IVIG Titration Protocol for 36.4g (364mL) Infusion
For a patient receiving 36.4 grams of IVIG (364 mL), the standard titration protocol involves administering the dose in divided portions over 2-5 consecutive days, with the most common approach being 0.4 g/kg/day for 5 days to reach a total dose of 2 g/kg, or alternatively dividing the total dose over 2 days. 1
Standard Dosing Schedules
Five-Day Protocol (Most Common)
- Administer 0.4 g/kg/day for 5 consecutive days to achieve total dose of 2 g/kg 1
- For a 36.4g total dose, this translates to approximately 7.3g (73 mL) per day over 5 days
- This approach is recommended for conditions including Guillain-Barré syndrome, myasthenia gravis, and immune checkpoint inhibitor-related neurologic toxicities 1
Two-Day Protocol (Alternative)
- Divide total dose into 2 equal portions over 2 consecutive days 1
- For 36.4g total: administer 18.2g (182 mL) on day 1 and 18.2g (182 mL) on day 2
- Maximum single dose should not exceed 140g 1
Infusion Rate Guidelines
Initial Infusion (First-Time or Long Gap Since Last Dose)
- Start at slow rate with extreme caution in patients not treated in previous 8 weeks or never treated 2
- These patients are at risk for potentially serious complement-mediated adverse reactions 2
- Monitor closely for first 30-60 minutes for signs of infusion reactions 3
Standard Rate Progression
- Begin infusion slowly and gradually increase rate as tolerated 3
- Infusing at a slow rate minimizes adverse effects 3
- First infusion should proceed over at least 4-6 hours 1
- Subsequent doses may be given over 2-4 hours if tolerated well 1
Pre-Medication Protocol
Administer the following before each infusion to minimize adverse reactions: 1
- Diphenhydramine (Benadryl) 1 mg/kg
- Acetaminophen (Tylenol) 10-15 mg/kg
- Consider corticosteroids for high-risk patients 1
Monitoring During Infusion
Observe for common adverse effects: 3
- Flushing, headache, malaise, fever, chills, fatigue (most common and transient)
- Serious reactions requiring immediate intervention: thrombosis, renal impairment, arrhythmia, aseptic meningitis, hemolytic anemia, TRALI 3
Vital signs monitoring:
- Check baseline vitals before starting
- Monitor every 15-30 minutes during first hour
- Monitor hourly thereafter if stable 3
Special Considerations
Contraindications
- Absolute contraindication: Selective IgA deficiency with detectable IgA antibodies 2
- Assess IgA levels before first infusion in patients with recurrent infections
Risk Mitigation
- Perform early assessment of risk factors including renal function, thrombotic risk, and cardiac status 3
- Ensure adequate hydration before and during infusion
- Consider switching to subcutaneous immunoglobulin (SCIG) if recurrent infusion reactions occur 3
Repeat Dosing
- For maintenance therapy in ITP: 0.4 g/kg doses have been used 2
- For immunodeficiency: 0.2-0.3 g/kg monthly 2
- Timing of repeat doses depends on clinical response and indication 1
Important Caveats
Do not administer plasmapheresis immediately after IVIG as it will remove the immunoglobulin 1
If patient sneezes during intranasal vaccine administration (unrelated to IVIG), do not repeat dose - this note appears in guidelines but is not relevant to IVIG infusion 1
Adverse effects are rarely disabling or fatal, and treatment mainly involves supportive measures with good prognosis 3