Should the next IV Immunoglobulin (IVIG) infusion be delayed for a week if a fever occurs after the first day of treatment?

Management of Fever After IVIG Infusion

If fever occurs after day one of an IV immunoglobulin (IVIG) infusion, the next infusion should not be delayed a week but rather administered with appropriate pretreatment to prevent infusion reactions.

Understanding IVIG-Related Fevers

Fever is a common reaction to IVIG therapy and can occur during or after infusion. According to guidelines, these reactions can be categorized as:

• Acute reactions: Occur during or within 24 hours of infusion 1
• Delayed reactions: Begin 1-14 days after infusion, usually consisting of myalgia, arthralgia, headache, fever, rash, and fatigue 1

Management Approach

1. Assessment of Fever

• Determine if fever is likely related to IVIG or indicates another condition
• Fever after day one is typically a delayed infusion reaction rather than a contraindication to continued therapy

2. Recommended Protocol

• Continue with scheduled IVIG treatment rather than delaying for a week
• Missing an infusion actually increases the chances of subsequent infusion reactions 1
• For Kawasaki disease specifically, prompt and complete IVIG therapy is critical to reduce the risk of coronary artery aneurysms 1

3. Pretreatment for Next Infusion

• Administer acetaminophen and diphenhydramine before the next infusion to mitigate reactions 1
• Consider slower infusion rate for the next dose 1, 2

4. Monitoring During Next Infusion

• Monitor vital signs carefully during subsequent infusions 2
• Be prepared to temporarily pause or slow the infusion if reactions occur 1

Special Considerations

For Severe Reactions

• If the patient experienced severe symptoms (hypotension, chest tightness, respiratory distress, dyspnea, bronchospasm, laryngeal edema), consult with a specialist before proceeding 1
• In such cases, alternative therapies may need to be considered

For Persistent Fever

• In Kawasaki disease, persistent fever beyond 36 hours after IVIG completion indicates resistance to IVIG and may require additional therapy 1
• For patients with persistent fever, a second dose of IVIG (2 g/kg) is generally recommended rather than delaying treatment 1

Conclusion

Fever after day one of IVIG infusion represents a common delayed reaction and should not prompt delay of subsequent scheduled therapy. Instead, the next infusion should proceed with appropriate premedication and potentially at a slower rate to minimize reactions. Delaying therapy could increase the risk of treatment failure and complications, particularly in conditions like Kawasaki disease where timely treatment is essential for preventing long-term sequelae.