Intravenous immunoglobulin dosage

Diabetes mellitus in a 36-year-old man with acute pancreatitis could not be controlled with continuous subcutaneous insulin infusion, even with doses up to 1800 U/ day, because of insulin resistance (168). Intravenous insulin by pump had to be stopped because of a catheter infection. The continuous subcutaneous infusion of freeze-dried insulin and the addition of aprotinin, a protease inhibitor, soluble dexamethasone or prednisolone, and intravenous immunoglobulin was ineffective. An implantable pump for intraperitoneal delivery established good regulation at a dosage of 30 U/day. 

The rate of adverse effects associated with intravenous immunoglobulin varies among different studies, which has been attributed to factors such as the indication, the dosage, the infusion rate, and the patient s age (12). In one study, headache and chills were related to a higher dosage. 

Of 56 patients with autoimmune diseases who received high dosages of intravenous immunoglobulin, 20 had at least one adverse effect after one or more courses of treatment (12). The most frequently reported adverse effects were low-grade fever, headache, and chills. The authors concluded that the occurrence of adverse effects with intravenous immunoglobulin was not related to the clinical response to treatment. However, patients who developed adverse effects during the first course of treatment were more at risk of adverse effects during subsequent courses. 

A 35-year-old woman with idiopathic thrombocytopenic purpura treated with high dosages of intravenous immunoglobulin developed a recurrent lymphocytic pleural effusion (53). 

Severe acute hemolysis due to acquisition of red cell alloantibodies from donor serum has been reported (67-69). In other cases, the suggested mechanism of hemolytic anemia after high dosages of intravenous immunoglobulin was the presence of anti-A and/or anti-B antibodies in the plasma product (70). 

Fatal hepatic veno-occlusive disease, characterized by hyperbilirubinemia, hepatomegaly, ascites, and weight gain, has been associated with intravenous immunoglobulin administered prophylactically to prevent trans-plant-related infections (79). To avoid such thrombotic complications, intravenous immunoglobulin should be infused at a slower rate in patients at risk, and high dosages (400-1000 mg/kg) should not be infused. 

Renal insufficiency after high dosages of intravenous immunoglobulin has been observed, mostly in patients with pre-existing renal disease (81). Acute renal insufficiency occurred within 7 days after the administration of intravenous immunoglobulin, with a peak at 5 days. About 40% of patients needed dialysis and 15% died despite treatment (all with severe underlying diseases) the mean time to recovery in survivors was about 10 days (82). 

Fieschi C, Bengoufa D, Oksenhendler E. Immunoglobulin dosage and switch from intravenous to subcutaneous immunoglobulin replacement therapy in patients with primary hypogammaglobulinemia decreasing dosage does not alter serum IgG levels. J Clin Immunol 2010 30(4) 602-6. 

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