What is the recommended dose of intravenous immunoglobulin (IVIG) for treatment?

IVIG Dosing for Treatment

The recommended dose of intravenous immunoglobulin (IVIG) is 1 g/kg as a single infusion, which can be repeated once after 1-2 days if needed for a total dose of 1-2 g/kg over 1-2 days. 1, 2

Standard Dosing Regimen

The modern approach uses 1 g/kg given over 1-2 days rather than the older 5-day regimen. 1, 2

• The traditional regimen of 0.4 g/kg/day for 5 consecutive days has been largely replaced by the more convenient 1 g/kg dosing 2, 3, 4
• The higher single-dose regimen (1 g/kg) produces faster platelet responses, with many patients responding within 24 hours compared to several days with the lower-dose regimen 1, 2
• IVIG may be discontinued after 1-2 days if adequate response is achieved 1

Expected Response and Duration

Patients typically respond within 24 hours to 2-4 days, but the effect is usually transient. 1, 2

• Up to 80% of patients respond initially, with approximately half achieving normal platelet counts 1
• Peak response occurs within 2-4 days 2
• Platelet counts typically return to pretreatment levels within 2-4 weeks, though some patients maintain response for months 1, 2

Emergency/Urgent Situations

For patients with uncontrolled bleeding or requiring urgent procedures, use IVIG 1 g/kg combined with high-dose corticosteroids. 1, 2

• This combination provides the most rapid platelet elevation 1, 2
• Consider adding platelet transfusions for life-threatening bleeding 2
• Prednisone plus IVIG is the recommended emergency treatment combination 1

Combination Therapy Considerations

Concomitant corticosteroids may enhance IVIG response and reduce adverse effects. 1, 2

• Corticosteroids can enhance the platelet response to IVIG 1
• Premedication with acetaminophen/paracetamol or corticosteroids (e.g., 20 mg prednisone) reduces infusion reactions 1, 2
• Combined therapy may prevent aseptic meningitis 1, 2

Special Populations

Maintenance Therapy for Immunodeficiency

• For patients with common variable immunodeficiency (CVID) and ITP, use high-dose IVIG initially followed by maintenance dosing of 0.3-0.4 g/kg every 3-4 weeks 1

Pregnancy

• IVIG 1 g/kg is recommended for pregnant patients requiring ITP treatment 2
• It is considered safe during pregnancy and is a first-line option 2

Immune Checkpoint Inhibitor-Related ITP

• For checkpoint inhibitor-induced ITP with platelets <50 × 10⁹/L, use IVIG 1 g/kg, often with corticosteroids 2

Critical Safety Considerations

Common adverse effects include headaches, but rare serious complications can occur. 1, 2

• Headaches are the most common adverse effect, ranging from moderate to severe 1, 2
• Rare but serious toxicities include renal failure and thrombosis 1, 2
• Other adverse effects include transient neutropenia, aseptic meningitis, flushing, fever, chills, fatigue, nausea, diarrhea, and blood pressure changes 1, 2
• IVIG is contraindicated in patients with IgA deficiency who have detectable IgA antibodies due to risk of anaphylactoid reactions; use IgA-depleted preparations in these cases 1

Important Clinical Pitfalls

• Infusion reactions are often related to infusion rate; slower infusion over several hours is required 1
• IVIG is a pooled blood product—inform patients of theoretical infectious disease transmission risk, though modern processing has minimized this 1, 2
• The response is typically transient, so plan for repeat dosing or alternative therapies if sustained response is needed 1, 2