title: Evaluation of osmolality and pH of various concentrations of methotrexate, cytarabine, and thiotepa prepared in normal saline, sterile water for injection, and lactated Ringer's solution for intrathecal administration.
abstract: BACKGROUND
  Neurotoxicity of intrathecal (IT) chemotherapy has been variously attributed to the preservatives, volume, osmolality, and pH of the preparations. There has been little evaluation of how different drug concentrations or diluents can affect the osmolality and pH of the final solution. We conducted a three-part study: survey of cancer centers regarding the drug concentrations and diluent used in preparing IT chemotherapy; review of the literature on common practice of preparing IT chemotherapy; evaluation of the pH and osmolality of commonly used chemotherapy preparations for IT.
  
  
  METHODS
  We surveyed selected cancer centers to provide information on their standard volume, drug concentrations, and choice of diluents. MEDLINE was searched for clinical reports using the MeSH terms of 'cytarabine,' 'methotrexate,' or 'thiotepa' with the subheading 'Cerebrospinal fluid' and combined with 'intrathecal' in all database fields. Data retrieved included the choice of diluent, volume, and/or drug concentration. We evaluated the pH and osmolality of methotrexate (1, 2, 5, and 10 mg/mL), cytarabine (2, 5, 10, and 25 mg/mL), and thiotepa (1, 2, and 5 mg/mL) in normal saline, sterile water for injection (SWFI), and lactated Ringer's solution.
  
  
  RESULTS
  Nine centers were surveyed (seven in Canada, one in Australia, one in United Kingdom). Most centers used 5 mL of preservative-free normal saline, irrespective of the drug or drug concentration used. Forty-four reports in the literature were reviewed. Most reported 5 mL of preservative-free normal saline. Most information on drug concentrations was provided for methotrexate, with an average concentration of about 1-2.5 mg/ mL. Cytarabine 0.4-20 mg/mL and thiotepa 1 mg/mL were also reported. In our in vitro evaluation, there was a trend of increased pH associated with increasing concentration of methotrexate and cytarabine. There was no apparent impact of thiotepa concentration on the pH values of the final preparations, irrespective of the diluent used. Except for cytarabine 10 and 25 mg/mL, all the tested solutions have pH within 10% of the physiologic range of CSF. There was a concentration-dependent change in osmolality with methotrexate and cytarabine preparations. Osmolality was increased with increased concentrations in all except methotrexate mixed in SWFI and thiotepa mixed in normal saline and lactated Ringer's solution. Except for some thiotepa solutions, all the tested solutions have osmolality within 10% of the physiologic range of CSF.
  
  
  CONCLUSIONS
  There is limited published literature on the potential impact of diluent and drug concentration on the pH and osmolality of IT chemotherapy preparation. Most cancer centers conventionally prepare IT chemotherapy with 5 mL of preservative diluent normal saline, irrespective of the specific drug or dose used. The conventional practice means that most methotrexate preparations are likely to have comparable pH and osmolality to CSF. In contrast, cytarabine preparations may show significantly higher pH than the CSF, while thiotepa preparations generally have lower osmolality than the CSF.
authors.affiliation: Provincial Systemic Therapy Program, BC Cancer Agency, Vancouver, BC, Canada. mdelemos@bccancer.bc.ca
authors.forename: Mário L
authors.initials: ML
authors.lastname: de Lemos
authors.forename: Shirin
authors.initials: S
authors.lastname: Monfared
authors.forename: Tetyana
authors.initials: T
authors.lastname: Denyssevych
authors.forename: Linda
authors.initials: L
authors.lastname: Hamata
authors.forename: Sarah
authors.initials: S
authors.lastname: Jennings
authors.forename: Brian
authors.initials: B
authors.lastname: Thiessen
authors.forename: Sharon
authors.initials: S
authors.lastname: Smith
authors.forename: Dawn
authors.initials: D
authors.lastname: Waterhouse
mesh_terms: D000970:Antineoplastic Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000737:chemistry; D002173:Cancer Care Facilities; D002626:Chemistry, Pharmaceutical; D003561:Cytarabine / Q000008:administration & dosage / Q000009:adverse effects / Q000737:chemistry*; D003625:Data Collection; D006863:Hydrogen-Ion Concentration; D007278:Injections, Spinal; D007552:Isotonic Solutions / Q000737:chemistry; D008727:Methotrexate / Q000008:administration & dosage / Q000009:adverse effects / Q000737:chemistry*; D009994:Osmolar Concentration; D014677:Pharmaceutical Vehicles / Q000737:chemistry; D000077325:Ringer's Lactate; D012965:Sodium Chloride / Q000737:chemistry; D013852:Thiotepa / Q000008:administration & dosage / Q000009:adverse effects / Q000737:chemistry*; D014867:Water / Q000737:chemistry
chemical_list: D000970:Antineoplastic Agents; D007552:Isotonic Solutions; D014677:Pharmaceutical Vehicles; D000077325:Ringer's Lactate; D003561:Cytarabine; D014867:Water; D012965:Sodium Chloride; D013852:Thiotepa; D008727:Methotrexate