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Frequently Asked Questions
May 16, 2012
We welcome your feedback on any of the pharmacy FAQs. Please send your comments or suggestions to Rhonda Kalyn. CHEMOTHERAPY ADMINISTRATION
CHEMOTHERAPY PREPARATION AND SAFE HANDLING
COMPLEMENTARY AND ALTERNATIVE MEDICATIONS (CAMS)
CONTACT INFORMATION
DRUG BENEFITS AND FINANCIAL SUPPORT
DRUG INFORMATION
SPECIAL ACCESS AND OTHER SPECIAL ORDERING PROCEDURES
| All rights to these materials are reserved in favour of BC Cancer Agency Branch, a branch society of the Provincial Health Services Authority. No part of this publication may be used for commercial purposes or gain, reproduced, stored in a retrieval system, or transmitted, in any form or by any means whether, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of the Provincial Health Services Authority. The recommendations in these materials were prepared by the BC Cancer Agency Pharmacy Education Team and reflect their views of currently accepted approaches to certain questions. Any reliance on these materials for any purpose is at your sole risk and expense and subject to the BC Cancer Agency’s Terms of Use. These materials are not intended to prescribe a standard of care. Nothing contained in these materials should be construed as providing professional advice. If professional advice is required, the services of a competent and qualified professional should be sought. Clinical decision making in a specific context requires the use of independent professional judgment in the context of individual clinical circumstances and remains the responsibility of attending professionals. Nothing contained in these materials should in any way be construed as being either official or unofficial policy of the BC Cancer Agency or Provincial Health Services Authority. |
CHEMOTHERAPY ADMINISTRATION
Q: How can we administer an oral cancer medication to a cancer patient who has just had an NG tube inserted? For safety reasons, we were told not to crush tablets or open capsules.
Oral cancer medications that are considered hazardous or cytotoxic should not be manipulated outside of a containment cabinet (ie. Biological Safety Cabinet) due to the risk of generating Hazardous Drug (HD) powder residue causing possible HD contamination and exposure. You may try dissolving or suspending the tablet/capsule particles in an enclosed system (i.e. syringe plus water) and administering the liquid through the NG tube.
If line occlusion occurs and impedes cancer drug administration you could consider holding the drug for a few days. For example; tamoxifen has an elimination half-life of ~ 5-7 days and the half-life of its active metabolite is ~ 9-14 days, so it is possible to hold tamoxifen therapy for ~2 weeks.
If the oral cancer medication cannot be withheld, it may be possible to compound it into a liquid dosage form. All activities likely to result in particle or aerosol generation, such as crushing tablets/capsules or compounding/pouring of oral solutions should be performed in a Biological Safety Cabinet (BSC) or Isolator. Oral solutions for hospital inpatients should be prepared in the pharmacy and dispensed to the ward in unit dose syringes. The nurses should not measure doses from a bottle.
Reference:
BCCA Division of Pharmacy. BCCA Pharmacy Practice Standards for Hazardous Drugs. 2008.
Revised 28 Jul 09 Top
Frequently asked questions about Baxter Elastomeric INFUSORS® (henceforth referred to as “Infusors”).
Q: We recently had an incident where the wrong elastomeric Infusor was selected for a patient. We had another incident where the incorrect diluent (normal saline) was selected instead of D5W. What other sources of errors should we watch for when providing elastomeric infusors to patients?
A: The following checklist can be used to help prevent rate errors from occurring with elastomeric Infusors.
Elastomeric Infusor Checklist for Rate Error Prevention 
Q: We occasionally encounter elastomeric Infusor that have either run too fast or too slow. How can we determine what caused this?
A: The following checklist can be used to determine possible causes of deviations from the expected infusion rates for elastomeric Infusors.
Elastomeric Infusor Checklist for Identifying Causes of Rate Errors
Contact Baxter (1-888-719-9955) to log an Infusor failure. You will be sent a canister for shipping the infusor to Baxter for testing.
Further information about elastomeric infusors can be found online as outlined below.
26 Jan 2012 Top
CHEMOTHERAPY PREPARATION AND SAFE HANDLING
Q: We have a pharmacy staff member who is planning to get pregnant and has requested to be removed from activities involving the preparation or checking of chemotherapy. Does the BC Cancer Agency (BCCA) have any policies which apply to this situation?
The governing regulation regarding this situation is actually from Work Safe BC. The Occupational Health and Safety (OHS) Regulation 6.49 relating to Reproductive Toxins states the following:
- At any worksite where a worker is occupationally exposed to a cytotoxic drug that is a reproductive toxin, the employer must develop policy and procedures appropriate to the risk, which may include protective reassignment
- The policy and procedures must inform workers about the reproductive toxin and identify ways to minimize exposure to the reproductive toxin for a worker who has advised the employer of pregnancy or intent to conceive a child
There are two BCCA Policies which address this situation.
Policy V-10 – Cytotoxic Agents, Safe Handling Standards states that:
It is the responsibility of Directors/ Managers and Supervisory Staff to make every effort to accommodate requests to change work assignments from staff who are pregnant, breastfeeding or attempting to reproduce.
Policy V-20 – Employee Health: Management of Risks Related to Cytotoxic Agents Regarding Pregnancy states that:
- Employees must be fully informed of the potential reproductive hazard
- It is the responsibility of the employee handling cytotoxic agents to discuss with their immediate supervisor any desired change in work assignment as a result of their pregnancy, breast-feeding or attempt to reproduce
Organizations are required to have policies and procedures in place to minimize exposure to chemotherapy and hazardous drugs for all employees at all times. Protective reassignment may not always be feasible due to staffing or other constraints. However, whenever possible, anyone who is pregnant, breastfeeding or actively trying to conceive should not handle chemotherapy or hazardous drugs. Individual employers or health authorities should be contacted for guidelines relating to the duration of time allowed for the protective reassignment of duties for someone who is attempting to conceive or is breastfeeding.
The BCCA considers each employee request for protective reassignment on an individual basis, since the circumstances of each situation can be quite varied.
Reviewed Apr 17, 2009 Top
Q: Can you recommend a respirator mask for people who are difficult to fit?
Some procedures that involve handling chemotherapy or hazardous drugs (HDs), such as full cleaning and decontamination of the biological safety cabinet (ie. whenever the BSC viewing window is raised) or HD spill clean up; require the worker to wear a particulate respirator mask. A particulate respirator mask is suitable for use with HDs if it is NIOSH-approved and has a rating of N95 or greater. The following are three different kinds of particulate respirators masks available:
- Disposable/filtering face piece respirator with built in filters
- Reusable or elastomeric respirator mask with filter attachments
- Powered Air Purifying Respirator (PAPR) masks
Disposable/filtering face piece and elastomeric1 respirators require fit testing while PAPR masks do not. A staff member who is having trouble fitting a disposable or elastomeric respirator has a couple of options:
- Try different brands. There is more than one brand of disposable/filtering face piece respirator (i.e. Kimberly-Clark and 3M) and they tend to fit differently. Or try different facial coverage (ie full vs. half face piece) for elastomeric masks.
- Obtain a PAPR with a hood or a loose-fitting face piece that does not require fit testing. This is a good option for staff members with facial hair (i.e. beards) that make them difficult to fit. Note that these are larger masks that require cleaning of non-disposable parts and require a power source to function.
References
1. BCCA Safe Handling Group/P4C. BCCA Draft Pharmacy Directive – Personal Protective Equipment, January, 2009.
Created Feb 10, 2010 Top
Q: Questions about Maximum Volumes for IV Bags and Syringes
Q: How much solution should be withdrawn from a bag before adding a cytotoxic drug?
A: The volume to be withdrawn from a bag depends on the original bag size and the volume of drug that is to be added. Solution bags are quite flexible and allow fairly large volumes to be added without difficulty. The intention of prior withdrawal is to ensure that the final volume of the bag is not so large that administration is difficult and that there is no risk of the bag rupturing. If the volume of drug to be added is small enough, no prior withdrawal is required.
The table below provides an example of guidelines for determining the volume to be withdrawn from a bag prior to adding cytotoxic drug.
|
Original Bag Volume |
Maximum Volume Addition Permitted Without Withdrawal |
Maximum Final Volume Permitted |
Maximum Final Volume Permitted
(if you factor in overfill volume) |
|
25 mL |
25 mL (100%) |
50 mL |
55 mL (overfill = 5 mL) |
|
50 mL |
25 mL (50%) |
75 mL |
80 mL (overfill = 5 mL) |
|
100 mL |
50 mL (50%) |
150 mL |
160 mL (overfill = 10 mL) |
|
250 mL |
50 mL (20%) |
300 mL |
325 mL (overfill = 25 mL) |
|
500 mL
(Braun) |
50 mL (10%) |
550 mL |
575 mL (overfill = 25 mL) |
500ml
(Baxter) |
50 mL (10%) |
550 mL |
600 mL (overfill = 50 mL) |
|
1000 mL |
100 mL (10%) |
1100 mL |
1150 mL (overfill = 50 mL) |
If drug volume to be added exceeds the maximum volume addition permitted without withdrawal, as listed above, the difference will be withdrawn. For Example; the maximum volume that can be added to a 250 mL bag is 50 mL. To add 70ml of rituximab (700mg) remove 20ml of D5W from the bag first.
Here is another option to consider for adding large volumes of drugs to a bag:
| Bag Size |
Drain Bag When |
| 250 mL |
Greater than 85 mL:
drain 250 mL from 500 mL bag |
| 500 mL |
Greater than 85 mL:
drain 500 mL from 1000 mL bag |
| 1000 mL |
Greater than 110 mL:
put into empty 2000 mL bag |
Q: What is the maximum volume that a syringe can be filled with a cytotoxic or hazardous drug?
A: Syringes should be filled to a maximum of 75% volume as illustrated in the table below.
| SYRINGE |
MAXIMUM DRUG VOLUME
(3/4 full) |
| 1 mL |
0.75 mL |
| 3 mL |
2.25 mL |
| 5 mL |
3.75 mL |
|
6 mL |
4.5 mL |
| 10 mL |
7.5 mL |
| 12 mL |
9 mL |
| 20 mL |
15 mL |
| 30 mL |
22.5 mL |
| 35 mL |
26 mL |
| 50 mL |
37.5 mL |
| 60 mL |
45 mL |
Revised May 16, 2012 Top
COMPLEMENTARY AND ALTERNATIVE MEDICATIONS (CAMS)
Q: I have several questions about Probiotics:
Please see "FAQ: Use of Probiotics During Chemotherapy Treatment" in the Systemic Therapy Update Newsletter:
- November 2011 issue, page 3
Dec 8, 2011 Top
Q: A few of my patients have asked me about flaxseed to prevent hot flushes while they are on tamoxifen. Should I recommend it?
Flaxseed has multiple mechanisms of action, and may act as a phytoestrogen. It may antagonize tamoxifen or even stimulate breast cancer growth. Explain to your patients that this is a controversial area, with limited and conflicting evidence for both efficacy and safety. Because the safety is unknown, the current BC Cancer Agency (BCCA) recommendation is cautious. We advise against the use of any phytoestrogen supplements during chemotherapy or radiation treatments. This recommendation applies to flaxseed, as well as other supplements such as black cohosh, dong quai, evening primrose, red clover, soy and others. However, food sources of phytoestrogens do not need to be restricted during treatment. Direct patients to our handout Natural Health Products and Breast Cancer for more information. Use our tamoxifen patient handout to help start a discussion on non-pharmacologic management of hot flushes.
Reviewed Apr 17, 2009 Top
CONTACT INFORMATION
Q: I would like contact information for oncology related programs.
Please see below as well as our Contact Us page.
BCCA Medical Oncology Tuesday Noon Rounds
To connect to Medical Oncology Rounds by videolink contact both of the following:
- Multimedia (for connection to BC Cancer Agency videolink rounds):
- Remy Malong (for email notification of topics for rounds):
Pharmacare
Revised Nov 30, 2010 Top
DRUG BENEFITS AND FINANCIAL SUPPORT
Q: How can I determine whether a drug is funded by the BC Cancer Agency (BCCA)?
The BCCA funds drugs that are used to actively treat cancer. The BCCA does not fund drugs that are used for supportive care purposes e.g. antiemetics, antibiotics, analgesics.
To determine whether a drug is covered by the BCCA, please refer to the BCCA Benefit Drug List, located on the BCCA website.
This document lists those drugs and their approved indications for use that are funded by the BC Cancer Agency and defines the three categories of coverage (Class I, Class II and case-by-case approved undesignated indications). The BCCA Benefit Drug List is formatted alphabetically, for ease in finding a specific drug. The document is updated on a regular basis, so it is recommended that it be accessed from the website for referral, as opposed to printed off and stored as a hard copy.
Be aware that some drugs used for active treatment of cancer, can also be used for supportive care purposes, e.g. dexamethasone for spinal cord compression or as an antiemetic; megestrol for advanced breast cancer or appetite stimulation. If used in supportive care, the prescription should be filled at a community pharmacy and the patient is responsible for cost.
Reviewed Apr 17, 2009 Top
Q: Filgrastim (G-CSF) is not on the Benefit List. Is it covered by the BC Cancer Agency (BCCA)?
Filgrastim is not on the BC Cancer Agency benefit list because it is not used for the active treatment of cancer. It is used to decrease the duration of neutropenia associated with cancer chemotherapy. However, there is a unique Pharmacare-BCCA Reimbursement program. For reimbursement, the use of filgrastim must meet specific criteria set by an expert committee from Pharmacare and BCCA. These criteria are outlined on the Filgrastim (G-CSF) Usage Form. Inpatients at CON hospitals are handled differently than outpatients, as described below. In both cases the Filgrastim Usage Form must be completed by the prescribing physician.
For Inpatients at CON Hospitals:
- If the drug is being used for one of the eligible indications, the filgrastim may be dispensed and the cost billed via OSCAR to the BCCA. The indication for filgrastim is filled in at the time of OSCAR billing. CON Hospital pharmacies are no longer required to fax Filgrastim (G-CSF) Usage Forms to the BCCA.
- For indications not listed on the Usage Form, the physician must submit an application to the Compassionate Access Program (CAP) through the CAP website. If approved the drug cost may be billed to the BCCA. If not approved, the filgrastim may be dispensed at the discretion of the hospital, but the cost will not be reimbursed by the BCCA.
For Outpatients at CON Hospitals:
- Outpatients are responsible for the cost of the drug as outlined below
- The completed Filgrastim (G-CSF) Usage Form must be faxed to Pharmacare
- If the drug is being used for an eligible indication, the patient may fill the prescription at a community pharmacy. The cost of the drug will count towards the patient’s annual Pharmacare deductible (if they have one).
- Patients should also be directed to check for third party coverage. The Patient and Family Counselling department at BC Cancer Agency centres may be contacted to advise in this process
- Patients who need assistance in paying for the drug may contact Amgen’s Victory Program who may be able to provide assistance depending on the patient’s financial status. Anyone may contact the program on behalf of the patient. It is important that this program is contacted before a prescription is filled. It does not provide retroactive reimbursement. See page 4 of the Patient Assistance Programs document for further information on the Amgen Victory Program.
Revised June 2, 2009 Top
Q: What programs are available to provide financial aid to cancer patients?
The Financial Information section of the BC Cancer Agency website contains information on obtaining financial assistance for cancer patients for the following topics:
- medical costs/equipment
- income loss
- childcare expenses
- financial
- Assistance for prescription drug costs
A brief overview of financial assistance for prescription drug costs is also covered below:
The Financial Support Drug Program (formerly Emergency Aid Drug program) is a joint partnership between the BC Cancer Agency (BCCA) and the Canadian Cancer Society (CCS), BC and Yukon division. This program was established to assist cancer patients with the cost of symptom management medications. The Canadian Cancer Society determines the patient’s financial eligibility. BCCA provides funding and identifies eligible medications. Please see the Financial Support Drug Program (FSDP) section of the BCCA website for more information, including a drug benefit list.
The BC Palliative Care Benefits Program is administered through the Fair Pharmacare Program. This program supports and enables individuals in the end-stage of any life-threatening illness or disease to remain at home by covering the cost of medication, medical supplies and equipment all at no charge to the patient. Please see the BC Palliative Care Benefits Program for:
- a physician guide (including the palliative care formulary)
- patient information sheet
- BC Palliative Care Benefits Program application form
Patient Assistance Programs
Please see the BCCA Patient Assistance Programs document for information about funding provided by some pharmaceutical manufacturers to assist patients in purchasing certain cancer drugs.
For those patients who require financial assistance beyond that availble through other sources, additional funding may be available through the regional Cancer Centres. Contact the Patient and Family Counselling Department at the nearest Cancer Centre for further information.
Updated Sep 23, 2010 Top
Q: Is it possible to obtain coverage for low molecular weight heparin (LMWH) for treatment of venous thromboembolism (VTE) in cancer patients?
Please see "Focus on: Low Molecular Weight Heparin for Treatment of Venous Thromboembolsims (VTE) – Pharmacare Coverage" in the Systemic Therapy Update Newsletter:
Top
DRUG INFORMATION
Q: I have several questions about taking corticosteroids with chemotherapy
Please see "Frequently Asked Questions: Corticosteroid Use During Chemotherapy" in the Systemic Therapy Update Newsletter:
- July-August 2008 issue, page 1.
Top
Q: What is the difference between dose-dense and dose-intense chemotherapy?
Dose-dense chemotherapy refers to a chemotherapy treatment plan where the interval between successive treatments is reduced when compared to a standard regimen. An example of this would be the BCCA protocol BRAJACTG (Adjuvant Therapy for Breast Cancer Using Dose Dense Therapy: Doxorubicin and Cyclophosphamide followed by Paclitaxel). The drugs given in this protocol are given in the same dose on a two week schedule rather than the standard three week treatment schedule of BRAJACT. Various dose-dense treatment regimens are being investigated as a way to improve survival benefit. Dose-dense chemotherapy also implies that the overall length of the chemotherapy period is reduced. There is increased concern about toxicity with dose-dense chemotherapy regimens, including neutropenia, for which filgrastim (G-CSF) is considered.
It is not common to refer to dose-intense chemotherapy, but rather to refer to the dose intensity of chemotherapy. Dose intensity is defined as the amount of drug delivered per unit of time, expressed as mg/m2/week, regardless of the schedule or route of administration. This is simply a method of comparing total dose given over a period of time between or among treatment protocols. Specific calculations can be made that then describe the intended dose intensity, the dose intensity of a treatment protocol, or the actual dose intensity received by the patient of a specific treatment regimen. These descriptions are based on the calculation of relative dose intensity (RDI), which is the amount of drug delivered per unit of time relative to an arbitrarily chosen standard. A reduction in dose intensity may negatively effect patient survival, particularly in those with potentially curable malignancies. There may be some variation in how these definitions are interpreted and examples of studies referring to dose-intense chemotherapy can be found in the literature.
Reviewed Apr 22, 2009 Top
Q: Should a breast cancer patient use a progestin releasing IUD?
There are two kinds of IUDs available: copper and levonorgestrel-releasing. In general, breast cancer patients should avoid the use of levonorgestrel-releasing IUDs. This is especially true for patients whose tumour was estrogen receptor and/or progesterone receptor positive. The answer is less clear for ER and PR negative tumours; however since there is no clinically significant difference in pregnancy rate between the copper IUD and the levonorgestrel-releasing IUD the copper IUD would be the choice with the least risk.
The levonorgestrel-releasing IUD, MIRENA®, contains 52 mg of levonorgestrel. Although the hormonal effect is primarily on the endometrium, there is a low detectable serum concentration which can be quite variable among patients, and enough to cause systemic adverse effects in some patients. This has the theoretic potential to promote metastatic tumour growth, especially in hormone sensitive tumours.
Therefore, a copper IUD is suggested for breast cancer patients choosing an IUD for contraception. The levonorgestrel-releasing IUD should not be used.
Sep 13, 2011 Top
Q: Is the amount of ethanol in either a PACLitaxel or a DOCEtaxel infusion enough to trigger a relapse in a patient who is currently abstinent after treatment for alcoholism?
Ethanol is used as the solvent for PACLitaxel and DOCEtaxel for injection. The amount of ethanol contained in an infusion varies depending on the dose of the taxane used.
For reconstituted PACLitaxel the concentration of ethanol is 396 mg/ml.1 For a typical dose of 175 mg/m2 IV infused over 3 hours, a person with a BSA of 1.7 m2 would receive close to 20 g of ethanol or about 6.5 g per hour. This is the equivalent of about one-half of a typical alcohol containing beverage each hour. (From CMA: one drink contains 13.6 g ethanol). For the weekly PACLitaxel dosing of 80 mg/m2 an average sized person would receive about 9 g of ethanol in one hour. There is the potential for patients to experience some CNS impairment from PACLitaxel infusions, especially in the alcohol naïve, when large volumes are required or during shorter infusion times.
There is also the potential to precipitate a relapse in a treated alcoholic patient. The risk is low, but present. The decision to use PACLitaxel should be based on clinical judgement of the benefits verses risks and with the full understanding of the patient. If the decision is to use PACLitaxel, the patient requires regular assessment about whether they are triggered, and if so switched to another treatment immediately. If sobriety has been short, the potential for relapse is higher and again an alternate treatment should be used. If this is not possible, an addiction specialist should be consulted.
DOCEtaxel infusions at typical doses contain less ethanol than PACLitaxel infusions. For example a 170 mg dose of DOCEtaxel would contain about 1.5 g – 3 g ethanol infused over one hour (depending on the manufacturer). With this amount of ethanol it is not expected that patients would experience the effects of CNS depression. The likelihood that a relapse would be triggered in a sober alcoholic is less than with PACLitaxel, but the possibility does still exist. Therefore, regular follow-up would still be required.
As a point of interest, nab-PACLitaxel does not contain ethanol.
Reference:
1. PACLitaxel Monograph page 5: BCCA Cancer Drug Manual. http://www.bccancer.bc.ca/HPI/DrugDatabase/DrugIndexPro/Paclitaxel.htm. Accessed August 3, 2011.
September 13, 2011 Top
SPECIAL ACCESS AND OTHER SPECIAL ORDERING PROCEDURES
Q: What is the process for obtaining REVLIMID® (lenalidomide)?
Please see "Frequently Asked Question - Pharmacy Access to Lenalidomide" in the Systemic Therapy Update Newsletter:
Q: Is it possible to transfer a special access drug from one facility to another?
The Special Access Program (SAP) was created by Health Canada (HC) to provide drugs not marketed in Canada to Canadian practitioners for treatment, diagnosis or prevention of serious or life-threatening conditions when conventional therapies have been considered and ruled out, have failed, are unsuitable, and/or unavailable. Drugs requested for access via the SAP will only be authorized to be shipped to hospital in-patient pharmacies, hospital blood banks, nuclear medicine departments or the requesting practitioner’s office.
HC advises that SAP drugs may be transferred to another location under certain circumstances:
1. For treatment of the same patient at a different facility:
- If the initial physician who has ordered the drug is comfortable shipping the drug to another facility for dispensing or treatment of the patient, and is comfortable retaining responsibility for care of that patient, no paperwork is required by HC. HC would ultimately seek any information regarding the drug from the responsible physician. This would be a professional judgment by the physician i.e. taking responsibility of drug treatment in a patient, when the patient is in another facility and being treated through another physician
- If the initial physician prefers to transfer responsibility of care for the patient to a second physician in another location, HC must be notified. In this case, the second physician must submit an SAP form to HC. However, in the quantity section of the form, the amount of drug to be transferred (i.e. vials/ tabs) must be specified, and it must be clearly marked that no additional supply is required ( i.e. by checking the box). If authorized by HC, the request is forwarded to the manufacturer for approval. Once confirmed, HC notifies the second physician that the transfer is authorized.
2. For treatment of a different patient at a different facility:
- If the original patient is no longer receiving the SAP drug, it can be transferred to another facility for a different patient. The physician ordering the drug for the new patient must submit an SAP form to HC. However, in the quantity section of the form, the amount of drug to be transferred (i.e. vials/ tabs) must be specified, and it must be clearly marked that no additional supply is required. If authorized by HC, the request is forwarded to the manufacturer for approval. Once confirmed, HC notifies the second physician that the transfer is authorized.
3. Future Use Drugs for more than one facility:
- SAP drugs are sometimes used in acute settings where their use is unpredictable. An example is hyaluronidase used for treatment of extravasation caused by chemotherapy. If HC determines that a drug is appropriate for future use access, they will allow one facility to order in stock of the drug for distribution to other facilities. For example, a buying group for a health authority can order hyaluronidase stock and distribute it to the hospitals located within the health region. The ordering practitioner will be required to account for all SAP drug requested and received. Each facility must keep track of the names of patients who receive hyaluronidase and this information must be submitted to the SAP with the subsequent order.
HC and/or the manufacturer can refuse the request to transfer SAP drugs to other facilities.
References:
1. Health Canada Special Access Program (SAP). Guidance for Industry and Practitioners: Special Access Programme for Drugs. Available at: http://www.hc-sc.gc.ca/dhp-mps/acces/drugs-drogues/index-eng.php#factsheets. Accessed Jun 2, 2009.
2. Health Canada Special Access Program (SAP). Transfer of SAP drug from one facility to another: E-mail recieved May 21, 2009
Revised July 28, 2009 Top
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