Table 10.

Comparison of desensitization protocols

Protocol	Study characteristics	Outcomes	Considerations
3-bag 12–13 step 4-bag 16–17 step	> 3000 published desensitizations Agents -  Carboplatin, cisplatin, oxaliplatin [5, 14, 31, 36, 41, 54] -  Paclitaxel, docetaxel [27, 31, 32, 41] -  Monoclonal antibodies (e.g., rituximab, infliximab) [31, 41, 60] Initial HSR severity (Brown) [5, 31, 32] -  Grade 1 10–32% -  Grade 2 16–73% -  Grade 3 17–52%	Breakthrough HSRs -  26% of desensitizations [5, 31] -  Grade 2, 7%* [31, 32, 60] -  Grade 3, < 1%* [31, 32, 60] Completed > 99% [14, 31, 32, 36, 41]	The 3-bag and 4-bag protocols are the most widely used and can be considered for most patients, particularly those with initial severe HSR and platin HSR [31, 41] Published risk stratification pathways used initial HSR severity, ST results, and patient characteristics to risk stratify patients to each protocol [31, 32]
2-bag 8-step	> 150 published desensitizations Agents -  Carboplatin, oxaliplatin [4, 14, 36] -  Paclitaxel, docetaxel [27, 32] Initial HSR severity: NR	Breakthrough HSRs -  12% of desensitizations [14] -  Severity NR Completed > 99% [4, 14, 36]	Published risk stratification pathways used initial HSR severity, ST results, and time since last reaction (for platins) to risk stratify patients to this protocol [14, 27, 32, 36] Criteria for receiving 2-bag 8-step protocols in published studies were: -  History of platin HSR > 1 month prior and negative ST [14, 36] -  History of previously tolerating 3-bag protocol (above) for taxanes without breakthrough reaction [32]
1-bag 9-step	490 published desensitizations Agents -  Carboplatin, cisplatin, oxaliplatin [55] -  Paclitaxel, docetaxel [55] -  Monoclonal antibodies (e.g. rituximab, cetuximab) [55] Initial HSR severity (Brown) [55] -  Grade 1 35% -  Grade 2 53% -  Grade 3 12%	Breakthrough HSRs -  5% of desensitizations (88% with platins) -  Grade 2, 2% -  Authors reported that none of the breakthrough HSRs were grade 3, but epinephrine was used for 3 of the grade 2 breakthrough HSRs Completed > 99% [55]	Most patients who received this protocol (n = 90) had less severe initial HSR than other studies For patients with mild initial HSR and negative ST, ease of preparation and shorter duration could make this an option at centers preferring to perform desensitization in the outpatient setting
1-bag 12–13 step	299 published desensitizations Agents -  Oxaliplatin, carboplatin, cisplatin [56] -  Paclitaxel [57] Initial HSR Severity (Brown) [56, 57] -  Grade 1 4–14% -  Grade 2 58–61% -  Grade 3 25–38%	Breakthrough HSRs -  16–17% of desensitizations -  Grade 2, 7–8% -  Grade 3, 1% Completed > 98% [56, 57]	Use of this protocol required a high-precision pump to deliver low doses

NR not reported

^*Applies to 3-bag 12-step protocol which constituted the majority of desensitizations. For 4-bag 16-step protocols, the rate of reactions is lower based on author’s clinical experience