Blinatumomab for B-cell precursor ALL: From hospital to home

Blinatumomab, a bispecific T cell–engager antibody administered as a continuous intravenous (IV) infusion, has several indications in B-cell precursor acute lymphoblastic leukaemia (ALL). Traditionally, in Hong Kong, patients receiving blinatumomab are hospitalized for 28-day treatment cycles. In an interview with MIMS Oncology, Dr Carol Cheung, Specialist in Haematology & Haematological Oncology, and clinical pharmacist Ms Kitty Leung shared insights into how a proactive outpatient infusion protocol at a local hospital has enabled patients to receive blinatumomab at home. They discussed how home infusion of blinatumomab works, along with its risks, challenges, and benefits for both patients and healthcare providers.

Evolving role of blinatumomab in ALL
“Blinatumomab has been available in Hong Kong for nearly a decade and has profoundly transformed the treat­ment landscape of ALL. Initially ap­proved for relapsed or refractory [R/R] cases, its role has since expanded to in­clude minimal residual disease [MRD]– positive disease and, more recently, it has become part of frontline consolida­tion therapy. This versatility highlights its relevance across various treatment set­tings. Even in MRD-negative patients, frontline use of blinatumomab has been shown to improve survival outcomes,” noted Cheung. “Furthermore, in Phil­adelphia chromosome [Ph]–positive ALL, there is a growing trend toward potentially eliminating chemotherapy al­together by incorporating blinatumom­ab. For Ph-negative cases, combining multiagent chemotherapy with bli­natumomab as initial therapy has demonstrated remarkable efficacy.” [Blincyto Hong Kong Prescribing In­formation, January 2023; N Engl J Med 2024;391:320-333; J Clin Med 2025;14:2055]

Continuous IV infusion: The need for outpatient options
Blinatumomab is administered via continuous IV infusion over 4 weeks (28 days), followed by a 14-day break, form­ing a 42-day treatment cycle. The total number of cycles is determined by the treating physician, based on indication. In­fusion should be initiated under the super­vision of experienced clinicians. Hospital­ization is generally required for treatment initiation and for subsequent cycles, with the length of hospital stay depending on indication. (Table 1) [Blincyto Hong Kong Prescribing Information, January 2023]

“In Hong Kong, the usual practice has been to hospitalize patients for the entire 28-day treatment cycle due to its inconvenient mode of administration,” Cheung remarked. “This approach, repeated with each cycle, is resource-intensive and burdensome for patients and caregivers, requiring long stays and frequent visits. It creates logistical and emotional challenges, highlighting the need for alternative delivery meth­ods to improve patient comfort and reduce strain on healthcare resources.”

“Therefore, we have introduced an outpatient infusion programme, allow­ing patients to receive blinatumomab at home once their condition is stable,” Cheung added.

Home infusion of blinatumomab: How does it work?
Patient eligibility
“Firstly, we identify patients suitable for home infusion. They should be fit adults with good performance status, support­ive caregivers, and a strong motivation for home infusion,” noted Cheung. “General­ly, we select stable patients with a low risk of developing cytokine release syndrome [CRS]. These patients should live close to the hospital or be able to reach it quickly in case of emergency. Patients and their caregivers need a basic understanding of how to manage outpatient infusion and the ability to operate and care for the pump after education. Motivation and will­ingness are key.”

“Conversely, patients on other IV medications, such as antibiotics, or those with abnormal baseline blood counts, sig­nificant concerns about home infusion, or a high risk of developing CRS are gener­ally not suitable. Ultimately, patient safety and their preference are our top consider­ations,” she continued.

Timing for transition
“In adult patients, hospitalization for ≥9 days during the first cycle is recom­mended for R/R ALL. In other settings, shorter durations are often sufficient,” said Cheung. (Table 1) “The initial hospital stay is crucial, even when outpatient treat­ment is planned, as it allows close moni­toring of adverse events [AEs], especially during the initial phase of the first cycle, when conditions like CRS or neurologi­cal toxicity are most likely to occur,” she explained. “To ensure safety, we usually keep patients in-hospital for close moni­toring during this period.”

“If clinically relevant AEs occur and treatment is interrupted at any point, blinatumomab should be restarted at 9 mcg/day. We typically monitor patients closely for ≥7 days until they reach the full dose of 28 mcg/day and show no signs of recurring toxicity before discharge,” Cheung continued.

“Hospital stays also offer patients the opportunity to receive training via videos, demonstrations and hands-on practice in managing the infusion pump and re­sponding to potential issues,” Cheung added. “The frontline healthcare team must ensure that patients are confident and competent in handling the pump and recognizing warning signs before autho­rizing discharge.”

“Generally, if the first cycle is tolerat­ed well without significant AEs, a patient is less likely to encounter major issues in subsequent cycles. These patients may require only 2–3 days of hospitalization for the second and later cycles, and some stable patients may even go home after 1–2 days. This timing is highlyindividual­ized depending on each patient’s condi­tion and ability to manage the treatment safely,” she shared.

Delivering blinatumomab at home
“When a patient’s condition is sta­ble, treatment can be continued at home using a small, portable IV infusion pump and an admixed infusion bag containing blinatumomab, reconstituted by a phar­macist in aseptic conditions,” Leung and Cheung explained. “Infusion bags are available for 7-day [1-week] infusion, as well as 1-day [24-hour], 2-day [48-hour], 3-day [72-hour] and 4-day [96-hour] infusions.”

“In our practice, we usually dispense the 7-day infusion bags for outpatient use. The drug in the infusion bag is delivered via the ambulatory pump at a constant, preset flow rate that cannot be modified by anyone except the supplier,” Leung continued. “The pump is programmable, lockable, non-elastomeric, and equipped with an alarm that alerts if drug delivery is interrupted.”

Patient education and supplies
“Before discharge, patients receive training via videos and demonstrations during hospitalization. They practice oper­ating the ambulatory pump with their 7-day infusion bag to build confidence,” said Cheung. “Trained nurses then complete a checklist to ensure patients can manage