Use of a pharmacy protocol to convert standard rituximab infusions to rapid infusion shortens outpatient infusion clinic visits

The Rate of Infusion Represents an Important Aspect of Administering Anticancer Agents

Background

Infusion rate is one of the essential elements that should be included in all intravenous orders. Patients may experience adverse consequences or risks associated with inappropriate infusion. Meanwhile, there is growing pressure on the chemotherapy unit to deliver treatment quickly, efficiently, and safely, and thus it is very necessary to improve the chemotherapy process and service to cancer patients. Clinicians should consider how to further standardize infusion therapy, and innovate new infusion strategies to increase efficacy, reduce toxicity, improve patient satisfaction and save health resource costs. Sporadic studies have evaluated the effects of infusion rates of anticancer agents on clinical outcomes, economic benefits, and administration efficiency. However, an update review has not been available.

Methods

Relevant literature was identified by search of PubMed until September 2023.

Results

Infusion rates may have significant effect on the efficacy of anticancer agents (e.g., methotrexate, fluorouracil, and arsenic trioxide). Slow infusion is safer for platinum compounds, doxorubicin and carmustine, whereas fast infusion is safer than slow infusion of gemcitabine. Optimal flow rates of paclitaxel and fluorouracil are based on the balance between multiple risks of toxicity. Optimal infusion rate may bring economic benefits. If efficacy and safety are not compromised, shortened infusion may result in higher patient satisfaction, improved institutional efficiency and more nursing time available for other activities (e.g., biosimilar products, endostar). Other concerns about infusion rate include clinical indications (eg, paclitaxel and rituximab, methotrexate), severity and type of hypersensitivity reactions (e.g., platinum compounds), formulation features (e.g., paclitaxel, doxorubicin), and genetic polymorphism (e.g., gemcitabine, methotrexate).

Conclusion

The latest knowledge of infusion rate concerns will enhance the appropriateness and accuracy in intravenous administration. Interdisciplinary teams should collaborate and implement relevant risk management and healthcare policy. It is worthwhile to conduct comparative studies of intravenous therapy with different infusion speeds.

Effects of an Ocrevus Rapid Infusion Protocol: A Literature Review and Quality Improvement Project

The administration of Ocrevus, an infusion therapy for the treatment of multiple sclerosis, is time and labor intensive, leading to poor patient adherence, treatment delays due to scheduling issues, and significant staff workload. This problem worsened during the COVID-19 pandemic, which created scheduling difficulties due to space restrictions. A US Food and Drug Administration-approved rapid infusion protocol for Ocrevus decreases the infusion time by 1.5 hours per patient. The purpose of this project was to complete a literature review on rapid infusion protocols and analyze the effects of the Ocrevus rapid infusion protocol on 2 outcomes of interest: total visit time and infusion reaction rates. Data were collected using retrospective chart review and analyzed by comparing the results of each outcome to the same data points prior to the implementation of the project. Results found a statistically significant decrease in visit time, with no increase in infusion reaction rates. These findings support the implementation of this rapid Ocrevus infusion protocol in the outpatient setting with the potential to improve patient scheduling, patient satisfaction, and nursing workload, while maintaining patient safety.

Safety and tolerability of a 90-minute rapid infusion of Sandoz biosimilar rituximab in B-cell lymphoproliferative disorders in a real-world setting

Although rituximab is generally well-tolerated, infusion-related reactions (IRRs) are common with the initial dose when administered intravenously according to standard recommendations. To prevent IRRs, premedication and low-speed infusion rates have been recommended. Consequently, intravenous (i.v.) infusion of rituximab can become a labor-intensive process. Rapid i.v. rituximab infusion over 90 min has demonstrated a favorable safety profile for the second and subsequent infusions during the course of therapy. The aim of this study was to investigate the safety and tolerability of 90-min rapid infusion of Sandoz rituximab biosimilar (SDZ-RTX) for patients with CD20+ lymphoma or chronic lymphocytic leukemia (CLL). We retrospectively reviewed all patients with CD20+ lymphoma or CLL who received SDZ-RTX infusions in 90 min from July 2019 to July 2021 at seven Spanish hospitals. The primary end point was the incidence of IRRs. We identified 124 patients and 576 rapid administrations of SDZ-RTX, with an average of five rapid infusions per patient. Most rapid infusions of SDZ-RTX were in combination with CHOP/CHOP-like therapy (48.4%), followed by SDZ-RTX alone (15.1%), in combination with bendamustine (14.5%), or with other regimens (22%). The 90-min SDZ-RTX infusion schedule was well-tolerated with no grade 3/4 IRRs. The incidence of any grade IRR during the first rapid infusion was 1% (5 grade 1 IRRs and 1 grade 2 IRR). In conclusion, rapid 90-min i.v. administration of SDZ-RTX for the second and subsequent infusions during the course of therapy is well-tolerated in patients with CD20+ lymphoma or CLL.

Impact of electronic interventions on guideline concordant ordering of rituximab infusion rate

INTRODUCTION

Rituximab carries a boxed warning for severe or fatal infusion reactions; most occurring with the initial infusion. Prior studies established that if the initial rituximab infusion is tolerated, subsequent infusions can be given safely over 90 min. The University of Chicago Medicine (UCM) did not have a standardized method to document infusion reactions for outpatient chemotherapy patients, making it challenging for providers to know a patients' eligibility for rapid infusion. This quality improvement project focused on a series of interventions to improve documentation and electronic ordering of rituximab.

METHODS

A flowsheet for nurses to record patients' tolerance of chemotherapy infusions was created within the electronic health record (EHR). Following results of flowsheet impact, a second intervention was implemented to modify ordering of rituximab. The primary endpoint was the incidence of guideline concordant rate ordering of rituximab. Secondary endpoints included the incidence of accurate chair time scheduling pre- and post-interventions and nursing compliance with flowsheet documentation.

RESULTS

Prior to flowsheet implementation, 85% of patients were infused at the guideline concordant rate, compared to 79% post-implementation. Prior to modification of rituximab ordering in the EHR, 85% of patients were infused at the guideline concordant rate, compared to 87% after implementation. Complete nursing documentation was done 89% of the time when the flowsheet was utilized, compared to 11% pre-interventions.

CONCLUSION

No difference in primary or secondary endpoints was found following our interventions. However, the infusion documentation flowsheet, when used, provided more complete reaction data compared to when it was not used.

Evaluation of a pharmacist-driven rapid infusion rituximab conversion protocol at a multisite cancer center

INTRODUCTION

Infusion-related reactions (IRR) are a common adverse event associated with rituximab, an anti-CD20 monoclonal antibody indicated for the treatment of B-cell lymphomas. IRR risk is highest with the first infusion, which is given by a slow titration over an average of 3.5 hours. Subsequent administrations can be given over an accelerated, rapid 90-minute infusion if patients meet specific criteria. To improve rapid infusion rituximab utilization, we developed and implemented a pharmacist-driven protocol which allows pharmacists to change the administration instructions to rapid infusion.

METHODS

A retrospective chart review was conducted to evaluate patients age ≥18 years with B-cell lymphomas who were eligible to receive rapid infusion rituximab following protocol implementation. The primary outcome was the prevalence of the use of rapid infusion rituximab for eligible patients. Secondary outcomes included the frequency of pharmacist-initiated conversions to rapid infusion rituximab and incidence of IRR with rapid infusions.

RESULTS

A total of 180 patients were included in this study; 89 patients in the pre-protocol group and 91 patients in the post-protocol group. Fifteen patients and 66 patients in the pre-protocol and post-protocol groups, respectively, received rapid infusion rituximab (17% vs. 73%, p < 0.00001). The pharmacist-driven protocol was used to convert 49 patients (54%) to rapid infusion. No IRR occurred in patients receiving rapid infusion rituximab.

CONCLUSION

The implementation of a pharmacist-driven protocol led to a significant improvement in the use of rapid infusion rituximab and optimized chair time utilization at our institution.

Increasing Operational Capacity and Reducing Costs of Rituximab Administration: A Costing Analysis

OBJECTIVE

Originator intravenous rituximab is an important rheumatology treatment but is costly, and administration requires several hours. Because biosimilar rituximab may cost less and subcutaneous rituximab requires a shorter visit, both may reduce costs and increase treatment capacity (infusions per year).

METHODS

We implemented time-driven activity-based costing (TDABC), a method to assess costs and opportunities to increase capacity, throughout the care pathway for 26 patients receiving a total of 30 rituximab infusions. Using the TDABC estimates, we created a base case, which included provider time, salaries, infusion rates and times, and drug formulation, to simulate an induction cycle (two infusions). We varied these parameters in sensitivity analyses and assessed the impact of infusion rates and formulation (biosimilar vs. subcutaneous) on capacity before and after assuming a fixed budget.

RESULTS

The base-case cost was $19 452; more than 90% was due to drug cost. In sensitivity analyses, varying projected biosimilar cost led to the greatest cost savings ($8,988 per cycle). Faster infusion rates and subcutaneous rituximab increased annual capacity (300% and 800%, respectively). With a fixed budget, subcutaneous rituximab led to a relative increase in capacity over biosimilar rituximab except when biosimilar cost savings relative to originator rituximab exceeded 40%; faster biosimilar infusion rates did not meaningfully affect these findings.

CONCLUSION

Using TDABC, we demonstrate that rituximab cost is the primary driver of treatment cost, but capacity is largely driven by treatment time. Subcutaneous rituximab leads to higher capacity than biosimilar rituximab across a range of plausible costs; its use in rheumatology should be studied.

Rapid-Infusion Rituximab in a Pediatric Population

OBJECTIVES The use of rapid rituximab infusion in certain pediatric populations has generally been regarded as safe. The safety of our institution's rapid rituximab protocol was evaluated.

METHODS The primary end point was the number of and severity of adverse drug reactions. Secondary end points included a description of the patient population defined by the indication, dose, and number of rituximab infusions administered. Additionally, the difference in infusion times in hours of those receiving rapid rituximab infusions versus the theoretical infusion time of subsequent administration rate schedules was defined.

RESULTS A total of 88 infusions for 22 patients were reviewed. No dose-limiting adverse reactions were observed. Three patients experienced grade 1 isolated infusion-related adverse events during a single infusion encounter. Two of the three patients received additional doses of rapid rituximab infusions without incident, whereas the other patient no longer required rituximab therapy.

CONCLUSIONS The use of a 90-minute rituximab infusion protocol in pediatric patients with non-rheumatic diseases was well tolerated.

Impact of transitioning inpatient chemotherapy regimens to the outpatient setting

BACKGROUND

Chemotherapy regimens historically have required admission of the patient to the hospital for extended infusions running over multiple days to complete each cycle of therapy. With the evolution of monitoring strategies readily available, a renaissance in patient care and healthcare cost utilization is necessary as transitioning the administration of these agents to the outpatient setting is seemingly achievable and is potentially more cost-effective.

PURPOSE

This evaluation sought to primarily measure cost-savings for an institution by transitioning inpatient chemotherapy regimens to the outpatient setting. Secondary outcomes evaluated the effect of this transition on overall patient length of stay, prevalence of adverse effects, and overall chemotherapy schedule adherence as a result of implementing transitions in sites of care. Barriers to receiving care in the outpatient setting were assessed by evaluating the acuity of performance status as well as distance from the hospital.

METHODS

This single-center retrospective, quantitative chart and expense analysis evaluated patients receiving rituximab, etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin (R-EPOCH) or rituximab, ifosfamide, carboplatin, and etoposide (R-ICE) chemotherapy regimens based on treatment setting at a single institution. Included patients were treated at the University of Chicago Medical Center. Those receiving inpatient-only management as compared with patients who received therapy in outpatient settings were compared in a matched cohort analysis. The control group was matched from the period before transition of therapy was instituted between November 2014 and November 2015, with those patients transitioned to outpatient therapy (December 2015 to November 2016), using demographic, diagnostic, treatment, and clinical status data to assure group similarity. Mean cost of therapy was compared between inpatient and outpatient regimens. Descriptive and demographic categorical data were compared using the Fisher's exact test. Continuous data were evaluated using the Student's t test. A significance level of alpha <0.05 was used for all analysis.

RESULTS

The cost of R-EPOCH therapy represented a significant difference across groups. R-ICE therapy similarly saw significant cost differences between inpatient and outpatient groups. If this was made standard of care for qualifying patients a retrospective annualized estimation of $466,507.85 with R-EPOCH therapy and $205,977.60 for R-ICE therapy could have been saved if this was utilized for patients who previously received their therapy as an inpatient.

CONCLUSION

The population of patients cared for at the University of Chicago Medicine during this time-period qualified for outpatient treatment for those treated with R-EPOCH and R-ICE regimens with no significantly identifiable prohibitive barriers between groups. As no significant complications manifested, it is reasonable to continue transitioning patients receiving these regimens to the outpatient setting where appropriate. R-EPOCH and R-ICE therapies were shown to be reasonable outpatient therapy while providing significant cost-savings for the institution.

Tolerance and safety of rapid 2-hour infusion of rituximab in patients with kidney-affecting autoimmune diseases and glomerulonephritides: a single-centre experience

Objective

According to the manufacturer's documentation, rituximab (RTX) should be administered with slow infusion rates to prevent infusion-related adverse events (AEs). Nevertheless, slow infusions are time-consuming and uncomfortable for patients and medical staff. Therefore, faster infusion rates have been studied and proven safe and well tolerated in lymphomas and rheumatoid arthritis (RA). A small amount of data is available for rapid RTX infusions in non-RA autoimmune diseases.

Methods

Beginning in September 2015, all RTX-reated patients in our centre and willing to participate, were switched from slow RTX infusions (4.25 hours, given at least once to all patients) to fast infusions (2 hours). A total of 85 RTX 2-hour infusions was administered to 53 patients with autoimmune diseases with renal involvement and selected primary glomerulonephritides (26 ANCA-associated vasculitis, nine systemic lupus erythematodes, seven membranous nephropathy, five IgM nephropathy and six other autoimmune disease). Most of the patients received chronic corticosteroid therapy. The prednisone equivalent dose median (IQR) was 0.1 (0.0-0.2) mg/kg/day.

Results

Rapid RTX infusions were generally well tolerated. Only two infusion-related AEs were recorded: one Common Terminology Criteria for Adverse Events, grade 3, (lower back pain and hypotension followed by chills necessitating methylprednisolone and dipyrone administration) and one grade 1 (subjective intolerance). The AEs frequency does not differ from other studies with rapid RTX infusions in patients with lymphomas and RA.

Conclusions

Our experience supported other published data and provides evidence concerning the safety of non-initial RTX 2-hour infusion which can be administered without raising the infusion-related AEs rate in patients with kidney-affecting autoimmune diseases and glomerulonephritides.

Sixty-minute infusion rituximab protocol allows for safe and efficient workflow

PURPOSE

Rituximab is a chimeric monoclonal antibody approved to treat B cell non-Hodgkin's lymphoma (NHL). Infusion reactions among NHL patients are common during the first exposure but decrease with subsequent infusions. We sought to assess the safety and feasibility of a rituximab rapid infusion protocol in the outpatient treatment area of a comprehensive cancer center.

PATIENTS AND METHODS

Patients with indolent and intermediate B cell NHL were invited to enroll in this prospective, single-institution study if they had received the first dose of rituximab according to the manufacturer-labeled standard titration schedule without grade >2 infusion reaction. The subsequent infusion proceeded without the use of steroid premedication at 100 mg/h administered over 15 min, with the remaining dose given over 45 min. Time savings between rapid infusion and standard titration were calculated.

RESULTS

Fifty patients received 60-min rituximab infusions during the second drug administration. No infusion-related reactions of any grade were observed with the rapid infusion protocol (0%, one-sided 97.5% CI 0-7.1%). The mean time for the rapid rituximab infusion was 62.4 min (95% CI 61.2-63.6). When compared to the standard second dose infusion recommendation, a mean time of 94.2 min (95% 90-98.4) was saved with rapid infusion. Nursing surveys demonstrated 100% satisfaction with the rapid infusion protocol.

CONCLUSIONS

Subsequent rituximab infusions can be safely administered over 60 min and without steroid premedication in an experienced outpatient infusion center when patients are appropriately screened. The faster infusions can reduce resource utilization and increase nursing satisfaction.

TRIAL REGISTRATION

NCT01206777.