12-01-2017 11:13 AM
Historically, we compounded the BCG for Bladder Instillation in our CACI. 3 years ago, we stop compounding hazardous drugs (and BCG) and only do non-hazardous in our CAI. I had a request from our Urology to look into BCG again. They state that BCG is now provided in a kit that contains an adapter for the diluent. I believe it is basically a CTSD, but am still looking for details myself. So my question is, if the kit is available with the CTSD system, is it ok to be reconstituted at the bedside, or should it still be compounded by pharmacy (and which environment - Hazardous vs Non-hazardous)? The Urology departement is telling me that outside practices are doing this, but seeing as these practices are within our walls, need to follow our policies/procedures.
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12-01-2017 11:46 AM
The 2016 NIOSH List places BCG in table 1 classifying it as antineoplastic drugs, including those witht he MSHG. Per USP <800>, because you are manipulating this further than counting or prepackaging, this drug would not be eligable for an AOR. This means this drug must be handled with all of USP <800> containment strategies (compounded in an C-PEC). This drug cannot be mixed and bedside.