High dose methotrexate chemotherapy: pharmacokinetics, folate and toxicity in osteosarcoma patients

Br J Clin Pharmacol. 2012 Jan;73(1):106-14. doi: 10.1111/j.1365-2125.2011.04054.x.


Aims: To investigate the relationships between pretreatment folate concentrations, MTX pharmacokinetics and acute toxicities following high dose methotrexate (HD MTX) therapy.

Methods: MTX and its major extracellular metabolite 7-OH-MTX were measured in eight serum samples per HD MTX cycle in 65 consecutive osteosarcoma patients (288 cycles) and AUC (area under the blood concentration-time curve) was calculated. Pretreatment concentrations of folate in serum (S) and erythrocytes (ER) were determined. Hepatic, renal and haematological toxicities, assessed by routine laboratory parameters, as well as mucositis were graded according to National Cancer Institute Common Terminology Criteria for adverse events (CTCAE v.3.0). Dermatitis and pleuritis were reported as occurred or not.

Results: S- and ER-folate pretreatment concentrations increased significantly with increasing number of HD MTX cycles (P < 0.001). ER-folate pretreatment concentrations were higher among males (median 610 nmol l⁻¹, 95% CI 550, 680) compared with females (median 465 nmol l⁻¹, 95% CI 430, 520, P < 0.001), but showed no correlation with MTX or 7-OH-MTX pharmacokinetics. We found correlations between alanine aminotransferase peak concentration (ALAT(max) ) and clearance of MTX (P < 0.001), gender (P < 0.001), age (P < 0.001) and 7-OH-MTX concentrations (P < 0.001), the latter being the main factor influencing ALAT(max) .

Conclusion: Our results suggest that 7-OH-MTX is involved in the development of HD MTX hepatic toxicity and that young female patients are most affected.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Age Factors
  • Antimetabolites, Antineoplastic / adverse effects
  • Antimetabolites, Antineoplastic / pharmacokinetics*
  • Area Under Curve
  • Bone Neoplasms / metabolism*
  • Child
  • Dose-Response Relationship, Drug
  • Female
  • Folic Acid / metabolism*
  • Humans
  • Male
  • Methotrexate / adverse effects
  • Methotrexate / pharmacokinetics*
  • Middle Aged
  • Osteosarcoma / metabolism*
  • Reduced Folate Carrier Protein / metabolism
  • Sex Factors
  • Treatment Outcome
  • Young Adult


  • Antimetabolites, Antineoplastic
  • Reduced Folate Carrier Protein
  • Folic Acid
  • Methotrexate