BAD THINGS IN SMALL PACKAGES ANTINEOPLASTIC AND CYTOTOXIC
BAD THINGS IN SMALL PACKAGES, ANTINEOPLASTIC AND CYTOTOXIC DRUGS • Daryl Lance, Pharm D, BCOP, • Susan Eisberg
INTRODUCTION • What is the problem?
INTRODUCTION • Communication is important.
WHAT ARE THESE CHEMICALS AND HOW ARE THEY USED?
WHAT ARE THESE CHEMICALS AND HOW ARE THEY USED? • Bone marrow suppression • Hair loss (alopecia) • Mucositis (mouth sores)
ALKYLATING AGENTS • First chemotherapy drug to be produced • Alkylation to the DNA base pairs
ALKYLATING AGENTS • Secondary tumors • Mutagenicity • Sterility
ALKYLATING AGENTS • Side effects: – Bone marrow suppression – Nausea and vomiting – Hemorrhagic cystitis – Sterility
ALKYLATING AGENTS • • Cyclophosphamide, Ifosfamide Cisplatin, Carboplatin Dacarbazine, Chlorambucil Busulfan, Chlorozotocin Streptozocin, Carmustine Semustine, Lomustine Melphalan, Mechlorethamine Procarbazine, Gemcitabine
ANTIMETABOLITES • Inhibition of enzymatic processes • False substrates
ANTIMETABOLITES • This was the second chemotherapy agent to be produced – Antifolates • Special applications
ANTIMETABOLITES • Side effects – Hair loss – Mucositis – Bone marrow suppression
ANTIMETABOLITES • • Azathioprine, Cyclosporin Cytarabine, Floxuridine Fluorouracil, Capcitabine Ganciclovir, Hydroxyurea Mercaptopurine Methotrexate Ribavirin, Thioguanine Fludarabine, Zidovudine
ANTI-TUMOR ANTIBIOTICS • Intercalation • Alkylation
ANTI-TUMOR ANTIBIOTICS • Highly colored. • Important clinically
ANTI-TUMOR ANTIBIOTICS • Side effects – Bone marrow suppression – Mucositis – Alopecia – Cardiac toxicity – Tissue vesicant agents – Nausea, vomiting
ANTI-TUMOR ANTIBIOTICS • • Doxorubicin, Idamycin, Mitomycin Bleomycin, Daunamycin Dactinomycin Plicamycin Mitoxantrone
SPINDLE POISONS AND NATURAL PRODUCTS • • Natural plant products Microtubule inhibition Mitosis inhibition Asparaginine inhibition
SPINDLE POISONS AND NATURAL PRODUCTS • Tumor types • Special applications
SPINDLE POISONS AND NATURAL PRODUCTS • Side effects – Alopecia – Bone marrow suppression – Peripheral neuropathy – Vesicants – Diabetes, Coagulopathies
SPINDLE POISONS AND NATURAL PRODUCTS • Vinca Alkyloids- Vincristine, Vinblastine, Vinorelbine • Podophyllotoxins- etoposide, teniposide • Taxanes- paclitaxol (taxol), Docetaxel • Enzymes- L-asparaginase
HEALTH CARE RISK • Risks to health care workers- Difficulties of relative risk – measurement of exposure – Long latent period – Identification of risk groups
BIOLOGIC RISKS WITH EXPOSURE • • Reproductive outcomes Chromosomal changes Urine mutagenicity Acute symptoms
LITERATURE DOCUMENTATION • Study by Falck et al – Nurses were found to have mutagenic substances in their urine
LITERATURE DOCUMENTATION • Study by Hemminki et al. – Spontaneous abortions and malformations in the offspring – of nurses exposed to anaesthetic gases, cytostatic drugs – and other potential hazards in hospitals based on – registerd information of outcome.
LITERATURE DOCUMENTATION • Study by Kilmodin-Hedman, et al, Urine mutagenicity – Study comparing 2 groups • one group utilizing personal protection • one group not using personal protection
LITERATURE DOCUMENTATION • Study by Selevan, et al. – Study of occupational exposure to antineoplastic drugs – and fetal loss in nurses.
LITERATURE DOCUMENTATION • Study by Benhaamou, et al. – Mutagenicity in urine from nurses handling cytostatic agents
LITERATURE DOCUMENTATION • Study by Conner, et al – Study of surface contamination with antineoplastic – agents in six cancer treatment centers in Canada – and the United States.
CHEMO/CYTOTOXIC EXPOSURE • Absorption • Inhalation • Ingestion
ABSORPTION • Can happen during preparation, administration or disposal of equipment OR while handling contaminated excreta or body fluids. • Know that body fluids and excreta can remain contaminated up to 48 hours after the last dose.
ABSORPTION Prevention Measures • Through skin, eyes, mucous membranes – Wear chemo gloves – Wash hands before & after gloves are used – If skin contact, wash ASAP – If eye contact, flush with normal saline liberally
INHALATION • Inhalation of aerosols can be very subtle and can occur without awareness from: – opening vials of the medication – clipping needles – expelling air from a syringe – splash effect when discarding contaminated excreta or body fluids into the toilet or measuring container.
INHALATION Prevention Measures • Use gauze pads when breaking vials • Don’t clip or remove needles or re-cap, dispose as a whole in the sharps containers • Use masks and/or goggles when there is a chance of creating an aerosol • Empty waste products into the toilet close to the water to minimize splashing
INGESTION • Eating, drinking, chewing gum, smoking or applying cosmetics or contact lenses may increase possible exposure
INGESTION Prevention Measures • Keep all foods and utensils away from drugs • Wash hands before and after contact with drug • Avoid hand to eye or hand to mouth contact
GENERAL PRECAUTIONS • Place waste in appropriate containers • “Chemotherapy Precautions” should begin when chemotherapy is initiated and continue for 48 hrs. after completion. • Staff should wear special chemotherapy gloves and gown whenever handling or administering IV, IM or subcutaneous AND whenever emptying body fluids of patients who are under “Chemo Precautions”
OSHA GUIDELINES • Basics of the guidelines - Handling CD’s – Drug Preparation – Drug Administration – Caring for Patients – Waste Disposal – Spills – Medical Surveillance – Storage & Transport – Training & Information
OSHA GUIDELINES • Basics of the guidelines - Handling CD’s – Drug Preparation – Drug Administration – Caring for Patients – Waste Disposal – Spills – Medical Surveillance – Storage & Transport – Training & Information
OSHA GUIDELINES • Basics of the guidelines - Handling CD’s – Drug Preparation – Drug Administration – Caring for Patients – Waste Disposal – Spills – Medical Surveillance – Storage & Transport – Training & Information
OSHA GUIDELINES • Basics of the guidelines - Handling CD’s – Drug Preparation – Drug Administration – Caring for Patients – Waste Disposal – Spills – Medical Surveillance – Storage & Transport – Training & Information
OSHA GUIDELINES • Basics of the guidelines - Handling CD’s – Drug Preparation – Drug Administration – Caring for Patients – Waste Disposal – Spills – Medical Surveillance – Storage & Transport – Training & Information
OSHA GUIDELINES • Basics of the guidelines - Handling CD’s – Drug Preparation – Drug Administration – Caring for Patients – Waste Disposal – Spills – Medical Surveillance – Storage & Transport – Training & Information
OSHA GUIDELINES • Basics of the guidelines - Handling CD’s – Drug Preparation – Drug Administration – Caring for Patients – Waste Disposal – Spills – Medical Surveillance – Storage & Transport – Training & Information
OSHA GUIDELINES • Website and OSHA information – www. osha. gov
EXPOSURE PREVENTION Having A Written Plan • Standard Operating Procedures • Criteria to determine and implement control measures – Engineering controls – PPE – Work Practices • Requirement that protective equipment (i. e. ventilation) functions properly
Having a Written Plan • • • Information & Training Medical Surveillance Designation of Responsible Person for Program Designation of handling area Use of BSC’s Procedures for safe removal of contaminated waste • Decontamination Procedures
CHEMO WASTE • Bulk Waste (i. e. -unadministered doses) should be disposed of as hazardous waste and picked up by licensed waste hauler. • Trace Waste (empty IV bags, syringes, etc. ) should be disposed of in containers specially marked for chemotherapy waste to be incinerated.
SPILL PREVENTION • Staff education • Handling techniques – Storage – Transport – Administration – Caring for Patients
SPILLS, UNAVOIDABLE, SO HOW DO YOU CLEAN THEM UP? • Steps in clean up • Who to contact • The spill kit and its contents • Personnel protection kits
SPILLS, UNAVOIDABLE, SO HOW DO YOU CLEAN THEM UP? • Getting dirty (or how to avoid getting dirty!) • Demonstration
STEPS IN CLEANUP • What to do immediately – Control Traffic – Rinse exposed body parts – Send someone for spill kit – Mark spill with caution sign • Containing the spill – Place spillows to prevent spread – Place absorbent towel over spill without touching spill
STEPS IN CLEANUP • Clean – Put on PPE (gown, gloves, mask and goggles) – Pick up towel and pillows and place in chemo waste container – Sweep any glass fragments with scoop and brush - place in chemo waste container – Wash all surfaces, including furniture – Absorb rinse water with 2 nd towel and place in chemo waste container – If on carpet, must be extracted
STEPS IN CLEANUP • Follow Up – Immediately Wash hands and all exposed skin areas with soap and water – Notify EVS for further clean-up with detergent and rinse water – Notify Pharmacy and Safety Department of spill – Order new spill kit
STEPS IN CLEANUP • Document – On Incident Report: • Date, time, location, amount of spill and drug involved • Area of body, personnel involved and action taken • Notification of Pharmacy and Safety Office – On Patient’s Chart • Amount of spill and the drug • MD notified
MEDICAL SURVEILLANCE • • Types of questions How frequent to survey? Who keeps these records? Where do you report the records?
SUMMARY AND QUESTIONS • What we said • What you missed • What else do you want to know.
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