What are the recommended IVIG (Intravenous Immunoglobulin) dilution and dosing guidelines?

IVIG Dilution and Dosing Guidelines

IVIG should be administered at a dose of 2 g/kg of ideal body weight, typically given over 2-5 consecutive days, with specific dosing adjusted based on the clinical indication. 1

Dosing Guidelines by Indication

• Immunodeficiency disorders: 300-400 mg/kg IV monthly for replacement therapy 1
• Autoimmune conditions: 1-2 g/kg of ideal body weight, usually given over 2 consecutive days 1
• Kawasaki Disease: 2 g/kg as a single infusion 1
• Multisystem Inflammatory Syndrome in Children (MIS-C): 2 g/kg based on ideal body weight 2
• Immune Thrombocytopenic Purpura (ITP): 1 g/kg as a one-time dose, which may be repeated if necessary 1
• Immune-related adverse events from checkpoint inhibitors: 2 g/kg over 5 days 2
• Guillain-Barré Syndrome: 0.4 g/kg/day for 5 days for a total dose of 2 g/kg 2
• Invasive bacterial infections with hypogammaglobulinemia: 400 mg/kg body weight every 2-4 weeks 2

Pre-Administration Assessment

• IgA deficiency screening: Check serum IgA level before administering IVIG to prevent severe anaphylactic reactions 1
• Risk factor assessment: Review medical history for renal dysfunction, thrombotic risk, or history of previous infusion reactions 1
• Cardiac function evaluation: Assess cardiac function and fluid status before administering IVIG, particularly in patients with cardiac dysfunction 2

Administration Protocols

• Standard dilution: IVIG should be diluted according to manufacturer's guidelines, typically in 5% dextrose or 0.9% sodium chloride 1
• Initial infusion rate: Begin at a slow rate (0.5-1 mg/kg/min) and gradually increase if tolerated 1
• Divided dosing: In patients with cardiac dysfunction, IVIG may be given in divided doses (1 g/kg daily over 2 days) 2
• Weight-based calculations: Using ideal body weight (IBW) or adjusted body weight (adjBW) rather than actual body weight (ABW) for dose calculations provides similar efficacy with cost savings 3

Premedication Recommendations

• Standard premedication: Diphenhydramine and acetaminophen before IVIG infusion 1
• For patients with history of reactions: Consider adding corticosteroids as premedication 1

Monitoring During Administration

• Vital signs: Monitor blood pressure, heart rate, respiratory rate, and temperature during infusion 1
• Renal function: Monitor urine output and serum creatinine during administration 1
• Infusion reactions: Watch for headache, flushing, chills, myalgia, wheezing, tachycardia, lower back pain, nausea, and hypotension 1

Management of Adverse Reactions

• Mild reactions: Slow or temporarily stop the infusion and administer additional antihistamines or antipyretics 1
• Severe reactions: Immediately cease infusion, administer epinephrine, and notify physician for anaphylaxis or severe hypotension 1

Special Considerations

• Patients with cardiac dysfunction: Consider divided dosing (1 g/kg daily over 2 days) to minimize fluid overload 2
• IgA deficiency: Use IVIG preparations with reduced IgA levels 1
• Dermatological autoimmune diseases: IVIG is typically administered at 2 g/kg distributed over 2-5 days every 4 weeks 4

Pitfalls and Caveats

• Volume overload risk: Patients with cardiac or renal dysfunction are at increased risk; consider slower infusion rates and divided dosing 1
• Thrombotic events: IVIG can increase blood viscosity; ensure adequate hydration and consider anticoagulation in high-risk patients 1
• Cost considerations: Using ideal body weight or adjusted body weight for dosing calculations provides similar efficacy with significant cost savings compared to actual body weight 3
• Initial infusions: Proceed with caution in immunodeficient patients who have not been treated during the previous 8 weeks or never treated, as they are at risk for complement-mediated adverse reactions 5