Dr Alex Bradshaw Consultant Clinical Oncologist Sept 2016

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1 Dr Alex Bradshaw Consultant Clinical Oncologist Sept 2016

2 Learning Points Recognising Acute Drug Reactions Preventing Acute Drug Reactions Treating Acute Drug Reactions Anaphylaxis

3 Recognising Anaphylaxis Breathlessness and panic after oxaliplatin Abdominal pain and vomiting after Irinotecan Blood in urine after epirubicin Itchy rash after gemcitabine Feeling of impending doom and sweating after docetaxel Agitation and collapse after etoposide Swollen lips after paclitaxel

4 Types of Acute Drug Reaction Irritant/inflammatory Flare Phlebitis

5 Types of Acute Drug Reaction Irritant/inflammatory Hypersensitivity Histamine / IgE immune driven reaction (allergic) Flushing, rash, itch Swelling/oedema Abdo pain, N&V Back pain Rigors Feeling unwell

6 Types of Acute Drug Reaction Irritant/inflammatory Hypersensitivity Anaphylaxis Acute severe hypersensitivity Usually rapid onset Addition of ABC compromise Agitation, feeling of impending doom May be fatal within 5 minutes

7 Types of Acute Drug Reaction Irritant/inflammatory Hypersensitivity Anaphylaxis Irinotecan acute cholinergic reaction Oxaliplatin laryngospasm Epirubicin SVT IV steroid rush Others

8 Who are you Worried About? Breathlessness and panic after oxaliplatin Abdominal pain and vomiting after Irinotecan Blood in urine after epirubicin Itchy rash after gemcitabine Feeling of impending doom and sweating after docetaxel Agitation and collapse after etoposide Swollen lips after paclitaxel

9 Taxanes Associated with hypersensitivity Premed including steroids and antihistamines (H1 and/or H2 blockers) Also cause angio-oedema inhibited by steroids

10 Common Situation Patient on docetaxel has forgotten to take his steroid premed What do you advise?

11 Taxane Hypersensitivity Paclitaxel hypersensitivity 40% 2-3% with dex premed Docetaxel hypersensitivity 30% 2% with dex premed Paclitaxel NAB (abraxane) hypersensitivity 4%

12 Common Situation Patient on docetaxel has forgotten to take his steroid premed What do you advise? Single dose of dex 8mg IV and chlorphenamine 10mg IV reduces risk reaction

13 Less Common Lady with ovarian cancer 6 cycles carbo/paclitaxel 2014 Now re-challenge carbo cycle 2 through hickman line Breathless, tachycardia, collapse Is this hypersensitivity?

14 Platinums Risk of hypersensitivity with carboplatin 2% Increases with repeated exposure Risk peaks at cycle 7 Highest risk cycle 2 of second course

15 Less Common Lady with ovarian cancer 6 cycles carbo/paclitaxel 2014 Now re-challenge carbo cycle 2 Breathless, tachycardia, collapse Is this hypersensitivity? YES (or line sepsis)

16 Management of Acute Drug Reaction Irritant/inflammatory Flare Slow infusion Phlebitis Topical steroids Observe to make sure not developing hypersensitivity (or extravasation)

17 Management of Acute Drug Reaction Irritant/inflammatory Hypersensitivity Stop infusion ABC If no ABC compromise consider antihistamine and rapid acting steroid Monitor for anaphylaxis Re-challenge as per protocol

18 Management of Acute Drug Reaction Irritant/inflammatory Hypersensitivity Anaphylaxis Rebound anaphylaxis may occur up to 6 hours after acute episode Stop Infusion ml 1:1000 adrenaline IM Manage airway, breathing, circulation Antihistamine and corticosteroid Do not re-challenge

19 Management of Acute Drug Reaction Irritant/inflammatory Hypersensitivity Anaphylaxis Others All of these can mimic hypersensitivity, monitor for anaphylaxis, if in doubt treat as hypersensitivity Irinotecan acute cholinergic reaction Atropine Oxaliplatin laryngospasm Warming Epirubicin SVT adenosine IV steroid rush reassurance

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