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Alkalinization of urine (with bicarbonate and/or acetazolamide) and intravenous hydration (1000 mL per square meter of body surface area over six hours prior to beginning the methotrexate infusion and 3000 mL per square meter of body surface area per day during the methotrexate infusion and for two days after the infusion is completed) are also important to prevent renal toxicity caused by methotrexate and/or its metabolites. Pregnant women with psoriasis or rheumatoid arthritis should not receive methotrexate (See CONTRAINDICATIONS). May aid in identifying patients with delayed methotrexate clearance; toxicity appears to be related at least as much to the length of time that methotrexate concentrations are elevated as to the peak concentrations achieved. Interstitial pneumonitis has been reported in a limited number of patients receiving infliximab concomitantly with a stable dosage of methotrexate. Patients treated with concomitant methotrexate had a lower rate of antibody development than patients on Humira monotherapy (1% versus 12%). Leucovorin also is indicated as a rescue after high-dose methotrexate therapy in osteosarcoma and as a part of chemotherapeutic treatment programs in the management of several forms of cancer. However, elderly patients are more likely to have age-related renal function impairment, which may require adjustment of dosage in patients receiving leucovorin as a rescue from the effects of high-dose methotrexate. Methotrexate has been reported to cause fetal death and/or congenital anomalies. Methotrexate elimination is reduced in patients with impaired renal function, ascites, or pleural effusions. He was treated for RA with infliximab (3 mg/kg) for 3 years, as well as methotrexate (20 mg/week), and corticosteroids. In patients receiving concomitant methotrexate, the incidence was 6% compared to 26% with Humira monotherapy. Patients treated with methotrexate should be advised to seek medical attention if they experience potential signs and symptoms of hepatotoxicity such as fever, rash, anorexia, nausea, vomiting, fatigue, right upper quadrant pain, dark urine, and jaundice.
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