Version June 2024
| Clinical situation | Laboratory findings | Management of levoleucovorin injection dosage and duration, and use of glucarpidase |
| Normal methotrexate elimination | Serum methotrexate level approximately 10 micromolar at 24 hours after administration, 1 micromolar at 48 hours, and less than 0.2 micromolar at 72 hours. | Levoleucovorin 7.5 mg IV every 6 hours for 60 hours (10 doses starting at 24 hours after start of methotrexate infusion). |
| Delayed late methotrexate elimination | Serum methotrexate level remaining above 0.2 micromolar at 72 hours and more than 0.05 micromolar at 96 hours after administration. | Continue levoleucovorin 7.5 mg IV every 6 hours until methotrexate level is less than 0.05 micromolar. |
| Delayed early methotrexate elimination and/or evidence of acute renal injury | Serum methotrexate level ≥50 micromolar at 24 hours, ≥30 micromolar at 36 hours, or ≥5 micromolar at 48 hours after administration; OR a 100% or greater increase in serum creatinine level from baseline at 24 hours after methotrexate administration (eg, an increase from 0.5 mg/dL to a level of 1 mg/dL or more). | Increase levoleucovorin to 75 mg IV every 3 hours until methotrexate level is less than 1 micromolar; then 7.5 mg IV every 3 hours until methotrexate level is less than 0.05 micromolar. If evidence of acute kidney injury with delayed MTX elimination, consider use of glucarpidase. Refer to UpToDate topics on use of methotrexate. |
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