title: Comparison of enteral and parenteral methods of urine alkalinization in patients receiving high-dose methotrexate.
abstract: Purpose Hyperhydration and urinary alkalinization is implemented with all high-dose (HD)-methotrexate infusions to promote excretion and prevent precipitation of methotrexate in the renal tubules. Our institution utilized enteral alkalinizing agents (sodium bicarbonate tablets and sodium citrate/citric acid solution) to alkalinize the urine of patients receiving HD-methotrexate during a parenteral sodium bicarbonate and sodium acetate shortage. The purpose of this study is to establish the safety and efficacy of the enteral route for urine alkalinization. Methods A single-center, retrospective, cohort study was conducted comparing cycles of HD-methotrexate using enteral alkalinizing agents to parenteral sodium bicarbonate. The primary objective was to compare the time, in hours, from administration of first inpatient administered dose of alkalinizing agent to time of achieving goal urine pH. Secondary objectives evaluated total dose of sodium bicarbonate required to achieve goal urine pH, time from start of urine alkalinizing agent until time of achieving methotrexate level safe for discharge, and toxicities associated with methotrexate and the alkalinizing agents. Results A total of 118 patients were included in this study, equally divided into two cohorts based on parenteral versus enteral routes of administration. No statistical difference was determined between the two cohorts regarding time to goal urine pH (6.5 h versus 7.9 h, P = 0.051) or regarding time to methotrexate level deemed safe for discharge (63.5 h versus 62.5 h, p = 0.835). There were no significant differences in methotrexate-induced toxicities. Conclusion Our study found enteral routes of urine alkalinization to be a viable alternative to the traditional parenteral sodium bicarbonate, especially during parenteral sodium bicarbonate and acetate shortages.
authors.affiliation: 1 Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD, USA.
authors.forename: Jamie A
authors.initials: JA
authors.lastname: Rouch
authors.affiliation: 1 Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD, USA.
authors.forename: Bradley
authors.initials: B
authors.lastname: Burton
authors.affiliation: 1 Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD, USA.
authors.forename: Alix
authors.initials: A
authors.lastname: Dabb
authors.affiliation: 1 Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD, USA.
authors.forename: Vicky
authors.initials: V
authors.lastname: Brown
authors.affiliation: 2 Physician Resource Management, INC., Ann Arbor, MI, USA.
authors.forename: Amy H
authors.initials: AH
authors.lastname: Seung
authors.affiliation: 3 Department of Pharmacy, The University of Washington Medical Center/Seattle Cancer Care Alliance, Seattle, WA, USA.
authors.forename: Katharine
authors.initials: K
authors.lastname: Kinsman
authors.affiliation: 4 Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Matthias
authors.initials: M
authors.lastname: Holdhoff
mesh_terms: D000863:Antacids / Q000008:administration & dosage / Q000009:adverse effects*; D002951:Citrates / Q000009:adverse effects; D005260:Female; D006801:Humans; D006863:Hydrogen-Ion Concentration; D007674:Kidney Diseases / Q000139:chemically induced; D008297:Male; D008727:Methotrexate / Q000008:administration & dosage / Q000009:adverse effects*; D008875:Middle Aged; D012189:Retrospective Studies; D019346:Sodium Acetate / Q000009:adverse effects; D017693:Sodium Bicarbonate / Q000009:adverse effects; D000077559:Sodium Citrate; D014556:Urine / Q000737:chemistry*
chemical_list: D000863:Antacids; D002951:Citrates; D000077559:Sodium Citrate; D019346:Sodium Acetate; D017693:Sodium Bicarbonate; D008727:Methotrexate
keywords: Sodium bicarbonate; methotrexate; urine alkalinization