| General precautionary measures | - Follow appropriate indications and dosing (possible switch to SCIG)
- Give first dose in a monitored setting
- Supervise subsequent doses if there has been a severe reaction
- Ensure adequate hydration prior to administration
- Risk-stratify patients and consider separating larger doses into multiple smaller doses for individuals at higher risk of VTE or AKI
- Slow initial infusion rates with gradual increases
- Keep track of products and lot numbers; avoid substituting different products unless there is an adverse reaction
|
| Specific reactions | Preventive measures |
| Anaphylaxis | - For patients with undetectable serum IgA:
- Evaluate for anti-IgA antibodies
- Switch to a low IgA product
- For primary and secondary immunodeficiency, change to SCIG
- If continued IVIG treatment is important, give test dose of new product and administer at very slow rates
- Desensitization can be performed but is rarely used
|
| Transfusion-related acute lung injury (TRALI) | - Use a different lot number or manufacturer
|
| Volume overload (TACO) | - Optimize cardiovascular and fluid status prior to infusion
- Use slow infusion rates
- Use extra caution with products having 5% concentration
- Administer diuretics if appropriate
|
| Immediate rate related and allergic | - Search for occult infections and treat bacterial infections before starting IVIG
- Reduce the infusion rate
- Premedication(s) for selected individuals:*
- Diphenhydramine
- Cyproheptadine (for headache)
- Acetaminophen
- NSAIDs
- Switch to SCIG if possible
- Use a different lot number
|
| Post-infusion headache | - Ensure adequate hydration prior to administration
- Reduce the infusion rate
- Premedication(s):*
- Mild – An NSAID or acetaminophen, possibly diphenhydramine
- Severe – Glucocorticoids or migraine prophylaxis if severe
- For aseptic meningitis, use SCIG or switch products
|
| Thrombosis or thromboembolism | - Avoid central venous catheter placement solely for IVIG
- Ensure adequate hydration prior to administration
- Use a low osmolality product
- Avoid prolonged immobility (eg, long airplane flight) in the days after infusion
|
| Acute kidney injury | - Ensure adequate hydration prior to administration
- Use a less-concentrated product (≤5% [≤5 g/100 mL] IgG)
- Divide large doses (1 to 2 g/kg) into smaller doses (eg, 400 mg daily for 5 days)
|
| Hemolysis | - For treating primary or secondary immunodeficiency, change lot number or brand, or change to SCIG
- Switch brands and/or lot numbers
- Consider products with reduced isoagglutinins
|
