Most dermatologist agree that infliximab (Remicade, Centocor) has important advantages for psoriasis treatment. Depending on a dermatologist's patient load, it may be reasonable to establish a facility for in-office infliximab infusion. This article discusses considerations for providing infliximab infusion in the office and for referring patients for administration.
National report - In-office infusion is not a service that all dermatologist can or want to provide, but those who might be interested because they care for a substantial number of patients who are candidates for infliximab (Remicade, Centocor) may be surprised to find the costs are lower and the logistics less complex than they might anticipate, according to Craig Leonardi, M.D.
"Considering the images that might be conjured up by that name, people who see our facility would probably be underwhelmed. The 'center' is located in a converted exam room and outfitted simply with several comfortable recliner chairs, a flat-screen TV and a DVD player," Dr. Leonardi tells Dermatology Times.
State regulations defining who can administer IV infusions vary, so it is important to know the laws in the state where one's practice is located.
For example, in Missouri, an LPN with IV certification is permitted to provide this care, while across the Mississippi River in Illinois, the infusion must be administered by an RN.
Dr. Leonardi notes that staffing costs can be controlled by scheduling all infusion patients for the same day and hiring an infusion nurse on a part-time basis to match the patient load. A good infusion nurse is able to care for four or five patients simultaneously, he says.
The infusion visit
Each infusion visit takes three hours.
Dr. Leonardi advises starting the IV before mixing the medication so that the expensive drug will not be wasted in case an IV cannot be established, because infliximab is stable for only six hours after it is mixed and then has to be discarded, he says.
The infusion is administered over two hours and the IV is left in place during a 30-minute post-infusion observation period.
Although the infusion rate can be accelerated to decrease the administration time, Dr. Leonardi notes that approach can be associated with an increased risk of infusion reactions.
"I have a very busy office practice where I see roughly 50 patients on an average day, and so it is important to me to avoid problems in the infusion center that will require my attention. There is no reason to rush getting the drug on board and so we run the infusion slowly in a way that creates the most stable situation for the patient and the office staff," he says.
To further minimize the risk of infusion reactions, all patients are premedicated when they arrive with acetaminophen 1 gm and loratadine 20 mg. They also receive a very brief physical exam to rule out any acute illness that would be a reason to delay the infusion.
If a minor infusion reaction occurs, the administration can be stopped and usually restarted at a lower rate within 30 minutes. For more serious infusion reactions, patients might be given parenteral diphenhydramine or dexamethasone through the established IV line.
Tailoring the regimen
Dr. Leonardi notes most dermatologist who prescribe infliximab are not equipped to offer in-office treatment and so send their patients elsewhere to receive the infusion.