Symptoms of IRs

Most IRs are mild to moderate in severity and the most common symptoms are influenza-like.1 Approximately 90% of patients experience symptoms such as pruritus, urticaria, and skin flushing, 40% have wheezing, and 30% to 35% demonstrate hypotension and gastrointestinal symptoms occurring within minutes to hours after drug administration. There are, however, other manifestations that can occur within different body systems, such as cardiovascular, central nervous system, dermatologic, endocrine, gastrointestinal, genitourinary, musculoskeletal, psychiatric, and respiratory effects.2 Some agents are associated with specific symptoms. For example, oxaliplatin can cause acute laryngopharyngeal dysesthesia, which is a cold sensation with dyspnea, difficulty talking and swallowing, jaw tightness, and odd sensations in the mouth.1

Prevention and Treatment of IRs

Premedication is frequently used with many different types of anticancer agents and this approach is effective in lowering the risk of an IR. For example, in one study, IRs were reduced from 26% to 10%, and severe IRs were reduced from 5% to 1%, with the use of premedications.7

The agents used for premedication will vary depending on the anticancer regimen, but commonly will include a corticosteroid such as dexamethasone and an antihistamine such as diphenhydramine.7 In addition, baseline vital signs will be recorded and patients will be asked about their medical history, past allergic disorders, and other drugs they may be taking to establish if any risk factors are present.1 During anticancer treatment administration, slowing the infusion rate can also help prevent an IR.2  

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During treatment infusion, the patient is closely monitored, and vital signs may be taken. If an IR occurs, infusion of the anticancer agent will be halted, which will resolve symptoms in most cases. Depending on the symptoms, corticosteroids, antihistamines, and oxygen may be administered. For patients who are experiencing hypotension, a position change may be initiated.

For more severe IRs, particularly those involving respiratory symptoms or severe hypotension, more aggressive measures are typically initiated. If anaphylaxis is suspected, treatment may include epinephrine, an antihistamine, anti–hypotensive or hypertensive agents, a beta-blocker, and corticosteroids. For cytokine release syndrome or other hypersensitivity reactions, treatment includes an antihistamine and a corticosteroid.

Depending on the severity and type of reaction, patients may be rechallenged with the anticancer agent, although they are typically infused at a slower rate.

References

  1. Roselló S, Blasco I, García Fabregat L, et al. Management of infusion reactions to systemic anticancer therapy: ESMO Clinical Practice Guidelines. Ann Oncol. 2017;28 (suppl_4):iv100-iv118.
  2. Vogel WH. Infusion reactions: diagnosis, assessment, and management. Clin J Oncol Nurs. 2010;14(2):E10-E21.
  3. Thompson LM, Eckmann K, Boster BL, et al. Incidence, risk factors, and management of infusion-related reactions in breast cancer patients receiving trastuzumab. Oncologist. 2014;19(3):228-234.
  4. Song X, Long SR, Barber B, et al. Systematic review on infusion reactions associated with chemotherapies and monoclonal antibodies for metastatic colorectal cancer. Curr Clin Pharmacol. 2012;7(1):56-65.
  5. Bupathi M, Hajjar J, Bean S, et al. Incidence of infusion reactions to anti-neoplastic agents in early phase clinical trials: the MD Anderson Cancer Center experience. Invest New Drugs. 2017;35(1):59-67.
  6. Bernardez B, Franco B, Mayo N, et al. Real world of infusion related reactions in an oncology outpatient clinic. J Clin Oncol. 2018;36 (15_suppl):e18872.
  7. Chung CH. Managing premedications and the risk for reactions to infusional monoclonal antibody therapy. Oncologist. 2008;13(6):725-732.