Tamoxifen: To Crush Or Not To Crush?

1. From: http://www.gghbpharmacy.scot.nhs.uk/Hospitals/Southern/NIL_BY_MOUTH.pdf

*States tamoxifen should not be crushed, but tablets can be dispersed in water.


2. From: http://www.rosemontpharma.com/education/healthcare-professional/tablets-not-to-crush & http://www.guardian.co.uk/uk/2006/oct/26/health.healthandwellbeing

Hormonal cytoxic or steroidal medicines (i.e. tamoxifen, methotrexate)


Risk assessment form requires completion if drug is to be crushed prior to administration. If the tablet is crushed, the drug may go into the air and the dose inadvertently received by the administrating nurse or carer.


3. From BCCA: http://www.bccancer.bc.ca/RS/CommunitiesOncologyNetwork/Educators/faqs.htm#One

1. How can we administer an oral cancer medication to a cancer patient who has just had an NG tube inserted? For safety reasons, we were told not to crush tablets or open capsules.

Oral cancer medications that are considered hazardous or cytotoxic should not be manipulated outside of a containment cabinet (ie. Biological Safety Cabinet) due to the risk of generating Hazardous Drug (HD) powder residue causing possible HD contamination and exposure. You may try dissolving or suspending the tablet/capsule particles in an enclosed system (i.e. syringe plus water) and administering the liquid through the NG tube.



If line occlusion occurs and impedes cancer drug administration you could consider holding the drug for a few days. For example; tamoxifen has an elimination half-life of ~ 5-7 days and the half-life of its active metabolite is ~ 9-14 days, so it is possible to hold tamoxifen therapy for ~2 weeks.



If the oral cancer medication cannot be withheld, it may be possible to compound it into a liquid dosage form. All activities likely to result in particle or aerosol generation, such as crushing tablets/capsules or compounding/pouring of oral solutions should be performed in a Biological Safety Cabinet (BSC) or Isolator. Oral solutions for hospital inpatients should be prepared in the pharmacy and dispensed to the ward in unit dose syringes. The nurses should not measure doses from a bottle.

Reference:

BCCA Division of Pharmacy. BCCA Pharmacy Practice Standards for Hazardous Drugs. 2008.

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Any other thoughts out there on how to handle the situation where tamoxifen tablets cannot be swallowed?