Vigilance, Rapid Interventions Key to Chemotherapy Reaction Management

Rapid interventions during chemotherapy reactions can be a matter of life or death, and depends on oncology nurses’ vigilance and recognizing type and grade of reaction. “Desensitization protocols vary but should be continued while the patient is undergoing treatment with the causative agent,” said Maura Price, MSN, RN, AOCNS, an oncology clinical nurse specialist at the Lehigh Valley Topper Cancer Institute in Muhlenberg, Pennsylvania.

Price detailed drug sensitivity, reaction types, and grading and desensitization during the 2023 Oncology Nursing Society (ONS) Bridge live virtual conference.

Recognizing and grading reaction types and prompt intervention are essential. Reaction symptoms include skin itching; redness; flushing; rash or urticaria (itchy, round red welts); fevers; rigors; lower back pain; or cardiovascular (chest pain/tightness, hypertension, hypotension, or tachycardia), gastrointestinal (nausea, vomiting, cramping), or respiratory (wheezing, stridor, shortness of breath, increased respiratory rate, or reduced pulse oximetry values) symptoms.

Adverse Reactions

Infusion reactions are immune-mediated reactions — essentially, allergic reactions that involve immunoglobulin E antibodies (IgE), IgG, immune complex, or cellular responses to therapeutic agents.

Price described 3 reaction types under the Common Terminology Criteria for Adverse Events (CTCAE):

• Anaphylaxis Acute inflammatory reaction triggering mast cells’ release of histamine and potentially deadly immune hypersensitivity, breathing difficulty, dizziness, hypotension, cyanosis, and loss of consciousness.
• Cytokine release syndrome A life-threatening release of high concentrations of cytokines triggering fever, tachypnea, headache, tachycardia, hypotension, rash, and/or hypoxia.
• Infusion-related reactions An adverse reaction to the infusion of drugs or biologic agents.

Under CTCAE, each of these reactions is graded on a scale of 1 to 5, with Grade 1 reactions being mild and transient with no required infusion interruption or intervention to Grade 5 (death).

A separate system for grading hypersensitivity reactions is the Brown Classification system: mild reactions involve skin or 1 organ system, moderate reactions involve 2 or more organ systems without changes in vital signs, and severe reactions involve 2 or more organ systems plus changes in vital signs, Price explained.

Platinum-based chemotherapy agents (carboplatin, cisplatin, and oxaliplatin), paclitaxel, docetaxel, procarbazine, L-asparaginase, and etoposide are chemotherapy regimen agents that commonly trigger reactions, Price noted. Cancer centers should maintain response protocols for these and any other chemotherapy agents with a high risk of reaction.

Skin testing is available for carboplatin, oxaliplatin, and L-asparaginase. Skin tests and tryptase levels can confirm that reactions stem from a true drug allergy. 

Reaction management can involve administering antihistamines, corticosteroids such as methylprednisolone, acetaminophen, epinephrine; beta2 agonists such as albuterol; oxygen support; meperidine analgesic; and parenteral electrolyte saline solution.

Except for grade 1 reactions, the management of reactions involves 7 steps oncology nurses should follow: halt infusion; summon help; maintain IV access; assess airway, breathing and circulation; consult and follow your center’s policy; notify patient provider; and document the reaction. (With severe reactions in particular, Price suggested a team debrief should be undertaken with a review of the patient’s baseline vital readings and the timing of intervention to improve responses to future incidents.)

Mild reactions should prompt rechallenge, sometimes with a slower infusion rate and additional premedications. But severe reactions should prompt consideration of alternate treatment agents or moving to the next line of treatment or desensitization with premedication.