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We agree that some patients are clinically complex and require specialized, time-intensive services in the ED, and note that this was considered during measure development

Currently there are 7 clinical trials registered for the use of itraconazole as a combinatory therapy in ovarian cancer patients and 6 in breast cancer patients (clinicaltrials.cov)

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Hypoglycemia Care: Ensure enough nutritional support around use times Consider dose reduction if hypoglycemia occurs Use glucose tracking protocols Have glucose use available if needed Injection Site Reaction Care: Rotate injection sites systematically Use proper injection technique Consider lower level solutions Apply cold compress if major reaction occurs Fluid Retention Care: Track body weight and signs of edema Consider dose reduction if major retention occurs Ensure enough hydration Track electrolyte balance Research Ethics and Informed Consent All research involving IGF1 LR3 should be conducted with appropriate ethical oversight and informed consent procedures

Put escalation steps into onboarding and ongoing team training