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11/4/25 Leucovorin Rescue IVPB Order Set
November 4, 2025
Good afternoon,
Inpatient oncology has seen a surge in patients receiving HDMTX (with a handful not clearing their MTX in a timely manner). Because of this, it has prompted us to re-evaluate our leucovorin rescue options in Cerner/MedManager.
Background: See below the excerpt from our HDMTX Onc Pharmacist Process document. Traditionally, larger doses of leucovorin were mixed in 250 mL of NS or D5W. If patients failed to clear their HDMTX in a timely manner, the leucovorin dose would be increased from the starting dose of 25 mg IV Push q6h, often resulting in the patient getting leucovorin dosed every 3 hours (and consequently 250 mL of fluid q3 hours).
There is now a new product selection in MedManager for leucovorin RESCUE IVPB if a patient fails to clear their methotrexate.
- Can be used to enter "high" doses of leucovorin that may be required for leucovorin rescue per our protocol (attached to this email and available on FormWeb) when MTX levels are elevated.
- Keep in mind - leucovorin doses > 150 mg have to be given as IV infusion due to calcium content.
- If a patient is receiving 100 mg/m2 of leucovorin and the dose is calculated to be > 150 mg due to their BSA, the leucovorin rescue product may be used. This product is NOT appropriate for 1000 mg/m2 doses (max concentration 10 mg/mL for IVPB solutions).
- Total volume = NS or D5W 50 mL over 30 minutes (as pump library is set to 30 minute infusions)
Leucovorin Dosing per the Onc Pharmacist MTX Process (available on FormWeb under leucovorin and or/methotrexate drug entry)
Methotrexate level at 24 to 35 hours:
|
Methotrexate Level (µM/L) |
Leucovorin dosing |
|
>100 |
1,000 mg/m2 IV every 6 hours |
|
>10 to <100 |
100 mg/m2 IV every 3 hours |
|
~1 to 10 |
10 mg/m2 IV 6 hours |
Methotrexate level at 36 to 71 hours:
|
Methotrexate Level (µM/L) |
Leucovorin dosing |
|
>100 |
1,000 mg/m2 IV every 6 hours |
|
>10 to <100 |
100 mg/m2 IV every 3 hours |
|
~1 to 10 |
100 mg/m2 IV every 6 hours |
Methotrexate level at 72+ hours:
|
Methotrexate Level (µM/L) |
Leucovorin dosing |
|
>10 |
100 to 1,000 mg/m2 IV every 3 hours |
|
~1 to 10 |
10 mg/m2 to 100 mg/m2 IV every 3 hours |
|
~0.1 to 1 |
10 mg/m2 IV every 6 hours |
Please reach out with any questions/comments/concerns,
Sam Lightle, PharmD
Clinical Pharmacy Specialist, Oncology/Hematology
Program Coordinator, PGY-2 Oncology Pharmacy Residency
Huntsville Hospital
Ascom: (256) 817-4196