Objective Three separate infliximab prescribing and administration guidelines were being used within the paediatric departments at LTHT. Over a 6 month period this caused selection errors which resulted in a number of administration rate errors. The aim of this project was to develop a single paediatric infliximab administration guideline which could be used by all paediatric specialities at LTHT to help reduce prescribing and administration errors.
Methods An extensive literature search was conducted to determine the ideal rate of administration of infliximab, the relationship between infusion reactions and infusion rate, and to establish what evidence there was for using a titrated infusion schedule when administering infliximab. Purposive sampling was utilised to contact 16 paediatric centres across the country to determine what guidelines and local practices they had in place for prescribing and administering infliximab. All LTHT infliximab guidelines and local guidelines from other paediatric centres were collated and critically appraised against the evidence base and discussed with stakeholders.
Results Ten relevant papers were included in the literature review; four of these were review articles. None of the studies specified the rate at which the infliximab infusions were given. All the studies were clear that infliximab is associated with infusion related reactions including acute reactions, delayed hypersensitivity and immunogenicity. Although there does not appear to be a direct correlation between infusion rate and infusion related reactions, some authors suggested using a titrated infusion schedule to reduce the risk of infusion related reactions; previously recommended in the American datasheet for infliximab. Of 16 paediatric centres contacted 12 had infliximab guidelines in place; 6 of these were for rheumatology and 8 were for gastroenterology indications. Only three centres had guidelines in place for both gastroenterology and rheumatology. Nine out of the 12 centres used a titrated infusion schedule when administering infliximab. The hospital protocols that advocating using titrated infusion schedules were based on a clinical trial (Protocol C0168T32). One centre had an infliximab administration drug chart in use and three centres used specific infliximab administration record sheets.
Local stakeholders were consulted with the evidence. It was decided a titrated infusion schedule would only be used for children with previous infusion reactions to infliximab. The format chosen for the guideline was a combined drug chart and guideline so that the guidance would be on hand as infliximab was prescribed and administered by the doctors and nurses.
Conclusion An infliximab drug chart which doubles as a guideline has been developed and is used for all paediatric patients receiving infliximab. We hope a single guideline will aid prescribing and reduce administration rate errors. An audit to evaluate the guideline and determine whether it has resulted in reduced errors is to be conducted shortly.