Table 1 Challenges related to blinatumomab administration and management as well as additional challenges specific to low- and middle-income context

Administration challenges

• Prolonged continuous infusion (1 cycle = 24 h per day for 28 days, typically 2 cycles per patient)• Dedicated intravenous (IV) line• Traditional routine nursing care, such as flushing the infusion line, may push the medicine through the line too quickly and cause an adverse event or overdose• Requires specific types of IV bags, tubing, and ambulatory pump

Management challenges

• Medication initiation requires premedication with steroids and hospital admission (3–8 days) due to the risk of SIRS response. After discharge, patients remain close to care facilities for frequent monitoring in outpatient infusion centers and are often supported by home health services

• Interruption in infusion for ≥ 4 h requires readmission to the hospital to restart the infusion

• Serious adverse events: cytokine release syndrome, seizure, and other neurotoxicities

○ May result in rapid blood pressure changes, fever, and oxygen requirement

○ May require management in the intensive care unit

• Management of adverse events with steroids or expensive medications such as tocilizumab

Examples of additional challenges in LMICs

• Logistical challenges due to medication importation and storage

• Limited resources for supportive care (outpatient infusion management, home health capabilities, inpatient bed availability, monitoring labs, ambulatory pumps, IV bags and tubing, medications to manage adverse events)

• Transportation challenges impeding rapid return to the hospital setting