Safe Handling of Oral "Cytotoxic" and "Caution" Medications

What does “Cytotoxic” or “Caution” medications mean?

You may be given a medication that has a “cytotoxic” or “caution” label. When you handle these medications, you have to take special precautions as they may be harmful to certain groups of people if not handled correctly.

Medications under the “Cytotoxic” category affect division of our body cells.
- Prolonged exposure or exposure to large amounts of cytotoxic drugs can lead to harmful effects to the normal body cells e.g. blood cells and cells lining the stomach and intestines.
Medications under the “Caution” category are those which can cause health problems such as airway irritation, irregular heartbeat and in some cases, increase the possibility of abnormal development of the baby in the womb. These medications can be used to treat a variety of diseases. Exposure to these agents may cause irritation to the skin, eyes or mucous membrane.

How should I handle the oral medications that are labelled “Cytotoxic” or “Caution”?

Do not handle these medications with your bare hands.Always wear a pair of disposable gloves when having direct contact with the tablets/capsules/syrups.
You may also use disposable medicine cups to handle the tablets or capsules to avoid direct contact with the medication.
Wash your hands thoroughly before and after handling these medications.
Avoid handling these medications if you are pregnant or breastfeeding.

How should oral “Cytotoxic” or “Caution” medication be administered?

The tablets/capsules should be swallowed whole with water. The medication should not be crushed or chewed unless advised by your doctor or pharmacist.
If you are unable to swallow the required tablet/capsule OR if less than a whole tablet/capsule is prescribed, please refer to the table below for guides on administration.
Tablets with special coating may not be suitable for cutting or dissolving. Please check with your doctor or pharmacist on how to handle them.
Oral “Cytotoxic” or “Caution” medications should be handled in a manner that avoids skin contact and the release of powdered medicine into the air. Direct contact with or breathing in these particles can cause harmful effects.
For tablets, sometimes it may be necessary to cut the tablet into half or quarters to obtain the correct dose, especially if prescribed for children.
- In such cases, use a tablet-cutter. Tablet-crushers are not preferred.
- Always wear gloves and cut the tablets in a still-air room (i.e. not directly under a fan).
- Use separate tablet cutters for “Caution” and “Cytotoxic” medications to avoid an unwanted or harmful mixingwith normal medications.
For capsules, it may be necessary to open the capsules in a still-air room and dissolve the contents in water before consuming. Always wear gloves and a mask. (Please refer to the table below for more information)

Table 1:Administration Guide for Patients who cannot Swallow or Partial Doses
For Tablets		For Capsules
DoseCAN be rounded to the nearest quarter tablet	DoseCANNOT be rounded to the nearest quarter tablet
1. You will need: An oral syringe A plastic measuring cup A pair of disposable gloves A mask A tablet cutter 2. Put on your gloves and mask. 3. Using a tablet-cutter, cut the tablet according to the required dose.Store any remaining tablet in a suitable container for the subsequent dose. Only cut one tablet at a time. 4. Put 5 to 10 ml of water into the measuring cup. 5. Place the required fraction of a tablet into the measuring cup and allow it to soften and disperse. This may take a few minutes. 6. Administer the entire solution to the patient.	1. You will need: An oral syringe A plastic measuring cup A pair of disposable gloves 2. Put on your gloves. 3. Put 5 to 10 ml water into the measuring cup. 4. Place the required tablet(s) into the measuring cup and allow it to soften and disperse. This may take a few minutes.	1. You will need: An oral syringe A plastic measuring cup A pair of disposable gloves Mask 2. Put on your gloves and mask. 3. Put 5 to 10 ml water into the measuring cup. 4. Gently twist and pull the capsule open, emptying the contents of required capsule(s) into the water. Take extra care not to breathe in the powder. Wrap the empty plastic capsule case in paper and throw it away with the mask and gloves.
	5. Syringe out required volume to administer to the patient. 6. Throw away any remaining solution in a suitable container to be brought back to the hospital for proper disposal.
It is recommended to throw away the plastic medicine cup and syringe after each use. However, if you wish to re-use these items, always wash them separately from other household items. You may re-use the syringe and plastic cup to handle the same oral “Cytotoxic” or “Caution” medication, but do not use them for any other purposes.

What should I do in case of accidental exposure?

Route of exposure	What to do ?
Direct contact with your skin, eye or mucous membrane	Wash the area of contact thoroughly, with plenty of water. Seek medical attention if there is any irritation (e.g. redness) over the area.
Breathing inaerosols and powders	Seek medical attention.
Accidental spillage	Wear a pair of gloves and cover the area with paper towels. Wipe the area with water then clean with household cleaner and water. Remove all contaminated clothing immediately and blot the clothing dry with paper towels. Wash separately from other laundry. Double-bag (place in bag, followed by another bag) all used paper towels before disposing it with the household waste. Wash your hands thoroughly after cleaning up the spillage.
Contamination of surfaces with patient’s vomit, faeces and urine	Wear a pair of gloves and cover the area with paper towels. Wipe the area with water then clean with household cleaner and water. Remove all contaminated clothing immediately and blot the clothing dry with paper towels. Wash separately from other laundry. Double-bag all used paper towels before disposing it with the household waste. Ensure that the bodily waste (i.e. vomit, faeces and urine) is emptied into the toilet bowl and flushed twice. Used diapers should be double-bagged before disposal as well. Wash your hands thoroughly after cleaning up the contaminated surfaces.

How should the oral “Cytotoxic” or “Caution” medication be stored and disposed of?

Store the medication in its dispensed container, in a cool, dry place.
Keep out of reach from children.
Any excess tablets/capsules/syrups should be returned to the hospital for disposal. Pack the medication into a bag and bring it back to the pharmacy where you received the medication from.
Double-bag the empty pill containers/oral syringes/syrup bottles before disposal with household waste.

Disclaimers

Please take note that the above is not a complete list of all possible side-effects. If you have any concerns about your medication or if you have other side-effects that you think are caused by this medication, please consult your doctor or pharmacist. If you take more than the recommended dose, please seek medical advice immediately. The information provided on this page does not replace information from your healthcare professional. Please consult your healthcare professional for more information.

This article is jointly developed by members of the National Medication Information workgroup. The workgroup consists of cluster partners (NHG Health, National University Health System and SingHealth), community pharmacies (Guardian, Unity and Watsons) and Pharmaceutical Society of Singapore. The content does not reflect drug availability and supply information in pharmacies and healthcare institutions. You are advised to check with the respective institutions for such information.