Intravenous Immune Globulin (IVIG) | Medication Reference

Bedside Snapshot

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

Brand & Generic Names

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

Medication Class

Pooled human IgG antibody preparation; immunomodulator and replacement therapy

Pharmacology

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

Dosing & Administration

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):

Indication	Total Dose	Schedule	Notes
Guillain-Barré syndrome	2 g/kg	0.4 g/kg/day IV × 5 days	Alternative: 1 g/kg/day × 2 days in some protocols
Immune thrombocytopenia (ITP)	1-2 g/kg	1 g/kg/day × 1-2 days or 0.4 g/kg/day × 5 days	Use for severe bleeding or pre-procedural platelet boost
Kawasaki disease	2 g/kg	Single IV infusion over 8-12 hours	Combined with aspirin; primarily pediatrics
Myasthenia gravis exacerbation	2 g/kg	0.4 g/kg/day × 5 days	Alternative to plasma exchange
Primary immunodeficiency (replacement)	0.2-0.8 g/kg	Every 3-4 weeks	Goal IgG trough levels per immunology
Other autoimmune/inflammatory indications	1-2 g/kg	Varies	Consult specialist; regimens differ widely

Infusion Rate: Start slow, increase as tolerated per product-specific max rates. Use slower rates in renal impairment, elderly, and high-risk patients.

Contraindications

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

Adverse Effects

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)

Monitoring

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

Indications / Clinical Uses (ICU/Acute Care Focus)

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

Clinical Pearls

Start Slowly: Begin infusions slowly and titrate up as tolerated; premedication with acetaminophen ± antihistamines reduces infusion reactions.

Renal Protection: Use sugar-free, low-osmolality formulations and lower infusion rates in patients with renal impairment or high thrombotic risk.

Hydration: Hydration before and during infusion mitigates renal and thrombotic risks.

Documentation: Document brand, dose, and lot, as patients may respond differently to different IVIG products and adverse reactions can be product-specific.

References

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.