i.v.i.g by: mohammed alsaidan. ivig ivig is a blood product derivative manufactured from the...
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I.V.I.G
BY: MOHAMMED ALSAIDAN
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IVIG
• IVIg is a blood product derivative manufactured from the sterilized, purified human plasma of between 1000 to 20,000 donors per batch.
• The final IVIg preparation is primarily composed of IgG, with trace amounts of IgA, IgM and albumin
• half-life of IVIg ranges from 3-5 weeks
• Crosses the placenta, and may be excreted in milk
• Distributed : 60% intravascular , 40 % extravascular
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MOA
• Functional blockade of the Fc receptors
• Neutralize complement , and block complement activation in early stage
• Anti-idiopathic antibodies can neutralize pathogenic antibodies
• Interfere with T-cell activation
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MOA
• Interfere with cellular migration
• Increase glucocorticoid receptor sensitivity
• In toxic epidermal necrolysis, IVIg blocks Fas (CD95) mediated keratinocyte death by inhibiting Fas – Fas ligand interactions
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Indications
• The efficacy of IVIg is best documented in patients with:• graft-versus-host disease• Kawasaki’s disease• dermatomyositis
• Autuimmune bullous dermatosis:• pemphigus vulgaris• pemphigus foliaceus• bullous pemphigoid• herpes gestationis• epidermolysis bullosa acquisita (EBA)• TEN/ SJS
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Indications
• Other indications: • Atopic dermatitis• psoriasis• scleroderma• Pyoderma gangrenosum• Chronic autoimmune urticaia
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When to use IVIG for bullous dis.
1)Progressive, uncontrolled,or rapid debilitating diseasefailure of conventional therapy2) significant adverse effects from conventional therapy3) contraindications, relative or absolute, to the use of high-dose long-term systemic therapy
*The patient age and pregnancy are not contraindications to the use of IVIG
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Before starting IVIG
• Vital signs • Weight to monitor for overload• Auscultate lungs and heart • Labs: • CBC• LFT • Renal profile• Immunoglobulin levels• RF and in patients at an increased risk of acute renal failure• For medicolegal reasons: HBV, HCV and HIV is advisable
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Pre medication
• To minimize the risk of infusion-related side effects, such as headaches, myalgias and rigors.• Analgesics (i.e., acetaminophen)• Antihistamines (i.e., diphenhydramine) • NSAID (i.e., celecoxib)• low-dose intravenous corticosteroids may be of benefit to a
subset of individuals
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Dosage
• The most common dosage in dermatology is 2 g/kg/cycle divided into 3 equal doses in 3 consecutive days
• Or 400mg/kg daily for 5 days
• Infusion: Slowly over 4 to 4 ½ hours
• Given monthly , but can be given every 2 weeks in very aggressive disease
• Tapering : keep the same dose with increasing the interval between infusions by 2 weeks (4,6,8,10,12,14,16) then D/C
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Dosage
• Careful monitoring for 1st infusion or different preparation
• All patients must be well hydrated prior to the infusion .
• When all these measures fail to correct or prevent the adverse reactions it could be useful to change to a different preparation of IVIG
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Anaphylaxis reaction
• More frequently with antibody deficiency , mainly in IgA deficiency with antibody against IgA
• Slow infusion seems to lower the risks
• Resolve with temporary interruption of the infusion or a slowing of its rate of administration
• Can be prevented by giving , paracetamol or anti-histamines before the treatment and/or hydrocortisone during it.
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Thromboembolic events
• Secondary to increased viscosity , leading to cerebral or myocardial infarction
• RISK FACTORS:• higher doses or rapid infusion • elderly patients• patients with previous cerebral or cardiac ischaemia• overweight patients• Those who are markedly hypovolaemic and immobilised
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Aseptic menengitis
• observed in patients with neurological and neuromuscular diseases treated with high doses of IVIG.
• The symptoms appear within 6–24 hours of the end of the infusion and disappear without sequelae in 3–5 days
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Renal disease
• Increases in creatinine or acute renal failure rarely in elderly, diabetic, poorly hydrated patients, with pre-existing renal disease or who are taking nephrotoxic drugs.
• These problems are probably related to damage caused to the renal tubules by the saccharose included in various preparations as a stabiliser.
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