Infliximab Infusion Guideline - Adults



Canberra Hospital and Health ServicesMedication GuidelineInfliximab Infusion Guideline - Adults Contents TOC \h \z \t "Heading 1,1,Heading 2,2" Contents PAGEREF _Toc445454830 \h 1Introduction PAGEREF _Toc445454831 \h 2Scope PAGEREF _Toc445454832 \h 2Section 1 – Preparation PAGEREF _Toc445454833 \h 2Section 2 – Alerts PAGEREF _Toc445454834 \h 3Section 3 – Administration PAGEREF _Toc445454835 \h 3Induction Phase (1 to 3 infusions) PAGEREF _Toc445454836 \h 3Reactive Infusion Rate PAGEREF _Toc445454837 \h 4Shortened/maintenance Infusion Protocol for Adults (4th Infusion onwards) PAGEREF _Toc445454838 \h 4Section 4- Side Effects PAGEREF _Toc445454839 \h 5Management of moderate infusion-related reactions PAGEREF _Toc445454840 \h 5Management of mild infusion-related reactions PAGEREF _Toc445454841 \h 6Implementation PAGEREF _Toc445454842 \h 6Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc445454843 \h 7References PAGEREF _Toc445454844 \h 7Definition of Terms PAGEREF _Toc445454845 \h 7Search Terms PAGEREF _Toc445454846 \h 8IntroductionTo provide a guideline for the accurate prescription and safe administration of intravenous infliximab to adult patients at Canberra Hospital for the treatment of Rheumatoid Arthritis (RA), Psoriatic Arthritis (PsA), Ankylosing Spondylitis (AS), Psoriasis, Crohn’s Disease, and Ulcerative Colitis (UC).Back to Table of ContentsScopeThis document pertains to all adult patients who require the administration of intravenous (IV) infliximab at Canberra Hospital. This document applies to:Medical OfficersNurses and Midwives who are working within their scope of practice (Refer to “Nursing and Midwifery Continuing Competence Policy”)Students under direct supervision.Back to Table of ContentsSection 1 – PreparationEnsure admission has been completed by clerical, medical officer and nurse.Obtain full set of baseline observations and record on the general observation chart.Conduct medical review of the patient to ensure the patient is medically well enough for the infusion and has no current infection or fever. If there is a concern, medical officer is to inform the patients’ admitting consultant.Ensure patient has correct identification band. Obtain written intravenous fluid order from medical officer or consultant.Obtain patient’s weight and document on IV fluid order. Document time on intravenous order form and scan to CHHS Pharmacy IV room. Establish IV access (with 20 or 22g Cannula) and obtain pre-infusion blood tests as ordered by consultant (e.g. FBC, EUC, LFT, CRP, ESR- definition of terms; page 7). Frequency of blood tests as documented on the request for admission (RFA). Inflammatory Bowel Disease (IBD) patients: FBC, EUC, LFT, CRP and ESR. Rheumatology patients: FBC, EUC, LFT, CRP, ESR.ANA, ENA, dsDNA- Frequency for these blood tests to be documented on the RFA by the consultant or their representative.? Administer pre-medications to the patient as ordered by medical officer:IBD patients:IV methylprednisolone 20 mg Oral paracetamol 1g Oral anti-histamine, non-drowsy (usually fexofenadine 180 mg) Rheumatology patients: IV hydrocortisone 100mg Back to Table of Contents Section 2 – AlertsInfliximab is contraindicated in patients who have:Known anaphylaxis to infliximab. Severe infections such as sepsis, abscesses, tuberculosis and opportunistic infections. Infliximab should not be given to patients with an active infection or illness.???The treating consultant or associated registrar must be informed by the medical officer of any contraindications or concerns present.? Section 3 – AdministrationUse IV giving set with in-line or added sterile non-pyrogenic, low protein-binding filter (0.2 micron or less). All observations in accordance with CHHS Vital Signs & Early Warning Scores Clinical Procedure.IBD Standard dose is 5 mg/kg in 250mL sodium chloride 0.9% Rheumatology patients standard dose is 3mg/kgONLY the treating consultant may vary the dose from 3mg/kg-10mg/kg depending on patient’s diagnosis and condition.Induction Phase (1 to 3 infusions)For the first three infliximab infusions: patient must stay in the ward area for 2 hours post-infusion for observations.Rate Volume to be Infused (mL)10 mL/hr2.5 mL20 mL/hr5 mL40 mL/hr10 mL80 mL/hr20 mL120 mL/hrFor remainder of infusionInduction Phase ObservationsObservations prior to commencement of infusion. Observations every 15 minutes for the first hour of infusion. Observations hourly until infusion completed. Observations half hourly for two hours post infusion.Reactive Infusion RateFor patients who have had previous reaction to infliximab and treating team confirms continuation of treatment at a slower rate. Patient must stay in the ward area for 1 hour post-infusion for observations, provided there has been no evidence of adverse reaction during infusion.Rate Volume to be infused 10 mL/hr 2.5 mL10 mL/hr 2.5 mL20 mL/hr 5 mL 40 mL/hr 10 mL60 mL/hr 15 mL 80 mL/hr 20 mL 100 mL/hr 25 mL 100 mL/hr 50 mL 120 mL/hr RemainderReactive ObservationsObservations prior to commencement of infusion. Observations every 15 minutes for the first hour of infusion. Observations hourly until infusion completed. Observations half hourly for one hour post infusion.Shortened/maintenance Infusion Protocol for Adults (4th Infusion onwards)For adult patients who have tolerated infliximab induction phase:Doses less than 6mg/kg: administer the infusion over a period of not less than 1 hour. Doses greater than 6 mg/kg: administer the infusion over a period of not less than two hours.Rate Volume to be infused 100mL/hr25mL300 mL/hr 75mL300 mL/hr 75mL300 mL/hr RemainderShortened Infusion Observations:Obtain full set of observations prior to commencement of infusion. Observations every 15 minutes for duration of infusion.Observations half hourly for one hour post infusion.Back to Table of Contents Section 4- Side EffectsAcute infusion reactions may develop during or within two hours of infusion and are most likely to occur with the first two infusions.Potential Side Effects include:Headache NauseaPruritus Urticaria DizzinessFeverRigors Diarrhoea Palpitations Chest pain Hypotension HypertensionDyspnoeaFlushingManagement of severe infusion-related reactionsSevere symptoms include:Progressive hypo/hypertension (+/- 40mmHg SBP)Chest painSignificant dyspnoeaStridorElevated temperature with rigorsManagement STOP INFUSION - Initiate Code Blue/Met CallManagement of moderate infusion-related reactionsModerate symptoms include:Progressive hypo/hypertension (+/- 20mmHg SBP)Chest discomfortDyspnoeaUrticariaIncreased temperatureManagementSlow infliximab infusion rate to 10mL/hr or stop infusion.Obtain full set of observation, monitor full observations every 5 minutes.Patient to be reviewed by medical officer.Additional antihistamine may be required to be administered if prescribed.Wait 20 minutes then progressively increase infliximab infusion rate every 15 minutes as tolerated.Rate Volume to be infused 20mL/hr5mL40mL/hr10mL80mL/hr20mL120mL/hrremainder Continue to monitor full observations every 5 minutes until the patient stabilises.Management of mild infusion-related reactionsMild symptoms include:FlushingHeadacheDizzinessPalpitationsNauseaManagementSlow Infusion rate to 10mL/hr.Obtain full set of observation, monitor full observations every 10minutes.Report to medical officer.Additional antihistamine may be required to be administered if prescribed.Wait 20 minutes then progressively increase infliximab infusion rate every 15 minutes as tolerated.Rate Volume to be infused 20mL/hr5mL40mL/hr10mL80mL/hr20mL120mL/hrremainder Continue to monitor full observations every 10 minutes until the patient stabilises.Back to Table of ContentsImplementation Face to face education for Medical Day unit nursing and medical team, as required.Medical Day unit information sessions.Team briefings by clinical nurse consultant and clinical development nurse, as required. Inclusion on the CHHS Policy Register.Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationPolicies and Standard Operating ProceduresCHHS Aseptic Non Touch Technique SOPCHHS Healthcare Associated Infections Procedure CHHS Consent and Treatment Policy CHHS Medication Handling Policy CHHS Patient Identification and Procedure Matching Policy CHHS Code Blue Response Procedure- Adults, Paediatrics, Neonates CHHS Management of Severe Allergic Reactions and Anaphylaxis in Adults and ChildrenCHHS Vital Signs & Early Warning Scores Clinical ProcedureBack to Table of ContentsReferencesAustralian Register of Therapeutic Goods. Product Information ID73827 Remicade (Infliximab). Accessed 11 August 2014.Janssen. Remicade. Product Information. 10 December 2013.Janssen. Remicade: Infusion Reaction Management Guide, July 2013, Australia.MIMS online. MIMS Australia. Version: February 2016. Accessed 11th February 2016. Info&searchKeyword=remicade&PreviousPage=~/Search/QuickSearch.aspx&SearchType=&ID=55660001_2. Accessed 30th July 2014. Van Runnard Heimel PJ, Franx A, Schobben AFAM et al. Corticosteroids, pregnancy and HELlP syndrome: A review. Obstet Gynecol Survey 2004; 60(1): 57-59.Back to Table of ContentsDefinition of TermsRARheumatoid Arthritis PsAPsoriatic Arthritis ASAnkylosing Spondylitis UCUlcerative ColitisIBDInflammatory Bowel DiseaseIVIntravenous FBCFull Blood CountUECUrea, Electrolytes, Creatinine LFTLiver Function TestCRPC-Reactive ProteinESRErythrocyte Sedimentation RateANAAnti Nuclear AntibodiesENAExtractable Nuclear AntigendsDNA double stranded AntibodiesSearch Terms InfliximabBack to Table of ContentsDisclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Date AmendedSection AmendedApproved By ................
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