Simple Adjustment Key to Paclitaxel Infusion Protocol That Reduced Hypersensitivity Reactions

WASHINGTON, DC — An infusion titration schedule that includes clearing the initial saline or priming solution in the IV tubing can significantly reduce hypersensitivity reactions in patients receiving paclitaxel, according to an oral presentation at the 2018 Oncology Nursing Society (ONS) Annual Congress.

Paclitaxol is a frequently used chemotherapy to treat several cancers including ovarian, breast, lung, cervical, and pancreatic cancers. It is a taxane and a plant alkaloid natural derivative. Many patients receiving paclitaxel experience mild to severe infusion-related hypersensitivity reactions, such as uticaria, facial flushing, shortness of breath, angioedema, and anaphylaxis. Most reactions occur during the first or second infusion, 78% within the first 10 to 15 minutes of drug initiation. 

Re-challenge protocols, however, lack titration guidelines for reducing reactions associated with higher infusion rates. “Paclitaxel prescribing information, and our hospital policy and procedure, simply state to ‘administer slowly,’” explained Carrie Patton, BSN, RN, OCN, of Todd Cancer Institute in Long Beach, California.

Patton and colleagues sought to develop a titration schedule that would decrease the incidence of infusion-related hypersensitivity reactions at their facility. For this project, the researchers conducted a retrospective chart review of all patients who received paclitaxel in the Ambulatory Infusion Center over a 14-month period. They also conducted in-person interviews with the unit nurses to review current nursing practices.

Their findings revealed an average infusion-related hypersensitivity reaction rate of more than 10% in patients receiving 3-hour infusions. Furthermore, the interviews revealed that hypersensitivity reaction incidence was significantly higher when the tubing was unprimed. Suggesting that the “slow infusion” stage was actually the saline in the tubing, and the rate titration was occurring when the drug finally reached the patient.

Based on these findings, the paclitaxel titration protocol included clearing the priming volume of the tubing — an initial bolus of 20 mL at 999 mL/hour over 1 minute — prior to initiating a stepwise titration schedule for paclitaxel of 10, 25, 50, and 100 mL/hour over 5 minutes each then 182 mL/hour for 2 hours 40 minutes for a 3-hour infusion or 35 mL/hour for 40 minutes for a 1-hour infusion.

The new titration protocol was used for every paclitaxel administration for a 3-month period. Data collected were administering nurse, date, patient initials, cycle/dose (mg), reaction, re-challenge with specific re-challenge protocol, and subsequent reaction with re-challenge. In that 3 month period, infusion reaction rate decreased to less than 1%.

A lack of concrete titration guidelines for paclitaxel infusions resulted in a variety of administration practices and an increased risk for hypersensitivity reactions. But these findings demonstrate several takeaways: prime the line every time to ensure the titration schedule begins with the administration of the drug and not saline or other priming solution; titration allows for early recognition and intervention in the event of a hypersensitivity reaction; and standardizing administration practices decreases reactions and increases nursing and patient confidence with infusion. 

Reference

Patton C, Hedgpeth N, Grabau K, Lu D. Evaluation of a standardized titration schedule to be utilized for the administration of all paclitaxel infusions. ONS 43rd Annual Congress; June 17-20, 2018; Washington, DC.