Summary for Practice
In maintenance-phase patients who have already tolerated infliximab, 1-hour flat-rate infusions are as safe as 2-hour titrated infusions and can improve chair throughput and patient experience. Transition only after documented tolerance and keep rapid reversion paths for any reaction or dose/interval changes.
Non-inferior safety (1 h vs 2 h)
Efficiency gains
Select only tolerant patients
Revert if any reaction
Eligibility to Accelerate (from 2 h → 60 min)
- 🟢 ≥ 4 consecutive uneventful 2-hour infusions (no infusion reactions).
- 🟢 No recent dose escalation or interval shortening.
- 🟢 Baseline vitals stable; no acute illness.
- 🟢 Provider approval and patient consent documented.
- 🔴 If any reaction or dosing/interval change occurs: return to 2-hour protocol and re-establish tolerance.
Many institutional protocols and trials use the “4 uneventful 2-hour infusions” threshold before attempting 60-minute infusions.
Monitoring & Readiness
- Before: verify eligibility & history; check vitals; confirm premeds per local policy.
- During: vitals at baseline → mid-infusion → end; watch for flushing, pruritus, dyspnea, chest tightness, hypotension.
- After: observe ≥ 30–60 min after first accelerated dose; document outcomes strictly.
Emergency readiness: epinephrine, corticosteroids, antihistamines, IV fluids, oxygen, and immediate ability to pause/slow infusion.
Stepwise Acceleration Protocol
| Phase | Minimum prior tolerated infusions | Infusion duration | Notes |
|---|---|---|---|
| Induction / Early | — | 2–3 h (titrated) | Highest reaction risk. Labeling recommends ≥2 h for initial doses. |
| Maintenance (baseline) | 2–4 uneventful 2 h | 2 h (titrated or flat) | Establish consistent tolerance in maintenance phase. |
| Accelerated Phase 1 | ≥4 uneventful 2 h | 90 min | Optional intermediate step per local policy. |
| Accelerated Phase 2 | ≥1–2 tolerated at 90 min (or straight from ≥4 at 2 h) | 60 min (flat-rate) | Some centers run first 15 min at ~½-rate, then full-rate. |
| Reversion rule | Any reaction or dose/interval change | Back to 2 h | Re-establish tolerance prior to re-acceleration. |
Local order sets may also permit 30-minute infusions after ≥4 uneventful 60-minute infusions (institution-specific).
Safety: 1 h vs 2 h
- RCT In IBD maintenance, 1 h was non-inferior to 2 h (12% vs 18% mild reactions; mostly asymptomatic hypotension).
- Meta-analysis Rapid ≤1 h infusions: no increase in reactions vs 2–3 h; pooled per-infusion risk often lower.
- Cohorts (adult & pediatric) Low reaction rates with 1-hour flat-rate in previously tolerant patients; high patient satisfaction.
Interpretation: Accelerate only in tolerant patients; initial infusions remain full-duration per label/guidance.
Acute Infusion Reaction — Quick Algorithm
1) Recognize & Stop
- Pause infusion; assess airway/breathing/circulation.
- Vitals & symptom check immediately.
- For mild cutaneous symptoms, consider slow restart once fully resolved.
2) Treat
- Anaphylaxis: IM epinephrine promptly; O2, IV fluids, bronchodilator, corticosteroid per protocol.
- Mild–moderate: H1 antihistamine ± corticosteroid; consider rate reduction.
3) Decide & Document
- Restart at reduced rate only if symptoms resolve and provider agrees.
- Document severity, timing, interventions, disposition.
- Flag chart: future doses revert to 2 h; reconsider premeds.
Documentation Checklist
- Eligibility proof for acceleration (dates, 4× uneventful 2 h infusions, provider approval).
- Infusion parameters (duration, flat vs titrated, any rate adjustments).
- Premeds given (agent, dose, time) and rationale if omitted.
- Vitals (pre / mid / post) and any symptoms or interventions.
- Patient counseling points & post-infusion observation period.
This pocket guide supports—but does not replace—prescribing information and institutional policies. Defer to local order sets and clinician judgment for patient-specific decisions.
Key Sources
- Abushamma S, et al. Accelerated Infliximab Infusion Safety and Tolerability (RCT). 2023. NCT05340764. PMC10243871
- Neef HC, et al. Meta-analysis: Rapid infliximab infusions are safe. Aliment Pharmacol Ther. 2013;38:365–376. PDF
- Mazzuoli S, et al. Accelerated infliximab infusion: Safety, satisfaction, cost. PLoS One. 2016. PLOS ONE
- Kaiser Permanente WA. Infliximab Infusion Therapy Plan Orders. ≥4 uneventful 2 h infusions before 60 min. PDF
- OHSU Infusion Orders (08/2024). First 4 infusions over 2 h; then rapid option. PDF
- REMICADE® Prescribing Information. PI
- Pediatric rapid-infusion experience (overview). PubMed