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(Biodrugs 2010;24:211; Immunotherapy 2009;1:995)

  • 2 general categories of use
    • Replacement of depleted IVIg (∼25% of use) includes primary (genetic) & secondary immunodeficiencies (e.g., HIV or malignancy)
      • General “replacement” dosing is lower (e.g., 200–800mg/kg × 1 dose Q3–4wk)
      • Uses: primary immunodeficiency, hematopoietic stem cell transplant with hypogammaglobulinemia, B-cell chronic lymphocytic leukemia hypogammaglobulinemia secondary to malignancy
    • Immunomodulatory (∼75% of use)
      • General immunomodulatory doses are higher & shorter duration; most common options: 1g/kg × 2 doses or 400mg/kg × 5d or 2g/kg × 1 dose
        • Hematological: HIV-associated thrombocytopenia (Transfusion 1994;34:759); autoimmune hemolytic anemia (Am J Med 1988;84:691); immune/idiopathic thrombocytopenic purpura acute & chronic
        • Neurological: chronic inflammatory demyelinating polyneuropathy, Guillan-Barré syndrome (Cochrane Database Syst Rev 2006:DC002063); multiple sclerosis (Transfus Med Rev 2007;21:9); myasthenia gravis (Neurology 2007;21:57)
        • Dermatological: dermatomyositis/polymyositis (Am J Med 1991;91:162); immunobullous diseases (Arch Dermatol 2002;138:1158)
  • Infectious uses: severe group A streptococcal (GAS)/toxic shock syndrome (Infect Dis 2003;37:333); necrotizing (PVL-associated) staphylococcal sepsis (Arch Dis Child 2006;91:201); severe or recurrent C. difficile colitis (Dig Dis Sci 2011;56:19)

(Biodrugs 2010;24:211–223; Immunotherapy 2009;1:995)

  • Generally well-tolerated: most common reactions (5–15%) are infusion related, mild, & reversible
    • Immediate side effects (5–15%): flushing, headache, chest tightness, malaise, chills, fever, vomiting, blood pressure changes, diarrhea, tachycardia, & anaphylactic reactions
    • Acute kidney failure (Black Box Warning): more common in products containing sucrose; high doses (1–2g/kg) or pts at risk for renal failure
  • Risk factors for AE: volume depletion, elderly, sucrose in formulation, high doses/high cumulative doses, rapid infusion rates, hyperosmotic solutions, 1st time receiving IVIg, >8wk between IVIg infusions, switching to new IVIg formulation, agammaglobulinemia/extreme hypogammaglobulinemia, history of migraines
  • Treatment/prevention of AEs → prehydrate; premedicate (APAP, ± diphenhydramine, ± antiemetic, ± HA prevention) if needed; ↓ infusion rate; if pt tolerating specific product, do not switch products arbitrarily; have epinephrine available for anaphylactic reactions

Monitoring Parameters

  • Renal function; hemolysis; platelets; transfusion related acute lung injury (TRALI: measure antineutrophil & anti-HLA antibodies if suspected); hyperviscocity (cryoglobulins, ↑ TGs, monoclonal gammopathies if at risk)

Miscellaneous Information

  • Give IVIg via separate infusion line & bring to room temperature before administration
  • Dose on actual body weight unless >100kg or >30kg/m2, then use adjusted body weight (Pharm Pract News 2010;37:8)

Table D-1 IVIg Products

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