Current through Register Vol. 49, No. 9, September, 2024
REGULATION
38
NUCLEAR PHARMACY
The practice of nuclear pharmacy is hereby recognized as a
specialty of pharmacy practice regulated by the Arkansas State Board of
Pharmacy. As such, the following rules are included to address those areas
specific or unique to this specialty practice. These regulations are intended
to supplement the regulations of other state and federal agencies.
Definitions:
A. "Authentication of Product
History"-Identifying the purchasing source, the ultimate fate, and any
intermediate handling of any component of a radiopharmaceutical or other
drug.
B. "Nuclear Pharmacy"-A
pharmacy which provides radiopharmaceutical services, and shall be licensed by
the Arkansas State Board of Pharmacy.
C. "Practice of Nuclear Pharmacy"-A
patient-oriented service that embodies the scientific knowledge and
professional judgement required to improve and promote health through the
assurance of the safe and efficacious use of radiopharmaceuticals and other
drugs.
D. "Qualified Nuclear
Pharmacist"-A pharmacist who holds a current license issued by the Board of
Pharmacy, and who is certified as a Nuclear Pharmacist by a Certification Board
recognized by the Arkansas State Board of Pharmacy, or satisfies each of the
following requirements:
1. Meets minimal
standards of training for status as an authorized user of radioactive material,
as specified by the Arkansas Department of Health, Division of Radiation
Control and Emergency Management of the Nuclear Regulatory
Commission.
2. Has successfully
completed a minimum of 200 contact hours of instruction in nuclear pharmacy and
the safe handling and use of radioactive materials from a College of Pharmacy
approved by the Arkansas State Board of Pharmacy, or other training program
recognized by the Arkansas State Board of Pharmacy, with the minimum 200 hours
apportioned as follows:
a. Radiation Physics
and Instrumentation
b. Radiation
Protection
c. Mathematics
pertaining to the use and measurement of radioactivity
d. Radiation Biology
e. Radiopharmaceutical Chemistry
3. Has attained a minimum of 500
hours of clinical/practical nuclear pharmacy training under the supervision of
a qualified nuclear pharmacist in, but not limited to, the following areas:
a. Procuring radioactive materials
b. Compounding radiopharmaceuticals
c. Performing routine quality control
procedures
d. Dispensing
radiopharmaceuticals
e.
Distributing radiopharmaceuticals
f. Implementing basic radiation protection
procedures
g. Consulting and
educating the nuclear medicine community, pharmacists, other health
professionals, and the general public.
4. Has submitted an affidavit of experience
and training to the Board of Pharmacy.
E. "Quality Assurance Procedures"-All
activities necessary to assure the quality of the process used to provide
radiopharmaceutical services, including authentication of product history and
maintenance of all records as required by pertinent regulatory
agencies.
F. "Quality Control
Testing"-The performance of chemical, biological and physical tests on
compounded radiopharmaceuticals and the interpretation of the resulting data to
determine their suitability for use in humans and animals.
G. "Radiopharmaceutical"-Any drug which
exhibits spontaneous disintegration of unstable nuclei with the emission of
nuclear particles or photons and includes any non-radioactive reagent kit or
nuclide generator which is intended to be used in the preparation of any such
substance but which does not include drugs such as carbon-containing compounds
or potassium-containing salts which contain trace quantities of naturally
occurring radionuclides. The term also includes any biological product, which
is labeled with a radionuclide or intended solely to be labeled with a
radionuclide.
H.
"Radiopharmaceutical Services"-The procurement, storage, handling, compounding,
preparation, labeling, quality control testing, dispensing, distribution,
transfer, record keeping, and disposal of radiochemicals, radiopharmaceuticals,
and ancillary drugs, and also includes quality assurance procedures,
radiological health activities, and consulting activities associated with the
use of radiopharmaceuticals, health physics, and any other activities required
for provision of pharmaceutical care.
General Requirements for Pharmacies Providing
Radiopharmaceutical Services
A. A permit to operate a nuclear pharmacy,
providing radiopharmaceutical services, shall only be issued to a facility
employing a qualified nuclear pharmacist. All personnel performing tasks in the
preparation and distribution of radiopharmaceuticals and ancillary drugs shall
be under the direct supervision of a qualified nuclear pharmacist, who shall be
in personal attendance when the nuclear pharmacy is open for business. The
pharmacist-in-charge shall be responsible for all operations of the nuclear
pharmacy.
B. The permit to operate
a nuclear pharmacy is effective only so long as the nuclear pharmacy also holds
a current Arkansas Department of Health or Nuclear Regulatory Commission
license.
C. Nuclear pharmacies
shall have adequate space and equipment, commensurate with the scope of
services required and provided. All pharmacies handling radiopharmaceuticals
shall include, but not be limited to, the following areas: radiopharmaceutical
preparation/dispensing area; radioactive material shipping/receiving area;
radioactive material storage area; and radioactive waste decay area. The
application for a permit to operate a nuclear pharmacy shall include detailed
floor plans and no material change may be made without the permission of the
Board.
D. The nuclear pharmacy
professional service area shall be secured from unauthorized personnel and
must.be totally enclosed and lockable.
E. Nuclear pharmacies shall maintain records
of acquisition, inventory and disposition of all radioactive materials in
accordance with Board and Arkansas Department of Health or Nuclear Regulatory
Commission statutes and regulations.
F. Nuclear pharmacies shall compound and
dispense radiopharmaceuticals in accordance with accepted standards of
radiopharmaceutical quality assurance. The Board of Pharmacy recognizes that
the preparation of radiopharmaceuticals involves the compounding skills of the
nuclear pharmacist to assure that the final drug product meets accepted
professional standards.
G. A
radiopharmaceutical shall be dispensed only to a licensed practitioner
authorized by the Arkansas Department of Health or Nuclear Regulatory
Commission to possess, use, and administer such drug. A radiopharmaceutical
shall be dispensed only upon receipt of a prescription or medication order from
such licensed practitioner. Otherwise, a radiopharmaceutical may be transferred
to a person who is authorized to possess and use such drug for non-clinical
applications.
H. A nuclear
pharmacy, upon receipt of an oral prescription order for a radiopharmaceutical,
shall immediately have the prescription order reduced to writing, or recorded
in a data processing system, which writing or record shall contain at least the
following:
1. the name of the institution and
prescriber, or prescriber's agent;
2. the date of dispensing and the calibration
time of the radiopharmaceutical;
3.
the name of the procedure;
4. the
name of the radiopharmaceutical;
5.
the dose or quantity of the radiopharmaceutical;
6. the serial number assigned to the order
for the radiopharmaceutical;
7. any
specific instructions;
8. the
initials of the person who dispensed the order.
Orders for routine diagnostic radiopharmaceuticals, which have
been previously established by the nuclear pharmacist with the physician, may
be taken by a pharmacy technician and entered into the computer. The nuclear
pharmacist shall verify the label with the written order. However, whenever an
order is for a therapeutic or blood-product radiopharmaceutical, the
prescription order must be received by a nuclear pharmacist and the patient's
name must be obtained and recorded prior to dispensing.
I. The immediate outer container
shield of a radiopharmaceutical to be dispensed shall be labeled with:
1. the name and address of the
pharmacy;
2. the name of the
prescriber;
3. the date of
dispensing;
4. the serial number
assigned to the order for the radiopharmaceutical;
5. the standard radiation symbol;
6. the words "Caution Radioactive
Material";
7. the name of the
procedure;
8. the radionuclide and
chemical form;
9. the amount of
radioactivity and the calibration date and time;
10. if a liquid, the volume;
11. if a solid, the number of items or
weight;
12. if a gas, the number of
ampoules or vials;
13. molybdenum
99 content to USP limits; and
14.
the name of the patient or the words "Per Physician's Order" in the absence of
a patient name. The requirements of this sub-section shall be met when the name
of the patient is readily retrievable from the physician upon demand.
When the prescription is for a therapeutic or blood-product
radiopharmaceutical, the patient name shall appear on the label prior to
dispensing.
J.
The immediate inner container label of a radiopharmaceutical to be dispensed
shall be labeled with:
1. the standard
radiation symbol;
2. the words
"Caution Radioactive Material";
3.
the identity of the radionuclide;
4. the chemical form;
5. the name of the procedure; and
6. serial number of the
radiopharmaceutical.
K.
When a radiopharmaceutical is dispensed under the authority of an
Investigational New Drug Application (IND), the nuclear pharmacy records shall
include an investigator's protocol for the preparation of the
radiopharmaceutical, a copy of the Institutional Review Board approval form (or
letter), and a letter from the manufacturer (sponsor) indicating that the
physician requesting the radiopharmaceutical is a qualified
investigator.
L. Each nuclear
pharmacy shall have a current copy of state and applicable federal regulations
governing the safe storage, handling, use, dispensing, transport, and disposal
of radiopharmaceuticals.
Minimum Equipment:
The professional area of the pharmacy shall have the following
equipment:
A. Radionuclide Dose
Calibrator;
B.
Refrigerator;
C. Single or multiple
channel scintillation counter with well-type Nal(TI) or Ge(Li)
detector;
D. Radiochemical fume
hood and filter system with suitable air sampling equipment;
E. At least two GM survey meters (including
one high-range meter);
F.
Microscope and hemacytometer;
G.
Supplies to perform quality assurance testing;
H. Syringe and vial radiation
shields;
I. Lead-shielded drawing
station;
J. Decontamination
supplies;
K. Supplies to perform
quality assurance testing;
L. Lead
transport shields for syringes and vials; and
M. D.O.T. approved USA Type A, 7A approved
transport containers and other labels and supplies for shipping radioactive
materials. (10/14/98)