IV immunoglobulin

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Created May 2007 and updated September 2008 by Charles Gomersall

Preparation

• batched blood product prepared from 1,00-15,000 plasmapheresis and blood donations
• >95% IgG with trace amounts of IgM and IgA
• there are significant differences in donor pool, stabilizers, additives and production processes between different manufacturers. Patients should receive the same brand with each course/dose because:
  • limiting exposure to a minimum donor pool reduces risk of infection
  • changing products is associated with a higher risk of adverse reactions

Clinical uses

Immunomodulatory therapy

Neuromuscular disorders

Established therapy for:

• Guillain-Barre
• Multifocal motor neuropathy with conduction block
• Chronic inflammatory demyelinating polyneuropathy
• myasthenia gravis unresponsive to other therapies
• Eaton-Lambert syndrome
• inflammatory myopathies:
  • polymyositis
  • dermatomyositis
  • inclusion body myositis

Some evidence of benefit in acute disseminated encephalomyelitis

Dermatological disorders

• Kawasaki disease. Reduces incidence of coronary aneurysms if given within 10 days of symptom onset
• ± Blistering disorders (eg pemphigus, pemphigoid) frequently treated with IVIG although controlled data supporting efficacy is limited
• Toxic epidermal necrolysis - again evidence of efficacy is limited

Vasculitic disorders

• ± ANCA associated systemic vasculitis

Infection

• Some evidence of benefit in streptococcal toxic shock syndrome
• Recent meta-analysis suggests may reduce mortality in critically ill septic patients

Haematological

• ITP
• ± Haemophagocytic syndrome
• ± Autoimmune haemolytic anaemia

Immunoreplacement

• acquired hypogammaglobulinaemia secondary to haematological malignancies (chronic lymphocytic leukaemia, multiple myeloma, non-Hodgkins lymphoma etc)
• primary immunodeficiency diseases with antibody deficiency

Not indicated

• antiphospholipid syndrome (non-obstetric)
• haemolytic uraemic syndrome
• sepsis (except possibly septic shock due to encapsulated bacteria, eg pneumococcus or patients with hypogammaglobulinaemia)
• others

Adverse effects

Immediate

• headaches, backache, chills, nausea, myalgia
  • usually infusion rate-related
  • more common in patients with co-existing infection
• anaphylaxis (very rare)

Transmission of infection

• Hepatitis C
  • most manufacturers have introduced additional precautions since last outbreak

Due to increasing serum immunoglobulin

• reversible renal impairment
• cerebral and coronary thromboses
• acute haemolysis
• neutropaenia
• acute aseptic meningitis
• eczema, urticaria, erythema multiforme, cutaneous vasculitis

Further reading

©Charles Gomersall, October, 2009 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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