Hi Krissy,Hello from Sydney, Australia!We have had one instance in the last 12 months where we had to obtain Glucarpidase for a sarcoma patient who was administered high dose Mtx and whose levels were not going down despite folinic acid rescue (we have at least 1-2 high dose mtx patients per week). We eventually received permission by our hospital executives for funding of drug (cost is $22,000 AUD for this dose) to obtain this.However the process in Australia is slightly different - we do not purchase stock directly via our regular wholesaler or from the drug company (despite their head office being based in Sydney). We have to contact the Peter MacCallum Cancer Centre (PMCC) in Melbourne (whose Pharmacy department hold stock and dispatch this to hospitals that require this within 24-48 hours. Note that in the event of requiring Glucarpidase out of normal business hours, their on-call pharmacist is able to facilitate this as well).We were able to borrow stock from a major paediatric hospital in Sydney so that we were able to treat the patient sooner and then replace the hospital with the stock ordered from PMCC, which arrived the following day.I have been working in oncology/haematology pharmacy for over ten years and it was the first time we have had to use Glucarpidase. Unless your hospital have high incidences of mtx toxicity refractory to leucovorin rescue, and if the procurement process of glucarpidase is more than 24 hours it may be a financial risk to keep stock on hand.Hope that helps!
We have a lot of patients on high-dose MTX but do not stock glucarpidase. Since its approval, we have not used the drug more than a handful of times. The company can usually provide this agent in less than 24 hours, if needed. I would not succumb to the pressure from the rep, but ensure that there is a process in place for ordering the drug whenever needed.
Sepideh Shayani, Pharm.D., BCOP
Clinical Manager | Department of Pharmacy Services
Director | PGY-2 Residency, Oncology/Hematology/Stem Cell Transplant
City of Hope National Medical Center, Duarte, California
Phone#: 626-218-2510 | Pager: 626-423-6471
(1) Do you routinely stock glucarpidase?
Our hospital does not stock glucarpidase routinely.
(2) Does your center administer high dose MTX frequently?
We do frequently administer high dose MTX as a lot of the lymphoma and leukemia regimens contains HDMTX. However, we haven't had to use a dose of glucarpidase in years. The last time we used it, I remember we call a 1-800 number and it gets overnighted to us. Meanwhile, we hydrate the patient aggressively and administer larger doses of leucovorin and watch for signs of mucositis. The paper we have been following in regards to managing patients who have received HDMTX is: Understanding and Managing Methotrexate Nephrotoxocity, Brigitte et. al., The Oncologist June 2006 vol. 11 no. 6 694-703. Our standard practice has since migrated to alklanizing patients with 150meq of sodium bicarb in 1L of D5 or SWFI and run at 150mL/hr. We maintain pt at that rate unless their serum CO2 starts to approach 30, then we back off on the sodium bicarb content in each bag. We also give the patient leucovorin at 50mg PO Q6hrs 24hrs from the end of MTX infusion (unless otherwise specified by specific study protocols). Our pharmacists facilitate the initiation of leucovorin and MTX lab ordering. We have since not had to use any glucarpidase.
Hope this is helpful
Hongchao Liu, PharmD, BCOP
University of New Mexico Comprehensive Cancer Center