Well, I’ve been meaning to do this for quite a while since I’m constantly asked and PM’d with questions regarding nuclear pharmacy. It’s a very specialized niche in our field...and unfortunately, many healthcare professionals (and even other pharmacists) have a very vague understanding of what we do.

So, here it goes...a very thorough description (sorry!) of the world that is nookyoolar pharmacy, and what I go through on a daily basis.

To give you a quick overview of the industry’s current standing: nuclear pharmacies are generally either institutional (and cater to a single medical center), or commercial. Centralized commercial pharmacies are contracted by hospitals/clinics to provide radiopharmaceuticals, and there really are only a few major players out there: GE (FKA Amersham), Triad (FKA Tyco, Mallinckrodt, or Covidien), and Cardinal Health (which bought out Syncor, among others)...and smaller independents.

Moly Generators and Compounding Radiopharmaceuticals

Unlike CT/MRI, nuclear imaging is great at assessing function, as opposed to just structure or anatomy. Technetium (Tc-99m) is by far the predominant isotope used...it’s an ideal diagnostic tracer and we use it to compound the vast majority of our radiopharmaceuticals. I won’t go into the gory details, but Tc is obtained by a eluting a generator: a vial of saline is placed at the entry point with an evacuated vial on the opposite end (encased by a heavy tungsten shield). The negative pressure draws the saline through the generator, and a Tc-99m eluate is produced (think radioactive saline). Depending on the amount of activity needed for the run (and the number of doses the pharmacy puts out), several generators are hit throughout the course of the day. This Tc-99m elution is then used to compound most kits.

In a LAFW with an L-block for protection, multidose vials of the various radiopharmaceuticals (also placed into tungsten vial shields) are compounded using specific amounts of Tc eluate and saline. Each drug kit has particular compounding steps (i.e. some require heating, venting, etc.).

The compounder/pharmacist then hands the prepared multidose vials with corresponding prescription labels to technicians, who (in their own hoods) safely draw up unit doses into syringes with the help of a leaded glass syringe shield. These are actually a little heavy and require a lot of dexterity/practice to use properly. The technician draws the volume indicated on the prescription label, and then verifies the activity by placing the syringe into a dose calibrator. The calibrator will indicate the current activity of the dose, as well as what it will read at the desired assay time indicated by the customer. (i.e. 82 mCi now, and 30 mCi at 08:00).

Each unit dose (syringe) is placed into a lead-shielded “pig”, labeled, capped, and placed into a case to be shipped out to the hospital or clinic. When the dose arrives to the customer, a nuclear medicine technician/physician will verify the dose in their own calibrator, and administer the dose to the patient.

In addition, prior to doses leaving the pharmacy, quality control by chromatography is performed on each and every kit that is prepared to ensure the drug is sufficiently bound to the isotope, there are no impurities, etc. USP sets certain percentage requirements for QC to pass for each drug, and each pharmacy may also set even more stringent internal requirements (i.e. 95% purity or above to pass).