Frequency and component analysis of contaminants generated in preparation of anticancer agents using closed system drug transfer devices (CSTDs)

A systematic study of CSTD-generated stress on different biomolecular modalities

Although Closed System Transfer Devices (CSTDs) are used in oncology for dose preparation and administration, the impact of CSTDs on biologics and other non-small molecular modalities are not fully understood. We investigated particle formation when preparing and mock administering three experimental biologics (mAb, ADC, and fusion protein) using seven models of CSTDs. A wide range of visible and subvisible particle formation was observed among CSTD models. Particles were found to consist of silicone oil and protein. X-ray micro-computed tomographic images of the fluid paths of the CSTDs showed that most have highly tortuous fluid paths. Computational fluid dynamics analysis of dose preparation using the CSTDs that produced the highest and lowest amounts of particles demonstrated a 154-fold difference in maximum shear stress as well as a significant difference in solution residence time. Control experiments with silicone oil spiking showed that exposing the proteins to silicone oil does not account for the majority of visible and subvisible particle formation. These results demonstrate that the geometry of the fluid paths of CSTDs can have a detrimental effect on protein stability.

Current industry practices on closed system drug-transfer devices for parenteral drug products

USP<800> and NIOSH provide guidance on the use of Closed System Drug-Transfer Devices for hazardous drug in the healthcare setting. However, CSTDs are used by clinical sites irrespective of drug hazard status. In this paper, previous publications that describe evaluation and CSTD risk assessment strategies are presented. In addition, a pharmaceutical industry survey was performed to describe the current strategies for evaluation of CSTDs and how these devices are managed for clinical studies. Finally, recommendations are proposed to mitigate risks associated with CSTDs. These recommendations incorporate: testing considerations, risk assessments, and communication.

Impact on Quality during In-Use Preparation of an Antibody Drug Conjugate with Eight Different Closed System Transfer Device Brands

The aim of this study was to investigate the in-use compatibility of eight commercially available closed system transfer device brands (CSTDs) with a formulated model antibody drug conjugate (ADC). Overall, in-use simulated dosing preparation applying the CSTD systems investigated raised concerns for several product quality attributes. The incompatibilities observed were mainly associated with increased visible and subvisible particles formation as well as significant changes in holdup volumes. Visible and subvisible particles contained heterogeneous mixtures of particle classes, with the majority of subvisible particles associated with silicone oil leaching from CSTD systems during simulated dose preparation upon contact with the ADC formulation. These observations demonstrate that CSTD use may adversely impact product quality and delivered dose which could potentially lead to safety and efficacy concerns during administration. Other product quality attributes measured including turbidity, color, ADC recovery, and purity by size exclusion HPLC, did not show relevant changes. It is therefore strongly recommended to test and screen the compatibility of CSTDs with the respective ADC, in a representative in-use simulated administration setting, during early CMC development, i.e., well before the start of clinical studies, to include information about compatibility and to ensure that the CSTD listed in the manuals of preparation for clinical handling has been thoroughly assessed before human use.

Safe handling of cytostatic drugs: recommendations from independent science

OBJECTIVES

Due to their mechanism of action, most classical cytostatic drugs have carcinogenic, mutagenic and/or reprotoxic properties. Therefore, occupational exposure of healthcare staff to these drugs should be prevented. Our objective was to lay out European legislation on this topic and reflect on the process of revising the European CM-directive. We summarise independent European and Dutch studies, and give a concise set of basic recommendations for safe working with cytotoxic drugs in healthcare facilities.

METHODS

We were directly involved in the process of revising the CM-directive: first, through an EU commissioned workshop in the Netherlands, and after that by contributing to the pan-European stakeholder symposium. For this aim, we had to gather the relevant study data from the Netherlands and from Europe. We analysed all relevant industry-independent studies and collated a set of basic recommendations.

RESULTS

Independent studies show that the development of measures in recent years can lead to a safe work environment. Standardising the cleaning process leads to a significant improvement in environmental contamination in the majority of hospitals. In the Netherlands, exposure of workers was shown to be well beneath the limit value of 0.74 µg cyclophosphamide per week, therefore showing that the measures taken in recent years are adequate.

CONCLUSIONS

The safety of healthcare workers is of the utmost importance. Current practice in the Netherlands show that measures taken in recent years are adequate. European legislation should be based on independent scientific research and practice. The first goal should be to bring countries with less safe working levels to a higher level instead of introducing measures that only increase healthcare budgets but not healthcare safety.

A Survey on Handling and Administration of Therapeutic Protein Products in German and Swiss Hospitals

Protein products in hospitals often have to be compounded before administration to the patient. This may comprise reconstitution of lyophilizates, dilution, storage, and transport. However, the operations for compounding and administration in the hospital may lead to changes in product quality and possibly even impact patient safety. We surveyed healthcare practitioners from three clinical units using a questionnaire and open dialogue to document common procedures and their justification and to document differences in handling procedures. The survey covered dose compounding, transportation, storage and administration. One key observation was that drug vial optimization procedures were used for some products, e.g., use of one single-use vial for several patients. This included the use of spikes and needles or closed system transfer devices (CSTDs). Filters or light protection aids were used only when specified by the manufacturer. A further observation was a different handling of the overfill in pre-filled infusion containers, possibly impacting total dose. Lastly, we documented the complexity of infusion administration setups for administration of multiple drugs. In this case, flushing procedures or the placement and use of filters in the setup vary. Our study has revealed important differences in handling and administration practice. We propose that drug developers and hospitals should collaborate to establish unified handling procedures.

Characterization of Silicone from Closed System Transfer Devices and its Migration into Pharmaceutical Drug Products

Closed System Transfer Devices (CSTDs) are increasingly used in healthcare settings to facilitate compounding of hazardous drugs but increasingly also therapeutic proteins. However, their use may significantly impact the quality of the sterile product. For example, contamination of the product solution may occur by leaching of silicone or particulates from the CSTDs. It was therefore the aim of the present study to identify and quantify the types of silicone oil in a panel of typically used CSTDs. Particles found after simulated CSTD compounding processes were evaluated using Light Obscuration and Micro-Flow Imaging and were confirmed to be silicone oil particles. The number of particulates shed from CTSDs was in single cases exceeding pharmacopeial limits for a final parenteral product. Using X-ray microtomography, lubrication was shown to be primarily applied at connecting parts of the CSTD. Quantitative and qualitative analysis by Fourier transform infrared spectroscopy (FTIR) revealed a total released amount between 0.8 and 16 mg per CSTD of polydimethylsiloxane or polymethyltrifluoropropylsiloxane per CSTD. While pronounced differences in total silicone content between CSTDs were observed, it did not fully correlate with particle contamination in the test solutions, potentially due to variations in CSTD design. The impact of typical surfactants in biological formulations on silicone migration into product was additionally evaluated. We conclude that CSTDs may compromise final product quality, as (different types of) silicone oil may be released from these devices and contaminate the administered product.

Clinical Oncology Society of Australia Position Statement: 2022 update to the safe handling of monoclonal antibodies in healthcare settings

AIM

The aims were to (a) review the scientific literature on occupational risk, including exposure mechanisms and risk assessment, with regards to handling monoclonal antibodies (mABs) in healthcare settings; and (b) update the recommendations in the Clinical Oncology Society of Australia (COSA) safe handling of monoclonal antibodies in healthcare settings position statement, published in 2013.

METHODS

A literature search was conducted between April 24, 2022, and July 3, 2022, to identify evidence relating to occupational exposure and handling of mABs in healthcare settings. Evidence in the literature was compared to the Position Statement published in 2013, and any potential additions, deletions, or revisions were discussed by the authors, and then agreed changes were made.

RESULTS

Thirty-nine references were included in this update, comprising of the 2013 Position Statement itself and 10 of its references, as well as 28 new references. The risks to healthcare workers in the preparation and administration of mABs arise from four distinct exposure mechanisms: dermal, mucosal, inhalation, and oral. Updates included recommendations on using protective eyewear during the preparation and administration of mABs, developing a local institutional risk assessment tool and handling recommendations, considerations for using closed system transfer devices, and to have awareness of the nomenclature change from 2021 for new mABs.

CONCLUSION

Practitioners should follow the 14 recommendations to lower occupational risk when handling mABs. Another Position Statement update should occur in 5-10 years to ensure the currency of recommendations.

Developing a flowchart to evaluate the use of Closed System Drug-Transfer Devices with monoclonal antibodies: Focus on the clinical trial setting

OBJECTIVE

Available guidelines are ambiguous about safe handling monoclonal antibodies (MABs) and whether or not to use a Closed System Drug-Transfer Device (CSTD). In this article we want to describe a standardized working method on handling MABs in a clinical trial setting.

DATA SOURCES

The current workflow at the clinical trial unit of the Ghent University Hospital was critically analyzed, after which an extensive literature review was performed using the National Institute for Occupational Safety and Health Working Group guidelines and the database PubMed (Keywords: monoclonal antibodies, closed system transfer devices, safety guidelines, safe handling, management, administration, (bio)compatibility, volume loss, contamination, clinical trial unit. Period: 2020-2022).

DATA SUMMARY

Literature data are ambiguous. CSTDs can reduce cross-contamination and minimize exposure to potential hazardous drugs for healthcare professionals. However, in recent years more questions have been raised about their in-use compatibility and their impact on final product quality. This makes the debate on implementing CSTDs a hot topic in daily pharmacy practice and demands a holistic and standardized approach when deciding whether or not to use a CSTD when handling MABs. In a clinical trial setting, where safety data are frequently not available and the compatibility of CSTDs and investigational product is often unknown, this poses additional challenges that need to be taken into account.

CONCLUSION

We developed a flowchart which standardizes the use of a CSTD when handling MABs. It allows other healthcare professionals and clinical trial sponsors to define and evaluate the necessary criteria when standardizing the position of a CSTD in their safe handling procedures.