Expert Guidelines

Consensus Guidelines Strongly Recommend: Act Early With Voraxaze®1

Beyond 48 to 60 hours, life-threatening toxicities and even death may not be preventable. Early and rapid reduction of methotrexate (MTX) concentrations can lower the risk of irreversible damage.1
Consensus guidelines for use recommend administration of Voraxaze® at 48 hours following initiation of high-dose methotrexate (HDMTX) therapy when MTX concentrations are above 5 μM (2.27 μg/mL) and the serum creatinine is elevated relative to the baseline measurement.1
Review Guideline Highlights

Voraxaze® Is Included in Multiple NCCN Guidelines2

Over the past 25 years, the National Comprehensive Cancer Network (NCCN) has developed guidelines in oncology to document evidence-based, consensus-driven management to ensure that all patients receive treatment that is most likely to lead to optimal outcomes.
Voraxaze® is included in the following guidelines:
  • Central nervous system cancers
  • Acute lymphoblastic leukemia
  • Pediatric acute lymphoblastic leukemia
  • B-cell lymphomas
  • T-cell lymphomas
  • Primary cutaneous lymphomas
Early intervention with Voraxaze®, a recombinant bacterial enzyme that provides an alternative route for methotrexate clearance, has shown efficacy in rapidly reducing plasma concentrations of methotrexate and preventing severe toxicity.
NCCN Guidelines for CNS Cancers2

Guidelines Advise Having 5 Vials of Voraxaze® Readily Available3

  • Expert Consensus Guidelines published in 2018 recommend that all hospitals that provide emergency care should stock 5 vials of Voraxaze®3
  • The Institute for Safe Medication Practices (ISMP) recommends that all appropriate antidotes should be readily available4
  • Standardized protocols and/or a coupled order should be set in place that permit the emergency administration of all appropriate antidotes used in the facility4

Stock Voraxaze® According to Guidelines

Not every patient requires Voraxaze®, but having it on hand can help you be prepared in an emergency.

Order Voraxaze® Today


  1. Voraxaze® [prescribing information]. BTG International Inc; 2013.
  2. Howard SC, et al. Preventing and managing toxicities of high-dose methotrexate. The Oncologist 2016; 21:1-12.
  3. Widemann BC, Balis FM, Kim A, et al. Glucarpidase, leucovorin, and thymidine for high-dose methotrexate-induced renal dysfunction: clinical and pharmacologic factors affecting outcome. J Clin Oncol. 2010; 28:3979-3986.
  4. 2013 Annual Meeting of the North American Congress of Clinical Toxicology (NACCT), Clinical Toxicology 2013; 51(7):575-724. doi:10.3109/15563650.2013.817658.
  5. Ramsey L, Balis FM, O’Brien MM, et al. Consensus guidelines for use of glucarpidase in patients with high-dose methotrexate induced acute kidney injury and delayed methotrexate clearance. Durham, NC. The Oncologist. 2017 Oct 27. doi: 10.1634/theoncologist.2017-0243
  6. Widemann BC, Adamson PC. Understanding and managing methotrexate nephrotoxicity. Oncologist. 2006;11:694-703
  7. Schwartz S, Borner K,Müller K, et al. Glucarpidase (carboxypeptidase G2) intervention in adult and elderly cancer patients with renal dysfunction and delayed methotrexate elimination after high-dose methotrexate therapy. Oncologist. 2007;12:1299-1308.
  8. Widemann BC, Balis FM, Kempf-Bielack B, et al. High-dose methotrexate-induced nephrotoxicity in patients with osteosarcoma. Cancer. 2004;100:2222-2232
  9. Data on file. BTG International Inc. 2012.
  10. de Miguel D, García-Suárez J Martín Y, Gil-Fernández JJ, Burgaleta C. Severe acute renal failure following high-dose methotrexate therapy in adults with haematological malignancies: a significant number result from unrecognized co-administration of several drugs. Nephrol Dial Transplant. 2008;23:3762-3766.
  11. Jahnke K, Korfel A, Martus P, et al; on behalf of the German Primary Central Nervous System Lymphoma Study Group (G-PCNSL-SG). High-dose methotrexate toxicity in elderly patients with primary central nervous system lymphoma. Ann Oncol. 2005;16:445-449
  12. Flombaum C, Meyers P. High-dose leucovorin as sole therapy for methotrexate toxicity. Journal of Clinical Oncology 1999; 17(5): 1589-1594.
  13. Murashima M, et al. Methotrexate clearance by high-flux hemodialysis and peritoneal dialysis: a case report. Am J Kidney Dis 2009; 53:781-874.
  14. Wall S, Johansen M, et al. Effective clearance of methotrexate using high-flux hemodialysis membranes. Am J Kidney Dis 1996; 28(6):846-854.
  15. Dart RC, Goldfrank LR, Erstad BL, et al. Expert consensus guidelines for stocking of antidotes in hospitals that provide emergency care. Ann Emerg Med. 2018;71(3):314-325.
  16. Green JM. Glucarpidase to combat toxic levels of methotrexate in patients. Ther Clin Risk Manag. 2012;8:403-4
  17. Glucarpidase (Voraxaze®) National Drug Monograph and Considerations for Use. U.S. Department of Veterans Affairs website. 2014. Drug_Monograph_and_Considerations_for_Use.doc. Published June 2014. Accessed November 04, 2016.
  18. Leucovorin [prescribing information]. Bedford Laboratories; 2011.