“…Here, they can undergo further biotransformation by the gut microbiota. , A bacterial enzyme, carboxypeptidase glutamate 2 (CPDG2; also referred to as folylpolyglutamate carboxypeptidase [FGCP]), can cleave the terminal glutamate residues of MTX and 7-OH-MTX , resulting in metabolites such as 2,4-diamino- N -10-methylpteroic acid (DAMPA) and 7-hydroxy-DAMPA, respectively . In addition, bacterial enzymes such as p -aminobenzoyl-glutamate hydrolase, found in E. coli , have also been shown to catalyze this reaction . As these produced metabolites do not have activity toward DHFR inhibition, glutamate hydrolysis by CPDG2 is seen as a detoxication process. , As such, CPDG2 is approved as a rescue agent in cancer patients presenting delayed MTX clearance and acute nephrotoxicity, and several clinical studies have reported positive results for its use in this role. ,, Even so, MTX and its relatively insoluble metabolites are still presumed to precipitate in kidneys, causing nephrotoxicity, as well as causing severe gastrointestinal toxicity such as vomiting, diarrhea, oral mucositis and, in some cases, the death of patients …”