Los Angeles—Peripheral IV administration of fosaprepitant (Emend, Merck) at 150 mL over 20 minutes results in an almost 15% rate of infusion-site reactions in selected patients, according to a poster study from the Ohio State University (OSU), in Columbus. This rate is much higher than the 3% rate reported in the literature and has spurred the investigators to make changes at their facilities.
“Because of the [results], we’ve already [revised] the dilution and rate of our default [infusion] in the computer system,” said Jordan Lundberg, PharmD, a postgraduate year 1 pharmacy resident at the OSU Wexner Medical Center. “We’re now using a 250-mL base solution given over 30 minutes,” based on manufacturer-provided external stability data, added Dr. Lundberg, who presented the poster study at the annual meeting of the Hematology/Oncology Pharmacy Association.
The Fosaprepitant Rationale
Last September, OSU’s Arthur G. James Cancer Hospital first added the 150-mL fosaprepitant regimen to its formulary. The addition was made, Dr. Lundberg noted, because the IV drug offered a more convenient alternative to the standard three-day course of oral aprepitant (Emend, Merck). The decision was bolstered by a Phase III trial showing that single-dose IV fosaprepitant is noninferior to the multiday oral aprepitant therapy (J Clin Oncol 2011;29:1495-1501).
After the cancer hospital started to use the IV regimen (based on the package insert [PI] recommendation, started approximately 30 minutes before chemotherapy)—clinicians noticed the higher-than-expected spike in infusion-site reactions.
To document the true rates of infusion reactions, Dr. Lundberg and his colleagues retrospectively reviewed the records of all patients who received fosaprepitant through a peripheral line preceding chemotherapy between Sept. 1, 2012 and Dec. 31, 2012. In the study, 100 patients received 192 doses of the fosaprepitant PI regimen through a peripheral line that was placed in the hand, forearm or antecubital fossa.
Preliminary evaluation of the 192 doses revealed 28 infusion-site reactions for an incidence of 14.6%, with most reactions being grade 1 or 2. “What we [saw was] some pretty high rates of infusion-site reactions compared to what is reported in the literature. Almost 15% of patients had infusion-site reactions,” said Dr. Lundberg. “I didn’t expect it would be that high.”
Based on the data, the hospital’s pharmacy and therapeutics committee recommended changing the dilution and rate of fosaprepitant to the aforementioned 250-mL base solution given over 30 minutes.
Lisa Holle, PharmD, BCOP, an oncology pharmacist at the University of Connecticut Health Center’s (UCHC) Carole and Ray Neag Comprehensive Cancer Center, in Farmington, said she found the study results “surprising,” given that its documented rate of infusion-site reactions is more than 10% higher than what has previously been reported. “We use oral aprepitant almost exclusively at UCHC’s Neag Cancer Center because we prefer the all-oral antiemetic regimens,” she said. “I look forward to the full results of this research (i.e., the results following use of a more dilute solution over a prolonged period). If less infusion-related reactions occur with this method, then we would likely recommend such a change in our institution for those few patients who may receive fosaprepitant.”
Both antiemetics are included as options in treatment guidelines from the National Comprehensive Cancer Network and the American Society of Clinical Oncology: The groups recommend a three-drug cocktail of oral aprepitant or IV fosaprepitant, a 5HT-3 receptor antagonist and dexamethasone.
Drs. Lundberg and Holle have no relevant financial conflicts of interest.