Class: Sclerosing Agents
CAS Number: 14807-96-6
Uses for Talc
Sclerosis of pleural serosal surfaces (pleurodesis) to prevent recurrence of malignant pleural effusions in symptomatic patients.
Intrapleural talc has resulted in absence of reaccumulation of effusions (determined by clinical examination or chest radiograph) in about 93% of patients with recurrent, symptomatic malignant pleural effusions.
Talc Dosage and Administration
Administer intrapleurally as an aerosol during thoracoscopy or open thoracotomy or as a slurry instilled via a chest tube. Do not administer IV.
Prior to intrapleural administration as an aerosol or slurry, adequately drain the effusion from pleural cavity. Success of talc pleurodesis apparently is related to completeness of pleural fluid drainage and full lung reexpansion.
Intrapleural Administration as an Aerosol
For intrapleural administration as an aerosol, commercially available in single-use aluminum spray canisters containing 4 g of talc suspended in 25 g of inert propellant (1,1,1,2-tetrafluoroethane [HFA-134a]).
Shake aerosol canister well before use; securely attach actuator button with delivery tube (15 or 25 cm) to canister valve stem.
Insert delivery tube through the pleural trocar; avoid placing distal end of the tube adjacent to lung parenchyma or directly against chest wall.
For optimal distribution, always maintain canister in an upright position.
Firmly hold delivery tube and pleural trocar together in one hand; gently press actuator button on the canister.
While pointing distal end of delivery tube in several different directions, administer short bursts to distribute talc equally and extensively on all visceral and parietal pleural surfaces.
Discard canister and delivery tube after administration.
Duration of chest tube drainage following sclerosis is dictated by the clinical situation.
Rate of Administration
Commercially available single-use canister is fitted with a continuous spray valve that delivers talc at a rate of approximately 1.2 g per second, but is not considered to be a metered-dose delivery system. Dose delivered depends on extent and duration of manual compression of the actuator button.
Intrapleural Administration as a Slurry
For intrapleural administration as a slurry, commercially available in single-use 100-mL bottles containing 5 g of talc powder for extemporaneous preparation of slurry.
Preparation of Slurry
Prepare slurry in a laminar flow hood using aseptic technique.
Attach 16-gauge needle to a 60-mL Leur-Lok syringe and draw up 50 mL of 0.9% sodium chloride injection into the syringe.
Vent bottle containing 5 g of talc with a needle and slowly inject syringe contents into the bottle. Swirl bottle to disperse talc powder; continue swirling to keep powder from settling.
Divide the slurry into two 60-mL irrigation syringes by withdrawing 25 mL of slurry into each syringe with continuous swirling. Draw up additional 0.9% sodium chloride injection so that total volume in each syringe is 50 mL. Draw air into each syringe to the 60-mL mark to provide 10 mL of space for mixing prior to administration.
After mixing, each irrigation syringe will contain slurry consisting of 2.5 g of talc in 50 mL of 0.9% sodium chloride injection with 10 mL of air space.
Appropriately label each syringe, including expiration date and time, identity of patient to receive the preparation, and the cautionary statements “For Pleurodesis Only–NOT FOR IV ADMINISTRATION” and “Shake Well Before Use.“
Use slurry within 12 hours of preparation.
Immediately prior to intrapleural administration, completely and continuously agitate irrigation syringes containing talc slurry (to evenly redisperse talc and avoid settlement) and vent the 10 mL of air (provided for mixing).
Attach adapter and place a syringe tip on adapter; maintain continuous agitation of the syringe.
Empty syringe contents through the chest tube into chest cavity by applying gentle pressure to syringe plunger.
Chest tube may be flushed with 10–25 mL of 0.9% sodium chloride solution to ensure complete dose delivery; clamp drainage tube.
Have patient move from supine to alternating decubitus positions at 20- to 30-minute intervals over a period of about 2 hours to distribute the talc within the chest cavity; however, recent evidence suggests that this step may not be necessary.
At end of this period, unclamp chest drainage tube and remove excess saline by routine continual external suction on the tube.
Usually 4–8 g (from 1–2 spray canisters) as a single dose.
Spray canister delivers talc at a rate of approximately 1.2 g per second; dose of talc delivered depends on extent and duration of manual compression of actuator button on the canister. (See Intrapleural Administration as an Aerosol under Dosage and Administration.)
5 g as slurry dispersed in 50–100 mL of 0.9% sodium chloride injection. (See Intrapleural Administration as a Slurry under Dosage and Administration.)
Optimal dose is unknown; 5 g was dose most frequently reported in published literature.
No special population dosage recommendations at this time.
Cautions for Talc
No known contraindications.
Potentially Curable Malignancies
Talc has no known antineoplastic activity; do not use alone for potentially curable malignancies when systemic antineoplastic therapy would be more appropriate (e.g., malignant effusion secondary to a potentially curable lymphoma).
Prior to intrapleural administration of talc, consider the possible need for future diagnostic and therapeutic procedures involving the hemithorax.
Sclerosis of pleural space may preclude subsequent diagnostic procedures of the pleura on the treated side and may complicate or preclude future ipsilateral lung resective surgery, including pneumonectomy for transplantation purposes.
Acute pneumonitis and ARDS reported in association with intrapleural talc; causal relationship not established. In 3 of 4 case reports, ARDS occurred following relatively large talc dose (10 g) administered intrapleurally via chest tube. No reported cases involved talc administered thoracoscopically or by insufflation.
IV† administration of talc causes pulmonary hypertension and lung parenchymal disease; not reported following intrapleural administration.
Inhaled talc associated with pulmonary diseases (e.g., silicosis or asbestos-like disease, chronic bronchitis, bronchogenic carcinoma, pleural plaques).
Aerosol Canister Pressure
Contents of the aerosol canisters are under pressure; do not puncture and do not store or use near heat or open flame. (See Aerosol under Stability.)
Do not use during pregnancy unless benefits outweigh risks.
Safety and efficacy not established in pediatric patients.
Safety and efficacy in geriatric patients not specifically evaluated.
Estimated mean and median ages of patients receiving intrapleural talc slurry via chest tube in clinical studies were 60 and 62 years, respectively. In other clinical studies, mean and median ages of patients receiving intrapleural talc ranged between 50 and 62 years.
Common Adverse Effects
Interactions for Talc
Unknown whether talc’s absorptive properties would diminish effectiveness of subsequent therapy with a second sclerosing agent
Extent of absorption after intrapleural administration not determined; integrity of pleural surface may affect systemic exposure.
Systemic exposure may be increased when administered immediately following lung resection or biopsy.
20–25°C; may be exposed to 15–30°C. Avoid freezing.
Contents under pressure and may rupture. Do not expose to temperatures >49°C, protect from sunlight, do not puncture or incinerate.
18–25°C. Protect from sunlight.
Use slurry within 12 hours of preparation; discard if not used within 12 hours.
Following intrapleural administration, talc induces inflammation that results in fibrosis and adherence of visceral to parietal pleura (pleurodesis), thereby obliterating the pleural space and reducing the chance of fluid reaccumulation.
Advice to Patients
Importance of describing the intrapleural procedure to patients prior to administration of talc.
Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, and any concomitant illnesses.
Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.
Importance of informing patients of other important precautionary information. (See Cautions.)
Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.
Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.
Sclerosol Intrapleural Aerosol (with 1,1,1,2-Tetrafluoroethane [HFA-134a] propellant)
Sterile Talc Powder
AHFS DI Essentials™. © Copyright 2022, Selected Revisions May 30, 2013. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.