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Updated Immune Globulin Therapy Recommendations

Intravenous immune globulin (IVIg) is a widely used immune modulating therapy for idiopathic and post-infectious autoimmune 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 IVIg occur with monthly intravenous (IV) doses of 2,000 mg (2 grams [g]) per kilogram [kg] body weight via slow drip.  A typical duration of treatment is 4 to 5 hours per infusion and then monthly in divided dose for up to a year until the desired effects are achieved. The choice of a given IVIg product or regimen depends upon the patient’s tolerance and propensity for side effects that may include transient headache, fever, chills, or rash, and rarely more severe occurrences.

Trained nurses with careful physician oversight administer IVIg at home.  Companies that specialize in home Infusion can provide the IVIg product shipped directly to your home, along with the needed equipment, and then either provide either their own nurses or third party nursing firms to administer the drug at your home.   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.   Doctors may prescribe pretreatment medications such as Tylenol or Benadryl shortly before the infusion.  There may be associated treatment side effects or complications that the ordering neurologist, local internist or pediatrician can identify as the likeliest inciting events and take immediate action along with the infusion service provider to prevent future occurrences. This may include a change to the IVIg product that better suits the medical status of the patient, modification of pretreatment medications, or transition to newer self-administered subcutaneous Ig (SC Ig) injectable products.

Yet even before treatment begins, there is a typically an arduous process of preauthorization by your insurance carrier and each insurance company has somewhat different guidelines for approval. This usually entails preparing a cohesive and compelling narrative of the patient’s medical history, examination, laboratory findings, neurological diagnosis and treatment program including exact doses and timetable of Ig treatment.  While the infusion firm may submit the preapproval material to the insurance firm, the administrative process of insurance certification process can lag for weeks delaying onset of treatment without proactive support of the prescribing neurologist who can help accelerate this process.  

Out of network infusion providers, while more expensive for the patient and insurance carrier, often provide the superior choice of biological products and nursing care. Moreover, with the increasing trends for insurance carriers to dictate the use of specific national care managers (infusion firms) and thus packaging of Ig products and nursing services through national care managers, the onus falls on the treating neurologist to assure the highest level of collaborative care.  At a minimum, patients receiving IVIg or SC Ig are examined at the outset of therapy to identify potential logistical problems and afterward with periodic visits to assure active treatment certification and to reassess the need for continued treatment. Those patients taking parenteral antibiotics, plasma exchange, injectable or oral immunosuppressant therapy, and other complex medications may need closer follow-up.  

Three questions arise in the COVID-19 era: Is there a risk to receiving IVIg therapy at home? No, there is no risk of the drug carrying the virus due to vigorous filtering process of manufacturers.  Assuming a nurse is wearing the proper protective equipment, the risk of coronavirus transmission is negligible compared to infusion centers where they are often more chances of exposure to COVID-19 carriers). Is there a role for IVIg therapy in treating possible or definite patients with COVID-19 exposure? Yes, IVIg therapy has the potential to boost immunity and improve clinical outcome after exposure to COVID-19 and to shorten the duration and severity of the illness.  Lastly, Are there forms of IVIg therapy used to treat COVID-19 exposure? Research is being carried out on this very question similar to the use of convalescent serum from recovered COVID-19 patients.