ASCO Mod - Oncology Emergencies

Question 1

What type of infusion reaction is common to Irinotecan?

How does it manifest?

Answer 1

Irinotecan-related anticholinergic syndrome

Manifests in first 24 hours after infusion with nausea/vomiting, diaphoresis, and abdominal cramping

Question 2

What signs should you look for that would indicate anaphylaxis?

Answer 2

Urticaria, repetetive cough, throat tightness, wheeze, change in voice, hypotension

Question 3

What symptoms might be clues that a patient is experiencing an infusion reaction that is NOT an anaphylactic reaction?

Answer 3

Fevers and muscle pain are not common with anaphylaxis

Question 4

What types of infusion reactions should you worry about with platinum chemotherapy?
When in the course of treatment do they tend to occur?

Answer 4

Platinum drugs are all associated with anaphylaxis reactions. Classic Type I IgE mediated.

Tend to occur after repeated cycles (need to be re-exposed in order to react in the IgE mediated way)

Question 5

What types of infusion reactions should you worry about with taxane chemotherapy?
What do they occur in course of therapy?

Answer 5

They are direct mast-cell mediated reactions that usually develop within 10-15 minutes of the first drug infusion

90% occur during the 1st or 2nd drug infusion

Question 6

How should rechallenge occur after anaphylactic reaction from platinum chemo?

Answer 6

Do NOT rechallenge without specialized desensitization. These patients will usually react again even with additional pre-treatment

Question 7

When in the treatment cycle do patients normally have reactions to Rituximab?
What makes a patient more high risk to have a reaction to this drug?
What can you do to reduce risk of reaction?

Answer 7

• First infusion most likely time for reaction
• High numbers of circulating lymphocytes and tumor burden increase risk of reaction
• To reduce risk: Reduce infusion rate or split dose over two days. And always use antipyretic and antihistamine pre-med

Question 8

Stepwise approach to managing suspected anaphylaxis:

Answer 8

-Stop infusion, assess vitals, ABC's, clinically evaluate
IF SUSPECTED:
-Epinephrine 0.5mg (or 0.3mg in the pen)
-Normal saline bolus
-IV benadryl 50, IV ranitidine 50
-Equivalent 1mg/kg IV methylprednisolone
AND
-If Brady -> atropine
-If hypotension -> pressors

Question 9

Patient has an infusion reaction to chemo, but WITHOUT acute onset of respiratory symptoms or hypotension. You believe it is a likely a hypersensitivity or CRS reaction to the drug. What are your next steps.
Grade 1:
Grade 2:
Grade 3:
Grade 4:

Answer 9

Grade 1: Slow the rate

Grade 2: Slow rate or stop briefly, IV dephenhydramine and ranitidine, 1-2mg/kg of IV methylprednisolone, restart rate at 50% and titrate

Grade 3/4: Stop infusion, IV diphenhydramine/ranitidine, 1-2mg/kg of IV methyprednisolone, rechallenge is discouraged

Question 10

How should you categorize grades 1, 2, 3, and 4 infusion reactions?

Answer 10

1: Mild transient reaction
2: Infusion interrupted, but reaction responds promptly to symptomatic treatment
3: Not rapidly responsive to therapy or initially improves with therapy and then worsens again
4: Life-threatening