Staying Proactive in the Management of Infusion-Related Reactions With Julianna Cebollero, PharmD, BCOP
For patients receiving cancer treatment, infusion-related reactions pose a significant risk and management is complicated by the lack of standardized terminology and varying risk factors. At the 48th Annual Oncology Nursing Society (ONS) Congress, Julianna Cebollero, PharmD, BCOP, Hematology-Oncology Clinical Pharmacy Specialist at Grady Health System, sat down with Oncology Data Advisor® to share valuable resources for optimizing the management of infusion-related reactions and the importance of patient education.
Oncology Data Advisor: Welcome to Oncology Data Advisor. Today, we're here at ONS Congress, and I'm joined by Juliana Cebollero. Thank you so much for joining today.
Julianna Cebollero, PharmD, BCOP: Thank you for having me.
Oncology Data Advisor: Would you like to introduce yourself and share what your work focuses on?
Dr. Cebollero: Sure, my name is Juliana Cebollero, like you said. I am a Hematology-Oncology Clinical Pharmacy Specialist. I work at Grady Health System in Atlanta, Georgia. At our cancer center, we serve a large underserved population; that's what we're known for. I work with a variety of projects, so I focus on oral chemotherapy education. I also assist the infusion nurses with the management of patients or any clarification that they have. I assist with new drug education, beacon builds, research builds, policy quality improvement, and shortage management, so a little bit of everything.
Oncology Data Advisor: Awesome. So, you're presenting a session later today about infusion-related reaction management in cancer treatment. What are some of the variables that make infusion-related reactions particularly difficult to prevent, recognize, and manage?
Dr. Cebollero: Like you said, Keira, it is a challenging topic. One of the things that contributes to that challenge is the fact that there isn't any standardized terminology when it comes to reactions in cancer treatments. You can look at clinical trials, at package inserts, and even amongst providers, but that consistent terminology is still lacking. The terminology for describing the reactions can be interchangeable and confusing. There are also inconsistencies, maybe in the description and the grading of the reaction, since it can be very subjective. Some symptoms can mask others. It can definitely be a challenge.
It's important that nurses and providers are using the Common Terminology Criteria for Adverse Events (CTCAE) to grade those appropriately. However, those gaps in the literature can also relate to just the safety of rechallenging patients after they've had a reaction, knowing that there are other risks associated. But there are also benefits to keeping the patients on the drug, so it's keeping a balance between those too.
Oncology Data Advisor: Definitely. Are there particular patients who are at a higher risk of experiencing them?
Dr. Cebollero: Absolutely, there are common risk factors for patients. Higher risk factors for patients can include female sex, older patients, and patients who have known comorbidities related to inflammatory issues. For example, you have chronic inflammatory diseases, like pulmonary diseases, so chronic obstructive pulmonary disorder (COPD) and asthma, especially if those are uncontrolled. Patients who have known cardiovascular issues related to inflammatory disease are at risk. There are also other inflammatory diseases, like rheumatoid arthritis (RA) and multiple sclerosis (MS). Even type 1 diabetes could increase the patient's risk, or just having previous allergies on their profile.
So, there are a lot of things. Knowing which patients have those high risks factors can help nurses and providers identify which patients could be at high risk for these reactions, and just help them in being more alert.
Oncology Data Advisor: Right, right. Have there been any new developments in the management of infusion-related reactions or any upcoming directions underway?
Dr. Cebollero: That's a great question. Like I mentioned earlier, the literature is still limited, and there is that lack of standardization in terms of how to define those terms and the grading. I think it's mainly institutions making adjustments, if they already have protocols, based on what they have seen. But we do need more institutions to be involved in the publication of that data to make it more readily available for other institutions.
The National Comprehensive Cancer Network (NCCN) has a few slides on the management of infusion reactions, but it's still limited. The ONS has some guidance that's very helpful. There are some European Society of Medical Oncology guidelines. I think they have probably one of the more comprehensive guidelines when it comes to management of these reactions.
But if there's something new brewing, I am not aware of, not at this time, but I would love to see more in the literature. I think this just shows that there is a need for increased multidisciplinary involvement in making sure that we're able to have this information available to provide what's best for our patients.
Oncology Data Advisor: Definitely. You mentioned the CTCAE for grading, as well as some of the guidelines. Are there any other resources that nurses can look to, to learn best practices for management?
Dr. Cebollero: Sure, so like I said, you have NCCN, ONS has some guidance, and I believe they have a new guidance coming out some time this summer. You also have the European Society of Medical Oncology. But I think ultimately, it's important for that education to be available for the nurses in learning about the mechanism of action of the drugs that may cause these, being able to provide education on how to classify these reactions and then ultimately grading them appropriately. Even talking to the patient and making sure that they're taking their pre-medications and their post-medications, to prevent any delayed reactions, can really make a difference in the patients and those outcomes.
Oncology Data Advisor: Are there any take-home messages from your presentation that you'd like to share with nurses?
Dr. Cebollero: I think one of the biggest take-homes is if your institution does not have an established nurse-driven protocol or have those standing orders available, you can advocate for one. You can also advocate for more education when it comes to learning about the mechanism of action of those drugs, what types of reactions to expect from those drugs, and when to expect them. Being able to have that information readily available can really make a difference.
Talking to the patient and the caregiver can also give you great insight on their past medical history or if they've had any history of previous reactions to other medications and just being more prepared. I think that nursing assessment and management can really be the key factor in determining whether a patient is rechallenged or not after having an infusion reaction.
Oncology Data Advisor: Definitely. Well, that's really great to know. Thank you so much for sharing all of this today.
Dr. Cebollero: Thank you. Have a great day.
About Dr. Cebollero
Julianna Cebollero, PharmD, BCOP, is a Hematology/Oncology Clinical Pharmacist Specialist at Grady Health System Cancer Center for Excellence in Atlanta, Georgia. In addition, she is an Adjunct Instructor at the Emory University School of Medicine's Department of Hematology and Medical Oncology. Dr. Cebollero practices as an Ambulatory Care Pharmacist, and her areas of interest include oral chemotherapy adherence, toxicity management, chemotherapy-related quality improvement, and specialty pharmacy practices.
For More Information
Cebollero J & Price M (2023). Infusion-related reaction management in cancer treatment. Presented at: 48th Annual Oncology Nursing Society Congress. Available at: https://ons.confex.com/ons/2023/meetingapp.cgi/Session/4953
National Cancer Institute (2017). Common Terminology Criteria for Adverse Events. Version 5.0. Available at: https://ctep.cancer.gov/protocoldevelopment/electronic_applications/docs/CTCAE_v5_Quick_Reference_5x7.pdf
Price M (2021). Acute infusion-related reactions: how to recognize and intervene when these reactions occur in practice. CJON, 25(5):591-594. DOI:10.1188/21.CJON.591-594
National Comprehensive Cancer Network (2023). Clinical Practice Guidelines in Oncology: management of immunotherapy-related toxicities. Version 2.2023. Available at: https://www.nccn.org/professionals/physician_gls/pdf/immunotherapy.pdf
Roselló S, Blasco I, García Fabregat L, et al (2017). Management of infusion reactions to systemic anticancer therapy: ESMO Clinical Practice Guidelines. Ann Oncol, 28(suppl_4):IV100-IV118. DOI:10.1093/annonc/mdx216
Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily reflect those of Oncology Data Advisor.