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Hypersensitivity reactions to chemotherapy

Key sources
The following summarized guidelines for the evaluation and management of hypersensitivity reactions to chemotherapy are prepared by our editorial team based on guidelines from the European Academy of Allergy and Clinical Immunology (EAACI 2022), the European Society of Medical Oncology (ESMO 2017), and the Comité de l'évolution de la pratique en oncologie (CEPO 2014).


1.Screening and diagnosis

Pathogenesis: recognize the pathogenetic mechanisms of hypersensitivity reactions to different chemotherapeutic agents:
Platinum compounds
IgE-mediated reactions in some immediate, often severe cases
Direct activation of complement system by the drug in the majority of cases
IgE-mediated reactions in some cases
Immunologic and non-immunologic mechanisms
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2.Classification and risk stratification

Risk factors: take into account other risk factors apart from being aware of the potential risk of an infusion reaction of a specific drug, when delivering anticancer drugs, and during which course it is most likely to happen.
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  • Severity grading

3.Diagnostic investigations

Skin testing: as per EAACI 2022 guidelines, recognize that skin testing is the most readily available diagnostic test.
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  • Drug provocation test

  • In vitro IgE testing

  • Tryptase and histamine tests

4.Medical management

Recognize that prompt recognition and immediate medical attention are essential.
Recognize that some patients feel odd or uncomfortable or express a need to urinate or defecate before an infusion reaction. Pay serious attention to those symptoms and evaluate the patient by measuring BP and pulse rate.

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  • Initial supportive therapy

  • Management of anaphylaxis

  • Drug desensitization

5.Nonpharmacologic interventions

Psychological support
Provide psychological intervention to alleviate symptoms of uncertainty related to a potential infusion reaction with anticancer drugs.
Provide psychological support and have a complete, informative discussion with the patient about the potential benefits of continuing with the drug and the risk of infusion reaction recurrence.

6.Preventative measures

Preparation before drug delivery: elicit a medical history, ask about previous allergic disorders, atopic status and concomitant treatments before the administration of any drug.
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  • Premedication

  • Rate of administration

  • Prevention of future episodes

7.Follow-up and surveillance

Post-reaction monitoring: obtain close observation for 24 hours after a severe reaction. Monitor vital signs and control recurrence symptoms.
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  • Rechallenge

8.Quality improvement

Reporting: ensure accurate documentation of the infusion reaction episode, including pre-infusion assessments, an appropriate description and grading of the infusion reaction (according to accepted classifications such as CTCAE), and how it was managed.