2025 Article # 5
July 2025
Hypersensitivity
Reactions: Priming Practice Change to Reduce Incidence in First-Dose Rituximab
Treatment
August 2018 •
Volume 22, number 4, pages 407 - 414 • DOI: 10.1188/18.CJON.407-414
Carissa Laudati, Caroline
Clark, Andrea Knezevic, Zhigang Zhang, and Margaret Barton-Burke
Background: Strategies
to reduce hypersensitivity reaction (HSR) incidence with rituximab include
premedications and slow titration. Literature is lacking on the priming method
used when preparing rituximab IV lines and the potential impact on HSR
incidence.
Objectives: The primary
objective is to evaluate HSR incidence in titrated first-dose rituximab
infusions when priming IV lines with rituximab, as compared to priming with
diluent.
Methods: A
retrospective, comparative, descriptive study with two arms (rituximab- versus
diluent-primed) was conducted. Variables were HSR incidence in relation to
priming method, age, sex, diagnosis, and premedications. For patients with HSR,
severity, time to onset, and infusion rate were examined.
Findings: HSR incidence was significantly higher in the diluent- versus the drug-primed arm. Other significant findings included higher HSR incidence in women and lower HSR incidence in patients premedicated with dexamethasone.
Implication for Practice:
- Reduce hypersensitivity reactions to first dose rituximab treatment by priming IV lines with the drug.
- Consider standardized premedication, including acetaminophen, diphenhydramine, and dexamethasone, for all patients receiving first-dose rituximab infusions to reduce hypersensitivity.
-Use a close system device and personal protective equipment to minimize exposure with drug-primed IV lines.
Conclusion:
Nurses are a key patient advocate
and member of the multidisciplinary team who can coordinate efforts to minimize
adverse events in patients undergoing treatment with high risk of HSR. This
study lays the groundwork for setting priming practice standards for
preparation of titrated MABs with high risk for HSR. Priming the IV line with
the drug is a simple intervention that can positively affect patient care.
Discussion Starting
Points:
Please choose two for your
response:
How does this research article
compare to our practice, policy and or procedure?
What are the advantages and
disadvantages to the proposed recommendations in the article?
What are the advantages and
disadvantages of implementing the article recommendations on your unit and/or
hospital?
Was the correct method used? Why or
why not?
Was the correct method used? Why or why not?
ReplyDeleteThe correct method was used for this descriptive study.
The Institutional Review Board approved investigators to conduct a chart review. Two study arms were used, data from charts from before the change in practice (October 1, 2015-April 1, 2016) and after (October 1, 2016-April 1, 2017). The change in practice was priming the line with the drug, rituxan, instead of using a diluent, normal saline. There were 100 patients receiving first time rituxan in each arm of the study.
Patients were pre-medicated with tylenol and benadryl, and only a few others were also given dexamethasone. Patients with the diluent had a higher incidence hypersensitivity reaction.
In my opinion, a reason for this could be that since rituxan is being infused with the diluent, the patient is not receiving the full dose during the first hour or so and appears to be tolerating the infusion. Another factor could be the administration of dexamethasone, the patients that received the premed were 59% less likely to have a reaction.
What are the advantages and disadvantages of implementing the article recommendations on your unit and or hospital?
For the most part, in my experience, most, if not all, of our patients (on 6NE) are pre-medicated with tylenol, benadryl, and dexamethasone. The line is not primed with normal saline and titration of the drug is our usual practice, with a starting dose of 50mg/hr and increasing 50mg/hr every 30 mins.
There have been a few instances where rituxan has been ordered by other MDs and not an oncologist and pre-medications have not been ordered. fortunately, the nurse did obtained orders pre-meds before the infusion was initiated.
It would be beneficial to adopt a change in practice when an MD orders rituxan; an order set that includes tylenol, benadryl, and dexamathasone in included.
How does the article compare to the practice at PSJMC: typically patients receiving Rituxan are pre medicated and infusion is titrated per order, usually every 30 minutes if tolerated by patient with explicit instructions on what to do if patient displays a reaction. Nurses are able to use clinical judgement based on patients reaction and use the protocol including when to pause infusion and restart. Depending on MD and diagnosis of patient, rescue drugs are usually part of the order. There are times that a doctor does not order pre meds and, in my experience, sometimes a doctor does not think it is necessary to do so. This is not common however.
DeleteAdvantages and disadvantages:
In my experience, having protocols using evidence based practice are beneficial for nurses. It provides immediate treatments for infusion reactions. Given that the rate of infusion reactions for Rituxan is so high, it is crucial. This is even more important for 6NE, a med Surg floor, that does not have immediate access to a physician. Having orders in place for pre treatments and rescue drugs elements a potential RRT and reduces harm to patients.