Management of Glutathione IV Allergy

Immediate Management

The American Society of Clinical Oncology recommends stopping the glutathione infusion immediately upon recognition of any allergic symptoms, maintaining IV access, and assessing for anaphylaxis using clinical criteria 1, 2, 3
The patient's airway, breathing, and circulation (ABCs) should be assessed, and their level of consciousness should be evaluated 1
The patient should be positioned appropriately, with the Trendelenburg position used if hypotensive, sitting upright if experiencing respiratory distress, and the recovery position if unconscious 1
Supplemental oxygen should be administered as needed, and medical assistance should be called for immediately 1, 3

The American College of Allergy, Asthma, and Immunology recommends epinephrine as the first-line treatment, which should be administered immediately at a dose of 0.01 mg/kg (maximum 0.5 mg) intramuscularly into the lateral thigh muscle 1
Epinephrine should be repeated every 5-15 minutes as needed, and IV epinephrine should be administered if there is an inadequate response 1, 3, 5
Fluid resuscitation with rapid infusion of 1-2 liters of normal saline at 5-10 mL/kg in the first 5 minutes is recommended, followed by crystalloids or colloids in 20 mL/kg boluses 1, 3, 5
Adjunctive medications, including combined H1/H2 antihistamines (diphenhydramine 50 mg IV plus ranitidine 50 mg IV), corticosteroids (methylprednisolone 1-2 mg/kg IV every 6 hours), and atropine 600 mcg IV for bradycardia, should be administered as needed 1, 3, 5

For mild reactions, the infusion should be stopped, and the patient should be switched to hydration fluid to keep the vein open, with monitoring for 15 minutes 6
Symptom-directed treatment, including ondansetron 4-8 mg IV for nausea, second-generation antihistamines (loratadine 10 mg PO or cetirizine 10 mg IV/PO) for urticaria, and avoidance of first-generation antihistamines, should be provided as needed 6
For moderate reactions, diphenhydramine 50 mg IV plus ranitidine 50 mg IV, corticosteroids (methylprednisolone 1-2 mg/kg IV every 6 hours), and mild hypotension treatment with normal saline IV to maintain systolic BP >100 mmHg should be administered 1, 3, 5, 6

The National Comprehensive Cancer Network recommends that glutathione IV should not be administered again to a patient who has experienced a severe life-threatening reaction (anaphylaxis) 8
Rechallenge is discouraged in severe reactions, even with premedication 3, 5

The reaction should be documented thoroughly, including specific symptoms, timing of onset, and treatments administered, with consideration of measuring tryptase levels 15 minutes to 3 hours after onset if anaphylaxis is suspected 1, 2, 5
Serial tryptase measurements (during reaction and baseline after recovery) are more useful than single measurements 1, 2, 5
Patient counseling and allergy documentation, including clear documentation of "glutathione IV allergy" in the medical record, counseling the patient about the reaction and need to avoid glutathione IV in the future, and consideration of referral to an allergist, should be provided 8

Delaying epinephrine administration in suspected anaphylaxis can rapidly progress to cardiovascular collapse, and corticosteroids should not be used alone without antihistamines in acute reactions 1, 7
First-generation antihistamines (diphenhydramine) should be avoided in mild reactions as they can exacerbate hypotension and tachycardia, and desensitization should not be attempted 6, 8