Administration of cytotoxic chemotherapy via the intrathecal route forms part of a number of cancer therapy regimens for haematological malignancies and solid tumours. Methotrexate, cytarabine, hydrocortisone and dexamethasone are commonly given by the intrathecal route. Occasionally rituximab and thiotepa may be given by this route.
Inadvertent administration of other cytotoxics or biological therapy NOT intended to be given into the cerebrospinal fluid by intrathecal injection are usually associated with devastating neurological effects, with fatal outcomes in 85% of the cases. Errors have resulted from inherent system defects and lack of awareness of the risks posed by incorrect administration.
Several peer-reviewed publications outline the risks associated with the accidental administration of neurotoxic chemotherapy by the intrathecal route and a number of guidelines outline the processes for reducing these risks.
Institutions where prescribing of intrathecal chemotherapy occurs must be aware of the risks and are recommended to take steps as outlined below and elsewhere in these guidelines to minimise the chances of error as far as practicable.
Medical staff that prescribe and administer intrathecal therapy must receive education and training with respect to the prescribing and administration of intrathecal therapy. Clinicians must be assessed as competent to prescribe and administer.
Prescriptions for intrathecal therapy must specify the route of administration as “INTRATHECAL” written in full, in capitals and in bold for computer generated proformas. The abbreviation “IT” is NOT acceptable.
Where practical, intrathecal injections should be scheduled to be administered on a day that no other parenteral chemotherapy is being administered to the patient and given in an area where no other cytotoxic chemotherapy, biological therapy or targeted therapy is accessible (Gilbar, 2014).
- Department of Health UK (Chief Medical Officer). Health Service Circular HSC 2008/001: Updated national guidance on the safe administration of intrathecal chemotherapy.; 2008 [cited 2016 Sep] Available from: http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_086844.pdf.
- Australian Commission on Safety and Quality in Health Care. High Risk Medication Alert – Vincristine. [homepage on the internet]; 2005 Dec [cited 2016 Sep]. Available from: https://safetyandquality.gov.au/wp-content/uploads/2012/01/valert.pdf.
- Goldspiel BR, DeChristoforo R, Hoffman JM. Preventing chemotherapy errors: updating guidelines to meet new challenges. Am J Health Syst Pharm 2015 Apr 15;72(8):668-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25825190.
- Marliot G, Le Rhun E, Sakji I, Bonneterre J, Cazin JL. Securing the circuit of intrathecally administered cancer drugs: example of a collective approach. J Oncol Pharm Pract 2011 Sep;17(3):252-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20525750.
- Noble DJ, Donaldson LJ. The quest to eliminate intrathecal vincristine errors: a 40-year journey. Qual Saf Health Care 2010 Aug;19(4):323-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20211962.
- Carrington C, Stone L, Koczwara B, Searle C, Siderov J, Stevenson B, et al. The Clinical Oncological Society of Australia (COSA) guidelines for the safe prescribing, dispensing and administration of cancer chemotherapy. Asia Pac J Clin Oncol 2010 Sep;6(3):220-37 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20887505.
- Gilbar PJ. Intrathecal chemotherapy: potential for medication error. Cancer Nurs 2014 Jul;37(4):299-309 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24201315.