Premedication for IVIG
Routine premedication before IVIG infusion is not necessary for most patients, but should be reserved for those who have previously experienced infusion reactions.
Standard Approach for IVIG-Naive Patients
Do not routinely premedicate patients receiving their first IVIG infusion, as premedication has not been shown to prevent initial infusion reactions and may unnecessarily expose patients to additional medications 1.
Start with a slow infusion rate and low concentration to minimize the risk of immediate adverse effects, which include headache, flushing, fever, chills, myalgia, chest tightness, and blood pressure changes 1.
Ensure adequate hydration before infusion, particularly in high-risk patients (those with renal disease, diabetes, advanced age, hypertension, or on nephrotoxic medications) to prevent renal complications 1.
Premedication Protocol for Patients with Prior Infusion Reactions
If a patient has experienced a previous infusion reaction to IVIG, implement the following premedication regimen:
Acetaminophen 650-1000 mg orally, given 30-60 minutes before infusion 1, 2.
Antihistamine (diphenhydramine 25-50 mg IV or oral equivalent) given prior to infusion 1, 2.
Corticosteroids may be added for patients with more severe prior reactions, though this is not routinely required for mild reactions 1.
Management of Acute Infusion Reactions
For mild to moderate reactions (Grade 1-2): immediately stop or slow the infusion rate, provide symptomatic treatment with antipyretics and antihistamines, and restart at 50% of the previous rate once symptoms completely resolve 1.
For severe reactions (Grade 3-4): stop the infusion immediately, administer aggressive symptomatic treatment including corticosteroids, antihistamines, and supportive care as needed 1.
Critical Pitfalls to Avoid
Avoid routine premedication in all patients, as this practice is not evidence-based and may lead to unnecessary medication exposure without proven benefit in preventing initial reactions 2, 3.
Do not use sucrose-containing IVIG products in patients with renal risk factors, as these cause osmotic injury leading to acute renal failure 1.
Avoid rapid infusion rates in high-risk patients (elderly, those with cardiovascular disease, diabetes, or history of thrombosis), as this increases risk of thromboembolic complications and hyperviscosity 1.
Monitor for IgA deficiency before first infusion, as IgA-deficient patients are at significantly higher risk for anaphylactic reactions 1.
Special Considerations for High-Risk Patients
For patients with renal disease, dehydration, diabetes, advanced age, hypertension, or concurrent nephrotoxic medications: