Cytotoxic Waste

RE: Cytotoxic Waste

Lucy Fleming — Tue, 26 Nov 2019 16:14:52 GMT

[quote user="bob lehner"]

Have a look at https://chemopet.co.uk/wp-content/uploads/Guidelines-ECVIM-Hazards-Cytotoxic-drugs-2nd-version-July-2007.pdf Appendix 3.

Might help.

[/quote]

This is perfect thank you! Had missed this one on their website somehow.

RE: Cytotoxic Waste

bob lehner — Tue, 26 Nov 2019 14:34:45 GMT

Have a look at https://chemopet.co.uk/wp-content/uploads/Guidelines-ECVIM-Hazards-Cytotoxic-drugs-2nd-version-July-2007.pdf Appendix 3.

Might help.

RE: Cytotoxic Waste

Lucy Fleming — Tue, 26 Nov 2019 12:27:57 GMT

Bumping an old thread in the hopes that someone can offer some help - I'm trying to find information about disposal of excreta from a patient receiving cytotoxic medication (it's an imaginary cat on a COP protocol so vincristine/ cyclophosphamide/ prednisolone, for an assignment rather than real life ) but struggling. Does anyone know for how long the cat's urine/ faeces/ vomit should be treated as cytotoxic after each treatment? What do those providing chemotherapy suggest to owners for safe handling and disposal?

RE: Cytotoxic Waste

John Flynn — Mon, 25 Apr 2016 19:56:06 GMT

[quote user="robloxley"]Carginocenicity from accidental exposure[/quote]

I guess what I'm looking for is informed opinion on the degree of risk posed and what are reasonable steps for an average general practitioner to take. Google tells me that 16% of chemotherapy nurses report skin exposure to chemotherapeutic drugs in an average year.

From what I've read about the level of care required, I assume the degree of risk to be many magnitudes higher for vincristine than for the immersion oil I currently have beside my microscope that also claims to be carcinogenic, or the petrol I filled my lawnmower up with this morning, or the perfume my wife wears etc. Though I can't find any information to substantiate this clearly, nor to "rank" the relevant drugs to me in order of risk.

As a result, I tend to do what I've always done and use the drugs I've always used and shy away from using anything new as it might be too dangerous for me to handle. As a result, I have never used doxorubicin for instance as the advice I read suggested a fume cupboard was required - I couldn't really see why i would need this for simply injecting the drug into a drip bag on an occasional basis but I decided not to risk it.

RE: Cytotoxic Waste

Bob Russell — Mon, 25 Apr 2016 14:10:55 GMT

I would tend to agree with the idea of making a sensible safety assessment of the products and acting accordingly.

Alizin may be potentially risky for a pregnant woman but almost none to a bloke. Handling an empty syringe or bottle should be minimal risk to anyone.

Higher risk people (female of child bearing age for example) - wear gloves and dispose of all contaminated materials into the right bin. All will be incinerated under proper conditions.

Nastier chemo agents need much more careful handling. With some the aerosol from mixing could cause issues. We don't have a fume cupboard so mixing (if needed) happens outside on a puppy pad. Gown, gloves and face shield and done by me alone! All materials including the pad go into a purple bin.

Use is infrequent therefore risk to me is acceptable.

HSE tend to be more sensible than independent advisors. If you have assessed the hazard properly and acted reasonably, prosecution is unlikely to be a problem.

A referral centre doing a lot of chemo without checking the faulty fume cupboard is likely to be given a hard time!

RE: Cytotoxic Waste

Rob Loxley — Mon, 25 Apr 2016 13:49:21 GMT

[quote user="John Flynn"]NIOSH[/quote]

I believe the NIOSH is a US body, so what they say is less directly relevant in the UK than HSE guidance: http://www.hse.gov.uk/healthservices/safe-use-cytotoxic-drugs.htm

[quote user="John Flynn"]what is actual risk associated with an average small animal general practitioner[/quote]

Carginocenicity from accidental exposure; I'm not sure it's more quantifiable than that

[quote user="John Flynn"]what are sensible measures in this circumstance as opposed to in a setting[/quote]

You need to do a risk assessment depending on the drugs you use, how often/much you use them, how they are prepared (bought in; fume cupboard?) and administered (closed systems?), and think about accidents (e.g. dropping the glass bottle), and come up with a safe operating procedure to minimise risks of exposure given these.

RE: Cytotoxic Waste

John Flynn — Sun, 24 Apr 2016 21:09:22 GMT

[quote user="bob lehner"]

[quote user="robloxley"]hormonal preps e.g. alizin/oxytocin/ oestrogen/progesterone drugs etc; cytostatic drugs e.g. ciclosporin/tacrolimus
[/quote]

Yes - I suspect quite a lot of people are not aware that these products fall into the cytotoxic/cytostatic category.

[/quote]

OK - I think this is one area where I'm getting confused.

I thought "cytotoxic drugs" were simply pharmacologic compounds that are detrimental or destructive to cells within the body. So that might include, to me, anything from lidocaine to gentamicin then? That seems to me a rather vague and unhelpful definition to be using when it comes to considering actual risk management associated with what I (or the NIOSH as it happens) might term "hazardous drugs": those which, in minute quantities, in humans or animals are reasonably suspected to show:

Carcinogenicity
Teratogenicity or other developmental toxicity
Reproductive toxicity
Organ toxicity at low doses
Genotoxicity

The risk posed by "hazardous drugs" is principally to the patient receiving such a drug, but healthcare workers may have risks associated with sufficient exposure. This will differ vastly on the amount and manner in which the drug/patient-excreting-the-drug/environment is handled by the healthcare worker and the frequency of this interaction. Whether this "hazardous drug" is therefore a significant risk depends on factors other than the drug labelled as hazardous, as the NIOSH puts it, before giving the example that: "Dispensing a single tablet to a patient poses little to no risk to the healthcare worker. A single pair of gloves would be adequate."

Which brings me back to what is actual risk associated with an average small animal general practitioner who happens to be male and not of child-bearing age of a specific drug (say vincristine or cyclophosphamide, used on a lymphoma dog once a month on average over the year; or oxytocin used on a whelping bitch twice a year)? And what are sensible measures in this circumstance as opposed to in a setting where administering chemotherapy is my job for 40 hours a week or there is the possibility I might be pregnant? I can only find advice referring to the latter scenarios.

RE: Cytotoxic Waste

bob lehner — Sun, 24 Apr 2016 16:57:32 GMT

[quote user="robloxley"]hormonal preps e.g. alizin/oxytocin/ oestrogen/progesterone drugs etc; cytostatic drugs e.g. ciclosporin/tacrolimus
[/quote]

Yes - I suspect quite a lot of people are not aware that these products fall into the cytotoxic/cytostatic category.

RE: Cytotoxic Waste

Rob Loxley — Sun, 24 Apr 2016 14:54:35 GMT

[quote user="John Flynn"]If so, what are the specfic quantifiable risks[/quote]

Remember that the size of the fine from the HSE for playing fast and loose with control measures around cytotoxic medications is a quantifiable risk

RE: Cytotoxic Waste

Rob Loxley — Sun, 24 Apr 2016 14:50:18 GMT

[quote user="John Flynn"]I often see stuff talking about "cytotoxic" waste and drugs, but I'm very unclear what is meant by this[/quote]

see https://www.bsava.com/Resources/BSAVAMedicinesGuide/Medicinewastedisposal.aspx and https://www.bsava.com/Resources/BSAVAMedicinesGuide/Prescribingandlabelling.aspx for some veterinary specific guidance

[quote user="John Flynn"]Can anyone simplify to me what we are talking about here in terms of actual drugs used in a small animal clinic[/quote]

Your chemo drugs - vincristine/blastine/leukeran/doxorubicin etc.; hormonal preps e.g. alizin/oxytocin/ oestrogen/progesterone drugs etc; cytostatic drugs e.g. ciclosporin/tacrolimus

RE: Cytotoxic Waste

John Flynn — Sat, 23 Apr 2016 22:16:12 GMT

I always thought health and safety was meant to be precisely about common sense and its relation to risk.

I often see stuff talking about "cytotoxic" waste and drugs, but I'm very unclear what is meant by this. I have googled again just now and am no clearer really, but seems to most commonly be used to refer to a limited selection of anti-neoplastic drugs?

Can anyone simplify to me what we are talking about here in terms of actual drugs used in a small animal clinic and actual risks?

I don't gown up and put on facial visor to bleach the toilet, or adminster other medicines with harmful effects to me should I splash them in my eye or inject myself with them, but should I for vincristine injection or popping a cyclophosphamide tablet down the throat of a dog with lymphoma then? If so, what are the specfic quantifiable risks and how do these differ from other substances harmful to human health that I handle much more frequently? Is there a risk that should I develop a form of cancer that having had minute contact with these drugs myself they will then not be effective in treating me due to an increased incidence of efflux pumps in my body cells targetting these drugs in a similar way to handling antibacterial drugs is likely to predispose me to multi-resistant bugs lurking on my body ready for a surgical site infection should I break a hip?

With respect to disposing of a gown that you have then been wearing - surely you only need to take precautions if you have accidently contaminated that gown as it surely shouldn't be coming into contact with, for instance, an injection of vincristine that you have administered?

I've always meant to ask and this thread seemed like a good time!

Cheers.

RE: Cytotoxic Waste

Martin Atkinson — Sat, 23 Apr 2016 16:20:58 GMT

Sadly health and safety rules don't include common sense!

RE: Cytotoxic Waste

Rob Loxley — Thu, 21 Apr 2016 14:48:46 GMT

[quote user="peter chalkley"]I can see why the bin should be sealed after use, but are there any H+S acceptable ways of filling that bin to the legal brim? [/quote]

Most sharps bins are designed to be closed but not sealed between use. Otherwise you'd be using a new sharps bin every day. What do you do if you have a bottle of alizin to dispose of - use a whole new cyto disposal bin?

RE: Cytotoxic Waste

peter chalkley — Thu, 21 Apr 2016 10:46:32 GMT

Thanks for the replies.

all along the same theme as my thoughts, very much not what is being allowed by the nurses!!

RE: Cytotoxic Waste

Rob Loxley — Tue, 19 Apr 2016 13:52:17 GMT

We have one bin for cyto sharps and one for 'soft' waste on the go. You can get cytotoxic waste bags but most wast companies then want these to go into rigid containers - either a sharps bin (we use 22l ones) or a purple topped box.

helapet.co.uk are a good supplier of cytotoxic protective/disposal gear

RE: Cytotoxic Waste

Sarah Keir — Mon, 18 Apr 2016 16:22:31 GMT

'Sharps' or anything physically connected to it goes into round purple lidded cytotoxic bin; it is not sealed between uses. This includes the catheter, Phaseal giving set and the two syringes attached to the giving set (one for the cytotoxic, one for flush).

'Soft' cytotoxic material (inco pad, swab from top of widthdrawal of catheter, gloves, gowns), go into a purple cytotoxic bag which then placed in square purple lidded cytototxic bin; lid is placed on top but not sealed until the whole bin is full.

Sarah

RE: Cytotoxic Waste

Bob Russell — Fri, 15 Apr 2016 16:32:21 GMT

We keep our cyto bin in the freezer until it is full. It keeps it away from casual contact and I assume frozen chemo agents are less likely to form aerosols. Lids closed but not locked.

Only use smaller containers but the cost can be spread over a number of treatments or patients.

RE: Cytotoxic Waste

Martin Atkinson — Fri, 15 Apr 2016 11:42:35 GMT

[quote user="peter chalkley"]

We have started doing more in house chemotherapy (referral centre directed dosing, we just do the dangerous monkey work of injecting the poison, please don't fill the thread with pitfalls of chemo and how evil it may be!)

We are using Chemopet so everything comes pre drawn up etc etc and waste produced is fairly minimal, but still cytotoxic waste.

We currently use 11L cytotoxic waste bins which essentially get sealed and disposed of with an inco pad, catheter, small extension line, 2 syringes and some tape bundled inside 2-3 pairs of gloves. (holding the bits in a gloved hand and ungloving to wrap it all together in a lovely "sealed" manor).

this seems very wasteful of the cyto bins, it becomes expensive to the client, adding £20+ to the bill for disposal of waste products.

from a H+S stand point, I can see why the bin should be sealed after use, but are there any H+S acceptable ways of filling that bin to the legal brim?

I think I am asking are there any sealable bags that meet safety standards that we could put into one collective bin.

what do other people do??

[/quote]Depending on your waste disposal company you can get smaller bins. We just use the larger bins and keep them in a secure location until they are full then seal and send. Am I being a naughty boy?