IVIG

Question 1

Adverse Effects

Answer 1

• Infusion-related general effects
  ○ Headache, myalgia, chills, flushing, fever, nausea, vomiting, low back pain, wheezing, chest pain, BP changes, tachycardia
  ○ Generally mild and occur 30-60 minute safter onset of infusion
  ○ Manage by slowing down infusion rare or temporarily discontinuing
  ○ Pre-treatment with paracetamol, NSAIDs, antihistamines +/- low dose steroids as needed
  • Anaphylaxis: patients with IgA deficiency having anti-IgA antibodies
  • Hypersensitivity reactions
  • Fluid overload: risk in patients with cardiac and renal disease
  • Neutropenia and haemolysis in patients with autoantibodies against blood group antigens of ABO and Rh system
  • Aseptic meningitis (headache, photophobia, self-limiting)
  • Thromboembolic events (CVA and AMI reported), risk high if higher dose and rapid infusion rate
  • Dyshidrotic eczema
  • Theoretical infection risk (blood borne infections)

Question 2

Absolute and relative contraindications to IVIG

Answer 2

Absolute contraindications
* Anaphylaxis from previous infusions
* Unable to consent to blood products/Jehovah’s witness

Relative contraindications (CR-I-RC)
1. Congestive cardiac failure (increased risk fluid overload)
2. Renal failure (increased risk fluid overload)
3. IgA deficiency (increased risk of anaphylaxis)
4. RF (increased risk of renal failure)
5. Cryoglobulinaemia (increased risk of renal failure)

Question 3

Indications for IVIG

Answer 3

• Kawasaki’s disease: IVIG 2g/kg single dose
  
  • Inflammatory dermatoses
  • Autoimmune CT dermatoses
  • Immunobullous dermatoses
  • GVHD
  • Eczema
  • Psoriasis
  • PG
  • SJS/TEN
    Urticaria

Question 4

Contraindications to IVIG

Answer 4

Anaphylaxis
Jehovah witness
Unable to consent to blood products

Relative
CCF, Renal failure = increased risk of fluid overload
IgA deficency
Rheumatoid Factor, Cryoglobulins (increased risk of Acute renal failure)

Question 5

Drug interactions for IVIG?

Answer 5

Nil

Question 6

Pregnancy / lactation advice for IVIG?

Answer 6

Not evaluated, not a C/I

Cat C

Crosses placenta especially in the third trimester and excreted into breast milk

Question 7

How would you explain IVIG to a patient?

Answer 7

IV immunoglobulin (mainly IgG) from purified human plasma pooled from >1000 blood donors

Immunomodulatory effect

Distribute through intravascular (60%) and extravascular spaces (40%)

Suppresses antibody production including pathogenic autoantibody production,
bind and neutralizes pathogenic Ab,
inhibits autoreactive T-cells,
block Fas-Fas ligand interactions and keratinocyte necrosis

Question 8

Half life of IVIG

Answer 8

3-5 weeks

Question 9

Side effects / risks of IVIG

Answer 9

Anaphylaxis
Hypersensitivity - dermatitis, pomphylyx, purpura

Fluid overload
- exacerbation of cardiac failure
- renal failure

Infusion reactions:
- Headache
- Fever, myaliga, chills
- flushing
- Nausea and vomiting
- chest pain, BP changes, tachycardia
- Wheezing
Generally occur 30 -60 mins after infusion onset.
Pre Rx with paracetamol, NSAIDS, antihistamines, low dose steroids

Neutropaenia, Haemolysis
Aseptic meningitis (headache, photophobia, self limiting)
Thromboembolic events (high dose, fast infusion)
Theoretical risk of infection

Question 10

Pre Rx Ix for IVIG

Answer 10

Baseline FBC, UEC, LFTs
Immunoglobulins
(esp IgA level)
RF, cryoglobulins
Hep B / C / HIV

Assess CVS and renal status