Management of Transient Infusion Reactions from Remicade (Infliximab)

Incidence and Recognition

Infusion reactions occur in 3-22% of patients receiving infliximab, with the majority being mild to moderate in severity, and common symptoms include fever, chills, and flushing 1, 2
Patients may experience pruritus, urticaria, and mild rash 1
Nausea is also a common symptom 1
Mild dyspnea or chest tightness can occur 1

For mild to moderate transient infusion reactions, immediately stop or slow the infusion rate, provide symptomatic treatment, and restart at 50% of the previous rate once symptoms resolve—most reactions are self-limiting and do not require permanent discontinuation 1
The American Journal of Hematology recommends stopping or slowing the infusion immediately and switching IV line to normal saline to keep vein open 3, 1
Provide symptomatic treatment, including antihistamines, such as diphenhydramine 25-50 mg IV or oral second-generation antihistamine, and antipyretics, such as acetaminophen 650-1000 mg for fever 3, 4, 1
Monitor for 15 minutes until symptoms resolve 3, 5
Restart infusion at 50% of the previous rate after complete symptom resolution, and if well tolerated for 15 minutes, gradually increase rate 1, 3

Consider premedication only for patients with prior infusion reactions, multiple drug allergies, or history of asthma 3
If premedication is used, administer antipyretic, such as acetaminophen 1000 mg, 30-60 minutes before infusion, and antihistamine, such as diphenhydramine 50 mg or equivalent 1
Use slower initial infusion rates for first dose 1

Observe patients for 1-2 hours after infusion completion 5, 2
Educate patients about delayed reactions that can occur up to 24 hours post-infusion, including flu-like symptoms, arthralgias and myalgias, and fever 3, 5, 2
Recommend NSAIDs for symptomatic relief of delayed symptoms 3

Do not rechallenge after severe (Grade 3-4) reactions, including bronchospasm, severe hypotension, angioedema, or anaphylaxis 4, 1
Do not restart infusion at full rate—always resume at 50% of previous rate after reaction resolution 3, 1
Monitor vital signs continuously during rechallenge, as most reactions (77%) occur during first infusion but can occur at any time 1, 2