Methotrexate for ectopic pregnancies: a national survey on pharmacy practice

Context
Methotrexate (MTX) is one of the treatments for ectopic pregnancy (EP). There is no suitable ready-to-use speciality on the market. MTX is a cytotoxic product and must be handled in accordance with the regulations. MTX doses are mainly prepared in cytotoxic preparation units (CPU) either on demand or in advance with reserve stocks. As the lack of supplies during on-call hours is a recurrent event that puts our department in difficulty, we wanted to study the different practices in other university hospitals (UH) for this preparation in order to improve our process.

Objectives
To identify the daytime and on-call management of MTX preparations for EP. To identify the elements distinguishing UH reporting dysfunctions (D) from the others.

Material and methods
Conduct of a telephone questionnaire with 28 university hospitals (interns or PCU pharmacists) detailing the following elements: daytime process, on-call process, use of preparations in advance, prepared dosages, element triggering a preparation, main storage place, notion of D.

Results
25 UH responded. During the day, 21 prepare MTX in PCU: 11 in advance and 10 on demand; the other 4 in the ward by the nurse. During on-call hours, 13 use advance preparation, 7 use preparation in the ward by the nurse, 3 use Metoject® and 2 use preparation on demand by the on-call intern and/or pharmacist. For the 13 UH that use advance preparation, the prepared doses range from 40 mg to 125 mg. The sector responsible for monitoring is mainly the PCU (10 UH). For 2 UH, the monitoring of stock is carried out by the preparation department and 1 UH by the pharmacy (distribution sector). The trigger for the preparation of a batch is: the dispensing of a syringe by the pharmacy or the PCU (6), a minimum stock level reached (3), the administration of a syringe (3), the administration of the entire stock (1). Finally, 4 university hospitals reported the notion of D on their process, such as: late renewals, weekends without stock.

Discussion
The points that we identified as being at risk of D are: a production dependent on a report by the ward (a factor present in 100% of the UH with D), the intervention of an intermediary sector between the care ward and the PCU for the monitoring of stock (66% of D for these UH). As a result, in our hospital, the PCU became the sector responsible for monitoring, and we also reduced the stock of the care ward by associating it with the constitution of a second stock within the PCU, allowing a new syringe to be dispensed as soon as it is administered. The preparation of a batch can thus be triggered as soon as a certain threshold is reached for the PCU stock without waiting for a request from the care ward.

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