Asif Yusuf*, Aujla Harjinder, Correa West Joanna. Birmingham Children’s Hospital
Introduction LA, 15 year old female diagnosed with tuberculosis meningitis (TBM). General paediatric team recommended,
in combination with existing adjunctive therapy, initiation of
Thalidomide, a non-formulary drug.Challenge Administration of medication, for LA, was via a
nasogastric tube. The cytotoxic nature of Thalidomide compounded with the lack of information from Celgene, the manufacturer of the only licensed Thalidomide in the United
Kingdom (UK) that supplied oral capsules, provided numerous
issues for administration. In addition, TBM was an unlicensed
indication for Thalidomide.
Outcome Approval through the Drug and Therapeutics Committee (DTC) was gained. Upon investigating into previous
use at the trust, another patient had received Thalidomide for
TBM in 2014, this was requested from the same consultant,
however on that occurrence there was ease of administration
through the oral route so the licensed oral capsules were
used. Combined with this previous case and a thorough literature search, a dose was calculated of 200 mg (3 mg/kg once a
day), which was agreed by the general paediatrics team.
An
unlicensed oral tablet formulation was sourced from another
manufacturer in the UK. Crushing syringes were sourced to
ensure the ‘crushing and dispersing process’ would occur in a
closed system. The relevant forms for Thalidomide initiation
were completed by the requesting consultant, with the patient
and family advised on the appropriate pregnancy prevention
measures. An administration guide via feeding tubes was developed for the nursing team.
Steps included: wearing gloves and
apron, using
a crushing syringe to crush the Thalidomide tablet in a
closed system, drawing 20 ml of water from a medicine pot
into the crushing syringe, agitating the syringe to disperse the
tablet, using the appropriate ENFIT adaptor to administer the
dispersed medication into the feeding tube and disposing of
appropriate waste into cytotoxic and clinical waste.
Incorporated into this, a safety information leaflet for staff was developed, also for the nursing team, detailing the appropriate
ward storage (controlled drugs cupboard) and handling measures, stressing the importance of the teratogenic nature of
Thalidomide. The nursing team on the relevant ward, caring
for LA, were counselled on and supplied with the guidance
that was produced for them. A brief pharmacy guide was
developed, detailing to the pharmacy team, the teratogenic
nature of Thalidomide along with the special storage conditions (controlled drugs cupboard) and handling measures.
The pharmacy team were informed of the case and guidance was sent out, to ensure that the correct safety measures
were in place. Prior to dispensing, dispensing staff and screening pharmacists were asked to complete a consent form, in
order to dispense/screen prescriptions for Thalidomide. Dispensing took place as per cytotoxic medications, with Thalidomide delivered in the relevant yellow sealed bags.
Moving on A Thalidomide policy was drafted and will be submitted to the DTC for approval. Once approved, this will be
available for the medical, nursing and pharmacy team, in the
future. A pharmacy Thalidomide folder was created, that
would house the policy and all the relevant forms required
for audit.
Archives of Disease in Childhood 2018:103(2).
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