Rituximab desensitization

Desensitization protocol instructions:
1. Confirm written consent is in medical record. Initial desensitization is performed in the medical ICU.
2. Please ensure preceding dose of beta blockers was held, unless otherwise advised by supervising physician.
3. Obtain IV access and vital signs (temperature, HR, BP, RR, oxygen saturation, peak flow).
4. Have at bedside: epinephrine 0.3 mg (for adult) for IM injection, peak flow meter, and BP cuff.
5. A nurse must closely observe the patient throughout the protocol (one to one).
Premedicate 20 minutes before starting infusion with diphenhydramine (25 mg IV) and famotidine (20 mg IV).
Administration: Hang each solution successively, changing the rate every 15 minutes, per protocol. The IV tubing should be pre-flushed with the appropriate solution (1, 2, or 3) and attached at the IV hub, prior to starting infusion with each bag. There is no reason to wait between bags. Vital signs should be taken and recorded every 15 minutes, and every 30 minutes during the last step (step 12).
Name of medication:				Rituximab
Target dose (mg)				600
Standard volume per bag (mL)				250
Final rate of infusion (mL/hour)				75

Calculated target concentration (mg/mL)				2.4
Standard time of infusion (minutes)				200

						Total mg per bag	Amount of bag infused (mL)
Solution 1			250	mL of	0.024 mg/mL	6.000	8.67
Solution 2			250	mL of	0.240 mg/mL	60.000	17.58
Solution 3			250	mL of	2.382 mg/mL	595.573	250.00
PLEASE NOTE: The total volume and dose dispensed are more than the final dose given to patient because the initial solutions are not completely infused
Step	Solution	Rate (mL/hour)	Time (minutes)	Volume infused per step (mL)	Dose administered with this step (mg)	Cumulative dose (mg)	Fold increase per step
1	1	1.9	15	0.47	0.0113	0.0113	–
2	1	4.7	15	1.17	0.0281	0.0394	2.5
3	1	9.4	15	2.34	0.0563	0.0956	2
4	1	18.8	15	4.69	0.1125	0.2081	2
5	2	4.7	15	1.17	0.2813	0.4894	2.5
6	2	9.4	15	2.34	0.5625	1.0519	2
7	2	18.8	15	4.69	1.1250	2.1769	2
8	2	37.5	15	9.38	2.2500	4.4269	2
9	3	9.4	15	2.34	5.5835	10.0104	2.481554688
10	3	18.8	15	4.69	11.1670	21.1774	2
11	3	37.5	15	9.38	22.3340	43.5114	2
12	3	75.0	186.875	233.59	556.4886	600.0000	2
Total time: 351.875 minutes = 5.86 hours
Monitoring and charting during desensitization:
Please clearly document any reaction, including:
a. Patient's symptoms, vital signs, and physical findings;
b. Exactly when the reaction occurred (ie, what step, how many minutes into that step);
c. Treatment administered, how and when the reaction resolved, and when the protocol was restarted.
Treatment of allergic reactions:
1. For mild reactions: In case of isolated itching, flushing, hives, mild chest tightness, nausea, abdominal pain, or back pain, with normal vital signs, stop the infusion and treat with IV diphenhydramine. Observe patient until the reaction subsides, then resume the protocol at the point where the infusion was stopped.
2. For severe reactions: In case of hypotension, throat swelling, wheezing/respiratory distress, or decreased oxygen saturation, stop the infusion and treat with epinephrine 0.3 mg IM × 1, diphenhydramine methylprednisolone IV, oxygen, nebulized albuterol for bronchospasm, and IV fluids (normal saline), per AHA guidelines. Place patient in a recumbent position if hypotensive. Consider glucagon 1 to 2 mg IV bolus if patient has taken beta blockers, followed by infusion at 1 to 5 mg/hour. Immediately alert the housestaff and supervising physician. When the patient is stable, the protocol will be resumed as instructed by the supervising physician. Patient should be discharged with prescription for an epinephrine autoinjector.
Contact the supervising physician for ANY severe or prolonged reaction, or any questions regarding the protocol, reactions, and appropriate management.

ICU: intensive care unit; IV: intravenous; HR: heart rate; BP: blood pressure; RR: respiratory rate; IM: intramuscular; AHA: American Heart Association.

Courtesy of Mariana C Castells, MD, PhD.

Graphic 80597 Version 5.0

خرید پکیج

Rituximab desensitization