Clinical management recommendations for HD IL-2 therapy
| 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. | ||
| 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 | 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 O2sat > 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 | 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 | 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 |