Mode of action
BCG (bacillus Calmette–Guerin) is live, attenuated Mycobacterium bovis, which produces a local inflammatory reaction, resulting in elimination or reduction of superficial tumour lesions of the bladder.
Indications
According to specialist protocol for bladder cancer
Precautions
History of systemic BCG infection—contraindicated.
Immunosuppression (including HIV infection or treatment with immunosuppressants)—contraindicated as immunosuppression increases the risk of disseminated BCG infection. It may also interfere with the immune response to BCG.
Treatment with antibacterials—may reduce efficacy of BCG as it is sensitive to many antibacterials, particularly antimycobacterials. BCG is contraindicated in infections requiring antimycobacterial treatment (eg active TB). Consider postponing BCG treatment in other types of infections.
Allergy to BCG vaccine—consider possibility of cross-sensitivity.
Febrile illness—postpone BCG until patient is well.
Genitourinary
Do not administer for 7–14 days (or until urinary mucosa heals) after biopsy, transurethral resection or traumatic catheterisation as this may increase the risk of a systemic BCG infection.
Postpone treatment in patients with gross haematuria and in those with a UTI (until urine culture is negative and antibacterial treatment is complete).
Use BCG with caution in patients with small bladder capacity as risk of bladder contracture may be increased.
Adverse effects
Common
cystitis (below); malaise, low grade fever and flu-like syndrome starting 2–4 hours after instillation and lasting for 24–48 hours
Rare
contracted bladder, allergic reactions (eg rash, arthralgia)
Cystitis
Symptoms such as dysuria, frequency, urinary urgency and haematuria may start a few hours after instillation and last up to 48 hours. They tend to develop following the second or third instillation and increase in severity after each instillation.
BCG infection
Granulomatous prostatitis due to BCG-contaminated urine is common but is usually asymptomatic; epididymo-orchitis occurs infrequently. Systemic infection is rare and usually presents with severe or prolonged fever, malaise, hepatitis, pneumonitis, other organ dysfunction or signs of sepsis.
Dosage – BCG
Consult specialist protocols. The following induction dose has been used which may be followed by maintenance therapy.
Adult, contents of 1 vial instilled in the bladder each week for 6 weeks.
Administration advice
Contains live, attenuated Mycobacterium bovis; prepare, handle and dispose of as infectious material.
Retain dose in the bladder for 2 hours, changing position every 15 minutes to ensure contact with the entire bladder.
Counselling
Do not drink any fluids for 4 hours before, or for the 2 hours the treatment is in your bladder. This helps to reduce the amount of urine in the bladder.
After the 2 hour period (and for the next 6 hours), urinate sitting on the toilet. Disinfect the toilet by adding undiluted household bleach to the bowl and leave for 15 minutes before flushing.
Tell your doctor if you develop any signs of infection (eg chills, cough, prolonged fever).
Some adverse effects are common (painful or frequent urination, blood in the urine, mild fever and flu symptoms) and may be a sign that the drug is working. Tell your doctor about them if they are severe or last more than 48 hours.
Practice points
