IVIG

Southern Regional Medical Center IVIG Administration Guidelines Updated Medication Use Criteria IVIG: •

4/06

Immune cytopenias which are considered life threatening and are unresponsive to steroids or where steroids are contraindicated and all other alternative treatment options have been unsuccessful. These include autoimmune thrombocytopenia (ITP), autoimmune neutropenia, HIV-related thrombocytopenia, autoimmune hemolytic anemia, and autoimmune fetal thrombocytopenia of pregnancy (orders should be initiated by a hematologist/oncologist).

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Kawasaki's syndrome Parvovirus infection in HIV infected individuals (order should be initiated by an infectious disease physician) Severe primary immunodeficiency states including agammaglobulinemia and common variable immunodeficiency. (order should be initiated by an infectious disease physician) Streptococcal A toxic shock syndrome (order should be initiated by an infectious disease physician) Isoimmune hemolytic neonatal jaundice (order should be initiated by a neonatologist) Neurology Indications (order must be initiated by a neurologist) • Guillain Barre (Acute Inflammatory Demyelinating Polyneuropathy-AIDP) • Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) • Myasthenia Gravis- when plasmapheresis is untenable • Inflammatory Myopathies (examples: polymyositis and dermatomyositis) refractory to steroids, immunosuppressants and or pheresis • Multiple Sclerosis refractory to pheresis and or steroids

Ordering Guidelines: • The order should include the indication for use.

• Attempts will be made to maintain supplies; product availability will dictate the product provided. A consistent product will be provided for each treatment course.

• Adult doses should be rounded to the nearest 5 grams.

• Obese adult patients should be dosed using adjusted body weight.

• Approval must be obtained from Dr Hamilton or Diamond/Prokesch for any IVIG indications not listed above. .

• The usual dosing range is 0.4gm to 1gm/kg/day given IV daily for 2-5 days (Kawasaki’s 2gm/kg/day IV x 1) • Gammagard is the only product that is not contraindicated in patients with IgA deficiency (serum IgA levels <0.05g/L) and is recommended when known antibodies against IgA exist.

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Administration: IVIG Monitoring Guidelines will be provided with each dose of IVIG dispensed.

Product

Initial Rate

Maximum Rate 0.08ml/kg/min

Filter

Sucrose content g/g of protein 0

IgA content

0.01ml/kg/min No 0.27mg/ml Gamunex 0.045mg/ml Bayer (10% soln) 0.5ml/kg/hr 4ml/kg/hr Yes 0 1.2mcg/ml Gammagard Baxter (5%) • Increase the rate every 15-30min as tolerated up to the maximum rate recommended above for the product provided.

Other Administration Precautions • •

IVIG should be infused through a separate line, without mixing with other IV fluids or medications.

Antibodies to immune globulin preparations may interfere with a patient’s responsiveness to live vaccines; live vaccines should be deferred for 8-11 months post treatment.

Adverse Events • ACUTE RENAL FAILURE (ARF) has been reported in association with the administration of IVIG products. Products with an increased sucrose content may provide greater risk. SRMC currently provides only NON-sucrose containing IVIG products.

IVIG should be used with caution when initiating therapy in any of the following risk populations: • Patients with any degree of preexisting renal insufficiency, diabetes mellitus, age > 65, volume depletion, sepsis, paraproteinemia, concomitant nephrotoxic drugs

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Do not exceed the recommended dose.

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Get baseline BMP and monitor renal function and urinary output periodically during therapy in risk patients. If renal function deteriorates, discontinue. Another brand of IVIG should be considered. Omit if CrCl <10ml/min.

• Patients receiving therapy, should be counseled to report any decreased urinary output, sudden weight gain, fluid retention or edema, and or shortness of breath to their physicians (possible early signs of renal failure) Thrombosis has been associated with the administration of IVIG when given rapidly Use caution when providing IVIG to patients with coronary artery disease, hypertension, cerebrovascular disease and diabetes.

Infusion related adverse effects include headache, nausea, chills, fever, hypotension, nausea, vomiting, chest tightness, dyspnea, back/hip pain and myalgia.

• Infusion related adverse reactions might be related to the infusion rate. Proper IVIG administration can reduce the incidence.

• Premedication with acetaminophen and/or diphenhydramine to minimize adverse reactions. Glucocorticoids may be considered.

• Epinephrine should be available for the treatment of acute anaphylactic reactions.

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