1. I.V.I.G
BY:
MOHAMMED ALSAIDAN

2. IVIG
IVIg is a blood product derivative manufactured from the sterilized, purified human plasma of between 1000 to 20,000 donors per batch.
The final IVIg preparation is primarily composed of IgG, with trace amounts of IgA, IgM and albumin
half-life of IVIg ranges from 3-5 weeks
Crosses the placenta, and may be excreted in milk
Distributed : 60% intravascular , 40 % extravascular

3. MOA Functional blockade of the Fc receptors
Neutralize complement , and block complement activation in early stage
Anti-idiopathic antibodies can neutralize pathogenic antibodies
Interfere with T-cell activation
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

4. MOA Interfere with cellular migration
Increase glucocorticoid receptor sensitivity
In toxic epidermal necrolysis, IVIg blocks Fas (CD95) mediated keratinocyte death by inhibiting Fas – Fas ligand interactions

5. Indications The efficacy of IVIg is best documented in patients with:
graft-versus-host disease
Kawasaki’s disease
dermatomyositis
Autuimmune bullous dermatosis:
pemphigus vulgaris
pemphigus foliaceus
bullous pemphigoid
herpes gestationis
epidermolysis bullosa acquisita (EBA)
TEN/ SJS

6. Indications Other indications: Atopic dermatitis psoriasis scleroderma
Pyoderma gangrenosum
Chronic autoimmune urticaia

7. When to use IVIG for bullous dis.
1)Progressive, uncontrolled,or rapid debilitating disease
failure of conventional therapy
2) significant adverse effects from conventional therapy
3) contraindications, relative or absolute, to the use of high-dose long-term systemic therapy
*The patient age and pregnancy are not contraindications to the use of IVIG

9. Before starting IVIG Vital signs Weight to monitor for overload
Auscultate lungs and heart
Labs:
CBC
LFT
Renal profile
Immunoglobulin levels
RF and in patients at an increased risk of acute renal failure
For medicolegal reasons: HBV, HCV and HIV is advisable

10. Pre medication
To minimize the risk of infusion-related side effects, such as headaches, myalgias and rigors.
Analgesics (i.e., acetaminophen)
Antihistamines (i.e., diphenhydramine)
NSAID (i.e., celecoxib)
low-dose intravenous corticosteroids may be of benefit to a subset of individuals

11. Dosage
The most common dosage in dermatology is 2 g/kg/cycle divided into 3 equal doses in 3 consecutive days
Or 400mg/kg daily for 5 days
Infusion: Slowly over 4 to 4 ½ hours
Given monthly , but can be given every 2 weeks in very aggressive disease
Tapering : keep the same dose with increasing the interval between infusions by 2 weeks (4,6,8,10,12,14,16) then D/C

12. Dosage Careful monitoring for 1st infusion or different preparation
All patients must be well hydrated prior to the infusion .
When all these measures fail to correct or prevent the adverse reactions it could be useful to change to a different preparation of IVIG

14. Anaphylaxis reaction
More frequently with antibody deficiency , mainly in IgA deficiency with antibody against IgA
Slow infusion seems to lower the risks
Resolve with temporary interruption of the infusion or a slowing of its rate of administration
Can be prevented by giving , paracetamol or anti-histamines before the treatment and/or hydrocortisone during it.

15. Thromboembolic events
Secondary to increased viscosity , leading to cerebral or myocardial infarction
RISK FACTORS:
higher doses or rapid infusion
elderly patients
patients with previous cerebral or cardiac ischaemia
overweight patients
Those who are markedly hypovolaemic and immobilised

16. Aseptic menengitis
observed in patients with neurological and neuromuscular diseases treated with high doses of IVIG.
The symptoms appear within 6–24 hours of the end of the infusion and disappear without sequelae in 3–5 days

17. Renal disease
Increases in creatinine or acute renal failure rarely in elderly, diabetic, poorly hydrated patients, with pre-existing renal disease or who are taking nephrotoxic drugs.
These problems are probably related to damage caused to the renal tubules by the saccharose included in various preparations as a stabiliser.