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Cytotoxic Drugs (Anti-neoplastics)

Cytotoxic drugs (CDs), also known as antineoplastics, are used to treat cancer. These same anti-cancer agents also have toxic effects on healthy cells, and thus pose a health risk to those employees who are involved in their preparation, storage, administration, and disposal.

Health Effects

Short term effects of exposure to CDs include skin injury, lightheadedness, dizziness, nausea, headache, and allergic reactions.

The long term effects are more serious. Some anti-neoplastics can cause cancer (carcinogens) and leukemia. Recent studies show that they may also cause birth defect (teratogens) and miscarriages, as well as chromosomal damage (mutagens).

How CDs Enter the Body

Exposure is mainly through inhaling droplets or dusts. These agents can also be absorbed through the skin, or by swallowing food, beverages, or cigarettes which are contaminated with CDs.

Safe Work Practices

The only SAFE level of exposure to CDs is NO exposure. OSHA has issued guidelines for the handling of CDs, from which the following recommendations are taken:

Clothing

Regardless of job tasks, all employees who come into contact with CDs or with blood, vomit, or excreta or patients who have received CDs in the last 48 hours should wear surgical latex gloves and disposable gowns with long sleeves tucked under the gloves. These gowns should not be worn out of the contaminated area.

NOTE: One recent study has shown that latex gloves only provide limited protection against the drug carmustine. Exposure -- even while wearing gloves -- should be strictly limited.

Drug Preparation

  • Drugs should be prepared under a Biological Safety Cabinet/Class II Laminar Flow (BSC) to prevent breathing mists. Work areas should be provided with shatter-proof disposal containers and the cabinet should be cleaned daily with 70% alcohol, and decontaminated weekly.
  • If a BSC is not available, a respirator with high efficiency filters (preferably a Powered Air-Purifying Respirator) should be worn. Surgical masks are not effective.
  • Drug administration sets should be attached and primed within the hood, before the drug is added to the fluid and medication vials should not be vented unless a BSC is used.

Drug Administration

  • Other protective equipment that should be used includes: gauze, alcohol wipes, disposable plastic-backed absorbent liner, vials for excess drug solution and puncture-proof containers for used needles.

Caring for Patients Receiving CDs

  • Linen contaminated with CDs, blood, vomit, or excreta of a patient who has received CDs in the last 48 hours should be placed in a labeled impervious bag. This bag and its contents should be pre-washed and then added to other laundry for additional wash. Personnel should wear surgical latex gloves while handling this material.

Waste Disposal

  • CD-related wastes should be put in labeled 4-mil thick polyethylene or 2-mil polypropylene bags with a warning label. Needles and other sharp items should be placed in a puncture proof box.
  • These wastes must be handled separately from other hospital trash and disposed of in accordance with regulations applicable to toxic wastes.

Cleanup of Spills

  • Small Spills (5ml or 5g) outside a hood should be wiped with absorbent gauze and then cleaned (three times) with detergent and clean water. Any glass fragments should be placed in a cardboard or plastic container and then into a CD disposal bag, along with used absorbent pads. Glassware or other contaminated reusable items should be placed in a plastic bag and washed with detergent.
  • Larger Spills should be covered with absorbent sheets or spill-control pads. Damp cloths or towels should be used if powder is involved. Care must be taken not to generate aerosols and access to spill areas should be restricted.

    Respirators should be used when there is any danger of airborne powder or aerosol being created.

    Chemical inactivators should NOT be applied to the absorbed drug because this may produce hazardous by-products. (However, sodium thiosulfate can be safety used to inactivate nitrogen mustard.)

    All contaminated surfaces should be thoroughly cleaned with detergent and then wiped with clean water. Contaminated materials should be disposed of in the CD disposal bag.
  • Spills In Hoods may require decontamination of all interior hood surfaces after the above spill procedures have been followed. If the HEPA filter of a hood is contaminated, the unit must be labeled "DO NOT USE -- CONTAMINATED," and the filter must be changed and disposed of properly as soon as possible.
  • Spill Kits, clearly labeled, should be kept in or near preparation or administrative areas. Kits should include: a respirator, chemical splash goggles, two pairs of gloves, two sheets (12x12) of absorbent material, 250-ml and 1-liter spill control pillows, and a small scoop to collect glass fragments. Finally, the kit should contain two large CD waste-disposal bags.

 

  • Larger Spills should be covered with absorbent sheets or spill-control pads. Damp cloths or towels should be used if powder is involved. Care must be taken not to generate aerosols and access to spill areas should be restricted.

    Respirators should be used when there is any danger of airborne powder or aerosol being created.

    Chemical inactivators should NOT be applied to the absorbed drug because this may produce hazardous by-products. (However, sodium thiosulfate can be safety used to inactivate nitrogen mustard.)

    All contaminated surfaces should be thoroughly cleaned with detergent and then wiped with clean water. Contaminated materials should be disposed of in the CD disposal bag.
  • Spills In Hoods may require decontamination of all interior hood surfaces after the above spill procedures have been followed. If the HEPA filter of a hood is contaminated, the unit must be labeled "DO NOT USE -- CONTAMINATED," and the filter must be changed and disposed of properly as soon as possible.
  • Spill Kits, clearly labeled, should be kept in or near preparation or administrative areas. Kits should include: a respirator, chemical splash goggles, two pairs of gloves, two sheets (12x12) of absorbent material, 250-ml and 1-liter spill control pillows, and a small scoop to collect glass fragments. Finally, the kit should contain two large CD waste-disposal bags.

Receiving, Storage and Transport

  • Damaged cartons which are received should be opened in an isolated area by an employee wearing an approved respirator and other protective clothing.
    Broken containers and contaminated packaging materials should be placed in puncture-resistant receptacles and then disposed of in CD disposal bags.
    Appropriate protective equipment and waste disposal materials should be kept in the area where shipments are received.
  • Storage areas should be limited to authorized personnel. These areas should be posted with large warning signs, with lists of drugs covered and detailing spill procedures. If possible, the facilities for storing CDs should not be used for other drugs, and should be designed to prevent containers from falling to the floor. Warning labels should be applied to all CD containers and shelves where they are stored.
  • Transport of CDs should be in capped or sealed packages in impervious packing materials. All drugs should be labeled clearly. Transport methods that produce stress on contents, such as pneumatic tubes, should not be used to transport CDs.

Training

  • General: All personnel involved in any aspect of the handling of CDs (shipment-receiving personnel, MDs, nurses, pharmacists, housekeeping, storage or transport, etc.) must receive information of risks of CDs and proper handling techniques.
  • Reproductive Hazards: OSHA also recommends that employees be fully informed of the potential reproductive hazard of cytotoxic drugs and, if they so request, staff members who are pregnant or breast-feeding should be transferred to comparable duties that do not involve handling CDs. A similar policy covering male or female personnel who are actively trying to conceive a child should be established. AFSCME emphasizes that employees who choose to transfer should not lose any pay or benefits.

Medical Surveillance

All employees with potential exposure to CDs should have a preplacement physical examination. The history should note any risk factors and a blood count to provide baseline information.

After an acute exposure, the employee should immediately remove gloves and gown. The affected skin should be washed immediately with soap (not germicidal cleaner) and water. For eye exposure, the eye should be flooded with water or isotonic eyewash. Employees should receive a physical examination with particular attention to the eyes, nasal mucous membranes, and skin. Exposures from needle-sticks should always be reported.

For more information on cytotoxic agents or other health care hazards, contact the AFSCME Research Department at 202-429-1215.

 

 

 ANTINEOPLASTIC AGENTS*

 

ALKYLATING AGENSTRADE NAMES ANTIBIOTICS
CIS-PLATINPLATINOL DOXORUBICINADRIAMYCIN
CYCLOPHOSPHAMIDECYTOXAN BLEOMYCINBLENOXANEBR
NEOSAR DACTINOMYCIN (ACTINOMYCIN-D)COSMEGEN
NITROGEN MUSTARDMUSTARGEN DAUNORUBICINCERUBIDINE
TRIETHYLENE THIPHOSPHORAMIDETHIOTEPA MITHRAMYCINMITHRACIN
CARMUSTINEBiCNU MITOMYCINMUTAMYCIN
STREPTOZOCINZANOSAR  
BUSULFAN MIOTIC INHIBITORS
CHLORAMBUCIL  
CCNUBELUSTINE VINCRISTINEONCOVIN
MELPHALAN (ALKERAN) VINBLASTINEVELBAN
MYLERAN

ETOPOSIDE (VP-16-213)VePESID

TEOSULFAN  
URACIL MUSTARDURAMUSTINE

MISCELLANEOUS

CHLORNAPHAZIN  
DACARBAZINEDIC L-ASPARAGINASEELSPAR
ANTIMETABOLITES DACARBAZINEDTIC
CYTOSINE ARABINOSIDECYTOSAR-U INVESTIGATIONALS
FLUOROURACILADRUCIL AZACTYIDINE
METHOTREXATE AMSACRINE
MERCAPTOPURINE ELPHALAN
AZATHIOPRIME VM-26
PROCARBAZINEMATULANE IFOSFAMIDE
  MITOXANTRONE
  VINDESINE
   

 *This is not a complete list and should be periodically updated.

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