Received: 6 March 2022 Revised: 20 June 2022 Accepted: 24 June 2022

DOI: 10.1111/jcpt.13739

COMMENTARY

Leucovorin (folinic acid) rescue for high-dose methotrexate:

A review

Ruiqi Jiang BS1,2 | Shenghui Mei PhD1,2 | Zhigang Zhao PhD1,2

1
Department of Pharmacy, Beijing Tiantan
Hospital, Capital Medical University, Beijing, Abstract
People's Republic of China High-dose methotrexate (HDMTX) is active against various malignancies; it possesses
2
Department of Clinical Pharmacology, College
serious toxicities and is associated with patient characteristics, dosage regimens,
of Pharmaceutical Sciences, Capital Medical
University, Beijing, People's Republic of China comedications, and physiological status. There are many strategies to overcome
HDMTX-induced toxicities, such as hydration, alkalization, leucovorin rescue, and
Correspondence
Shenghui Mei, Department of Pharmacy, haemodialysis. Leucovorin rescue is a cornerstone for toxicity prevention in HDMTX
Beijing Tiantan Hospital, Capital Medical
treatment. However, the leucovorin dose adjustment and the existence of leucovorin
University, Beijing, People's Republic of China.
Email: meishenghui1983@126.com overrescue are still controversial. At present, various methods for calculating leucov-
Zhigang Zhao, Department of Pharmacy, orin doses in different tumour types have been proposed, including empirical calcula-
Beijing Tiantan Hospital, Capital Medical
University, Beijing, P. R. China.
tions based on MTX plasma concentration, the Bleyer nomogram, and other
Email: 1022zzg@sina.com methods. Nonetheless, leucovorin rescue protocols differ greatly across tumour

Funding information
types and medical institutions. Further studies are needed to investigate the optimal
National Key R&D Program of China, Grant/ dosage regimen for leucovorin rescue in various tumours using HDMTX.
Award Number: 2020YFC2008306

KEYWORDS
high-dose methotrexate, individualized therapy, leucovorin rescue, therapeutic drug
monitoring

1 | WHAT IS KNOWN AND OBJECTIVE
Methotrexate (MTX), which is a folate antimetabolite, interferes with
folic acid metabolism by competitively and reversibly inhibiting the
activity of dihydrofolate reductase in cells.1 Doses of 500 mg/m2 or
2,3
higher are regarded as high-dose methotrexate (HDMTX). More-
over, HDMTX is the first-line drug against various malignancies,
including lymphomas, acute lymphoblastic leukaemia (ALL), osteosar-
coma, and breast cancer.4
Although HDMTX is safely administered to the most patients, it
can induce serious toxic responses, such as acute kidney injury (2%–
12% of patients), gastrointestinal toxicity (10%–30% of patients), liver
toxicity (25%–60% of patients), and neurotoxicity (up to 15% of
patients). 1,5
Nephrotoxicity is one of the most significant toxicities of
MTX.6 MTX is cleared primarily by the kidneys (more than 90%), and
its nephrotoxicity is suspected to be caused by the formation of crys-
tals of MTX and its metabolite (7-hydroxy methotrexate) in the renal
7
tubules due to their poor water solubility in acidic environments; an
increase in the urine pH from 6 to 7 could significantly increase their
water solubility.8 Therefore, hydration, alkalinization in combination
with MTX monitoring, and leucovorin rescue are routine strategies to
overcome MTX-induced toxicities.9 In clinical practice, alkalinization is
typically achieved with intravenous and/or oral sodium bicarbonate,
sodium acetate, or acetazolamide, and the urine pH is suggested to be
maintained at 7.0 or greater before and during HDMTX therapy.
Excessive alkalinization increases the risk of an acid–base distur-
bance.1,9,10 However, by using these strategies, nephrotoxicity still
occurs in 2%–10% of patients.8
Therefore, MTX plasma level-guided leucovorin rescue is used to
overcome HDMTX-induced toxicities. Currently, various methods
have been published for the determination of MTX levels in the
plasma and urine.11 However, the use of urine may not replace blood
for MTX monitoring due to its poor correlation (R2, 0.16 to 0.51).10
Patients with serum MTX levels less than 10, 1, and 0.1 μmol/L at
24, 48, and 72 h, respectively, after the start of MTX infusion are con-
sidered to have normal elimination mechanisms, and patients with
greater serum MTX levels are considered to have delayed MTX elimi-
nation mechanisms and may be at increased risks of toxicity.7,12 In
addition, patients with serum MTX levels greater than 50 μmol/L at
24 h, greater than 5 μmol/L at 48 h, or greater than 0.2 μmol/L at

1452 © 2022 John Wiley & Sons Ltd. wileyonlinelibrary.com/journal/jcpt J Clin Pharm Ther. 2022;47:1452–1460.
COMMENTARY
TABLE 1 Glucarpidase administration recommendations15
Methotrexate infusion
dose and duration Indication for glucarpidase administration
2
1–8 g/m HDMTX 36-hour plasma MTX
infusion 24 h concentration > 30 μmol/L, or 42-hour
plasma MTX concentration > 10 μmol/L, or
48-hour plasma MTX
concentration >5 μmol/L
1–8 g/m2 HDMTX 48-hour plasma MTX concentration >5 μmol/
infusion 36–42 h L
8–12 g/m2 HDMTX 24-hour plasma MTX
infusion ≤6 h concentration > 50 μmol/L, or 36-hour
plasma MTX concentration > 30 μmol/L, or
42-hour plasma MTX
concentration > 10 μmol/L, or 48-hour
plasma MTX concentration >5 μmol/L
72 h after the start of infusion are considered to have seriously
7
delayed MTX elimination mechanisms. Moreover, many other MTX
target concentrations have been published, such as a MTX
level <1.0 μmol/L at 42 h or 0.4 μmol/L at 48 h. 13
Standardized supportive care, which can differ across tumour
types, must be given to prevent HDMTX-induced toxicities.14 Both
glucarpidase and leucovorin are recommended for the treatment of
MTX-induced toxicities.9 Glucarpidase (carboxypeptidase G2) can
hydrolyse circulating MTX into its inactive form deoxyaminopteroic
acid and reduce plasma MTX levels by >95% within 15 min of admin-
istration.15 Additionally, glucarpidase cannot hydrolyse intracellular
MTX; therefore, leucovorin rescue is still required after glucarpidase
interventions. According to the indication in the drug instructions,16
glucarpidase is indicated for the treatment of toxic MTX plasma con-
centrations (>1 μmol/L) in patients with delayed MTX clearance due
to impaired renal function. Moreover, glucarpidase is not indicated for
patients with normal or mildly impaired renal function. In addition, leu-
covorin administration is not recommended within 2 h before or after
glucarpidase dosing because glucarpidase can hydrolyse leucovorin. A
consensus guideline15 provides recommendations for glucarpidase
use (details in Table 1) and suggests that glucarpidase should be given
within 48–60 h from the start of HDMTX infusion because life-
threatening toxicities may not be preventable beyond this time point.
However, glucarpidase is very expensive and has not been approved
in many countries.
There are some problems with the administration of glucarpidase.
MTX concentrations can only be reliably measured by using a chro-
matographic method because deoxyaminopteroic acid could affect its
analysis via immunoassays.16 In addition, deoxyaminopteroic acid is
approximately 10-fold less soluble than MTX and is excreted by the
kidneys. However, it remains unclear whether deoxyaminopteroic acid
could affect MTX pharmacokinetics and pharmacodynamics.17
Leucovorin is a 5-formyl derivative of tetrahydrofolic acid and
does not require reduction by dihydrofolate reductase to exhibit its
bioactivity as a one-carbon donor for DNA and RNA synthesis.7,18
Therefore, leucovorin bypasses the dihydrofolate reductase that is
1453
blocked by MTX to rescue. Cells and to counteract the bioactivities of
MTX.7 There is a hypothesis that leucovorin selectively rescues
healthy cells from toxicity because malignant cells have a reduced
capacity for leucovorin uptake and gain little benefit from this
effect.5,18,19 Some studies have found that leucovorin overrescue
exists. For example, Skarby et al.20 found that doubling the leucovorin
dose increased the relapse risk by 22% (95% confidence interval of 1–
49%, P = 0.037) in children with ALL. In addition, leucovorin over res-
cue may occur for low-dose MTX and mega-dose leucovorin. Tishler
et al.21 performed a prospective and unblinded study in rheumatic dis-
ease patients who received 45 mg leucovorin per week for 4 weeks at
4–6 h after oral MTX administration (7.5–12 mg MTX). They found
that MTX-induced nausea disappeared; however, rheumatic disease
worsened in all of the patients. However, Cohen22 reviewed the
related literature and found that there was no convincing evidence for
leucovorin overrescue by using its current doses for HDMTX therapy.
In addition, they proposed that neurotoxicity was inversely correlated
with leucovorin dose.22,23 The method of how to adjust the leucov-
orin dose, especially in patients with severe toxicities, is still contro-
versial in clinical practice.24
At present, various methods for calculating leucovorin doses in
different tumour types have been proposed, including empirical calcu-
lations based on MTX plasma concentrations,25 the Bleyer
nomogram,14 and other methods.26 Nonetheless, leucovorin rescue
protocols differ greatly across tumour types and medical institutions.
Thus, this study aimed to review the leucovorin rescue protocols in
patients with ALL, lymphomas, and osteosarcoma who received
HDMTX therapy.
2 | LITERATURE SEARCH AND DATA
EX TRACT I ON
A systematic literature search was performed in PubMed, Web of
Science, and Embase from its inception to January 2022. Medical
Subject Headings (MeSH) and free terms were used for the search.
The following free terms were used in all of the databases: leucovorin,
folinic acid, calcium leucovorin, calcium folinate, rescue, high dose,
methotrexate, amethopterin, and MTX. The following MeSH terms
were used: leucovorin and methotrexate. The search algorithm was
(“leucovorin” OR “folinic acid” OR “calcium leucovorin” OR “calcium
folinate”) AND (“rescue”) AND (“high dose”) AND (“methotrexate”
OR “amethopterin” OR “MTX”) in all of the fields (PubMed and
Embase) and topics (Web of Science). A total of 2033 articles were
identified; after excluding 977 duplicates, 1056 articles remained. The
titles and abstracts were screened, and 86 articles remained for analy-
sis. The full-text articles that described leucovorin dose adjustments
were subsequently reviewed and enrolled. After the full-text assess-
ment, 24 articles were included for further analysis (detailed in
Figure 1). The leucovorin rescue protocols for HDMTX were classified
by tumour type, and the practicability and disadvantages were ana-
lysed and discussed. Leucovorin rescue protocols for different tumour
types (ALL, lymphoma, and osteosarcoma) are illustrated in Table 2.
1454
FIGURE 1 Flow chart of the literature search
3 | RESULTS
The details of the planned leucovorin rescues are shown in Table 2.
We failed to obtain unified results for augmented leucovorin rescue
for each disease because the rescue time, judgement criteria, leucov-
orin dose, and MTX dose differed greatly among the published stud-
ies. For ALL, measurements of MTX plasma concentrations and
2
planned leucovorin rescue (15–50 mg/m every 6 h) were usually per-
formed at 36–54 h after the start of MTX infusion (the MTX doses
ranged from 2.85 to 8 g/m2).9,13,20,26–31 For lymphoma, the measure-
ments of MTX plasma concentrations and planned leucovorin rescue
2
(15–25 mg/m or 30–100 mg every 6 h) were usually performed at
18–48 h after the start of MTX infusion (the MTX doses ranged from
2 to 8 g/m2).32–34 For osteosarcoma, the measurements of MTX
plasma concentrations and planned leucovorin rescue (15 mg/m2 or
10–12 mg every 6 h) were usually performed at 6–24 h after the start
of MTX infusion (the MTX doses ranged from 10 to 12 g/m2).35–37 If
MTX plasma concentrations were not within the expected range, aug-
mented leucovorin rescue was performed at 42 h to 54 h for
ALL, 9,13,20,26–31
at 48 h to 72 h for lymphoma, 32–34
and at 24 h to
72 h for osteosarcoma36,38,39 after the start of MTX infusion.
3.1 | ALL
At 42 h after 5 g/m2 HDMTX infusion comedicated with
6-mercaptopurine or other drugs, Schrappe et al.13 and Möricke
et al. 30
gave an additional dose (not specified) when the MTX concen-
tration exceeded 1.0 μmol/L. Niinimaki et al.26 have recommended
that leucovorin rescue started at 42 h after MTX infusion at 30–
COMMENTARY
75 mg/m2 every 6 h (MTX concentrations within 1–4.9 μmol/L at
42 h) and at (15 mg/m2 plus serum MTX [μmol/L]  bodyweight [kg])
every 6 h (MTX concentrations ≥5.0 μmol/L at 42 h). In addition, they
found that nearly half of the courses administered proton pump inhib-
itors, but there was no significant difference in delayed elimination
between the groups that were co-medicated with or without proton
pump inhibitors. At 42 h after HDMTX (2.85–6.70 g/m2) infusion co-
medicated with cytarabine and other drugs, Wall et al.28 and Aumente
et al.29 performed augmented leucovorin rescue at 30 mg/m2 every
6 h (MTX concentrations within 2.0–5.0 μmol/L) and 100 mg/m2
every 6 h (MTX concentrations within 5.0–10.0 μmol/L). At 42 h after
HDMTX (5–8 g/m2) infusion, Skarby et al.20 performed augmented
leucovorin rescue at 30–75 mg/m2 every 6 h (MTX concentrations
within 1–5 μmol/L), and the leucovorin dose (mg) per 6 h was calcu-
lated by using serum MTX concentration (μmol/L)  body weight
(kg) every 6 h (MTX concentrations ≥5.0 μmol/L).
At 48 h after 5 g/m2 HDMTX infusion with 6-mercaptopurine
and other concomitant drugs, Schrappe et al.13 and Möricke A et al.30
gave additional leucovorin (not specified) when the MTX concentra-
tion was greater than 0.4 μmol/L. Niinimaki et al.26 recommended that
the leucovorin dose should be adjusted according to the MTX concen-
trations at 48 h after dosing, which was similar to those described
above (at 42 h). At 48 h after 3–5 g/m2 HDMTX infusion, Zhang
et al.27 performed augmented leucovorin rescue at 30 mg/m2 every
6 h when the MTX plasma concentration was within 1–2 μmol/L and
at 45 mg/m2 every 6 h if the MTX concentration was greater than
2 μmol/L.
A new published, evidence-based practice guideline of HDMTX9
recommended that 30–75 mg/m2 leucovorin be given every 6 h when
the MTX concentration is within 1–5 μmol/L; if the MTX concentra-
tion is above 5 μmol/L, the leucovorin dose per 6 h was calculated by
using serum MTX concentration (μmol/L)  weight (kg).
Ramamoorthy et al.31 used 100 mg/m2 leucovorin every 6 h
when the concentration was less than 1 μmol/L at 54 h after MTX
infusion and 200 mg/m2 leucovorin every 6 h when the concentration
was greater than 2 μmol/L. They successfully used this strategy to
rescue a patient with kidney damage. An ALL patient received 2 g/m2
HDMTX, after which he developed acute renal failure with a serum
creatinine of 8.3 mg/dl and a MTX level of 40 μmol/L at 36 h. There-
fore, high filtration dialysis for 4 h daily and leucovorin rescue at
200 mg/m2 every 3 h were used. The results showed that serum cre-
atinine decreased to 1.5 mg/dl on day 10, and the MTX level was
0.08 μmol/L. The patient ultimately received a total of 14.4 g of
leucovorin.
3.2 | Lymphoma
At 48 h after 2–8 g/m2 MTX infusion with rituximab and other con-
comitant medications, Barreto et al.34 gave 50–200 mg/m2 leucovorin
every 6 h if MTX concentrations were within 1–19.9 μmol/L and
500 mg/m2 leucovorin every 6 h if MTX concentrations were within
20–50 μmol/L. In addition, they found that for patients with a history
COMMENTARY 1455

TABLE 2 Leucovorin rescue protocols

Leucovorin
Study rescue time Planned leucovorin rescue Augmented leucovorin rescue MTX dose
Acute lymphoblastic leukaemia
Aumente29 36 h 15 mg/m2 every 6 h NA 3 g/m2
42 h < 2.0 μmol/L: 15 mg/m2 2–5 μmol/L: 30 mg/m2 every 6 h, then 15 mg/
every 6 h m2 every 6 h
5–10 μmol/L: 100 mg/m2 every 6 h
Möricke 30
42 h < 1.0 μmol/L: 30 mg/m 2
> 1.0 μmol/L: additional dose 5 g/m2
every 6 h
48 h < 0.4 μmol/L: 15 mg/m2 > 0.4 μmol/L: additional dose
every 6 h
54 h NA > 0.25 μmol/L: continued rescue
Niinimäki 26
42 h < 1.0 μmol/L: 15 mg/m 2
1–1.9 μmol/L: 30 mg/m2 every 6 h 5 g/m2
every 6 h 2–2.9 μmol/L: 45 mg/m2 every 6 h
3–3.9 μmol/L: 60 mg/m2 every 6 h
4–4.9 μmol/L: 75 mg/m2 every 6 h
≥ 5.0 μmol/L: 15 mg/m2 + serum MTX (μmol/
L)  bodyweight (kg) every 6 h
48 h < 1.0 μmol/L: 15 mg/m2 1–1.9 μmol/L: 30 mg/m2 every 6 h
every 6 h 2–2.9 μmol/L: 45 mg/m2 every 6 h
3–3.9 μmol/L: 60 mg/m2 every 6 h
4–4.9 μmol/L: 75 mg/m2 every 6 h
≥ 5.0 μmol/L: serum MTX (μmol/L)  weight
(kg)
Ramamoorthy31 54 h < 0.5 μmol/L: 15 mg/m2 0.5–1 μmol/L: 100 mg/m2 every 6 h 2 g/m2
every 6 h > 2 μmol/L: 200 mg/m2 every 6 h
Schrappe 13
42 h < 1.0 μmol/L: 30 mg/m 2
> 1.0 μmol/L: additional leucovorin 5 g/m2
every 6 h
48 h < 0.4 μmol/L: 15 mg/m2 > 0.4 μmol/L: additional leucovorin
every 6 h
Skarby20 36 h 15 mg/m2 every 6 h NA 5 g/m2
2
50 mg/m every 6 h 8 g/m2
42 h < 1 μmol/L: 15 mg/m2 every 1- < 2 μmol/L: 30 mg/m2 every 6 h 5–8 g/m2
6h 2- < 3 μmol/L: 45 mg/m every 6 h
2

3- < 4 μmol/L: 60 mg/m2 every 6 h

4- < 5 μmol/L: 75 mg/m2 every 6 h
≥ 5 μmol/L: serum MTX (μmol/L)  weight
(kg) every 6 h
Wall28 36 h 15 mg/m2 every 6 h NA 2.85 to 6.70 g/m2
42 h < 2.0 μmol/L: 15 mg/m 2
2–5 μmol/L: 30 mg/m every 6 h, then 15 mg/
2

every 6 h m2 every 6 h
5–10 μmol/L: 100 mg/m2 every 6 h
Song9 42–48 h < 0.1–0.2 μmol/L: commonly 1–2 μmol/L: 30 mg/m2 every 6 h 2–5 g/m2
unnecessary
0.2–1 μmol/L: 15 mg/m2 2–3 μmol/L: 45 mg/m2 every 6 h
every 6 h
3–4 μmol/L: 60 mg/m2 every 6 h
4–5 μmol/L: 75 mg/m2 every 6 h
≥ 5.0 μmol/L: serum MTX (μmol/L)  weight
(kg) every 6 h

(Continues)
1456 COMMENTARY

TABLE 2 (Continued)

Leucovorin
Study rescue time Planned leucovorin rescue Augmented leucovorin rescue MTX dose
27 2
Zhang 36 h 15 mg/m every 6 h NA 3–5 g/m2
48 h < 1 μmol/L: 15 mg/m every
2
1–2 μmol/L: 30 mg/m every 6 h
2

6h > 2 μmol/L: 45 mg/m2 every 6 h

Lymphoma
Barreto34 48 h 0.1–0.99 μmol/L: 25 mg/m2 1–4.99 μmol/L: 50 mg/m2 every 6 h 2–8 g/m2
every 6 h 5–9.99 μmol/L: 100 mg/m every 6 h
2

10–19.9 μmol/L: 200 mg/m2 every 6 h

20–50 μmol/L: 500 mg/m2 every 6 h
Joerger33 24 h 15 mg/m2 every 6 h 12 times NA NA
48 h 15 mg/m2 every 6 h Intensified dose
Peng32 18 h or 24 h 100 mg, followed by 30 mg NA 3.5 g/m2
every 6 h
72 h NA > 0.1 μmol/L: rescue every 6 h and hydration
regimens were continued until the serum
MTX concentration reached a nontoxic level
Osteosarcoma
Rosen39 24 h NA > 20 μmol/L: daily leucovorin dose = the usual 12–18 g
daily dose of leucovorin * (serum MTX level/
the upper limit of MTX levels)
48 h NA > 2 μmol/L: daily leucovorin dose = the usual
daily dose of leucovorin * (serum MTX level/
the upper limit of MTX levels)
Marina35 24–48 h 15 mg/m2 every 6 h Adjusted with the dosing nomogram 12 g/m2
Pignon 38
36 h NA Leucovorin (mg) = 10  [MTX] 13.2 ± 2 g/m2
(mg/L)  0.76  weight (kg) every 6 h
Zelcer36 24 h ≤ 10 μmol/L: 10 mg every 10–20 μmol/L: 20 mg every 6 h 12 g/m2
6h 20–30 μmol/L: 30 mg every 6 h
30–50 μmol/L: 50 mg every 6 h
≥ 50 μmol/L: 1 g over 24 h
48 h ≤ 1 μmol/L: continue > 1 μmol/L: consider dose escalation
previous 24 h dosing
72 h ≤ 0.1 μmol/L: discontinue > 0.1 μmol/L: continue previous 48 h dosing
leucovorin
Zhang37 6–8 h 12 mg every 6 h NA 10 g/m2
delayed excretion NA Increase leucovorin dose
Without specific tumour type
Cerminara41 24 h (30 minute 15 mg/m2 every 6 h Dosing nomogram • 500 mg/m2 over <4 h or
to 6 h MTX ≥1 g/m2 over >4 h
infusion)
48 h (24 h MTX 15 mg/m2 every 6 h Dosing nomogram
infusion)
Howard1 NA NA Dosing nomogram NA
Jolivet3 2h 15 mg/m2 every 6 h for 7 NA 50–250 mg/kg
doses
36 h 200 mg/m2 for 12 h NA 1.5 g/m2
2
48 h 25 mg/m every 6 h for 6 NA
doses
48 h < 0.5 μmol/L: 15 mg/m2 0.5–1 μmol/L: 100 mg/m2 every 6 h 50–250 mg/kg and 1.5 g/m2
every 6 h 1–2 μmol/L: 200 mg/m2 every 6 h infusion
COMMENTARY
TABLE 2 (Continued)
Leucovorin
Study rescue time Planned leucovorin rescue
Stoller 40
36 h NA
Bleyer14 NA NA
Bleyer WA42 NA NA
43
Widemann NA NA
Abbreviations: MTX, methotrexate; ALL, acute lymphoblastic leukaemia; and NA, not available.
of acute kidney injury, the prescription of high-dose leucovorin with a
subsequent MTX dose was not protective against the subsequent
acute kidney injury. If serum creatinine has a 50% or greater
increase compared to the pre-MTX value at any time, then leucov-
2
orin would be increased to 200 mg/m every 6 h until the MTX
level <0.1 μmol/l. In the label of leucovorin, if there was a 100% or
greater increase in the serum creatinine level at 24 h after MTX
administration, the leucovorin dose was increased to 150 mg every
3 h until the MTX level <1 μmol/L, after which the dose was 15 mg
every 3 h until the MTX level <0.05 μmol/L. In a review, Joerger
7
et al.33 suggested that if MTX levels remained high at 48 h after
infusion, the leucovorin dose should be intensified according to res-
cue algorithms, but this review did not mention the specific rescue
algorithms. If the MTX level was >0.1 μmol/L at 72 h, then Peng
C. continued leucovorin rescue and hydration regimens until MTX
levels were less than 0.1 μmol/L. 32
3.3 | Osteosarcoma
At 24 h after 12 g/m2 MTX infusion, Zelcer et al.36 used 20–50 mg
oral leucovorin every 6 h when the MTX level was within
10–50 μmol/L and 1 g intravenous leucovorin per day when the
MTX level was greater than 50 μmol/L. They continued the previ-
ous dose when the MTX level was ≤1 μmol/L at 48 h; otherwise,
leucovorin dose escalation was considered. Moreover, they dis-
continued leucovorin when the MTX level was ≤0.1 μmol/L at
72 h; otherwise, leucovorin rescue was continued. However, at
24 h and 48 h after 12–18 g MTX infusion, Rosen et al.39 calcu-
lated the daily leucovorin dose by the following method: daily leu-
covorin dose = the usual daily dose of leucovorin * (serum MTX
level/the upper limit of MTX levels) (20 μmol/L for 24 h and
2 μmol/L for 48 h).
2 38
At 36 h after 13.2 ± 2 g/m MTX infusion, Pignon et al.
lated the leucovorin dose per 6 h from the following formula: leucov-
orin (mg) = 10  [MTX] (mg/L)  0.76  weight (kg).
3.4 | Without a specific tumour type
3
The previous review provided the following typically planned regi-
men: the initiation of leucovorin rescue with 15 mg/m2 every 6 h at
1457
Augmented leucovorin rescue MTX dose
Leucovorin dose (mg/m ) = MTX36 h *
2
0.8–1.35 g/m2
10/(5/30)
Dosing nomogram NA
Dosing nomogram NA
Dosing nomogram NA
2 h for seven doses after MTX infusion for the Jaffe regimen (50–
250 mg/kg MTX over 6 h infusion); the initiation of 200 mg/m2 leu-
covorin every 6 h at 36 h after the start of MTX infusion and 25 mg/
m2 leucovorin every 6 h for six doses at 48 h for the alternative regi-
men (bolus intravenous administration of 50 mg/m2 MTX, followed
by the infusion of 1.5 g/m2 MTX over 36 h). For both the Jaffe regi-
men and the alternative regimen with MTX levels greater than
0.5 μmol/L at 48 h, an additional leucovorin dose was needed: 15 mg/
m2 leucovorin every 6 h for eight doses for MTX levels within 0.5–
1 μmol/L, 100 mg/m2 leucovorin every 6 h for eight doses for MTX
levels within 1 and 2 μmol/L, and 200 mg/m2 leucovorin every 6 h for
8 doses for MTX levels >2 μmol/L.
At 36 h after 0.8–1.35 g/m2 MTX infusion, 40 patients with
advanced neoplasms received individualized leucovorin treatments
(adjusted by MTX level).40 The plasma MTX half-life was calculated by
using 18 h and 24 h MTX levels, after which these actual levels were
used to predict 36 h MTX levels. This study attempted to achieve leu-
covorin plasma levels that were 10-fold higher than the 36 h MTX
level. Due to the lack of a reliable assay for leucovorin, they assumed
that comparable MTX and leucovorin doses would yield equivalent
peak plasma levels (5 μmol/L for 30 mg/m2 MTX). Subsequently, by
using this ratio of dosage to plasma concentration, the leucovorin
dose was calculated by the equation leucovorin dose (mg/m2) = MTX
36 h * 10/(5/30).40
In addition, some studies1,41–43 have followed recommendations
based on the Bleyer nomogram.14 The Bleyer nomogram-guided leu-
covorin rescue was based on plasma MTX levels.
4 | DI SCU SSION
Currently, leucovorin rescue protocols differ greatly across tumour
types and medical institutions. In a guideline,15 MTX doses were
calcu- similar for both ALL (1–5 g/m2) and lymphoma (1–8 g/m2), but the
leucovorin initiation time was different (42 h and 18–24 h after infu-
sion for ALL and lymphoma). For osteosarcoma, the dosage of MTX
is commonly 8–12 g/m2, and the leucovorin initiation time is
24 h.9,15 ALL have the largest amount of literature among the three
tumour types for leucovorin rescue, and the rescue plan was rela-
tively complete.9,13,20,26–31 More attention should be given to leu-
covorin rescue in patients with osteosarcoma and lymphoma.
Moreover, leucovorin over rescue can reduce MTX efficacy both
1458
in vitro44 and in vivo,20,45 but there has not yet been enough clinical
evidence to support this view.22,46 Therefore, prospective random-
ized clinical trials comparing MTX efficacy and toxicities between
different leucovorin rescue strategies for patients with HDMTX
therapy are necessary.20,22
A fixed dose of leucovorin was used when the MTX concentra-
27–29,31
tion was above a certain level, but an individualized leucovorin
dose was required for patients. Unfortunately, a consensus on how to
obtain the individualized leucovorin dose has not been reached. The
Bleyer nomogram-based empiric dose adjustment of leucovorin
according to the MTX plasma concentrations14 has been widely used
in clinical practice.1,41–43 However, there are some deficiencies to the
nomogram, including whether the curve can be extrapolated at both
sides for patients with acute toxicities (before 20 h) or delayed MTX
19
excretion (more than 120 h). If the MTX level falls between the two
time points, then the lower point (with the lower dose of leucovorin)
is generally used in clinical practice1; however, we did not know
whether the dose is sufficient for all patients, and there is currently
9,20,26
no dose adjustment plan. In addition, three studies have recom-
mended that the leucovorin dose (mg) should be calculated by using
serum MTX (μmol/L)  weight (kg), and the dose was used every 6 h
if the MTX level was greater than 5 μmol/L at 42–48 h after MTX
infusion. Pignon et al.38 calculated the leucovorin single dose by using
the following equation: leucovorin dose (mg) = 10  [MTX] (mg/L) 
0.76  weight (kg). Another formula (daily leucovorin dose = the
usual daily dose of leucovorin * [serum MTX level/the upper limit of
MTX levels]) was proposed by Rosen et al39 These formulas are
mostly used in children, and their feasibility in adults should be evalu-
ated before application.
However, there are still some problems with leucovorin rescue
that require further study. First, MTX concentration measurements
require an accurate sampling time (36 h to 54 h for ALL, 18 h to
72 h for lymphoma, and 24 h to 72 h for osteosarcoma after MTX
infusion); however, in clinical practice, the MTX sampling time is not
very accurate, and its value could not be directly used to guide leu-
covorin dose adjustments. The conversion of the inaccurately sam-
pled MTX concentration to the accurately sampled MTX
concentration by pharmacometrics is a challenge for clinicians and
pharmacists.20,31,32,36 Second, in different studies, MTX doses, leu-
covorin doses, and the criteria for delayed MTX elimination have
been different.26,30 In some studies, leucovorin dose adjustments
have been similar for different MTX doses.27,28 Moreover, some
studies did not provide details for leucovorin dose optimization.13,30
Moreover, leucovorin dose adjustments have been based on
plasma MTX monitoring, which is often not available, especially in the
developing countries.47 The question as to how to adjust the leucov-
orin dose without monitoring the MTX level is a challenge. Via assidu-
ous monitoring of urine pH and serum creatinine, extended hydration,
and twice-daily examination of mucosal membranes,48 the administra-
tion of additional doses of leucovorin can allow for the safe adminis-
tration of HDMTX for the most patients. The leucovorin rescue
protocol used in the studies without MTX level monitoring was similar
to those with MTX-level monitoring (6–12 doses of 10–15 mg/m2
COMMENTARY
leucovorin every 6 h at 24–42 h after 1–5 g/m2 MTX infusion).47,49–51
At present, no article has been published on leucovorin dose adjust-
ments based on indicators other than MTX plasma levels. Some studies
have confirmed that serum creatinine, creatinine clearance rate, and
serum cystatin C were useful to identify patients with a high risk of
delayed MTX elimination if MTX monitoring was not available.52,53
Therefore, further studies on how to adjust the leucovorin dose accord-
ing to other indicators would be necessary when plasma MTX monitor-
ing was not available.
5 | W H A T I S N E W A N D C O N C LU S I O N
At present, the manner of how to adjust the leucovorin dose is still
controversial, and there is no complete protocol. Various methods for
calculating the leucovorin dose of different tumour types have been
proposed, including the empirical calculation based on MTX plasma
concentrations, the Bleyer nomogram, and other methods. However,
each of these methods has much to be improved upon. Therefore, fur-
ther studies are needed to investigate the optimal dosing for leucov-
orin rescue to prevent toxicity and to improve efficacy.
FUNDING INF ORMATI ON
This study was supported by National Key R&D Program of China
(2020YFC2008306).
CONFLIC T OF INT ER E ST
The authors declare that they have no conflict of interest.
OR CID
Shenghui Mei https://orcid.org/0000-0003-1385-4315
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How to cite this article: Jiang R, Mei S, Zhao Z. Leucovorin
(folinic acid) rescue for high-dose methotrexate: A review.
J Clin Pharm Ther. 2022;47(9):1452‐1460. doi:10.1111/jcpt.
13739
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