Chapter 52

Although overdoses of antineoplastics are infrequent, these events are of greater consequence than overdoses of many other xenobiotics because of their narrow therapeutic index. This is evident from survey data from poison centers in the United States. From 1988 to 2007, the median annual number of people exposed to antineoplastics reported to US poison centers was about 1000. In the last 5 years, the number of annual exposures to these agents has steadily increased to slightly over 1500 (see Chap. 135). These exposures represent about one per 1000 cases of exposures to pharmaceutical agents, or one per 2000 cases of all exposures annually reported to US poison centers. Approximately two-thirds of the people exposed to antineoplastic agents in these reports were adults, one-fourth of the group was young children, and the remainder was adolescents. The annual trend for the proportion of exposures among adults and children appears to have remained at 70% and 20%, respectively, from 2001 to 2007. Children and adolescents between the ages of 6 and 19 years accounted for approximately 7% of the population annually exposed, and this frequency did not change between these years. Although these differences among age groups can represent the incidence of cancer in these populations, further analysis is warranted to better define the reasons for these observations because they are not apparent.

From 2001 to 2007, the annual prevalence of exposures to antineoplastics reported to US poison centers that resulted in toxicity that was defined as moderate or major in severity has declined from approximately 10% to 5% in the last 2 years. The mortality was about two per 1000 exposures in this same period. This frequency of significant morbidities was higher than expected because unintentional exposures to antineoplastics occurred eight times more frequently than intentional exposures. This observation is consistent with a hospital-based survey and is attributed to the increased toxicity of these agents.21 The prevalence of the exposure to antineoplastic agents is expected to increase over the next few years because of the increased availability of oral formulations, such as capecitabine, etoposide, vinorelbine, erlotinib and sorafenib, and their expanding therapeutic indications.

The importance of understanding the occurrence of medication errors is to prevent future events of a similar nature. Fortunately, medical errors related to the use of antineoplastics occur infrequently. The reported medical error rate for the antineoplastics ranges from 0.06% to 5.5% based on data from US centers,12,21,59 although the true prevalence of this event remains unknown. The rates reported by international centers are similar.35,36,54 These reported estimates vary by the clinical setting, hospital versus outpatient, and the patient population, adults versus children. The outpatient setting and the treatment of children present several unique challenges to the healthcare system: increased volumes, decreased control measures, increased workload, and unique dosing schemes such as dose based on body surface area.21,59 In a satellite pharmacy setting, two of the potentially lethal overdoses of ...

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