IVIG Dosing for Stevens-Johnson Syndrome
For Stevens-Johnson syndrome, administer IVIG at a total dose of 2-3 g/kg divided over 3-5 consecutive days, with the optimal regimen being 1 g/kg/day for 3 consecutive days. 1
Recommended Dosing Protocol
The standard high-dose regimen of 2-3 g/kg total dose is associated with improved survival compared to low-dose regimens. 1, 2 This should be divided over 3-5 consecutive days, with most successful protocols using 1 g/kg/day for 3 days. 1, 2
Critical Dosing Considerations:
Never use low-dose IVIG (0.4 g/kg/day for 4 days), as this regimen showed mortality rates of 42% in TEN patients and correlates with worse outcomes. 1, 2
For obese patients, use ideal body weight or adjusted body weight rather than actual body weight to prevent excessive dosing. 1
For patients with cardiac dysfunction, divide the total dose over 2 days to minimize fluid overload risk. 1
Pre-Administration Requirements
Before initiating IVIG, complete the following assessments:
Check serum IgA levels to identify patients at risk for severe anaphylaxis; use IgA-depleted preparations if deficiency is detected. 1
Evaluate renal function including serum creatinine and urine output. 1
Assess thrombotic risk factors and cardiac function, especially in patients with pre-existing cardiac disease. 1
Document history of previous infusion reactions. 1
Premedication and Monitoring
Administer diphenhydramine and acetaminophen as standard premedication before IVIG infusion. 1
Consider adding corticosteroids (such as 20 mg prednisone) for patients with prior infusion reactions. 1
Administer IVIG over several hours and monitor renal function throughout the infusion. 1
Watch for common adverse effects including headaches, fever, and fatigue, as well as serious complications such as renal failure and thrombosis. 1
Evidence Quality and Clinical Context
While high-dose IVIG shows promise, it is important to recognize that no randomized controlled trials have demonstrated unequivocal benefit for Stevens-Johnson syndrome. 1, 2 The evidence supporting IVIG use is level 3-4, based primarily on retrospective studies and case series. 2
High-quality multidisciplinary supportive care remains the absolute priority regardless of specific interventions, and IVIG should be considered an adjunct rather than a replacement for comprehensive management. 1, 2
Supporting Evidence:
A retrospective multicenter study of 12 SJS patients treated with IVIG at 0.6 g/kg/day for 4 days showed 100% survival and skin healing within 8.3 days on average. 3
A pediatric study showed shortened fever duration (8 days vs 14 days) in IVIG-treated patients compared to non-IVIG treatment, though statistical significance was marginal. 4
Combination therapy with IVIG and corticosteroids arrested disease progression earlier and decreased hospitalization time compared to corticosteroids alone. 5
Pediatric Considerations
Pediatric patients with Stevens-Johnson syndrome have significantly lower mortality than adults (0% vs 21.6%), making IVIG a particularly attractive option in this population. 2
- Pediatric dosing follows the same weight-based protocol as adults: 2-3 g/kg total dose divided over 3-5 days. 1
Critical Pitfalls to Avoid
Do not perform plasmapheresis immediately after IVIG administration, as it will remove the immunoglobulin. 1
Do not delay initiation of IVIG while waiting for diagnostic confirmation if clinical suspicion is high, as earlier treatment is associated with shorter healing times. 3
Ensure adequate supportive care is prioritized, as IVIG efficacy depends on comprehensive multidisciplinary management including wound care, fluid management, and infection prevention. 1, 2