Q&A with Allegra DePietro, MS, RPh, BCNP
BPS Specialty Council Vice-Chair on Nuclear
Pharmacy, Nuclear Pharmacy Manager,
Division of Nuclear Medicine & Molecular Imaging,
Massachusetts General Hospital
Pharmacy Purchasing & Products: How would you characterize the role of a nuclear pharmacist in your facility?
Allegra DePietro: At Massachusetts General Hospital (MGH), the nuclear medicine department employs three full-time authorized nuclear pharmacists (ANPs)—one for nuclear medicine and two for the preparation of PET radiopharmaceuticals. These ANPs oversee the preparation and dispensing of radiopharmaceuticals and adjunct medications used for nuclear medicine imaging. Having nuclear pharmacists on staff is a somewhat unique situation generally limited to large academic institutions, since most hospitals’ nuclear medicine departments are not large enough to justify an onsite nuclear pharmacy. Most nuclear medicine departments in the United States utilize a commercial nuclear pharmacy to prepare the majority of their radiopharmaceuticals, which are then shipped to the hospital in unit-dose form ready for patient use. The nuclear medicine department may prepare some medications in the hospital for emergency or on-call needs, such as Tc-99m MAA for lung perfusion scans or Tc-99m labeled red blood cells for a gastrointestinal bleed scan.
However, in our case, as part of their job duties, nuclear pharmacists at MGH are charged with ensuring that the nuclear medicine department is in compliance with The Joint Commission’s (TJC) medication management standards, USP <797> standards, and Massachusetts State Radiation Control Program regulations, among others. In a recent step to close the information gap between pharmacy and nuclear pharmacy and help formalize this relationship, the MGH pharmacy director added me—the nuclear pharmacy manager—to the MGH Medication Education Safety Advisory Committee (MESAC). This has been a positive step for both departments to increase communication and facilitate the appropriate use of all medication products throughout the institution.
PP&P: What nuclear medicine practices is pharmacy least informed on?
DePietro: Most pharmacy schools do not include medications utilized in diagnostic imaging—specifically radiopharmaceuticals—in their curriculum, so practitioners in the hospital pharmacy department often lack the expertise necessary to evaluate nuclear medicine’s use of these products. However, the pharmacy department can be very helpful to nuclear pharmacy practices simply by contributing what they already know about activities common to both practices, such as sterile medication preparation, aseptic technique training and media fill testing, and medication storage, labeling, and dispensing procedures. A recently published book, entitled Diagnostic Imaging for Pharmacists (available from the American Pharmacists Association),1 was written to help inform non-nuclear trained pharmacists about radiopharmaceutical use and management, including contrast-imaging agents and other medications used in diagnostic imaging on a day-to-day basis. This is the first reference of this kind that I am aware of, and it appears timely given the emphasis TJC is placing on hospital pharmacy departments to enforce management of radiopharmaceuticals in the same manner as other medications used in the facility.
PP&P: How is formulary review performed for radiopharmaceuticals?
DePietro: The list of radiopharmaceuticals used in the hospital setting is extremely small compared with the number of non-radioactive medications used. In addition, there are very few product duplications, so evaluating which radiopharmaceutical to use for a given procedure in the nuclear medicine department is much more straightforward than what the hospital pharmacy is used to. Furthermore, the term formulary is not generally used by nuclear medicine; rather, our facility has been granted a broad radioactive materials license that is managed by our radiation safety committee, which also is responsible for adding every drug that is used in nuclear medicine onto our permit. We have a protocol for identifying all the radiopharmaceuticals that can be used by each authorized user (AU) permit holder, including what they are used for. Thus, any time a new radiopharmaceutical becomes available that we want to use, we have to amend the permit and add that drug.
When a radiopharmaceutical is required in the hospital setting, the nuclear medicine physician has two options: write an order for the imaging procedure, including the specific radiopharmaceutical, adjunct medication (if needed), dose, and route of administration; or, protocols can be established for each imaging procedure including this information. At MGH, we utilize standardized protocols for all of our imaging exams. Additional attention should be given to, and guidelines created for, pediatric or obese patient dosing based on weight or BMI.
PP&P: What patient screening parameters are required for radiopharmaceuticals?
DePietro: All nuclear medicine patients should be screened for drug and food allergies, drug and food interactions (which include other radiopharmaceuticals that may interfere with imaging), pregnancy and breastfeeding status, lab values, contraindications, as well as the appropriateness of the requested imaging exam, prior to being injected with a radiopharmaceutical. The primary goal of nuclear medicine practice is to obtain quality tests and scans for the physician to interpret without delaying diagnosis and treatment of the patient or exposing the patient to unnecessary radiation by having to repeat scanning procedures. Furthermore, and in keeping with TJC’s medication management standard—MM 05.01.01—the medication order review process should be performed by a pharmacist unless a licensed independent practitioner controls the ordering, preparation, and administration of the medication or when a delay would harm the patient in an urgent situation.
PP&P: Does nuclear medicine interact with the pharmacy information system?
DePietro: Nuclear medicine departments generally do not use the same software for order entry and dispensing of radiopharmaceuticals as the pharmacy; nonetheless, pharmacy should evaluate the software and labeling of the radiopharmaceutical doses to be sure those practices meet institutional guidelines.
Similar to the functions of pharmacy’s drug management, tracking, and administration systems, the software used in the nuclear medicine department should assist in avoiding human-use errors by establishing default radiopharmaceuticals and doses for individual imaging exams and calculating pediatric doses based on established protocols.
PP&P: How are radiopharmaceutical products handled from a waste perspective?
DePietro: Radiopharmaceuticals must be stored for 10 half-lives and then checked to be sure that the storage containers are no longer radioactive before being sent out of the institution as medical waste, a process known as decay-in-storage. At our facility, radiopharmaceutical waste is stored by the radiation safety department in a large waste room located in the basement of the hospital. As most of the products we use have a six-hour half-life, those products must be stored for at least 60 hours prior to disposal. We do use some products that have a three-day to eight-day half-life, which would need to be stored much longer—from one to three months. Regardless of the products used, a hospital’s radiation safety department should certainly have procedures in place for the storage, documentation, and disposal of radiopharmaceuticals.
PP&P: What are some suggestions to foster better communication between pharmacy and nuclear medicine?
DePietro: As with any interdepartmental analysis, the pharmacy department should tour the nuclear medicine department and meet with key personnel and management. (For a sample list of questions and concepts to review with nuclear medicine, see Table 1.)
When considering the roles of each group and how best to interact, begin by acknowledging that the nuclear medicine department is best equipped to handle radiation safety concerns and to select the appropriate commercial nuclear pharmacy to supply their radiopharmaceuticals based on cost, delivery schedules, and customer service needs. However, to assist these practices, the pharmacy department can provide considerable support by lending their expertise to evaluating and ensuring that the nuclear medicine department is safely storing, labeling, preparing, and dispensing medications. In general, nuclear medicine technology educational curriculum does not focus heavily on medication preparation and medication management standards, so insight from the pharmacy department in these areas is important to ensure that the facility is in compliance with TJC and USP standards.
Ultimately, pharmacy and nuclear medicine should both seek to foster a positive working relationship through increased communication and the establishment of friendly interactions to mutually provide educational resources to each other. As well, consider formalizing the relationship between the nuclear pharmacy or nuclear medicine department and the pharmacy department, such as inclusion of management representatives on P&T committees or medication safety boards. Simply remaining abreast of the issues, challenges, and successes each department faces on a regular basis can lead to a mutually beneficial relationship.
Allegra DePietro, MS, RPh, BCNP, is the nuclear pharmacy manager in the division of nuclear medicine & molecular imaging at Massachusetts General Hospital in Boston. She is also the vice-chair of the board of pharmacy specialties council on nuclear pharmacy. Allegra received a BS in pharmacy from Purdue University and a MS in administrative studies from Boston College.