1887

Safety and handling of chemotherapeutic agents

Most drugs used in veterinary practice do not pose a major hazard to the person handling them or handling an animal treated with them (or its waste). Chemotherapeutic agents are the exception. People who are exposed to these drugs during their use in animals risk serious side effects. In addition, chemotherapeutic agents pose a serious risk to patient welfare if not used correctly. They should only be used when absolutely indicated (i.e. histologically confirmed diseases that are known to be responsive to them). Investigational use should be confined to controlled clinical trials.

Personnel
  • The preparation and administration of cytotoxic drugs should only be undertaken by trained staff.
  • Owners and staff (including cleaners, animal caretakers, veterinary surgeons) involved in the care of animals being treated with cytotoxic drugs must be informed (and proof available that they have been informed) of:
    • The risks of working with cytotoxic agents
    • The potential methods for preventing aerosol formation and the spread of contamination
    • The proper working practices for a safety cabinet
    • The instructions in case of contamination
    • The principles of good personal protection and hygiene practice.
  • As a general rule, pregnant women and immunocompromised personnel should not be involved in the process of preparing and/or administering cytotoxic agents, caring for animals that have been treated with cytotoxic drugs, or cleaning of the areas these animals have come into contact with. It is the responsibility of the employee to warn their supervisors if they are pregnant, likely to become pregnant or are immunocompromised.
Equipment and facilities
  • All areas where cytotoxic agents are prepared and/or administered, or where animals who have received cytotoxic drugs are being cared for, should be identified by a clear warning sign. Access to these areas should be restricted.
  • Ideally a negative pressure pharmaceutical isolator with externally ducted exhaust filters, which has been properly serviced and checked, should be used. If such an isolator is not available then a suitably modified Class 2B Biological Safety Cabinet (BSC) may be used.
  • There must be adequate materials for cleaning of spilled cytotoxic agents (cytotoxic spill kit).
  • Closed or semi-closed systems should be used to prevent aerosol formation and control exposure to carcinogenic compounds. Special spike systems (e.g. Codan and Braun) can be used. Other systems specifically developed for the use of cytotoxic agents are recommended (e.g. Spiros, Tevadaptor, Oncovial and PhaSeal). If such systems are not available, then at the very least infusion sets and syringes with Luer-lock fittings should be used.
Preparation of cytotoxic drugs
  • Manipulation of oral or topical medicines containing cytotoxic drugs should be avoided. If a drug concentration is required that is not readily available, then a specialist laboratory with a Veterinary Specials Authorisation should be contacted to reformulate the drug to the desired concentration. This may be useful for drugs such as piroxicam, hydroxycarbamide and lomustine. Tablets should never be crushed or split. If reformulation is not possible then using smaller sized tablets or adjusting the dosage regimen is often sufficient.
  • When drug preparation is complete, the final product should be sealed in a plastic bag or other container for transport before it is taken out of the ventilated cabinet. It should be clearly labelled as containing cytotoxic drugs.
  • All potentially contaminated materials should be discarded in special waste disposal containers, which can be opened without direct contact with hands/gloves (e.g. a foot pedal). Local regulations as to the disposal of this waste should be followed.
  • There should be a clear procedure regarding how to handle cytotoxic drugs following an injection accident.
  • During the preparation and administration of cytotoxic drugs, personal protection should be worn, including special disposable chemoprotective gloves, disposable protective clothing, and eye and face protection.
  • After the preparation and/or administration of cytotoxic drugs, or after nursing a treated animal, the area used should be properly cleaned using a specific protocol before other activities commence.
Administration of cytotoxic drugs
  • All necessary measures should be taken to ensure that the animal being treated is calm and cooperative. If the temperament of the animal is such that a safe administration is not to be expected, then the veterinary surgeon has the right (and is obliged) not to treat these animals.
  • Many cytotoxic drugs are irritant and must be administered via a preplaced i.v. catheter. Administration of bolus injections should be done through a catheter system, which should be flushed with 0.9% NaCl before, during and after the injection.
  • Heparinized saline should be avoided as it can interact with some chemotherapeutic drugs (e.g. doxorubicin).
  • Drugs should be administered safely using protective medical devices (such as needleless and closed systems) and techniques (such as priming of i.v. tubing by pharmacy personnel inside a ventilated cabinet or priming in line with non-drug solutions).
  • The tubing should never be removed from a fluid bag containing a hazardous drug, nor should it be disconnected at other points in the system until the tubing has been thoroughly flushed. The i.v. catheter, tubing and bag should be removed intact when possible.
  • Hands should be washed with soap and water before leaving the drug administration area.
  • Procedures should be in place for dealing with any spillages that occur and for the safe disposal of waste. In the event of contact with skin or eyes, the affected area should be washed with copious amounts of water or normal saline. Medical advice should be sought if the eyes are affected.
Procedures for nursing patients receiving chemotherapy
  • Special wards or designated kennels with clear identification that the patients are being treated with cytotoxic agents are required.
  • Excreta (saliva, urine, vomit, faeces) are all potentially hazardous after the animal has been treated with cytotoxic drugs, and should be handled and disposed of accordingly.
  • During the period of risk, personal protective equipment (such as disposable gloves and protective clothing) should be worn when carrying out nursing procedures.
  • All materials that have come into contact with the animal during the period of risk should be considered as potentially contaminated.
  • After the animal has left the ward, the cage should be cleaned according to the cleaning protocol.
Guidelines for owners
  • All owners should be given written information on the potential hazards of the cytotoxic drugs. Written information on how to deal with the patient’s excreta (saliva, urine, vomit, faeces) must also be provided.
  • If owners are to administer tablets themselves, then written information on how to do this must also be provided. Drug containers should be clearly labelled with ‘cytotoxic contents’ warning tape.
Further information

For further information readers are advised to consult specialist texts and the guidelines issued by the European College of Veterinary Medicine – Companion Animals (ECVIM-CA) on ‘Preventing occupational and environmental exposure to cytotoxic drugs in veterinary medicine’.

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