Oral Methotrexate and cytotoxic precautions?

Hey guys,

Recently someone brought to my attention the safety of administering the drug Methotrexate in its oral form, which often occurs in the ward for patients with rheumatoid arthritis.  It is also used to treat certain cancers as it interfere with certain quickly reproducing cells within the body such as bone marrow and skin cells.      

However there seems to be some confusion on precautions with this medication.  As an antimetabolite it comes under the heading of being a hazardous drug.  So like most drugs, the doses and routes vary depending on the condition and course of treatment, so the dose for rheumatoid arthritis tends to be smaller and in an oral form then the dose for oncology purpose which will often be a higher dose and likely a intravenous route.  

When using IV Methotrexate cytotoxic precautions are generally used, however when oral Methotrexate is used, this is where the lines become blurry.  Each health care facility will have protocols on hazardous drugs and precautions, but sometimes these can also be non-specific.  EviQ is a fantastic website by the Cancer Institute of NSW which goes through different protocols and has a bucket load of information for health professionals as well as offers professional education.  This website is a great resource and I really recommend checking it out!

Anyway, it talks about the different risks with the different formulas, and how exposure can be made 'safe' if it is for example if a tablet is coated.  But if you need to crush the tablet or dissolve it... well it suddenly isn't 'safe' anymore.  Oral Methotrexate can be 'film coated', which I'm assuming decreases the risk, but do we still need to apply precautions to it in it's oral form?  I had a chat with a pharmacist and they recommended not touching the tablet, washing hands after administration, and to avoid if pregnant.  I know some places use full precautions whilst others use none.... So which is right?  I would love to hear your thoughts and what happens in your ward!