Hazard Meds: Navigating the Warning Beacons

Size: px

Start display at page:

Download "Hazard Meds: Navigating the Warning Beacons"

Elvin Lawrence
5 years ago
Views:

1 Hazard Meds: Navigating the Warning Beacons Disclosures I have nothing to disclose at this time. Mark Twohey, Pharm.D., BCOP Palmetto Health Richland March 24, 2012 Objectives Understand the reasons for using chemotherapy List the different routes of administration and the dangers involved Discuss symptomatic safeguards to minimize preparation errors Understand proper techniques when handling/disposing hazardous medications What is cancer? Cancer = a group of diseases characterized by uncontrolled growth and spread of abnormal cells Seven Warning Signs of Cancer: (CAUTION) (C): Change in bowel or bladder habits (A): A sore that does not heal (U): Unusual bleeding or discharge (T): Thickening or lump in breast or elsewhere (I): Indigestion or difficulty in swallowing (O): Obvious change in a wart or mole (N): Nagging cough or hoarseness How Do Cancer Cells Differ From Normal Cells? Ability to clone: originate from genetic changes in a single cell, which then multiply to form a clone of malignant cells Autonomy: not controlled by normal biochemical/physical forces in body Tumor suppressor genes control inappropriate cell division Tumor-suppressor gene: negative regulator of cell cycle Negative regulation of cell cycle - allows cell cycle to halt for repairs Possible modulation of cytotoxic drug effects mutation of p53 linked to resistance Anaplasia: do not develop into normal cells from which the clone arose Metastasis: grow in parts of the body other than the site of origin Travels through the blood/lymph Types of Cancer Carcinomas: arise in epithelial tissue Form the outer surface of the body/line body cavity Sarcomas: arise from mesenchymal tissues Giving rise to connective tissues (i.e. soft tissue/bone) Lymphomas: lymphoid tissues Hodgkin s disease/ Non-Hodgkin s disease Leukemia: bone marrow 1

2 Lymphoma Cancer originating in lymphocytes (i.e. leukocytes) of the immune system Patients with weakened immune system (i.e. HIV) have higher incidence of certain lymphomas Often originates in lymph nodes - seen as an enlargement of the node (a tumor) 1832 Thomas Hodgkin published description of lymphoma 1982 classification of non-hodgkins lymphoma Divided into 16 different diseases 2001 World Health Organization 43 different forms of lymphoma divided into 4 broad groups Leukemia Bone marrow/blood-forming organs- production of certain WBCs (i.e. leukocytes) Overproduction of immature/abnormal WBCs suppress production of normal WBCs, RBCs, and platelets Results: Increased risk of infection (due to neutropenia) Anemia Bleeding (due to thrombocytopenia) Leukemia Acute or chronic based on cell of origin, cell line maturation, progression, response Leukemic cells: derived from single clonogenic cell Cell of origin: leukemia may include cells of more than one lineage Four major leukemias: (WBC proliferating abnormally) Acute lymphocytic (lymphoblastic)- med age: 10 Acute myeloid (nonlymphocytic) - med age: 65 * Untreated acute leukemias: death in weeks/months Chronic lymphocytic Chronic myeloid Leukemia (continued) Myeloid vs. Lymphoid Myeloid stem cells gives rise to 6 types of blood cells erythrocytes, t platelets, ltlt monocytes, basophils, neutrophils, and eosinophils Lymphoid stem cells differentiates to form circulating B & T lymphocytes Cancer Statistics Lung, breast, colon and rectal cancer - most common Lung cancer is leading cause of death in men & women And the most important statistic to me is that one-third of all cancers are due to carcinogens in cigarette smoke Dr. John Mendelsohn President, M.D. Anderson Medical Center Larry King Live, CNN April 23,2007 Risk is related to age, ethnicity, immunosuppression, family history, genetic predisposition and exposure to carcinogens Carcinogens Carcinogens = any substance or agent that produces or increases the risk of cancer Environmental - radiation, viruses Human Papilloma virus (HPV) linked to cervical ca HPV-16 & HPV-18: 70% of invasive cervical cancers Gardasil - Human Papillomavirus vaccine (6,11,16,18) HPV-6 and HPV-11 associated w/ genital warts HPV also linked to anal, vaginal, oropharyngeal ca Occupational - asbestos Lifestyle - tobacco, alcohol Drugs chemotherapy agents Example: Acute Myeloid Leukemia- previous chemo? 2

3 How do we use Chemotherapy? Induction tx for advanced diseases Adjunctive therapy for local treatment Primary treatment of localized tumor Direct instillation into areas of the body most affected by tumor Review of Terms INDUCTION THERAPY - primary treatment (No reasonable alternative exists) NEOADJUVANT CHEMOTHERAPY administered prior to surgery and/or radiotherapy with the aim of reducing tumor burden and prevent the development of metastases ADJUVANT THERAPY - treatment after the primary tumor has been surgically removed or irradiated when there is known to be a high risk of future tumor recurrence SALVAGE THERAPY - therapy in patients who failed at least one course of induction treatment PALLIATIVE THERAPY - used to relieve symptoms Direct Infusion Intrathecal (spinal fluid) Cytarabine, Methotrexate Reconstitute with preservative free NS Liposomal Cytarabine Dexamethasone bid x 5 days must be administered i d Prevent arachnoiditis (symptoms: n/v, headache, fever) Arachnoiditis can be fatal if untreated Pleural space (lungs) Talc (Decreases risk of malignant pleural effusion recurrence associated w/ metastatic tumors) Bleomycin (sclerosing agent for malignant pleural effusion) Direct Infusion Hepatic Artery (Chemoembolization) Cisplatin, Doxorubicin, Mitomycin Administered in radiology Dosed in high concentrations induces a blood clot to cut off blood supply to the tumor Direct Infusion SALADS: The First Course Can Be Hard To Swallow Intraperitoneal (via IP drain) Cisplatin, Taxol (Paclitaxel) Vinca alkaloids Vincristine (Oncovin ) Taxanes Paclitaxel (Taxol ) Use in treating malignant ascites Vinblastine (Velban ) Docetaxel (Taxotere ) *Always note fluid amount and dwell time Mannitol CANNOT be mixed with Cisplatin for INTRAPERITONEAL use Vinorelbine (Navelbine ) Epothilones Ixabepilone (Ixempra ) Protein-bound Paclitaxel (Abraxane ) 3

4 TOPOISOMERASE II INHIBITORS ANTIMETABOLITES Anthracyclines Doxorubicin (Adriamycin ) Liposomal Doxorubicin (Doxil ) Idarubicin (Idamycin ) Epirubicin (Ellence ) Epipodophyllotoxins Etoposide (VP-16) Tenoposide (Vumon ) Miscellaneous Mitoxantrone Folate Antagonists Methotrexate Pemetrexed (Alimta ) Pyrimidine analogues Cytarabine (Cytosar-U ) Gemcitabine (Gemzar ) Fluorouracil (5-FU) Capecitabine (Xeloda ) Decitabine (Dacogen ) Purine analogues Thioguanine (Tabloid ) Mercaptopurine (Purinethol ) Fludarabine (Fludara ) Cladribine (Leustatin ) Daunorubicin (Cerubidine ) (Novantrone ) Monoclonal Antibodies Tyrosine Kinase Inhibitors Bevacizumab (Avastin ) Cetuximab (Erbitux ) Rituximab (Rituxan ) Trastuzumab (Herceptin ) Panitumumab (Vectibix ) - metastatic colorectal cancer Infliximab (Remicade ) - rheumatoid arthritis, Crohn s,etc. Daclizumab (Zenapax ) - immunosuppressant Alemtuzumab (Campath ) - B-cell chronic lymphocytic leukemia Palivizumab (Synagis ) - prevention - respiratory syncytial virus Adalimumab (Humira ) - rheumatoid arthritis, Crohn s Imatinib (Gleevec ) Dasatinib (Sprycel ) Erlotinib (Tarceva ) Sunitinib (Sutent ) Sorafenib (Nexavar ) advanced renal cell cancer Lapatinib (Tykerb ) used in combo w/capecitabine for advanced, metastatic HER2 positive breast cancer Nilotinib (Tasigna ) treatment of chronic- and accelerated-phase Philadelphia chromosome-positive CML in patients resistant to prior therapies, including imatinib Chemo Regimens: Like a Cookbook? Acute Lymphocytic Leukemia/ Non-Hodgkins Lymphoma Hyper-CVAD Cycle A Cyclophosphamide 300mg/m 2 IV over 3 hours every 12 hours for 6 doses on days 1, 2, 3 Mesna 600mg/m 2 IV over 24 hours on days 1, 2, 3 ending 12 hours after last dose of cyclophosphamide Vincristine 2mg IV on days 4 and 11 Doxorubicin 50mg/m 2 IV on day 4 Dexamethasone 40mg PO or IV on days 1-4 and Not Like Mom Used To Make Hyper-CVAD Cycle B Methotrexate 1000mg/m 2 IV over 24 hours on day 1 Leucovorin 50mg IV every 6 hours starting 12 hours after completion of Methotrexate until methotrexate level < 0.05 Cytarabine 3 grams/m 2 IV over 3 hours every 12 hours for 4 doses on days 2 and 3 CNS Prophylaxis Methotrexate 12mg Intrathecal on day 2 of each cycle Cytarabine 100mg Intrathecal on day 7 of each cycle 4

5 LET THE GAMES BEGIN A PICTURE IS WORTH A THOUSAND WORDS Stuck In A Rut Code Yellow Safety 1st Caution- Hazardous 5

Jeopardy Pictures Stuck In a Rut Code Yellow Safety 1st Caution- Hazardous 10 10 10 10 10 The Appropriate Place To Prepare Hazardous Medications 20 20 20 20 20 30 30

in a vertical flow Class IIA Biological Safety Cabinet Difference between horizontal & vertical flow hoods Picture 10 points Picture 20 points The Proper Technique For

6 Jeopardy Pictures Stuck In a Rut Code Yellow Safety 1st Caution- Hazardous The Appropriate Place To Prepare Hazardous Medications Picture 10 points The Proper Technique for Cleaning a Biological Class IIA Sft Safety Cbi Cabinet Chemotherapy must be prepared in a vertical flow Class IIA Biological Safety Cabinet Difference between horizontal & vertical flow hoods Picture 10 points Picture 20 points The Proper Technique For Withdrawing a Hazardous Medication Disinfecting a chemotherapy vertical flow hood Use 10% bleach solution Direction Lint free cloths Picture 20 points Picture 30 points 6

7 Aseptic technique Negative pressure Chemo Dispensing Pin (as shown) The Proper Technique In Handling Needles Priming tubing lines Picture 30 points Picture 40 points One-handed method The Appropriate Place To Dispose of Hazardous Medications Palm-to-palm method Picture 40 points Picture 50 points Yellow color ChemoGator sturdy plastic container Covered to reduce exposure to waste Picture 50 points Name 3 disease states other than cancer Chemotherapy is used to treat. Stuck In a Rut 10 points 7

8 Lupus other autoimmune processes Crohn s disease Et Ectopic pregnancy Sickle Cell anemia Most cancers require what type of chemotherapy regimens Stuck In A Rut 10 points Stuck In A Rut 20 points Combinations of different agents with varying mechanisms of action. Name 2 medications NOT used to treat cancer that are considered hazardous. Stuck In A Rut 20 points Code Yellow 20 points Zidovudine Pentamidine Ganciclovir The purpose of MSDS Code Yellow 20 points Code Yellow 50 points 8

9 MSDS-material safety data sheets contain summaries provided by the manufacturer to describe the chemical properties and hazards of specific chemicals and ways in which workers can protect themselves from exposures to these chemicals. This type of lettering on packages has been shown to decrease medication errors. Code Yellow 50 points Safety 1st 10 points TALL man lettering Name a chemotherapy agent that CANNOT be given intrathecally. Safety 1st 10 points Safety 1st 20 points Vincristine vinblastine Name 2 simple things that can be done in your pharmacy to minimize risk of medication mix-ups Safety 1st 20 points Safety 1st 30 points 9

Separate look-alikes SALAD labels- warning labels Name 2 ways to prevent errors when preparing chemotherapy Safety 1st 30 points Safety 1st 40 points Verify correct

be worn when preparing hazardous medications?

10 Separate look-alikes SALAD labels- warning labels Name 2 ways to prevent errors when preparing chemotherapy Safety 1st 30 points Safety 1st 40 points Verify correct dilution requirements Pharmacists double check product prior to preparation Use proper tubing/bags Filter or Not to Filter Which of the following items is NOT required to be worn when preparing hazardous medications? Hair cover Approved CHEMOTHERAPY SAFETY GOWN 2 pairs of gloves Shoe covers Specific hazardous scrubs Safety 1st 40 points Caution-Hazardous 10 points Proper Attire The Process In Place at Palmetto Health Richland To Reduce Chemotherapy Errors Caution-Hazardous 10 points Caution-Hazardous 30 points 10

A chemo spill kit contains the following:

waste bag Final Jeopardy Caution-Hazardous 50

11 A chemo spill kit contains the following: Caution-Hazardous 30 points Caution-Hazardous 50 points Absorbent pads Shoe covers Gloves Gown N-95 Mask Safety glasses Scoop Warning sign Yellow waste bag Final Jeopardy Caution-Hazardous 50 points Contributions Shannon Derienzo, Pharm.D Melissa Woods, CphT 11

12 References Venes D (Editor). Taber s Cyclopedic Medical Dictionary. 20 th edition Dipiro J, et.al. Pharmacotherapy: A Pathophysiologic Approach. 7 th edition Chapter 130: Caner Treatment and Chemotherapy; Chapter 131: Breast Cancer; Chapter 132: Lung Cancer; Chapter 133: Colorectal Cancer; Chapter 135: Lymphomas; Chapter 137: Acuter Leukemias; Chapter 138: Chronic Leukemias. Harrison TR, et.al. Harrison s Principles of Internal Medicine. 16 th edition Chapter 52: Anemia and Polycythemia. Solimando DA, et.al. Drug Information Handbook For Oncology: A Complete Guide to Combination Chemotherapy Regimens.7 th edition Chu E., et.al. Physician s Cancer Chemotherapy Drug Manual

VI.2 Elements for a Public Summary VI.2.1 Overview of Disease Epidemiology Acute Nausea and Vomiting (N&V) Etiologies:

VI.2 Elements for a Public Summary VI.2.1 Overview of Disease Epidemiology Acute Nausea and Vomiting (N&V) Incidence: The incidence of acute and delayed N&V was investigated in highly and moderately emetogenic