What is the management approach for a patient with a known allergy to glutathione (glutathione) intravenous (IV) therapy?

Management of Glutathione IV Allergy

Immediate Management

If a patient develops an allergic reaction during glutathione IV infusion, immediately stop the infusion, maintain IV access, and assess for anaphylaxis using clinical criteria. 1

Stop Infusion and Initial Assessment

• Stop the glutathione infusion immediately upon recognition of any allergic symptoms 1
• Maintain the IV access for medication administration 1
• Assess ABCs (airway, breathing, circulation) and level of consciousness 1
• Position the patient appropriately: 1
  • Trendelenburg position if hypotensive
  • Sitting upright if respiratory distress
  • Recovery position if unconscious
• Administer supplemental oxygen as needed 1
• Call for medical assistance immediately 1

Determine Severity: Anaphylaxis vs. Mild-Moderate Reaction

Anaphylaxis is present if the patient has acute onset within minutes and meets any two of the following: 1

• Skin/mucosal involvement (urticaria, flushing, angioedema)
• Respiratory compromise (bronchospasm, dyspnea, wheezing)
• Reduced blood pressure or end-organ dysfunction
• Persistent vomiting or severe diarrhea

Treatment Based on Severity

For Anaphylaxis (Grade 3-4 Reaction)

Epinephrine is the first-line treatment and must be administered immediately: 1

• Epinephrine 0.01 mg/kg (maximum 0.5 mg) intramuscularly into the lateral thigh muscle 1
• Repeat every 5-15 minutes as needed 1
• If inadequate response, administer IV epinephrine 1

Fluid resuscitation: 1

• Rapid infusion of 1-2 liters normal saline at 5-10 mL/kg in first 5 minutes 1
• Crystalloids or colloids in 20 mL/kg boluses, followed by slow infusion 1

Adjunctive medications: 1

• Combined H1/H2 antihistamines: diphenhydramine 50 mg IV plus ranitidine 50 mg IV 1
• Corticosteroids: methylprednisolone 1-2 mg/kg IV every 6 hours 1
• If bradycardia: atropine 600 mcg IV 1
• If patient on beta-blockers: glucagon 1-5 mg IV infusion over 5 minutes 1

Monitor vital signs continuously until resolution and observe for 24 hours if severe reaction 1

For Mild-Moderate Reactions (Grade 1-2)

For mild reactions (flushing, rash, pruritus without systemic symptoms): 1, 2

• Stop the infusion and switch to hydration fluid to keep vein open 1
• Monitor for 15 minutes - most reactions are self-limiting 1
• If symptoms persist after 15 minutes: administer hydrocortisone 200 mg IV 1

Symptom-directed treatment: 1, 2

• For nausea: ondansetron 4-8 mg IV 1
• For urticaria: second-generation antihistamine (loratadine 10 mg PO or cetirizine 10 mg IV/PO) 1
• Avoid first-generation antihistamines (diphenhydramine) in mild reactions as they can worsen hypotension 1

For moderate reactions (urticaria with mild hypotension or respiratory symptoms): 1

• Diphenhydramine 50 mg IV plus ranitidine 50 mg IV 1
• Corticosteroids: methylprednisolone 1-2 mg/kg IV every 6 hours 1
• Mild hypotension: normal saline IV to maintain systolic BP >100 mmHg 1

Future Management

Absolute Contraindication to Re-exposure

Do not administer glutathione IV again to this patient. 1, 2

• For severe life-threatening reactions (anaphylaxis), the implicated drug should never be used again 1
• Do not attempt to restart the infusion at a slower rate - a full body rash or systemic reaction requires permanent discontinuation 2
• Rechallenge is discouraged in severe reactions even with premedication 1

Documentation and Follow-up

Document the reaction thoroughly: 1, 3

• Record specific symptoms, timing of onset, and treatments administered 1
• Consider measuring tryptase levels 15 minutes to 3 hours after onset if anaphylaxis suspected (though normal levels don't rule out anaphylaxis) 1
• Serial tryptase measurements (during reaction and baseline after recovery) are more useful than single measurements 1

Patient counseling and allergy documentation: 3, 4

• Clearly document "glutathione IV allergy" in the medical record 3
• Counsel the patient about the reaction and need to avoid glutathione IV in the future 1, 3
• Consider referral to an allergist for formal evaluation and documentation 1, 3
• Provide the patient with written documentation of the allergy 3

Critical Pitfalls to Avoid

• Never delay epinephrine administration in suspected anaphylaxis - it can rapidly progress to cardiovascular collapse 2
• Do not use corticosteroids alone without antihistamines in acute reactions - combination therapy is superior 1, 2
• Avoid first-generation antihistamines (diphenhydramine) in mild reactions as they can exacerbate hypotension and tachycardia 1
• Do not attempt desensitization - this is only considered when no acceptable alternative exists for a life-saving medication, which does not apply to glutathione 1, 3
• Do not confuse with other "glutathione allergies" - the FDA-labeled glutathione products are for intraocular irrigation only, not IV infusion 5