With a dosimeter clipped to her lab coat and another one on her finger, preparing radiopharmaceuticals behind lead shielding is just another day at the office for Allegra L. DePietro, RPh, MS, BCNP.
As the Nuclear Pharmacy Manager at Boston’s Massachusetts General Hospital, DePietro prepares radiopharmaceuticals and adjunct imaging agents that result in 75 to 125 patient doses each day that are used for nuclear medicine diagnostic scans. She is also involved with broader hospital-wide initiatives like ensuring compliance with Joint Commission medication management standards, outwitting isotope shortages, and participating in clinical trials with investigational radiopharmaceuticals and other medications.
DePietro and a group of three other nuclear pharmacists are located in the hospital, which is a somewhat unique situation. Most hospitals use a commercial nuclear pharmacy to prepare radiopharmaceuticals, which are then shipped to the hospital for patient use.
Working inside Mass General “allows us to have face-to-face interactions all day long with physicians, nuclear medicine technologists, and other health care professionals,” said DePietro. “We’re right there to [provide information about] doses or make adjustments to radiopharmaceuticals in case a physician wants a different dose or volume, or a medication customized, such as having a capsule dissolved. We’re interacting with health care professionals constantly and are really an integral part of the health care team.”
DePietro provides support for patients in the general nuclear medicine and nuclear cardiology departments, as well as for the hospital’s Thyroid Associates practice, where she mixes up radioactive iodine for the treatment of thyroid cancer and hyperthyroidism. DePietro’s patients are mostly outpatients, although there are some inpatients.
It takes around 1 to 4 hours to complete a diagnostic scan. The nuclear medicine department performs bone scans to look for metastases primarily from breast cancer and prostate cancer, although patients occasionally come in with a stress fracture in the bone or osteomyelitis. The team also performs lung scans to look for pulmonary embolism and cardiac stress scans to look for ischemia or infarction in the heart.
“The nuclear medicine studies are noninvasive studies,” DePietro told Pharmacy Today. “We’re getting functional information from the patient, as compared to a CT scan or magnetic resonance imaging [MRI] where you get information about structure and anatomy.”
The equipment used to perform the imaging studies is more open than a CT or MRI machine. “There’s a camera on each side of the patient—one above and one below or in an L-shape around the patient—and the cameras rotate around or move up and down the patient’s body,” said DePietro. With nuclear medicine studies, “the radiation is in the radiopharmaceutical that is injected into the patient, and the camera images what is going on in the body based on where the radiopharmaceutical localizes,” DePietro explained.
DePietro begins her day around 6:00 am. She spends about 4 to 6 hours preparing all of the radiopharmaceuticals needed for the day. “Our drugs are only good for about 12 hours, so every day we have to make everything fresh,” said DePietro.
Although patient counseling is not a primary component of her job, DePietro makes a special point to talk to patients who come in for complex procedures. For example, there is a study where patients receive radioactive iodine, but “we do not want the radioactive iodine to go to the patient’s thyroid. We have to pretreat them with nonradioactive iodine to protect their thyroid. I explain to them how to take that properly,” said DePietro.
She also counsels patients with bone metastases who come to the department for pain therapy with samarium Sm 153. “I’ll talk to the patient about what pain medication they are already taking and describe what they can expect from samarium 153,” she explained. There is also a radiation safety aspect to the samarium 153 therapy. “Over the next few days, the patient will need to follow a set of precautions because radiation will be in their urine and blood. They need to know how to handle that properly,” said DePietro.
At the end of each day, DePietro reviews all medication orders for scans that are scheduled for the next day. She checks the electronic medical records to see if patients have any allergies or drug interactions, or if they have had a recent scan that will interfere with their scheduled exam. “We usually have to wait 2 days between nuclear medicine scans to give the activity time to decay—longer if the patient has been treated with radioactive iodine,” DePietro explained.
DePietro developed and implemented this medication order review process in 2007. The pharmacists make about two interventions per day in the general nuclear medicine department, she noted. “We want to identify any issues that will interfere with getting a quality scan prior to administering any medication to the patient to ensure that diagnosis and treatment is not delayed and to avoid [an] extra radiation dose to the patient from having to repeat a study,” she said.
In addition to preparing doses and working with patients, DePietro is also involved with several clinical trials. “Getting to work with and treat patients with an investigational drug before it’s been approved is one of my favorite parts of my job,” she explained. DePietro is currently working on an expanded access trial of radium Ra 223, which will be used for the treatment of bone metastases in patients with prostate cancer. “This is an alpha emitter, which is new to nuclear medicine,” she added.
One of the biggest challenges of DePietro’s career was the 2007–09 shortage of technetium Tc 99m, the main isotope used in diagnostic imaging tests. The more than 15-month shortage was caused mainly by the shutdown of a Canadian reactor which usually supplies about one-third of the technetium 99m in the world.
“There were a lot of institutions that canceled scheduled [scans], but it was my goal not to turn anybody away, especially anyone who was already scheduled,” said DePietro. During this time DePietro kept everyone from physicians to vendors in constant communication. “We communicated about scheduling and how many patients we could accommodate each day. We studied the restrictions and worked extra hard to get everything done,” DePietro explained.
She believes that the shortage brought a new understanding of drugs to some health professionals. “When there is a shortage, everyone needs to be educated about the supply chain,” said DePietro. “It makes people realize that this is something we take for granted, but [these radiopharmaceuticals] are key parts of our day and our department.”
Becoming an authorized nuclear pharmacist is no easy task. It requires 700 hours of training in nuclear pharmacy, including 200 classroom hours and 500 on-the-job training hours. After 4,000 hours of practicing nuclear pharmacy and passing the Board of Pharmacy Specialties (BPS) certification exam, a pharmacist may become a Board Certified Nuclear Pharmacist.
Pharmacy education and board certification is a topic that is near and dear to DePietro’s heart. She currently serves as the Chair of the Specialty Council on Nuclear Pharmacy for BPS. “It’s been an amazing [experience] to put together the exam for board certification in nuclear pharmacy and work with the psychometrics company to learn how to write the questions and create a legally defensible exam each year,” said DePietro.
At Mass General, she is involved with educating technologists, physicians, physicists, and students about nuclear medicine. “I see this as an opportunity to train people properly, and my hope is that they take these practices and teach them to other people,” explained DePietro. “It’s helpful for physicians to realize what goes in to preparing [the dose]. There’s a lot behind that. I believe they appreciate seeing what goes on behind the scenes.”
For DePietro, nuclear pharmacy provides an exciting, challenging, and rewarding environment for pharmacy practice. “It allows you to use a lot of the chemistry and physics knowledge you learned in school, plus there is a lot of interaction with the health care team,” said DePietro, who enjoys being right there with the physicians and the technologists. Being on hand to help diagnose and treat patients “is an opportunity to be part of a health care team and be the medication expert,” she said.