[Pharmwaste] Re:NIOSH Update and groundwater From: Russell Mankes

[Theresa O'Keefe]

The fact that no cytotoxic or antineoplastic drugs were "bedside wasted"
over the course of Dr. Mankes' study is positive testimony to the great work
of the American Society of Health-Based Pharmacists (ASHP) who in 1990
recommended that all unused cytotoxic drugs be handled as RCRA waste.  Their
work can serve as a poster-child for Drug Take Back programs.

 

It is not surprising that no cancer treatments appear in the top 200 drugs
listings by either sales ($) or unit.  In the US, most drugs are prescribed
for chronic conditions - the patient will take the drug one or more times
per day for the rest of his/her life.  For the most part, cancer treatments
are acute treatments - the patient is treated for a short period of time and
then either enters remission or sadly dies.  Cytotoxic chemotherapy drugs,
by their nature, are overwhelming for the patients.  The most common are low
cost generics (i.e. cyclophosphamide, doxorubicin, 5-FU, etoposide); are not
specific to cancer cells and instead attack ALL fast growing cells in the
body by causing DNA/RNA damage.  The aim is to poison as many fast growing
cancer cells as possible while not overwhelming the patient's healthy cells.
For that reason, a chemotherapy protocol includes on average 2-6 infusions
with several weeks between infusions to give the patient's body a chance to
recover. As the drugs are generics and are used less than 6 times in a
patient's life, they should never appear on the top 200 drug list. 

 

In the US, the National Comprehensive Cancer Network
(http://www.nccn.org/professionals/drug_compendium/content/contents.asp)
recommends 209 different medications for standard oncology treatment.  Of
these 103 are listed by NIOSH as hazardous.  NIOSH also lists an additional
7 older drugs not in common usage.  Only 24 hazardous cancer treatments (+1
no longer used) are well known to exit patients in large quantities of
active drugs.  The information about each of these drugs was known BEFORE
the drugs were approved by the FDA.  It can be found in the
Pharmacokinetics/Pharmacodynamics sections of each Drug Insert (that tightly
folded page that comes with every drug but nobody reads).  For example, up
to 25% of an infused dose of cyclophosphamide (U058,
http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=591d9955-3d9c-4cdc-a30
8-2f1288376b9f) is excreted in the urine as intact drug in the 24 hours
after infusion.  The danger to others of the excreted intact cytotoxic drugs
is why OSHA (http://www.osha.gov/dts/osta/otm/otm_vi/otm_vi_2.html) has
strict guidelines for handling not only the bodily fluids but also linens
and dishes used by the patients during the period of active excretion.
Cyclophosphamide is also notorious because greater than 98% of it exits
wastewater treatment as the original chemical (Buerge et al. 2006 Envir Sci
Tech).  

 

Because highly toxic cytotoxic drugs are used rarely in the US health care
population when compared to the total prescription drug volume, their
extreme danger is frequently overlooked.  But just as we used to overlook
the danger of mercury in our homes, a rare extreme danger can cause a huge
amount of damage.

 

Theresa O'Keefe, Ph.D.
Chief Scientific Officer
Pharma-Cycle Inc.
Helping Cancer Patients Protect Their Families

www.pharma-cycle.com



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