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IV Immunoglobulin (IVIG)

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💉 Intravenous Immunoglobulin (IVIG)

Plasma-derived blood product containing concentrated IgG from thousands of donors.
Main roles: replacement therapy (immunodeficiency) and immune modulation (autoimmunity/inflammation).

🧪 Composition

>95% purified IgG (all subclasses: IgG1–4).
Trace IgA & IgM may be present.
Stabilised with sugars (sucrose, maltose) or amino acids (glycine).

⚙️ Mechanism of Action

Replacement: Provides protective antibodies in immunodeficient patients.
Immune modulation: Blocks Fc receptors, dampening autoantibody-driven inflammation.
Anti-inflammatory: Downregulates cytokines & complement activation.
Autoantibody clearance: Competes for binding & accelerates removal.

🎯 Indications

Primary immunodeficiencies: e.g. CVID, X-linked agammaglobulinaemia.
Autoimmune/neurological: ITP, Guillain–Barré Syndrome (GBS), Chronic Inflammatory Demyelinating Polyneuropathy (CIDP), Myasthenic crisis.
Inflammatory diseases: Kawasaki disease (prevents coronary aneurysms), dermatomyositis, multifocal motor neuropathy.
Infectious risk reduction in severe immunocompromised states.

💊 Administration

Given IV over hours; dose varies by indication (e.g. 0.4 g/kg/day × 5 days in GBS; single 2 g/kg in Kawasaki).
Pre-medicate (paracetamol, antihistamines ± steroids) to reduce infusion reactions.
Requires close monitoring during infusion for headache, fever, rash, or hypotension.

⛔ Contraindications

Known allergy to Ig products.
IgA deficiency with anti-IgA antibodies: risk of anaphylaxis.

⚠️ Side Effects

Common: Headache, fatigue, fever, chills, nausea.
Serious: Aseptic meningitis, thromboembolism, anaphylaxis, acute kidney injury (esp. sucrose-containing IVIG).

🔎 Precautions

Use cautiously in elderly and those with renal/cardiovascular disease → hydrate and infuse slowly.
All products undergo viral inactivation/screening, but still plasma-derived.
Do not combine with plasmapheresis in the same course (removes infused Ig → no added benefit).

💡 Teaching Pearl: - IVIG = “ready-made antibodies” → used for replacement (e.g. CVID) and modulation (e.g. GBS, ITP, Kawasaki). - In Kawasaki disease, it reduces coronary aneurysm risk – classic exam question.

📊 Plasmapheresis vs Intravenous Immunoglobulin (IVIG)

Feature	Plasmapheresis (PLEX)	Intravenous Immunoglobulin (IVIG)
Mechanism	Physically removes pathogenic substances (autoantibodies, immune complexes, complement) from plasma and replaces with albumin/FFP.	Supplies pooled donor IgG → modulates immune system by blocking Fc receptors, neutralising autoantibodies, and downregulating inflammation.
Onset of Action	Rapid (hours–days).	Rapid (days).
Administration	Requires central venous access, specialised machine, and trained staff.	Given as IV infusion (typically over 2–5 days); easier to deliver in most hospitals.
Duration	Usually 5 exchanges over 7–14 days.	Typically 2 g/kg total dose, divided over 2–5 days.
Indications (neurology)	GBS, Myasthenia Gravis crisis, severe MS relapse, anti-GBM disease, TTP (life-saving).	GBS, Myasthenia Gravis crisis, CIDP, Kawasaki disease, ITP, some autoimmune encephalitides.
Advantages	Removes autoantibodies directly; useful in hyperviscosity, cryoglobulinaemia, TTP (curative role).	More widely available, easier to administer, no need for vascular access.
Disadvantages	Invasive, risk of line infection/thrombosis, fluid shifts, hypocalcaemia (from citrate), bleeding risk.	Expensive; risk of volume overload, aseptic meningitis, renal impairment (rarely thromboembolic events).
Contraindications	Severe coagulopathy, poor vascular access, haemodynamic instability.	IgA deficiency with anti-IgA antibodies (risk of anaphylaxis), severe renal impairment, volume overload.
Availability	Specialist centres only (ICU/renal/neurology units).	More widely available in secondary care settings.
Relative Effectiveness	In GBS and Myasthenia crisis → equally effective. Choice depends on logistics, availability, comorbidities.

💡 Teaching Pearl: - Both PLEX and IVIG are first-line in GBS and myasthenic crisis — never use together (no added benefit). - PLEX is life-saving in TTP (unique). - IVIG has broader autoimmune indications (Kawasaki, ITP, CIDP).

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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