Download Management of Chemotherapy Reactions

Guideline for management of chemotherapy related
hypersensitivity
Guideline development process
Group membership
Phase 1
Phase 2
Phase 3
Dr Scullin and Dr Millar
Dr Scullin and Dr Millar, BCH
Sr Dympna McParlan, BCH Infusion Services
Team Leader, BCH
Sr Colette Knowles, Senior Clinical Nurse,
BCH.
Anne Lyttle, BCH Pharmacy.
Dr Scullin and Dr Millar, BCH
Sr Dympna McParlan, BCH Infusion Services
Team Leader, BCH
Sr Colette Knowles, Senior Clinical Nurse,
BCH.
Ms Anne Lyttle, BCH Pharmacy
Sr Caitlin McCoy, Ulster Hospital, Dundonald
S/N Palmer, Antrim Area Hospital
Action
Drafted guidelines
Discussed at Oncology Haematology
Governance Meeting during 2005
Discussion and amendments made
Discussed again at BCH Oncology
Haematology Governance Meeting
2006
Agreement to take to NICaN
Chemotherapy Group
Presented to NICaN Chemotherapy
meeting October 2006, and asked for
membership from units
Group met and amendments made
Units involved in consultation process
Amended version presented back to
NICaN Chemotherapy Group
Consultation period extended until 16th
May 2007
Status
For sign off at NICaN Chemotherapy
Meeting 18th May 2006
Then to NICaN Board for ratification
and dissemination
Underpinning Evidence
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Group examined available literature (pubmed and medscape search using “hypersensitivity”),
engaged with drug manufacturers (Bristol-Myers Squibb and Sanofi-Aventis) regarding their
suggestions for management and studied trial protocols (SCOTROC 3 and HERA)
Discussion with multiprofessional staff who deal with patients
Discussion at Oncology Haematology Clinical Governance
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Guideline for management of chemotherapy related
hypersensitivity
Chemotherapy related hypersensitivity can occur with any chemotherapy drug but is most
commonly seen with platinums and taxanes. Different patterns of reaction occur with
different drugs e.g. taxane reactions are more likely to occur early in treatment, while
patients are more likely to react to platinum agents with successive treatments. However,
the same broad principles of management apply.
The following guidelines relate to the management of cytotoxic chemotherapy related
hypersensitivity reactions. They should be used in conjunction with local policies and
guidelines in the treatment of anaphylactic reactions.
For further guidance on management of infusion related effects or hypersensitivity reactions
please consult the electronic medicines compendium (http://emc.medicines.org.uk) or
relevant chemotherapy prescription sheet.
While there is a spectrum of severity of reactions, for the purpose of management it is best
to classify reactions as mild, moderate or severe.
Symptoms and Signs of Chemotherapy Hypersensitivity
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MILD – erythema, itch
MODERATE - erythema, itch, mild facial / tongue swelling (can also have
chest, abdominal and back pain with taxanes)
SEVERE – diffuse erythroderma, itch, facial swelling, throat or chest
tightness, bronchospasm, rigor, tachycardia, hypertension or hypotension
Prevention is better than cure, therefore ensure the appropriate premedication has
been given in the case of taxanes or where the patient has had a prior
hypersensitivity reaction.
Appropriate intervention is based on the assessment of severity (see flow chart)
Nursing staff should contact the appropriate member of medical staff but in the event
of severe reactions should institute immediate therapy as detailed in the table
overleaf.
If patients who have previously reacted are being re-challenged, this should be
undertaken between 9am and 5pm with an anaphylaxis kit beside the patient.
Emergency resuscitation equipment and personnel should be available during the rechallenge period.
The patient’s consultant must be informed if there is a moderate or severe reaction,
so that decision can be made regarding rechallenge.
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Management of chemotherapy related hypersensitivity
Immediate action
 Stop the chemotherapy infusion immediately
 Assess the patient: Pulse, BP, Oxygen saturation
 Call Medical Officer: Do not leave patient unattended
Mild Reaction
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Erythema/itch
Moderate Reaction
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Chlorphenamine
10mg intravenous
bolus over 1 min
Hydrocortisone
200mg slow
intravenous bolus
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Severe Reaction
Erythema/itch
Mild facial/tongue
swelling (can also have
chest, abdominal and
back pain with taxanes)
Tachycardia
May be hypoxic
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Diffuse erythroderma/itch
Facial /tongue swelling
Wheezing
Throat/chest tightness/pain
Tachycardia
Bronchospasm
Hyper- or hypo-tension
Hypoxia
100 % O2
Chlorphenamine 1020mg intravenous bolus
over 1 min
Hydrocortisone 200mg
slow intravenous bolus
Consider Ranitidine
50mg intravenous in
20ml sodium chloride
0.9% over 2 mins
Establish intravenous
infusion of sodium
chloride 0.9% until
Medical Officer arrives
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100% Oxygen
Secure airway
If hypotensive, lie flat and raise
legs or if patient vomitting lie on
their side
500mcgs Adrenaline (0.5ml
1:1000) by deep intra-muscular
injection – can be repeated after
5 mins in absence of clinical
improvement (see notes below)
Chlorphenamine 10mg-20mgs
intravenous bolus over 1 min.
Hydrocortisone 200mg slow
intravenous bolus
Ranitidine 50mg intravenous in
20ml sodium chloride 0.9% over
2 mins
Salbutamol 5mg nebuliser
Establish intravenous infusion of
sodium chloride 0.9% until
Medical Officer arrives
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When symptoms and
signs subside restart
infusion at 50% of
original rate
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1
Do not re-challenge that
day
Monitor patient for one
hour1
Reassess medically &
allow home if stable –
warn patient of risk of
relapse when drugs
wear off
Consider oral
Chlorphenamine 4mgs
PRN for 24-48hours
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Consultant makes decision as
to whether to re-challenge or
not
Admit for observation
Assisted ventilation and ICU
may be necessary
Caution in patients with heart disease, hypertension, arrhythmia, CVA etc.
Patients on non cardio selective beta blockers may not respond to
Adrenaline
Patients on tricyclic antidepressants are more prone to arrhythmia (use
50% adrenaline dose)
In the absence of clear evidence an observation period of 1 hour has been arbitrarily chosen.
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