A Safe Environment for Administration

Radiation safety practices include treatment area set-up and cleanup, conducted in coordination with nuclear medicine experts and the cancer center’s radiation-safety officer. Procedures should be formalized to avoid contamination of floors and walls, patient toilet area floors, toilet seats and lids (using water-resistant padding2), and sinks, door handles, countertops, faucets, and patient tray tables.2

Lu-177 infusion is administered by a nuclear medicine technologist or physician using a gravity infusion method at least 30 minutes after an amino acid infusion.2 NaCl 0.9% (250 mL) infusion delivered at a rate of 1 drop every 3 seconds for the first 15 minutes, followed by a maximum flow drop rate for 15 minutes.2 Lu-177 infusion requires approximately 30 minutes.2

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“Despite the complex nature of administering and coordinating care, our biggest challenge was reassuring staff that they were safe caring for these patients,” noted Ryan Doering, RN, BSN, OCN, and colleagues.8 “Even after strong education about administration of hazardous drugs in the infusion room, we identified gaps related to radiation safety education for staff.”

Should a Lu-177 spill occur, the priorities are to protect the patient, control the extent of contamination using absorbent paper towels, and to clean up the contaminated areas.8 The authorized user contacts nuclear medicine, radiation safety, and diagnostic medical physics personnel.

Pre- and Posttreatment Support

Supportive care is an important component of Lu-177 treatment. Patients receive a long-acting antiemetic (fosaprepitant or aprepitant), a short-acting antiemetic (granisetron), and an H-2 blocker (famotidine) prior to the administration of the amino acid solution, Ms Romanowski explained.

“The patients are also provided a prescription for an antiemetic (eg, ondansetron or prochlorperazine) to use at home for any breakthrough nausea,” she noted.

Patients must be monitored for adverse events. Common side effects including lymphopenia, increased GGT, AST, or ALT enzymes, nausea, vomiting, hyperglycemia, and hypokalemia.4 Serious adverse effects include myelosuppression, secondary myelodysplastic syndrome or leukemia, renal toxicity, and hepatotoxicity, as well as neuroendocrine hormonal crises and infertility.4

“Patients are monitored with a complete blood count and comprehensive metabolic panel every 2 weeks after the start of treatment,” Ms Romanowski said. “Specifically, we are monitoring for any changes in red blood cells, white blood cells, platelets, renal and liver function.  Potential adverse events [of any grade] include anemia, neutropenia, thrombocytopenia, renal toxicity and hepatotoxicity.”

Another adverse event is IV infusion extravasation.6 “In our outpatient setting, the biggest challenges were coordination of patient care between multiple disciplines (such as nursing and radiology), the actual number of patients we can treat based on the need for extra nursing staff, and to ensure adequate distance between patients receiving Lu-177 and our general-infusion patient population,” Ms Romanowski said.

“As systematic radioactive infusion therapies advance, nursing standards of practice must be defined,” Victoria Wertz, MS, RN, and colleagues at Stanford Health Care in Stanford, California, reported at the ONS 44th Annual Congress.6 “While the incidence of extravasation is lower in patients receiving a 2-amino-acid solution, registered nurses must remain vigilant when monitoring for extravasation.”

Patients should be informed that for 3 days after therapy, they should limit potential irradiation of others by avoiding public spaces; using a designated bathroom at home that is not used by others, if possible; twice flushing the toilet after use; frequent handwashing; and use of separate linens.2 Men should urinate sitting down to avoid toilet splashing.2