Methotrexate and its polyglutamate derivatives in erythrocytes during and after weekly low-dose oral methotrexate therapy of children with acute lymphoblastic leukemia.

Methotrexate and methotrexate polyglutamates were quantitatively determined in red blood cells from 12 children with acute lymphoblastic leukemia who were treated with MTX (15-20 mg/m2 per week) and daily 6-mercaptopurine orally during the steady-state period of erythrocyte MTX concentration (ery-MTX). The terminal decline of the ery-MTX and its polyglutamate metabolites were determined for up to 15 weeks after cessation of MTX treatment. Methotrexate polyglutamates with 2-4 extra glutamyl derivatives (MTX-glu2-5) constituted 75% of the MTX in the entire red blood cell population. MTX-glu3 was the principal metabolite; no MTX-glu6-7 was identified. After discontinuation of MTX therapy, the ery-MTX declined in a non-linear manner because of different half-lives for the individual polyglutamates. From about 5 weeks until 13-15 weeks after the last MTX dose, the erythrocyte MTX elimination curve was linear. The approximate half-life of MTX-glu1 was 2-3 days; for MTX-glu2 it was 4-15 days. The concentration of MTX-glu3-5 remained constant in the erythrocyte throughout its life span and declined only with age-dependent destruction of the red blood cell. It was calculated that 80%-90% of MTX in newly formed reticulocytes was MTX-glu1+2, the remainder being MTX-glu3-5. Mature red blood cells did not form methotrexate polyglutamates to any significant degree. There was a significant correlation between the amount of MTX-glu3-5 and the steady -state ery-MTX, which to some extent explained the interindividual variation of the ery-MTX in children with ALL in maintenance therapy.