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.
It is important to be aware that many cytotoxic agents are NOT intended for intrathecal use. Over the past 50 years, multiple reports of the inadvertent administration of vinca alkaloids and other agents into the cerebrospinal fluid by intrathecal injection have been published. For example, vincristine has been repeatedly reported (both in Australian and international literature) to be associated with fatal outcomes in 85% of the cases where it has been inadvertently administered via the intrathecal route. Devastating neurological effects are reported in the minority of patients that survive. Similar fatalities have been reported with accidental intrathecal administration of bortezomib.
In most cases the errors in administration have resulted from inherent system defects and lack of awareness of the risks posed by incorrect administration. Institutions where prescribing, dispensing and administration of intrathecal chemotherapy occur must therefore 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.
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.
All staff responsible for prescribing, dispensing and administering intrathecal chemotherapy should be aware of the catastrophic outcomes associated with the errors in administering incorrect chemotherapy medications via the intrathecal route.
All institutions where intrathecal chemotherapy is administered should have a procedure in place outlining the processes for prescribing, dispensing and administering intrathecal chemotherapy within that institution. This procedure must be developed with the involvement of all the relevant staff groups (medical, pharmacy and nursing staff) and must be approved by whichever body within the institution has delegated governance responsibility for approving medication policies or procedures.
All staff involved in prescribing, dispensing and administering intrathecal therapy should undergo appropriate training and be assessed as competent to perform their roles and responsibilities regarding intrathecal therapy.
A register of staff designated as competent to prescribe, prepare, dispense, supply, receive or administer intrathecal therapy for cancer should be maintained and accessible across the institution. Only staff listed on the register should undertake the specified tasks.
- Society of Hospital Pharmacists of Australia. High-risk medication alert for vincristine injection. Appendix 3: Literature review.; 2005 [cited 2016 Sep] Available from: https://safetyandquality.gov.au/wp-content/uploads/2012/02/vlitera2.pdf.
- Gilbar PJ, Seger AC. Accidental intrathecal administration of bortezomib: preventing fatalities. Asia Pac J Clin Oncol 2013 Sep;9(3):290-1 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23176407.
- Dyer C. Doctors suspended after injecting wrong drug into spine. BMJ 2001 Feb 3;322(7281):257 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11157519.
- 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.
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- 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.