Rapid Rituximab and Infliximab Infusions in Pediatric HSCT Patients Are Well Tolerated

Background: Rituximab and infliximab are two monoclonal antibodies administered intravenously. Both medications are generally administered over prolonged infusion times per manufacturer guidelines in order to avoid infusion-related toxicities. Rituximab is a chimeric anti-CD20 monoclonal antibody used primarily for the treatment of EBV viremia, autoimmune cytopenias and steroid refractory graft versus host disease (srGVHD) in hematopoietic stem cell transplant patients (HSCT) at Cincinnati Children’s Hospital Medical Center (CCHMC). Recommended infusion times for rituximab average 5-6 hours for the initial dose and 3-4 hours for subsequent doses. Infliximab is an anti-TNFα monoclonal antibody used for srGVHD in HSCT patients at CCHMC. Recommended infusion of infliximab is over 2-3 hours. Due to the these infusion times, administration of both medications is associated with decreased patient satisfaction, increased health care costs and can also lead to compatibility/access issues. Data exists to support rapid infusion (RI) administration (over 1 hour) of these agents in non-HSCT adult patients, but data in pediatric HSCT patients is limited. Here we describe our experience with 1-hour infusions of rituximab and infliximab at CCHMC.

Methods: All HSCT patients who received rituximab or infliximab between March 2013 and October 2013 were administered their first dose by the standard manufacturer guidelines. If patients tolerated the first infusion they were eligible to receive infusion of subsequent doses over 1 hour. Patients were observed for infusion related reactions during and for 30 minutes after infusion. Additionally, patients and family members were advised to report any possible reactions within the 24 hours following infusion.

Results: Seven patients received 24 RI rituximab doses. The median number of doses per patient was 3; (range 1-7). Five patients were on corticosteroids as part of their baseline regimen, no patients (including those not on baseline steroids) received additional steroid pre-medication prior to infusion. No adverse effects were reported with the RI of rituximab. A total of 49 doses of RI infliximab were administered to 8 patients. All 8 patients were on corticosteroids as part of their daily regimen and no one received additional steroid as pre-medication prior to their infusion. The median number of infliximab RIs per patient was 7.5 (range 1-17 doses). One patient receiving RI infliximab experienced a rash that resolved without intervention during the first RI. The patient received 4 additional RIs without side effects. No additional side effects were seen in any other patients.

Conclusion: Rapid-infusions of rituximab and infliximab were safe and well tolerated when administered as the second and subsequent infusion in a course of therapy. Patient and family satisfaction were also improved.