From: High dose interleukin-2 (Aldesleukin) - expert consensus on best management practices-2014
Issue | Considerations | Management |
---|---|---|
Venous access | Central line (for possible vasopressors) | Typical |
Double or triple lumen | PICC line placement | |
Power inject and large volume capacity | Remove temporary lines at end of cycle | |
Minimize catheter associated infection | Variations | |
Broviac/Hickman catheter | ||
Subclavian/IJ catheter | ||
IV fluids | Maintenance of volume with CLS | Typical |
Boluses for blood pressure support | D5NS or D5LR 10 ml - 125 ml/hr | |
Administration of drugs | PRN KCL, HCO3, Mg replacement | |
Replacement of electrolytes | Variations | |
IL-2 only compatible with D5W | D5W, NS, 0.45% NaCl | |
Infections | No active infections | Typical |
Prevention | Gram + prophylactic antibiotic | |
IV catheter likeliest source | Variations | |
Avoid unnecessary in-dwelling catheters | Expanded coverage per hospital | |
Chills/rigors | Chills and rigors occur 1-2 hrs after IL-2 | Fever-Typical |
Prophylaxis | ||
Fever | Fever is common 2-4 hrs after IL-2 | Acetaminophen 650 mg 30 min pre-dose, q 4-6 hrs and prn |
Indomethacin 25 mg q 6-8 hrs | ||
Constitutional symptoms | Muscle joint aches continuous and progressive during IL-2 treatment | Fever-Variation |
Naproxen | ||
Ibuprofen | ||
Chills-Typical | ||
Meperidine 25 mg IV q 15 m prn | ||
Morphine 2-4 mg IV q 15 m prn | ||
Nausea/vomiting | Episodic occurrence throughout therapy | Typical- Prophylaxis |
Nausea > vomiting | Ondansetron 0.15 mg/kg q 8 hrs | |
Variations | ||
Granisetron 1 mg daily | ||
Ondansetron at longer interval | ||
Compazine 10 mg po q 6 hrs | ||
Use of antinausea agents prn | ||
Epigastric distress | Gastritis induced by stress, medications | Typical |
H2 blocker prophylaxis | ||
Variation | ||
PPI prophylaxis | ||
Mucositis/stomatitis | Progressive with continued treatment | Typical |
No prophylaxis | ||
Oncology mouthwash | ||
Diarrhea | Can be profuse and increases with therapy | Typical |
5HT-3 antagonist anti-emetic prophylaxis | Imodium | |
may have positively impacted | Lomotil | |
 | Narcotic | |
 | Break between IL-2 doses | |
 | Variations | |
 | 5HT-3 antagonist prophylaxis | |
Patient monitoring | I & O, Weight | Per shift and daily |
Blood pressure, pulse, respirations, temp | Q 2-4 hrs | |
Blood work | Daily | |
EKG | Continuous cardiac monitoring | |
O2 Saturation | Q 2-4 hrs | |
Mental status examination | Q 8 hrs | |
Increase frequency as needed | ||
Aldesleukin/Interleukin-2 dose and administration | IL-2 incompatible with salt solutions. | Typical: 600,000 IU/kg infused over 15 minutes Q 8 hrs up to 14 doses. |
Dissolve in sterile water for injection Dilute into 50 cc D5W | Variations: 720,000 IU/kg Q 8 hrs Q 12 hrs < 14 maximum doses | |
Stop infusion, flush IV tubing with 50 cc D5W before and after each dose. | Â | |
Hypotension | Maintain systolic BP 80-90 mm hg | Fluid boluses, 250-500 ml NS |
Blood pressure nadirs 4-6 hrs after each dose with diminished recovery with cumulative dosing | 2xday | |
Increase maintenance fluid rate | ||
Phenylephrine 0.1-4.0 mcg/kg/min | ||
Hold next dose | ||
Prior to each dose anticipate ability to respond to next nadir | DC IL-2 | |
Variations: | ||
Dopamine 1-6 ug/kg/min | ||
Progressive refractoriness to support measures | Pressors with minimal fluids | |
Fluids without pressors | ||
Cardiac arrhythmias | Sinus tachycardia | Manage BP and fever |
Common and progresses over a cycle | ||
Peaks 2-4 hrs after dose with fever and hypotension | ||
Must resolve prior to next dose | ||
Supraventricular tachycardia, atrial fibrillation | Medical Conversion | |
Less common | Cardizem as needed | |
Atrial fibrillation | Digoxin | |
Ventricular tachycardia | Medical Conversion | |
Acute treatment | ||
Discontinue IL-2 | ||
Renal function | Â | Typical |
Oliguria | Output less than 50-100 cc/8 hrs Fluid bolus, if no improvement next shift hold IL-2 dose | |
Rising creatinine | Creatinine >3-4 | |
Stop NSAIDS and nephrotoxic antiobiotics | ||
Urine output and creatinine resolve after discontinuation of IL-2 | Hold overnight dose | |
If am creatinine improved continue | ||
If only one kidney always consider obstruction of ureter | Variations | |
Dopamine 1-6 mcg/kg/min | ||
Furosemide | ||
Pulmonary | Tachypnea/Dyspnea | Typical |
Diagnose etiology and treat | Oxygen 2-4 L nasal cannula, increasing up to 35% rebreather | |
Hypoxic causes-Fluid overload, capillary leak, bronchospasm | Reassurance or sedative for anxiety, treat bronchospasm or acidosis if appropriate | |
Non hypoxic causes | Hold IL-2 dose if O2sat < 95% | |
Anxiety, fever, acidosis | ||
Maintain O 2 sat > 92-5% | Variation | |
Furosemide | ||
Bronchodilators | ||
Monitor bicarbonate | ||
Peripheral edema | Expect to gain 5-10% body weight | Elevation, compression, limit fluid support in subsequent cycles |
Treat edema symptomatically | Diuretics upon conclusion of IL-2 dosing are not necessary but may speed process | |
Entrapment of peripheral nerves in upper extremity may need therapy | Treat peripheral nerve pain | |
Neurotoxicity | Â | Typical |
Protean manifestations | Formal neuro checks | |
Gradual onset with sudden worsening near end of cycle | Enlist family evaluation | |
May persist after cessation of therapy | Lorazepam and Haloperidol | |
Delusions, Visual hallucinations | Hold IL-2 liberally for suspected neurotoxicity | |
Warn patient of vivid dreams after discharge | ||
Dermatologic | Â | Typical |
Rash, erythema, dry desquamation | Emollient lotions and creams Oatmeal bath | |
Pruritus | Antihistamines | |
Moist dermatitis | Hold IL-2 dose | |
Variations | ||
Crisco | ||
Gabapentin | ||
Naloxone | ||
Narcotics | ||
Nonalcohol, no steroid topicals | ||
Metabolic | Hypomagnesemia, hypocalcemia (but low albumin - so corrected may be WNL), Hypokalemia- | Daily electrolyte panels |
Acidosis due to diarrhea, hypoperfusion | Correct electrolytes cautiously prn | |
Hypothyroidism a slow onset problem | Magnesium and HCO3, particularly if diarrhea a problem | |
HCO3 < 18 meq/L hold dose of IL-2 | ||
Check TSH at beginning of cycle | ||
RL as support fluids may decrease need for HCO3 | ||
Hepatic | ↑Bilirubin (up to 10) | Monitor daily |
↓Albumin (down to 1.8) | No intervention except if SGOT SGPT are >5x | |
↑Hepatic aminotransferases | Resolves spontaneously | |
 | Stop acetaminophen if bilirubin > 5 | |
Hematologic | ↓Platelets | Transfuse platelets if < 20 K |
Lymphs ↓during IL-2, ↑post therapy | Other abnormalities require no intervention | |
Eosinophils progressively ↑with several cycles | Significant anemia needs evaluation for cause | |
Endocrine | Hypothyroidism - slow onset after completion of treatment | Check TFTs at beginning of cycle and monitor TFTs with subsequent visits |
Requires serial monitoring |