As in the US, residents here rotate on a monthly schedule so today I started working with an entirely new batch of residents doing oncology for the first time. Because I was a little more familiar with the patients I was able to help out with some of the history of the visit to get the residents up to speed.
One of my new patients today experienced an acute methotrexate overdose over the weekend though he has not shown any symptoms yet other than a bump in his creatinine. Whenever this happens, it's always on the weekend for some reason (Murphy's law right?). His 24 hour methotrexate level was about 35 (the usual target is 1) and his creatinine jumped from 77 to 211 in a day (oops forgot that we use the metric system over here...that would be from 0.87 to 2.39), which got worse during the day.
We're sort of stuck deciding whether the patient is sick enough to order the antidote because he hasn't shown any of the other toxicities yet. The common MTX toxicities would be nephrotoxicity, mucositis, diarrhea, myelosuppression, and pneumonitis and he only has one of them. The problem is there is no supplier in Singapore that stocks the antidote, Voraxaze (glucarpidase), which can dramatically bring down the MTX level in a day by cleaving the drug. If we were to order it, it would take 24-48 hours to arrive in Singapore from the UK. In the meantime, we're trying as hard as we can to hydrate and diurese him in the hopes that he'll start to clear the drug on his own. We'll see what happens tomorrow. Stay tuned!
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