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Transcript of BAD THINGS IN SMALL PACKAGES, ANTINEOPLASTIC AND CYTOTOXIC DRUGS Daryl Lance, Pharm D, BCOP, Susan...
![Page 1: BAD THINGS IN SMALL PACKAGES, ANTINEOPLASTIC AND CYTOTOXIC DRUGS Daryl Lance, Pharm D, BCOP, Susan Eisberg.](https://reader030.fdocuments.us/reader030/viewer/2022032706/56649de95503460f94ae4029/html5/thumbnails/1.jpg)
BAD THINGS IN SMALL PACKAGES,
ANTINEOPLASTIC AND CYTOTOXIC DRUGS
• Daryl Lance, Pharm D, BCOP,
• Susan Eisberg
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INTRODUCTION
• What is the problem?
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INTRODUCTION
• Communication is important.
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WHAT ARE THESE CHEMICALS AND HOW ARE
THEY USED?
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WHAT ARE THESE CHEMICALS AND HOW ARE
THEY USED?
• Bone marrow suppression
• Hair loss (alopecia)
• Mucositis (mouth sores)
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ALKYLATING AGENTS
• First chemotherapy drug to be produced
• Alkylation to the DNA base pairs
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ALKYLATING AGENTS
• Secondary tumors
• Mutagenicity
• Sterility
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ALKYLATING AGENTS
• Side effects:– Bone marrow suppression– Nausea and vomiting– Hemorrhagic cystitis– Sterility
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ALKYLATING AGENTS
• Cyclophosphamide, Ifosfamide• Cisplatin, Carboplatin• Dacarbazine, Chlorambucil• Busulfan, Chlorozotocin• Streptozocin, Carmustine• Semustine, Lomustine• Melphalan, Mechlorethamine• Procarbazine, Gemcitabine
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ANTIMETABOLITES
• Inhibition of enzymatic processes
• False substrates
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ANTIMETABOLITES
• This was the second chemotherapy agent to be produced– Antifolates
• Special applications
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ANTIMETABOLITES
• Side effects– Hair loss– Mucositis– Bone marrow suppression
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ANTIMETABOLITES
• Azathioprine, Cyclosporin
• Cytarabine, Floxuridine
• Fluorouracil, Capcitabine
• Ganciclovir, Hydroxyurea
• Mercaptopurine Methotrexate
• Ribavirin, Thioguanine
• Fludarabine, Zidovudine
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ANTI-TUMOR ANTIBIOTICS
• Intercalation
• Alkylation
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ANTI-TUMOR ANTIBIOTICS
• Highly colored.
• Important clinically
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ANTI-TUMOR ANTIBIOTICS
• Side effects– Bone marrow suppression– Mucositis– Alopecia– Cardiac toxicity– Tissue vesicant agents– Nausea, vomiting
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ANTI-TUMOR ANTIBIOTICS
• Doxorubicin, Daunamycin
• Idamycin, Dactinomycin
• Mitomycin Plicamycin
• Bleomycin, Mitoxantrone
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SPINDLE POISONS AND NATURAL PRODUCTS
• Natural plant products
• Microtubule inhibition
• Mitosis inhibition
• Asparaginine inhibition
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SPINDLE POISONS AND NATURAL PRODUCTS
• Tumor types
• Special applications
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SPINDLE POISONS AND NATURAL PRODUCTS
• Side effects– Alopecia– Bone marrow suppression– Peripheral neuropathy– Vesicants– Diabetes, Coagulopathies
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SPINDLE POISONS AND NATURAL PRODUCTS
• Vinca Alkyloids- Vincristine, Vinblastine, Vinorelbine
• Podophyllotoxins- etoposide, teniposide
• Taxanes- paclitaxol (taxol), Docetaxel
• Enzymes- L-asparaginase
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HEALTH CARE RISK
• Risks to health care workers- Difficulties of relative risk– measurement of exposure– Long latent period– Identification of risk groups
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BIOLOGIC RISKS WITH EXPOSURE
• Reproductive outcomes
• Chromosomal changes
• Urine mutagenicity
• Acute symptoms
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LITERATURE DOCUMENTATION
• Study by Falck et al– Nurses were found to have mutagenic
substances in their urine
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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.
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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
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LITERATURE DOCUMENTATION
• Study by Selevan, et al. – Study of occupational exposure to
antineoplastic drugs– and fetal loss in nurses.
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LITERATURE DOCUMENTATION
• Study by Benhaamou, et al.– Mutagenicity in urine from nurses handling
cytostatic agents
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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.
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CHEMO/CYTOTOXIC EXPOSURE
• Absorption
• Inhalation
• Ingestion
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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.
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ABSORPTIONPrevention 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
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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.
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INHALATIONPrevention 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
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INGESTION
• Eating, drinking, chewing gum, smoking or applying cosmetics or contact lenses may increase possible exposure
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INGESTIONPrevention 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
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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”
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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
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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
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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
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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
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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
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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
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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
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OSHA GUIDELINES
• Website and OSHA information– www.osha.gov
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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
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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
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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.
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SPILL PREVENTION
• Staff education
• Handling techniques– Storage– Transport– Administration– Caring for Patients
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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
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SPILLS, UNAVOIDABLE, SO HOW DO YOU CLEAN THEM
UP?• Getting dirty (or how to avoid getting
dirty!)
• Demonstration
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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 spill pillows to prevent spread– Place absorbent towel over spill without
touching spill
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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 2nd towel and place in
chemo waste container– If on carpet, must be extracted
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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
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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
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MEDICAL SURVEILLANCE
• Types of questions
• How frequent to survey?
• Who keeps these records?
• Where do you report the records?
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SUMMARY AND QUESTIONS
• What we said
• What you missed
• What else do you want to know.