Infliximab Infusion Protocol

Patient Name :_____________________________

MRN : ________________
ID : __________________
Date : ________________
1.

ALLERGIES/REACTIONS ________________________

2.

DIAGNOSIS:

3.

CURRENT MEDICATIONS:____________________________________________

4.

Do not initiate therapy in patient with unstable Heart Failure (HF). If a patient has a history of
HF, nurse is to assess and monitor patient for exacerbation of HF and notify provider of
changes.

5.

LABS: (Prior to 1st Dose)

Crohns Disease (C.D)

Ulcerative Colitis (U.C)

Verify TUBERCULOSIS TESTING (TB) has been done. If not done, conduct one of the following tests PRIOR
to initiating the first dose of infliximab (Remicade.)

PPD skin test if patient not on a steroid

If PPD is positive notify provider and request new start date.
Treatment of Latent TB infection should be initiated prior to therapy with infliximab.

High-risk patients: Quantiferon TB Gold

CXR
Verify HBcAb Total (IgG) & HBsAg have been done.
If not done, initiate test(s) Prior to the first dose of infliximab (Remicade).
6.

INFLIXIMAB (REMICADE) ADMINISTRATION:

Crohns Disease:
5 mg/kg
10 mg/kg
Ulcerative Colitis:
5 mg/kg
Other:
mg/kg

7.

Height:

8.

CALCULATED DOSE:

9.

INFLIXIMAB (REMICADE) DOSE FREQUENCY:

Three Doses (Day 0, 2 weeks, 6 weeks) followed by infusions every 8 weeks thereafter OR _____

cm

Actual Weight:

kg

mg (rounded to the nearest 100 mg)

10. OTHER MEDICATIONS:

Nurse May Initiate IV Catheter Care, Outpatient Physician Order
For Infusion Reactions Initiate Drug Related Hypersensitivity Physician Order
Pre-medication: Give 30 minutes prior to infusion

Diphenhydramine (Hudo) 25 mg PO or IV (if unable to tolerate PO) times 1 dose

Acetaminophen (Paracetamol ) 1 gram PO or IV (if unable to tolerate PO) times1 dose

Other ____________________________

10.

OTHER MEDICATION :

PRN Medication:

Diphenhydramine (Benadryl) 25 mg IV every 4 hours PRN itching or hives

Acetaminophen (Tylenol) 650 mg PO every 4 hours PRN aches or temperature change greater
than 1C LIMIT THE TOTAL DOSE OF ALL ACETAMINOPHEN CONTAINING PRODUCTS
TO 3,000 MG PER DAY Infusion Directions:
Final concentration to be between 0.4 mg/ml and
4 mg/ml Do not shake Include 1.2 micron (or smaller) in-line filter
Do not infuse other medication into the IV line with infliximab (Remicade).
Flush with saline before and after medication administration.
Infuse per the following infusion rate schedule or maximum tolerated by patient:

Time
(Minute)
0
15
30
45
60
90
120

Infusion Rate Schedule

Initiate therapy at 10/ml hour times 15 minutes
Increase to 20 ml/hour times 15 minutes
Increase to 40 ml/hour times 15 minutes
Increase to 80 ml/hour times 15 minutes
Increase to 150 ml/hour times 30 minutes
Increase to 250 ml/hour times 30 minutes
End of therapy

11. VITAL SIGNS:

Obtain baseline vital signs. Monitor for signs and symptoms of drug reaction every 30 minutes, with vital signs.
Obtain vital signs at completion of infusion and 30 minutes post infusion.
Call physician if:
Systolic BP less than
mmHg Pulse greater than
Temperature greater than
C
12. DISCHARGE:
If stable 30 minutes post infusion, discharge patient home on current reconciled home medications

DATETIME

PHYSICIANS SIGNATURE

Treatment of Infliximab Infusion Reactions

Signs of an Infusion Reaction for Infliximab :
I . Acute Reaction : Start from the time of infusion up to 24 hrs of infusion (Mild , Moderate , Sever)
For mild reactions (Flushing , Dizziness , Sweating , Palpitation , Nausea )
1.The rate of infusion should be decreased to 10 mL/hour.
2. Initiate a NS infusion (500-1000 mL/hour) and appropriate symptomatic treatment (eg, acetaminophen and
diphenhydramine)
3. monitor vital signs every 10 minutes until normal.
4. After 20 minutes, the infliximab infusion may be increased at 15-minute intervals, as tolerated, to completion
[initial increase to 20 mL/hour, then 40 mL/hour, then 80 mL/hour, etc (maximum of 125 mL/hour)]
For moderate reactions (Chest Tightness , Shortness of breath , Hypotension , Hypertension (change more
than 20 mm hg in systolic blood pressure , raised temperature , urticarial )
1. The infusion should be stopped or slowed.
2. Initiate a NS (500-1000 mL/hour) and appropriate symptomatic treatment.
3. Monitor vital signs every 5 minutes until normal.
4. After 20 minutes, the infliximab infusion may be reinstituted at 10 mL/hour; then increased at 15-minute
intervals, as tolerated, to completion [initial increase 20 mL/hour, then 40 mL/hour, then 80 mL/hour, etc
(maximum of 125 mL/hour)].
For severe reactions ( Hypo/Hypertension change more than 40 mm hg in systolic BP , raised temperature
with rigors , chest tightness , Shortness of breath with wheezing auscultate with stethoscope , stridor )
1. the infusion should be stopped with administration of appropriate symptomatic treatment (eg,
hydrocortisone/methylprednisolone, diphenhydramine and epinephrine) and frequent monitoring of
vitals.
2. Retreatment after a severe reaction should only be done if the benefits outweigh the risks and with
appropriate prophylaxis.

II . Delayed infusion reactions typically occur 1 to 7 days after an infusion.

1. Rash and Urticaria : Give a second generation Antihistamine (Levocertrizine 10 mg )
2. Myalgia , Influenza like Symptoms , Arthralgia , stiffness , Headache give Paracetamol
3. Severe Arthritis : give Analgesia at maximum dose Paracetamol up to 4 * 1 gram + Diclofenac up to 3*50
mg + Tramadol up to 4* 50 mg ,if unsatisfactory result add prednisone 40 mg , which should gradually
reduce in few weeks
4. Fatigue : No specific Treatment

Prophylaxis of infusion reactions

Premedication with acetaminophen and diphenhydramine 90 minutes prior to infusion may be

considered in all patients with prior infusion reactions, and in patients with severe reactions
corticosteroid administration is recommended.

Steroid dosing may be oral (prednisone 50 mg orally every 12 hours for 3 doses prior to infusion) or
intravenous (a single dose of hydrocortisone 100 mg or methylprednisolone 20 to 40 mg administered
20 minutes prior to the infusion).

On initiation of the infusion, begin with a test dose at 10 mL/hour of infliximab for 15 minutes.
Thereafter, the infusion may be increased at 15-minute intervals, as tolerated, to completion (initial
increase 20 mL/hour, then 40 mL/hour, then 80 mL/hour, etc).

A maximum rate of 125 mL/hour is recommended in patients who experienced prior mild-moderate
reactions and 100 mL/hour is recommended in patients who experienced prior severe reactions.

In patients with cutaneous flushing, Aspirin may be considered .

For delayed infusion reactions, premedication with acetaminophen and diphenhydramine 90 minutes
prior to infusion.

On initiation of the infusion, begin with a test dose at 10 mL/hour for 15 minutes.

Thereafter, the infusion may be increased to infuse over 3 hours.

Post infusion therapy with acetaminophen for 3 days and an antihistamine for 7 days is recommended.
Note: In a trial of pediatric patients, premedication with acetaminophen (20 mg/kg; maximum single
dose: 1000 mg) and cetirizine (0.3 mg/kg if <5 years, 10 mg if 5 years) did not significantly impact
incidence of infusion-related reactions; patients should be monitored closely.