Princess Margaret Hospital, Okus Road, Swindon SN1 4JU, UK
SIR, We read the letter from Hordon et al. [1] with some interest. Our department recently had a patient who was inadvertently given 10 mg methotrexate tablets instead of 2.5 mg tablets and promptly consumed 60 mg instead of 15 mg. Fortunately, folinic acid rescue prevented a disaster. This was the second such experience of methotrexate tablet confusion. May we encourage people to write to the manufacturers on this issue, which does have a fairly obvious remedy, namely to make the appearance of the 2.5 and 10 mg tablets entirely different.
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