Quantifying chemotherapy wastage in an ambulatory cancer centre in Singapore

INTRODUCTION

To ensure the efficient use of chemotherapy drugs, chemotherapy wastage is an area that can be investigated. This study aims to quantify current parenteral chemotherapy wastage and estimate parenteral chemotherapy wastage when dose banding is executed, using a chemotherapy wastage calculator in an ambulatory cancer centre. The study also examines the variables that significantly predict the total cost of chemotherapy wastage, investigates the reasons for wastage, and explores opportunities to reduce wastage.

METHODS

Data were collected from the pharmacy in National Cancer Centre Singapore over 9 months retrospectively. Chemotherapy wastage is the sum of wastage in the preparation phase and potential wastage in the administration phase. The calculator was created using Microsoft Excel and generated chemotherapy wastage in terms of cost and amount (mg) and analysed the reasons for potential wastage.

RESULTS

The calculator reported a total of 2.22 million mg of chemotherapy wastage generated over 9 months, amounting to $2.05 million (Singapore Dollars, SGD). Regression analysis found that the cost of drug was the only independent variable that significantly predicted the total cost of chemotherapy wastage (P = 0.004). The study also identified low blood count (625 [29.06%]) as the top reason for potential wastage and no-show ($128,715.94 [15.97%]) as the reason that incurred the highest cost of potential wastage.

CONCLUSION

The pharmacy has generated a considerable amount of chemotherapy wastage over 9 months. Interventions in both the preparation and administration phases are required to reduce chemotherapy wastage. The use of the chemotherapy wastage calculator in pharmacy operations could guide efforts to reduce chemotherapy wastage.

Determining acceptance and perceptions of chemotherapy dose banding in an ambulatory cancer centre

INTRODUCTION

Despite the advantages of dose banding (DB) and numerous plans to adopt this practice, uptake of DB is still poor. As opinions of healthcare professionals were deemed essential in DB's acceptance, this study surveyed key stakeholders to determine the acceptance, facilitators, and barriers of DB in chemotherapy to improve its implementation.

METHODS

A cross-sectional study at the National Cancer Centre Singapore, involving physicians, nurses, and pharmacy staff, was conducted in February 2022. The Theory of Planned Behaviour was adapted to design a survey questionnaire to obtain the acceptance, facilitators, and barriers of DB. Additional questions on maximum acceptable dose variance and essential criteria for selecting drugs for DB were included.

RESULTS

A total of 93 participants responded, with a mean 9.75  ±  7.37 years of clinical experience. Less than half have heard of DB while few had prior experience. Drug cost was the top selection criteria for DB, followed by toxicity, therapeutic index, frequency of use and drug wastage. Acceptance rate of DB was 41.9%, with majority agreeing to use DB in various drugs but to determine patient suitability before usage. Being greatly affected by subjective norms, having a positive outlook for DB's impacts, and no effect on toxicity significantly influenced acceptance.

CONCLUSION

Prior to implementing DB at the institutional level, educational training addressing concerns over toxicity, and providing technological support can help improve acceptance. Future studies can involve patients' perspectives and more institutions for greater diversity in opinions.

Long-term physicochemical stability of 5-fluorouracil at selected standardised rounded doses in polyolefin bags

BACKGROUND

Chemotherapy doses are usually prescribed on the basis of body surface area but dose banding is emerging as an efficient alternative. Dose banding presents the possibility of in-advance preparation in a Centralized Intravenous Admixture Service.

AIM OF THE STUDY

To evaluate the long-term stability of 5-fluorouracil at banded doses (700 mg and 800 mg) in polyolefin bags.

MATERIALS AND METHODS

Ten polyolefin bags were prepared under aseptic conditions and stored at 23 ± 2°C for 24 days. Five of them were composed of 14 mL 5-fluorocuracil (700 g) in 100 mL 0.9% sodium chloride solution and the five other of 16 mL 5-fluorouracil (800 mg) in 100 mL 0.9% sodium chloride solution. At defined times, physical stability parameters were assessed: optical densities, pH measurements, visual and microscopical inspections. Solutions concentrations were measured using high-performance liquid chromatography coupled with a photodiode array detector.

RESULTS

No change was observed on pH and optical density measurements during the study period. Visual and microscopical inspections remained free of colour change, precipitate, microagregate or crystal. The concentrations of 5-Fluorouracil in 800 mg bags remained stable for 24 days while the concentration in 700 mg bags showed a stability of at least 17 days.

CONCLUSION

Five-fluorouracil at banded doses of 700 and 800 mg in polyolefin bags is physicochemically stable for at least 17 days at 23 ± 2°C. These results support the possibility of in advance centralised preparation.

Dose banding of intravenous ganciclovir: Banding scheme proposal and audit of toxicity and efficiency

WHAT IS KNOWN AND OBJECTIVE

Dose banding is a strategy to optimize processing without reducing patient safety. Prescribed doses are rounded up or down to predetermined standard doses. Although it has been mostly used in chemotherapy, other drugs are suitable for this strategy, such as the antiviral ganciclovir. The aim of this work is to assess the safety and efficiency of a dose-rounding system for intravenous ganciclovir.

METHODS

Dose bands were established for a maximum of 10% variation from the individualized dose. The number of annual preparations that expired before use and the number of ganciclovir vials saved were documented as indicators of efficiency. Toxicity was assessed comparing haematological parameters before and after ganciclovir treatment in a sample of patients who received doses above the theoretical dose (n = 121) and in the rest of the cohort (n = 129).

RESULTS AND DISCUSSION

Five ganciclovir standard doses were established. It was shown that the bulk of the preparations (83.7%) had a maximum variation between the exact dose prescribed and the adjusted dose of ±10%. Three years after its implementation, a mean of 2848 annual preparations were compounded. The average percentage of annual expired preparations was lower than 1% of the total compounded doses, and the dose-rounding system allowed for saving 699 manufactured ganciclovir vials annually. There was no significant difference between haemoglobin and leucocyte levels measured before and after ganciclovir treatment in both groups.

WHAT IS NEW AND CONCLUSION

Ganciclovir dose banding allows for efficient management of preparations without an increased risk of acute haematological side effects.

[Support of oncology caregivers by pharmacists]

Beyond the checking of a prescription, the pathophysiological characteristics of the patient and the other prescribed medicines, pharmacists contribute to the field of oncology in their other missions. The benefits in terms of the reduction of risks for caregivers have been favoured by the centralisation of preparations combined with the application of other methods derived from industry. Research is continuing in order to dispense safe medicines which comply with the prescription and control the risks linked to the use of these highly active medicines.

An evaluation of cetuximab dosing strategies using pharmacokinetics and cost analysis

OBJECTIVES

Cetuximab dosing is based on body surface area (BSA), an approach that is associated with significant wastage due to available vial sizes. NHS England recently introduced an alternative strategy for cetuximab dosing based on dose banding. The aim of this work was to investigate approaches to cetuximab dosing to improve its cost-effectiveness.

METHODS

A simulation study using a population pharmacokinetic model was used to assess the performance of dosing strategies using exposure, probability of target attainment and cost. Two dosage regimens (500 and 400/250 mg/m² ) were investigated; 5% and 10% dose banding, fixed and optimised dosing strategies were evaluated and compared to BSA strategy.

KEY FINDINGS

The percentage of the total cost associated with wastage for the 400/250 mg/m² regimen were 8.75%, 5.13%, 3.61%, 9.2% and 0% for BSA; 5 and 10% bands; fixed and optimal strategies, respectively. Similar results were obtained for 500 mg/m² regimen. In comparison with BSA strategy, other strategies have comparable or improved performance. Optimised strategy showed consistent performance and ensures equal exposure and probability of target attainment.

CONCLUSIONS

Cost-effectiveness of cetuximab treatment can be improved with alternative strategies by reducing wastage without compromising exposure.

Standard dose development for medications commonly used in the neonatal intensive care unit

OBJECTIVES

To establish standardized, rounded doses of medications for neonates in the neonatal intensive care unit (NICU) through a multi-institutional peer-reviewed process.

METHODS

Pediatric faculty and pediatric pharmacy residents from the Ernest Mario School of Pharmacy (Piscataway, NJ) conducted a systematic review of rounded, weight-based medication information for neonatal patients from September 2010 to April 2011. After initial review, an expanded workgroup of expert neonatal pharmacy clinicians from academic institutions throughout the United States were invited to conduct a final review. The workgroup identified 74 medications or indications in the NICU. Recommended standardized doses were established for discrete weight categories at workgroup consensus web meetings conducted from June to December 2011. Workgroup recommendations were cross-referenced with published neonatal pharmacology resources. Consensus was obtained when references provided insufficient information on medication information.

RESULTS

Seventeen weight categories of increasing ranges were used, from 40 g for the lowest weights (e.g., 410-450 g) to 840 g for the highest weights (e.g., 3660-4500 g). Medications were divided into 3 categories of administration routes: oral (n = 4), intermittent intravenous (n = 64), and other (e.g., intramuscular; n=6). A significant majority of standardized doses (84%) were within 15% of their corresponding weight-calculated dose.

CONCLUSIONS

Establishment of a portfolio of standardized, rounded doses of medications commonly used in the NICU was feasibly established by a multi-institutional peer review process, with the great majority of standardized doses being within clinically acceptable ranges of administration. Use of standardized, rounded doses for reduction in dosing errors may be feasible on a systematic level.