{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T17:22:28Z","timestamp":1791393748379,"version":"4.3.3"},"reference-count":42,"publisher":"MDPI AG","issue":"20","license":[{"start":{"date-parts":[[2025,10,20]],"date-time":"2025-10-20T00:00:00Z","timestamp":1760918400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: High-dose methotrexate (HDMTX) is widely used for acute lymphoblastic leukaemia (ALL), but its pharmacokinetic (PK) variability and toxicity require therapeutic drug monitoring (TDM). Our 10-year retrospective study investigated HDMTX PK parameters and their associations with renal and hepatic biomarkers in an Italian cohort of adult patients with ALL. Methods: Plasma MTX concentrations [MTX C(p)] were measured at 24-, 48-, and 72 h post-infusion. PK modelling was performed to calculate area under the curve (AUC0 \u2192 72 h) and half-life (t\u00bd). Creatinine, total bilirubin, and sample quality indices were retrieved from routine clinical laboratory analyses. Results: Mean (\u00b1SEM) MTX plasma concentrations were 36.09 \u00b1 15.53 \u03bcmol\/L, 0.93 \u00b1 0.43 \u03bcmol\/L, and 0.30 \u00b1 0.07 \u03bcmol\/L at 24, 48, and 72 h, respectively, with marked inter-patient variability. PK analysis showed a mean AUC0 \u2192 72 h of 112.85 \u00b1 34.09 h\u00b7\u03bcmol\/L and a t\u00bd of 17.15 \u00b1 2.40 h. MTX C(p) and AUC0 \u2192 72 h showed significant positive correlations with serum creatinine at all time points, confirming renal function as a major MTX clearance determinant. Age moderated the relationship at 72 h, with younger patients showing stronger correlations. Hepatic function measured by total bilirubin also correlated with MTX C(p) and AUC0 \u2192 72 h at 48 and 72 h, especially in younger patients, suggesting a hepatic contribution to MTX variability. No associations were found between the PK parameters and lipemic, icterus, or haemolysis indices. Conclusions: These findings highlight the value of integrating renal and hepatic biomarkers into HDMTX drug monitoring protocols. Such biomarker-informed TDM may improve the safety and efficacy by identifying patients at risk of delayed clearance and toxicity, especially younger individuals or those with renal insufficiency.<\/jats:p>","DOI":"10.3390\/jcm14207400","type":"journal-article","created":{"date-parts":[[2025,10,20]],"date-time":"2025-10-20T13:54:41Z","timestamp":1760968481000},"page":"7400","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Pharmacokinetics and Monitoring of Methotrexate in Adults with Acute Lymphoblastic Leukaemia: A 10-Year Follow-Up at an Italian Centre"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8652-3667","authenticated-orcid":false,"given":"Pasquale Fabio","family":"Calabr\u00f2","sequence":"first","affiliation":[{"name":"Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8401-4615","authenticated-orcid":false,"given":"Letizia","family":"Biso","sequence":"additional","affiliation":[{"name":"Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marianna","family":"Lastella","sequence":"additional","affiliation":[{"name":"Unit of Clinical Pharmacology and Pharmacogenetics, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy"},{"name":"Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-8966-7604","authenticated-orcid":false,"given":"Arianna","family":"Bandini","sequence":"additional","affiliation":[{"name":"Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0672-2066","authenticated-orcid":false,"given":"Marta","family":"Banchi","sequence":"additional","affiliation":[{"name":"Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Costanza","family":"Tacchi","sequence":"additional","affiliation":[{"name":"Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Donghao","family":"Tang","sequence":"additional","affiliation":[{"name":"Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1447-4947","authenticated-orcid":false,"given":"Marco","family":"Carli","sequence":"additional","affiliation":[{"name":"Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stefano","family":"Fogli","sequence":"additional","affiliation":[{"name":"Unit of Clinical Pharmacology and Pharmacogenetics, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy"},{"name":"Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aldo","family":"Paolicchi","sequence":"additional","affiliation":[{"name":"Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy"},{"name":"Unit of Clinical Pharmacology and Pharmacogenetics, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marco","family":"Scarselli","sequence":"additional","affiliation":[{"name":"Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy"},{"name":"Unit of Clinical Pharmacology and Pharmacogenetics, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2661-6183","authenticated-orcid":false,"given":"Antonello","family":"Di Paolo","sequence":"additional","affiliation":[{"name":"Unit of Clinical Pharmacology and Pharmacogenetics, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy"},{"name":"Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7120-9141","authenticated-orcid":false,"given":"Guido","family":"Bocci","sequence":"additional","affiliation":[{"name":"Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy"},{"name":"Unit of Clinical Pharmacology and Pharmacogenetics, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,10,20]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"748","DOI":"10.1592\/phco.25.5.748.63584","article-title":"High-Dose Methotrexate in Acute Lymphoblastic Leukemia: Where Is the Evidence for Its Continued Use?","volume":"25","author":"Mantadakis","year":"2005","journal-title":"Pharmacotherapy"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"157","DOI":"10.1159\/000203749","article-title":"Treatment of Acute Leukemia with Amethopterin (4-Amino, 10-Methyl Pteroyl Glutamic Acid)","volume":"4","author":"Meyer","year":"1950","journal-title":"Acta Haematol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"231","DOI":"10.1016\/j.jpeds.2013.10.029","article-title":"Methotrexate: New Uses for an Old Drug","volume":"164","author":"Hashkes","year":"2014","journal-title":"J. Pediatr."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1177\/14782715241312256","article-title":"Low-Dose Methotrexate in Rheumatology: A Reinvented Drug","volume":"55","author":"Gupta","year":"2025","journal-title":"J. R. Coll. Physicians Edinb."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"512","DOI":"10.1080\/09546634.2020.1770170","article-title":"Topical Methotrexate in Dermatology: A Review of the Literature","volume":"33","author":"Aickara","year":"2022","journal-title":"J. Dermatol. Treat."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1159","DOI":"10.1111\/aogs.14617","article-title":"Methotrexate vs Expectant Management for Treatment of Tubal Ectopic Pregnancy: An Individual Participant Data Meta-analysis","volume":"102","author":"Solangon","year":"2023","journal-title":"Acta Obstet. Gynecol. Scand."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"2380","DOI":"10.1200\/JCO.2015.62.4544","article-title":"Dexamethasone and High-Dose Methotrexate Improve Outcome for Children and Young Adults with High-Risk B-Acute Lymphoblastic Leukemia: A Report From Children\u2019s Oncology Group Study AALL0232","volume":"34","author":"Larsen","year":"2016","journal-title":"J. Clin. Oncol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"67","DOI":"10.1200\/JOP.18.00271","article-title":"Acute Lymphoblastic Leukemia in the Older Adult","volume":"15","author":"Aldoss","year":"2019","journal-title":"J. Oncol. Pract."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1903","DOI":"10.1182\/blood.2023023568","article-title":"Management of ALL in Adults: 2024 ELN Recommendations from a European Expert Panel","volume":"143","author":"Boissel","year":"2024","journal-title":"Blood"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1471","DOI":"10.1634\/theoncologist.2015-0164","article-title":"Preventing and Managing Toxicities of High-Dose Methotrexate","volume":"21","author":"Howard","year":"2016","journal-title":"Oncologist"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"689","DOI":"10.1038\/s41397-018-0047-z","article-title":"Genetic Markers in Methotrexate Treatments","volume":"18","author":"Giletti","year":"2018","journal-title":"Pharmacogenom. J."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"131","DOI":"10.1080\/17512433.2025.2465426","article-title":"Therapeutic Drug Monitoring in Acute Lymphoblastic Leukemia\u2013a Deep Dive into Pharmacokinetics, -Dynamics, and -Genetics of Antileukemic Drugs","volume":"18","author":"Toksvang","year":"2025","journal-title":"Expert. Rev. Clin. Pharmacol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"2456","DOI":"10.1111\/bcp.15134","article-title":"Medication Therapy of High-dose Methotrexate: An Evidence-based Practice Guideline of the Division of Therapeutic Drug Monitoring, Chinese Pharmacological Society","volume":"88","author":"Song","year":"2022","journal-title":"Br. J. Clin. Pharmacol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"150","DOI":"10.1016\/j.curtheres.2009.04.005","article-title":"Relationship of Serum Methotrexate Concentration in High-Dose Methotrexate Chemotherapy to Prognosis and Tolerability: A Prospective Cohort Study in Chinese Adults with Osteosarcoma","volume":"70","author":"Lin","year":"2009","journal-title":"Curr. Ther. Res."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"694","DOI":"10.1634\/theoncologist.11-6-694","article-title":"Understanding and Managing Methotrexate Nephrotoxicity","volume":"11","author":"Widemann","year":"2006","journal-title":"Oncologist"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"291","DOI":"10.1093\/nop\/npad008","article-title":"Hepatotoxicity from High-Dose Methotrexate in Primary Central Nervous System Lymphoma","volume":"10","author":"Zhang","year":"2023","journal-title":"Neuro-Oncol. Pract."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"e15","DOI":"10.1515\/cclm-2015-0321","article-title":"Evaluation of the New Methotrexate CMIA Assay on the Architect I2000SR","volume":"54","author":"Florin","year":"2016","journal-title":"Clin. Chem. Lab. Med. (CCLM)"},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Tian, G., Wu, Y., Jin, X., Zeng, Z., Gu, X., Li, T., Chen, X., Li, G., and Liu, J. (2022). The Incidence Rate and Influence Factors of Hemolysis, Lipemia, Icterus in Fasting Serum Biochemistry Specimens. PLoS One, 17.","DOI":"10.1371\/journal.pone.0262748"},{"key":"ref_19","unstructured":"(2015). Quality Management Systems\u2014Requirements (Standard No. ISO 9001:2015)."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"306","DOI":"10.1016\/j.cmpb.2010.01.007","article-title":"PKSolver: An Add-in Program for Pharmacokinetic and Pharmacodynamic Data Analysis in Microsoft Excel","volume":"99","author":"Zhang","year":"2010","journal-title":"Comput. Methods Programs Biomed."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Wickham, H. (2016). Ggplot2 Graphics for Data Analysis, Springer. [2nd ed.].","DOI":"10.1007\/978-3-319-24277-4"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"666","DOI":"10.1124\/jpet.102.034330","article-title":"Characterization of Methotrexate Transport and Its Drug Interactions with Human Organic Anion Transporters","volume":"302","author":"Takeda","year":"2002","journal-title":"J. Pharmacol. Exp. Ther."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"8259470","DOI":"10.1155\/sci5\/8259470","article-title":"Combating Methotrexate Resistance in Cancer Treatment: A Review on Navigating Pathways and Enhancing Its Efficacy With Fat-Soluble Vitamins","volume":"2025","author":"Kakkadath","year":"2025","journal-title":"Scientifica"},{"key":"ref_24","first-page":"92","article-title":"Importance of Sex-Dependent Differences for Dosing Selection and Optimization of Chemotherapeutic Drugs","volume":"70","author":"Seydoux","year":"2024","journal-title":"Chemotherapy"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1339","DOI":"10.1007\/s00280-019-03966-4","article-title":"Population Pharmacokinetic Analysis of High-Dose Methotrexate in Pediatric and Adult Oncology Patients","volume":"84","author":"Kawakatsu","year":"2019","journal-title":"Cancer Chemother. Pharmacol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"3569","DOI":"10.1182\/blood.V92.10.3569","article-title":"Pharmacokinetics and Pharmacodynamics of Oral Methotrexate and Mercaptopurine in Children with Lower Risk Acute Lymphoblastic Leukemia: A Joint Children\u2019s Cancer Group and Pediatric Oncology Branch Study","volume":"92","author":"Balis","year":"1998","journal-title":"Blood"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"e70136","DOI":"10.1111\/cts.70136","article-title":"The Role of Candidate Polymorphisms in Drug Transporter Genes on High-Dose Methotrexate in the Consolidation Phase of the AIEOP-BFM ALL 2009 Protocol","volume":"18","author":"Braidotti","year":"2025","journal-title":"Clin. Transl. Sci."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"106","DOI":"10.1111\/j.1365-2125.2011.04054.x","article-title":"High Dose Methotrexate Chemotherapy: Pharmacokinetics, Folate and Toxicity in Osteosarcoma Patients","volume":"73","author":"Holmboe","year":"2012","journal-title":"Br. J. Clin. Pharmacol."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Lin, C., Ma, R., Zeng, X., Zhang, B., Cao, T., Jiao, S., Chen, H., He, Y., Liu, M., and Cai, H. (2024). Integration of Genomics, Clinical Characteristics and Baseline Biological Profiles to Predict the Risk of Liver Injury Induced by High-Dose Methotrexate. Front. Pharmacol., 15.","DOI":"10.3389\/fphar.2024.1423214"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1354","DOI":"10.1111\/bjh.19365","article-title":"High-dose Methotrexate Pharmacokinetics and Its Impact on Prognosis of Paediatric Acute Lymphoblastic Leukaemia Patients: A Population Pharmacokinetic Study","volume":"204","author":"Chen","year":"2024","journal-title":"Br. J. Haematol."},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"Gao, X., Qian, X.-W., Zhu, X.-H., Yu, Y., Miao, H., Meng, J.-H., Jiang, J.-Y., Wang, H.-S., and Zhai, X.-W. (2021). Population Pharmacokinetics of High-Dose Methotrexate in Chinese Pediatric Patients with Acute Lymphoblastic Leukemia. Front. Pharmacol., 12.","DOI":"10.3389\/fphar.2021.701452"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"7719","DOI":"10.12659\/MSM.912999","article-title":"Renal Function and Plasma Methotrexate Concentrations Predict Toxicities in Adults Receiving High-Dose Methotrexate","volume":"24","author":"Yang","year":"2018","journal-title":"Med. Sci. Monit."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"279","DOI":"10.1002\/pbc.25305","article-title":"Statistical Analysis of Relation between Plasma Methotrexate Concentration and Toxicity in High-dose Methotrexate Therapy of Childhood NonHodgkin Lymphoma","volume":"62","author":"Tsurusawa","year":"2015","journal-title":"Pediatr. Blood Cancer"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"32","DOI":"10.1097\/BS9.0000000000000142","article-title":"Effects of Genetic Polymorphisms on Methotrexate Levels and Toxicity in Chinese Patients with Acute Lymphoblastic Leukemia","volume":"5","author":"Hao","year":"2023","journal-title":"Blood Sci."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"847","DOI":"10.1007\/s00280-006-0388-1","article-title":"Methotrexate Pharmacokinetics in Infants with Acute Lymphoblastic Leukemia","volume":"59","author":"Thompson","year":"2007","journal-title":"Cancer Chemother. Pharmacol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"439","DOI":"10.1007\/BF00562319","article-title":"Renal Function and the Rate of Disappearance of Methotrexate from Serum","volume":"8","author":"Kristensen","year":"1975","journal-title":"Eur. J. Clin. Pharmacol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"111","DOI":"10.1515\/cclm-2023-0350","article-title":"A Sensitive LC-MS\/MS Methotrexate Assay Capable of Assessing Adherence to Methotrexate Therapy in Rheumatoid Arthritis","volume":"62","author":"McTaggart","year":"2024","journal-title":"Clin. Chem. Lab. Med. (CCLM)"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"172","DOI":"10.1093\/labmed\/lmab048","article-title":"Evaluation of the Preanalytical Interference of Hemoglobin, Bilirubin, or Lipids in Therapeutic Drug Monitoring Assays on Beckman Coulter AU Analyzers","volume":"53","author":"Li","year":"2022","journal-title":"Lab. Med."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"119","DOI":"10.1093\/ajcp\/aqw088","article-title":"Evaluation of a Methotrexate Chemiluminescent Microparticle Immunoassay","volume":"146","author":"Hernando","year":"2016","journal-title":"Am. J. Clin. Pathol."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1043","DOI":"10.21873\/anticanres.15565","article-title":"Risk Factors for Hepatic Toxicity of High-Dose Methotrexate in Patients with Osteosarcoma","volume":"42","author":"Abe","year":"2022","journal-title":"Anticancer Res."},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Moghadam, A.R., Tutunchi, S., Namvaran-Abbas-Abad, A., Yazdi, M., Bonyadi, F., Mohajeri, D., Mazani, M., Marzban, H., \u0141os, M.J., and Ghavami, S. (2015). Pre-Administration of Turmeric Prevents Methotrexate-Induced Liver Toxicity and Oxidative Stress. BMC Complement. Altern. Med., 15.","DOI":"10.1186\/s12906-015-0773-6"},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"He, X., Yao, P., Li, M., Liang, H., Liu, Y., Du, S., Zhang, M., Sun, W., Wang, Z., and Hao, X. (2021). A Risk Scoring Model for High-Dose Methotrexate-Induced Liver Injury in Children with Acute Lymphoblastic Leukemia Based on Gene Polymorphism Study. Front. Pharmacol., 12.","DOI":"10.3389\/fphar.2021.726229"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/20\/7400\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,20]],"date-time":"2025-10-20T14:17:56Z","timestamp":1760969876000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/20\/7400"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,10,20]]},"references-count":42,"journal-issue":{"issue":"20","published-online":{"date-parts":[[2025,10]]}},"alternative-id":["jcm14207400"],"URL":"https:\/\/doi.org\/10.3390\/jcm14207400","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,10,20]]}}}