Assessment

• Assess patient for nausea and vomiting secondary to methotrexate therapy or folic acid antagonists (pyrimethamine and trimethoprim) overdose. Parenteral route may be necessary to ensure that patient receives dose

» Monitor for development of allergic reactions (rash, urticaria, wheezing). Notify health care professional if these occur

• Assess degree of weakness and fatigue

• Leucovorin rescue: Monitor serum methotrexate levels to determine dose and effectiveness of therapy. Leucovorin calcium levels should be equal to or greater than methotrexate level. Rescue continues until serum methotrexate level is <5 × 10M

» Monitor CCr and serum creatinine prior to and every 24 hr during therapy to detect methotrexate toxicity. An increase >50% over the pretreatment concentration at 24 hr is associated with severe renal toxicity

» Monitor urine pH every 6 hr during therapy; pH should be maintained >7 to decrease nephrotoxic effects of high-dose methotrexate. Sodium bicarbonate or acetazolamide may be ordered to alkalinize urine

» Megaloblastic anemia—Monitor plasma folic acid levels, hemoglobin, hematocrit, and reticulocyte count prior to and periodically during therapy

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