Influences Shaping Clinicians' Monoclonal Antibody and Immune Checkpoint Inhibitor Preparation and Administration Management Practices: A Systematic Review

OBJECTIVES

In 30 years, monoclonal antibodies (mAbs) and immune checkpoint inhibitors (ICPIs) have enhanced cancer survival and quality of life. Limited knowledge exists regarding the long-term risks of repeated exposure, especially for cancer nurses, who prepare and administer them. This systematic review aimed to identify influences shaping clinicians' awareness and practices in the safe preparation and administration of mAbs and ICPIs.

DATA SOURCES

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The databases CINAHL, EMBASE, Joanna Briggs Institute, OVID, MEDLINE, and Cochrane were searched. Eligibility and risk of bias were assessed by four reviewers.

RESULTS

Of 7301 identified studies, 481 duplicates were removed, and 6673 were excluded after title and abstract review. A full-text review was conducted on 147 studies; six studies were included. A narrative synthesis generated two themes: (1) ambiguity contributes to variation in handling practices and (2) continuing professional development (CPD) is vital but hard to implement without evidence.

CONCLUSION

Lack of evidence regarding long-term risks and consensus creates uncertainty about the hazardous nature of unconjugated mAbs and ICPIs. Resulting in varied risk reduction strategies during preparation and administration, and inconsistent CPD. Protecting the long-term health of clinicians necessitates consensus on risk reduction strategies. This will be challenging without compelling evidence or international agreement on their hazardous classification.

IMPLICATIONS FOR NURSING PRACTICE

In nursing, policy gaps and inconsistent CPD related to unconjugated mAbs and ICPIs may expose nurses to risks. Understanding the educational needs of nurses and global standardized guidelines are urgently needed.

Part I: Significant reduction of lyophilization process times by using novel matrix based scaffolds

To improve the long-term stability of drugs with limited stability (e.g., biologicals such as monoclonal antibodies, antibody drug conjugates or peptides), some pharmaceuticals endure a lengthy and cost-intensive process called lyophilization. While the shelf life of lyophilized drugs may be prolonged compared to their liquid form, the drawbacks come in the form of intensified manufacturing, preparation, and dosing efforts. The use of glass vials as the primary container unit for lyophilized products hinders their complication-free, fast and flexible use, as they require a skilled healthcare professional and an aseptic environment in which to prepare them. The feasibility of substituting glass vials with novel container designs offering the complete transfer of the lyophilizate cake into modern administration devices, while reducing the economic footprint of the lyophilization process, was investigated. The lyophilization process of a monoclonal antibody solution was studied by assessing primary drying conditions, homogeneity of the drying process, and critical quality attributes after successful lyophilization. The creation of novel container designs utilized vacuum-forming to generate confined containers with removable bottoms and rapid prototyping, including subtractive and additive manufacturing methods, to generate porous 3D structures for drug housing. The novel container designs generated lyophilizates twice as fast and achieved a threefold faster reconstitution compared to their vial counterparts, without adaptation of the processing conditions. We conclude that the use of intermediate process containers offers significant relief for healthcare professionals in terms of reduced probability of handling errors, while drug manufacturers benefit from the accelerated processing times, increased batch homogeneity, and sustainability.

The need to protect cancer nurses from exposure to hazardous drugs

Freelance medical writer Christine Clark (chris@salt.u-net.com) reports on an online meeting held in May 2022 as part of a series on the risks of exposure to hazardous drugs for nurses working in oncology.

Staff sensitisation to therapeutic monoclonal antibodies resulting from workplace exposure: A case report

Monoclonal antibodies were introduced to clinical practice in 1980s and play a vital role in a variety of diseases and clinical interventions including cancer, inflammatory disease, and ophthalmologic disease. There is a lack of substantial research or evidence on the effect of occupational exposure on staff, leading many staff to have significant concerns about what is a safe level of exposure, especially given their increasing availability and use. This report describes a case in which a nurse became sensitised to monoclonal antibodies as a result of preparing and administering them in a clinical area, and the subsequent actions taken in response to the incident to reduce the risk to staff.

Closed-system drug-transfer devices plus safe handling of hazardous drugs versus safe handling alone for reducing exposure to infusional hazardous drugs in healthcare staff

BACKGROUND

Occupational exposure to hazardous drugs can decrease fertility and result in miscarriages, stillbirths, and cancers in healthcare staff. Several recommended practices aim to reduce this exposure, including protective clothing, gloves, and biological safety cabinets ('safe handling'). There is significant uncertainty as to whether using closed-system drug-transfer devices (CSTD) in addition to safe handling decreases the contamination and risk of staff exposure to infusional hazardous drugs compared to safe handling alone.

OBJECTIVES

To assess the effects of closed-system drug-transfer of infusional hazardous drugs plus safe handling versus safe handling alone for reducing staff exposure to infusional hazardous drugs and risk of staff contamination.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, OSH-UPDATE, CINAHL, Science Citation Index Expanded, economic evaluation databases, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov to October 2017.

SELECTION CRITERIA

We included comparative studies of any study design (irrespective of language, blinding, or publication status) that compared CSTD plus safe handling versus safe handling alone for infusional hazardous drugs.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified trials and extracted data. We calculated the risk ratio (RR) and mean difference (MD) with 95% confidence intervals (CI) using both fixed-effect and random-effects models. We assessed risk of bias according to the risk of bias in non-randomised studies of interventions (ROBINS-I) tool, used an intracluster correlation coefficient of 0.10, and we assessed the quality of the evidence using GRADE.

MAIN RESULTS

We included 23 observational cluster studies (358 hospitals) in this review. We did not find any randomised controlled trials or formal economic evaluations. In 21 studies, the people who used the intervention (CSTD plus safe handling) and control (safe handling alone) were pharmacists or pharmacy technicians; in the other two studies, the people who used the intervention and control were nurses, pharmacists, or pharmacy technicians. The CSTD used in the studies were PhaSeal (13 studies), Tevadaptor (1 study), SpikeSwan (1 study), PhaSeal and Tevadaptor (1 study), varied (5 studies), and not stated (2 studies). The studies' descriptions of the control groups were varied. Twenty-one studies provide data on one or more outcomes for this systematic review. All the studies are at serious risk of bias. The quality of evidence is very low for all the outcomes.There is no evidence of differences in the proportion of people with positive urine tests for exposure between the CSTD and control groups for cyclophosphamide alone (RR 0.83, 95% CI 0.46 to 1.52; I² = 12%; 2 studies; 2 hospitals; 20 participants; CSTD: 76.1% versus control: 91.7%); cyclophosphamide or ifosfamide (RR 0.09, 95% CI 0.00 to 2.79; 1 study; 1 hospital; 14 participants; CSTD: 6.4% versus control: 71.4%); and cyclophosphamide, ifosfamide, or gemcitabine (RR not estimable; 1 study; 1 hospital; 36 participants; 0% in both groups).There is no evidence of a difference in the proportion of surface samples contaminated in the pharmacy areas or patient-care areas for any of the drugs except 5-fluorouracil, which was lower in the CSTD group than in the control (RR 0.65, 95% CI 0.43 to 0.97; 3 studies, 106 hospitals, 1008 samples; CSTD: 9% versus control: 13.9%).The amount of cyclophosphamide was lower in pharmacy areas in the CSTD group than in the control group (MD -49.34 pg/cm², 95% CI -84.11 to -14.56, I² = 0%, 7 studies; 282 hospitals, 1793 surface samples). Additionally, one interrupted time-series study (3 hospitals; 342 samples) demonstrated a change in the slope between pre-CSTD and CSTD (3.9439 pg/cm², 95% CI 1.2303 to 6.6576; P = 0.010), but not between CSTD and post-CSTD withdrawal (-1.9331 pg/cm², 95% CI -5.1260 to 1.2598; P = 0.20). There is no evidence of difference in the amount of the other drugs between CSTD and control groups in the pharmacy areas or patient-care areas.None of the studies report on atmospheric contamination, blood tests, or other measures of exposure to infusional hazardous drugs such as urine mutagenicity, chromosomal aberrations, sister chromatid exchanges, or micronuclei induction.None of the studies report short-term health benefits such as reduction in skin rashes, medium-term reproductive health benefits such as fertility and parity, or long-term health benefits related to the development of any type of cancer or adverse events.Five studies (six hospitals) report the potential cost savings through the use of CSTD. The studies used different methods of calculating the costs, and the results were not reported in a format that could be pooled via meta-analysis. There is significant variability between the studies in terms of whether CSTD resulted in cost savings (the point estimates of the average potential cost savings ranged from (2017) USD -642,656 to (2017) USD 221,818).

AUTHORS' CONCLUSIONS

There is currently no evidence to support or refute the routine use of closed-system drug transfer devices in addition to safe handling of infusional hazardous drugs, as there is no evidence of differences in exposure or financial benefits between CSTD plus safe handling versus safe handling alone (very low-quality evidence). None of the studies report health benefits.Well-designed multicentre randomised controlled trials may be feasible depending upon the proportion of people with exposure. The next best study design is interrupted time-series. This design is likely to provide a better estimate than uncontrolled before-after studies or cross-sectional studies. Future studies may involve other alternate ways of reducing exposure in addition to safe handling as one intervention group in a multi-arm parallel design or factorial design trial. Future studies should have designs that decrease the risk of bias and enable measurement of direct health benefits in addition to exposure. Studies using exposure should be tested for a relevant selection of hazardous drugs used in the hospital to provide an estimate of the exposure and health benefits of using CSTD. Steps should be undertaken to ensure that there are no other differences between CSTD and control groups, so that one can obtain a reasonable estimate of the health benefits of using CSTD.