Preparation and handling of hazardous drugs for special administration

HAZARDOUSGUIDE

NOTE: Please consult Drug Information or pharmacist for specific instructions before proceeding to reconstitute any hazardous drugs including cytotoxics!

Azathioprine Tablet (cytotoxic)


[Off-label]
Note: administer the dispersion immediately after preparing.
1. Stop enteral feed. Flush the enteral feeding tube with the recommended volume of water.
2. Gloves and mask should be worn in case of accidental spillage and exposure.
3. Place the tablet in the barrel of an appropriate size and type of syringe (eg. 20mL Terumo syringe).
4. Draw 10mL of Water for Injection into the syringe and allow the tablet to dissolve, shaking if necessary.
5. Flush the medication dose down the feeding tube.
6. Draw another 10mL of Water for Injection into syringe and flush this via feeding tube (this will rinse the syringe and ensure that total dose is administered).
7. Finally, flush with the recommended volume of water.
8. Dispose the syringe as cytotoxic waste.




Hydroxyurea Capsule (cytotoxic)


Note: administer the disperson immediately after preparing. 1. Stop enteral feed. Flush the enteral feeding tube with the recommended volume of water.
2. Gloves and mask should be worn in case of accidental spillage and exposure.
3. Open the capsule and carefully pour the powder contents into a disposable medicine cup.
4. Add 15mL of Water for Injection, and stir to disperse the powder.
5. Draw the liquid into an appropriate syringe (eg. 20mL Terumo syringe) and administer via the feeding tube.
6. Add another 15mL Water for Injection to the medicine pot; Stir to ensure that any powder remaining in the pot is mixed with water.
7. Draw up this dispersion and flush down tube. This will ensure that the whole dose is given.
8. Finally, flush with the recommended volume of water.
9. Dispose the syringe as cytotoxic waste.




Cyclophoshamide Tablet (cytotoxic)


  1. Tablets should NOT be used to prepare Cyclosphosphamide solution for tube feeding. Instead, Cyclophosphamide (Endoxan) 1g injection vial should be used to form oral solution for administration
  2. Oral solution to be prepared by Pharmacy Lab. Please contact the ward pharmacist or call Pharmacy Lab for more information

    Info for Pharmacy Lab (Use of Reconstituted Cyclophosphamide Solution for Oral Administration)
    - Reconstitute Cyclophosphamide 1g injection vial with 100mL of 0.9% Sodium Chloride (NS) to form a solution with final concentration of 10mg/mL
    - Reconstituted solution (with NS) is stable for up to 24 hours at room temperature, and up to 6 days when refrigerated at 2 -8°C
    References:
    (i) Email Correspondence with Baxter (Oct 2015);
    (ii) Cyclophosphamide Prescribing Information - Baxter (accessed from FDA)




Methotrexate Tablet (cytotoxic)


[Off-label]
Note: administer the dispersion immediately after preparing.
1. Stop enteral feed. Flush the enteral feeding tube with the recommended volume of water.
2. Gloves and mask should be worn in case of accidental spillage and exposure.
3. Place the tablet in the barrel of an appropriate size and type of syringe (eg. 20mL Terumo syringe).
4. Draw 10mL of Water for Injection into the syringe and allow the tablet to dissolve, shaking if necessary.
5. Flush the medication dose down the feeding tube.
6. Draw another 10mL of Water for Injection into syringe and flush. this via feeding tube (this will rinse the syringe and ensure that total dose is administered).
7. Finally, flush with the recommended volume of water.
8. Dispose the syringe as cytotoxic waste.




Imatinib Capsule (cytotoxic)


Note: administer the dispersion immediately after preparing. 1. Stop enteral feed. Flush the enteral feeding tube with the recommended volume of water.
2. Gloves and mask should be worn in case of accidental spillage and exposure.
3. Open the capsule and carefully pour the powder contents into a disposable medicine cup.
4. Add 15mL of Water for Injection, and stir to disperse the powder.
5. Draw the liquid into an appropriate syringe (eg. 20mL Terumo syringe) and administer via the feeding tube.
6. Add another 15mL Water for Injection to the medicine pot; Stir to ensure that any powder remaining in the pot is mixed with water.
7. Draw up this dispersion and flush down tube. This will ensure that the whole dose is given.
8. Finally, flush with the recommended volume of water.
9. Dispose the syringe as cytotoxic waste.




Acitretin Capsule


[Off-label]
Note: administer the dispersion immediately after preparing.
1. Stop enteral feed. Flush the enteral feeding tube with the recommended volume of water.
2. Gloves and mask should be worn in case of accidental spillage and exposure.
3. Open the capsule and carefully pour the powder contents into a disposable medicine cup.
4. Add 15mL of Water for Injection, and stir to disperse the powder.
5. Draw the liquid into an appropriate syringe (eg. 20mL Terumo syringe) and administer via the feeding tube.
6. Add another 15mL Water for Injection to the medicine pot. Stir to ensure that any powder remaining in the pot is mixed with water.
7. Draw up this dispersion and flush down tube. This will ensure that the whole dose is given.
8. Finally, flush with the recommended volume of water.




Anastrozole Tablet


[Off-label]
Note: administer the dispersion immediately after preparing.
1. Stop enteral feed. Flush the enteral feeding tube with the recommended volume of water.
2. Gloves and mask should be worn in case of accidental spillage and exposure.
3. Place the tablet in the barrel of an appropriate size and type of syringe (eg. 20mL Terumo syringe).
4. Draw 10mL of Water for Injection into the syringe and allow the tablet to dissolve, shaking if necessary.
5. Flush the medication dose down the feeding tube.
6. Draw another 10mL of Water for Injection into syringe and flush this via feeding tube (this will rinse the syringe and ensure that total dose is administered).
7. Finally, flush with the recommended volume of water.




Bicalutamide Tablet


[Off-label] Note: administer the dispersion immediately after preparing. 1. Stop enteral feed. Flush the enteral feeding tube with the recommended volume of water.
2. Gloves and mask should be worn in case of accidental spillage and exposure.
3. Place the tablet in the barrel of an appropriate size and type of syringe (eg. 20mL Terumo syringe).
4. Draw 10mL of Water for Injection into the syringe and allow the tablet to dissolve, shaking if necessary.
5. Flush the medication dose down the feeding tube.
6. Draw another 10mL of Water for Injection into syringe and flush this via feeding tube (this will rinse the syringe and ensure that total dose is administered).
7. Finally, flush with the recommended volume of water.




Entecavir Tablet


[Off-label] Note: administer the dispersion immediately after preparing. 1. Stop enteral feed. Flush the enteral feeding tube with the recommended volume of water.
2. Gloves and mask should be worn in case of accidental spillage and exposure.
3. Place the tablet in the barrel of an appropriate size and type of syringe (eg. 20mL Terumo syringe).
4. Draw 10mL of Water for Injection into the syringe and allow the tablet to dissolve, shaking if necessary.
5. Flush the medication dose down the feeding tube.
6. Draw another 10mL of Water for Injection into syringe and flush this via feeding tube (this will rinse the syringe and ensure that total dose is administered).
7. Finally, flush with the recommended volume of water.




Finasteride Tablet


[Off-label] Note: administer the dispersion immediately after preparing. 1. Stop enteral feed. Flush the enteral feeding tube with the recommended volume of water.
2. Gloves and mask should be worn in case of accidental spillage and exposure.
3. Place the tablet in the barrel of an appropriate size and type of syringe (eg. 20mL Terumo syringe).
4. Draw 10mL of Water for Injection into the syringe and allow the tablet to dissolve, shaking if necessary.
5. Flush the medication dose down the feeding tube.
6. Draw another 10mL of Water for Injection into syringe and flush this via feeding tube (this will rinse the syringe and ensure that total dose is administered).
7. Finally, flush with the recommended volume of water.




Leflunomide Tablet


[Off-label] Note: administer the dispersion immediately after preparing. 1. Stop enteral feed. Flush the enteral feeding tube with the recommended volume of water.
2. Gloves and mask should be worn in case of accidental spillage and exposure.
3. Place the tablet in the barrel of an appropriate size and type of syringe (eg. 20mL Terumo syringe).
4. Draw 10mL of Water for Injection into the syringe and allow the tablet to dissolve, shaking if necessary.
5. Flush the medication dose down the feeding tube.
6. Draw another 10mL of Water for Injection into syringe and flush this via feeding tube (this will rinse the syringe and ensure that total dose is administered).
7. Finally, flush with the recommended volume of water.




Medroxyprogesterone Tablet


[Off-label] Note: administer the dispersion immediately after preparing. 1. Stop enteral feed. Flush the enteral feeding tube with the recommended volume of water.
2. Gloves and mask should be worn in case of accidental spillage and exposure.
3. Place the tablet in the barrel of an appropriate size and type of syringe (eg. 20mL Terumo syringe).
4. Draw 10mL of Water for Injection into the syringe and allow the tablet to dissolve, shaking if necessary.
5. Flush the medication dose down the feeding tube.
6. Draw another 10mL of Water for Injection into syringe and flush this via feeding tube (this will rinse the syringe and ensure that total dose is administered).
7. Finally, flush with the recommended volume of water.




Megestrol Tablet


[Off-label] Note: administer the dispersion immediately after preparing. 1. Stop enteral feed. Flush the enteral feeding tube with the recommended volume of water.
2. Gloves and mask should be worn in case of accidental spillage and exposure.
3. Place the tablet in the barrel of an appropriate size and type of syringe (eg. 20mL Terumo syringe).
4. Draw 10mL of Water for Injection into the syringe and allow the tablet to dissolve, shaking if necessary.
5. Flush the medication dose down the feeding tube.
6. Draw another 10mL of Water for Injection into syringe and flush this via feeding tube (this will rinse the syringe and ensure that total dose is administered).
7. Finally, flush with the recommended volume of water.




Norethisterone Tablet


[Off-label] Note: administer the dispersion immediately after preparing. 1. Stop enteral feed. Flush the enteral feeding tube with the recommended volume of water.
2. Gloves and mask should be worn in case of accidental spillage and exposure.
3. Place the tablet in the barrel of an appropriate size and type of syringe (eg. 20mL Terumo syringe).
4. Draw 10mL of Water for Injection into the syringe and allow the tablet to dissolve, shaking if necessary.
5. Flush the medication dose down the feeding tube.
6. Draw another 10mL of Water for Injection into syringe and flush this via feeding tube (this will rinse the syringe and ensure that total dose is administered).
7. Finally, flush with the recommended volume of water.




Tacrolimus Capsule (Prograf)


Note: Manufacturer does not suggest opening of capsules as there are no available PK studies to support extemporaneous oral formulation of immediate-release tacrolimus (email correspondence with Prograf, Astellas Pharma 2020) [Off-label] Note: administer the dispersion immediately after preparing. DO NOT USE PVC containing tube, syringe or cup to prepare/administer tacrolimus products e.g. Ryle's brand. Administer the dispersion immediately after preparing. 1. Stop enteral feed. Flush the enteral feeding tube with the recommended volume of water.
2. Gloves and mask should be worn in case of accidental spillage and exposure.
3. Open the capsule and carefully pour the powder contents into a disposable medicine cup.
4. Add 15mL of Water for Injection, and stir to disperse the powder.
5. Draw the liquid into an appropriate syringe (eg. 20mL Terumo syringe) and administer via the feeding tube.
6. Add another 15mL Water for Injection to the medicine pot; Stir to ensure that any powder remaining in the pot is mixed with water.
7. Draw up this dispersion and flush down tube. This will ensure that the whole dose is given.
8. Finally, flush with the recommended volume of water.





References
1) White, R., & Bradnam, V. (2015). Handbook of drug administration via enteral feeding tubes. London: Pharmaceutical Press.
2) Drug Product Inserts for respective drugs

Last updated 17 Feb 2021

Rationale For Closed System Administration of Cytotoxics
  • This closed system is preferred for cytotoxics for which no liquid formulation is available, so as to avoid environmental contamination and exposure of carer to the hazardous medicine. Not recommended to be crushed due to risk of powder inhalation

  • Exposure to such substances is dangerous; therefore, contact with the skin and inhalation of dust should be avoided and protective equipment devices (gloves and mask) must be used

  • Women with pregnancy potential should avoid handling crushed or broken tablets. To wear gloves and mask when handling

  • Suitable protective clothing should be worn. Contaminated equipment should be disposed of as cytotoxic waste

  • Adapted from: White, R., & Bradnam, V. (2015). Handbook of drug administration via enteral feeding tubes. London: Pharmaceutical Press.