Severe bone marrow suppression due to methotrexate toxicity following aceclofenac-induced acute kidney injury

Abstract

Methotrexate is one of the most commonly used drugs in autoimmune disorders like rheumatoid arthritis. Gastrointestinal symptoms like nausea and stomatitis, skin rashes, alopecia, central nervous system symptoms like headache and confusion, hepatotoxicity and myelosuppression are some of the adverse effects. However, low oral doses on a weekly basis seldom show any signs of toxicity. Leucovorin or folinic acid is given along with methotrexate as rescue to reduce the toxic effects like bone marrow suppression. Non-steroidal anti-inflammatory drugs, like aceclofenac, are also used in chronic inflammatory conditions like rheumatoid arthritis and osteoarthritis. Nephrotoxicity is one of the adverse effects of both methotrexate and non-steroidal anti-inflammatory drugs; and its combined administration should be done with caution. This is a case of an elderly woman, a known case of rheumatoid arthritis, who presented in severe bone marrow suppression due to methotrexate toxicity following aceclofenac-induced acute kidney injury.

Single Low-Dose Methotrexate and Vitamin B12 Deficiency-Induced Pancytopenia Causing Fatality: A Case Report

“…Amid worsening pancytopenia, a bone marrow biopsy was warranted due to multiple potential contributors. The results were concordant with previously reported findings of bone marrow biopsies found with MTX toxicity in the literature: hypocellular marrow with trilineage hypoplasia consistent with myelosuppression induced by MTX [ 10 ]. There were also reported neutrophils hypersegmentation and erythrocyte budding, a finding that is also found in B12 deficiency.…”

Methotrexate Induced Oral Mucositis and Bone Marrow Suppression in Psoriatic Patient

“…In renal impairment cases, low doses are enough to cause bone marrow suppression and also diabetes mellitus may have role for altering the pharmacokinetics of MTX by physiological environment altering of the body [9]. In the year 1996, a literature review by Pearce and Wilson have identified 47 cases of MTX induced skin ulceration which was reported between the years of 1951 and 1967 and further of 17 cases between the year 1967 and 1996 (including two of their own patients and those of which by Roenigk et al and Lawrence and Dhal) [10].…”

Aceclofenac: a balance of efficacy and safety in the treatment of pain and inflammation

“…Риск желудочно-кишечных кровотечений или изъязвлений может повышаться при использовании НПВП одновременно с системными глюкокортикостероидами, антикоагулянтами (например, варфарином), селективными ингибиторами обратного захвата серотонина или антиагрегантами, например, аспирином. Совместное применение НПВП и метотрексата может повысить уровень метотрексата в плазме, что приводит к увеличению его токсичности [35,53,56].…”