CHHS16/044 Canberra Hospital and Health Services Medication Guideline Infliximab Infusion Guideline - Adults Contents Contents..................................................... 1 Introduction................................................. 2 Scope........................................................ 2 Section 1 – Preparation......................................2 Section 2 – Alerts...........................................3 Section 3 – Administration...................................3 Induction Phase (1 to 3 infusions).........................3 Reactive Infusion Rate......................................4 Shortened/maintenance Infusion Protocol for Adults (4 th Infusion onwards)..........................................4 Section 4- Side Effects......................................5 Management of moderate infusion-related reactions...........5 Management of mild infusion-related reactions...............6 Implementation............................................... 6 Related Policies, Procedures, Guidelines and Legislation.....7 References................................................... 7 Definition of Terms..........................................7 Search Terms................................................. 8 Doc Number Version Issued Review Date Area Responsible Page CHHS16/044 1 11/03/2016 01/04/2019 Medicine 1 of 10 Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
Transcript
CHHS16/044
Canberra Hospital and Health ServicesMedication GuidelineInfliximab Infusion Guideline - Adults Contents
Doc Number Version Issued Review Date Area Responsible PageCHHS16/044 1 11/03/2016 01/04/2019 Medicine 1 of 8
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
CHHS16/044
Introduction
To 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).
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Scope
This document pertains to all adult patients who require the administration of intravenous (IV) infliximab at Canberra Hospital.
This document applies to: Medical Officers Nurses and Midwives who are working within their scope of practice (Refer to “Nursing
and Midwifery Continuing Competence Policy”) Students under direct supervision.
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Section 1 – Preparation
Ensure 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.
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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
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Section 2 – Alerts
Infliximab 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 – Administration
Use 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/kg
ONLY 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/hr 2.5 mL20 mL/hr 5 mL40 mL/hr 10 mL80 mL/hr 20 mL
120 mL/hr For remainder of infusion
Induction Phase Observations Observations prior to commencement of infusion. Doc Number Version Issued Review Date Area Responsible PageCHHS16/044 1 11/03/2016 01/04/2019 Medicine 3 of 8
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CHHS16/044
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 infused10 mL/hr 2.5 mL10 mL/hr 2.5 mL20 mL/hr 5 mL40 mL/hr 10 mL60 mL/hr 15 mL80 mL/hr 20 mL
100 mL/hr 25 mL100 mL/hr 50 mL120 mL/hr Remainder
Reactive Observations Observations 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 infused100mL/hr 25mL300 mL/hr 75mL300 mL/hr 75mL300 mL/hr Remainder
Shortened 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.
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Section 4- Side EffectsDoc Number Version Issued Review Date Area Responsible PageCHHS16/044 1 11/03/2016 01/04/2019 Medicine 4 of 8
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Acute infusion reactions may develop during or within two hours of infusion and are most likely to occur with the first two infusions.
Management of severe infusion-related reactionsSevere symptoms include:Progressive hypo/hypertension (+/- 40mmHg SBP)Chest painSignificant dyspnoeaStridorElevated temperature with rigors
Management of moderate infusion-related reactionsModerate symptoms include:Progressive hypo/hypertension (+/- 20mmHg SBP)Chest discomfortDyspnoeaUrticariaIncreased temperature
Management Slow 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 infused20mL/hr 5mL40mL/hr 10mL80mL/hr 20mL
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120mL/hr remainder
Continue to monitor full observations every 5 minutes until the patient stabilises.
Management Slow 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 infused20mL/hr 5mL40mL/hr 10mL80mL/hr 20mL
120mL/hr remainder
Continue to monitor full observations every 10 minutes until the patient stabilises.
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Implementation
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.
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Related Policies, Procedures, Guidelines and Legislation
Policies and Standard Operating Procedures CHHS Aseptic Non Touch Technique SOP CHHS Healthcare Associated Infections Procedure CHHS Consent and Treatment Policy CHHS Medication Handling Policy CHHS Patient Identification and Procedure Matching Policy
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CHHS Code Blue Response Procedure- Adults, Paediatrics, Neonates CHHS Management of Severe Allergic Reactions and Anaphylaxis in Adults and Children CHHS Vital Signs & Early Warning Scores Clinical Procedure
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References
Australian 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. https://www.mimsonline.com.au/Search/AbbrPI.aspx?ModuleName=Product 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.
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Definition of Terms
RA Rheumatoid Arthritis PsA Psoriatic Arthritis AS Ankylosing Spondylitis UC Ulcerative ColitisIBD Inflammatory Bowel DiseaseIV Intravenous FBC Full Blood CountUEC Urea, Electrolytes, Creatinine LFT Liver Function TestCRP C-Reactive ProteinESR Erythrocyte Sedimentation RateANA Anti Nuclear AntibodiesENA Extractable Nuclear AntigendsDNA double stranded Antibodies
Search Terms
Infliximab
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CHHS16/044
Disclaimer: 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 Amended Section Amended Approved By
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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
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