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Risk of confusion between cytarabine and liposomal cytarabine (Depocyte)

Rapid Response Report: Risk of confusion between cytarabine and liposomal cytarabine (Depocyte®) - thumbnail image
Reference number
1027
Central Alert System (CAS) reference
Rapid Response Report 1
Issue date18 June 2007
DH Gateway reference
8396
TypeAlert

This Rapid Response Report alerts staff involved in the preparation and administration of intrathecal cytarabine to the potential for confusion between two similar preparations of the drug. Both are chemotherapy medicine products.


The two licensed preparations are cytarabine (standard form) and liposomal cytarabine (Depocyte®), the newer long-acting formulation. Other preparations of cytarabine injection are available but are not licensed to be administered by the intrathecal route.


Possible confusion between the two licensed cytarabine products for administration by the intrathecal route can lead to:


  • over dosing or under dosing, because the dose frequencies of the two licensed cytarabine products are different;
  • induction of severe acute arachnoiditis due to the use of lyposomal cytarabine (Depocyte®) without concomitant administration of a steroid.

The chief pharmacists of healthcare organisations should:

  • ensure that medical, nursing and pharmacy staff involved in intrathecal chemotherapy are aware of the potential risk; and
  • take local actions to minimise potential risk.
Although the deadline for actions has passed, this guidance remains best practice. It should be followed to prevent future patient safety incidents.
Cytarabine and liposomal cytarabine - Rapid Response Report
Cytarabine and liposomal cytarabine - Rapid Response Report - 62 KB 1027 - Cytarabine and liposomal cytarabine - Rapid Response Report - 2007-06-18 - V1