What are best practices in management of severe acute infusion reaction from infliximab?

Severe infusion reactions to infliximab are not typically IgE-mediated. The presumption is that it is ‘anaphylactoid’ due to IgG antibodies directed against the mouse chimeric proteins in the molecule. Stopping the infusion is essential (at least temporarily) and administering antihistamines such as IV diphenhydramine is all that is generally required if the patient was given peri-infusional steroids. The need for epinephrine has been generally cited as <1% of infusions (Cheifetz et al., PMID 12818276; Choquette et al., PMID 26077415). With clearing of symptoms, reinitiation of infliximab infusion at a slower rate can be attempted. If the patient is to be rechallenged at a later date, prednisone (~1 mg/kg) can be given the night before the ...