Intravenous Immune Globulin (IVIG)

• Pooled IgG Preparation: From thousands of donors, used for immune replacement and immunomodulation in autoimmune, inflammatory, and immunodeficiency states
• Common ICU Indications: Guillain-Barré syndrome (GBS), immune thrombocytopenia (ITP) with severe bleeding, Kawasaki disease, severe autoimmune disorders
• Dosing: Weight-based in g/kg, often 0.4 g/kg/day × 5 days or 1-2 g/kg total over 1-5 days depending on indication
• Major Risks: Infusion reactions, aseptic meningitis, hemolysis, thrombosis, acute kidney injury (especially with risk factors like renal disease, volume depletion, hyperviscosity)
• Product Differences: Formulations differ in stabilizers, sugar content, IgA levels; brand-specific considerations matter in IgA deficiency and renal impairment
• Infusion Strategy: Start slowly, titrate as tolerated; premedication with acetaminophen ± antihistamines reduces reactions

• Generic Name: Immune globulin intravenous (human)
• Brand Names: Gammagard, Privigen, Gamunex-C, and many others

Pooled human IgG antibody preparation; immunomodulator and replacement therapy

Mechanism of Action:

• Complex, indication-dependent mechanisms including Fc receptor blockade, modulation of complement activation, neutralization of autoantibodies, suppression of pathogenic cytokines, regulation of B- and T-cell function
• In ITP: IVIG saturates Fc receptors on macrophages in spleen and liver, reducing clearance of IgG-coated platelets
• In GBS and autoimmune neuropathies: Likely neutralizes pathogenic antibodies and modulates complement and inflammatory pathways in peripheral nerves
• In immunodeficiency: Provides passive immunity by supplying broad spectrum of IgG antibodies against common pathogens

Pharmacokinetics:

• Distribution: Initially intravascular, then distributes into extravascular spaces over days; volume approximates plasma volume but expands with time
• Half-life: Typically 2-4 weeks, depending on patient factors and indication
• Metabolism: IgG catabolized by reticuloendothelial system; FcRn recycling prolongs IgG half-life; clearance increased in inflammatory states or high catabolic conditions

Available Forms:

• IVIG products vary: commonly 5% (50 mg/mL) or 10% (100 mg/mL) IgG solutions
• Stabilizers may include sugars (sucrose, maltose, glucose) or amino acids (glycine) and impact renal/metabolic safety
• Some products have very low IgA content, preferred in patients with severe IgA deficiency and anti-IgA antibodies

IVIG Dosing (Adult; Indication-Specific):

Contraindications:

• History of severe systemic reaction (anaphylaxis) to IVIG
• Selective IgA deficiency with anti-IgA antibodies and prior severe reaction to blood products (relative; may use low-IgA products with caution)

Major Precautions:

• Acute kidney injury risk: Especially with sucrose-containing products, pre-existing renal disease, diabetes, dehydration, or concomitant nephrotoxins
• Thrombotic events: DVT, PE, MI, stroke due to increased serum viscosity and procoagulant effects; caution in hypercoagulable patients
• Hemolysis: Due to passive transfer of blood group antibodies; monitor hemoglobin and DAT if anemia develops
• Aseptic meningitis syndrome: Headache, meningismus, photophobia, often within 24-48 hours after infusion
• Volume overload: In heart failure or renal impairment; consider concentration and infusion rate

Common:

• Infusion reactions: headache, flushing, chills, fever, myalgias
• Nausea, vomiting
• Mild hypertension or hypotension

Serious:

• Anaphylaxis, especially in IgA deficiency with anti-IgA antibodies
• Thromboembolic events (DVT, PE, MI, stroke)
• Hemolytic anemia
• Aseptic meningitis
• Acute renal failure (more common with sucrose-stabilized products)

During Infusion:

• Vital signs (especially early): BP, HR, respiratory status
• Signs of infusion reactions: headache, chest tightness, dyspnea, flushing, back pain

Before and After Treatment:

• Renal function (SCr, urine output) in high-risk patients
• Hemoglobin/hematocrit and LDH if hemolysis suspected
• IgG levels and clinical response for replacement therapy

• Guillain-Barré syndrome (GBS): Non-ambulatory patients or those with rapid progression
• Immune thrombocytopenia (ITP): Significant bleeding or need for rapid platelet rise (e.g., pre-op, intracranial hemorrhage)
• Kawasaki disease: Especially pediatrics, to reduce coronary aneurysm risk
• Hypogammaglobulinemia: With recurrent severe infections (immune replacement)
• Autoimmune neurologic disorders: Myasthenia gravis crisis, CIDP under specialist guidance
• Severe systemic autoimmune disease flares: Specialist-directed

• 1. Lexicomp. (2024). Immune globulin (intravenous): Drug information. Wolters Kluwer.
• 2. Orange, J. S., Hossny, E. M., Weiler, C. R., et al. (2006). Use of intravenous immunoglobulin in human disease: A review of evidence. Journal of Allergy and Clinical Immunology, 117(4), S525–S553.