Introduction:

High-alert medications have an increased risk of causing significant patient harm when used incorrectly. Methotrexate (MTX) is an antimetabolite used in the treatment of rheumatologic diseases and an example of a high-alert medication.

Case report: We present the case of a 64-year-old male who took daily 17,5 mg of oral MTX despite using this medication for several years. The patient was evaluated for dysphagia, pruritic skin rash, and halitosis. The physical examination revealed extensive oral mucositis and oropharyngeal edema. After therapeutic review, it was realized that the patient was taking the prescribed dose daily instead of weekly. He was then referred to the emergency room to evaluate medullary involvement.

Comment:

Patient accidental intoxication is the most common cause of MTX toxicity, frequently with severe side effects, which can be fatal. This case report allows reflecting on some important aspects of medication safety with this type of drug.

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