Pancytopenia related to low-dose pulse methotrexate in the treatment of rheumatoid arthritis undergoing maintenance hemodialysis

We report two dialysis patients with the early onset of pancytopenia related to low-dose weekly pulse methotrexate (MTX) with rheumatoid arthritis. Case 1: A 46-year-old woman on maintenance hemodialysis for 15 years was admitted because of genital bleeding, severe mucositis and fever. Two weeks before admission she began to receive 5.0mg of MTX a week for RA. On admission, her white blood cell (WBC) count was 200/μl with 2% neutrophils, 20% eosinophils, 0% basophils, 0% basophils, 73% lymphocytes and 0% monocytes. Hemoglobin was 3.8g/dl and the platelet count was 35, 000/μl. She was treated with granulocyte colony stimulating factor (G-CSF), antibiotics, and platelet and red blood cell transfusions. Peripheral blood recovery was apparent by the 12th day after admission. MTX has not been restarted. Case 2: A 49-year-old woman on maintenance hemodialysis for 9 months was admitted because of treatment for RA. She had previously received prednisolone (10mg/day) and diclofenac sodium (50mg/day). These drugs were not very effective for joint swelling and tenderness, so she started taking 2.5mg of MTX a week. On the 10th day after administration of MTX, she developed severe mucositis and fever. On the 15th day, her WBC count was 300/μl with 0% neutrophils, 30% eosinophils, 1% basophils, 69% lymphocytes and 0% monocytes. Hemoglobin was 5.8 g/dl and the platelet count was 13, 000/μl. She was treated with G-CSF, antibiotics, and leucovorin and platelet transfusions. Peripheral blood recovery was apparent by the 19th day after the second administration of MTX. MTX has not been restarted. Low-dose pulse MTX therapy is effective for RA. Pancytopenia resulting from this therapy has been reported in patients with impaired renal function, advanced age, decreased serum albumin and concurrent ingestion of nonsteroidal anti-inflammatory drugs. We recommend that dialysis patients avoid low-dose MTX, since MTX is poorly removed by hemodialysis and the patients show an allergic reaction to MTX.