Spring Education Exchange (SEE): Recognizing and Responding to Challenges Related to Dinutuximab Administration in the Pediatric Patient with Neuroblastoma

Presented by:  
Kristen Dalton MSN RN CPNP-AC CPHON®
Jennifer Saggio, MSN CRNP
Shannon Markert, MSN CPNP-AC

Session Details: Day 1: May 13, Session 2 12:45 PM-1:45 PM EDT (11:45 am CDT / 10:45 am MDT / 9:45 am PDT) 

Overview of Session: This session will explore the following challenges related to GD-2 directed monoclonal antibody dinutuximab administration in the pediatric patient with neuroblastoma: neurotoxicity, anaphylaxis, and length of stay (with its potential impact on hospital census and patient/family satisfaction). Dinutuximab-associated neurotoxicity: A 5-year retrospective analysis of incidence presentation, risk factors and nursing interventions Despite its black box warning for neurotoxicity, the full spectrum of adverse effects related to dinutuximab remains poorly classified, limiting clinical guidance. Notably, systematic reviews reveal a lack of nurse-specific guidance for monitoring and managing dinutuximab-associated neurotoxicity. In a retrospective descriptive study at a large medical center, analyzing 437 cycles of dinutuximab administered to 65 patients between 2018 and 2023 we sought to 1) characterize neurotoxicity symptoms, 2) summarize initial nursing interventions, and 3) examine neurotoxicity risk factors and outcomes. We found that dinutuximab-related neurotoxicity is common and often presents early in treatment. Findings suggest targeted neurologic monitoring and nursing interventions are needed for safe administration. Understanding toxicity presentation can inform development of practice guidelines, though further research is needed to evaluate intervention effectiveness and outcomes. You’re doing what in the clinic? Initiating dinutuximab in the outpatient oncology setting Dinutuximab has a side effect profile that requires close monitoring and supportive care in an inpatient setting. At a time when many inpatient units are overflowing with patients, these long admissions may put additional strain on hospital systems already under stress. We proposed, developed, and implemented a new pathway for initiating dinutuximab in the outpatient setting prior to hospital admission.

The project also served as a pilot, empowering nurses to activate chemo/immunotherapy orders via the electronic order entry system. The team addressed logistical challenges regarding supply availability, emergency preparedness, and patient transport as well as provided comprehensive education to nurses. Strict eligibility criteria have kept the number of patients following the pathway low, however, those who followed the new pathway experienced shorter hospital stays and expressed increased satisfaction with care. Dinutuximab desensitization in patients with relapsed/refractory neuroblastoma Dinutuximab therapy is associated with severe allergic symptoms in up to 26% of patients, manifested in bronchospasm, angioedema, and anaphylaxis. Historically, patients who experience severe allergic symptoms often require administration of epinephrine and discontinuation of this treatment. We developed a desensitization protocol that would enable patients with previous severe allergic symptoms to continue this therapy. Dinutuximab is infused over approximately 19.5 hours utilizing three bags of dinutuximab containing increasing concentrations of drug. Nursing increases the infusion rate at 12 different time points throughout the infusion and administers a standard supportive care regimen of antipyretics, antihistamines, intravenous fluids, and bronchodilators. To date, six patients were able to continue their dinutuximab therapy without experiencing severe allergic symptoms while utilizing the desensitization protocol. 

Learning Outcomes:  

• Describe the most common clinical presentation and timing of neurotoxicities typically associated with dinutuximab and identify common nursing actions required to manage neurotoxicity in this patient population 

• Understand the process for developing and implementing a new clinical pathway for initiating dinutuximab in the outpatient setting prior to hospital admission 

• Explain how the development of a desensitization protocol would enable patients with previous severe allergic symptoms to continue dinutuximab therapy 

This contains 1 section:   

1. Post-session Evaluation

Continuing Education Credit 

APHON will provide 1 nursing continuing professional development (NCPD) contact hour(s) for the successful completion of this session. Successful completion requires attendance for the entire session and the completion of the post-session evaluation. 

The Spring Education Exchange (SEE) sessions and post-session evaluations will be available for 30 days.  

The Association for Pediatric Hematology Oncology Nurses is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation. This provider is also approved by the California Board of Registered Nursing, Provider Number 14513. 

None of the planners for this activity have relevant financial relationship(s) to disclose with ineligible companies.  

Questions or concerns? Contact education@aphon.org.  

The APHON Spring Education Exchange is sponsored by ONCC.