Transitioning patients with IBD to rapid infliximab infusions and providing treatment at home in selected patients appears to be safe and effective.
A Melbourne study compared 169 IBD patients who received 2,214 standard two-hour IFX infusions between 2005-2013 and 129 patients who received 1,461 rapid infliximab infusions between 2014 to 2017 at a single IBD centre.
There was a stepwise approach towards the rapid infusions with patients’ first three infusions delivered over the standard two hours, infusions 4-6 delivered over one-hour, and then subsequent infusions delivered over 30 minutes.
Patients only progressed to the next step if there were no adverse reactions.
When comparing the standard versus rapid infusion cohorts, the study found the overall relative risk for a mild adverse reaction was 10.7% and 7.8% respectively and 3.0% and 0.0% for a severe reaction.
The study found a lower BMI (< 22 kg/m2), the presence of one or more extra intestinal manifestations, longer disease duration (> 3 years) and previous exposure to another biologic were each independently associated with a higher likelihood of reaction to rapid infusions.
No adverse reactions were observed in the small sub-group of rapid-infusion patients who received their infliximab at home.
The study, published in the World Journal of Gastroenterology, found the median needle to departure time was 108 minutes per infusion with the standard protocol compared to 50 minutes with the rapid protocol (p < 0.001).
The cost of delivering infusions in hospital was significantly higher in the standard cohort than in the rapid infusion cohort ($107.50 v $49.77 per infusion; p < 0.001). However there was no significant difference in costs between delivering rapid infusions in hospital or at home ($49.80 v $39.20 per infusion; p= 0.20).
Patients preferred the rapid infusions over standard infusions, however the home based infusions raised some issues.
These included a lack of coordination and communication of the timing of infusions, unforeseen delays, lack of nursing staff on some days forcing patients to attend hospital for their infusions, and a lack of sufficiently skilled nurses resulting in difficulties obtaining intravenous access and/or administering infusion at slower rates than prescribed.
“Additionally, others reported a reluctance to “medicalise” their home and/or have infusions in presence of family members (especially their children) or work colleagues,” the study said.
“Also, some patients missed the familiarity of the same nursing staff and the camaraderie enabled by attending the same infusion centre, as many had done, for several years.”
The study said they have demonstrated “a rigorous framework for the safe, potentially cost saving delivery of not only infliximab but potentially other similar medical infusions at home.”
“With careful patient selection, we have demonstrated that the risk of ADRs with home-based infusions is negligible and thus these data are reassuring to patients, clinicians and healthcare providers alike.”
Lead author Dr Anuj Bohra, a gastroenterology fellow at Eastern Health, told the limbic that rapid infusions have essentially become routine in most tertiary centres in Australia.
“There is now data to suggest that this can be done safely outside of traditional infusion centres in hospitals. It can be done safely at home. And it’s not just for IBD but infusion therapy recipients in general.”
He said home-based infusions might particularly suit patients with rheumatological and neurological illnesses who might have functional impairments that make it challenging to travel to hospital for treatment.
“There is some degree of patient profiling that needs to be done in selecting the right candidates for people who have infusion therapy at home. But you can do it safely at home. Consider doing infusions at home if you have the right patients and they are willing.”
Dr Bohra said the rapid infusion protocol was driven by the safety data for patients.
However the productivity increases for hospitals – higher throughput without the need for additional nursing and support staff – was also a win.
“Transitoning to home takes that one step further. Transitioning to home has allowed us to do these infusions on Saturdays which is very advantageous for people who are working full time – which is a huge proportion of our patients because it is a disease which affects the young and the old. A lot of IBD is in working age people rather than some of the chronic diseases you see in a more elderly population.”
He said that everyone who received infusions at home had done so by choice.
“There was no mandatory transition; it was all driven by choice and I think there has only been one patient who has gone back to hospital.”
“So we have been able to retain a degree of success and I think that service has now evolved further and I think a lot of these smaller issues that occur with home-based infusions have been ironed out,” he said.
“It’s now a smoother, well-oiled machine.”