Delivering Meds Via Pneumatic Tube
full update June 2025
Pneumatic tubes are commonly used for med delivery in hospitals. Factors to consider when determining whether to tube a med include effects on the med, consequences of loss, and effects on the system and staff if there’s a spill.1,11 Tubes can move at up to 20 mph (32 km/hr), so meds that might be altered by shaking (e.g., emulsions [which can crack], proteins [which can denature]) are often considered “do not tube” items.2,3 (If a protein-based med has not been reconstituted or is frozen, tubing may be allowed.) Follow pharmacy policy and size and weight limits for your system. Use padding to prevent breakage.
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Considerations for a “Do Not Tube” List1,2,9,10 |
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Type of Drug |
Concern |
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Fragile Medications |
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Meds that could denature if shaken (e.g., proteins) and any med with labeling that says, “Do Not Shake.” |
Alteration of the med. (As a rule of thumb, meds with names ending in “mab” are all proteins.)8 Some meds should not be shaken because of a risk for excessive foaming (e.g., daptomycin, pegvisomant [Somavert]) |
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Controlled Substances |
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Meds that require accountability such as a signature by the receiver. |
Risk of diversion. (An exception might be if your system has a security feature, such as secure tracking.) |
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Investigational Drugs |
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Any drug labeled as “investigational” or with a label that says “IND” (investigational new drug). |
Risk of loss. (An exception might be if your system has a security feature, such as secure tracking.) |
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Living Creatures |
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Leeches or maggots. |
May be harmed in transport. |
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Hazardous Substances |
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Hazardous meds (e.g., chemotherapy), flammable products (e.g., collodion, nitroglycerin spray), products labeled “radioactive,” others. |
Spillage could contaminate or damage the system and create hazards to staff. (Note that tubing hazardous substances that do not have a spill risk, such as capsules or tablets, may be allowed.) |
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Meds Where Loss Has a High Impact |
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Very costly meds (e.g., angiotensin II, dexrazoxane, paliperidone injection) or those difficult to prepare or procure (e.g., parenteral nutrition, patient’s own meds, meds in very short supply). |
Risk of loss. (An exception might be if your system has a security feature, such as secure tracking.) |
Drugs That Might Be Altered or Damaged by Agitation
The drugs listed below are emulsions, peptides, or proteins. Product labeling may or may not specify “do not shake.” This list is not all-inclusive. The brand names listed in brackets are examples only and not all inclusive; generally also consider generics/biosimilars of the meds listed below as potentially damaged or altered by agitation unless specifically indicated otherwise by the manufacturer.
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Abatacept (Orencia) |
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Adalimumab (Humira) |
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Agalsidase beta (Fabrazyme) |
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Albumin (Grifols has stated there is no concern with tubing its albumin.)9 |
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Aldesleukin (Proleukin) |
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Alemtuzumab (Lemtrada, MabCampath-Canada) |
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Alglucosidase alfa (Lumizyme-US, Nexviazyme-Canada) |
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Alirocumab (Praluent) |
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Alpha-1 proteinase inhibitor (Prolastin-C) |
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Alprostadil injectable (Caverject) |
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Alteplase (Activase, Cathflo) |
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Anakinra (Kineret) |
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Anti-inhibitor coagulant complex (FEIBA, FEIBA NF) |
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Antithrombin III (Thrombate III) |
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Antithymocyte globulin (Atgam) |
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Antivenins (e.g., Anavip, Crofab) |
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Aprepitant, fosaprepitant injection and oral suspension (Cinvanti-US only, Emend) |
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Avalglucosidase (Nexviazyme – US only) |
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Basiliximab (Simulect) |
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BCG (Bacillus Calmette-Guerin) vaccines (TICE BCG-US, Oncotice-Canada) |
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Beractant (Survanta) |
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Bevacizumab (Avastin) |
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Bezlotoxumab (Zinplava-US only) |
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Bivalirudin (Angiomax) |
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Botulinum toxin formulations (A and B) (Botox, Myobloc-US only) |
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C1 esterase inhibitor (Berinert, Cinryze-US only) |
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Calfactant (Infasurf-US only) |
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Canakinumab (Ilaris) |
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Certolizumab (Cimzia) |
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Cetrorelix (Cetrotide) |
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Cetuximab (Erbitux) |
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Chorionic gonadotropin, human (HCG) (Pregnyl) |
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Collagenase clostridium histolyticum (Xiaflex-US only) |
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Cyclosporine ophthalmic emulsion (Restasis), oral solution (Gengraf-US) and injectable (Sandimmune) |
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Daptomycin (Cubicin) |
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Daratumumab (Darzalex) |
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Darbepoetin alfa (Aranesp) |
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Digoxin Immune Fab (DigiFab) |
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Dinutuximab (Unituxin) |
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Dornase alfa (Pulmozyme) |
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Elotuzumab (Emliciti) |
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Epoetin alfa, Erythropoietin (Epogen, Eprex-Canada) |
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Epoprostenol (Flolan, Caripul-Canada) |
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Eptifibatide (Integrilin [previous brand]) |
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Etanercept (Enbrel) |
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Evolocumab (Repatha) |
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Blood Factors (e.g., Factor VIIa [NovoSeven RT - US only], VIII [Esperoct], and IX [Alprolix, Rixubis]) |
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Fat emulsions, Lipids (Intralipid, Smoflipid) |
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Fibrinogen concentrate (Fibryga, RiaSTAP) |
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Filgrastim (Neupogen) |
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Follitropin alfa (Gonal-F) and beta (Follistim AQ-US, Puregon-Canada) |
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Galsulfase (Naglazyme) |
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Glatiramer (Copaxone) |
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Golimumab (Simponi) |
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Hyaluronidase (Hylenex-US only) |
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Idarucizumab (Praxbind) |
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Any type of Immune globulin (Cytogam, Gammagard, Privigen) |
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Infliximab (Inflectra-US, Remicade) |
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Insulina (The US manufacturer of Lilly [Humalog, Humulin] pens and vials states they believe these can be tubed without incident.6 The US manufacturer of Novo Nordisk [Levemir, Novolin, NovoLog] pens and vials states these should be tubed one time only.5 The US manufacturer of Lantus pens and vials states these should not routinely be tubed, and there is no information for other Sanofi insulins.7) Note that premixed insulin drips (Myxredlin) do not appear to have a significant loss of potency when tubed.4 |
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Interferons (Avonex, Betaseron, Pegasys) |
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Laronidase (Aldurazyme) |
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Letermovir (Prevymis) |
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Menotropins (Menopur) |
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Mepolizumab (Nucala) |
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Natalizumab (Tysabri) |
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Necitumumab (Portrazza-US only) |
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Nirsevimab (Beyfortus) |
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Omalizumab (Xolair) |
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Ofatumumab (Arzerra-US, Kesimpta-Canada) |
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Palifermin (Kepivance-US only) |
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Palivizumab (Synagis) |
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Pegaspargase (Oncaspar) |
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Pegfilgrastim (Neulasta) |
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Pegvisomant (Somavert) |
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Pembrolizumab (Keytruda) |
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Pertuzumab (Perjeta) |
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Propofol (Diprivan) (US labeling states to shake well [shake gently per Canadian labeling] prior to use; however, there is a theoretical risk of separation of the emulsion with the agitation from the pneumatic tube. Due to this conflicting information, propofol is not included on all institutions’ “do not tube” lists.)9 |
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Rasburicase (Elitek-US, Fasturtec-Canada) |
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Rituximab (Rituxan) |
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Romiplostim (Nplate) |
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Sargramostim (Leukine-US only) |
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Secukinumab (Cosentyx) |
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Somatrogon (Ngenla) |
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Somatropin (human growth hormone, Genotropin, Humatrope, Saizen) |
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Tenecteplase (TNKase) |
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Tocilizumab (Actemra) |
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Trastuzumab (Herceptin) |
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Treprostinil injection (Remodulin) |
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Ustekinumab (Stelara) |
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Vaccines, including live-attenuated influenza;measles, mumps, rubella; measles, mumps, rubella, and varicella; poliovirus; rotavirus; typhoid; varicella; yellow fever |
References
- Peak A, Fleming M, Rykovich, L. Medications that should not be transported via pneumatic tube systems [wall chart]. Thomas Land Publishers Inc. 2011.
- Peak A. Delivering medications via a pneumatic tube system. Am J Health Syst Pharm. 2002 Jul 15;59(14):1376.
- Wykes S. Gone with the wind: tubes are whisking samples across hospital. Stanford Medicine News Center. January 11, 2010. http://med.stanford.edu/news/all-news/2010/01/gone-with-the-wind-tubes-are-whisking-samples-across-hospital.html#.html. (Accessed May 30, 2025).
- Leja N, Wagner D, Smith K, Hurren J. Transportation of a commercial premixed intravenous insulin product through a pneumatic tube system. Am J Health Syst Pharm. 2021 Sep 7;78(18):1720-1723.
- Personal communication (written). Medical information. Novo Nordisk. Plainsboro Township, NJ 08536. November 19, 2021.
- Personal communication (written). Medical information. Eli Lilly & Company. Indianapolis, IN 46285. November 19, 2021.
- Personal communication (written). Sanofi. Bridgewater Township, NJ 08807. November 19, 2021.
- Scott GN. Sorting through the confusion of biologic drug names. August 19, 2016. https://www.medscape.com/viewarticle/867446_2. (Accessed May 30, 2025).
- Wang P, Nguyen L. Update to delivering medications via a pneumatic tube system. Am J Health Syst Pharm. 2017 Oct 1;74(19):1521-1522.
- ASHP. Pneumatic tube system medication guide. https://www.ashp.org/-/media/assets/pharmacy-practice/resource-centers/patient-safety/FINAL-ASHP-Medication-Safety-SAG-Pneumatic-Tube-System-Recommendations.ashx?la=en&hash=6AB6850C6FED94394D161032D630F3565A3AB1BF. (Accessed May 30, 2025).
- Safioleas AJ. Create an effective do not tube list. November 2024. https://www.pppmag.com/article/3341. (Accessed June 4, 2025).
Cite this document as follows: Clinical Resource, Delivering Meds Via Pneumatic Tube. Pharmacist’s Letter/Pharmacy Technician’s Letter/Prescriber Insights. June 2025. [410664]