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Treatment Name: Immune Globulin (IVIG, IV IgG)

Immune Globulin (IVIG, IV IgG) is a Supportive Care Therapy to treat Immune Thrombocytopenic Purpura (ITP)

How does intravenous immunoglobulin (IVIG, or IV IgG) work?
In patients with ITP, Intravenous immunoglobulin (IVIG) increases the platelet count by decreasing the destruction of platelets in your spleen. IVIG may also work in patients with or without a spleen by binding to and neutralizing the antibodies responsible for destroying platelets.

IV - IntraVenous
IgG - Immunoglobulin G

Trade names for IVIG include (listed alphabetically):

  • Carimune
  • Flebogamma
  • Gammagard
  • Gammaked
  • Gammaplex
  • Gamunex-C
  • Octagam
  • Privigen

Goals of Intravenous Immune Globulin (IVIG, IV IgG) therapy for ITP:
Intravenous Immune Globulin (IVIG) is given to temporarily increase the platelet count to a level which prevents bleeding or to a level that is safe to allow the patient to have surgery. Other therapies may be needed to prevent the platelet count from decreasing back to a dangerous level.

Schedule

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  • Intravenous Immune Globulin (IVIG) 2 gram/kg per course, divided in multiple doses:
    • IVIG 1 gram/kg/day for 2 consecutive days. If after the first of these two doses the platelet count increases to an adequate level after 24 hours, the second dose may be withheld
      OR
    • IVIG 0.4 gram/kg/day for 5 consecutive days, with each dose being given over several hours. This lower dose given more often may be recommended for those who have fluid overload, edema, or heart problems

Example dose: If a 70 kg person (154 lbs.) received 1 gram/kg/day for 2 days, they would receive 70 grams/day each day, for a total of 140 grams per course

  • Initial and maximum infusion rate to be determined based upon exact IVIG product chosen and patient-specific risk factors for kidney dysfunction or blood clots

Estimated total infusion time for this treatment:

  • Up to 24 hours for each dose; as short as several hours based upon total dose prescribed, weight of patient, and tolerability
  • Infusion times with IVIG may vary considerably depending on doctor preference or patient tolerability.
  • Pre-medications and intravenous (I.V.) fluids, such as hydration, may add more time

When used for low platelet counts in patients with ITP, Immune Globulin (IVIG) may be given in an outpatient infusion center, allowing the person to go home afterwards. It could also require a 1 - 5 day stay in a hospital, depending upon: the response to the medication, if someone is too sick for outpatient treatment, is at a high risk for bleeding, or is currently bleeding.

Intravenous Immune Globulin (IVIG) may be repeated at various time points when chronic ITP patients have a relapse in their platelet count or require surgery.

Side Effects

Clinical studies give the best estimate of what to expect. In clinical studies, the most commonly reported side effects of Intravenous Immune Globulin (IVIG) for ITP are shown here:

Note: Although rare, severe reactions, such as hypersensitivity, have occurred in some patients receiving intravenous immune globulin products. IVIG should be discontinued immediately and acute hypersensitivity support care medications such as epinephrine may need to be given. Patients with a known condition of "IgA deficiency" may be at higher risk for hypersensitivity reactions.

In two clinical trials that studied IVIG use in patients with ITP, 2 out of 76 patients (~3%) discontinued IVIG due to the following side effects: hives and headache + fever + vomiting.

Side effect videos Side Effect Videos
BleedingBleedingBlood ClotsBlood ClotsFatigue Fatigue Nausea and VomitingNausea and VomitingAnemiaAnemia

Monitoring

How often is monitoring needed?
Labs (blood tests) may be checked before treatment, periodically thereafter until stable. Labs often include: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), plus any others your doctor may order.

How often is imaging needed?
Imaging is rarely needed for patients with ITP as blood tests are commonly used to monitor response to therapy. Imaging may be checked if there is a suspicion of bleeding, blood clots, or lung injury. infection, such as pneumonia. Depending upon the reason for imaging, your doctor may order one or more of the following: CT scan, Ultrasound, chest x-ray, or others.

How might blood test results/imaging affect treatment?
Depending upon the results, your doctor may advise to continue Intravenous Immune Globulin (IVIG) as planned, discontinue when treatment is complete, delay the next dose until a side effect goes away, or switch to an alternative therapy.

Depending upon your doctor's recommendation, if the BUN/SCr increase (markers of kidney function found on a CMP), the infusion duration may be prolonged or the dose may be held until kidney function returns to baseline.

Questions to Ask Your...

A better understanding of your treatments will allow you to ask more questions of your healthcare team. We then hope that with the answers, you will get better results and have greater satisfaction with your care. Because we know it's not always easy to know what questions to ask, we've tried to make it easy for you!

Choose any healthcare provider below to see common questions that you may want to ask of this person. Then, either print each list to bring to your clinic visits, or copy the questions and send them as a message to your healthcare team through your electronic medical record.

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Questions to ask your DoctorNursePharmacist

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        Questions to ask your NurseDoctorPharmacist

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              Questions to ask your PharmacistDoctorNurse

                    ChemoExperts Tips

                    • Response rates to IVIG vary considerably in patients with ITP. In one clinical study, IVIG increased the platelet count from less than 20 k/uL to more than 50 k/uL within 7 days in 90% of patients. This response was sustained for 7 or more days in 74% of patients. Your doctor may recommend additional ITP therapy in case IVIG does not work or stops working
                    • Not all IVIG products are indicated for the treatment of ITP and may not have insurance coverage. Additionally, not all IVIG products are considered interchangeable. Ask your doctor or pharmacist for more information. Some IVIG products may not be ideal for patients with kidney problems. In general, IVIG products that do not contain sucrose are preferred for patients with kidney problems
                    • Aseptic meningitis syndrome (AMS) (symptoms may include: severe headache, neck stiffness, confusion, drowsiness, fever, increased sensitivity to light known as photophobia, nausea or vomiting) may occur infrequently, with the risk increasing for high doses or rapid infusions. If it occurs, aseptic meningitis usually resolves on its own without lasting side effects. If aseptic meningitis occurs, the infusion should be stopped until the symptoms go away. For future doses, the rate should be slowed. Corticosteroids such as prednisone taken as a pre-medication (or to treat ITP) may help to prevent future episodes of aseptic meningitis
                    • To prevent decreased kidney function, it is important to ensure adequate hydration on the days you are receiving intravenous immune globulin
                    • Intravenous immune globulin may interfere with the immune response to live vaccines, such as measles, mumps and rubella (MMR). Talk to your doctor or pharmacist about this interaction if it is recommended that you receive live vaccines after receiving IVIG
                    • A pharmacist should ALWAYS review your medication list to ensure that drug interactions are prevented or managed appropriately
                    • Clinical trials may exist for ITP. Ask your doctor if any studies are currently enrolling in your area. If not, go to clinicaltrials.gov to search for other centers offering study medications.
                    • If you are looking for patient assistance or co-pay coverage for medications in the IVIG regimen, we have provided links to PAN Foundation or PSI, which may offer financial assistance

                    Patient Assistance & Co-payment Coverage

                    Patients under the age of 65 years, or those with private insurance plans:
                    If you have insurance and are looking for patient assistance or copay assistance for Immune Globulin (IVIG, IV IgG), we have provided links that may help.

                    Visit our Patient Assistance page and click the links to various patient assistance programs for help paying for Immune Globulin (IVIG, IV IgG). Depending upon your income, they may be able to help cover the cost of:

                    • Immune Globulin

                    For Branded medications (may be available for generic medications too), check with the manufacturer to determine if a co-pay card is offered and if it could reduce your monthly copay.

                    • If you are uninsured, check with the manufacturer to determine if you are eligible to receive medication at no cost.

                    Medicare and Medicaid patients (Patients 65 years or older):
                    The clinic providing treatment will likely pre-authorize medications and immune therapies such as Immune Globulin (IVIG, IV IgG) and are the best source to help you understand drug cost.

                    • Ask to speak with a patient assistance technician or financial counselor at the clinic or hospital administering this therapy.

                    Emotional Wellness

                    What is Emotional Wellness?
                    Emotional wellness is having a positive outlook balanced with a realistic understanding of current life events. This requires both an awareness and acceptance of your emotions. It is with this knowledge that you can develop a plan to take the necessary actions to positively impact your life.

                    Emotional wellness uses an ongoing process to continually reflect on the stressors of life in a constructive manner to move forward and create happiness.

                    Because emotional wellness is deeply connected with physical, social, and spiritual wellness, pursuing it often becomes particularly difficult in times of major illness. Despite this difficulty, working toward emotional wellness has been connected to improved treatment outcomes and a higher likelihood of achieving goals of therapy.

                    Learn more about pursuing emotional wellness while receiving treatment with Immune Globulin (IVIG, IV IgG)

                    Individual Drug Label Information

                    Immune Globulin (IVIG, IV IgG)

                    • There are many types of IVIG, including (listed alphabetically): Carimune, Flebogamma, Gammagard, Gammaked, Gammaplex, Gamunex-C, Octagam, Privigen
                    • Immune Globulin (IVIG, IV IgG) is an intravenous infusion
                    • Blood clots (thrombosis) may occur after receiving IVIG. Risk factors may include: advanced age, sitting or laying for extended periods of time, history of blood clots, use of estrogen-containing medications, intravenous line, or heart disease. To minimize the risk, the lowest dose should be infused over the longest period of time that is practical. Patients should be adequately hydrated
                    • Tell your doctor if you pregnant or are planning to become pregnant or are nursing (breast feeding) 
                    General side effects from Intravenous Immune Globulin (IVIG)
                    • Cough
                    • Runny nose
                    • Sore throat
                    • Headache
                    • Asthma
                    • Nausea
                    • Fever
                    • Diarrhea
                    • Decreased kidney function
                    • Fluid overload (edema)
                    • Theoretic risk of infection
                    • May lead to false-positive tests for various viruses
                    • Rarely, Lung injury (symptoms typically occur 1 - 6 hours after treatment)
                    • Click on the Intravenous Immune Globulin (IVIG) package insert below for reported side effects, possible drug interactions, and other Intravenous Immune Globulin (IVIG) prescribing information

                    Side Effect Videos
                    Nausea and VomitingNausea and VomitingFatigue Fatigue BleedingBleedingAnemiaAnemiaBlood ClotsBlood Clots

                    See DailyMed package insert.

                    References

                    Intravenous immune globulin (IVIG, IV IgG) drug label information. IVIG package insert. Accessed 6/15/18.

                    Created: June 15, 2018 Updated: June 15, 2018

                    What is Immune Thrombocytopenic Purpura (ITP)?

                    A disorder where platelets decrease in number due to decreased production in the bone marrow and increased destruction in the blood. This can lead to an increased risk of spontaneous bruising or bleeding (without injury), especially when the platelet count drops below 30,000 cells per microliter of blood.

                    I  = Immune, ITP is caused by a disturbance in the immune system
                    T  = Thrombocytopenic, a medical term meaning low platelet count
                    P  = Purpura, a type of bleeding in the skin

                    ITP is NOT a cancer, but it is commonly managed by hematologists (blood doctors) who often treat blood cancers as well. ITP is an uncommon condition and may be caused by auto-immune disorders, infections, certain medications, or pregnancy. However, in many cases, a cause cannot be identified which gives rise to its other name-idiopathic (meaning “cause unknown”) thrombocytopenic purpura. Although ITP may spontaneously resolve, for some patients lifelong therapy may be needed.

                    The effectiveness of medications may depend upon the causes of ITP and the ability to remove these causes, or whether a splenectomy (removal of the spleen) has been performed, or is able to be performed.

                    Deciding on a treatment for ITP is in a way like buying, owning, and driving a car. Think about the following similarities to help you understand which treatment is right for you:

                    BUYING: "0 - 50 time" (0 to 50 k/µL platelets, instead of 0 - 60 m.p.h) is an important performance feature
                    Once the platelet count exceeds 50 k/µL, bleeding episodes are rare. Therefore, the time it takes to go from very few platelets to a platelet count over 50 k/µL matters. In general, steroids such as prednisone and dexamethasone have the fastest "0 - 50" time.

                    • Although exceptions, the thrombopoeitin receptor agonists romiplostim and eltrombopag usually have a 0 - 50 k/µL platelet time of 1 - 2 weeks
                    • Although exceptions, one-half of rituximab recipients have a 0 - 50 k/µL platelet time below 5.5 weeks, and the other half over 5.5 weeks. The response to rituximab is often unpredictable

                    OWNING: Warranty offered?
                    A 5-year bumper-to-bumper warranty helps us worry less about something breaking or going wrong with our vehicle after we buy it. Likewise, not all medications used for ITP have a long-lasting effect in keeping the platelet count above 50 k/µL.

                    • When it works, rituximab can work for 1 - 2 years, but lasting responses beyond two years are rarer. The 5 year rituximab response rate is estimated at 20 - 25%. When the rituximab "warranty" runs out and platelets fall, patients with ITP that had a long lasting response to rituximab may respond to another course of therapy. Certain insurances require the platelet count to be less than 30 k/µL before it will be covered.
                    • When they work, the thrombopoeitin receptor agonists romiplostim and eltrombopag generally have lasting effect beyond that of rituximab. The "warranty" period where the platelet count remains above 50 k/µL often lasts 2 years or longer

                    DRIVING: Cruise control optional?
                    The ability for a treatment to maintain the platelet count within the goal range is similar to setting the cruise control on a car.

                    • Steroids are given in a pulse (example: dexamethasone daily for 4 consecutive days) or given daily for several weeks (example: prednisone), then decreased over several weeks and eventually discontinued a few months after it is started. As a result, when steroids are no longer taken there is a chance for ITP to relapse
                    • Because eltrombopag and romiplostim are administered continuously, these medications have the highest likelihood of keeping the platelet count in the goal range for the long haul
                    • Rituximab is typically given once weekly for 4 doses, and usually takes several weeks to determine if it is working (see above), therefore it is difficult to predict who will have a lasting response to this therapy
                    NOTE: Treatment Options listed below are not all-inclusive. Other treatments may be available. ChemoExperts provides drug information and does not recommend any one treatment over another. Only your Doctor can choose which therapy is appropriate for you.