chemo emergencies

Last updated Dec 14, 2022 Edit Source

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• Adverse effects

# taxane hypersensitivity

• double check chemo plans, also triple remind the pts (home-based regimens, they will need to remember to take the steroids, etc.)

• anaphylaxis most common in areas w Lone star tick bites, allergy to red meat

# rituximab

• infusion reaction, different than hypersensitivity rxn (not IgE mediated)
• prevention: premed APAP + antihistamine
• slow titration of infusion rate
• if rxn occurs (usu anaphylactoid, usu w/in 30-120min):
  • stop or slow rate (50%), depending on severity
  • if stopped, wait a bit, give steroids (dealer’s choice, but IV hydrocortisone is pretty standard), and whatever else you think is indicated (e.g. meperidine), and restart at 50% of prior rate, increase every 30min or so

# daratumumab

• hypersensitivity
• 1st infusion, occurs in up to 50% of pts on IV therapy (~13% of SQ)

# obinutuzumab

• reaction and hypersensitivity

# gemtuzumab ozogamicin

• hypersensitivity
• same deal: stop infusion, give steroids, resume at 50% when sx resolved

# 5-FU or capecitabine

• homozygotes for dihydropyrimidine dehydrogenase (DPD) mutation, or thymidylate synthase mutation.
• severe GI, hematologic, cardiac, neurologic toxicities
• antidote: uridine triacetate, direct antagonist (removes benefit of 5-FU, also reduces)
• 615-343-9211 chemo pharmacist on-call

# HD-MTX

• protocolized, antidote is glucarpidase (Voraxaze)

# ifosfamide encephalopathy

• confusion (80%), hallucination (30%), incontinence/muscle twitching. Can look comatose.
• biggest risk: elevated creatinine
• tx: methylene blue (MAO pathway -> chloracetaldehyde, ifos metabolite thought to be the offending agent. unknown if methylene blue actually helps)

# gemcitabine

• “gem flu”: w/in 24-48h after infusion: 45% fever (usually low, but can be very high), 20% flu-like sx
• gemcitabine-related TMA: mimics TTP. can occur at any time, v rare. tx w holding drug, consider eculizumab.

# everolimus

• SWISH study gave dexamethasone swish and spit, helped reduce incidence of stomatitis

• most oral agents are ok to hold, particularly if the goal of tx is palliative

• irritant: PIV
• vesicant: central line (port, PICC), but not absolute rule

• infusional chemo
• vesicant chemo w high rate of rxn: e.g. anthracycline, higher dose cisplatin, most breast cancer regimens, aggressive leukemia/lymphoma regimens
• e.g. TCHP
• if had PICC for their first cycle, try to get a port for the next cycle (or if you have time before the first cycle and they’ll need a PICC eventually, can get a port instead)

• most important question: is the med reservoir empty?
• if pump is messed up, get them an Extended Hours Clinic appt
• if messed up w/in 72h of chemo and neulasta not given, ok to place one-time order for SQ pegfilgrastim and schedule infusion appt

# 5-FU

• call infusystem: 1-800-315-3287

# blinatumumab

• call attg and infusystem