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Happy November!
I am so happy we are starting our 6th club this year.
We made it!
This month Jodi Garcia kindly volunteered to lead. The second article she selected was written by our Gyn Onc team.
I look forward to our discussion.
Here are the articles for this month and Jodi’s introduction:
Management of Hypersensitivity Reactions to Taxanes
Outpatient desensitization in selected patients with platinum hypersensitivity reactionsHi, my name is Jodi Garcia. I am an infusion nurse at MillRun Gynecology Oncology. We deal with reactions to both the Platin and Taxane drugs daily.
Our experience with the Taxanes has been more of a reaction to the Cremophor; the solubilizer. The reactions can be mild to severe. Rescue drugs have generally helped patients with recovery, but it is more the stopping of the drug at the start of the reaction that helps the most. Once recovered the Taxane is re-introduced at a slower rate to basically “trick” the body into accepting it.
Platin drugs like Carboplatin and Cisplatin in general are initially tolerated well. It is the cumulative effect and usually around the 5th to 6th cycle is the most vulnerable time for the patient.Hi Jodi! My name is Kristin Moore, and I work in the outpatient Sarcoma clinic. I am a primary nurse for a surgeon but will cross cover for the medical oncology team at times. I found this information interesting as I was unaware of wide range of symptoms that can occur when receiving platinum-based chemotherapies. From rash and facial flushing to potential life-threatening respiratory compromise or hypotension. Being able to identify at risk patients with skin testing and desensitization to help prevent HSR is incredible. I learned that HSR can occur immediately after infusion starts, or patients can have a nonimmediate reaction that can manifest from hours to weeks after the infusion. Having the experience and understanding to be able to differentiate between HSR vs potential pre-med adverse reaction is essential. Dexamethasone can cause facial flushing that can be confused with an immediate hypersensitivity reaction. Does the Gyn Onc team use skin testing or desensitization after a patient has a reaction? I was not clear if this is only done after the reaction or is this something that can be done prior to the first infusion? Very interesting articles!
Hi Kristin,
We do not use skin testing that I am aware of. Our protocol has some new guidelines but in general if it is a mild reaction and they recover well they will resume with a 4 step for that treatment and subsequent treatments. We have 8 and 16 step plans as well. Any more than that they either change treatments or they can be admitted for even a slower infusion.
Thanks for your response.Thanks Jodi for hosting this journal club. You guys at Mill Run sure are the “experts” of dealing with taxane reactions as it seems to happen more than the 10% the article talks about. My name is Jeff and I am one of the ambulatory float pool nurses- and we go to all infusion areas where infusion reactions happen with regularity.
1. What was the knowledge gained from the article? In the first article it mentions that there is a regimen with paclitaxel where patients can take steroid premeds the night before and also the morning of infusion. I also haven’t seen a plan where patients take steroids 3 days before docetaxel administration. I didn’t know that taxane molecules “can be isolated from yew tree pollen, as well as hazelnut trees and its nuts.” In the 2nd article- I wasn’t aware of the exact percentages of platinum based reactions being 1% of all administrations. It is also interesting that the longer a patient is between platinum based antineoplastics (less than 12 months vs greater than 12 months) had more than double the likelihood of HSR.
2. Will the research/information in this article change or influence your practice? If so how? This information will not change my response to HSR, but it will give me further insight to HSR and how to manage them. I have already been in practice of staying the room for 1st and 2nd doses of taxols and then about the 5th dose of platinums I start to be more aware that HSR can occur. Physicians typically want to rechallenge the platinums or taxanes and already want to do a titration as the standard of practice. The articles may have me more likely to suggest steroids as a day before and the day of instead of just the day of.
3. What other questions does the article raise about current practice? We draw IGG and other immunoglobulin blood tests- is there a blood test we can draw that would be able to predict a likelihood of taxane reactions- similar to a skin test? Do people who eat hazelnuts have a higher or lower incidence of taxane reactions since the potential environmental exposure? Why are younger women more at risk of platinum HSR?
4. Do you agree/disagree with the conclusions of the author, why? I agree with both authors and that experienced healthcare staff are necessary to respond rapidly to HSR reactions from both taxanes and platinums. The articles were talking about how recognizing HSR and responding appropriately increased outcomes. I think here at The James we do a great job of training our new staff to recognize HSR and use our nursing judgement to intervene to help our patients.Hi Jody, thanks for hosting a journal club that is so important to the safety of our oncology patients who are receiving chemotherapy. I work in the outpatient float pool at the James and see these regimens being given on the daily. I hope to visit Mill Run infusion soon to see you all =)
1. What was the knowledge gained from the article?
Over the past year a lot of light has been shined on HSR and how to manage them more effectively, but there is still a lacking on how to predict who will have a reaction (or more than one) and who will progress to a severe reaction. The articles discussed skin tests and Tryptase testing which I wasn’t aware of. I think having a standardized blood or skin test to predict reactions and their severity could not only decrease HSRs but also improve patient experience and decrease their fear, reduce chair times in infusion areas, and reduce need for 16-step desensitization. Prevention is key and being able to more accurately predict who will react and the severity of the reaction will save distress, money, and ultimately lives!2. Will the research/information in this article change or influence your practice? If so how?
At this point, the articles will not change how I respond to a HSR but could affect how we manage and predict HSRs moving forward. This past year at OSU we have moved in the direction of treating a reaction as mild, moderate, or severe and I think differentiating reactions has helped with management overall tremendously. I also like the cheat sheets we have available in IHIS on how to manage a reaction. At this point in time, I think we respond very well to HSRs but am quite interested in predicting who will react and why some patients do vs. others who don’t. I look forward to more studies on IgE and skin testing.3. What other questions does the article raise about current practice?
The question I have after reading both articles is why we don’t utilize steroids as a pre-medication the night before treatment and then again 30 minutes prior to treatment (at least for 1st and 2nd dose Taxanes or 7th plus dose of platinum)? The first article named using 2 doses of steroids the night before and 30 minutes prior as the “standard protocol” and 1 dose of steroid 30 minutes prior the “simplified protocol”. The article states that using the simplified protocol could entail a “slightly higher risk of reaction”. Knowing this why don’t we use the standard protocol until a patient has had at least one dose of Taxane without a reaction or with each dose of platinum chemo starting with dose 7?4. Do you agree/disagree with the conclusions of the author, why?
I agree that reactions to Taxanes and platinum chemos are common and almost all patients can be safely retreated with desensitization or rechallenge, but I do think more research into who reacts and why they do is needed to decrease/prevent HSRs. HSRs are terrifying to the patient/family, costly, timely, and can prevent a patient from receiving future treatment with the drug in the future so it’s imperative we continue to research HSRs and find a way to predict and prevent them.Hi Jody, thank you for hosting this month’s journal club. These are great articles! My name is Trish and I am an after-hours triage nurse in the clinical call center. My role with patients related to these articles is mainly to help the patient with steroid prescriptions they need to take prior to the next infusion.
1. What was the knowledge gained from the article?
I was surprised how many patients have a sensitivity for the taxanes, 10% seems very high. Thinking of allergic reactions that worsen with each exposure, it seems very counterintuitive that the Patient can be de-sensitized and continue on this same treatment for subsequent doses. The second article explained that the higher the lifetime dose can also increase the hypersensitivity as well, especially for patient that have the BRACA mutation. I would imagine that the patient’s anxiety would significantly increase if they had a reaction during the first dose. I had no idea that there are skin and lab tests that could predict sensitivities prior to treatment. I don’t know if the James uses these, but I have never seen anything documented in patient’s chart referencing this. The second eye-opener for me is that the reaction, particularly skin reactions, can occur up to two weeks after!2. Will the research/information in this article change or influence your practice? If so how?
This information will not change my practice since I am not bedside during the infusion. I do help patient get the premed steroid prescriptions called in when the patient doesn’t realize that they don’t have refills and they are supposed to start the steroids over the weekend, but I have always done this. These articles just reinforce the importance of the day before and day of steroid pre-treatment for the patients on these treatments. It is very helpful to know that the patient can still show signs of hypersensitivity up to two weeks after the infusion.3. What other questions does the article raise about current practice?
Are all Gyn/onc patients that receive platinum-based chemotherapy treatments prescreened for the BRACA mutation since it seems that they are more likely to have a hypersensitivity? Why don’t we use skin testing to help identify increased risk of a hypersensitivity? I imagine there is a lot of anxiety with starting chemotherapy in general, but with a
reaction in the first dose would only increase anxiety surrounding future treatments. Wouldn’t being super conservative and using preventative measures to thwart or at least lessen the potential hypersensitivity be in the best interest for the patient’s compliance? is there just not enough time to wait for test results or is this an insurance issue?Hi Jeff, I also didn’t know that patients take steroids 3 days before docetaxel administration is a recommendation. I mostly see the day before, day of and the day after. I also didn’t know that the longer a patient is between platinum based antineoplastics (less than 12 months vs greater than 12 months) had more than double the likelihood of HSR. The
Hi Jenkins.1629, I agree that pretesting to predict which patients are at high risk would no only reduce HSR’s severity, reduce patient’s anxiety related to chemotherapy, but also avoid delays in treatment during the de-sensitizing period as I would imagine that effects the patient’s overall prognosis.
Hello, Jody, thank you for hosting a journal club. Stay current is important to the care of patients, as we all know medicine is always changing. My name is Kathy and use to work at the Infusion Clinic but now work in pt. triage. I found these article very informative and hope to see James Cancer Hospital incorporate more of these practices.
1. What was the knowledge gained from the article? I liked that the article explained the processes behind these reactions and that they are often due to the inactive substance used to solubilize the drug, rather than the drug itself. I have seen the steroids ordered the night before and 30 minutes prior to administration. We did desensitization in my old unit, but I did not know how it worked, that it was intended to trick the body and to build tolerance. I learned just how important it of a role pre-medications are in decreasing HSR’s and the different ways of doing them. The effectiveness of desensitization in managing HSRs is a move in the right direction so pt.’s can continue their treatment. I had no idea that pt’s could react hours after treatment, good to know. I also was unaware that there was skin and lab testing they could do to predict who is art greater risk of reaction.
2. Will the research/information in this article change or influence your practice? If so, how? As a triage RN I am not administering any chemo treatments to patients, but the enhanced understanding of delayed HSR reactions can help me with a more informed triage assessment, and timely interventions.
3. What other questions does the article raise about current practice? What are the specific criteria for selecting patients for outpatient versus inpatient desensitization? What are the long-term outcomes and safety of repeated desensitization protocols? How can communication and patient education be improved to help patients understand the risks and management of HSR? Why don’t we incorporate more of these protocols for prevention, like the skin and lab test?
4. Do you agree/disagree with the conclusions of the author, why? I agree with the conclusions of both articles. The success in desensitization protocols in permitting patient to continue their chemo treatment in spite of their HSR safety is a step in the right direction. They have also proven that pre and post medication is very effective in preventing HSR. The protocols read here are supported by clinical evidence and offer a structured approach that can improve pt outcomes and minimize risk.
Hello, Kristin my name is Kathy I use to work in the infusion clinic at the Morehouse. I will have to say that I saw a lot Taxanes react if not the 1st dose sometimes that 2nd, but after reading these articles I don’t think they are out of the woods like we use to think. If they made it through the first and second dose they were good to go. The platins rarely if ever reacted to their first dose or even early doses as it does accumulate in the body. It was always the later doses you worried about. In saying that we saw a definite shift in platin reactions with people having had COVID or getting the vaccine. Pt were starting to react on the first dose of oxaliplatin. I keep all of us more on alert for HSR for sure.
Trish I 100% agree that it is helpful to know that the patient can still show signs of hypersensitivity hours after the infusion. I had no clue there are rare skin reactions. I also wonder if we can not do better to decrease these patient anxiety after a reaction. I have seen pt so scared after having a reaction and I wondered how all the anxiety effected their over all health
Hi Kathy,
I also do not administer the drugs but am also interested in seeing more and better patient education to help to understand the risks and management of HSR. This will help me be better able to educate patients if questions arise. I also find it very interesting to hear there are reactions to platins associated with COVID or the vaccines.Hi Trish,
I have really learned a great deal from these articles and everyone’s responses. I find it very interesting those with BRACA mutation have an increased sensitivity. It would seem better patient care if everyone can be tested for sensitivity prior to starting the first does. I agree the anxiety must be tremendousSarah- Good point about the changes we’ve made in the last year with mild/ moderate/ severe reactions and how the protocol has changed. I know certain clinics were resistant at first to these changes but after reading the articles it makes sense to differentiate so that patients can retry taxols/ platinum based drugs in the future. Some of the tables/figures in the articles were surprising to me that with wheezing and throat involvement they were only considered mild to moderate reactions?!?!?
Trish I agree that it’s crazy to think reactions could potentially be worse with each subsequent exposure. BUT with some disease processes these classes of drugs are all that have proven to show even some semblance of working. It’s a tough spot for physicians to be in but also us as infusion nurses. “yes you reacted last time and needed to be admitted to the hospital for observation but you know what we’re going to give you the same drug again.” That would definitely provoke some anxiety to patients hearing that (especially in some disease lines where the patients already have increased levels of anxiety.
Hello,
Thank you Jodi for leading this discussion. My name is Amy McHale and I am a nurse in medical oncology at the breast center. This topic is very interesting to me because we are now giving a lot more carboplatin to our patients than ever before, as one of our newer regimens approved gives carbo/taxol x12 in the neoadjuvant setting. From the article, i learned that there is an incidence of HSR in up to 27% of patients who have received 7 or more cycles of carboplatin, which is very high. I agree with Kristin, being able to identify at risk patients with skin testing and desensitization to help prevent HSR is incredible, and that BRCA mutations have an increased risk of sensiitvity. That is so interesting and something I never knew. I am curious if we will start using skin testing more in the future, or if we will start identifying more patients as “increased risk” for sensitivity. I also always find it fascinating the wide range of reaction and timeframe for these. As a med onc nurse, our biggest involvement with reactions tends to be through phone triage, so its good to always keep this in mind when talking with a patient who has had a recent infusion. Jeff, i agree with you, i was surprised by the symptoms involved in mild and moderate reactions. Jeff and Jodi, I am curious, in your experience, do we tend to grade these higher? And with the new protocols, did the grading stay the same?
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