DOXOrubicin liposomal mix-up

At an outpatient infusion center, a patient coming in for an IV dose of conventional DOXOrubicin HCl 50 mg was given DOXOrubicin HCl liposome injection (DOXIL or generic equivalent) by mistake. The pharmacy prepared the dose, and a nurse administered it via IV push. Whereas DOXOrubicin HCl can be administered IV push via a running IV line, the liposomal product should not be administered undiluted or by IV push due to the risk of infusion reactions. The patient experienced an infusion reaction with flushing, vomiting, and hypotension. The infusion was stopped, and the patient received methylPREDNISolone and prochlorperazine.

Since 1996, we have been warning practitioners about accidental administration of the liposomal form of DOXOrubicin instead of the conventional form, DOXOrubicin HCl. The Doxil product is marked, “Liposomal Formulation—Do Not Substitute for DOXOrubicin HCl,” in a red color band on the front label panel. Below that, the label states, “For Intravenous Infusion Only.” Still, mix-ups occur, resulting in severe side effects, and even death.

These drugs should never be substituted for one another on a “mg for mg” basis. All staff handling chemotherapy need to be aware of the consequences of confusing DOXOrubicin liposome injection with conventional DOXOrubicin, and vice versa. In the pharmacy, store these products in separate areas from one another. Include the potential for mix-ups in continuing educational programs. Special quality control checks need to be in place, including independent checks by at least two healthcare professionals, and a system of documenting all drugs, diluents, lot numbers, and expiration dates for each patient. Encourage staff to refer to all liposomal products by their brand names.