What premedications are recommended for patients receiving Intravenous Immunoglobulin (IVIG)?

Premedication Recommendations for Intravenous Immunoglobulin (IVIG)

Standard premedication for IVIG should include acetaminophen and diphenhydramine administered 30-60 minutes before infusion to reduce the risk of infusion reactions. 1

Standard Premedication Protocol

First-Line Premedications:

• Acetaminophen: 650-1000 mg orally 30-60 minutes before infusion
• Diphenhydramine (or another H1-antihistamine): 25-50 mg orally 30-60 minutes before infusion 2, 1

Additional Premedications for High-Risk Patients:

Patients with any of these risk factors may benefit from additional premedication:

• History of previous IVIG reactions
• Multiple drug allergies
• IgA deficiency
• Asthma

For these patients, consider adding:

• H2-antihistamine (e.g., ranitidine 150 mg or famotidine 20 mg)
• Hydration with normal saline before infusion, especially in patients with risk factors for renal dysfunction 1, 3

Monitoring During Infusion

• Vital signs every 30 minutes during infusion
• Then hourly (±15 min) for 4 hours after infusion
• Observe for signs of infusion reactions: headache, flushing, chills, fever, nausea, back pain, chest tightness 1

Management of Infusion Reactions

Mild to Moderate Reactions:

1. Stop the infusion immediately
2. Provide symptom-specific treatment:
   • Nausea: 5-HT3 antagonist (ondansetron)
   • Urticaria: Second-generation antihistamine
   • Mild hypotension: IV hydration with normal saline 1
3. If symptoms completely resolve, consider restarting infusion at 50% of the initial rate after 15 minutes

Severe Reactions:

1. Stop the infusion immediately
2. For anaphylaxis: Administer epinephrine
3. Consider IV corticosteroids and H2 antagonists 1

Important Considerations and Precautions

Avoid These Practices:

• Do not use first-generation antihistamines like diphenhydramine during reactions (may convert minor reactions to hemodynamically significant events) 1
• Do not routinely use systemic corticosteroids as premedication unless specifically indicated 1
• Do not administer IVIG rapidly (increases risk of adverse events) 4, 3

Special Populations:

• Renal impairment: Use non-sucrose containing IVIG products, ensure adequate hydration, slower infusion rate 3
• Cardiovascular risk factors: Slower infusion rate, especially in elderly patients or those with hypertension, diabetes, or previous thromboembolic disease 3, 5
• IgA deficiency: Check IgA levels before first infusion; use IVIG preparations with reduced IgA content 2

Medications to Have Available During Infusion

• Acetaminophen
• NSAIDs (e.g., indomethacin)
• H1 and H2 antihistamines
• Analgesics
• Epinephrine (for anaphylaxis)
• Oxygen and suction equipment 2, 1

Despite premedication, approximately 26% of patients may still experience some form of adverse reaction to IVIG, with the most common being fever, chills, headache, and vomiting 6, 7. However, premedication significantly reduces the severity of these reactions and allows for successful completion of the infusion in most cases.