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.
What are the advantages and disadvantages to the proposed recommendations in the article?
ReplyDeleteThe advantage of priming the tubing with the medication specifically rituximab instead of a diluent is knowing immediately that the patient will receive the medication and therefore can anticipate earlier and prepare sooner for any HSR that may happen. Also, the nurse can timely give the pre medication knowing the exact time that the patient will receive the medication versus getting the diluent first. One disadvantage that I can think of resulting in priming the tubing with the medication instead of the diluent, is the higher risk of accidental exposure or spillage of the medication specially if an anti spill adaptor is not routinely used.
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DeleteHow does this research article compare to our practice, policy and or procedure?
ReplyDeleteOn our unit, rituximab is administered as a titratable drug. Patients are pre-medicated with Tylenol and Benadryl prior to infusion. However, it is unknown to me if the tubing is actually primed with Normal saline or the medication itself.
How does this research article compare to our practice, policy and or procedure?
ReplyDelete- It is normal practice for us to premedicate patients with Tylenol, Benadryl, and dexamethasone prior to Rituxan iv infusion. Rituxan is always ordered as a titratable drug that is based on nursing judgement and the MDs orders. It is unbeknownst to me, however, if the tubing is primed for us with either Rituxan or a compatible diluent.
What are the advantages and disadvantages of implementing the article recommendations on your unit and/or hospital?
- An advantage of this study shows that there was truly a lower incidence of hypersensitivity reaction when the tubing was primed with the Rituxan rather than a compatible diluent. A disadvantage of this would be that there is an unclear policy/procedure of how the tubing is primed for these types of infusions. Because we do not mix our own chemos, only the pharmacy would know what is in the tubing. I feel that this would be a miscommunication between departments and therefore increases the risk of the patient having a hypersensitivity reaction.
In our current practice, we do follow the standard of giving premedications like Tylenol, Benadryl, and dexamethasone, which lines up with what the article recommends. Where we may be different is with the priming process, since, like you mentioned, it isn’t always clear to us as nurses whether the tubing is primed with diluent or rituximab because that step is done in pharmacy. This makes the article really relevant, because it shows that something as small as how the line is primed can affect the patient’s risk for a hypersensitivity reaction.
DeleteI also agree with you that one of the biggest challenges in applying this recommendation is communication. If pharmacy primes the tubing without us knowing what is used, it could create gaps in safety and make it harder to standardize practice across the unit. On the other hand, if pharmacy and nursing work together to update the policy and clarify the priming method, it could reduce reactions and improve outcomes. So the advantage is definitely safer patient care, but the disadvantage is the potential for confusion between departments unless there’s a clear procedure in place.
What are the advantages and disadvantages to the proposed recommendations in the article?
ReplyDeleteOne of the biggest advantages of priming IV lines with rituximab instead of diluent is that it lowers the number of hypersensitivity reactions in patients getting their first dose. This makes treatment safer and less stressful for patients, since reactions can sometimes be serious. Another advantage is using the same set of premedications, like acetaminophen, diphenhydramine, and dexamethasone, which helps keep care consistent for everyone. Together, these steps can improve the overall experience for patients and also make it easier for nurses to give rituximab with more confidence.
The main disadvantage is cost, since rituximab is expensive and some of the drug would be wasted when it is used to prime the line. There is also a higher risk for nurse exposure when priming with the drug, so protective equipment and special closed systems are needed. Another challenge is that changing practice requires time and training, and not every hospital or clinic may be ready to make the switch. Also, since the study was done at one place and only looked back at past cases, the results might not apply to every patient population or setting.
Was the correct method used? Why or why not?
The study used a retrospective, comparative design, which means the researchers looked back at patient records and compared outcomes between lines primed with rituximab and those primed with diluent. This method worked well for a first step because it gave useful information without having to run a big trial right away. However, it also has limits, like the risk of bias and the fact that patients were not randomly assigned to groups. Because of this, the study shows an association but not a definite cause-and-effect. The method used here was still a good starting point for exploring this practice.
How does this article compare to our practice, policy, and/or procedure?
ReplyDeleteOur current procedure is to premeditate the patient with dexamethasone, Tylenol, and Benadryl before we give Rituxan. Our pharmacy does not inform us of the fluid that is used to prime the tubing, however it is not common practice for us to ask about it. The Rituxan is a titratable drug based on patient response, vital signs, and nursing judgement. Maybe part of our nursing judgement could be to stop and ask pharmacy what they put in the tubing before we advance the titration.
What are the advantages and disadvantages of implementing the article recommendations on your unit and/or hospital?
The advantage of implementing the article recommendation on our unit would be lower incidence of reactions. We currently premedicate with dexamethasone as the article suggests. However, in our current practice we are unaware if we are using diluent-primed vs drug-primed med. Increased communication about this between our pharmacists that mix our meds and 6NE staff would help us make informed decisions and know when we are using drug-primed Rituxan.
How does this research article compare to our practice, policy and or procedure?
ReplyDeleteBefore getting an infusion of Rituxan, patients are given a pre-medication. A nurse monitors the patient closely and adjusts the infusion rate, usually every 30 minutes, if the patient tolerates it well.
If a patient has a reaction, the nurse follows a specific protocol that outlines what to do, including pausing and restarting the infusion. Nurses can also use their clinical judgment to manage the situation.
Rescue medications are typically ordered by the doctor as part of the treatment plan.
What are the advantages and disadvantages to the proposed recommendations in the article
Priming an IV line with a small amount of Rituximab may help to lessen the chance and seriousness of a patient's reaction to the drug, especially during their first infusion. This is because the patient is exposed to a tiny, gradual dose of the medication, which allows their body to adjust more slowly.If there is a lot of air in the IV tubing, the drug will have to be returned to the pharmacy to be primed with a diluent. This can cause a delay in the patient receiving their medication.