Rx Update: June 2005
Joan Murhammer, R.Ph., Mary Ross, R.Ph., M.B.A., Kevin Bebout,
R.Ph.
Peer Review Status: Internally Reviewed
Red Man Syndrome (RMS) is a commonly observed adverse drug event associated with vancomycin therapy. It is characterized by a sudden and/or profound drop in blood pressure, a maculopapular rash, angioedema, pruritus, erythema, wheezing, or dyspnea . Any or all of these effects may be seen. While rare, changes in blood pressure have been severe enough to produce cardiovascular collapse. The reaction may occur within a few minutes of starting an IV infusion of vancomycin or occur near its completion; the skin rash typically subsides several hours after completion of the infusion. RMS can cause discomfort to the patient, interrupt therapy, and inappropriately label a patient as being allergic to vancomycin.
RMS is most frequently seen with rapid intravenous infusions, but it has been reported with slow intravenous infusions, intraperitoneal administration, and oral vancomycin use. While the precise causes of the cardiovascular and cutaneous reactions to vancomycin are unknown, histamine is believed to mediate the syndrome. Various studies have demonstrated that the amount of histamine released correlates to the overall severity of the reaction.
Investigators have conducted studies to compare the effect of different size IV doses (500 mg versus 1000 mg), the use of antihistamine pretreatment, and the impact of extending drug infusion times. Recommendations to minimize this adverse effect have included: limiting vancomycin doses to 500 mg, pretreating all patients with antihistamines, and administering all vancomycin infusions over 2 hours. However, these recommendations may not be practical for all patients.
Although it has been a recognized adverse effect for many years, Red Man Syndrome continues to be seen at UIHC. Recommendations at UIHC to reduce the incidence of RMS associated with vancomycin infusions include:
Vancomycin dose increases may require a lengthening of the infusion time to avoid the development of RMS. Patients who have experienced RMS in the past may benefit from pretreatment with an antihistamine, such as hydroxyzine, or the further lengthening of the infusion time to at least 2 hours.
Medications that May Affect Your Risk of Bleeding
A new chart titled, "Medications That May Affect Your Risk of Bleeding," has been created to be used as a patient information guide. It can be given to patients who should not be taking anticoagulant, antiplatelet, or other medications that may prolong bleeding time because of their current medications, medical condition, or upcoming surgical procedure. It also lists medications that can be taken for pain that do not affect blood clotting.
The chart can be found in the Formulary and Handbook ( http://www.formularyproductions.com/uihc ). On the first screen choose the box 'Additional Links' and then choose the 'Medications That May Affect Your Risk of Bleeding' link. Please call the Drug Information Center at 6-2600 if you have any questions about accessing the chart.