Bedside Snapshot
- Use It For
- Guillain-Barré syndrome (unable to walk, within 2 weeks of onset); ITP with serious bleeding or need for a rapid platelet rise; Kawasaki disease; myasthenic crisis
- Adult Dose
- GBS: 0.4 g/kg/day IV × 5 days (total 2 g/kg)
- ITP, bleeding: 1 g/kg IV once, may repeat (max 2 g/kg per course)
- Myasthenic crisis: 2 g/kg IV over 2–5 days
- Pediatric Dose
- Kawasaki: 2 g/kg IV once over 10–12 hr, with aspirin. ITP with serious bleeding: 0.8–1 g/kg IV once; further doses per hematology. GBS: total 2 g/kg per course
- Onset / Duration
- IV: ITP platelet response in 2–7 days (median 2.5), lasting a median of about 2 weeks; Kawasaki fever usually resolves within 36 hr; GBS and MG recovery is gradual
- Do Not Give / Hold If
- Immune globulin anaphylaxis; IgA deficiency with anti-IgA and prior reaction; hyperprolinemia (Privigen); fructose intolerance (Gammaplex 5%); corn allergy (Octagam 5%). Stop for anaphylaxis, hypoxemia, rising creatinine
- Watch For
- Infusion reactions (headache, chills, BP change); thrombosis (limb swelling, chest pain, stroke signs); AKI (rising creatinine, oliguria); hemolysis (Hb drop at 36 hr–10 days)
- Reversal / Rescue
- No reversal agent. Slow or stop, then restart slower; anaphylaxis: stop, IM epinephrine; TRALI: oxygen and ventilatory support; AKI or hemolysis: stop, hydrate, recheck labs
- Must Remember
- Hydrate first and use the minimum dose and rate practicable: thrombosis and renal failure are boxed warnings. Rates and dilution are brand-specific, and maltose brands falsely raise some glucometer readings
Indications
ED / ICU / Transport
- Guillain-Barré syndrome (GBS): the patient cannot walk unaided and onset was within 2 weeks. Plasma exchange is the alternative. Off-label in the US
- ITP with serious bleeding or a need for a rapid platelet rise (urgent surgery, high bleeding risk, steroid failure): with IV corticosteroids and platelets
- Kawasaki disease: within 10 days of fever onset. After day 10, use it only with ongoing fever or coronary changes plus active inflammation
- Myasthenic crisis: Plasma exchange is the alternative, and it may act faster. Off-label in the US
Other Uses
- Primary immunodeficiency: IgG replacement; extra dose after measles exposure
- Chronic ITP: age 15 and older (Privigen), adults (Octagam 10%); CIDP: adults; dermatomyositis: adults (Octagam 10%)
- Specialist-directed: MIS-C, isoimmune hemolytic disease of the newborn, secondary hypogammaglobulinemia. Dose per the specialist team
Dosing & Administration
Start with the indication, then read its row. Every dose below is a labeled or published guideline regimen.
Available Forms
- 10% liquid: 100 mg/mL (Privigen; Octagam 10%). 5% liquid: 50 mg/mL (Octagam 5%, Gammaplex 5%): the same g/kg dose is twice the volume
- Stabilizers: Privigen has L-proline, Octagam has maltose and Gammaplex 5% has sorbitol. Sucrose is the one to watch: sucrose-containing products carry more renal risk
- IgA content differs: Privigen 25 mcg/mL or less; Octagam 10% averages 106 mcg/mL; Octagam 5% not more than 0.2 mg/mL
Adult Dosing
Acute courses total 1–2 g/kg IV. Replacement therapy runs 200–800 mg/kg.
| Indication | Dose & Route | Repeat / Max | Notes |
|---|---|---|---|
| Guillain-Barré syndrome | 0.4 g/kg/day IV × 5 days (total 2 g/kg) | Total 2 g/kg; no second course | Within 2 weeks of onset. Off-label. No IVIG straight after plasma exchange. |
| ITP: bleeding or urgent platelet rise | 1 g/kg IV once; may repeat the next day | Max 2 g/kg per course (label: 1 g/kg/day × 2 days) | With corticosteroids; life-threatening bleeding: add IV steroids, do not delay platelets. Alternative: 0.4 g/kg/day × 5 days. |
| Myasthenic crisis or severe MG | 2 g/kg IV over 2–5 days | Total 2 g/kg per course | Off-label; neurology-directed. Trial regimens: 1 g/kg/day × 2 days or 0.4 g/kg/day × 5 days. |
| CIDP | Loading 2 g/kg IV over 2–5 days; maintenance 1 g/kg IV every 3 weeks | Maintenance in 1–2 infusions; not studied beyond 6 months | Privigen label regimen. |
| Primary humoral immunodeficiency | 200–800 mg/kg IV every 3–4 weeks | Adjust to IgG trough and response | Measles exposure: extra 400 mg/kg within 6 days. At risk and under 530 mg/kg every 3–4 weeks: raise to at least 530 mg/kg. |
Pediatric Dosing
| Indication | Dose (per kg) & Route | Max Single / Max Total | Notes |
|---|---|---|---|
| Kawasaki disease | 2 g/kg IV once over 10–12 hr, with aspirin | 2 g/kg per dose; a second 2 g/kg if fever persists or recurs 36 hr or more after the infusion ends | Within 10 days of fever onset. High aneurysm risk (age 6 months or younger, or LAD or RCA z-score 2.5 or more): add corticosteroids or infliximab to the first dose. Resistance: second IVIG dose, corticosteroids or infliximab; other agents per cardiology. |
| ITP: serious bleeding | 0.8–1 g/kg IV once | 1 g/kg per dose; further doses per hematology | With IV steroids and platelets for intracranial or life-threatening bleeding. No or minor bleeding: observation is recommended over IVIG. |
| Guillain-Barré syndrome | Total 2 g/kg IV (0.4 g/kg/day × 5 days) | Total 2 g/kg per course | EAN/PNS regimen; confirm with neurology. |
| Primary humoral immunodeficiency | 200–800 mg/kg IV every 3–4 weeks | Adjust to IgG trough and response | Privigen studied from age 3. |
Need the weight math? Work it through here: pediatric weight-based dosing.
Continuous Infusion
| Setting | Example Concentration | Start | Titrate | Usual Range / Max |
|---|---|---|---|---|
| Privigen 10%: immunodeficiency or CIDP | 100 mg/mL (undiluted) | 0.5 mg/kg/min (0.005 mL/kg/min) | Increase gradually | Max 8 mg/kg/min (0.08 mL/kg/min) |
| Privigen 10%: chronic ITP | 100 mg/mL (undiluted) | 0.5 mg/kg/min (0.005 mL/kg/min) | Increase gradually | Max 4 mg/kg/min (0.04 mL/kg/min) |
| Octagam 10%: chronic ITP | 100 mg/mL (do not dilute) | 1 mg/kg/min (0.01 mL/kg/min) for 30 min | Every 30 min if tolerated: 2, 4, then 8 mg/kg/min | Max 12 mg/kg/min (0.12 mL/kg/min); at renal or thrombotic risk, not over 3.3 mg/kg/min (0.03 mL/kg/min) |
| Octagam 10%: dermatomyositis | 100 mg/mL (do not dilute) | 1 mg/kg/min (0.01 mL/kg/min) for 30 min | Every 30 min if tolerated: 2, then 4 mg/kg/min | Max 4 mg/kg/min (0.04 mL/kg/min); at renal or thrombotic risk, not over 3.3 mg/kg/min |
Thrombosis, renal or volume risk? Use the minimum rate practicable.
Preparation & Administration
- Handling: room temperature (up to 25 °C (77 °F)); do not shake; discard if cloudy, frozen or particulate. Dedicated line, flushed before and after with 0.9% sodium chloride or D5W
- Dilution: Privigen may be diluted with D5W. Octagam 10% must not be diluted. Pooled vials: start within 8 hr
- Slow start: Begin at 0.5 mg/kg/min or less (Privigen) if the patient is IVIG-naive, more than 8 weeks out from the last dose, or switching products. These patients react more above 4 mg/kg/min
- Reactions: Slow or stop the infusion. Restart at a lower rate once symptoms settle. After a prior reaction, premedicate with acetaminophen, antihistamine, NSAID, antiemetic or corticosteroid
Dosing Notes:
- Hydrate first. When thrombosis or renal risk is present, use the minimum dose and rate practicable.
Contraindications & Precautions
Contraindications
- Anaphylaxis or severe systemic reaction to human immune globulin
- IgA deficiency with anti-IgA antibodies and prior hypersensitivity
- Hyperprolinemia (Privigen); acute hypersensitivity to corn (Octagam 5%)
- Hereditary fructose intolerance, or unestablished sucrose or fructose tolerance in infants (Gammaplex 5%, sorbitol)
Precautions
- Thrombosis: older age, immobilization, hypercoagulability, prior venous or arterial thrombosis, estrogens, central catheters, hyperviscosity (cryoglobulins, high triglycerides, monoclonal gammopathy), cardiovascular risk factors
- Renal: pre-existing insufficiency, diabetes, age over 65, volume depletion, sepsis, paraproteinemia, nephrotoxic drugs
- Hemolysis: doses of 2 g/kg or more; non-O blood group, especially with pre-existing anemia or cardiovascular or pulmonary compromise
- Heart failure, oliguria or hypertension: The fluid load is large. BP can reach 180/120 mmHg or higher during or after the infusion
- Corn allergy: Octagam 10% contains corn-derived maltose. That is a warning, not a contraindication
- IgA deficiency without a prior reaction: Anti-IgA antibodies can form, and anaphylaxis can follow. IgA content differs by product. When IVIG is needed, the specialist chooses among a low-IgA product, a slow first infusion and anaphylaxis readiness.
- Blood product: It is made from pooled human plasma. A small residual infection risk remains
FDA Boxed Warning: Any immune globulin can cause thrombosis, even in patients with no risk factors. Predisposed patients can develop renal dysfunction, acute renal failure, osmotic nephrosis and death, and sucrose-containing products make that more likely. In at-risk patients give the minimum dose and rate practicable and hydrate first. Watch for thrombosis, and check blood viscosity if hyperviscosity is possible.
Adverse Effects & Toxicity
Common
- Headache (45% in the Privigen immunodeficiency trial), fatigue, nausea, chills; laboratory hemolysis 14–21% in Privigen ITP studies (2 g/kg courses)
Serious / Life-Threatening
| Effect | Recognition | Management |
|---|---|---|
| Anaphylaxis | Urticaria, wheeze, angioedema, hypotension | Stop; IM epinephrine, airway, fluids; see anaphylaxis |
| Thrombosis | DVT, PE, MI or stroke during or after infusion | Stop; emergency evaluation and standard treatment |
| Acute kidney injury | Rising creatinine and BUN, oliguria | Stop or slow; correct volume depletion; avoid nephrotoxins |
| Hemolysis | Falling hemoglobin days later, positive DAT, dark urine | Confirm with labs; careful crossmatch; can cause renal failure or DIC |
| Aseptic meningitis | Severe headache, neck stiffness, fever within hours to 2 days; more likely with 2 g/kg or rapid rates | Neurologic exam and CSF to exclude infection; resolves within days |
| TRALI | Dyspnea, hypoxemia, pulmonary edema, fever 1–6 hr after infusion | Stop; oxygen and ventilatory support; anti-HLA and anti-neutrophil antibody testing |
| Volume overload or hyperviscosity | Dyspnea, edema, hypertension | Stop or slow; diuresis; minimum rate |
Overdose & Toxicity
- Management: stop the infusion; oxygen, diuresis, BP control; check renal function and hemoglobin. Antidote: none
Monitoring
| Parameter | When / How Often | Target / Act If |
|---|---|---|
| Clinical: vitals and breathing | Before, during and after each infusion; breathing 1–6 hr after | Reaction: slow or stop. SBP ≥180 or DBP >120 mmHg: notify prescriber. Hypoxemia: stop; oxygen; consider TRALI vs volume overload |
| Clinical: thrombosis and meningism | During and for days after | Limb swelling, chest pain or focal deficit: stop. Severe headache with neck stiffness: neurologic exam and CSF |
| Laboratory: creatinine; hemoglobin | Creatinine before the first infusion and in at-risk patients; hemoglobin before, about 36 hr and 7–10 days after in high-risk patients (Privigen label) | Rising creatinine or oliguria: consider stopping. Significant hemoglobin drop: DAT, LDH, bilirubin; careful crossmatch |
| Laboratory: sodium; glucose | If sodium falls; glucose during and after Octagam | Low sodium with raised osmolar gap: pseudohyponatremia; do not restrict water. Use a glucose-specific method |
| Response: platelets (ITP); fever (Kawasaki) | Platelets within 24 hr; fever after the infusion ends | No rise or ongoing bleeding: further IVIG, steroids or platelets per hematology. Fever 36 hr or more after IVIG ends = IVIG resistance |
Interactions & Compatibility
Clinically Significant Interactions
| Drug / Class | Effect | What To Do |
|---|---|---|
| Live virus vaccines (measles, mumps, rubella, varicella) | Passive antibodies blunt the response | Defer by dose (ACIP): 8 months after 300–400 mg/kg, 10 months after 1 g/kg, 11 months after 2 g/kg. Vaccine given less than 14 days before IVIG: repeat after the interval unless serology shows protection |
| Glucose meters using GDH-PQQ or glucose-dye-oxidoreductase strips | Maltose reads falsely high: insulin errors, masked hypoglycemia | Use a glucose-specific method |
| Nephrotoxic drugs; estrogens; serologic tests | Additive kidney injury and thrombosis risk; passive antibodies distort serology and DAT | Hydrate; minimum rate; note the IVIG date on lab requests |
IV Compatibility
- Dedicated line; do not mix with other medications or another brand. Verify with an institutional compatibility resource.
Special Populations
- Pediatrics: Kawasaki disease and ITP with serious bleeding are the core uses. Hemolysis is more frequent with the high Kawasaki dose. Doses are in the Pediatric Dosing table.
- Pregnancy: There are no human or animal data on fetal risk. IgG crosses the placenta more and more after 30 weeks. Give it when it is clearly needed. IVIG is a first-line option in ITP of pregnancy.
- Lactation: There are no data on transfer into milk. Weigh the benefit against the maternal need.
- Older Adults: Over 65 means a higher risk of renal failure and thrombosis. Use the minimum dose and rate.
- Renal Impairment: correct volume depletion; check BUN and creatinine; avoid sucrose-containing products; stop if renal function worsens.
- Hepatic Impairment: no specific adjustment established.
- Obesity / Dosing Weight: The label doses by kg without naming actual or ideal weight. Follow pharmacy protocol.
- Blood Groups A, B and AB: Non-O blood raises hemolysis risk. Check hemoglobin after high doses.
Field & Transport Considerations
- Scope: It is started in the hospital. RNs and critical-care transport crews may continue it during an interfacility transfer. The rules vary by state and agency protocol.
- Storage & Stability: It depends on the brand. Privigen holds up to 25 °C (77 °F) and stays protected from light. Octagam 10% goes in the fridge at 2–8 °C (36–46 °F). It may sit at 25 °C (77 °F) or below for up to 9 months. Do not freeze it
- Carried Concentration and Pump: Read the bag. Confirm the brand and whether it is 5% or 10%. The same mg/kg/min dose gives a mL/hr rate that differs twofold between the two
- Handoff Essentials: indication, brand, lot, total dose and day of course, current rate, reactions, latest creatinine and hemoglobin
Clinical Pearls
The glucometer lies with maltose: A GDH-PQQ strip counts Octagam's maltose as glucose. Insulin dosed off that false high has caused life-threatening hypoglycemia.
Low sodium after IVIG may be fake: Blame the protein load: it makes the sodium read low. Restricting free water adds thrombosis risk.
GBS treatment discriminators (exam favorite):
- IVIG and plasma exchange are alternatives for a patient who cannot walk unaided.
- Corticosteroids are not recommended. There is no routine second IVIG course, and no IVIG straight after plasma exchange.
Kawasaki follow-up traps: IVIG raises the ESR on its own, so judge the response by fever. Still febrile 36 hr or more after the infusion ends? That is IVIG resistance. Measles and varicella vaccines wait 11 months.
Check the brand's rate, then recheck hemoglobin: For ITP, Privigen stops at 4 mg/kg/min. Octagam 10% goes to 12 mg/kg/min, but at renal or thrombotic risk it stays at 3.3 or below. Hemolysis can bottom out 7–10 days after a high dose.
Pharmacology
Mechanism of Action
- Replacement: The IgG tags and neutralizes pathogens. That is the protection an antibody-deficient patient lacks.
- Immunomodulation: The mechanism is not fully defined. Cytokine modulation and anti-idiotypic antibodies lead to less autoimmune injury.
- ITP: Fc-gamma receptors on macrophages get blocked. Fewer antibody-coated platelets are cleared.
Pharmacokinetics
| Route | Onset | Peak | Duration |
|---|---|---|---|
| IV | ITP: platelet response in 2–7 days; Kawasaki fever usually resolves within 36 hr | ITP: about day 7 | ITP: median about 2 weeks; replacement redosed every 3–4 weeks |
- Half-life: about 4–6 weeks in immunodeficiency; Privigen with 4-weekly dosing: median 37.3 days (range 20.6–96.6; n=22).
- Elimination and distribution: The reticuloendothelial system breaks it down. FcRn recycling is what prolongs the half-life. Vd at steady state is 50–84 mL/kg, and clearance is about 1.3 mL/day/kg.
Names & Classification
- Generic Name
- Immune globulin intravenous (human), IGIV; 5% and 10% liquids
- Brand Names
- Privigen, Gammagard Liquid, Gammagard S/D, Gamunex-C, Gammaked, Gammaplex, Octagam 5% and 10%, Panzyga, Flebogamma DIF, Bivigam, Asceniv, Alyglo, Yimmugo
- Pharmacologic Class
- Pooled human immunoglobulin G (polyvalent IgG from donor plasma)
- Therapeutic Class
- Immunomodulator; antibody replacement therapy
- Controlled Substance
- Not controlled
- ISMP High-Alert
- No
- Look-Alike / Sound-Alike
- Brands differ in concentration, stabilizer, IgA content and maximum rate: order and document by brand and percentage
References
- CSL Behring. (2026). Privigen (immune globulin intravenous [human], 10% liquid) [prescribing information] (DailyMed version posted May 2026). DailyMed, National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=7e5649da-75be-4a42-8eeb-4aeba562c401
- Pfizer Laboratories. (2024). Octagam 10% (immune globulin intravenous [human]) liquid [prescribing information]. DailyMed, National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=eb4c342b-122c-0072-1428-1747882e6c00
- Pfizer Laboratories. (2024). Octagam 5% (immune globulin intravenous [human]) liquid [prescribing information]. DailyMed, National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=fb07257b-e5e2-64c8-666c-65009f0aa604
- Bio Products Laboratory. (2025). Gammaplex 5% (immune globulin intravenous [human], 5% liquid) [prescribing information]. DailyMed, National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=6c3ce068-59f0-413b-9f93-85fb597d55e5
- van Doorn, P. A., Van den Bergh, P. Y. K., Hadden, R. D. M., Avau, B., Vankrunkelsven, P., Attarian, S., et al. (2023). European Academy of Neurology/Peripheral Nerve Society guideline on diagnosis and treatment of Guillain-Barré syndrome. European Journal of Neurology, 30(12), 3646–3674. https://doi.org/10.1111/ene.16073
- Provan, D., Arnold, D. M., Bussel, J. B., Chong, B. H., Cooper, N., Gernsheimer, T., et al. (2019). Updated international consensus report on the investigation and management of primary immune thrombocytopenia. Blood Advances, 3(22), 3780–3817. https://doi.org/10.1182/bloodadvances.2019000812
- Neunert, C., Terrell, D. R., Arnold, D. M., Buchanan, G., Cines, D. B., Cooper, N., et al. (2019). American Society of Hematology 2019 guidelines for immune thrombocytopenia. Blood Advances, 3(23), 3829–3866. https://doi.org/10.1182/bloodadvances.2019000966
- McCrindle, B. W., Rowley, A. H., Newburger, J. W., Burns, J. C., Bolger, A. F., Gewitz, M., et al. (2017). Diagnosis, treatment, and long-term management of Kawasaki disease: A scientific statement for health professionals from the American Heart Association. Circulation, 135(17), e927–e999. https://doi.org/10.1161/CIR.0000000000000484
- Centers for Disease Control and Prevention. (2024). Timing and spacing of immunobiologics: Table 3-6, recommended intervals between antibody-containing products and measles- or varicella-containing vaccine. ACIP General Best Practice Guidelines for Immunization. https://www.cdc.gov/vaccines/hcp/imz-best-practices/timing-spacing-immunobiologics.html
- Henderson, L. A., Canna, S. W., Friedman, K. G., Gorelik, M., Lapidus, S. K., Bassiri, H., Behrens, E. M., Kernan, K. F., et al. (2022). American College of Rheumatology clinical guidance for multisystem inflammatory syndrome in children associated with SARS–CoV‐2 and hyperinflammation in pediatric COVID‐19: Version 3. Arthritis & Rheumatology, 74(4). https://doi.org/10.1002/art.42062
- Narayanaswami, P., Sanders, D. B., Wolfe, G., Benatar, M., Cea, G., Evoli, A., Gilhus, N. E., Illa, I., et al. (2021). International consensus guidance for management of myasthenia gravis: 2020 update. Neurology, 96(3), 114–122. https://doi.org/10.1212/WNL.0000000000011124
- Pavlekovics, M., Engh, M. A., Lugosi, K., Szabo, L., Hegyi, P., Terebessy, T., et al. (2023). Plasma exchange versus intravenous immunoglobulin in worsening myasthenia gravis: A systematic review and meta-analysis with special attention to faster relapse control. Biomedicines, 11(12), 3180. https://doi.org/10.3390/biomedicines11123180
Medical Disclaimer
- For Educational Purposes Only: This content is intended for educational reference and should not be used for clinical decision-making.
- Not a Substitute for Professional Judgment: Always consult your local protocols, institutional guidelines, and supervising physicians.
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