Handling Cytotoxic Drugs;

A HEALTH AND SAFETY REVIEW

 OVERVIEW
Ansell Healthcare Products LLC has an ongoing commitment to the development of quality
hand barrier products and services for the healthcare industry. This self-study, Clinical
Reference Manual: Handling Cytotoxic Drugs; a Health and Safety Review, is one in a
series of continuing educational services provided by Ansell. This educational module
examines glove use in handling cytotoxic drugs.

INTENDED AUDIENCE
The information contained in this self-study guidebook is intended for use by healthcare
professionals who are responsible for or involved in the following activities related to this
topic:
Educating healthcare workers
Establishing institutional or departmental policies and procedures
Decision-making responsibilities for hand-barrier products
Maintaining regulatory compliance with agencies such as OSHA, ANA and CDC
Managing employee health and infection prevention services

PROGRAM OVERVIEW
Upon completion of this educational activity, the learner should be able to:
Discuss hazardous drugs used in chemotherapy
Discuss standard testing method of material used in handling chemotherapy drugs
Describe steps to prepare and administer cytotoxic drugs
Describe the characteristics of good barrier protection of the different gloving
HANDLING CY TOTOXIC DRUGS

materials available
Discuss standard of practice to glove use in handling chemotherapy drugs
 INSTRUCTIONS
Ansell Healthcare is a provider approved by the California Board of
Registered Nursing, Provider # CEP 15538 for 2 contact hour(s). Obtaining
full credit for this offering depends on completion of the self-study materials
on-line as directed below.
Approval refers to recognition of educational activities only and does not imply
endorsement of any product or company displayed in any form during the educational
activity. To receive contact hours for this program, please go to the "Program Tests" area
and complete the post-test. You will receive your certificate via email.
AN 85% PASSING SCORE IS REQUIRED FOR SUCCESSFUL COMPLETION
Any learner who does not successfully complete the post-test will be notified and given an
opportunity to resubmit for certification.
For more information about our educational programs please contact Ansell Healthcare
Educational Services at 1-732-3452162 or e-mail us at edu@ansellhealthcare.com.
Planning Committee Members:
Luce Ouellet, DESS, BSN, RN
Patty Taylor RN, BA
Pamela Werner, MBA, BSN, RN CNOR
As employees of Ansell; Mme Ouellet, Mrs. Taylor and Ms. Werner have declared an
affiliation that could be perceived as posing a potential conflict of interest with
development of this self-study module.
Roy Zacharius Jr., CST, BS, FAST
As an employee of The Meridian Institute, Mr. Zacharias has declared an affiliation that
could be perceived as posing a potential conflict of interest with the development of this
HANDLING CY TOTOXIC DRUGS

self-study module.
This module will include discussion of commercial products referenced in generic
terms only.

Ansell Healthcare
Products LLC
111 Wood Avenue South,
Suite 210
Iselin, NJ 08830
USA
Tel: 1-800-952-9916
www.ansellhealthcare.com
 CONTENTS
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Classes of Cytotoxic Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Carcinogenic Agent Toxicology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Securing Health Professionals; Handling Hazardous Drugs . . . . . . . . . . . . . . . . . 3

H A N D L I N G C Y T O T O X I C D R U G S ; A H E A LT H A N D S A F E T Y R E V I E W

The Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Effects of Chemicals on Gloves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Testing for Glove Permeation by Chemotherapy Drugs . . . . . . . . . . . . . . . . . . . . 5

Interpreting Breakthrough Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Glove Selection in Handling Cytotoxic Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Glove Fit and Sizing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Double Gloving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Donning and Doffing Gloves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Donning Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Closed Donning Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Open Donning Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Glove Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Removing Examination Gloves Safely . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Glove Recommendations in Handling Cytotoxic Drugs . . . . . . . . . . . . . . . . . . . 11

Drug Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Working Securely with Cytostatics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Administering Cytostatics to Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Drug Administration; Glove use Recommendation . . . . . . . . . . . . . . . . . . . . . . . 14

Drug Clean Up and General Handling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Summary of Glove Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
INTRODUCTION
According to the World Health Organization
(WHO), between now and 2030 the
cancer rate is going to increase by 50%
to about 13 million new cases a year,
worldwide. The predicted increase in new
cases will mainly be due to the existence
of a steadily aging population in both
developed and developing countries, but
also to the current prevalence of smoking
and the rise in numbers of those adopting
unhealthy lifestyles1. One of the most
frequently used treatments for cancer is
chemotherapy.
Chemotherapy treatments are utilized in
suppressing and/or inhibiting cell growth
and division. It is used as an adjuvant to
surgery, and/or treatment of metastatic
cells. Unfortunately, it is well known that
cytostatic agents are potentially hazardous
for the manipulator (pharmacist, assistant,
nurse, surgeon, pharmacy technicians,
etc.)2.
Cytostatics are known to be3:
Mutagenic - induce or increase
genetic mutations by causing changes
in DNA.
Carcinogenic - cancer-causing in
animal models, in patient
population, or both.
Teratogenic - causing fertility
impairment in animal studies or
treated patients.
Some of the other potential effects are:
Decrease in fertility
Fetal malformation
Abortion
Extra uterine pregnancy
High toxicity for certain organs
Handling cytotoxic drugs poses potential
occupational risks. The occupational
risk is highly dependent of the following
criteria4:
Intrinsic toxicity of cytostatic
Duration of exposure
Frequency of exposure
Handling method- before, during,
and after use
CLASSES OF
CYTOTOXIC DRUGS
Traditional antineoplastic drugs, which still
constitute most of the anticancer drugs
used today, generally target either the DNA
inside the nucleus of a cell directly, inhibit
the synthesis of new DNA strands, or stop
the mitotic processes of a cell. In the first
case, the objective is to cause physical
changes in the DNA itself, resulting in
mutations of the DNA attempting to
replicate. In the second case, these agents
usually stop the synthesis of DNA by
stopping the synthesis of the necessary
building blocks of DNA. In the third case,
the objective is to stop cell replication
in one of the stages of mitosis, often by
inhibiting synthesis or breakdown of the
cellular structure.5
1
 I. Antineoplastic agents which directly
attack DNA in the nucleus belong to the
following categories:
A. Alkylating agents:
These agents directly alkylate or
covalently modify the nitrogenous bases of
DNA molecules. This can result in
H A N D L I N G C Y T O T O X I C D R U G S ; A H E A LT H A N D S A F E T Y R E V I E W
mispairing of bases, or loss of bases, or
actual splitting of the DNA backbone.
Examples:
Altrtamine (Hexalen)
Busulfan (Myleran)
Carboplatin (Paraplatin)
Chlorambucil (Leukeran)
Cisplatin (Platinol)
Cyclophosphamide
Dacarbazine (DTIC)
Ifosfamide (Ifex)
Melphalan (Alkeran)
Oxiliplatin (Eloxatin)
Procarbazene (Matulane)
Telomozomide (Temodar)
ThioTEPA
B. Intercalating agents:
These agents bind tightly to the DNA
double helix, preventing the unwinding of
the double helix at that point.
Examples:
Dactinomycin (Cosmegen)
Daunorubicin (Cerubidine)
Doxorubicin (Adriamycin)
Plicamycin (Mithramycin)
C. DNA Topoisomerase inhibitors:
By inhibiting this enzyme involved in
supercoiling, these agents somehow
cause the actual scission or breakage of
DNA strands in the nucleus.
2
Example:
Etoposide (VePesid, VP-16)
II. Antineoplastic agents which stop the
synthesis of DNA precursors are:
A. Folic Acid antagonists:
These agents stop the formation of
tetrahydrofolate, which is necessary for
the synthesis of both purines
and pyrimidines.
Example:
Methotrexate (MTX)
B. Purine antagonists:
These agents are competitive inhibitors of
enzymes in the purine nucleotide synthetic
pathways.
Examples:
Mercaptopurine (Purinethol)
Thioguanine (Tabloid)
C. Pyrimidine antagonists:
These agents are competitive inhibitors of
enzymes in the pyrimidine nucleotide
synthetic pathways.
Examples:
Floxuridine (FUDR)
Fluorouracil (5-FU)
Cytarabine (Cytosar, ARA-C)
D. Ribonucleotide diphosphate reductase
inhibitors:
These agents will effectively interfere with
DNA construction. These agents damage
cells during S phase.
Example:
Hydroxyurea (Hydrea)
III. Antineoplastic agents which affect their inherent toxicity as well as the type
the synthesis or breakdown of the of exposure that may occur in the
mitotic spindles belong to the general workplace. Today that workplace
category of alkaloid antineoplastic drugs. environment may be a hospital clinic,
other patient unit, a physicians office,
A. Alkaloids exert their actions on tubulin pharmacy, or in the patients home.
synthesis/breakdown: Chemotherapy administration has also
evolved over the years. Chemotherapy
Examples:
agents are administered via intravenous
Vinblastine (Velban, Velsar)
push as well as a continuous infusion
Vincristine (Vincasar, Oncovin)
through a variety of implanted access
Pacitaxel (Taxol)
devices. Exposure, to the healthcare
worker or a family member in the home,
CARCINOGENIC may be through ingestion of food that may
AGENT TOXICOLOGY have been exposed to the drug, inhalation
of drug particles that may become
The International Agency for Research on
aerosolized during preparation, handling of
Cancer (IARC) is part of the WHO. Its major
patient excreta during home care, or direct
goal is to identify causes of cancer. The
skin contact of the drug. Studies have
most widely used system for classifying
been conducted to assess the indirect
carcinogens comes from the IARC. In the
exposure of healthcare workers, i.e.
past 30 years, the IARC has evaluated the
nurses and pharmacists, to determine if
cancer-causing potential of more than 900
there was any chromosomal damage to
likely candidates, placing them into one of
these workers that prepared and
the following groups: 6
administered these drugs. This and other
Group 1: Carcinogenic to humans
reports point to the need for excellent
(109 agents)
exposure control measures and excellent
Group 2A: Probably carcinogenic to
compliance to safe handling procedures.7
humans (65 agents)
Group 2B: Possibly carcinogenic to
humans (275 agents) SECURING HEALTH
Group 3: Unclassifiable as to PROFESSIONALS;
carcinogenicity in humans (503 agents) HANDLING
Group 4: Probably not carcinogenic to HAZARDOUS DRUGS
humans (1 agent)
The Standards
The hazards encountered during the
The FDA Glove Guidance manual offers
preparation, administration, clean up and
specific guidance for labeling exam gloves
general handling of any cytotoxic drug
used in chemotherapy;
have been well documented. Public
concern is magnified by the perception
that cancer risks are imposed upon
workers, nurses and pharmacists that are
involved in these procedures. The dangers
of handling hazardous drugs come from

3
 To market the glove for use in the
handling and/or preparation of
chemotherapeutic drugs, you should label
the glove as a Patient examination Glove
or Surgeons glove and tested for use
with (name of chemotherapeutic drugs).
We recommend that you include the
following labeling information:
H A N D L I N G C Y T O T O X I C D R U G S ; A H E A LT H A N D S A F E T Y R E V I E W
Chemical resistance data (test method
used, chemicals tested) for consumer
review, if desired.
The statement Gloves used
forprotection against chemotherapy
drug exposure should be selected
specifically for the type of chemicals
used and instructions for users to
review drug labeling or material safety
data sheets for the chemicals being
used to determine an adequate level of
protection for the intended use.8
The Oncology Nurses Society mentions in
their standards that the use of a class II
safety cabinet does not eliminate the need
for PPE (Personal Protective Equipment).
Because spills are possible during any
handling, PPE must be used to prevent
workers exposure. Gowns made of
materials that protect from Hazardous
Drugs (HD) permeation and double gloves,
tested to the ASTM standard 2005, are
universally recommended for HD handling.
USP 797 requires two pair of gloves, the
outer one sterile, for compounding sterile
preparations. When wearing double
gloves, tuck the cuff of the inner glove
under the gown sleeve and the cuff of the
outer glove over the gown sleeve. Change
the outer gloves immediately whenever
contamination is suspected. Change both
gloves if the outer glove is torn, punctured
or contaminated by an obvious spill.
4
At the end of each batch, the outer gloves
should be removed and sealed in a zipper-
lock bag. Remove and discard the gown
before removing the inner pair of gloves.9
EFFECTS OF
CHEMICALS ON
GLOVES
Chemicals can penetrate, degrade, and/or
permeate through a glove. All effects can
happen at once. They can let chemicals
through to skin. To understand, we must
consider them one by one.
1. Penetration is defined as the movement
of a chemical and/or micro-organism
through porous materials, tears, pinholes
or other imperfections or manufacturing
defects in a protective glove material on a
non-molecular level. It implies that you
can see the holes.
2. Degradation is a deleterious change in
one or more properties of a material.
When degradation is caused by chemicals,
the rubber swells, softens, and weakens
and plastic shrinks, stiffens, or
becomes brittle.
3. Permeation is the process by which a
chemical moves through a protective
glove material on a molecular level. It
involves the following:
a. Adsorption of the molecules of the
chemical into the contacted or outer
surface of a material
b. Diffusion of the absorbed molecules in
the material.
c. Desorption of the molecules from the
opposite or inner surface of the material
TESTING FOR GLOVE
PERMEATION BY
CHEMOTHERAPY
DRUGS
Chemotherapy drugs can represent a
significant health risk to healthcare
personnel. Some chemotherapy drugs
have been found to be carcinogenic, to
cause chromosomal damage and may
also cause damage to normal skin and
necrosis of compromised skin. The most
common exposures are the result of
inadvertent ingestion of a drug on food,
inhalation of drug dusts or droplets or
direct skin contact. Proper training and
the use of personal protective equipment
such as suitable gloves are critical to the
safety of healthcare workers who handle
chemotherapy drugs.10
ASTM D 6978-05 is the test method
specifically designed to test breakthrough
times of cytostatic drugs on gloves. It is
defined as Standard of Practice for
Assessment of Resistance of Medical Gloves
to Permeation by Chemotherapy Drugs.11
Chemotherapy drugs used in testing molecules are attracted to lipids. A
incorporate a minimum of nine currently substance is lipophilic if it is able to
used clinical drugs
Test measurements using the thinnest
area of the glove between palm and
the cuff
Tested for up to 4 hours
Detection Limit is
0,01 g (= 10 ng) / (cm x min)
The ASTM F 739-07 Resistance of
protective clothing materials to permeation
by liquids or gazes under continuous
contact is adapted to test chemicals
breakthrough times on clothing used in
the most industrial sector of activities.
All chemicals
Test measurements using the palm of
the glove
Tested for up to 2 hours
Detection Limit is 0,1 g
Every glove may react differently in terms
of permeation and therefore assumptions
are not acceptable. Every cytostatic
molecule may react differently in terms of
permeation. Therefore, a claim as Good
for cytostatic handling is dangerous and
misleading. This is due to the physico-
chemical heterogeneity of the cytostatics.
The Universit Catholique de Louvain,
Brussels, Belgium have developed a
unique dynamic permeation device. They
have tested gloves under dynamic
physical conditions for stretching, tension,
and rubbing.12
Not all drugs or combinations of drugs can
be tested. Hence, Dr. Wallemcacks study
advised caution when working with
lipophilic and low molecular weight
cytotoxic agents. Lipophilic or 'lipid-loving'
dissolve much more easily in lipid (a class
of oily organic compounds) than in water,
i.e. Taxol, Carmustine, ThioTEPA.
The Federal Drug Agency, Oncology
Nurses Society as well as The Canadian
Pharmacist Oncology Association
recognizes the need to test gloves as per
ASTM D6978-05 method.
5
 Device chamber used for permeation test
cell ASTM F-739 within this method 13
H A N D L I N G C Y T O T O X I C D R U G S ; A H E A LT H A N D S A F E T Y R E V I E W
Products tested for permeation as per
ASTM F-739 often used in the oncology
department for disinfecting are:
70% isopropyl alcohol (IPA)
accelerated hydrogen peroxide (H2O2)
Products for decontamination are:
Hypochlorite sodium (bleach)
Sodium Thiosulfate
Mechloretamine (chlormetine).
INTERPRETING
BREAKTHROUGH TIME
Breakthrough time will measure how
quickly a chemical can permeate a glove.
It is specific for glove material type used
in the test. Thinner gloves made from the
same material will have a shorter break-
through time. For tasks with inevitable
contact, the breakthrough time is the
maximum time the glove may be used
before it should be discarded. If the work
lasts for longer than the breakthrough
time, gloves should be changed part-way
through. You should allow a safety margin:
stretching of gloves during use may mean
that breakthrough occurs more quickly
than in a test environment. Do not rely on
touch to detect breakthrough. Skin
exposure will occur long before any
perceptible feeling of wetness on the inner
surface of the glove.
6
It is important to note that:
Permeation results differ in time and
average permeation rate.
The risk posed by a chemical
permeating a glove is related not just to
the speed at which it can diffuse
through, but also the flow rate. A
combination of a short breakthrough
time and a low permeation rate may
expose a glove wearer to less chemical
than a combination of a longer
breakthrough time and a much higher
breakthrough rate, if the glove is not
changed frequently enough.
Gloves should be changed before
permeation occurs. Since permeation
breakthrough in actual end use may
occur sooner than breakthrough under
lab test conditions, a margin of safety
should be allowed when specifying
glove change intervals based on lab data.
Always check the material safety data
sheet (MSDS) for personal protective
equipment requirements in selecting
gloves specifically for the type of
chemicals used. Verify permeation time
and rate to choose the right glove.
As per ASTM F-739 in handling cleaning
compounds
As per ASTM-D6978-05 in handling
chemotherapy drugs
Permeation test chemicals mixed at any
other concentrations will cause data to be
generated that will give invalid
comparisons when matched against data
obtained using the standard
concentrations.
GLOVE SELECTION IN
HANDLING CYTOTOXIC
DRUGS
Informed use of PPE is a very critical
component of a hospitals health and
safety program. Appropriate PPE includes
gloves, gowns, face shields, masks, eye
protection, and ventilation devices where
there is likelihood of contact with
potentially contaminated material.
When choosing a glove, the first
consideration should be the barrier
requirement related to the procedure or
task at hand. Be aware of the level of
exposure risk that the patient-care
activities will require. Procedures that
involve exposure to blood, bodily fluids,
and other potentially hazardous material
require a glove material that provides
appropriate barrier protection.
When selecting a medical glove, the
primary considerations should be the
barrier protection, the fit and allergen
content. If a glove does not provide an
intact barrier, it is not doing its job. To
maximize barrier effectiveness, you may
wish to choose a glove manufacturer that
is reliable and experienced, so that your
gloves will be of consistent quality and
regularly available.
In handling chemotherapy drugs with the
current guidelines on double gloving,
insuring a proper fit to the personnel may
become a task in itself.
Glove Fit and Sizing
Having protective equipment that fits
properly is absolutely vital to the safety of
employees. Knowing how to accurately
measure and choose glove sizes can
increase safety and productivity in the
workplace.
If gloves do not fit properly, it can often
delay work or result in hand injuries. If the
hand protection is too small, it may cause
hand fatigue. If the protective material is
stretched out, it is more likely to rip or tear
during use which is costly to replace, as
well as dangerous for the wearer. Gloves
that are too small also decrease dexterity.
On the other hand, gloves that are too
large create safety issues.
It is imperative to understand how to
appropriately measure the hand in order
to get a glove that fits correctly. If the
glove fits properly, it will provide the
worker with maximum protection without
compromising dexterity.
To find the appropriate glove size, use a
tape measure to measure around the
knuckles of the dominant hand. The inch
measurement of your hand should
correspond directly to the numbered sizes
of the glove. For example, if you measure
your hand to be 8 inches, you would wear
a size 8 glove. If your hand measures over
8 inches it is wise to choose the next size
up to avoid hand fatigue or discomfort
from a glove that is too small. Some
gloves come in lettered sizes such as XS,
S, M, L, and XL. These can easily convert
to a numerical size for simple selection.
7
 See the table for numerical and lettered sizing relation.
Mens
Inch cm
XS 7 18
S 7 1/2-8 20
M 8 1/2-9 23
L 9 1/2-10 25
XL 10 1/2-11 28
H A N D L I N G C Y T O T O X I C D R U G S ; A H E A LT H A N D S A F E T Y R E V I E W
DOUBLE GLOVING
Is there a proper technique for double
gloving? While double gloving sizing
depends on individual needs, today three
practices are common. Some people find
that a larger glove inside with a smaller
one outside works for them, or vice versa
and others use the same size glove for
both inside and outside glove. The
aforementioned study published in the
European Journal of Cardiothoracic
Surgery found almost an equal distribution
of glove sizes used by surgeons for double
gloving: larger glove inside 31%, smaller
glove inside 35% and both gloves the
same size 31%.14
Donning and Doffing Gloves
Gloves made of various materials form an
important part of our safety practices.
End-users rely on gloves to protect their
hands against corrosive or toxic
chemicals, and potential infectious
pathogens. We have repeatedly
emphasized the importance of choosing
gloves made of material appropriate for
the hazardous substance(s) being handled.
Users must also consider the level of
dexterity needed for the anticipated
manipulation.
8
Women
Inch cm
XS 6 15
S 6 1/2 17
M 7 18
L 7 1/2 19
XL 8 20
The vast majority of end-users have
developed the habit of putting on gloves
for work involving hazardous substances.
However, we are now seeing a problem of
people not taking off gloves when they
really should have done so. Although
wearing gloves can prevent skin contact
with hazardous chemicals, not taking
them off at the right time may actually
turn the used gloves into a source of
contamination, and increase the risk of
hazardous chemical exposure for the
wearer and the environment. 15-16
DONNING
TECHNIQUES
There are two techniques for donning
sterile gloves, "Closed Donning" and
"Open Donning".
Closed Donning Technique
1. Peel open the outer pack from the
corners. The inner pack is sterile. Gripping
it through your gown, open it to display
the gloves.
2. With your gown covering your fingers, hand should only touch the folded cuff -
use your right hand to remove the left the rest of the glove remains sterile.
glove. Hold your left hand palm up, fingers
straight. Lay the glove on your left wrist,
and grip the cuff with your left thumb.

2. Slide your right fingertips into the folded

cuff of the left glove. Pull out the glove
and fit your right hand into it.
3. Place your right thumb inside the top
cuff edge. Make a fist with your right hand
and stretch the glove over your left
fingertips.

3. Unfold the cuffs down over your gown

sleeves. Make sure your gloved fingertips
do not touch your bare forearms or wrists.

4. Keeping your left fingers straight, pull

down the glove.

Glove Removal

The key to removing both sterile and non-

5. Repeat the above procedure to don the
other glove, that is: use your gloved left
hand to lay the right glove on your right
wrist. Slide your left thumb inside the top
of the cuff, make a fist, and stretch the
cuff over your right fingertips. Pull down
the sleeve and glove together.
sterile gloves is
"Dirty to Dirty - Clean to Clean"
Contaminated surfaces only touch other
contaminated surfaces: your bare hand,
which is clean, touches only clean areas
inside the other glove.

Open Donning Technique 1. Take hold of the first glove at the wrist.

1. Pick up the cuff of the right glove with

your left hand. Slide your right hand into
the glove until you have a snug fit over the
thumb joint and knuckles. Your bare left

9
 2. Fold it over and peel it back, turning it
inside out as it goes. Once the glove is
off, hold it with your gloved hand.
H A N D L I N G C Y T O T O X I C D R U G S ; A H E A LT H A N D S A F E T Y R E V I E W
1. With right hand, pinch palm of glove on
left hand and pull left glove down and off
fingers. Form left glove into a ball and hold
in fist of right hand.

3. To remove the other glove, place your

bare fingers inside the cuff without
touching the glove exterior. Peel the glove
off from the inside, turning it inside out as
it goes. Use it to envelope the other glove.

REMOVING
EXAMINATION
GLOVES SAFELY 2. Insert one or two fingers of left
ungloved hand under inside rim of right
As you remove the gloves, avoid allowing glove on palm side; push glove inside out
the outside surface of the gloves to come and down onto fingers and over balled
in contact with your skin, because the left glove.
outer surface may have become
contaminated. Avoid letting gloves snap,
as this may cause contaminants to fly into
your eyes or mouth or onto your skin or
other people in the area. Remove used
gloves before touching anything. Counter
tops, faucets, pens and pencils are often
contaminated because workers wearing
gloves touch them.

The following is a common way of safely

removing gloves.

10
3. Grasp gloves, which are now together
and inside out, with left hand and remove
from right hand.
4. Discard gloves in plastic bag and seal bag.
5. Wash hands thoroughly.
GLOVE
RECOMMENDATIONS
IN HANDLING
CYTOTOXIC DRUGS
Powder-free neoprene and nitrile
examination gloves tested for D6978-05
are the best recommended choices
during all activities around handling
chemotherapy drugs as they also have
better resistance to disinfecting and
decontamination products than latex.
Surgical neoprene, nitrile, natural rubber,
and polyisoprene gloves, tested using
ASTM D-6978-05, are recommended
when preparing and handling
chemotherapy drugs. Please use a
glove rated for the handling of specific
chemotherapy drugs.
Polyvinyl chloride (PVC) gloves are NOT
recommended for handling
chemotherapy drugs.
Always use powder-free gloves. The
dispersing of chemotherapy drugs into
the surrounding air and the possibility of
inhalation is a serious matter and should
be treated as such. Also, glove powders
may contaminate chemotherapy work
areas.
If double gloving, insert first glove under
the cuff and place the second glove over
the cuff. If single gloving, place the
clean glove over the cuff of the gown.
Before handling chemotherapy drugs,
always inspect gloves for holes, tears or
any type of defect. Unless the film is
intact, it cannot provide a barrier.
Although surgical gloves are
recommended for preparation,
administration, clean up and general
handling, sterility is not always required,
as for example, direct patient care,
handling laundry, and housekeeping
procedures.17 Gloves are available in
non-sterile presentations for these
purposes.
DRUG PREPARATION
Working Securely with Cytostatics
As the number of cancer patients rises, so
does the use of chemotherapy treatment.
While effective in treating disease, these
drugs are also potentially hazardous for
the oncology nurses, pharmacists and
other healthcare professionals who handle
them. Yet worldwide research indicates
that insufficient care is being taken with
cytostatic agents. Studies report
widespread, low-level contamination of
areas where cytostatic drugs are used.
Traces of cytostatic drugs have been
found on workbenches, floors, vials and
exterior surfaces of safety cabinets and
isolators even on the floor outside
preparation rooms. Once contamination
with cytostatic drugs has occurred it is
extremely difficult to eradicate.18
To better protect healthcare workers,
heightened awareness of this serious
problem must be combined with both
improved cytostatic handling procedures
and the use of appropriate hand
protection. Here is a step by step guide to
the safe preparation and administration of
11
 cytostatic mixtures, as well as
recommendations for suitable hand
protection.
Before actually preparing the cytostatic
mixture, the following activities have
been identified. These may be
influenced by ruling protocols
Don special protective clothing including
H A N D L I N G C Y T O T O X I C D R U G S ; A H E A LT H A N D S A F E T Y R E V I E W
non-sterile examination gloves.
[Photo 1]
Unpack all material. During the
unpacking or handling of the vials, the
healthcare workers hand should be
protected as the outside surface of the
vials might be contaminated with
cytostatic drugs. [Photo 2]
Disinfect the work area. [Photo 3, 4]
Assemble and disinfect all material
necessary to prepare the cytostatic
drugs. [Photo 5, 6, 7]
Similar care should be taken in the Similar
12
Similar care should be taken in the
preparation, administration and disposal of
chemotherapy drugs. In addition to
healthcare professionals, patients and
persons that are directly involved in home
care should also be taught these safety
standards and guidelines.
Always wear gloves when handling the
drug.
Avoid touching the drug.
Wash hands before putting gloves on
and after wearing gloves.
Gloves used for protection against
chemotherapy drugs must be selected.
specifically for the type of chemicals
used.
Use medical grade, sterile or non-sterile,
gloves depending on the technique
recommended by your healthcare
facility.
Always use powder-free gloves.
- Glove powders may contaminate
chemotherapy work area.
Choose a natural rubber latex, nitrile or
neoprene glove - Polyvinyl chloride
(PVC) gloves are not recommended for
handling chemotherapy drugs.
Use ASTM D6978-05 tested gloves that
extend over the cuff of the protective
gown. Please use a glove rated for the
handling of the specific chemotherapy
drugs.
Double gloving is strongly advised when
there is a risk of exposure during
preparation or administration of
chemotherapy drugs.
 - If double gloving, insert first glove under
the cuff and place the second glove over
the cuff.
Before handling chemotherapy drugs
- Observe gloves for any break in barrier.
- Change gloves after each use, tear, and
puncture or medication spill or after 30
minutes of wear.
Upon removal, both gloves need to be
turned inside out
Never flick, snap, or toss your gloves.
Follow recommendations implemented
by your healthcare facility for the
disposal of gloves.

Now you are ready for the

reconstitution of the cytostatic mixture
and transfer it to the perfusion set.
Don sterile gloves. [Photo 8, 9, 10, 11]
Disinfection of procedure material.
[Photo 12]
Reconstitution of the cystostatic mixture.
[Photo 13, 14, 15, 16] and,
[Photo 17, 18, 19, 20]
Perform a final disinfection of end product.
[Photo 21, 22]
Pack the product and label it.
[Photo 23, 24]

13
 ADMINISTERING
CYTOSTATICS TO
PATIENTS
Once the cytostatic mixture has been
prepared, it is administered to the
patient following established
guidelines. (Photo 25, 26)
H A N D L I N G C Y T O T O X I C D R U G S ; A H E A LT H A N D S A F E T Y R E V I E W
Drug Administration; Glove Use
Recommendation
Inspect glove for visible defects.
Wear high quality gloves that have been
tested for use with the specific
chemotherapy drugs to be used.
Double gloving is recommended.
Wash hands before putting on gloves.
Change contaminated gloves
immediately.
Wash hands after removing gloves.
Dispose of gloves according to proper
hospital toxic waste procedures.
14
Drug Clean Up and General Handling
Wear high quality gloves that have been
tested for use with chemotherapy drugs
when dealing with blood, vomitus,
excreta and other bodily fluids from
chemotherapy treated patients.
Discard gloves after each use.
Laundry personnel coming into contact
with linen contaminated with
chemotherapy drug patients body fluids
should wear high quality gloves that
have been tested for use with
chemotherapy drugs.
Housekeeping personnel should wear
high quality gloves that have been
tested for use with chemotherapy drugs
when handling waste containers.
Spills should only be cleaned up by
personnel wearing a double layer of
gloves.
Spill kits for use in responding to spills
should include two (2) pairs of gloves;
one outer pair of utility gloves and one
inner pair of latex or synthetic gloves.
All personnel involved in any aspect of
handling chemotherapy drugs must
receive an orientation on chemotherapy
drugs including proper use of protective
equipment.
Summary of Glove Use

AREAS OF GLOVE USE

Open packaging
Storage
Sterile drug preparation
Intramuscular or subcutaneous injections
Intravenous drug administration
Percutaneous drug administration
Oral and nasal enteral tube drug administration
Intraocular drug administration
Garbage disposal
Post drug delivery patient care delivery - 2 days
Patient care
Spills
Cleanroom housekeeping
Cabinet cleaning
Departemental housekeeping
Handling linen

15
 REFERENCES
1 http://www.who.int/gho/publications/world_health_statistics/EN_WHS2012_Full.pdf
2
American Society of health system pharmacists,2006.ASHP guidelines on handling
hazardous drugs, American journal of health system Pharmacists, 63,1172-1193
3
Occupational health and safety Administration(1999) OSHA technical manual,
H A N D L I N G C Y T O T O X I C D R U G S ; A H E A LT H A N D S A F E T Y R E V I E W

Categorization of drugs as hazardous retrieved from http://www.osha.gov/dts/osta/otm_

vi/otm_vi_2.htlm#2
4
Polovich M Ed. (2011) Safe handling of hazardous drugs (2nd ed.) Pittsburg, PA:
Oncology Nursing Society.
5
Occupational health and safety Administration(1999) OSHA technical manual,
Categorization of drugs as hazardous retrieved from http://www.osha.gov/dts/osta/otm_
vi/otm_vi_2.htlm#2
6
http://monographs.iarc.fr/ENG/Classification/index.php
7
Polovich M Ed. (2011) Safe handling of hazardous drugs (2nd ed.) Pittsburg, PA:
Oncology Nursing Society.
8
FDA Medical Glove guidance manual (2008) pg. 22-23
9
Polovich M Ed. (2011) Safe handling of hazardous drugs (2nd ed.) Pittsburg, PA:
Oncology Nursing Society.
10
National Institute for Occupational safety and health (2004) Preventing occupational
exposure to antineoplastic and other hazardous drugs in health care settings. Retrieved
from http://www.cdc.gov/niosh/docs/2004-165
11
American safety and testing method; ASTM D-6978-05 Practice for Assessment of
Resistance of Medical Gloves to Permeation by Chemotherapy Drugs (2005)
12
P.Wallemacq, PhD et al. Permeation of 13 cytotoxic agents through 13 different gloves
under controlled dynamic conditions, AJHP March 15, 2006 Vol. 63, # 6 pg. 547-56
13
Ansell 8th edition Chemical resistance guide, Permeation and degradation data pg4
14
Hollaus PH, et al. Glove perforation rate in open lung surgery. European Journal of
CardioThoracic Surgery. 1999; 15:461-464

16
15
Fransman,W.,Vermeulen,R.,Kromhout, H., Occupational dermal exposure to
cyclophosphamide in Dutch hospital: a Pilot study. Annals of Occupational Hygiene
(2004) 48,237-44
16
Fransman,W.,Vermeulen,R., Kromhout, H., Dermal exposure to cyclophosphamide in
hospitals during preparation, nursing and cleaning activities. International Archives of
Occupational and Environmental Health (2005) 78, 403-12
17
Occupational safety and health Administration (2002) Guidelines for laundry in health
care facilities retrieved from http//www.osha.gov/od/ohs/otm_vi.2.htlm
18
By Celeste Caskey, Daniel J. Hurley, Raymond R. Liguori, Assessing environmental
contamination by cytoxic drugs ; Chemical Health & Safety, September/October 2005;
26-28

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