Infusion-Related Reactions Induced by Cadonilimab (PD-1/CTLA-4 Bispecific Antibody): Seven Case Reports

Introduction

Cadonilimab (AK104) is an innovative human programmed cell death-1 (PD-1)/cytotoxic T lymphocyte antigen-4 (CTLA-4) bispecific antibody. Compared with the combination therapy of PD-1 and CTLA-4 blockers, less cellular toxicity of cadonilimab was significantly manifested. As one of the characteristic adverse effects of cadonilimab, infusion-related reactions (IRRs) represent fever, chills, rash, decreased blood pressure, and other symptoms.

Case Presentation

Here, we documented seven cases of IRRs after the administration of cadonilimab. The symptoms of IRRs were relieved after the discontinuation of cadonilimab and the administration of diphenhydramine, dexamethasone, and cimetidine. Notably, 3 patients were able to tolerate the subsequent cadonilimab therapy under the pretreatment.

Conclusion

In this study, we discovered that cadonilimab-related IRRs might be lessened or prevented by administering medication and the proper pretreatment and lowering the infusion rate.

Intraductal pressure in experimental models of acute and chronic pancreatitis in mice

BACKGROUND/OBJECTIVES

Pancreatic intraductal pressure is related to the development of pancreatitis, including post-ERCP (endoscopic retrograde cholangiopancreatography) pancreatitis. In this study, we investigate pancreatic intraductal pressure in various mouse models of acute and chronic pancreatitis.

METHODS

Post-ERCP pancreatitis was induced by retrograde infusion of normal saline or radiocontrast at the constant rate of 10 or 20 μL/min. Obstructive pancreatitis was induced by ligation of the pancreatic duct followed by a single injection of caerulein and the changes of intraductal pressure were recorded in day 3 for obstructive acute pancreatitis and day 14 for obstructive chronic pancreatitis. Non-obstructive pancreatitis was induced by repetitive intraperitoneal injections of caerulein. The changes of intraductal pressure were recorded right after the last caerulein injection for non-obstructive acute pancreatitis and after the completion of 4-week caerulein injections for non-obstructive chronic pancreatitis.

RESULTS

Elevated pancreatic intraductal pressure was observed in both normal saline and radiocontrast infusion groups and was furtherly indicated that was positively correlated with the viscosity of solution but not genders. In the models of obstructive pancreatitis, a rise in intraductal pressure was observed in both acute and chronic pancreatitis; whereas in the models of non-obstructive pancreatitis, a rise in intraductal pressure was only observed in chronic, but not acute pancreatitis.

CONCLUSIONS

During ERCP, the elevations in pancreatic intraductal pressure are induced by increasing rate or viscous solution of infusion. During different forms of experimental acute and chronic pancreatitis, obstructive or non-obstructive etiologies of pancreatitis also induces the elevations in pancreatic intraductal pressure.

Influence of rate of administration on the mechanism behind propofol induced loss of consciousness

BACKGROUND

Propofol effect-site time course models included in TCI systems have been under discussion. We hypothesized that the rate of administration is a major contributor affecting the construction of a useful effect-site model: yielding different plasmatic concentrations, loss of consciousness may occur by different mechanisms more complex than the pharmacological effect-site.

METHODOLOGY

ASA III patients were randomized in two groups: rapid induction (RI) received TCI of propofol effect-site (CeCALC) 5.4 μg/mL (modified Marsh model), and slow induction (SI) propofol infusion of 10 mg/kg/hour. A neurologist, blinded to induction method, performed neurological assessments using the FOUR score until the loss of consciousness (LOC). At LOC, the presence of brain stem reflexes, EEG index (PSI) and infusion time/mass of drug were registered. Fisher's exact test was used to describe differences between brain stem reflexes and respiration components of the FOUR score and CeCALC for 4 propofo models at LOC time.

RESULTS

16 patients divided in two groups were included. All patient in SI had brainstem reflexes free at LOC. In the RI, all patients had brain stem reflexes abolished and 1 patient had B and R of 4 points in the FOUR score (brain stem reflexes unaffected; P < .001). CeCALC at LOC time were contradictory at LOC in both groups and using 4 different Pk/Pd models.

CONCLUSIONS

Depending of the infusion rate, propofol CeCALC at LOC calculated by different Pk/Pd models could be the source of confuse data to be used to guide the state of general anesthesia.

Influence of rate of administration on the mechanism behind propofol induced loss of consciousness

BACKGROUND

Propofol effect-site time course models included in TCI systems have been under discussion. We hypothesized that the rate of administration is a major contributor affecting the construction of a useful effect-site model: yielding different plasmatic concentrations, loss of consciousness may occur by different mechanisms more complex than the pharmacological effect-site.

METHODOLOGY

ASA III patients were randomized in two groups: rapid induction (RI) received TCI of propofol effect-site (CeCALC) 5.4 μg/mL (modified Marsh model), and slow induction (SI) propofol infusion of 10 mg/kg/hour. A neurologist, blinded to induction method, performed neurological assessments using the FOUR score until the loss of consciousness (LOC). At LOC, the presence of brain stem reflexes, EEG index (PSI) and infusion time/mass of drug were registered. Fisher's exact test was used to describe differences between brain stem reflexes and respiration components of the FOUR score and CeCALC for 4 propofo models at LOC time.

RESULTS

16 patients divided in two groups were included. All patient in SI had brainstem reflexes free at LOC. In the RI, all patients had brain stem reflexes abolished and 1 patient had B and R of 4 points in the FOUR score (brain stem reflexes unaffected; P < .001). CeCALC at LOC time were contradictory at LOC in both groups and using 4 different Pk/Pd models.

CONCLUSIONS

Depending of the infusion rate, propofol CeCALC at LOC calculated by different Pk/Pd models could be the source of confuse data to be used to guide the state of general anesthesia.

Characterization and evaluation of tea bag papers

The infusion kinetics of tea bags containing black tea or green tea has been studied in detail in the past. However, the tea bag papers have never been characterized and evaluated earlier to understand their contribution towards tea bag infusion. In the present work, papers used for making tea bags were characterized for thickness, wettability, surface topography, pore size, porosity and permeance to understand their influence on infusion kinetics of tea bags. Scanning electron microscopy studies highlighted the pore structure and porous nature of tea bag papers. The porosity of tea bag paper was quantified using image processing and permeance was determined experimentally. Besides, a relationship between porosity and permeance of tea bag papers has been perceived. A general trend of increase in permeance with increasing porosity was observed. Woven nylon paper showed the highest permeance (23.9 × 10^-5 m/s) when compared with other tea bag papers. Furthermore, an initial infusion rate was determined using initial infusion data of tea bag infusion for different tea bag papers. The influence of permeance on the initial infusion rate of tea bag papers has also been investigated.

Warming efficacy of Ranger™ and FT2800 fluid warmer under different room temperatures and flow rates

The comparison of the heating capabilities with different warming system between 3M™ Ranger™ warmer (3M) and FT2800 fluid warmer (FT) under different room temperatures and infusion rates, has been rarely reported previously. The study was then aimed to compare the warming efficacies of dry heat technology (3M) and coaxial warming system (FT) under different room temperatures and infusion rates, the advantages and disadvantages of both infusion systems would be compared to provide reference for clinical infusion practice. In the study, both target warming temperatures of 3M and FT warmer were set at 41 °C, fluid was administrated under 20, 22 and 24 °C room temperatures and drip rates of 60, 80, 100, 120, 140, 160, 200, 350 drops min^-1. The fluid temperature at the outlet of the infusion tube (T_outlet) was measured and compared. The T_outlet of FT was higher than that of 3 M (P < 0.001) under different room temperatures. The T_outlet of FT increased with the room temperature raised (P < 0.05). As for 3M, T_outlet was lowest at 20 °C (P < 0.001) and no statistical difference of T_outlet was found between 22 and 24 °C (P = 0.667). Linear regression showed that the T_outlet of 3M increased with the speed up of drip rate, while the T_outlet of FT was decreased. The relationship between T_outlet & room temperature & drip rate for both 3M and FT warmers was calculated by a formula. 3M Ranger™ and FT2800 show different heating capabilities under different room temperatures and drip rates. 3M is more efficient at high flow rate while FT is more efficient at low flow rate. There is a formula relationship between T_outlet & room temperature & drip rate for both 3M and FT warmers.

Efficacy and Safety of IQYMUNE®, a Ten Percent Intravenous Immunoglobulin in Adult Patients With Chronic, Primary Immune Thrombocytopenia

Background

Intravenous immunoglobulin (IVIG) IQYMUNE® is a highly purified 10% IVIG that was assessed using the new stringent definition of response described in the revised guideline on the clinical investigation of IVIG. The efficacy and the safety of IQYMUNE® were investigated in adult patients with chronic primary immune thrombocytopenia (ITP).

Methods

In this phase III multinational, multicentre, prospective, uncontrolled, open-label, single-arm study, adult patients with a baseline platelet count < 30 × 10⁹/L were treated with IVIG 10% at a dose of 2 g/kg body weight administered over 2 consecutive days. The primary endpoint was Response over the study period and was defined according to the recent and most stringent European Medicines Agency guidelines (platelet count ≥ 30 × 10⁹/L and a ≥ 2-fold increase from baseline, no new bleeding, and no concomitant treatment with drugs that affect platelet count and/or induce bleeding cessation).

Results

Thirty-eight patients were enrolled; 73 infusions were administered (38 on Day 1 and 35 on Day 2). Response was reached by 24 patients corresponding to 63.2% of patients in the full analysis set (95% CI: 46.0; 78.2) and 68.6% of patients in the per-protocol set (95% CI: 50.7; 83.1). The median time to Response was 1 day. The median duration of Response was 13.5 days. Reasons for non-response were failure to reach the required platelet count (n = 12), a new bleeding event (n = 1), and forbidden medication use (n = 1). Among the 23 patients with a baseline platelet count ≤ 20 × 10⁹/L, 19 patients (82.6%) achieved a platelet count ≥ 50 × 10⁹/L at least once before Day 5 (previous European Medicines Agency definition of response). Treatment was well tolerated even in patients with a high flow rate (≥ 6 mL/kg/h in 40% of patients). Headache (34.2%), pyrexia (15.8%), and creatinine renal clearance decrease, including one case of decrease in glomerular filtration rate (10.5%) were the most frequently reported drug-related adverse events.

Conclusions

Administration of IQYMUNE® for 2 consecutive days at a dose of 2 g/kg was safe and efficacious. These results support the treatment of adult patients with chronic ITP with IQYMUNE®.

Safety of shortened infusion times for combined ipilimumab and nivolumab

BACKGROUND

Combined ipilimumab and nivolumab induces encouraging response rates in patients with unresectable or metastatic melanoma. However, the approved protocol for dual checkpoint inhibition (3 mg/kg ipilimumab over 90 min and 1 mg/kg nivolumab over 60 min) is time-intensive and several trials have shown that both single agents can be safely administered at faster infusion rates.

AIM

To investigate whether combined checkpoint inhibition with 3 mg/kg ipilimumab and 1 mg/kg nivolumab can be safely administered over 30 min per agent.

PATIENTS AND METHODS

We reviewed the rate of infusion-related reactions (IRRs) in the first 12 months of our single-institution experience using shortened infusion times for combined checkpoint inhibition with ipilimumab and nivolumab.

RESULTS

Between May 24, 2016 and June 10, 2017, a total of 46 melanoma patients received 100 shortened cycles of combined 3 mg/kg ipilimumab and 1 mg/kg nivolumab. One patient (2.2%; 1/46) had a questionable reaction after administration of 1 mg/kg nivolumab over 30 min, but none of the other patients had a bona fide IRR.

CONCLUSIONS

Shortened infusion times for combined ipilimumab and nivolumab treatment are safe, thereby facilitating a more efficient use of outpatient facilities and enhancing patient's convenience.

Transfusion-associated circulatory overload: A survey among Dutch intensive care fellows

OBJECTIVES

Transfusion-associated circulatory overload (TACO) is a severe pulmonary transfusion reaction and leading cause of transfusion-related morbidity and mortality in Europe. TACO is of particular importance in critically ill patients, since they often receive blood transfusions and have multiple risk factors for TACO. This study investigates transfusion practices in patients at risk of developing TACO, and furthermore knowledge concerning risk factors, diagnoses and treatment strategies among Dutch intensive care unit (ICU) fellows.

MATERIAL AND METHODS

An unannounced paper-based survey was conducted among Dutch ICU fellows during an educational conference. The survey consisted of 16 multiple and open choice questions.

RESULTS

Of all 65 Dutch ICU fellows 56.8% completed the survey; of respondents 88.9% identified the correct constellation of symptoms for TACO. In total, 29.7% of the respondents are aware they are obligated to report TACO cases to the blood bank. Major risk factors for TACO that respondents identified were reduced left ventricular function, infusion volume and infusion rate. In a non-emergency setting, 45.9% of fellows start red blood cell transfusion with 2 units or more. Transfusion rates exceeded national guidelines in 15.4% of fictitious cases. TACO is treated with furosemide by 94.5% of the fellows, however goals of the therapy varied greatly.

CONCLUSION

Dutch ICU fellows are knowledgeable of TACO symptoms, risk factors and treatment, however knowledge on reporting and transfusion practice in the setting of at risk patients for TACO should be improved.

The importance of albumin infusion rate for plasma volume expansion following major abdominal surgery - AIR: study protocol for a randomised controlled trial

BACKGROUND

Administration of fluids to restore normovolaemia is one of the most common therapeutic interventions performed peri-operatively and in the critically ill, but no study has evaluated the importance of infusion rate for the plasma volume-expanding effect of a resuscitation fluid. The present study is designed to test the hypothesis that a slow infusion of resuscitation fluid results in better plasma volume expansion than a rapid infusion.

METHODS/DESIGN

The study is a single-centre, assessor-blinded, parallel-group, randomised prospective study. Patients over 40 years of age admitted to the post-operative care unit after a Whipple procedure or major gynaecological surgery and presenting with signs of hypovolaemia are eligible for inclusion. Patients are randomised in a 1:1 fashion with no stratification to either rapid (30 minutes) or slow (180 minutes) infusion of 5% albumin at a dose of 10 ml/kg ideal body weight. Plasma volume is measured using 125I human serum albumin at baseline (prior to albumin infusion) as well as at 30 minutes and 180 minutes after infusion start. The primary endpoint is change in plasma volume from baseline to 180 minutes after the start of 5% albumin infusion. Secondary endpoints include the integral of plasma volume over time from baseline to 180 minutes after the start of the infusion and transcapillary escape rate of albumin (%/h) from 180 minutes to 240 minutes after the start of albumin infusion. In addition, diuresis, change in central venous oxygen saturation, lactate and blood pressure will be evaluated. A total of 70 patients will be included in the study, and the study has 80% power to detect a difference of 4 ml/kg in plasma volume expansion between the two groups.

DISCUSSION

The present study is the first clinical investigation of the importance of infusion rate for the plasma volume-expanding effect of a resuscitation fluid.

TRIAL REGISTRATION

EudraCT identifier: 2013-004446-42 . Registration date: 20 December 2013. ClinicalTrials.gov identifier: NCT02728921 . Registration date: 31 March 2016.

Slow infusion rate of doxorubicin induces higher pro-inflammatory cytokine production

Different infusion rates of doxorubicin (DOX) have been used for treating human malignancies. Organ toxicity after DOX infusion is a major issue in treatment disruption. However, whether different DOX infusion rates induce different toxicity is still unknown. In this study, we examined the toxicity effects of different DOX infusion rates in the early phase of organ toxicity. Thirty-six rats were randomly divided into 5-, 15-, and 30-min infusion rate groups. A single dose of DOX (8.3 mg/kg, I.V.) was administered at different infusion rates. Blood samples were collected from the femoral artery at 1, 3, 6, 9, 12, 18, 24, 36, and 48 h after DOX administration. The blood cell count and blood biochemistry were analyzed. The liver, kidney, and heart were removed for pathological examinations after the rats were sacrificed. Our findings show that the 30-min group had higher injury markers in the liver (glutamic oxaloacetic transaminase and glutamic pyruvic transaminase), kidneys (blood urea nitrogen and creatinine), and heart (creatine phosphokinase-MB and lactate dehydrogenase), and had higher tumor necrosis factor-alpha and interleukin 6 levels than did the other groups. The 30-min group also had more severe damage according to the pathological examinations. In conclusion, slower infusion of DOX induced a higher inflammatory response and greater organ damage.

The effect of infusion rate and catheter length on the temperature of warming fluid

Background

We used warming fluid for maintenance of body temperature in operating room or intensive care unit. This study was aimed to investigate the effect of infusion rate and catheter length on the temperature of warming fluid.

Methods

Normal saline was used for testing infusion and temperature of infusion was maintained by a warmer as 40℃. The temperatures of solution in infusion line were measured at 0, 25, 50, 75, and 100 cm apart from warmer at six different flow rates (100, 200, 300, 700, 1,400, and 2,100 ml/h). We also measured the temperature changes at room temperature (RT) and 5℃, 10℃, and 15℃ above RT.

Results

The time to maintain solution temperature as 40℃ was 165, 122, 37, 37, 21, and 19 s at flow rate 100, 200, 300, 700, 1,400, and 2,100 ml/h. The peak temperature was 43.58 ± 0.58, 44.43 ± 1.18, 44.37 ± 0.70, 43.79 ± 0.61, 42.82 ± 0.97, and 42.11 ± 0.92℃ according to increasing flow rate. The temperature at 100 cm apart from warmer was 23.96 ± 1.53, 25.46 ± 2.76, 29.32 ± 3.47, 31.40 ± 5.38, 31.39 ± 6.75, and 38.14 ± 0.96℃ according to increasing flow rate.

Conclusions

These results suggested that the decreasing rate of temperature was related inversely to the flow rate and directly to the catheter length. There may be needed a rapid infusion pump with adequate heating system at a high flow rate and to locate the warmer close to patient for reserving a heating effect.