Intravenous Immunoglobulin

OVERVIEW

Intravenous immunoglobulin (IVIG)

  • initially developed for replacement therapy for patients with humoral immune deficiency
  • immunomodulatory agent
  • similar indications in autoimmune disease as for plasma exchange
  • blood product prepared from the serum of between 1000 and 15,000 donors per batch

DOSE

  •  ‘replacement dose’ of 200–400 mg/kg body weight, given approximately 3-weekly for antibody deficiencies
  •  ‘high dose’ IVIG (hdIVIG) at 2 g/kg/month as an immunomodulatory agent

MECHANISM

  • modulates T and B cells, macrophages -> interfering with antibody production and degradation
  • modulates complement and cytokine networks
  • regulation of cell growth

Four separate components:

  • actions of variable regions F(ab′)2
  • actions of Fc region on a range of Fc receptors (FcR)
  • actions mediated by complement binding within the Fc fragment
  • immunomodulatory substances other than antibody in the IVIG preparations (e.g. cytokines)

INDICATIONS

Haematological

  • idiopathic thrombocytopenic purpura (ITP)
  • post plasma exchange course completion
  • antiphospholipid syndrome (APLS)
  • chronic graft versus host disease (hypogammaglobulinaemia)

Infections

  • toxic shock syndromes (staphyloccocal and streptococcal)

Vasculidities

Dermatological

  • pemphigus vulgaris
  • bullous pemphigoid
  • SJS/TEN (controversial)

Neuromuscular

  • GBS (AIDP)
  • dermatomyositis
  • myasthenia gravis
  • chronic inflammatory demyelinating peripheral neuropathy (CIDP)
  • Eaton-Lambert syndrome
  • Stiff Person Syndrome
  • Multiple sclerosis

Renal transplant rejection (controversial)


References and Links

  • Momin SB. Review of intravenous immunoglobulin in the treatment of stevens-johnson syndrome and toxic epidermal necrolysis. J Clin Aesthet Dermatol. 2009 Feb;2(2):51-8. PMC2958184.
  • Hartung HP, Mouthon L, Ahmed R, Jordan S, Laupland KB, Jolles S. Clinical applications of intravenous immunoglobulins (IVIg)–beyond immunodeficiencies and neurology. Clin Exp Immunol. 2009 Dec;158 Suppl 1:23-33. PMC2801038.
  • Jolles S, Sewell WA, Misbah SA. Clinical uses of intravenous immunoglobulin. Clin Exp Immunol. 2005 Oct;142(1):1-11. PMC1809480.
  • Shankar-Hari M, Spencer J, Sewell WA, Rowan KM, Singer M. Bench-to-bedsidereview: Immunoglobulin therapy for sepsis – biological plausibility from a critical care perspective. Crit Care. 2012 Dec 12;16(2):206. doi:10.1186/cc10597. PMC3584720.

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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