Successful rapid desensitization to intravenous etoposide using a 14-step protocol

Successful desensitization to etoposide in a patient after cardiac arrest

INTRODUCTION

Etoposide phosphate is a chemotherapeutic agent used to treat various malignant neoplasms. Hypersensitivity reactions may occur with its use, and in rare cases, an anaphylactic reaction can manifest. Available options for patients experiencing hypersensitivity reactions include premedication, changing treatment, or undergoing desensitization. Various pediatric desensitization protocols have been described, ranging from six to fifteen steps, while published adult cases are rare.

CASE REPORT

We report the case of a 61-year-old woman with small-cell lung cancer and brain metastases. In November 2019, she underwent the second cycle of cisplatin and etoposide phosphate treatment. While receiving etoposide phosphate, she experienced dyspnea and suffered a cardiorespiratory arrest, leading to cardiopulmonary resuscitation and subsequent admission to the Intensive Care Unit. Her acute tryptase levels were notably elevated at 18 µg/L (compared to a baseline tryptase level of 6,6 µg/L) during the reaction.

CASE MANAGEMENT

We implemented a 16-step desensitization protocol (without premedication) under close monitoring in an intermediate care unit. The protocol was successfully executed over three cycles until tumor progression mandated a modification in systemic treatment.

DISCUSSION

To our knowledge, this is the first documented case of successful desensitization to etoposide phosphate in a patient who experienced cardiac arrest during a hypersensitivity reaction. Although protocols of varying lengths have been published, we emphasize the importance of individualizing each protocol to fit the severity of the reaction and the resources and experience of each unit.

Safety and efficacy of rapid drug desensitization in children

BACKGROUND

Any drug taken at the recommended dosage may cause hypersensitivity reactions (DHR). Rapid drug desensitization (RDD) protocols have been developed in the case of a confirmed or highly suspected HSR to allow safe administration of the medicine when there is no alternative drug or in the presence of a less effective or more toxic alternative. The aim of this study was to evaluate the characteristics of children who underwent desensitization, the safety and efficacy of RDD in children, as well as, the characteristics and management of breakthrough reactions.

METHOD

This retrospective study concerned children who underwent RDD due to physician-diagnosed HSRs during or up to 48 hours after the infusion of various drugs between February 2010-February 2021. Patients with a chronic disease needing chronic drug usage and acute infections seen in patients with chronic diseases were included. The results of RDD were documented.

RESULTS

The study included 48 patients [8.1(IQR = 3.32-13.4) years, 60.4% male] with 58 HSRs of which 62.1% were classified as moderate and 5.2% as severe. Most of the patients were being treated for leukemia (41.7%), solid tumors (29.2%), and infections (6.3%). Skin tests were done for 41 out of 58 HSRs in 35 patients, and twenty of them were positive. A total of 269 RDDs were performed for 18 different drugs. Ninety percent of desensitizations were achieved with no reaction, and 3.7% and 5.6% with mild and moderate reactions, respectively. In multivariate analysis, skin test positivity was the only risk factor for breakthrough reactions (OR = 8.5, CI = 1.72-42.15, p = .009).

CONCLUSION

We demonstrated the safety and efficacy of RDD in childhood, thereby offered the first line treatment options to children with chronic diseases with hypersensitivity reactions (HSRs).

Six-step etoposide desensitization protocol: A pediatric, adolescent, and young adult case series

Etoposide administration can be complicated by hypersensitivity reactions. Desensitization may provide a strategy to prevent hypersensitivity recurrence. One challenge with desensitization is regimen complexity. This case series describes 12 pediatric, adolescent, and young adult patients who received a simplified six-step etoposide desensitization protocol. This protocol contains 50% fewer titration steps compared with previously described protocols and eliminates infusion rate changes during titration. Simplified titration may minimize risk of error during administration and improve safety. This protocol was tolerated by 92% of patients. Given increasing frequency and duration of drug shortages, a simplified desensitization protocol provides a valuable treatment option.

A pediatric desensitization protocol for etoposide

Purpose

The implementation of a pediatric desensitization protocol specific to etoposide in an adolescent with Hodgkin lymphoma is described.

Summary

Etoposide is part of many chemotherapy regimens used to treat malignancies in children and adults, and it is also part of the backbone of many regimens used in clinical trials. Etoposide is known to produce hypersensitivity reactions during administration. Substitution with etoposide phosphate, which has less potential for hypersensitivity reactions, is used in place of etoposide after severe hypersensitivity reactions. Etoposide desensitization protocols (EDPs) have been reported in adult patients.

Conclusion

The implementation of an etoposide desensitization protocol for pediatric patients is safe and helpful to prevent the elimination of etoposide from treatment protocols. The use of an EDP allowed the patient to remain on clinical trial and complete the prescribed treatment.

Etoposide and etoposide phosphate hypersensitivity in children: Incidence, risk factors, and prevention strategies

Introduction

Etoposide is critical in treating pediatric cancers, although hypersensitivity can be severe and treatment-limiting. Reported rates of hypersensitivity range from 2% to 51%. Hypersensitivity data for etoposide phosphate, a newer product, are lacking. The primary objective of this study was to assess etoposide and etoposide phosphate hypersensitivity incidence. Secondary objectives included evaluation of potential risk factors for hypersensitivity and strategies to prevent recurrence.

Methods

This retrospective cohort study evaluated pediatric patients who received initial etoposide phosphate or etoposide dose between August 2012 and July 2017. The primary outcome was documentation of hypersensitivity within four months of initial dose. Potential risk factors evaluated included age, allergies, dose, infusion rate, infusion concentration, and premedication.

Results

Of 246 patients, hypersensitivity reactions occurred in five of 54 patients (9.3%) who received etoposide phosphate and 52 of 192 patients (27.1%) who received etoposide ( p = 0.0061). For etoposide, the mean initial infusion rate was 64.6 ± 40.9 mg/m2/h for patients with hypersensitivity and 49.5 ± 33.4 mg/m2/h without hypersensitivity ( p = 0.0886). Etoposide phosphate rate was not associated with hypersensitivity. Recurrent hypersensitivity occurred in one of nine patients (11.1%) who received etoposide desensitization and one of 38 patients (2.6%) who changed formulation to etoposide phosphate.

Conclusions

Etoposide was associated with more hypersensitivity than etoposide phosphate in pediatric patients. Etoposide hypersensitivity was associated with higher infusion rates, but not etoposide phosphate. Differences in hypersensitivity incidence and infusion rate influence indicate a formulation-effect. Etoposide hypersensitivity recurrence may be prevented by changing to etoposide phosphate formulation. During etoposide phosphate shortages, etoposide desensitization may prevent recurrent hypersensitivity.