Loading
If you have had a true allergic reaction to a cancer drug that is still your best treatment, allergy specialists can often give it again safely by desensitisation: starting with a tiny, very diluted dose and building up slowly over several hours, under close watch. The protection lasts only while the drug is in your body, so it is repeated at every treatment.
After a hypersensitivity reaction, the choices are desensitisation, skin testing to stratify risk, risk stratification and a drug challenge without testing, or avoiding the drug if an equally effective alternative exists (AAAAI/ACAAI practice parameter 2022). The first task is phenotyping: non-IgE reactions to chemotherapy or biologics can be managed with slower infusion, graded dose escalation or premedication without desensitisation (a conditional suggestion), while candidates for desensitisation include type I (mast-cell or IgE-mediated) reactions, including anaphylaxis. Empiric desensitisation is described as reasonable and safe even without skin testing; for platinums, skin testing can stratify risk and show when desensitisation is unnecessary; for antibodies it should be considered when the drug is the preferred therapy.
Oncology guidance is more cautious. ESMO (2017) says rechallenge after a CTCAE grade 3 or higher reaction or true anaphylaxis should not be attempted [V, B], and that desensitisation has been used for some drugs with varying success in experienced centres, with no standard protocol. The method gives an initial small, diluted dose over a prolonged infusion with gradual escalation; tolerance is temporary, so it is repeated at every course. The best-known protocol, a standardised 12-step, three-bag regimen, gave 413 desensitisations in 98 patients with 94% mild or no reactions and no deaths. One-bag protocols appear similarly safe, with less data after severe reactions. In 241 women with gynaecological cancers, survival after desensitisation for platinum or taxane reactions was comparable to that without reactions.
Why: Non-allergic reactions can usually be managed by slowing the drip and premedication; desensitisation is for true allergy.
“Suggestion that patients with non-IgE chemotherapy or biologic reactions be treated with slowed infusion rate, graded dose escalation, and/or pre-medications without desensitization”
AAAAI/ACAAI Joint Task Force on Practice Parameters (Journal of Allergy and Clinical Immunology, Khan et al.) 2022 · Suggestion
Why: A second full-speed exposure after a severe allergic reaction can be fatal.
“Rechallenge in IRs with CTCAE severity grade 3 or higher or in true anaphylaxis should not be attempted [V, B].”
Why: Each route has different risks, time costs and chances of keeping the best treatment.
“The main approaches to care after a presumed hypersensitivity reaction (HSR) to a chemotherapeutic include (1) desensitization, (2) skin testing to assist with risk stratification, (3) risk stratification without skin testing and drug challenge or (4) avoidance of the offending agent if an equally efficacious alternative exists.”
Why: Desensitisation lets people keep their most effective treatment instead of switching to a weaker one.
“If the clinical assessment is consistent with a HSR, then empiric desensitization is a reasonable and safe approach to care and can be performed even when skin testing is not possible (i.e., outpatient clinic without access to chemotherapy drugs for skin testing).”
Why: Some people with a reaction history are not truly allergic and can be treated more simply.
“Skin testing may be useful in the management of patients with platin HSRs and also identifies cases where desensitization may be unnecessary despite a clinical history suggestive of an HSR.”
Why: Building up slowly lets the immune cells that cause the reaction be quietened step by step.
“In desensitisation protocols, an initial small diluted dose of the agent with a prolonged infusion time and gradual escalation of the dose is administered.”
Why: Breakthrough reactions happen, most often on the first desensitisation and the last step, and need treating at once.
“For patients who have recurrent IRs despite premedication, desensitisation protocols have been used with certain drugs with varying success in experienced centres.”
Why: The tolerance wears off once the drug has cleared from the body; the person is still allergic.
“Patients remain allergic to the drug and must be desensitised for every course of treatment.”
Why: Antibodies often have no equal alternative.
“In contrast, for patients with immediate reactions including anaphylactic reactions to mAbs, drug desensitization should be considered when the implicated drug is the preferred therapy.”
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
Phenotype the reaction first; manage non-IgE reactions with slower infusion, graded escalation or premedication (AAAAI/ACAAI 2022, conditional suggestion); for true type I reactions, including anaphylaxis, offer desensitisation in an experienced centre when the drug is still the best treatment, with skin testing as an option for platinums, and repeat it at every course. The guidelines differ in emphasis: the allergy practice parameter calls empiric desensitisation reasonable and safe, while ESMO 2017, written for oncologists, says rechallenge after grade 3 or higher reactions or anaphylaxis should not be attempted [V, B] and that desensitisation has varying success, with no standard protocol. These are compatible if 'rechallenge' means re-exposure at the usual rate rather than desensitisation.
AAAAI/ACAAI Joint Task Force on Practice Parameters (Journal of Allergy and Clinical Immunology, Khan et al.) 2022 · ESMO (Annals of Oncology, Roselló et al.) 2017 · Journal of Allergy and Clinical Immunology (Castells et al.) 2008 · European Academy of Allergy and Clinical Immunology (Allergy, Pagani et al.) 2022
Where it differs: Three bags of increasing concentration infused in 12 steps; the first desensitisations were done in intensive care and later ones as outpatients, intravenously or intraperitoneally.
Evidence: 413 desensitisations in 98 patients reacting to carboplatin, cisplatin, oxaliplatin, paclitaxel, doxorubicin (including liposomal) or rituximab: 94% mild or no reactions, no life-threatening reactions or deaths, and every patient received the full dose (Castells 2008).
Journal of Allergy and Clinical Immunology (Castells et al.) 2008
Where it differs: Uses a single bag with a stepped infusion rate, which is simpler and quicker to prepare.
Evidence: The 2022 practice parameter says increasing evidence suggests similar safety and efficacy to three-bag protocols, with more data needed after severe initial reactions.
Where it differs: Desensitises on the day of the initial reaction rather than at a later, planned session.
Evidence: A Spanish retrospective cohort (570 desensitisations in 120 patients with platinum or taxane reactions) found breakthrough reactions in 15% with same-day and 24% with planned rapid desensitisation; a Bayesian model estimated a 14.6-point lower probability with same-day. Observational and single-centre.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| For immediate taxane reactions, the severity of the initial reaction may assist risk stratification and management “Suggestion that for patients with immediate reactions to taxanes, the severity of the initial reaction may assist in risk stratification and management” | Suggestion | AAAAI/ACAAI Joint Task Force on Practice Parameters (Journal of Allergy and Clinical Immunology, Khan et al.) 2022 |
| Non-IgE reactions to monoclonal antibodies may be managed with slowed infusion, graded escalation or premedication without desensitisation “Suggestion that patients with non-IgE reactions to monoclonal antibodies (mAb) may be treated with a slowed infusion, graded dose escalation, and/or premedication without desensitization” | Suggestion | AAAAI/ACAAI Joint Task Force on Practice Parameters (Journal of Allergy and Clinical Immunology, Khan et al.) 2022 |
Shares Infusion reactions, hypersensitivity and extravasation, Oxaliplatin, Rituximab, Paclitaxel / nab-paclitaxel.
Shares Docetaxel, Paclitaxel / nab-paclitaxel, Cisplatin, Carboplatin.
Shares Oxaliplatin, Docetaxel, Paclitaxel / nab-paclitaxel, Carboplatin.
Shares Docetaxel, Paclitaxel / nab-paclitaxel, Cisplatin, Carboplatin.
Shares Docetaxel, Cisplatin, Carboplatin.
Shares Oxaliplatin, Docetaxel, Carboplatin.
Shares Oxaliplatin, Cisplatin, Carboplatin.
Shares Infusion reactions, hypersensitivity and extravasation, Oxaliplatin.