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Initial Management of Hypersensitivity Reactions to Medications Used for Oncology Indications – Adult – Inpatient/Ambulatory

Initial Management of Hypersensitivity Reactions to Medications Used for Oncology Indications – Adult – Inpatient/Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Oncology


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Initial Management of Hypersensitivity
Reactions to Medications Used for
Oncology Indications – Adult –
Inpatient/Ambulatory
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY .................................................................................................... 3
SCOPE ................................................................................................................................ 3
METHODOLOGY ................................................................................................................ 4
DEFINITIONS ...................................................................................................................... 4
INTRODUCTION ................................................................................................................. 6
RECOMMENDATIONS ....................................................................................................... 7
UW HEALTH IMPLEMENTATION ................................................................................... 11
APPENDIX A. EVIDENCE GRADING SCHEME(S) ....................................................... 13
APPENDIX B: SUMMARY OF KEY PRACTICE RECOMMENDATIONS ..................... 14
REFERENCES .................................................................................................................. 16
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Contact for Content:
Name: Jason Bergsbaken, PharmD, BCOP – Pharmacy
Phone Number: (608) 265-0341
Email Address: jbergsbaken@uwhealth.org
Contact for Changes:
Name: Philip Trapskin, PharmD, BCPS – Pharmacy, Drug Policy Program
Phone Number: (608) 263-1328
Email Address: ptrapskin@uwhealth.org
Name: Sara Shull, PharmD, MBA, BCPS – Pharmacy, Drug Policy Program
Phone Number: (608) 262-1817
Email Address: ssmith-shull@uwhealth.org
Guideline Author(s):
Jodie Ritchie, PharmD – Pharmacy
Jason Bergsbaken, PharmD, BCOP – Pharmacy
Sarah Lentz, RPh, BCOP – Pharmacy
Costa Grapsas, PharmD, BCOP – Pharmacy
Kendra O’Connell, RN, BSN, OCN – Nursing
Jessica Branson, RN, DNP, OCN – Nursing
Coordinating Team Members:
Mary Mably, RPh, BCOP – Pharmacy
Review Individuals/Bodies:
Lisa Barroilhet, MD – Medicine, Gynecology/Oncology
Aric Hall, MD – Medicine, Hematology/Oncology
Ticiana Leal, MD – Medicine, Hematology/Oncology
Committee Approvals/Dates:
Oncology Practice Committee: February 2017
Oncology Service Line Executive Committee: February 2017
Chemotherapy Council: April 2017
Pharmacy & Therapeutics Committee: June 2017
Release Date: June 2017 | Next Review Date: June 2020
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Executive Summary
Guideline Overview
This clinical practice guideline contains recommendations for the management of
hypersensitivity reactions related to agents used to treat cancer patients. It is compiled
from an extensive literature review of current evidence and external clinical practice
guidelines related to the management of hypersensitivity reactions.
Key Practice Recommendations
ξ Hypersensitivity reactions to agents used to treat oncology indications are
prevalent and dangerous
ξ Depending on the symptoms type, presentation of symptoms, and symptom
severity, initial management of hypersensitivity reactions can vary
ξ Mediations used to initially manage hypersensitivity reactions include
antihistamines, corticosteroids, oxygen, nebulized bronchodilators and
intravenous fluids
ξ During and following a hypersensitivity reaction, patients should be monitored for
resolution of symptoms to determine further management
ξ Please see Appendix B for key practice recommendations for the management of
hypersensitivity reactions for medications used to treat cancer
Companion Documents
1. Renal Function-Based Dose Adjustments – Adult – Inpatient/Ambulatory
2. Intravenous Administration of Formulary Medications – Adult – Inpatient/Ambulatory
3. Carboplatin Dosing – Adult – Inpatient/Ambulatory
Scope
Disease/Condition(s): Patients receiving medications used to treat cancer
Clinical Specialty: Adult Oncology
Intended Users: Physicians, Advanced Practice Providers, Nurses, Pharmacists, and
Respiratory Therapists
Objective(s): Minimize morbidity by standardizing the management of hypersensitivity
reactions caused by medications used to treat cancer
Target Population: Patients greater than or equal to 18 years of age in the inpatient or
ambulatory setting who are receiving medications used to treat cancer
Interventions and Practices Considered:
ξ Identification of hypersensitivity reactions
ξ Management of hypersensitivity reactions
o Medication administration
o Monitoring
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Major Outcomes Considered:
ξ Rates of hypersensitivity reactions
ξ Emergency medications administered
ξ Patient outcomes
o Discontinuation of therapy
o Hospitalization
o Mortality
ξ Total medication infusion time
ξ Total chair time
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline
author(s) and workgroup members to collect evidence for review. Expert opinion and
clinical experience were also considered during discussions of the evidence.
Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and
expert experience. All recommendations endorsed or developed by the guideline
workgroup were reviewed and approved by other stakeholders or committees (as
appropriate).
Methods Used to Assess the Quality of the Evidence/Strength of the
Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.
Internally developed recommendations, or those adopted from external sources without
an assigned evidence grade, were evaluated by the guideline workgroup using an
algorithm adapted from the Grading of Recommendations Assessment, Development
and Evaluation (GRADE) methodology (see Figure 1 in Appendix A).
Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating scheme(s) used within this document.
Definitions
1. Types of reactions1
1.1. Hypersensitivity reactions
1.1.1. Type I hypersensitivity = caused by IgE-mediated release of histamines,
leukotrienes and prostaglandins from mast cells in tissue and basophils in
peripheral blood
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1.1.1.1. Characterized by rapid contraction of smooth muscle and dilation of
capillaries, resulting in urticaria, rash, angioedema, bronchospasm and
hypotension
1.2. Infusion reactions
1.2.1. Caused by cytokine release
1.2.1.1. Characterized by mild to moderate (flushing, rash, fever, rigors,
chills, dyspnea, hypotension) and severe (bronchospasms, hypotension
requiring treatment, cardiac dysfunction)
2. Grading of hypersensitivity reactions/infusion reactions(National Cancer Institute
Common Terminology Criteria for Adverse Events)1
2.1. To be categorized within a Grade, a patient needs to experience only one of the
criteria
2.2. Grade 1
2.2.1. Transient flushing or rash
2.2.2. Drug fever ≥38°C (≥100.4°F)
2.2.3. Intervention not indicated
2.3. Grade 2
2.3.1. Rash
2.3.2. Flushing
2.3.3. Urticaria (hives)
2.3.4. Drug fever ≥38°C (≥100.4°F)
2.3.5. Requires therapy or infusion interruption but responds promptly to
symptomatic treatment
2.3.6. Prophylactic medication indicated for ≥24 hours
2.4. Grade 3
2.4.1. Symptomatic bronchospasm, with or without urticaria
2.4.2. Parenteral medication(s) indicated
2.4.3. Allergy-related edema/angioedema
2.4.4. Hypotension
2.4.5. Prolonged (not rapidly responding to symptomatic medication)
2.4.6. Recurrence of symptoms following initial improvement
2.4.7. Hospitalization indicated for other clinical sequelae
2.5. Grade 4
2.5.1. Anaphylaxis
2.5.2. Life-threatening
2.5.3. Pressor or ventilator support indication
2.6. Grade 5
2.6.1. Death
3. Mild-moderate versus severe symptoms1
3.1. Mild to moderate (Grades 1 and 2) – characterized by flushing, fevers, chills,
dyspnea, and mild hypotension
3.2. Severe (Grades 3 and 4) – associated with hypotension requiring treatment,
cardiac dysfunctions, anaphylaxis and other symptoms
4. Typical presentation of reactions to certain classes of agent used to treat cancer
4.1. Taxanes2,3
4.1.1. Timing
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4.1.1.1. Reactions occur during the first or second infusion
4.1.1.2. Rapidly, within the first 10 minutes of the infusion
4.1.2. Severity
4.1.2.1. Severe reactions (Grades 3-5) occur in about 2% of patients
treated with taxane-based medications
4.2. Platinums4-6
4.2.1. Timing
4.2.1.1. Reactions typically occur only after multiple cycles of therapy
4.2.2. Severity
4.2.2.1. Severe reactions (Grades 3-5) occur in about 2% of patients
treated with platinum-based medications
4.3. Monoclonal antibodies1
4.3.1. Cetuximab – severe infusion reactions were observed during the first
infusion
4.3.2. Rituximab – reactions can occur during any infusion, but there is a higher
incidence with the first infusion
4.4. This is not an inclusive list of agents associated with hypersensitivity reactions
4.4.1. Check package insert or other resources for specific agent information on
prevalence of hypersensitivity reactions
5. Chair time – the time from pre-medications given to the patient to the end of the
medication infusion
6. Purpose of emergency medications in hypersensitivity reactions
6.1. Histamine1 blockers – compete for histamine1 receptors. Histamine is released
during hypersensitivity reactions, causing blood vessels to widen and expand.
This causes redness, swelling, and inflammation. These medications work to
block the effects of histamine (e.g. diphenhydramine, loratadine, cetirizine)
6.2. Histamine2 blockers – compete for histamine2 receptors. Histamine is released
during hypersensitivity reactions, causing blood vessels to widen and expand.
This causes redness, swelling, and inflammation. These medications work to
block the effects of histamine (e.g. ranitidine, famotidine)
6.3. Beta2 agonists– relax bronchial smooth muscle by action on beta2-receptors.
Bronchial constriction, shortness of breath, and wheezing can occur during
hypersensitivity reactions. These medications work to open up the airway and
prevent the constriction (e.g. albuterol)
6.4. Steroids – work to suppress the normal immune response, including neutrophil
migration and production of inflammatory markers during a hypersensitivity
reaction (e.g. dexamethasone)
Introduction
Systemic chemotherapy agents are critical in the treatment of most cancers; however
many of these therapies are associated with possible hypersensitivity reactions.1
Hypersensitivity reactions can range from mild, such as itching and flushing, to severe;
anaphylaxis and even death. Reactions to agents used to treat cancer are unpredictable
and the exact mechanism is often unclear. Since the pathophysiology of the reactions is
not understood, the reaction may be labeled and categorized incorrectly. The variability
in reaction type, lack of consistency in identifying reactions, and inexperience in dealing
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with reactions can lead to unpreparedness and unfamiliarity with recognition, grading
and management of hypersensitivity.. This can then lead to inappropriate medication
administration to patients, unnecessary discontinuation of treatment and limited options
for future treatment.
Taxane-based chemotherapy, platinum-based chemotherapy and monoclonal
antibodies are used in most modern oncology regimens and are associated with the
highest incidence of hypersensitivity reactions.7-9 The incidence with certain taxane
drugs is estimated to be 8-45%, with mild reactions in 40% of patients and severe
reactions in 1.3% of patients. With platinum drugs, the incidence of hypersensitivity
reactions can range from 12-19%, with severe reactions in 2% of patients. The
frequency of reactions increases with increased exposure. Monoclonal antibodies have
the highest reported incidence of reactions, rituximab, for exampls, has an estimated
77% of mild to moderate reactions with infusion. Even though the incidence of severe
hypersensitivity reactions is relatively low, the consequences of mismanagement of any
reaction can pose a threat to patient safety.
The National Comprehensive Cancer Network (NCCN) guidelines provide
recommendations on the management of reactions to platinums, taxanes, liposomal
doxorubicin, and biotherapeutic agents.10 The administration of antihistamines,
corticosteroids, epinephrine, oxygen, and nebulized bronchodilators are all
recommended, depending on the severity of the reaction. Within the NCCN guideline,
there are no recommendations regarding rescue medication timing, dosing or specific
medications to use. These are important aspects to the management of chemotherapy-
induced hypersensitivity reactions and their inclusion in this guideline will contribute to
standardization and patient safety.
Recommendations
1. Management of hypersensitivity reactions
1.1. If the patient experiences any symptom of a hypersensitivity reaction, the
infusion of the medication should be stopped and the patient should be
assessed1,2,7,9,11,12 (UW Health GRADE HIGH quality evidence, strong
recommendation)
1.2. Symptoms include, but are not limited to1:
1.2.1. Urticaria (hives)
1.2.2. Itching
1.2.3. Flushing
1.2.4. Swelling of the lips and/or tongue
1.2.5. O2 saturation less than 90%
1.2.6. Shortness of breath
1.2.7. Tachypnea (>20 breaths per minute)
1.2.8. Wheezing
1.2.9. Bronchial constriction
1.2.10. Hypotension (decrease in systolic blood pressure of >20 mmHg)
1.3. Assessment1 (UW Health GRADE HIGH quality evidence, strong recommendation)
1.3.1. Patient vitals should be obtained including:
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1.3.1.1. Blood pressure
1.3.1.2. Heart rate
1.3.1.3. Respiratory rate
1.3.1.4. O2 saturation
1.3.1.5. Temperature (only if patient complains of flushing or chills)
1.3.2. In addition to vitals, a focused physical assessment should be obtained
1.3.2.1. Focused physical assessment – evaluate patient depending on the
symptoms they are experiencing
1.4. After assessment, it should be determine if symptoms require intervention (Table
1.)1,7 (UW Health GRADE LOW quality evidence, strong recommendation)
2. Providers should be notified of any hypersensitivity reaction (UW Health GRADE LOW
quality evidence, strong recommendation)
2.1. Providers include, but are not limited to, the physician
2.1.1. Respiratory therapist and pharmacist
2.1.2. Research coordinators
3. If symptoms do not require intervention and no change in vital signs from baseline,
the patient should be observed for 15-30 minutes for symptoms to resolve and then,
in collaboration with the provider and pharmacist, the infusion should be restarted1,7
(UW Health GRADE LOW quality evidence, strong recommendation)
3.1.1. If symptoms are limited to patient reported feeling of minor throat
irritation, the patient should be observed for 15-30 minutes, to allow for
symptoms to resolve
3.1.1.1. The provider should be notified of the minor reaction
3.1.1.2. In collaboration with the provider and pharmacist, the medication-
specific administration instructions should be referrenced to determine
if, and at what rate to restart the infusion1,5,7,9 (UW Health GRADE HIGH
quality evidence, strong recommendation)
4. If the patient experiences a mild to moderate or severe reaction, symptom type
should be evaluated to determine appropriate intervention1,7 (UW Health GRADE LOW
quality evidence, strong recommendation)
4.1.1.1. Based on the symptoms, the emergency medications needed
should be determined
4.1.1.2. Refer to Table 1
Table 1.
Symptoms* Emergency Medication(s) to
Administer
Monitoring
Urticaria (hives)
Itching
Flushing
Diphenhydramine 50 mg IV
push
+
Ranitidine 50 mg IV push
Return to baseline =
resolution of urticaria, itching,
flushing or swelling
Swelling of the lips and tongue Diphenhydramine 50 mg IV
push
+
Ranitidine 50 mg IV push
+
Dexamethasone 10 mg IV push
Return to baseline =
resolution of swelling
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O2 saturation < 90% Oxygen via oxy-mask or nasal
cannula
Return to baseline =
increased O2 sat to > 90%
Shortness of breath
Tachypnea (>20 breaths per
minute)
Wheezing
Bronchial constriction†
Oxygen via oxy-mask or nasal
cannula
+
Albuterol 2.5 mg/3 mL by
nebulization
+
Dexamethasone 10 mg IV push
Return to baseline =
resolution of symptoms
Tachypnea resolution (< 20
breaths per minute)
Hypotension (decrease in
systolic blood pressure of >20
mmHg)‡
Sodium Chloride 0.9% 500 mL
bolus administered wide open
+
Dexamethasone 10 mg IV push
Return to baseline = blood
pressure back to within 10%
of original
*if experiencing ANY of the symptoms within a category, administer the appropriate associated
medications (patient does NOT need to be experiencing all symptoms)
†If patient experiences severe bronchial constriction, it may be appropriate to call a rapid
response/code blue and consider administration of epinephrine intramuscular (IM) per provider
‡ if patient does not respond to fluid bolus, call a rapid response/code blue and consider
administration of epinephrine IM per provider
5. Emergency Medication Administration and Monitoring
5.1. One of more of the following emergency medication administration sections
could apply if the patient is experiencing different types of symptoms
5.1.1. If the patient experiences urticaria, itching, and/or flushing, the following
should be done4,7,11,13 (UW Health GRADE LOW quality evidence, strong
recommendation):
5.1.1.1. Administer diphenhydramine 50 mg intravenously
5.1.1.2. Administer ranitidine 50 mg intravenously
5.1.1.3. Monitor for patient to return back to baseline
5.1.1.3.1. Resolution of symptom
5.1.1.3.2. No new symptoms
5.1.1.4. If no new symptoms occur and the previous symptoms have
resolved, in collaboration with the provider and pharmacist, the
medication-specific administration instructions should be referrenced to
determine if, and/or at what rate to restart the infusion
5.1.2. If the patient experiences swelling of the lips or tongue, the following
should be done (UW Health GRADE Low qualify of evidence, strong
recommendation):
5.1.2.1. Administer diphenhydramine 50 mg intravenously
5.1.2.2. Administer ranitidine 50 mg intravenously
5.1.2.3. Administer dexamethasone 10 mg intravenously
5.1.2.4. Monitor patient for return back to baseline
5.1.2.4.1. Resolution of swelling of lips and/or tongue
5.1.2.5. If the patient returns to baseline, in collaboration with the provider
and pharmacist, the medication-specific administration instructions
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should be referrenced to determine if, and/or at what rate to restart the
infusion
5.1.3. If the patient experiences a decrease in oxygen saturation to less than
90%, the following should be done4,7,11,13 (UW Health GRADE LOW quality
evidence, strong recommendation)
5.1.3.1. Administer oxygen via oxymask or nasal cannula, whichever device
is available
5.1.3.2. Monitor for patient to return back to baseline
5.1.3.2.1. Increased oxygen saturation to greater than 90%
5.1.3.3. If the patient returns to baseline, in collaboration with the provider
and pharmacist, the medication-specific administration instructions
should be referrenced to determine if, and/or at what rate to restart the
infusion
5.1.4. If the patient experiences shortness of breath, tachypnea, wheezing,
and/or bronchial constriction, the following should be done4,7,11,13 (UW Health
GRADE LOW quality evidence, strong recommendation)
5.1.4.1. Administer oxygen via oxy-mask or nasal cannula, whichever
device is available
5.1.4.2. Administer albuterol 2.5 mg/3 mL by nebulization
5.1.4.3. Administer dexamethasone 10 mg intravenously
5.1.4.4. Monitor for patient to return back to baseline
5.1.4.4.1. Resolution of symptoms
5.1.4.5. If the patient returns to baseline, in collaboration with the provider
and pharmacist, the medication-specific administration instructions
should be referrenced to determine if, and/or at what rate to restart the
infusion
5.1.5. If the patient experiences hypotension (decrease in systolic blood
pressure of >20 mmHg), the following should be done4,7,11,13 (UW Health
GRADE LOW quality evidence, strong recommendation)
5.1.5.1. Administer sodium chloride 0.9% 500 milliliter bolus run wide open
5.1.5.2. Administer dexamethasone 10 mg intravenously
5.1.5.3. Monitor for patient to return back to baseline
5.1.5.3.1. Blood pressure within 10% of original value
5.1.5.4. If the patient returns to baseline, in collaboration with the provider
and pharmacist, the medication-specific administration instructions
should be referrenced to determine if, and/or at what rate to restart the
infusion
5.1.6. If the patient experiences severe bronchial constriction, it may be
appropriate to call a code blue and consider administration of epinephrine 1
mg intramuscularly per provider1,7 (UW Health GRADE LOW quality evidence,
strong recommendation)
5.1.7. If the patient experiences hypotension and does not respond to the fluid
bolus, a code blue should be called and administration of epinephrine 1 mg
intramuscularly should be considered (UW Health GRADE LOW quality
evidence, strong recommendation)
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5.2. Clinical judgment should always be used when assessing whether or not to
administer emergency medications (UW Health GRADE LOW quality evidence,
strong recommendation)
5.2.1. Populations who may require dose reductions of emergency medications
and/or additional monitoring after administration include, but are not limited
to (UW Health GRADE LOW quality evidence, strong recommendation)
5.2.1.1. Elderly patients
5.2.1.2. Diabetics
5.2.1.3. Patients with decreased renal function
5.2.1.4. Patients with baseline lung dysfunction
5.2.1.5. Allergies to other medications or environmental agents
6. The patient should be monitored for 15-30 minutes, depending on the severity of the
symptoms1,7 (UW Health GRADE LOW quality evidence, strong recommendation)
6.1. If patient returns to baseline, in collaboration with the physician and pharmacist,
the infusion should be restarted
6.1.1. The infusion should be restarted at the last tolerated rate or a lower rate,
depending on the medication being infused
6.2. If symptoms worsen, the patient should be reassessed and additional
emergency medications should be administerd in collaboration with the provider
(UW Health GRADE LOW quality evidence, strong recommendation)
6.2.1. If symptoms continue to worsen (e.g. significant decrease in blood
pressure, worsening hives or itching, increased oxygen needs) it may be
appropriate to call a rapid response/code blue (UW Health GRADE LOW
quality evidence, strong recommendation)
7. If the patient does not return to baseline after emergency medication administration,
the infusion should be discontinued and collaboration with the provider should
determine next steps (UW Health GRADE LOW quality evidence, strong recommendation)
8. Documentation (UW Health GRADE LOW quality evidence, strong recommendation)
8.1. The nurse should document the infusion, infusion rate, reaction, and
consequences of the reaction in the electronical medical record
8.1.1. Consequences include restarting the infusion, discontinuing the infusion,
and/or patient admission into the hospital
8.1.2. Emergency medications administered can be seen on the medication
administration record (MAR)
UW Health Implementation
Potential Benefits:
ξ Standardized approach to initial management of hypersensitivity reactions
ξ Increased patient safety
ξ Maximized efficiency in chemotherapy administration
Potential Harms:
ξ Inappropriate administration of emergency medications
Qualifying Statements:
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ξ Recommendations are based upon available clinical evidence and expert opinion
as indicated by the level of evidence and strength of recommendation
ξ Patient-specific characteristics and experiences may require deviation from these
recommendations
ξ Recommendations included in this guideline are subject to change with
publication of additional evidence
Pertinent UW Health Policies & Procedures
1. Beacon Protocols
Patient Resources
ξ None identified
Guideline Metrics
ξ None planned
Implementation Plan/Clinical Tools
1. Guideline will be posted on u-Connect in a dedicated location for Clinical Practice
Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter.
3. Content and hyperlinks within clinical tools, documents, or Health Link related to the
guideline recommendations (such as the following) will be reviewed for consistency
and modified as appropriate.
Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation
and treatment of patients. This guideline outlines the preferred approach for most
patients. It is not intended to replace a clinician’s judgment or to establish a protocol for
all patients. It is understood that some patients will not fit the clinical condition
contemplated by a guideline and that a guideline will rarely establish the only
appropriate approach to a problem.
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13
Appendix A. Evidence Grading Scheme(s)
Figure 1. GRADE Methodology adapted by UW Health
GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true
effect, but it is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated
effect.
GRADE Ratings for Recommendations For or Against Practice
Strong The net benefit of the treatment is clear, patient values and
circumstances are unlikely to affect the decision.
Weak/conditional
Recommendation may be conditional upon patient values and
preferences, the resources available, or the setting in which the
intervention will be implemented.
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Appendix B: Summary of Key Practice Recommendations
Figure 2: Initial Management of Hypersensitivity Reactions
If patient experiences a reaction – STOP
INFUSION and assess
Obtain BP, HR, RR, O2 saturation,
temperature*
Perform focused physical assessment†
If major symptoms - evaluate
symptom type (refer to Table
1)
Administer emergency
medications (Table 1)
Monitor 15-30 minutes,
depending on the severity of
symptoms (Table 1)
If symptoms worsen, re-
administer emergency
medications as needed
If patient returns to baseline,
restart infusion‡
If patient returns to baseline,
restart infusion‡
If patient does not return to
baseline, discontinue
infusion∆
Restart infusion‡
If symptoms do not require
intervention and no change in
vital signs from baseline, allow
15-30 mins for symptoms to
resolve
Notify provider(s)
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15
*Take temperature if patient experiences flushing or chills
†Focused physical assessment – evaluate patient depending on the symptoms they are
experiencing
Example: if patient is experiencing flushing, look for rash or urticaria
‡Restart infusion in collaboration with provider
∆If symptoms continue worsen (decrease in BP, worsening hives/itching, increased oxygen needs),
it may be appropriate to call a rapid response or a Code Blue
Table 1.
Symptoms* Emergency Medication(s) to
Administer
Monitoring
Urticaria (hives)
Itching
Flushing
Diphenhydramine 50 mg IV
push
+
Ranitidine 50 mg IV push
Return to baseline =
resolution of urticaria, itching,
flushing or swelling
Swelling of the lips and tongue Diphenhydramine 50 mg IV
push
+
Ranitidine 50 mg IV push
+
Dexamethasone 10 mg IV push
Return to baseline =
resolution of swelling
O2 saturation < 90% Oxygen via oxy-mask or nasal
cannula
Return to baseline =
increased O2 sat to > 90%
Shortness of breath
Tachypnea (>20 breaths per
minute)
Wheezing
Bronchial constriction†
Oxygen via oxy-mask or nasal
cannula
+
Albuterol 2.5 mg/3 mL by
nebulization
+
Dexamethasone 10 mg IV push
Return to baseline =
resolution of symptoms
Tachypnea resolution (< 20
breaths per minute)
Hypotension (decrease in
systolic blood pressure of >20
mmHg)‡
Sodium Chloride 0.9% 500 mL
bolus administered wide open
+
Dexamethasone 10 mg IV push
Return to baseline = blood
pressure back to within 10%
of original
*if experiencing ANY of the symptoms within a category, administer the appropriate associated
medications (patient does NOT need to be experiencing all symptoms)
†If patient experiences severe bronchial constriction, it may be appropriate to call a rapid
response/code blue and consider administration of epinephrine intramuscular (IM)
‡ if patient does not respond to fluid bolus, call a rapid response/code blue and consider
administration of epinephrine IM
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

16
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Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org