Paclitaxel-associated hypersensitivity reactions: experience of the gynecologic oncology program of the Cleveland Clinic Cancer Center

Preliminary experience with a modified premedication protocol that included intravenous diphenhydramine and calcium bromide for the prophylaxis of paclitaxel-related hypersensitivity reactions

BACKGROUND

Paclitaxel often causes severe hypersensitivity reactions (HSRs) rapidly after infusion, even in patients given prophylactic therapy. The purpose of this study was to analyze the incidence of paclitaxel-related HSRs in patients with non-small cell lung cancer (NSCLC) retrospectively, and to assess the feasibility of a modified premedication protocol.

METHODS

One hundred and seven patients who were pretreated with either a conventional premedication regimen (two doses of dexamethasone) or a short premedication regimen (single dose of dexamethasone with oral diphenhydramine and intravenous ranitidine), prior to paclitaxel infusion were retrospectively analyzed. A modified premedication regimen, consisting of 12.5 ml of Rescalmin (intravenous diphenhydramine 50 mg and calcium bromide 437.5 mg), intravenous ranitidine 100 mg, and intravenous dexamethasone 20 mg, was given 30 min prior to paclitaxel, with oral dexamethasone 8 mg given on the night before the paclitaxel. Patients received paclitaxel intravenously at 175 mg/m(2) over 3 h, followed by carboplatin, AUC 5, over 1 h on day 1 every 3 weeks.

RESULTS

In the conventional premedication group, 21 patients had HSRs (32.3%); in 1 of these patients the HSR was considered to be severe (1.5%). In the short premedication group, 19 patients had HSRs (45.2%); in 6 of these patients the HSRs were considered to be severe (14.3%). The incidence of severe HSRs was significantly higher in the short premedication group than in the conventional premedication group (P = 0.027). In the modified premedication protocol study, HSR events were recorded in 14 patients (63.6%); 14 showed flushing, 2 had skin rash, and 1 had tachycardia. No severe HSRs were seen.

CONCLUSIONS

The incidence of HSRs in the short premedication group tended to be higher than that in the conventional premedication group. The modified premedication protocol was found to be feasible for preventing paclitaxel-related HSR, but case accumulation is needed.

Weekly low-dose paclitaxel and carboplatin in the treatment of advanced or recurrent cervical and endometrial cancer

BACKGROUND

The purpose of this study was to evaluate the toxicity profile of weekly low-dose paclitaxel and carboplatin in patients with gynecologic malignancies.

METHODS

Patients had measurable disease defined by clinical examination or radiographic studies. Each cycle of treatment consisted of carboplatin at an AUC of 2 and paclitaxel at 80 mg/m2 on days 1, 8, and 15 of a 28-day cycle.

RESULTS

Twenty-eight patients with advanced or recurrent cervical and endometrial cancers were included in this study. The overall response rate (ORR) was 39% (2 CR, 9 PR). Among the 15 cervical cancers the ORR was 20%, while the 13 endometrial cancers had a 62% ORR. Median time to progression and overall survival was 3.4 and 7.6 months for those with cervical cancer and 5.5 and 15.4 months for those with endometrial cancer. Grade 3 or 4 hematologic toxicity was uncommon (7% grade 3 anemia, 21% grade 3 or 4 neutropenia, 7% grade 3 or 4 thrombocytopenia).

CONCLUSION

A regimen of weekly low-dose paclitaxel and carboplatin has an acceptable toxicity profile that is easily managed by dose adjustment and the use of erythropoietic therapy. This regimen appears to have activity in advanced or recurrent endometrial cancer which warrants further evaluation.

[Nutrition, lifestyle, physical activity, and supportive care during chemotherapeutic treatment]

With improvements in cancer survival rates, more patients with cancer are living longer and the influence of nutrition, lifestyle, physical activity as well as supportive care during and after chemotherapy is of increasing interest. In several malignancies smoking cessation increases cancer survival. Similar effects are expected by healthy nutrition. Regular physical activity of cancer patients reduces drug interactions of chemotherapy, decreases the number of comorbid conditions, and helps patients maintain independence as long as possible. For supportive care during chemotherapy the 5-HT3 receptor antagonists are more effective for the prevention of chemotherapy-induced nausea and vomiting. There are several colony-stimulating factors (e.g. GCSF, erythropoietin) for hematopoietic recovery post-chemotherapy. Altogether supportive care of chemotherapy reduces toxicity and increases efficacy.

Atypical presentations of carboplatin hypersensitivity reactions: Characterization and management in patients with gynecologic malignancies

OBJECTIVES

Carboplatin skin testing (ST) can help identify patients with platinum hypersensitivity (PH), however, we have encountered patients who do not immediately test positive yet exhibit subtle or delayed allergy symptoms prior to PH. We describe the "atypical platinum reactions" (APH) of 14 patients and our experience with skin testing and desensitization.

METHODS

Retrospective chart review was performed on carboplatin-treated patients. Patients with +ST, PH or APH were offered desensitization, and the number of successful additional treatments was recorded.

RESULTS

A total of 73 ST were administered to patients receiving their >6th carboplatin cycle. 19 +ST and 10 PH with -ST were identified. 14 APH were identified including delayed +ST conversions and allergy symptoms. The median onset and duration of symptoms after treatment were 6 and 3.5 days respectively. 12 APH patients had ST on their next cycle, seven of which were immediately positive. ST was positive in 36% of those tested, resulting in a negative predictive value of 76%. The median number of carboplatin cycles received prior to ST conversion, PH or APH was eight. 29% of patients with a +ST, PH, or APH had a prior history of systemic allergic reaction to other medications or allergens. Desensitization and dose escalation were successful in 14/20 patients (70%) for an average of 1.9 cycles/patient.

CONCLUSIONS

ST will not identify all patients with carboplatin-associated reactions. Careful questioning regarding symptoms in between chemotherapeutic cycles may identify patients who will benefit from desensitization, allowing continuation of treatment and prevention of life-threatening adverse events.

Rapid desensitization for hypersensitivity reactions to chemotherapy agents

PURPOSE OF REVIEW

Hypersensitivity reactions (HSRs) to chemotherapy agents have limited their use for fear of inducing severe reactions or death. Alternative regimens may be limited by tumor sensitivity and the need to provide first-line therapy. Rapid desensitizations allow patients to be treated with medications to which they have presented a HSR. The purpose of this review is to highlight the indications and recent developments in chemotherapy rapid desensitization protocols.

RECENT FINDINGS

Intravenous and oral rapid desensitization protocols are available for taxenes, platinums, doxorubicin, monoclonal antibodies and others. Candidate patients present mild to severe type I hypersensitivity, mast cell/IgE-dependent reactions, as seen with platinums. Anaphylactoid reactions, such as those with taxenes, can be treated with the same protocols. Repeat desensitizations in outpatient settings are well tolerated and allow patients to remain in clinical studies/trials. Breakthrough symptoms during desensitizations are less severe than the initial reaction and no deaths have been reported. Cancer remissions are similar to those for nondesensitized patients.

SUMMARY

The use of rapid desensitization protocols for cancer patients with HSRs to chemotherapy depends on their demonstrated tolerability and efficacy in selected populations. Education of nurses, pharmacists, and oncology and allergy specialists is needed to improve their universal application as standard of care.

Paclitaxel Hypersensitivity Reactions

Several studies have suggested the usefulness of a test dose of paclitaxel to reduce the incidence of hypersensitivity reactions and the resulting cost of drug wastage. The aim of this study was to assess the utility of implementing such a test dose.

METHOD

We retrospectively reviewed the medical charts of patients who had received one or two courses of single-agent paclitaxel or a combination chemotherapy regimen to calculate hypersensitivity reaction incidence and the cost of drug wastage. Thereafter, a paclitaxel test-dose program was routinely implemented during the first and second cycles of paclitaxel treatment for all patients. Hypersensitivity reaction incidence and drug wastage cost were again assessed.

RESULTS

Before the routine use of a test dose, 162 patients received one or two paclitaxel infusions alone or in combination therapy from January 1, 1997 to February 28, 2003. Ten (6.2%) patients experienced a hypersensitivity reaction; one of them was severe. After implementation of the test-dose program, 130 patients received 244 test doses (12 mg paclitaxel/10 mL normal saline) with an intensified premedication regimen at the first and second cycles of chemotherapy from June 28, 2003 to March 2, 2005. Three patients (2.3%) experienced a minor hypersensitivity reaction, one immediately after the test dose and two during infusion of the full dose despite a well-tolerated test dose. Thus, the negative predictive value of the test dose was 98.4%. The overall incidence of hypersensitivity reactions experienced during the first or second cycle of paclitaxel chemotherapy decreased about 63% compared with the incidence before implementation of the test dose (P < 0.20). The test-dose program resulted in a 29% increase in the cost of chemotherapy (approximately 6100 dollars for 130 patients).

CONCLUSION

To our knowledge, this is the largest study ever reported to test the potential cost-saving benefit of the implementation of a paclitaxel test-dose program to prevent hypersensitivity reactions. The results suggest that the routine use of a test dose is not a cost-effective measure.

Rapid inpatient/outpatient desensitization for chemotherapy hypersensitivity: Standard protocol effective in 57 patients for 255 courses

OBJECTIVES

Hypersensitivity reactions (HR) to chemotherapy often prompt permanent discontinuation and deprive the patient of the most active regimen. We investigated the safety and effectiveness of a rapid desensitization protocol used in inpatient and outpatient settings for patients with HR to various chemotherapy and related agents.

METHODS

A 3-solution, 12-step protocol delivered doubling drug doses by step, infusing the target dose over 5.8 h for inpatient and 3.8 h for outpatient administration.

RESULTS

57 consecutive patients who had moderate to severe HR to chemotherapy were evaluated for desensitization. All 57 patients successfully completed 255 courses of desensitization (127 to carboplatin, 114 to paclitaxel, and 14 to four other agents) where 16 patients received 51 courses in the outpatient setting (34 to carboplatin and 17 to paclitaxel). 225 courses (88.2%) were completed without any HR. 18 patients had breakthrough symptoms (BS) over 30 courses (11.8%) that were less severe than their initial HR. After management of breakthrough symptoms, these patients finished all 30 courses and tolerated subsequent desensitizations on a modified protocol. 21 of 26 patients (81%) with HR to carboplatin had positive skin tests to carboplatin. Cancer response to chemotherapy administered by desensitization was within the expected range after 1-3 years of follow-up.

CONCLUSION

The rapid desensitization protocol was safe and effective in both the inpatient and outpatient settings and allowed appropriate patients with moderate to severe HR to continue chemotherapy. This study warrants the incorporation of the protocol into standard clinical practice.

Tapering and discontinuation of glucocorticoid prophylaxis during prolonged weekly to biweekly paclitaxel administration

BACKGROUND

Taxanes cause hypersensitivity reactions, averted by premedication with H1 blockers and high glucocorticoid (GC) doses. Prolonged weekly taxane administration may lead to GC toxicity.

PURPOSE

To determine whether patients not hypersensitive to initial paclitaxel (PTX) infusion after high-dose GC premedication will tolerate subsequent, prolonged PTX treatment without GC prophylaxis.

PATIENTS AND METHODS

In 115/122 breast cancer patients not hypersensitive to initial PTX treatment, 20 mg dexamethasone (DXM) doses were tapered by 2.0 mg/week, reaching 0 in those receiving 9 or more courses. After 4 PTX courses, diphenhydramine was administered orally, rather than intravenously.

RESULTS

PTX was administered 143 times after 2.0-5.0 mg of DXM and 357 times without DXM. A total of 46 patients received 1-40 PTX courses without DXM. None of these 115 patients experienced hypersensitivity reactions.

CONCLUSION

Patients unreactive to their first PTX infusions, after high-dose and tapering GC premedication, may not require GC prophylaxis for subsequent PTX therapy.

Improving Patient Outcomes in an Ambulatory Infusion Setting

Nurses working in the outpatient ambulatory setting treat patients with multiple infusion drug regimens. Patients can have allergic reactions to infusions ranging from very mild to life-threatening. The reaction and the subsequent treatment measures can be very disconcerting to the patients and to the visitors in the infusion area. The nursing team described in this article took a proactive approach to minimize infusion reactions in the authors' facility, thereby ensuring the safety of other patients. Staff members examined the performance improvement data, conducted a retrospective study, and collaborated with the primary physician providers to develop rechallenge protocols for patients receiving paclitaxel and carboplatin regimens.

Incidence and risk factors for paclitaxel hypersensitivity during ovarian cancer chemotherapy

Hypersensitivity reaction (HSR) is still a major concern during cancer chemotherapy with paclitaxel. In the present study, we investigated retrospectively the incidence of HSRs to paclitaxel and the risk factors in 105 patients (553 courses) who received adjuvant chemotherapy (paclitaxel and carboplatin) for ovarian cancer. Moderate to severe HSRs that led to cessation or discontinuation of the chemotherapy, including respiratory distress and hypotension, were observed in 14 patients (13.3%) and 16 courses (2.9%), regardless of the use of conventional premedication with glucocorticoid, and histamine H(1) and H(2) antagonists. The incidence of HSRs to paclitaxel in patients with ovarian cancer seemed to be considerably higher than those reported by other investigators in patients with other carcinomas such as non-small-cell lung cancer and breast cancer. Four risk factors were identified: (1) history of mild dermal reactions such as facial flushing and urticaria in previous courses, (2) presence of respiratory dysfunction, (3) obesity (body mass index >25), and (4) postmenopausal at the time of ovariectomy. The incidence of hypersensitivity increased linearly as the number of risk factors increased (r=0.992, P=0.008). It is likely that disappearance of the estrous cycle facilitates the occurrence of HSRs to paclitaxel.

Rapid desensitization for hypersensitivity reactions to paclitaxel and docetaxel: a new standard protocol used in 77 successful treatments

OBJECTIVE

Administration of paclitaxel is associated with hypersensitivity reactions (HSRs) in up to 9% of patients despite premedication. The purpose of this study was to evaluate the effectiveness of a standardized desensitization protocol in patients with HSRs to taxanes, based on our experience with carboplatin desensitization.

METHODS

We analyzed seventeen consecutive patients with documented HSRs to taxanes who required continued treatment with a taxane agent. The patients were treated with either paclitaxel or docetaxel using the 6- to 7-h standard desensitization protocol.

RESULTS

Seventeen patients who previously had severe taxane HSRs successfully completed 77 planned cycles of desensitization to paclitaxel or docetaxel, 72 of which were without reactions. Four patients developed HSRs during the desensitization protocol that were much less severe than their original HSRs and tolerated the re-administration of infusions without further reactions. Of these four patients, the first had palmar erythema 8 h after her 1st desensitization. The second patient had mild abdominal pain during her 1st cycle, and the third patient developed mild chest burning during her 2nd and 4th cycles. These three patients also completed subsequent desensitization cycles without reactions. The fourth patient developed a delayed urticaria reaction and gastrointestinal symptoms 6 h after completing her 1st desensitization. She elected to be treated with an alternative chemotherapy and did not receive additional courses of desensitization.

CONCLUSION

The rapid standard desensitization protocol provides a safe and effective strategy for the re-administration of paclitaxel or docetaxel even after severe HSRs.

Similarity and difference in the acute lung injury induced by a radiographic contrast medium and an anticancer agent paclitaxel in rats

Paclitaxel is one of the most frequently used anticancer agents but its use is sometimes limited because of the incidence of severe hypersensitivity reactions. The clinical symptoms of the reactions, including dyspnea and pulmonary edema, are similar to those induced by iodinated contrast medium during radiographic examination. Therefore, the premedication for the prophylaxis of hypersensitivity reactions to paclitaxel is carried out in accordance with that for radiographic contrast medium. In the present study, we compared the effects of paclitaxel and an iodinated radiocontrast medium ioxaglate on vascular permeability and pulmonary function in rats. Both paclitaxel (15 mg/kg) and ioxaglate (4 g iodine/kg) caused perivascular edema, plasma extravasation and decrease in arterial PaO2. Dexamethasone inhibited plasma extravasation induced by the two compounds. In contrast, histamine H1 and H2 antagonists attenuated the effects of ioxaglate without inhibiting those of paclitaxel. On the other hand, a neurokinin NK1 antagonist (LY303870: 0.5 mg/kg) significantly inhibited the pulmonary responses induced by paclitaxel but not by ioxaglate. Therefore, it is suggested that paclitaxel and ioxaglate cause similar acute lung injury but the mechanisms are different between the two compounds, in which histamine and substance P are involved in the pulmonary dysfunction induced by ioxaglate and paclitaxel, respectively. These findings also raise a possibility that more effective premedication is required for the prophylaxis of paclitaxel hypersensitivity.

Pemirolast potently attenuates paclitaxel hypersensitivity reactions through inhibition of the release of sensory neuropeptides in rats

The effects of anti-allergic agents on the hypersensitivity reactions to paclitaxel, an anti-cancer agent, were examined in rats. Intravenous injection of paclitaxel (15 mg/kg) caused a marked extravasation of plasma protein in lungs and a transient decrease in arterial partial oxygen pressure (PaO(2)). The paclitaxel-induced protein extravasation was inhibited by low doses (0.1-1 mg/kg) of pemirolast or high doses (30-100 mg/kg) of cromoglycate. However, ketotifen was not effective. The decrease in PaO(2) induced by paclitaxel was also significantly reversed by pemirolast. On the other hand, the paclitaxel-induced plasma extravasation was not attenuated by a histamine H(1) blocker diphenhydramine or an H(2) blocker famotidine, but was significantly reduced by a neurokinin NK(1) antagonist LY303870 (0.5 mg/kg) and an NK(2) antagonist SR48968 (1 mg/kg). The concentrations of proteins and sensory peptides such as substance P, neurokinin A and calcitonin gene-related peptide but not histamine in the rat bronchoalveolar lavage fluid were elevated by paclitaxel injection. Both cromoglycate and pemirolast reduced the paclitaxel-induced rise in proteins and sensory peptides. Therefore, we demonstrated for the first time that sensory nerve peptides are involved in paclitaxel hypersensitivity and that an anti-allergic agent pemirolast attenuates the paclitaxel response by inhibiting the release of sensory nerve peptides.

Docetaxel Versus Paclitaxel for Adjuvant Treatment of Ovarian Cancer

The objective of this study was to evaluate the toxicity profile of docetaxel/carboplatin versus paclitaxel/carboplatin. All patients with primary ovarian, fallopian tube, or peritoneal malignancies treated with docetaxel and platinum at the University of Iowa between January 1996 and June 1999 were identified. Controls, treated with paclitaxel and platinum, were matched for age, date of diagnosis, type of cancer, stage, and residual disease. Toxicity was evaluated prior to each cycle and was graded according to the Gynecologic Oncology Group criteria. Twenty patients were identified in each group and evaluated. In the docetaxel/carboplatin group, sixteen (80%) patients experienced hematologic toxicity. Nine (45%) had grade III or IV neutropenia and fever developed in two of these patients. Grade III or IV thrombocytopenia developed in two patients. In contrast, among the paclitaxel/carboplatin group, grade III or IV neutropenia developed in only three patients (p < 0.05) and grade III or IV thrombocytopenia developed in two patients. There were no significant differences between the two groups with regard to gastrointestinal or renal toxicity. In the paclitaxel/carboplatin group, 13 patients developed neuropathy compared to only 2 patients (10%) in the docetaxel/carboplatin group (p < 0.05). There was no difference in the clinical response between the two treatment groups. In conclusion, neutropenia was more common with the docetaxel/carboplatin regimen, whereas neuropathy was more common in the paclitaxel-based regimen. The therapeutic efficacy was equivalent between the two groups.

Role of sensory nerve peptides rather than mast cell histamine in paclitaxel hypersensitivity

Paclitaxel is one of the most extensively used anticancer agents, however, its use is often limited by severe hypersensitivity reactions, including respiratory distress, bronchospasm, and hypotension, which can occur despite premedication with dexamethasone and histamine H1 and H2 antagonists. The present study was designed to determine the mechanisms of paclitaxel hypersensitivity. In rats, paclitaxel (15 mg/kg, intravenously) caused a marked increase in pulmonary vascular permeability and edema. PaO2 decreased, whereas PaCO2 increased, transiently after paclitaxel injection. The paclitaxel-induced pulmonary vascular hyperpermeability was blocked by dexamethasone but not by histamine H1 or H2 antagonists. Paclitaxel increased the vascular permeability in lungs of mast cell-deficient rats Ws/Ws(-/-) to almost the similar extent as that elicited in wild-type rats. On the other hand, the paclitaxel-induced pulmonary vascular hyperpermeability was reversed by sensory denervation with capsaicin or pretreatment with LY303870 and SR48968, NK1 and NK2 antagonists, respectively. Consistent with these findings, a marked elevation of sensory neuropeptides such as substance P, neurokinin A, and calcitonin gene-related peptide was observed in rat bronchoalveolar lavage fluid after paclitaxel injection. These findings suggest that sensory nerves rather than mast cells are implicated in the etiology of paclitaxel hypersensitivity.

Management of toxicities associated with the administration of taxanes

The taxanes (paclitaxel and docetaxel) are highly active cytotoxic antineoplastic agents. Common toxicities of the drugs include total alopecia, hypersensitivity reactions, bone marrow suppression (principally neutropenia), arthralgia, myalgias, and peripheral neuropathy. When administered as a 3-h infusion, paclitaxel appears to be associated with a lower risk of neutropenia and a greater risk of peripheral neuropathy, compared to either 24-h infusion paclitaxel or docetaxel (1-h infusion). Neither paclitaxel nor docetaxel is associated with a high risk for significant emesis. High cumulative doses of docetaxel have been shown to produce fluid retention (e.g., oedema, ascites, pleural effusions), while paclitaxel, when combined with doxorubicin, increases the risk of anthracycline-induced heart failure. Both paclitaxel and docetaxel have been administered at lower dose levels, on a weekly schedule, with acceptable toxicity profiles. In general, the side effects of the taxanes are manageable, and few patients discontinue treatment due to excessive toxicity.

10. Drug allergy

Adverse drug reactions are common, but only 6% to 10% are immunologically mediated. Unlike most adverse drug reactions, allergic drug reactions are unpredictable. Whereas some drug-induced allergic reactions may be easily classified into one of the four Gell and Coombs hypersensitivity categories, many others that appear to have an immunologic component cannot be classified because of our lack of mechanistic information. Theoretically, any drug can induce an immune response. However, some drugs are more likely to elicit clinically relevant immune responses than are others. Drugs in this category include antimicrobial drugs, anticonvulsants, chemotherapeutic agents, heparin, insulin, protamine, and biologic response modifiers. After a drug-disease connection is established, it must be determined whether the reaction was immunologically mediated. Subsequently, confirmatory tests, if available, should be used to determine the allergic status of the patient. If these tests are not available, a graded challenge or desensitization may be considered, depending on the type of clinical reaction previously demonstrated and the need for drug readministration. Education of the patient and primary care physician is an important component of patient management.

Premedication strategy for weekly paclitaxel

PURPOSE

Dexamethasone and histamine antagonists have been employed commonly as premedications for prophylaxis of hypersensitivity reactions (HSRs) to paclitaxel. Frequent premedications for weekly administration of paclitaxel are associated with added side-effects and extra cost. We analyzed our experience of HSRs to paclitaxel administered every 3-4 weeks, and designed a treatment algorithm to eliminate premedications in a majority of patients receiving weekly paclitaxel.

PATIENTS AND METHODS

The incidence of HSRs was analyzed retrospectively in patients who received 3-hr infusions of paclitaxel (135-225 mg/m2) every 3-4 weeks in our institution over a period of 5 years. On the basis of the results of this analysis, we designed a premedication schema for patients receiving weekly paclitaxel, 50-90 mg/m2/week, as follows: Thirty minutes prior to the first weekly dose of paclitaxel, patients received intravenously (i.v.) dexamethasone (10 mg), diphenhydramine (25 mg), and cimetidine (300 mg). If no HSRs occurred, all premedications were deleted for subsequent weekly paclitaxel doses. For patients who experienced HSRs, 20 mg of dexamethasone was given orally 12 and 6 hr prior to re-challenge with paclitaxel in addition to diphenhydramine and cimetidine.

RESULTS

Over a period of 5 years, 358 patients received 1608 3-hr infusions of paclitaxel (135-225 mg/m2). Hypersensitivity reactions, which occurred exclusively during the first cycle of paclitaxel administration, were observed in 14 patients. Of these 14 patients, 11 were successfully retreated with paclitaxel without HSRs, two had recurrent HSRs upon paclitaxel re-challenge, and one refused further treatment. These observations indicate that HSRs to paclitaxel occurred in 4% of patients upon first exposure, that most of these patients can be retreated successfully with paclitaxel without recurrent HSRs, and that if no HSRs occur during the first cycle, HSRs are unlikely to occur with subsequent paclitaxel administration. The premedication schema was applied to 30 patients receiving 205 one-hr infusions of weekly paclitaxel. Using this premedication strategy, no HSRs have been observed during the initial or subsequent administration of paclitaxel.

CONCLUSION

We conclude that this premedication strategy is feasible and worthy of further study for patients receiving weekly paclitaxel.

Implementation and results of a test dose program with taxanes

PURPOSE

A pilot taxane test-dose policy was developed and implemented to determine whether the severity of patient hypersensitivity reaction and drug waste would be reduced.

PATIENTS AND METHODS

Data from 206 eligible cancer patients undergoing first-dose taxane chemotherapy were analyzed. The severity of hypersensitivity reactions before and after the implementation of taxane test dose was graded (scale 1-4) and analyzed for statistical differences between groups. Average drug wastage was calculated before and after program initiation.

RESULTS

Twenty-two of 206 patients (10.7%) experienced a hypersensitivity reaction. The mean hypersensitivity reaction severity for reacting patients who did not receive a test dose (N = 12) was 3.3, and for those who were given a test dose (N = 10), it was 1.5. Only one of five patients who experienced a hypersensitivity reaction that required hospitalization was from the test-dose group. The value of drug alone wasted before test-dose utilization was about $1794 per reacting patient, and the use of taxane test doses saved approximately $1784 per reacting individual. This represented more than a $178 savings for every patient receiving a taxane for the first time. These figures do not include resuscitation, hospital, and other subsequent other costs associated with morbidity.

CONCLUSIONS

Implementation of a taxane test-dose policy significantly reduced hypersensitivity reaction severity, drug wastage, and hospitalizations.

Epithelial ovarian cancer

Epithelial ovarian cancer is the most lethal of all gynecologic malignancies. Most women have advanced stage disease. Access to appropriate initial surgical management by a gynecologic oncologist is important because treatment and survival are affected by appropriate surgical staging and debulking of tumor. After debulking/staging surgery, chemotherapy with platinum-taxane-based regimens is appropriate for most patients. Patients with early stage, low-risk tumors may be cured with surgery alone. Interval cytoreductive surgery may be appropriate for patients who are initially suboptimally cytoreduced and are stable or responding to chemotherapy. The role of second-look surgery remains to be defined. Patients with recurrent or relapsed ovarian cancer are incurable. There are several chemotherapy agents that can achieve disease responses, which may be associated with palliation of tumor-related symptoms. Participation in clinical trials is encouraged for all patients. Novel approaches to managing minimal residual disease are being tested in hopes of decreasing the number of patients who relapse after achieving complete clinical remission.

Prevention and management of antineoplastic-induced hypersensitivity reactions

Acute hypersensitivity reactions (HSRs) are an unpredictable and potentially catastrophic complication of treatment with chemotherapeutic agents. Reactions may affect any organ system in the body and range widely in severity from mild pruritus to systemic anaphylaxis. Certain classes of chemotherapeutic agents, such as the taxanes, platinum compounds, asparaginases, and epipodophyllotoxins are commonly associated with HSRs. The clinical characteristics of these high risk agents with respect to HSRs are discussed in this review. Protocols to prevent or reduce the severity of these reactions have been developed, but despite these attempts, HSRs will still happen. Should a reaction occur, it is imperative that it be recognised quickly in order to minimise exposure to the inciting agent and implement appropriate therapeutic and supportive measures. When a patient becomes sensitised to a chemotherapeutic agent, avoidance of re-exposure is the mainstay of future prevention. For sensitised patients who have derived clinically meaningful benefit from a particular agent, however, continuation of treatment with the agent is desirable. Options may include attempting a trial of desensitisation or treatment with a related compound. Virtually all patients demonstrating HSRs to paclitaxel and docetaxel are able to successfully tolerate re-treatment following discontinuation and administration of diphenhydramine and hydrocortisone. Re-treatment has generally been less successful with platinum compounds. with recurrent HSRs occurring in up to 50% of patients following desensitisation protocols. Patients sensitised to asparaginase are often able to tolerate the alternative preparations, Erwinia carotovora asparaginase or polyethylene glycol-modified Escherichia coli asparaginase. There is very little experience with re-treatment following sensitisation to the epipodophyllotoxins. As re-treatment may have serious consequences, careful consideration of the risks and benefits of these strategies is imperative when deciding among these options.

A comparison of two prophylactic regimens for hypersensitivity reactions to paclitaxel

OBJECTIVE

The aim of this study was to compare the rates of hypersensitivity reactions to paclitaxel with the conventional prophylactic regimen of two doses of oral corticosteroids and a modified regimen of a single dose of intravenous corticosteroid.

METHODS

This was a retrospective historical cohort study assessing the rates of hypersensitivity reactions in patients receiving paclitaxel for ovarian or primary peritoneal carcinoma at the Hamilton Regional Cancer Centre from 1996 to 2000. Until 1998, all patients received the conventional prophylactic regimen consisting of two doses of oral dexamethasone (20 mg), 12 and 6 h prior to paclitaxel. From 1998 to the present, patients received a single dose of intravenous dexamethasone (20 mg), 30 min prior to paclitaxel. All patients also received an H(1) and H(2) blocker intravenously prior to paclitaxel administration. The analysis was corrected for potential covariates such as dose of paclitaxel and rate of infusion. The primary outcome measure was the rate of hypersensitivity reactions as defined by the National Cancer Institute of Canada-Clinical Trials Group. The Yates-corrected chi(2) test was used to compare the rates of these reactions, and a logistic regression analysis was used to determine whether any of the covariates were significant factors in these reactions.

RESULTS

One hundred seven patients received the conventional corticosteroid prophylaxis prior to paclitaxel, and 110 received the single-dose intravenous corticosteroid prophylaxis. Of the 107 patients in the conventional prophylaxis group, 8 had a hypersensitivity reaction (7.5%), and only 1 of these was severe (0.9%). In contrast, of the 110 patients in the single-dose IV corticosteroid group, 19 had a hypersensitivity reaction (17.3%), and 8 of these were severe (7.3%). The difference in hypersensitivity reaction rates was significant (chi(2), P = 0.047). In the logistic regression analysis, the only significant factor related to hypersensitivity reactions was the type of prophylactic steroid regimen.

CONCLUSIONS

In this series, the single-dose intravenous corticosteroid prophylactic regimen appeared to be associated with a higher rate of hypersensitivity reactions to paclitaxel than the conventional two-dose oral corticosteroid regimen.

Severe interstitial pneumonitis associated with docetaxel administration

BACKGROUND

Interstitial pneumonitis has not been reported as a toxicity of docetaxel. The authors report the presentation and natural history of four patients who developed a severe interstitial pneumonitis after receiving docetaxel.

METHODS

The hospital and outpatient records of patients treated with docetaxel were reviewed to identify whether any of these patients required an evaluation for respiratory problems.

RESULTS

Four patients developed an interstitial pneumonitis that could be explained only as a toxicity of docetaxel. None had metastatic disease to the lung, and all had normal liver function before receiving chemotherapy. The patients presented with acute dyspnea and fever within 1-2 weeks of receiving docetaxel. All developed progressive interstitial infiltrates and respiratory failure that required mechanical ventilation. An exhaustive workup for other causes of pneumonitis was negative. Broad-spectrum antibiotics and corticosteroids were ineffective. Two patients died of complications related to the pulmonary process. The two survivors required ventilatory support for more than 21 days. The clinical and pathologic findings of these patients are presented.

CONCLUSIONS

Interstitial pneumonitis is a rare and potentially fatal complication of docetaxel treatment. Prolonged ventilatory support is appropriate in patients with a favorable prognosis.

Prophylaxis for paclitaxel hypersensitivity reactions

OBJECTIVE

To evaluate clinical literature supporting the prophylactic use of single-dose intravenous dexamethasone to prevent hypersensitivity reactions (HSRs) to paclitaxel infusion.

DATA SOURCES

Clinical literature accessed through MEDLINE (from 1986 to 2000).

DATA SYNTHESIS

Prophylaxis for paclitaxel-related HSRs generally includes repeated dexamethasone doses beginning 12 hours before paclitaxel, and administration of diphenhydramine plus a histamine2-receptor antagonist 30 minutes before infusion of paclitaxel. Singe-dose intravenous dexamethasone administered with ancillary medications 30 minutes before infusion of paclitaxel has been used to prevent regimen-related HSRs.

CONCLUSIONS

Single-dose intravenous dexamethasone can be used in combination with appropriate ancillary medications to prevent paclitaxel-related HSRs.

Famotidine: Prevention of Paclitaxel Hypersensitivity Reactions

Off-Label Drug Uses

This Hospital Pharmacy feature is extracted from Off-Label DrugFacts, a quarterly publication available from Facts and Comparisons. Off-Label DrugFacts is a practitioner-oriented resource for information about specific FDA-unapproved drug uses. This new guide to the literature will enable the health care professional/clinician to quickly identify published studies on off-label uses and to determine if a specific use is rational in a patient care scenario. The most relevant data are provided in tabular form so that the reader can easily identify the scope of information available. A summary of the data—including, background, study design, patient population, dosage information, therapy duration, results, safety, and therapeutic considerations—precedes each table of published studies. References direct the reader to the full literature for more comprehensive information prior to patient care decisions. Direct questions or comments on “Off-Label Drug Uses” to hospitalpharmacy@drugfacts.com .