The Pharmaceutical Journal
Vol 278 No 7458 p760
30 June 2007

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Risk of confusion over cytarabine

Confusion between cytarabine and liposomal cytarabine has been highlighted as a potential risk in an early warning report issued by the National Patient Safety Agency.

The “rapid response report” is the first to be issued by the NPSA as part of a pilot of one-page information sheets, which are intended to communicate important patient safety issues to NHS professionals rapidly. The rapid response reports are different from existing NPSA safety announcements, such as patient safety alerts and safer practice notices.

The report alerts staff to possible confusion between two preparations of intrathecal cytarabine — standard cytarabine and a newer, longer-acting formulation, liposomal cytarabine (Depocyte).

Administration of liposomal cytarabine without concomitant steroids can induce severe acute arachnoiditis. In addition, administration of the wrong preparation can lead to over- or under-dosing due to the dosing frequency of the two products being different.

The warning follows an incident reported to the NPSA in which a patient was given liposomal cytarabine rather than the standard formulation that was prescribed. In the reported case, the pharmacist failed to follow normal checking procedures to establish the correct drug was administered, believing that the haematology unit’s drug of choice was Depocyte even though standard cytarabine (without steroid cover) had been prescribed.

The report requires action by 18 July 2007 and instructs chief pharmacists to ensure that medical, nursing and pharmacy staff involved in intrathecal chemotherapy are aware of the potential risk. It also requires local action to be taken to minimise this risk.

The NPSA would welcome feedback on the pilot and the rapid response report and comments can be e-mailed to rrr@npsa.nhs.uk