Immune globulin (Ig) is the most widely employed immune modulating agent for autoimmune neurological disorders. It is also used in the treatment of post-infectious disorders where the immune system goes awry, leaving in its wake, tandem central, peripheral and autonomic nervous system dysfunction. The immune modulating and anti-inflammatory actions of Ig is seen employing monthly intravenous (IV) doses of 2,000 mg (2 grams [g]) per kilogram [kg] body weight (BW) via slow drip with saline, Tylenol, and Benadryl pretreatment for 3 to 6 months and often longer until the desired effect is achieved. The choice of a given regimen, administered weekly or over two consecutive days, is guided by the patient’s propensity for side effects that may include transient headache, fever, chills, rash, erythema, flushing, nausea, myalgia, arthralgia, abdominal cramps, chest or back pain, and rarely aseptic meningitis or anaphylaxis.
The first dose of IVIg is always administered in a controlled setting such as an infusion center or outpatient hospital infusion unit with careful and nursing and physician oversight. The two most important cautionary steps to assure uneventful and safe administration are adequate oral and intravenous pre-hydration and an infusion rate that does not exceed 10 grams per hour. If there are associated treatment side-effects or complications, the ordering neurologist and the local internist or pediatrician can usually identify the likeliest inciting event and take immediate action along with the infusion service provider to prevent future occurrences. This may include a change the IVIg product that better suits the medical status of the patient. Subcutaneous Ig (SC Ig) is an alternative preparation that is preferred in patients with intolerable side effect to IVIg and those receiving low monthly doses that can be self-administered.
Yet even before treatment begins there will be a somewhat arduous process of certification for either IVIg or SC Ig that is guided by the insurance carrier and the patient’s benefits plan. The initial request for drug certification usually triggers a sequence of reviews by insurance personnel that culminates in the final disposition by a Medical Director. This individual whose identity may only come to light after careful investigation or signature on correspondence relating to the request for treatment, will variably be available for a peer-to-peer conversation with the ordering neurologist by phone or correspondence. This important point of contact is often the best hope for success especially when the ordering neurologist is prepared to provide a cohesive and compelling narrative of the patient’s medical history, examination, laboratory findings, neurological diagnosis and treatment program including doses and timetable of Ig treatment. The administrative insurance certification process can lag for weeks and months delaying onset of treatment unless the case is actively pursued by the ordering neurologist and Ig provider.
Out of network providers of Ig product and nursing, while more expensive for the patient and insurance carrier, nonetheless will often provide the superior choice of biological products and nursing care. There are only a handful of highly recommended out of network providers in contrast to a cadre of in-network, providers subcontracted by the insurance carrier to whom a referral may be automatically forwarded. Moreover, with the increasing trends for insurance carriers to package Ig products and nursing through national care managers, the onus falls more heavily on the treating neurologist to assure the highest level of collaborative care. At a minimum a patient receiving IVIg or SC Ig as monotherapy should be examined monthly at the outset of therapy to pin-point logistical problem areas and make adjustments in the care plan. Afterward, patients can be safely seen at quarterly intervals or longer in follow-up visits to assure that they are on the right trajectory of improvement, to maintain an active treatment certification and reassess the need for adjunctive therapy. Those patients taking parenteral antibiotics, plasma exchange, injectable or oral immunosuppressant therapy, and other complex medications will generally need to be seen regularly by other consultants.