Methotrexate (MTX) is one of the most used drugs in the treatment of Rheumatoid Arthritis (RA), with a good profile of efficacy/tolerance. However, its particular dosing scheme has led to Medication Errors (ME). We report a case of suspected MTX intoxication in a patient diagnosed with RA. She was admitted to the hospital for ulcers in the oral cavity and erythematous lesions in body, developing a severe inmunodepression with pancytopenia and requiring isolation. Furthermore, we observed renal, liver and lung impairment. When we reviewed the pharmacotherapeutic history, we detected a possible ME. Adverse drug events were similar to those described in the literature. In our case, the patient had a full recovery, unlike some reports with fatal outcome
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