Chapter 4: Immuneglobulin Products Flashcards
List 3 types of immune globulin products provided by CBS.
IVIg
SCIg
RhIg
How do immuneglobulin products affect vaccine efficacy?
IVIig leads to decreased response to parenteral live virus vaccines
BUT NOT inactivated virus vaccines Live oral/intranasal vaccines, or BCG
What formats do immuneglobulin products come in?
sterile solutions
lyophilized concentrates
What class of human immunoglobulin are immuneglobulin products made from?
IgG
May have traces of others
How can Immunoglobulin administration affect serological testing results?
passively transferred antibodies in the patient’s blood may cause positive serological testing results, which can be misinterpreted
E.g.:
Passive transmission of antibodies to red cell antigens (e.g., A, B, and D) may cause a positive direct or indirect antiglobulin (Coombs) test.
serological testing results for other antibody-mediated tests (e.g., hepatitis B core antibody [anti-HBc], hepatitis A, varicella) may also be misleading
Why should we do hepatitis B testing with hepatitis B surface antigen (HBsAg) in patients before Ig therapy is initiated?
After Ig administration, serological testing results for hepatitis B core antibody [anti-HBc], hepatitis A, may be misleading.
We should test before giving Ig to inform the risk of hepatitis B reactivation
What resource can you consult of you want to know what Ig products are offered by CBS?
E-formulary for plasma protein and related products
What is the method of action by which IVIg offers protection against infection and supplementation for congenital/primary and acquired/secondary immune deficiency
By supplementing array of IgG antibodies to facilitate destruction and neutralization of pathogens
What is the proposed mechanism by which IVIg helps with immune modulation in autoimmune or modulatory conditions
anti-inflammatory activity by dendritic cells and/or blockade of Fc receptors in the reticuloendothelial system
What is the proposed mechanism by which IVIg helps with immune modulation in autoimmune or modulatory conditions
anti-inflammatory activity by dendritic cells and/or blockade of Fc receptors in the reticuloendothelial system
What is the proposed mechanism by which RhIg prevents alloimmunization against RhD?
Accelerated clearance of RhIg coated cells
Suppression of B-cell mediated response to Rh exposure and mitigation of Rh alloimmunization
List 6 indications for IVIg
Primary immune deficiency (PID)
Secondary immune deficiency (SID)
ITP
Chronic inflammatory demyelinating polyneuropathy (CIDP)
Guillain-Barré syndrome (GBS)
Multifocal motor neuropathy (MMN)
Why are there authorization forms for IVIg ordering and who provides regional guidance on the use of IVIg in Canada?
BC blood coordinating office
ORBCoN
Atlantic blood utilization strategy working group
What group developedcriteria for the clinical use of Igas part of an evidence-based framework to aid transfusion services and clinicians?
Prairie Collaborative Immune Globulin Utilization Management Framework Project
Who provides guidance on utilization of there are Ig shortages in Canada?
National Advisory Committee on Blood and Blood Products (NAC)
IVIg is contraindicated for what groups of individuals?
People with:
IgA deficiency and anti-IgA antibodies
Prior anaphylaxis or multiple severe allergic reactions
What Ig products can you use for individuals with IgA deficiency who have anti-IgA antibodies instead of IVIg?
SCIg
Do we routinely test for IgA deficiency before IVIg?
No
IVIG dosing?
Depends on clinical indication
Immune replacement 0.4–0.6 g/kg a month + extra dose in the first month of therapy if serum IgG low
Immunosuppressive dose: 1–2 g/kg over 1–5 days, and some conditions may require ongoing maintenance therapy, usually given monthly, with efforts made to reduce the dose or extend the treatment interva
IVIG dosing?
Depends on clinical indication
Immune replacement 0.4–0.6 g/kg a month + extra dose in the first month of therapy if serum IgG low
Immunosuppressive dose: 1–2 g/kg over 1–5 days, +/- monthly maintenance
Reduce the dose or extend the treatment interval as tolerated
IVIg hemolysis mechanism?*
Contraindications to IVIg?
IgA deficiency with anti-IgA antibodies. Can try SCIg with such patients instead.
Alternative for patients who have had anaphylaxis or multiple severe reactions to IVIg?
S/D plasma
Privigen contraindications?
Same as IVIg plus hyperprolinemia
Weight adjusted dosing for immune globulin products- what is the formula?
Dosing weight = ideal weight + [0.4x (actual weight - ideal weight)]
If patient weight is less than IBW, or patient is a child, use actual weight
Weight adjusted dosing for immune globulin products- what is the formula?
Dosing weight = ideal weight + [0.4x (actual weight - ideal weight)]
If patient weight is less than IBW, or patient is a child, use actual weight
How is ideal body weight calculated?
Male @ birth: 50 kg + 2.3 kg/ inch over 5 ft
Female @ birth: 45.5 kg x 2.3 kg,/inch over 5 ft
IVIg infusion rate?
0.01 mL/kg/min
Increase or decrease based on patient tolerance
IVIg storage temperature?
2-25 degrees C
IVIg adverse events? How to manage,?
Minor:
H/a
Fever, chills
Anxiety
Nausea
Pruritis/rash
Chest pain
Slow infusion rate, stop infusion, premedicate, switch product
Severe:
Hemolysis
Aseptic meningitis
Anaphylaxis
TRALI
Thromboembolism
Is IVIg hemolysis usually DAT pos or neg?
DAT Positive
Define IVIg associated hemolysis
Drop of Hgb by 10 or more
Positive DAT
Within 10 days of IVIg
AND (need at least 2):
Increased retics
Increased LDH
Low hapto
Increased unconjugated bili
Red serum hemoglobinemia
Hemoglobinuria
Spherocytosis
Define IVIg associated hemolysis
Drop of Hgb by 10 or more
Positive DAT
Within 10 days of IVIg
AND (need at least 2):
Increased retics
Increased LDH
Low hapto
Increased unconjugated bili
Red serum hemoglobinemia
Hemoglobinuria
Spherocytosis
What increases risk of IVIg hemolysis?
High dose especially at 2g/kg
Non O blood group due to passive transfer of anti-A and anti-B isohemagglutins and density of A and B Ag on RBC surface
Highway Rush: group A pr SB patient getting 2g/kg or higher
Cause of aseptic meningitis from IVIg? How to recognize aseptic meningitis?
Dose related
Typically occurs within 6-48 hours
CSF shows high protein, normal to low glucose, WBC pleocytosis, neg cultures
Recovery within 5 days
Possible future recurrence with IVIg
Anaphylaxis in IVIg
IgA deficiency with anti IgA antibodies
Significance of Ab Class (IgG vs IgE anti-IgA)
Can try SCIg or IgA depleted products
Anaphylaxis in IVIg
IgA deficiency with anti IgA antibodies
Significance of Ab Class (IgG vs IgE anti-IgA)
Can try SCIg or IgA depleted products
What Thromboembolic events can occur with IVIg?
CVA
TIA
DVT
PE
Retinal vein occlusion
Retinal artery infarct
Timeframe of IVIg related thromboembolism in relation to IVIg infusion?
During or up to 8 days after
Timeframe of IVIg related thromboembolism in relation to IVIg infusion?
During or up to 8 days after
Patients at increased risk of IVIg related thromboembolism?
CV disease
Immobilization
Advanced age
H/o Thromboembolic events
Mitigate risk by hydration, monitoring, slow infusion, lower doses
SCIg indications?
Replacement therapy in PID or SID (lifelong)
Immunomodulation in CIDP
Benefits of SCIg over IVIg?
Convenience/lifestyle
No vascular access needed
Less truth of side effects
SCIg contraindications?
History of anaphylactic or severe allergic reactions to Ig products (but this is also a reason who patients switch from IVIg to SCIg … Confusing)
Storage temperature of SCIg?
2-25C
Dose and administration of SCIg?
Depends on brand
100-200 mg/kg,/wk plus extra 0.4 g/kg n first month if very low serum IgG
Administration rate varies
Dose and administration of SCIg?
Depends on brand
100-200 mg/kg,/wk plus extra 0.4 g/kg n first month if very low serum IgG
Administration rate varies
Calculation for switching from IVIg to SCIg?
Divide monthly IVIg dose by 4 to get weekly SCIg dose then titrate to get trough levels at bottom of serim IgG ref range for age
Average dude 100-125 mg/kg/wk
Can give cumulatively q 3-4 weeks thereafter
Adverse reactions with SCIg?
Similar to IVIg
What are hyperimmune globulin fractionation products?
Mar from pooled plasma
Select for high Ab titres with desired specificities
Viral inactivation
hyperimmune globulin products?
RhIg
Hep B Ig
VZV Ig
CMV Ig
Intramuscular Ig
Storage temperature for hyperimmune globulin products?
2-8C
User within 4 hours of reconstitution
