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Pemetrexed: Drug information

Pemetrexed: Drug information
(For additional information see "Pemetrexed: Patient drug information")

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)
Brand Names: US
  • Alimta;
  • Pemfexy
Brand Names: Canada
  • Alimta;
  • TARO-PEMEtrexed
Pharmacologic Category
  • Antineoplastic Agent, Antimetabolite;
  • Antineoplastic Agent, Antimetabolite (Antifolate)
Dosing: Adult

Note: New treatment cycles should not begin unless ANC ≥1,500/mm3, platelets ≥100,000/mm3, CrCl ≥45 mL/minute, and recovery of nonhematologic toxicity to ≤ grade 2.

Premedication: Start vitamin supplements 1 week before initial pemetrexed dose: Folic acid 400 to 1,000 mcg orally once daily (begin 7 days prior to treatment initiation; continue daily during treatment and for 21 days after last pemetrexed dose) and vitamin B12 1,000 mcg IM 7 days prior to treatment initiation and then every 3 cycles. Subsequent vitamin B12 doses may be administered on the same day as pemetrexed treatments. In patients without preexisting anemia, some data suggest that pemetrexed and cyanocobalamin may be started simultaneously to avoid delaying pemetrexed initiation (Ref). Administer dexamethasone 4 mg orally twice daily for 3 days, beginning the day before treatment to minimize cutaneous reactions.

Bladder cancer, metastatic

Bladder cancer, metastatic (off-label use): IV: 500 mg/m2 on day 1 of each 21-day cycle until disease progression or unacceptable toxicity (Ref).

Cervical cancer, recurrent or persistent

Cervical cancer, recurrent or persistent (off-label use): IV: 500 mg/m2 on day 1 of each 21-day cycle until disease progression or unacceptable toxicity occurs (Ref) or 900 mg/m2 on day 1 of each 21-day cycle (Ref).

Malignant pleural mesothelioma

Malignant pleural mesothelioma: IV: 500 mg/m2 on day 1 of each 21-day cycle (in combination with cisplatin); continue until disease progression or unacceptable toxicity. American Society of Clinical Oncology guidelines for malignant pleural mesothelioma recommend first-line platinum/pemetrexed-based therapy for 4 to 6 cycles (Ref).

Off-label dosing/combinations: IV:

500 mg/m2 on day 1 of each 21-day cycle in combination with carboplatin (Ref) or 500 mg/m2 on day 1 of each 21-day cycle (in combination with carboplatin) until disease progression, unacceptable toxicity, or for a maximum of 9 cycles (Ref) or 500 mg/m2 on day 1 of each 21-day cycle as single-agent therapy until disease progression or unacceptable toxicity (Ref) or 500 mg/m2 on day 1 every 3 weeks (in combination with cisplatin and bevacizumab) for up to 6 cycles, followed by bevacizumab maintenance therapy until disease progression or unacceptable toxicity (Ref).

Non–small cell lung cancer, nonsquamous

Non–small cell lung cancer, nonsquamous:

Initial treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC):

In combination with cisplatin: IV: 500 mg/m2 on day 1 of each 21-day cycle (in combination with cisplatin) for up to 6 cycles or until disease progression or unacceptable toxicity.

In combination with cemiplimab and a platinum (off-label combination): IV: 500 mg/m2 on day 1 of each 21-day cycle (in combination with cemiplimab and either carboplatin or cisplatin) for 4 cycles, followed by pemetrexed maintenance therapy and cemiplimab until disease progression or unacceptable toxicity, or for up to 108 weeks; refer to protocol for further information (Ref).

Initial treatment of metastatic NSCLC:

In combination with pembrolizumab and a platinum: IV: 500 mg/m2 on day 1 of each 21-day cycle (in combination with pembrolizumab and either carboplatin or cisplatin) for 4 cycles; following platinum-based therapy, may continue pemetrexed (alone or with pembrolizumab) as maintenance therapy until disease progression or unacceptable toxicity (Ref).

In combination with durvalumab, tremelimumab, and a platinum (off-label combination): IV: 500 mg/m2 on day 1 of each 21-day cycle (in combination with either carboplatin or cisplatin, durvalumab, and tremelimumab) for 4 cycles, followed by optional pemetrexed maintenance therapy (in combination with durvalumab) if eligible; continue until disease progression or unacceptable toxicity; refer to protocol for further information (Ref).

Maintenance treatment of locally advanced or metastatic NSCLC (after 4 cycles of initial platinum-based therapy): IV: 500 mg/m2 on day 1 of each 21-day cycle (as a single-agent); continue until disease progression or unacceptable toxicity.

Second-line treatment of recurrent/metastatic disease (after prior chemotherapy): IV: 500 mg/m2 on day 1 of each 21-day cycle (as a single-agent); continue until disease progression or unacceptable toxicity.

Ovarian cancer, platinum-resistant

Ovarian cancer, platinum-resistant (off-label use): IV: 500 mg/m2 on day 1 of each 21-day cycle (Ref).

Thymic malignancies, metastatic

Thymic malignancies, metastatic (off-label use): IV: 500 mg/m2 on day 1 of each 21-day cycle for 6 cycles or until disease progression or unacceptable toxicity occurs (Ref).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Adult

The renal dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Kenar D. Jhaveri, MD; Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason A. Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.

Kidney impairment prior to treatment initiation:

Altered kidney function: IV:

Note: Kidney function may be estimated using the Cockcroft-Gault formula. Measures to mitigate nephrotoxicity (eg, avoiding dehydration, nonsteroidal anti-inflammatory drugs, other potentially nephrotoxic agents during pemetrexed maintenance therapy) should be considered. Ibuprofen administration decreases pemetrexed elimination, specifically in CrCl <80 mL/minute; consult drug interactions database for more information.

CrCl ≥45 mL/minute: IV: No dosage adjustment necessary (Ref). Note: Patients with CrCl 45 to 60 mL/minute may be at increased risk of hematological, GI, and kidney-related toxicities; use with caution (Ref).

CrCl <45 mL/minute: IV: Use not recommended (Ref). Pharmacokinetic modeling suggests substantially lower doses would be necessary to avoid severe neutropenia (Ref). Additionally, an increased risk of hematologic toxicity in patients with CrCl <45 mL/minute has been reported (Ref).

Augmented renal clearance (measured urinary CrCl ≥130 mL/minute/1.73 m2):

Note: Augmented renal clearance (ARC) is a condition that occurs in certain critically ill patients without organ dysfunction and with normal serum creatinine concentrations. Young patients (<55 years of age) admitted post trauma or major surgery are at highest risk for ARC, as well as those with sepsis, burns, or hematologic malignancies. An 8- to 24-hour measured urinary CrCl is necessary to identify these patients (Ref).

IV: Although the correlation of renal function with AUC suggests an increased dose of pemetrexed may be needed in patients with documented ARC, there are no clinical data to support the efficacy or safety of this approach (Ref).

Hemodialysis, intermittent (thrice weekly): IV: Somewhat dialyzable (Ref): Avoid use (Ref).

Peritoneal dialysis: IV: Dialyzability unknown: Avoid use (Ref).

CRRT: IV: Avoid use (Ref). In a single case report, a patient receiving pemetrexed (in combination with cisplatin) had persistent pemetrexed concentrations in ascites and plasma despite receiving continuous veno-venous hemodialysis (Ref).

PIRRT (eg, sustained, low-efficiency diafiltration): IV: Avoid use (Ref).

Nephrotoxicity during therapy: Acute kidney injury attributed to single-agent pemetrexed or pemetrexed in combination with other chemotherapy agents has been reported. Causality of acute kidney injury with pemetrexed reported in retrospective analysis and case reports is often confounded by concurrent or recent cisplatin or carboplatin administration (Ref). Consider interrupting pemetrexed therapy if acutely deteriorating kidney function attributable to pemetrexed is suspected (Ref). Additionally, withhold pemetrexed if CrCl falls below 45 mL/minute and do not reinitiate until CrCl is ≥45 mL/minute (Ref).

Dosing: Hepatic Impairment: Adult

There are no dosage adjustments provided in the manufacturer's labeling; however, elevated AST, AST, or total bilirubin do not appear to affect pemetrexed pharmacokinetics.

Dosing: Obesity: Adult

American Society of Clinical Oncology guidelines for appropriate systemic therapy dosing in adults with cancer with a BMI ≥30 kg/m2: Utilize patient's actual body weight for calculation of BSA- or weight-based dosing; manage regimen-related toxicities in the same manner as for patients with a BMI <30 kg/m2; if a dose reduction is utilized due to toxicity, may consider resumption of full, weight-based dosing (or previously tolerated dose level) with subsequent cycles only if dose escalations are allowed in the prescribing information, if contributing underlying factors (eg, hepatic or kidney impairment) are sufficiently resolved, AND if performance status has markedly improved or is considered adequate (Ref).

Dosing: Adjustment for Toxicity: Adult

Note: Dosage modification of other concomitant anticancer agents may also be recommended.

Hematologic toxicity: Upon recovery to ANC ≥1,500/mm3 and platelets ≥100,000/mm3, reinitiate therapy as stated below. Note: If ANC <500/mm3 or platelets <50,000/mm3 in previous cycles, permanently reduce pemetrexed dose.

ANC <500/mm3 and platelets ≥50,000/mm3: Reduce pemetrexed dose to 75% of previous dose.

Platelets <50,000/mm3 without bleeding: Reduce pemetrexed dose to 75% of previous dose.

Platelets <50,000/mm3 with bleeding: Reduce pemetrexed dose to 50% of previous dose.

Recurrent grade 3 or 4 myelosuppression after 2 dose reductions: Discontinue pemetrexed.

Nonhematologic toxicity: Withhold treatment until recovery to ≤ grade 2; upon recovery, reinitiate or discontinue therapy as follows:

Grade 3 or 4 toxicity (excluding mucositis and neurotoxicity): Reduce pemetrexed dose to 75% of previous dose.

Grade 3 or 4 diarrhea or any diarrhea requiring hospitalization: Reduce pemetrexed dose to 75% of previous dose.

Grade 3 or 4 mucositis: Reduce pemetrexed dose to 50% of previous dose.

Grade 3 or 4 neurotoxicity: Permanently discontinue pemetrexed.

Interstitial pneumonitis: Interrupt therapy and evaluate promptly for acute onset new or progressive pulmonary symptoms (eg, dyspnea, cough, fever); if interstitial pneumonitis is confirmed, permanently discontinue pemetrexed.

Radiation recall signs/symptoms: Permanently discontinue pemetrexed.

Severe or life-threatening bullous, blistering, or exfoliating dermatologic toxicity: Permanently discontinue pemetrexed.

Recurrent grade 3 or 4 nonhematologic toxicity after 2 dose reductions: Permanently discontinue pemetrexed.

Dosing: Older Adult

Refer to adult dosing.

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Reported adverse reactions are for monotherapy in adults.

>10%:

Dermatologic: Desquamation (≤14%), skin rash (≤14%)

Gastrointestinal: Anorexia (19% to 22%), diarrhea (5% to 13%; grades 3/4: 1%), nausea (12% to 31%; grades 3/4: ≤3%), stomatitis (≤15%; grades 3/4: ≤1%), vomiting (6% to 16%; grades 3/4: 2%)

Hematologic & oncologic: Anemia (15% to 19%; grades 3/4: 3% to 5%), neutropenia (6% to 11%; grades 3/4: 3% to 5%)

Nervous system: Fatigue (18% to 34%)

Respiratory: Pharyngitis (≤15%)

1% to 10%:

Cardiovascular: Edema (5%)

Dermatologic: Alopecia (6%), erythema multiforme (<5%), pruritus (7%)

Gastrointestinal: Abdominal pain (1% to 5%), constipation (6%)

Hematologic & oncologic: Febrile neutropenia (<5%), thrombocytopenia (8%; grades 3/4: 2%)

Hepatic: Increased serum alanine aminotransferase (8% to 10%), increased serum aspartate aminotransferase (7% to 8%)

Hypersensitivity: Hypersensitivity reaction (<5%)

Infection: Infection ( 5%)

Nervous system: Neuropathy (sensory: 9%; motor: <5%)

Ophthalmic: Conjunctivitis (≤5%), increased lacrimation (1% to <5%)

Miscellaneous: Fever (8%)

<1%:

Cardiovascular: Pulmonary embolism (grades 3/4), supraventricular cardiac arrhythmia, syncope (grades 3/4), ventricular tachycardia (grades 3/4)

Gastrointestinal: Gastrointestinal obstruction (grades 3/4)

Nervous system: Depression (grades 3/4), pain (grades 3/4)

Renal: Renal failure syndrome

Postmarketing (may be reported as part of combination chemotherapy regimen):

Dermatologic: Bullous rash, Stevens-Johnson syndrome, toxic epidermal necrolysis

Gastrointestinal: Colitis, pancreatitis

Hematologic & oncologic: Hemolytic anemia

Respiratory: Interstitial pneumonitis

Miscellaneous: Radiation recall phenomenon

Contraindications

Severe hypersensitivity to pemetrexed or any component of the formulation.

Canadian labeling: Additional contraindications (not in the US labeling): Concomitant yellow fever vaccine.

Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Warnings/Precautions

Concerns related to adverse effects:

• Bone marrow suppression: Pemetrexed may cause severe myelosuppression, including anemia, neutropenia, thrombocytopenia and/or pancytopenia; myelosuppression is often dose-limiting. Severe myelosuppression may require blood transfusion or may lead to neutropenic infection. Prophylactic folic acid and vitamin B12 supplements are necessary to reduce hematologic toxicity, febrile neutropenia and infection; initiate supplementation 1 week before the first dose of pemetrexed and continue for 21 days after the last pemetrexed dose (the risk for myelosuppression is higher in patients who did not receive vitamin supplementation).

• Cutaneous reactions: Serious and occasionally fatal, bullous, blistering, and exfoliative dermatologic toxicity may occur; pretreatment with dexamethasone is necessary to reduce the incidence and severity of cutaneous reactions. Rarely, Stevens-Johnson syndrome and toxic epidermal necrolysis have been reported.

• GI toxicity: GI toxicity may occur; prophylactic folic acid and vitamin B12 supplements are necessary to reduce GI toxicity. Initiate supplementation 1 week before the first dose of pemetrexed and continue for 21 days after the last pemetrexed dose.

• Hypersensitivity: Hypersensitivity (including allergic reaction) has been reported with pemetrexed.

• Nephrotoxicity: Pemetrexed may cause severe (and potentially fatal) kidney toxicity (kidney toxicity may occur with single-agent pemetrexed or when used in combination with other chemotherapy agents).

• Pulmonary toxicity: Interstitial pneumonitis has been observed; may be serious and/or fatal. Signs/symptoms indicative of interstitial pneumonitis may include acute onset new or progressive pulmonary symptoms such as dyspnea, cough, or fever.

• Radiation recall: Radiation recall may occur in patients administered pemetrexed who received radiation previously (weeks to years).

Disease-related concerns:

• Renal impairment: Pemetrexed is primarily cleared by the kidneys; decreased renal function results in increased toxicity. Concurrent nephrotoxic medications may result in delayed pemetrexed clearance.

• Third space fluid: Although the effect of third space fluid on pemetrexed pharmacokinetics has not been fully defined, studies have determined pemetrexed concentrations in patients with mild to moderate ascites/pleural effusions were similar to concentrations in trials of patients without third space fluid accumulation.

Concurrent drug therapy issues:

• Ibuprofen: Ibuprofen may reduce the clearance of pemetrexed. In patients with CrCl 45 to 79 mL/minute, interrupt ibuprofen therapy 2 days prior to, during, and 2 days after pemetrexed therapy. If concomitant use cannot be avoided, monitor for myelosuppression, renal, and gastrointestinal toxicity.

Dosage form specific issues:

• Propylene glycol: Some dosage forms may contain propylene glycol; large amounts are potentially toxic and have been associated with hyperosmolality, lactic acidosis, seizures, and respiratory depression; use caution (AAP 1997; Zar 2007).

Product Availability

Pemetrexed 100 mg/10 mL, 500 mg/50 mL, 1,000 mg/100 mL single dose vials: FDA approved May 2023; anticipated availability is currently unknown. Information pertaining to this product within the monograph is pending revision. Consult prescribing information for additional information.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution, Intravenous:

Pemfexy: 500 mg/20 mL (20 mL) [contains propylene glycol]

Solution, Intravenous [preservative free]:

Generic: 100 mg/4 mL (4 mL); 500 mg/20 mL (20 mL); 1 g/40 mL (40 mL)

Solution, Intravenous, as disodium:

Generic: 100 mg/4 mL (4 mL); 500 mg/20 mL (20 mL)

Solution, Intravenous, as disodium [preservative free]:

Generic: 100 mg/4 mL (4 mL); 500 mg/20 mL (20 mL); 850 mg/34 mL (34 mL); 1 g/40 mL (40 mL)

Solution Reconstituted, Intravenous:

Alimta: 500 mg (1 ea)

Generic: 100 mg (1 ea); 500 mg (1 ea); 1000 mg (1 ea)

Solution Reconstituted, Intravenous [preservative free]:

Alimta: 100 mg (1 ea)

Generic: 100 mg (1 ea); 500 mg (1 ea); 750 mg (1 ea); 1000 mg (1 ea)

Generic Equivalent Available: US

Yes

Pricing: US

Solution (PEMEtrexed Disodium Intravenous)

1 g/40mL (per mL): $27.00 - $31.34

100 mg/4 mL (per mL): $30.31 - $210.58

500 mg/20 mL (per mL): $27.33 - $210.57

850MG/34ML (per mL): $27.33

Solution (PEMEtrexed Intravenous)

1 g/40mL (per mL): $56.48

100 mg/4 mL (per mL): $59.46

500 mg/20 mL (per mL): $59.46

Solution (Pemfexy Intravenous)

500 mg/20 mL (per mL): $252.03

Solution (reconstituted) (Alimta Intravenous)

100 mg (per each): $970.32

500 mg (per each): $4,851.60

Solution (reconstituted) (PEMEtrexed Disodium Intravenous)

100 mg (per each): $13.96 - $856.16

500 mg (per each): $60.18 - $4,280.78

750 mg (per each): $866.26 - $6,421.18

1000 mg (per each): $222.84 - $8,561.57

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Solution Reconstituted, Intravenous:

Alimta: 100 mg (1 ea); 500 mg ([DSC])

Generic: 100 mg (1 ea); 500 mg (1 ea); 1000 mg (1 ea)

Administration: Adult

IV: Infuse over 10 minutes. When used in combination with platinum-based therapy (cisplatin or carboplatin), administer pemetrexed prior to the platinum. Administer pemetrexed after pembrolizumab if administered on the same day. When used in combination with durvalumab and tremelimumab, administer tremelimumab first, followed by durvalumab and then pemetrexed on the day of dosing.

Hazardous Drugs Handling Considerations

Hazardous agent (NIOSH 2016 [group 1]).

Use appropriate precautions for receiving, handling, storage, preparation, dispensing, transporting, administration, and disposal. Follow NIOSH and USP 800 recommendations and institution-specific policies/procedures for appropriate containment strategy (NIOSH 2016; USP-NF 2020).

Use: Labeled Indications

Malignant pleural mesothelioma: Initial treatment of malignant pleural mesothelioma (in combination with cisplatin) that is unresectable or in patients who are not otherwise candidates for curative surgery.

Non-small cell lung cancer, nonsquamous:

Initial treatment of locally advanced or metastatic nonsquamous non-small cell lung cancer (NSCLC) (in combination with cisplatin).

Initial treatment of metastatic, nonsquamous NSCLC (in combination with platinum chemotherapy and pembrolizumab) in patients with no epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) genomic tumor aberrations.

Maintenance treatment (single-agent) of locally advanced or metastatic nonsquamous NSCLC if no progression after 4 cycles of platinum-based first-line therapy.

Single-agent treatment (after prior chemotherapy) of recurrent/metastatic nonsquamous NSCLC.

Limitation of use: Pemetrexed is not indicated for the treatment of squamous cell NSCLC.

Use: Off-Label: Adult

Bladder cancer, metastatic; Cervical cancer, persistent or recurrent; Ovarian cancer, platinum-resistant; Thymic malignancies, metastatic

Medication Safety Issues
Sound-alike/look-alike issues:

PEMEtrexed may be confused with methotrexate, pembrolizumab, PRALAtrexate

High alert medication:

This medication is in a class the Institute for Safe Medication Practices (ISMP) includes among its list of drug classes which have a heightened risk of causing significant patient harm when used in error.

Metabolism/Transport Effects

Substrate of OAT1/3

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.

5-Aminosalicylic Acid Derivatives: May enhance the myelosuppressive effect of Myelosuppressive Agents. Risk C: Monitor therapy

Abrocitinib: May enhance the immunosuppressive effect of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid combination

Antithymocyte Globulin (Equine): Immunosuppressants (Cytotoxic Chemotherapy) may enhance the adverse/toxic effect of Antithymocyte Globulin (Equine). Specifically, these effects may be unmasked if the dose of cytotoxic chemotherapy is reduced. Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Antithymocyte Globulin (Equine). Specifically, infections may occur with greater severity and/or atypical presentations. Risk C: Monitor therapy

Baricitinib: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Baricitinib. Risk X: Avoid combination

BCG (Intravesical): Myelosuppressive Agents may diminish the therapeutic effect of BCG (Intravesical). Risk X: Avoid combination

BCG Products: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the adverse/toxic effect of BCG Products. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of BCG Products. Risk X: Avoid combination

Brincidofovir: Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Brincidofovir. Risk C: Monitor therapy

Brivudine: May enhance the adverse/toxic effect of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid combination

Chikungunya Vaccine (Live): Immunosuppressants (Cytotoxic Chemotherapy) may enhance the adverse/toxic effect of Chikungunya Vaccine (Live). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Chikungunya Vaccine (Live). Risk X: Avoid combination

Chloramphenicol (Ophthalmic): May enhance the adverse/toxic effect of Myelosuppressive Agents. Risk C: Monitor therapy

Chloramphenicol (Systemic): Myelosuppressive Agents may enhance the myelosuppressive effect of Chloramphenicol (Systemic). Risk X: Avoid combination

Cladribine: May enhance the myelosuppressive effect of Myelosuppressive Agents. Risk X: Avoid combination

Cladribine: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Cladribine. Risk X: Avoid combination

CloZAPine: Myelosuppressive Agents may enhance the adverse/toxic effect of CloZAPine. Specifically, the risk for neutropenia may be increased. Risk C: Monitor therapy

Coccidioides immitis Skin Test: Immunosuppressants (Cytotoxic Chemotherapy) may diminish the diagnostic effect of Coccidioides immitis Skin Test. Management: Consider discontinuing cytotoxic chemotherapy several weeks prior to coccidioides immitis skin antigen testing to increase the likelihood of accurate diagnostic results. Risk D: Consider therapy modification

COVID-19 Vaccine (Adenovirus Vector): Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of COVID-19 Vaccine (Adenovirus Vector). Management: Administer a 2nd dose using an mRNA COVID-19 vaccine (at least 4 weeks after the primary vaccine dose) and a bivalent booster dose (at least 2 months after the additional mRNA dose or any other boosters). Risk D: Consider therapy modification

COVID-19 Vaccine (Inactivated Virus): Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of COVID-19 Vaccine (Inactivated Virus). Risk C: Monitor therapy

COVID-19 Vaccine (mRNA): Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of COVID-19 Vaccine (mRNA). Management: Give a 3-dose primary series for all patients aged 6 months and older taking immunosuppressive medications or therapies. Booster doses are recommended for certain age groups. See CDC guidance for details. Risk D: Consider therapy modification

COVID-19 Vaccine (Subunit): Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of COVID-19 Vaccine (Subunit). Risk C: Monitor therapy

COVID-19 Vaccine (Virus-like Particles): Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of COVID-19 Vaccine (Virus-like Particles). Risk C: Monitor therapy

Deferiprone: Myelosuppressive Agents may enhance the neutropenic effect of Deferiprone. Management: Avoid the concomitant use of deferiprone and myelosuppressive agents whenever possible. If this combination cannot be avoided, monitor the absolute neutrophil count more closely. Risk D: Consider therapy modification

Dengue Tetravalent Vaccine (Live): Immunosuppressants (Cytotoxic Chemotherapy) may enhance the adverse/toxic effect of Dengue Tetravalent Vaccine (Live). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Dengue Tetravalent Vaccine (Live). Risk X: Avoid combination

Denosumab: May enhance the immunosuppressive effect of Immunosuppressants (Cytotoxic Chemotherapy). Management: Consider the risk of serious infections versus the potential benefits of coadministration of denosumab and cytotoxic chemotherapy. If combined, monitor patients for signs/symptoms of serious infections. Risk D: Consider therapy modification

Deucravacitinib: May enhance the immunosuppressive effect of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid combination

Dipyrone: May enhance the adverse/toxic effect of Myelosuppressive Agents. Specifically, the risk for agranulocytosis and pancytopenia may be increased Risk X: Avoid combination

Etrasimod: May enhance the immunosuppressive effect of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid combination

Fexinidazole: Myelosuppressive Agents may enhance the myelosuppressive effect of Fexinidazole. Risk X: Avoid combination

Filgotinib: May enhance the immunosuppressive effect of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid combination

Ibuprofen: May increase the serum concentration of PEMEtrexed. Management: In patients with an estimated creatinine clearance of 45 to 79 mL/min, avoid ibuprofen for 2 days before, the day of, and 2 days following the administration of pemetrexed. Monitor for increased pemetrexed toxicities if combined. Risk D: Consider therapy modification

Inebilizumab: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Inebilizumab. Risk C: Monitor therapy

Influenza Virus Vaccines: Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Influenza Virus Vaccines. Management: Administer influenza vaccines at least 2 weeks prior to initiating chemotherapy if possible. If vaccination occurs less than 2 weeks prior to or during chemotherapy, revaccinate at least 3 months after therapy discontinued if immune competence restored. Risk D: Consider therapy modification

Leflunomide: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Leflunomide. Management: Increase the frequency of chronic monitoring of platelet, white blood cell count, and hemoglobin or hematocrit to monthly, instead of every 6 to 8 weeks, if leflunomide is coadministered with immunosuppressive agents, such as cytotoxic chemotherapy. Risk D: Consider therapy modification

Lenograstim: Antineoplastic Agents may diminish the therapeutic effect of Lenograstim. Management: Avoid the use of lenograstim 24 hours before until 24 hours after the completion of myelosuppressive cytotoxic chemotherapy. Risk D: Consider therapy modification

Lipegfilgrastim: Antineoplastic Agents may diminish the therapeutic effect of Lipegfilgrastim. Management: Avoid concomitant use of lipegfilgrastim and myelosuppressive cytotoxic chemotherapy. Lipegfilgrastim should be administered at least 24 hours after the completion of myelosuppressive cytotoxic chemotherapy. Risk D: Consider therapy modification

Methotrexate: PEMEtrexed may increase the serum concentration of Methotrexate. Management: Avoid coadministration of pemetrexed and methotrexate if possible. If coadministration is required, monitor closely for methotrexate toxicities (eg, hematological, gastrointestinal, nephrotoxicity toxicities). Risk D: Consider therapy modification

Mumps- Rubella- or Varicella-Containing Live Vaccines: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the adverse/toxic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Risk X: Avoid combination

Nadofaragene Firadenovec: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the adverse/toxic effect of Nadofaragene Firadenovec. Specifically, the risk of disseminated adenovirus infection may be increased. Risk X: Avoid combination

Natalizumab: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Natalizumab. Risk X: Avoid combination

Nitisinone: May increase the serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk C: Monitor therapy

Ocrelizumab: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Ocrelizumab. Risk C: Monitor therapy

Ofatumumab: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Ofatumumab. Risk C: Monitor therapy

Olaparib: Myelosuppressive Agents may enhance the myelosuppressive effect of Olaparib. Risk C: Monitor therapy

Palifermin: May enhance the adverse/toxic effect of Antineoplastic Agents. Specifically, the duration and severity of oral mucositis may be increased. Management: Do not administer palifermin within 24 hours before, during infusion of, or within 24 hours after administration of myelotoxic chemotherapy. Risk D: Consider therapy modification

Pidotimod: Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Pidotimod. Risk C: Monitor therapy

Pimecrolimus: May enhance the immunosuppressive effect of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid combination

Pneumococcal Vaccines: Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Pneumococcal Vaccines. Risk C: Monitor therapy

Poliovirus Vaccine (Live/Trivalent/Oral): Immunosuppressants (Cytotoxic Chemotherapy) may enhance the adverse/toxic effect of Poliovirus Vaccine (Live/Trivalent/Oral). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Poliovirus Vaccine (Live/Trivalent/Oral). Risk X: Avoid combination

Polymethylmethacrylate: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the potential for allergic or hypersensitivity reactions to Polymethylmethacrylate. Management: Use caution when considering use of bovine collagen-containing implants such as the polymethylmethacrylate-based Bellafill brand implant in patients who are receiving immunosuppressants. Consider use of additional skin tests prior to administration. Risk D: Consider therapy modification

Pretomanid: May increase the serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk C: Monitor therapy

Promazine: May enhance the myelosuppressive effect of Myelosuppressive Agents. Risk C: Monitor therapy

Pyrimethamine: May enhance the adverse/toxic effect of PEMEtrexed. Risk C: Monitor therapy

Rabies Vaccine: Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Rabies Vaccine. Management: Complete rabies vaccination at least 2 weeks before initiation of immunosuppressant therapy if possible. If combined, check for rabies antibody titers, and if vaccination is for post exposure prophylaxis, administer a 5th dose of the vaccine. Risk D: Consider therapy modification

Ritlecitinib: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Ritlecitinib. Risk X: Avoid combination

Ropeginterferon Alfa-2b: Myelosuppressive Agents may enhance the myelosuppressive effect of Ropeginterferon Alfa-2b. Management: Avoid coadministration of ropeginterferon alfa-2b and other myelosuppressive agents. If this combination cannot be avoided, monitor patients for excessive myelosuppressive effects. Risk D: Consider therapy modification

Ruxolitinib (Topical): Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Ruxolitinib (Topical). Risk X: Avoid combination

Sipuleucel-T: Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Sipuleucel-T. Management: Consider reducing the dose or discontinuing the use of immunosuppressants, such as cytotoxic chemotherapy, prior to initiating sipuleucel-T therapy. Risk D: Consider therapy modification

Sphingosine 1-Phosphate (S1P) Receptor Modulator: May enhance the immunosuppressive effect of Immunosuppressants (Cytotoxic Chemotherapy). Risk C: Monitor therapy

Tacrolimus (Topical): Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Tacrolimus (Topical). Risk X: Avoid combination

Talimogene Laherparepvec: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the adverse/toxic effect of Talimogene Laherparepvec. Specifically, the risk of infection from the live, attenuated herpes simplex virus contained in talimogene laherparepvec may be increased. Risk X: Avoid combination

Taurursodiol: May increase the serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk X: Avoid combination

Teriflunomide: May increase the serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk C: Monitor therapy

Tertomotide: Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Tertomotide. Risk X: Avoid combination

Tofacitinib: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Tofacitinib. Risk X: Avoid combination

Typhoid Vaccine: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the adverse/toxic effect of Typhoid Vaccine. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Typhoid Vaccine. Risk X: Avoid combination

Ublituximab: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Ublituximab. Risk C: Monitor therapy

Upadacitinib: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Upadacitinib. Risk X: Avoid combination

Vaborbactam: May increase the serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk C: Monitor therapy

Vaccines (Inactivated/Non-Replicating): Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Vaccines (Inactivated/Non-Replicating). Management: Give inactivated vaccines at least 2 weeks prior to initiation of chemotherapy when possible. Patients vaccinated less than 14 days before initiating or during chemotherapy should be revaccinated at least 3 months after therapy is complete. Risk D: Consider therapy modification

Vaccines (Live): Immunosuppressants (Cytotoxic Chemotherapy) may enhance the adverse/toxic effect of Vaccines (Live). Specifically, the risk of vaccine-associated infection may be increased. Vaccines (Live) may diminish the therapeutic effect of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid combination

Yellow Fever Vaccine: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the adverse/toxic effect of Yellow Fever Vaccine. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Yellow Fever Vaccine. Risk X: Avoid combination

Reproductive Considerations

Verify pregnancy status prior to treatment initiation in patients who could become pregnant. Patients who could become pregnant should use effective contraception during treatment and for at least 6 months after the last pemetrexed dose. Patients with partners who could become pregnant should use effective contraception during treatment and for 3 months after the last pemetrexed dose. Pemetrexed may impair fertility in males.

Pregnancy Considerations

Based on findings in animal reproduction studies and on the mechanism of action, pemetrexed may cause fetal harm if administered during pregnancy.

Breastfeeding Considerations

It is not known if pemetrexed is present in breast milk. Due to the potential for serious adverse reactions in the breastfed infant, breastfeeding is not recommended during treatment and for 1 week after the last pemetrexed dose.

Monitoring Parameters

CBC with differential and platelets (at the beginning of each cycle, and on days 8 and 15 of each cycle if clinically indicated); renal function tests (serum creatinine, creatinine clearance, BUN; prior to each cycle and as needed) total bilirubin, ALT, AST (periodic). Verify pregnancy status prior to treatment initiation (in patients who could become pregnant). Monitor for signs/symptoms of mucositis and diarrhea, pulmonary toxicity, dermatologic toxicity, and radiation recall (monitor for inflammation or blistering in areas of prior radiation treatment).

The American Society of Clinical Oncology hepatitis B screening and management provisional clinical opinion (ASCO [Hwang 2020]) recommends hepatitis B virus (HBV) screening with hepatitis B surface antigen, hepatitis B core antibody, total Ig or IgG, and antibody to hepatitis B surface antigen prior to beginning (or at the beginning of) systemic anticancer therapy; do not delay treatment for screening/results. Detection of chronic or past HBV infection requires a risk assessment to determine antiviral prophylaxis requirements, monitoring, and follow-up.

Mechanism of Action

Pemetrexed is an antifolate; it disrupts folate-dependent metabolic processes essential for cell replication. Pemetrexed inhibits thymidylate synthase (TS), dihydrofolate reductase (DHFR), glycinamide ribonucleotide formyltransferase (GARFT), and aminoimidazole carboxamide ribonucleotide formyltransferase (AICARFT), the enzymes involved in folate metabolism and DNA synthesis, resulting in inhibition of purine and thymidine nucleotide and protein synthesis.

Pharmacokinetics (Adult Data Unless Noted)

Distribution: Vdss: 16.1 L

Protein binding: 81%

Metabolism: Minimal

Half-life elimination: Normal renal function: 3.5 hours

Excretion: Urine (70% to 90% as unchanged drug)

Pharmacokinetics: Additional Considerations (Adult Data Unless Noted)

Altered kidney function: Pemetrexed clearance decreases and AUC increases as renal function decreases; in patients with CrCl of 45, 50, and 80 mL/minute, AUC was increased 65%, 54%, and 13%, respectively, compared with patients with CrCl of 100 mL/minute.

Brand Names: International
International Brand Names by Country
For country code abbreviations (show table)

  • (AE) United Arab Emirates: Pemetrexed spc;
  • (AR) Argentina: Alimta | Alltrexed | Ekel | Enzastar | Holista | Lidoras | Martxel | Paxequime | Pemetrexed gp pharm | Pemetrexed ima | Pemetrexed varifarma | Peymetrel | Praxed | Sukuba | Tepenac | Trexam | Venusted | Xulia;
  • (AT) Austria: Alimta | Armisarte | Pemegerolan | Pemetrexed accord | Pemetrexed ever pharma | Pemetrexed fresenius kabi | Pemetrexed krka | Pemetrexed sandoz | Pemetrexed stada | Pemetrexed zentiva;
  • (AU) Australia: Alimta | Dbl pemetrexed | Pemetrexed accord | Pemetrexed aft | Pemetrexed apotex | Pemetrexed juno | Pemetrexed myx | Pemetrexed sandoz | Pemetrexed sun | Reladdin | Tevatrexed;
  • (BD) Bangladesh: Alimta;
  • (BE) Belgium: Alimta | Armisarte | Pemetrexed accord | Pemetrexed eg | Pemetrexed ever pharma | Pemetrexed Fresenius Kabi | Pemetrexed fresenius kabi | Pemetrexed hospira | Pemetrexed krka | Pemetrexed mylan | Pemetrexed sandoz;
  • (BG) Bulgaria: Alimta | Armisarte | Pemetrexed alvogen | Pemetrexed heaton | Pemetrexed sandoz;
  • (BR) Brazil: Alimta | Atred | Eroxym | Mesotem | Pemeglenn | Pemetrexede | Pemetrexede dissodico | Pemetrexede dissodico heptaidratado | Pemtryx | Plexeden | Sukhi;
  • (CH) Switzerland: Alimta | Amtiris | Pemetrexed accord | Pemetrexed mylan | Pemetrexed pfizer | Pemetrexed sandoz | Pemetrexed Spirig HC | Pemetrexed Teva | Pemetrexed zentiva;
  • (CL) Chile: Alimta | Pemetrexed;
  • (CN) China: Alimta | Ao tian cheng | Jie bai li | Pu lai le | Sai zhen | Yi luo ze;
  • (CO) Colombia: Alimta | Cacitab | Enzastar | Genetrexed | Lekarna | Martxel | Nextrexed | Paxib | Pemeker | Pemeta | Pemetrexed | Pemetrexed kemex | Pemetrexseven | Pemgem | Pemintas | Pexed | Pexitaz | Pleurex | Prelonex | Prelun | Revotrain | Sumitrexed | Taxitan | Tremzated | Venprex;
  • (CZ) Czech Republic: Alimta | Armisarte | Pemetrexed accord | Pemetrexed ever pharma | Pemetrexed fresenius kabi | Pemetrexed glenmark | Pemetrexed heaton | Pemetrexed krka | Pemetrexed sandoz | Pemetrexed Teva | Pemetrexed zentiva | Trixid;
  • (DE) Germany: Albotiva | Alimta | Pemetrexed accord | Pemetrexed beta | Pemetrexed ever pharma | Pemetrexed fresenius kabi | Pemetrexed Fresenius Kabi | Pemetrexed hexal | Pemetrexed hospira | Pemetrexed medac | Pemetrexed mylan | Pemetrexed neocorp | Pemetrexed ribosepharm | Pemetrexed seacross | Pemetrexed stada | Pemetrexed sun | Pemetrexed tad | Pemetrexed zentiva;
  • (DO) Dominican Republic: Alimta;
  • (EC) Ecuador: Alimta | Enzastar | Pemetrexed | Sukuba;
  • (EE) Estonia: Alimta | Pemetrexed accord | Pemetrexed alvogen | Pemetrexed medac | Pemetrexed sandoz;
  • (EG) Egypt: Alimta;
  • (ES) Spain: Alimta | Armisarte | Mintayax | Pemetrexed accord | Pemetrexed Aurovit | Pemetrexed ebewe | Pemetrexed ever pharma | Pemetrexed Fresenius Kabi | Pemetrexed hospira | Pemetrexed mylan | Pemetrexed sala | Pemetrexed Stadage | Pemetrexed sun | Pemetrexed tillomed;
  • (ET) Ethiopia: Pemetrexed | Pemxcel;
  • (FI) Finland: Alimta | Pemetrexed accord | Pemetrexed ever pharma | Pemetrexed Fresenius Kabi | Pemetrexed hexal | Pemetrexed medac;
  • (FR) France: Alimta | Armisarte | Pemetrexed | Pemetrexed accord | Pemetrexed ever pharma | Pemetrexed Fresenius Kabi | Pemetrexed mylan | Pemetrexed zentiva;
  • (GB) United Kingdom: Alimta | Pemetrexed | Pemetrexed hospira | Pemetrexed sandoz | Pemetrexed seacross;
  • (GR) Greece: Alimta;
  • (HK) Hong Kong: Alimta | Dbl pemetrexed | Pemenon;
  • (HR) Croatia: Alimta;
  • (HU) Hungary: Alimta | Armisarte | Pemetrexed accord | Pemetrexed pharmaswiss | Pemetrexed sandoz | Pemetrexed stada | Pemetrexed Teva | Trixid;
  • (ID) Indonesia: Alimta | Fontrexed | Kabipem | Pemtero | Primexa;
  • (IE) Ireland: Armisarte | Pemetrexed | Pemetrexed krka | Pemetrexed mylan;
  • (IL) Israel: Alimta;
  • (IN) India: Adpem | Kabipem | Pamifect | Pemanat | Pemecad | Pemeplast | Pemetero | Pemex | Pemexar | Pemgem | Pemmet | Pemotide | Pemxcel | Pexetrust | Pexitaz | Pleumet | Prexx | Relitrexed | Strimta | Symyx | Temeran | Zupemed;
  • (IT) Italy: Alimta | Armisarte | Pemetrexed accord | Pemetrexed eg | Pemetrexed ever pharma | Pemetrexed Fresenius Kabi | Pemetrexed hospira | Pemetrexed mylan | Pemetrexed reddy | Pemetrexed sandoz | Pemetrexed sun;
  • (JO) Jordan: Alimta | Pemitra | Trixem;
  • (JP) Japan: Alimta | Pemetrexed;
  • (KE) Kenya: Alimta;
  • (KR) Korea, Republic of: Alexia | Algik | Alimta | Alimxed | Mainta | Pelimta | Pemebit | Pemecin | Pemecine | Pemed | Pemed s | Pemirex | Pemta | Pemxed | Pfizer pemetrexed;
  • (KW) Kuwait: Alimta;
  • (LB) Lebanon: Alimta | Pleutrex;
  • (LT) Lithuania: Alimta | Pemetrexed accord | Pemetrexed alvogen | Pemetrexed ebewe | Pemetrexed fresenius kabi | Pemetrexed medac | Pemetrexed mylan | Pemetrexed zentiva;
  • (LV) Latvia: Alimta | Pemetrexed accord | Pemetrexed alvogen | Pemetrexed fresenius kabi;
  • (MA) Morocco: Alimta | Pemetrexed zenith;
  • (MX) Mexico: Alimta | Asocapul | Bemetad | Empet | Itara | Martxel | Pemetrexed | Pexitaz | Tec pred | Tremzated | Trexedical | Virplazit | Zulamed;
  • (MY) Malaysia: Accord pemetrexed | Ontrex | Pemenon | Podoxred;
  • (NL) Netherlands: Alimta | Armisarte | Pemetrexed | Pemetrexed accord | Pemetrexed b medical | Pemetrexed cf | Pemetrexed ever pharma | Pemetrexed fresenius kabi | Pemetrexed krka | Pemetrexed mylan | Pemetrexed sandoz | Pemetrexed zentiva;
  • (NO) Norway: Alimta | Pemetrexed | Pemetrexed accord | Pemetrexed Fresenius Kabi | Pemetrexed fresenius kabi | Pemetrexed medac | Pemetrexed sandoz;
  • (NZ) New Zealand: Alimta | Dbl pemetrexed | Pemetrexed | Pemetrexed juno;
  • (PE) Peru: Alimta | Enzastar | Metanex | Pemeker | Pemetrexed;
  • (PH) Philippines: Alimta | Pemirex | Pexate;
  • (PK) Pakistan: Algik | Alimta | Maclimta | Pemetrexed sandoz | Proxed;
  • (PL) Poland: Alimta | Pemetreksed sun | Pemetrexed accord | Pemetrexed alvogen | Pemetrexed Fresenius Kabi | Pemetrexed glenmark | Pemetrexed sandoz;
  • (PR) Puerto Rico: Alimta | Pemetrexed;
  • (PT) Portugal: Alimta | Pemetrexed sandoz | Pemetrexed stada | Pemetrexedo accord | Pemetrexedo ebewe | Pemetrexedo ever pharma | Pemetrexedo fresenius kabi | Pemetrexedo Refta;
  • (PY) Paraguay: Alimta | Enzastar | Holista | Lekarna | Lidoras | Mytrex | Pemeker | Pemetrexed bauel top | Pemetrexed imedic | Pemetrexed intas | Pemetrexed kemex | Pemetrexed medicine | Pemetrexed prosalud | Pemetrexed sandoz | Pemetrexed varifarma | Venusted;
  • (QA) Qatar: Alimta;
  • (RO) Romania: Alimta | Armisarte | Pemetrexed accord | Pemetrexed dr reddys | Pemetrexed stada | Pemetrexed sun | Pemetrexed zentiva;
  • (RU) Russian Federation: Alimta | Folitrex | Ispolat | Pemelan | Pemetrexed | Pemetrexed J | Pemetrexed nativ | Pemetrexed TL | Pemjem | Verotrexed;
  • (SA) Saudi Arabia: Almetra | Pemetrexed spc | Pemitra;
  • (SE) Sweden: Alimta | Armisarte | Pemetrexed | Pemetrexed accord | Pemetrexed ever pharma | Pemetrexed fresenius kabi | Pemetrexed hexal | Pemetrexed hospira | Pemetrexed mylan | Pemetrexed reig jofre | Pemetrexed stada;
  • (SG) Singapore: Alimta;
  • (SI) Slovenia: Pemetreksed accord | Pemetreksed krka;
  • (SK) Slovakia: Alimta | Pemetrexed accord | Pemetrexed ever pharma | Pemetrexed fresenius kabi | Pemetrexed generics | Pemetrexed glenmark | Pemetrexed pharmevid | Pemetrexed sandoz | Pemetrexed stada | Pemetrexed Teva | Trixid;
  • (TH) Thailand: Alimta | Emetex | Pemetrex venus;
  • (TN) Tunisia: Alimta | Cytolim | Pemetrexed neapolis | Trexam;
  • (TR) Turkey: Alimta | Pemtrex | Prexet | Relitrexed;
  • (TW) Taiwan: Alimta | Apeta | Pemeda | Pemetrexed | Pexeda;
  • (UA) Ukraine: Alimta | Pemetrexed mb | Pemetro;
  • (UY) Uruguay: Alimta | Pemetrexed;
  • (VE) Venezuela, Bolivarian Republic of: Pemetrexed;
  • (VN) Viet Nam: Pemehope;
  • (ZA) South Africa: Aliloma | Alimta | Pemetrexed accord | Pemetrexed fresenius kabi | Pemject | PEMTORI IV | Terexta
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