REMINDER: Methotrexate 10mg tablet alert warning

Further recent incident in November 2018

The incident occurred in the Portsmouth locality and has been kindly brought to our attention by Simon Norman, Directorate Pharmacist, Rheumatology & MSK, Portsmouth Hospital NHS Trust.

Please read and action the recommendations shown below and ensure the whole team is briefed on this important issue.

Previous incident reported in October 2017

The patient reported that when she had her last prescription of Methotrexate she was given 10mg instead of 2.5mg tablets. The patient knew she had to take 4 tablets, as she had previously been prescribed the medication, and hence took a dose of 40mg rather than the 10mg prescribed. The patient had previously had a prescription filled at the same particular pharmacy before and was given 2.5mg tablets, so did not check the bottle this time.

The Rheumatology Nurses at hospitals tend to counsel their patients by telling them how many (2.5mg) tablets to take on a weekly basis, and this is then also written onto the prescription. It is good practice from them also to indicate on the prescription, the dose to be dispensed using 2.5mg tablets, but this is not always done.

There have been two similar incidents where patients have been issued with 10mg tablets (although the patients took the correct methotrexate dose on these occasions) - and fed this back to the Nurses at the hospital, that if they had just gone by the number of tablets that they had been instructed to take, they likely would have overdosed.

CPSC are jointly issuing this reminder to ensure vigilance over Methotrexate prescriptions.

From a safety perspective we have the following recommendations:

• Advised the LMC that the 10mg tablets should never prescribed.
• Not to stock the 10mg tablets at all in community pharmacies.