Supplemental material:

Between-course targeting of methotrexate exposure using pharmacokinetically-guided

dosage adjustments

Jennifer L. Pauley1, John C. Panetta1,4, Kristine R. Crews1,4, Deqing Pei2, Cheng Cheng2, John
McCormick1, Scott C. Howard3,4, John Sandlund3,4, Sima Jeha3,4, Raul Ribeiro3,4, Jeffrey
Rubnitz3,4, Ching-Hon Pui3,4, William E. Evans1,4, Mary V. Relling1,4

Departments of 1Pharmaceutical Sciences, 2Biostatistics, and 3Oncology, St. Jude Children's

Research Hospital, Memphis, TN; 4Colleges of Medicine and Pharmacy, University of
Tennessee, Memphis

Address reprint requests to Mary V. Relling, PharmD, Department of Pharmaceutical Sciences,

St. Jude Children’s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105-3678;
Phone: 901-595-2348; Fax: 901-525-8869; e-mail: [email protected]
 Supplemental Table 1: Leucovorin rescue dose schema

Window Therapy
Time from Plasma Recommended Leucovorin rescue
start of MTX concentration
Concentration thresholds for
action
23 hr if > 30 µM For 24 hr infusion: check that hydration and alkalinization are adequate, check for nephrotoxic drugs,
check creatinine
For 4 hr infusion: all of above plus consider glucarpidase and/or early LV rescue
> 50 µM For either infusion schedule: All of above plus check another concentration, consider possible early LV
rescue, obtaining glucarpidase, etc.
42 hr < 0.5 µM protocol rescue (50 mg/m2 IV at hr 44, then 15 mg/m2 IV q6h x 7 doses)
0.5 – 1 µM 50 mg/m2 IV, then 30 mg/m2 IV q 6h x 7 doses
1-2 µM 60 mg/m2 IV, then 45 mg/m2 IV q 6 hrs
2 - 5 µM 60 mg/m2 IV q 6 hrs
5-10 µM 100 mg/m2 IV q 6 hrs
10-20 µM 200 mg/m2 IV q 6 hrs
>20 Individualized
66 hr < 0.1 µM per protocol and stop checking
0.1-0.2 µM 5 mg/m2 po/IV q 12 hrs and keep checking ~ q 24 hrs until MTX concentration < 0.1
0.2-0.5 µM 15 mg/m2 po/IV q 6 hrs
0.5-1.0 µM 30 mg/m2 po/IV q 6 hrs
1.0-2.0 µM 45 mg/m2 q 6 hrs
2-5 µM 60 mg/m2 IV q 6 hrs
> 5 µM Individualized
92 hr and later 0.1 - 0.2 µM 5 mg/m2 q 12 hrs
0.2 - 0.5 µM 15 mg/m2 q 6 hrs
0.5 - 1.0 µM 30 mg/m2 q 12 hrs
> 1.0 µM as above under 68 hrs

Consolidation Therapy
Time from Plasma Recommended Leucovorin rescue
start of MTX concentration
Concentration thresholds for
action
23 hr--- 2.5 if > 45 µM Check that hydration and alkalinization are adequate; check for nephrotoxic drugs; check creatinine,
g/m2 (targeted notify the house officer and floor nurse to be particularly vigilant with urine output.
to 33 µM) > 150 µM all of above plus obtain another blood sample for assay, consider possible early LV rescue, obtaining
glucarpidase, etc.
23 hr--- 5.0 if > 95 µM Check that hydration and alkalinization are adequate; check for nephrotoxic drugs; check creatinine;
g/m2 (targeted notify the house officer and floor nurse to be particularly vigilant with urine output.
to 65 µM) > 150 µM all of above plus obtain another blood sample for assay, consider possible early LV rescue, obtaining
glucarpidase, etc.
42 hr < 1 µM protocol rescue (10 mg/m2 po q 6 hrs x 5 doses for LR and 15 mg/m2 IV/po x 5 doses for SR/HR)
1-2 µM 30 mg/m2 po/IV q 6 hrs
2-5 µM 50 mg/m2 IV q 6 hrs
5-10 µM 100 mg/m2 IV q 6 hrs
10-20 µM 200 mg/m2 IV q 6 hrs
>20 Individualized
66 hr < 0.1 µM per protocol and stop checking
0.1-0.2 µM 5 mg/m2 po/IV q 12 hrs and keep checking until MTX concentration < 0.1
0.2-0.5 µM 15 mg/m2 po/IV q 12 hrs
0.5-1.0 µM 15 mg/m2 po/IV q 6 hrs
1.0-2.0 µM 30 mg/m2 po/IV q 6 hrs
2-5 µM 50 mg/m2 IV q 6 hrs
>5 µM individualized
92 hr and later < 0.1 µM stop LV and stop checking
0.1-0.2 µM 5 mg/m2 po/IV q 12 hrs
0.2-0.5 µM 15 mg/m2 po/IV q 12 hrs
0.5 - 1.0 µM 15 mg/m2 po/IV q 6 hrs
> 1.0 µM as above under 68 hrs
LV: Leucovorin. IV: intravenous. PO: oral. q 6 hrs: dose every 6 hours. q 12 hrs: dose every 12
hours.
Supplemental Table 2: Patient Demographics

Low Risk Standard/High Risk

All patients Only those All patients Only those

who received who received
Targeted MTX Targeted MTX

n 233 220 252 224

Sex Male 114 109 160 137

Female 119 111 92 87

Self-Declared Race Caucasian 191 180 197 175

African American 32 32 49 44

Other 10 8 6 5

Lineage/Ploidy B lineage Hyperdiploid 102 95 18 16

B lineage Non-Hyperdiploid 131 125 160 143

T 0 0 74 65

Age (years) Median (min, max) 4.0 (1.0, 18.5) 3.9 (1.0, 18.5) 8.3 (1.0, 18.9) 8.3 (1.0, 18.9)
Supplemental Table 3: Univariate analysis of clinical features vs grade 3 or greater
gastrointestinal toxicity (A) in patients on the low risk arm and (B) patients on the
standard/high risk arm.

(A)

Parameter
Estimates Odd Ratio
Odd P
Clinical Variables Clinical Level Estimate Std err Ratio 95% CI of OR Values
MTX Cpss MTX Cpss 0.0464 0.0201 1.05 1.01 to 1.09 0.0210
MTX 42 hr concentration MTX 42 hr concentration 0.1701 0.1515 1.19 0.88 to 1.60 0.2614
Log-Total Leucovorin dose Log-Total Leucovorin dose 0.3758 0.7826 1.46 0.31 to 6.75 0.6311
Targeting success In Target -0.2593 0.8149 0.77 0.16 to 3.81 0.7504
Over Target 1.0121 0.8203 2.75 0.55 to 13.73 0.2173
Under Target
MTX Delayed Excretion MTX delayed 0.4893 0.7666 1.63 0.36 to 7.33 0.5233
Other

(B)

Parameter
Estimates Odd Ratio
Odd 95% CI of P
Clinical Variables Clinical Level Estimate Std err Ratio OR Values
MTX Cpss MTX Cpss 0.0083 0.0072 1.01 0.99 to 1.02 0.2491
MTX 42 hr concentration MTX 42 hr concentration 0.0751 0.0452 1.08 0.99 to 1.18 0.0970
Log-Total Leucovorin dose Log-Total Leucovorin dose 1.0741 0.2237 2.93 1.89 to 4.54 <.0001
Targeting success In Target 0.1378 0.4537 1.15 0.47 to 2.79 0.7614
Over Target 0.2439 0.4926 1.28 0.49 to 3.35 0.6206
Under Target
MTX Delayed Excretion MTX delayed 1.1068 0.3759 3.02 1.45 to 6.32 0.0032
Other
MTX: methotrexate. Cpss: Steady-State methotrexate concentration. In Target: achieved Cpss
within 20% of targeted Cpss. Over Target: achieved Cpss greater than 20% above targeted
Cpss. Under Target: achieved Cpss below 20% of targeted Cpss. MTX delayed: methotrexate
concentration greater than 1 µM at 42 hours. Std err: Standard Deviation. CI: Confidence
Interval. OR: Odds Ratio. The Odds Ratio and corresponding p-value were determined using a
univariate generalized estimating equation model. MTX Cpss, MTX 42 hr concentration, and
log-total leucovorin dose were analyzed as continuous variable data; targeting success and
MTX delayed excretion were analyzed as categorical variables.
 Supplemental Figure 1: Methotrexate Dose Individualization Scheme at Consolidation

Low Risk Arm

Standard/High Risk Arm

Estimate MTX CL from previous HDMTX course Estimate MTX CL from previous HDMTX course

Previous MTX CL ≤ Previous

125 ml/min/m2
MTX CL > 125 ml/min/m2 or first 55 patient

Use previous MTX CL to predict MTX CL for current course.

Use to
Use previous MTX CL, CRE, BILI, and SGPT previous
predict MTX
MTX CL
CL to
forpredict
currentMTX CL for current cou
course.*

Use predicted
Use predicted MTX CL to predict MTX dose needed to achieve a CpssMTX
of 33CL
µMto predict MTX dose needed to achieve a Cpss of 65 µM

Estimated dose is NOT within 50% of previous dose. Estimated dose is NOT within 50% of previous dose
Estimated dose is within 50% of previous dose. Estimated dose is within 50% of previous dose.
   

Use estimated dose Use estimated

Maximumdose
increase or decrease of 50% of previous do
Maximum increase or decrease of 50% of previous dose
MTX: methotrexate. CL: clearance. HDMTX: High Dose methotrexate. CRE: creatinine. BILI:
bilirubin. SGPT: Serum Glutamic Pyruvic Transaminase. Cpss: Steady-State methotrexate
concentration.

* Log(MTX CL) = 4.349 + 0.1152·Log(Previous MTX CL) - 0.3422·CRE – 0.2390·BILI –

0.000582·SGPT
Supplemental Figure 2: Methotrexate clearance (MTX CL) vs serum chemistries obtained
within 24 hours before targeted courses during consolidation in standard/high risk
patients (n=683 courses in 187 patients). Circles are the individual measurements and the
solid line is the best fit line. (A) creatinine (r2=0.037, p<10-4), (B) bilirubin (r2=0.048, p<10-4)
and (C) SGPT (Serum Glutamic Pyruvic Transaminase) (r2=0.014, p<2.5Χ10-3).

(A)
(B)
(C)