withhold or discontinue Methotrexate Tablets taking into account the importance of Methotrexate Tablet treatment in the context of the severity of the disease being treated, the severity of the adverse drug reaction, and availability of alternative therapy
[see Dosage and Administration ].,5.7 Dermatologic ReactionsSevere, including fatal dermatologic reactions, such as toxic epidermal necrolysis, Stevens-Johnson syndrome, exfoliative dermatitis, skin necrosis, and erythema multiforme, can occur with methotrexate
[see Adverse Reactions ].Exposure to ultraviolet radiation while taking methotrexate may aggravate psoriasis.
Methotrexate can cause radiation recall dermatitis and photodermatitis (sunburn) reactivation.
Monitor patients for dermatologic toxicity and withhold or permanently discontinue Methotrexate Tablets for severe dermatologic reactions taking into account the importance of Methotrexate Tablet treatment in the context of the severity of the disease being treated, the severity of the adverse drug reaction, and availability of alternative therapy
[see Dosage and Administration ].Advise patients to avoid excessive sun exposure and use sun protection measures.)].5.8 Renal ToxicityMethotrexate can cause renal toxicity, including irreversible acute renal failure
[see Adverse Reactions ].Monitor renal function at baseline, periodically during treatment and as clinically indicated. Withhold or discontinue Methotrexate Tablets for severe renal toxicity taking into account the importance of Methotrexate Tablet treatment in the context of the severity of the disease being treated, the severity of the adverse drug reaction, and availability of alternative therapy
[see Dosage and Administration ].Administer glucarpidase in patients with toxic plasma methotrexate concentrations (> 1 micromole per liter) and delayed methotrexate clearance due to impaired renal function. Refer to the glucarpidase prescribing information for additional information.
Methotrexate Tablets are a dihydrofolate reductase inhibitor indicated for the:
• Treatment of adults and pediatric patients with acute lymphoblastic leukemia (ALL) as part of a combination chemotherapy maintenance regimen ()1.1 Neoplastic DiseasesMethotrexate Tablets are indicated for the:
• treatment of adults and pediatric patients with acute lymphoblastic leukemia (ALL) as part of a combination chemotherapy maintenance regimen• treatment of adults with mycosis fungoides (cutaneous T-cell lymphoma) as a single agent or as part of a combination chemotherapy regimen• treatment of adults with relapsed or refractory non-Hodgkin lymphomas as part of a metronomic combination chemotherapy regimen
• Treatment of adults with mycosis fungoides ()1.1 Neoplastic DiseasesMethotrexate Tablets are indicated for the:
• treatment of adults and pediatric patients with acute lymphoblastic leukemia (ALL) as part of a combination chemotherapy maintenance regimen• treatment of adults with mycosis fungoides (cutaneous T-cell lymphoma) as a single agent or as part of a combination chemotherapy regimen• treatment of adults with relapsed or refractory non-Hodgkin lymphomas as part of a metronomic combination chemotherapy regimen
• Treatment of adults with relapsed or refractory non-Hodgkin lymphoma as part of a metronomic combination regimen ()1.1 Neoplastic DiseasesMethotrexate Tablets are indicated for the:
• treatment of adults and pediatric patients with acute lymphoblastic leukemia (ALL) as part of a combination chemotherapy maintenance regimen• treatment of adults with mycosis fungoides (cutaneous T-cell lymphoma) as a single agent or as part of a combination chemotherapy regimen• treatment of adults with relapsed or refractory non-Hodgkin lymphomas as part of a metronomic combination chemotherapy regimen
• Treatment of adults with rheumatoid arthritis ()1.2 Rheumatoid ArthritisMethotrexate Tablets are indicated for the treatment of adults with rheumatoid arthritis.
• Treatment of pediatric patients with polyarticular juvenile idiopathic arthritis (pJIA) ()1.3 Polyarticular Juvenile Idiopathic ArthritisMethotrexate Tablets are indicated for the treatment of pediatric patients with polyarticular Juvenile Idiopathic Arthritis (pJIA).
• Treatment of adults with severe psoriasis ()1.4 PsoriasisMethotrexate Tablets are indicated for the treatment of adults with severe psoriasis.
• Instruct patients and caregivers to take the recommended dosage as directed, because medication errors have led to deaths. (,2.1 Important Dosage and Safety InformationVerify pregnancy status in females of reproductive potential before starting Methotrexate Tablets
[see Contraindications , Warnings and Precautions ].Instruct patients and caregivers to take the recommended dosage as directed, because medication errors have led to deaths
[see Warnings and Precautions ].When switching the dosing regimen from oral administration to intravenous, intramuscular, or subcutaneous administration, an alternative dosing regimen may be necessary.
Do not administer to patients who are unable to swallow a tablet.
Methotrexate Tablets is a cytotoxic drug. Follow applicable special handling and disposal procedures.1
)5.9 Risk of Serious Adverse Reactions with Medication ErrorDeaths occurred in patients as a result of medication errors. Most commonly, these errors occurred in patients who were taking methotrexate daily when a weekly dosing regimen was prescribed.
For patients prescribed a once weekly dosing regimen, instruct patients and caregivers to take the recommended dosage as directed, because medication errors have led to death.
• Verify pregnancy status in females of reproductive potential before starting Methotrexate Tablets. (,4 CONTRAINDICATIONSMethotrexate Tablets are contraindicated in:
• Pregnant women receiving Methotrexate Tablets for treatment of non-neoplastic diseases[see Warnings and Precautions (5.1), and Use in Specific Populations ].• Patients with a history of severe hypersensitivity reactions, including anaphylaxis, to methotrexate[see Warnings and Precautions ].
• In pregnancy for non-neoplastic diseases• History of severe hypersensitivity to methotrexate
)5.1 Embryo-Fetal ToxicityBased on published reports and its mechanism of action, Methotrexate Tablets can cause fetal harm, including fetal death, when administered to a pregnant woman. Methotrexate Tablets is contraindicated for use in pregnant women receiving Methotrexate Tablets for the treatment of non-malignant diseases. Advise pregnant women with neoplastic diseases of the potential risk to a fetus. Advise females of reproductive potential to use effective contraception during treatment with Methotrexate Tablets and for 6 months after the final dose. Advise males with female partners of reproductive potential to use effective contraception during Methotrexate Tablets treatment and for 3 months after the final dose
[seeContraindications , Use in Specific Populations ].• ALL: The recommended dosage is 20 mg/m2 orally once weekly as a part of a combination chemotherapy maintenance regimen. ()2.2 Recommended Dosage for Neoplastic DiseasesAcute Lymphoblastic LeukemiaThe recommended starting dosage of Methotrexate Tablets is 20 mg/m2 orally once weekly, as part of a combination chemotherapy maintenance regimen. After initiating Methotrexate Tablets, periodically monitor absolute neutrophil count (ANC) and platelet count and adjust the dose to maintain ANC at a desirable level and for excessive myelosuppression.
Mycosis FungoidesThe recommended dosage of Methotrexate Tablets is 25 to 75 mg orally once weekly when administered as a single agent or 10 mg/m2 orally twice weekly as part of a combination chemotherapy regimen.
Relapsed or Refractory Non-Hodgkin LymphomasThe recommended dosage of Methotrexate Tablets is 2.5 mg orally 2 to 4 times per week (maximum 10 mg per week) as part of a metronomic combination chemotherapy regimen.
• Mycosis fungoides: The recommended dosage is 25 to 75 mg orally once weekly as monotherapy; 10 mg/m2 orally twice weekly as part of combination chemotherapy. ()2.2 Recommended Dosage for Neoplastic DiseasesAcute Lymphoblastic LeukemiaThe recommended starting dosage of Methotrexate Tablets is 20 mg/m2 orally once weekly, as part of a combination chemotherapy maintenance regimen. After initiating Methotrexate Tablets, periodically monitor absolute neutrophil count (ANC) and platelet count and adjust the dose to maintain ANC at a desirable level and for excessive myelosuppression.
Mycosis FungoidesThe recommended dosage of Methotrexate Tablets is 25 to 75 mg orally once weekly when administered as a single agent or 10 mg/m2 orally twice weekly as part of a combination chemotherapy regimen.
Relapsed or Refractory Non-Hodgkin LymphomasThe recommended dosage of Methotrexate Tablets is 2.5 mg orally 2 to 4 times per week (maximum 10 mg per week) as part of a metronomic combination chemotherapy regimen.
• Relapsed or refractory non-Hodgkin lymphoma: The recommended dosage is 2.5 mg orally two to four times per week as part of metronomic combination chemotherapy. ()2.2 Recommended Dosage for Neoplastic DiseasesAcute Lymphoblastic LeukemiaThe recommended starting dosage of Methotrexate Tablets is 20 mg/m2 orally once weekly, as part of a combination chemotherapy maintenance regimen. After initiating Methotrexate Tablets, periodically monitor absolute neutrophil count (ANC) and platelet count and adjust the dose to maintain ANC at a desirable level and for excessive myelosuppression.
Mycosis FungoidesThe recommended dosage of Methotrexate Tablets is 25 to 75 mg orally once weekly when administered as a single agent or 10 mg/m2 orally twice weekly as part of a combination chemotherapy regimen.
Relapsed or Refractory Non-Hodgkin LymphomasThe recommended dosage of Methotrexate Tablets is 2.5 mg orally 2 to 4 times per week (maximum 10 mg per week) as part of a metronomic combination chemotherapy regimen.
• Rheumatoid Arthritis: The recommended starting dosage is 7.5 mg orally once weekly; adjust dose to achieve an optimal response. ()2.3 Recommended Dosage for Rheumatoid ArthritisThe recommended starting dosage of Methotrexate Tablets is 7.5 mg orally once weekly with escalation to achieve optimal response. Dosages of more than 20 mg once weekly result in an increased risk of serious adverse reactions, including myelosuppression. When responses are observed, the majority occurred between 3 and 6 weeks from initiation of treatment; however, responses have occurred up to 12 weeks after treatment initiation.
Administer folic acid or folinic acid to reduce the risk of methotrexate adverse reactions
[see Warnings and Precautions ].• pJIA: The recommended starting dosage is 10 mg/m2 orally once weekly; adjust dose to achieve an optimal response. ()2.4 Recommended Dosage for Polyarticular Juvenile Idiopathic ArthritisThe recommended starting dosage of Methotrexate Tablets is 10 mg/m2orally once weekly with escalation to achieve optimal response. Dosages of more than 30 mg/m2once weekly result in an increased risk of serious adverse reactions, including myelosuppression. When responses are observed, the majority occurred between 3 and 6 weeks from initiation of treatment; however, responses have occurred up to 12 weeks after treatment initiation.
Administer folic acid or folinic acid to reduce the risk of methotrexate adverse reactions
[see Warnings and Precautions].• Psoriasis: The recommended dosage is 10 to 25 mg orally once weekly until adequate response is achieved. ()2.5 Recommended Dosage for PsoriasisThe recommended dosage of Methotrexate Tablets is 10 to 25 mg orally once weekly until an adequate response is achieved. Adjust the dose gradually to achieve optimal clinical response; do not exceed a dose of 30 mg per week. Once optimal clinical response has been achieved, reduce the dosage to the lowest possible dosing regimen.
Administer folic acid or folinic acid supplementation to reduce the risk of methotrexate adverse reactions
[see Warningsand Precautions ].
Methotrexate Tablets USP, 2.5 mg
2.5 mg tablets are supplied as a yellow, round slightly biconvex tablet, scored on one side and product identification “54 323” debossed on the other side.
Limited published literature report the presence of methotrexate in human milk in low amounts, with the highest breast milk to plasma concentration ratio reported to be 0.08:1. There are no data on the effects of methotrexate or its metabolites on the breastfed child or their effects on milk production. Because of the potential for serious adverse reactions in a breastfed child, instruct women not to breastfeed during treatment with Methotrexate Tablets and for 1 week after the final dose.
Methotrexate Tablets are contraindicated in:
• Pregnant women receiving Methotrexate Tablets for treatment of non-neoplastic diseases[see Warnings and Precautions (5.1), and Use in Specific Populations (,8 USE IN SPECIFIC POPULATIONSLactation:Instruct not to breastfeed.8.1 PregnancyRisk SummaryMethotrexate Tablets are contraindicated in pregnant women with non-neoplastic diseases
[see Contraindications ].Based on published reports and its mechanism of action
[see Clinical Pharmacology ], methotrexate can cause embryo-fetal toxicity and fetal death when administered to a pregnant woman. There are no animal data that meet current standards for nonclinical developmental toxicity studies. Advise pregnant women with neoplastic diseases of the potential risk to a fetus.In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.
DataHuman DataPublished data from case reports, literature reviews, and observational studies report that methotrexate exposure during pregnancy is associated with an increased risk of embryo-fetal toxicity and fetal death. Methotrexate exposure during the first trimester of pregnancy is associated with an increased incidence of spontaneous abortions and multiple adverse developmental outcomes, including skull anomalies, facial dysmorphism, central nervous system abnormalities, limb abnormalities, and sometimes cardiac anomalies and intellectual impairment. Adverse outcomes associated with exposure during second and third trimesters of pregnancy include intrauterine growth restriction and functional abnormalities. Because methotrexate is widely distributed and persists in the body for a prolonged period, there is a potential risk to the fetus from preconception methotrexate exposure.
A prospective multicenter study evaluated pregnancy outcomes in women taking methotrexate less than or equal to 30 mg/week after conception. The rate of spontaneous abortion and miscarriage in pregnant women exposed to methotrexate was 42% (95% confidence interval [95% CI] 29, 59), which was higher than in unexposed patients with autoimmune disease (22%; 95% CI: 17, 30) and unexposed patients with nonautoimmune disease (17%; 95% CI: 13, 23). Of the live births, the rate of major birth defects in pregnant women exposed to methotrexate after conception was higher than in unexposed patients with autoimmune disease (adjusted odds ratio (OR) 1.8 [95% CI: 0.6, 6]) and unexposed patients with non-autoimmune disease (adjusted OR 3.1 [95% CI: 1, 10]) (2.9%). Major birth defects associated with pregnancies exposed to methotrexate after conception were not always consistent with methotrexate-associated adverse developmental outcomes.
8.2 LactationRisk SummaryLimited published literature report the presence of methotrexate in human milk in low amounts, with the highest breast milk to plasma concentration ratio reported to be 0.08:1. There are no data on the effects of methotrexate or its metabolites on the breastfed child or their effects on milk production. Because of the potential for serious adverse reactions in a breastfed child, instruct women not to breastfeed during treatment with Methotrexate Tablets and for 1 week after the final dose.
8.3 Females and Males of Reproductive PotentialMethotrexate can cause malformations and fetal death at doses less than or equal to the recommended clinical doses
[Use in Specific Populations ].Pregnancy TestingVerify the pregnancy status of females of reproductive potential prior to initiating Methotrexate Tablets
[see Contraindications , Use in Specific Populations ].ContraceptionFemalesAdvise females of reproductive potential to use effective contraception during treatment with Methotrexate Tablets and for 6 months after the final dose.
MalesMethotrexate can cause chromosomal damage to sperm cells. Advise males with female partners of reproductive potential to use effective contraception during treatment with Methotrexate Tablets and for 3 months after the final dose.
InfertilityFemalesBased on published reports of female infertility after methotrexate, advise females of reproductive potential that methotrexate can cause impairment of fertility and menstrual dysfunction during treatment with Methotrexate Tablets and after the final dose. It is not known if the infertility may be reversed in all affected females.
MalesBased on published reports of male infertility after methotrexate, advise males that methotrexate can cause oligospermia or infertility during treatment with Methotrexate Tablets and after the final dose. It is not known if the infertility may be reversed in all affected males.
8.4 Pediatric UseThe safety and effectiveness of Methotrexate Tablets in pediatric patients have been established for the treatment of ALL as part of the combination chemotherapy maintenance regimen and the treatment of pJIA
[see Indications and Usage , Dosage and Administration ]. No new safety signals have been observed in pediatric patients in clinical studies[see Adverse Reactions ].The safety and effectiveness of Methotrexate Tablets have not been established in pediatric patients for the other indications
[see Indications and Usage ]. Patients with renal impairment are at increased risk for methotrexate adverse reactions. Closely monitor patients with renal impairment [creatinine clearance (CLcr) less than 90 mL/min, Cockcroft-Gault] for adverse reactions. Reduce the dosage or discontinue Methotrexate Tablets as appropriate[see Warnings and Precautions ].8.7 Hepatic ImpairmentThe pharmacokinetics and safety of methotrexate in patients with hepatic impairment is unknown. Patients with hepatic impairment may be at increased risk for methotrexate adverse reactions based on the elimination characteristics of methotrexate
[see Clinical Pharmacology ].Closely monitor patients with hepatic impairment for adverse reactions. Reduce the dosage or discontinue Methotrexate Tablets as appropriate[see Warnings and Precautions ].)].8.3 Females and Males of Reproductive PotentialMethotrexate can cause malformations and fetal death at doses less than or equal to the recommended clinical doses
[Use in Specific Populations ].Pregnancy TestingVerify the pregnancy status of females of reproductive potential prior to initiating Methotrexate Tablets
[see Contraindications , Use in Specific Populations ].ContraceptionFemalesAdvise females of reproductive potential to use effective contraception during treatment with Methotrexate Tablets and for 6 months after the final dose.
MalesMethotrexate can cause chromosomal damage to sperm cells. Advise males with female partners of reproductive potential to use effective contraception during treatment with Methotrexate Tablets and for 3 months after the final dose.
InfertilityFemalesBased on published reports of female infertility after methotrexate, advise females of reproductive potential that methotrexate can cause impairment of fertility and menstrual dysfunction during treatment with Methotrexate Tablets and after the final dose. It is not known if the infertility may be reversed in all affected females.
MalesBased on published reports of male infertility after methotrexate, advise males that methotrexate can cause oligospermia or infertility during treatment with Methotrexate Tablets and after the final dose. It is not known if the infertility may be reversed in all affected males.
• Patients with a history of severe hypersensitivity reactions, including anaphylaxis, to methotrexate[see Warnings and Precautions ()].5.2 Hypersensitivity ReactionsHypersensitivity reactions, including anaphylaxis, can occur with methotrexate
[see Contraindications , AdverseReactions ].If anaphylaxis or other serious hypersensitivity reaction occurs, immediately and permanently discontinue Methotrexate Tablets
[see Dosage and Administration ].