Practice Safe Nursing When Handling Oral Hazardous Drugs

Following is "Practice Safe Nursing With Oral Hazardous Drugs," an article featured in the January 2010 issue of ONS Connect. 

The num­ber of cur­rently avail­able haz­ardous oral drugs is increas­ing and now includes small mol­e­cules and hor­mones in addi­tion to tra­di­tional agents such as cyclophos­phamide. Nurses are pre­sented with unique safety chal­lenges in han­dling these medications.

Gen­eral guide­lines should be fol­lowed for han­dling haz­ardous oral drugs.

  • Use dou­ble gloves.
  • Wear a face shield if there is a poten­tial for spray­ing, aerosoliza­tion, or splashing.
  • Crush­ing or manip­u­lat­ing should be done in a bio­logic safety cabinet.
  • Wash hands thor­oughly with soap and water after remov­ing gloves.
  • Spoons, oral syringes, dis­pos­able med­i­cine cups, or other equip­ment used to admin­is­ter the agents must be dis­carded as haz­ardous waste.

Some med­ica­tions can­not be crushed, often because of timed-​​release or enteric coat­ings. When crush­ing haz­ardous oral drugs is nec­es­sary for use in naso­gas­tric or gas­tric tubes or to mix with food, nurses may be at extremely high risk for exposure.

A rec­om­mended method for dis­solv­ing and admin­is­ter­ing a cap­sule by syringe is to remove the plunger from the oral syringe and place the cap­sule inside. Replace the plunger, draw warm fluid into the syringe, and allow the cap­sule to dis­solve. The sus­pen­sion can be admin­is­trated orally or via feed­ing tube.

The Insti­tute for Safe Med­ical Prac­tices empha­sizes the use of spe­cial­ized oral syringes (not stan­dard slip tip or luer-​​lock syringes) for admin­is­ter­ing oral haz­ardous drugs to pre­vent inad­ver­tent IV administration.

Figure 1. Oral Chemother­apy Agents

Altre­t­a­mine, hexa­m­ethylme­lamine, HMM (Hexalen®, MGI Phar­ma­ceu­ti­cals)
Bexarotene (Tar­gretin®, Lig­and Pharam­ceu­ti­cals)
Busul­fan (Myleran®, Glax­o­SmithK­line)
Capecitabine (Xeloda®, Roche Lab­o­ra­to­ries)
Chlo­ram­bu­cil (Leuk­eran®, Glax­o­SmithK­line)
Cyclophos­phamide (Cytoxan®, Bristol-​​Myers Squibb)
Estra­mus­tine (Emcyt®, Pfizer Inc.)
Etopo­side (VePesid®, Bristol-​​Myers Squibb)
Hydrox­yurea (Hydrea®, Bristol-​​Myers Squibb)
Lenalido­mide (Revlimid®, Cel­gene Corp.)
Lomus­tine (CCNU, CeeNu®, Bristol-​​Myers Squibb)
Mel­pha­lan (Alk­eran®, Glax­o­SmithK­line)
Mer­cap­top­urine (6-​​MP, Purinethol®, Gate Phar­ma­ceu­ti­cals)
Methotrex­ate (Trex­all®, Barr Lab­o­ra­to­ries)
Mitotane (Lyso­dren®, Bristol-​​Myers Squibb)
Pro­car­bazine (Mat­u­lane®, Sigma-​​Tau Phar­ma­ceu­ti­cals)
Temo­zolo­mide (Temodar®, Scher­ing Corp.)
Thalido­mide (Thalo­mid®, Cel­gene Corp.)
Thiogua­nine (Tabloid®, Glax­o­SmithK­line)
Tretinoin (Vesanoid®, Roche Lab­o­ra­to­ries)
Vorino­s­tat (Zolinza®, Merck & Co., Inc.)

Fig­ure 2. Hor­mones and Tyro­sine Kinase Inhibitors

Tamox­ifen (Nolvadex®, AstraZeneca Phar­ma­ceu­ti­cals)
Anas­tra­zole (Arim­idex®, AstraZeneca Phar­ma­ceu­ti­cals)
Exemes­tane (Aro­masin®, Pfizer Inc.)
Letra­zole (Femara®, Novar­tis Phar­ma­ceu­ti­cals)
Mege­strol (Megace®)
Dasa­tinib (Sprycell®, Bristol-​​Myers Squibb)
Erlotinib (Tarceva®, Genen­tech, Inc.)
Gefi­tinib (Iressa®, AstraZeneca Phar­ma­ceu­ti­cals)
Ima­tinib (Gleevec®, Novar­tis Phar­ma­ceu­ti­cals)
Lap­a­tinib (Tykerb®, Glax­o­SmithK­line)
Nilo­tinib (Tasigna®, Novar­tis Phar­ma­ceu­ti­cals)
Sorafenib (Nex­avar®, Bayer Health­Care and Onyx Phar­ma­ceu­ti­cals)
Suni­tinib (Sutent®, Pfizer Inc.)