Florida Hospital IVIG Triage Plan
Strength/Quality Of the Evidence*
FDA-Approved Indications:
For all patients Immunodeficient Patients Bone Marrow Transplantation Chronic Lymphocytic Leukemia in Patients with Hypogammaglobulinemia Pediatric HIV Infection Idiopathic Thrombocytopenia Purpura (ITP) Kawasaki Syndrome
Triage Plan to be implemented in times of decreased IVIG supply*: Level I: When in house stores of IVIG are < 2,250 g† (or < 35% of institution’s normal supply) Patients fitting the following criteria will receive IVIG in a preferential fashion Bone marrow transplant (BMT), Adult patients
Patients with CMV disease (infection of the organs) Adult allogeneic BMT patients (2 doses of 250 mg/kg prophylaxis) Patients with RNA virus infection (RSV, influenza, parainfluenza) Encapsulated bacterial sepsis in hypogammaglobulinemic patients
A, I
BMT, Pediatric patients
Allogenic BMT patients with an active viral infection Allogenic BMT patients during the first 3 months post-transplant Allogenic BMT patient with acute or chronic graft-versus-host-disease (GVHD), on immunosuppression, who is not making any immunoglobulin Congenital immunodeficient patient with documented hypogammaglobulinemia and infection history
A,I
-
Idiopathic thrombocytopenic purpura (ITP) in adults with platelets < 20,000/uL who are experiencing acute life-threatening bleeding and have had a splenectomy, or who are Rho negative Immune mediated HITT in patients for who a direct thrombin inhibitor is contraindicated ITP in neonates (particularly preterm newborns) Immunodeficient patients Kawasaki syndrome Neonatal sepsis, treatment Neonates with blood group incompatibilities Neurology patients (in whom alternative therapies [i.e., plasmapheresis, corticosteroids, or immunosuppressants]have been ineffective or are contraindicated)
Chronic Inflammatory demyelinating polyneuropathy (CIDP) Guillain-Barre syndrome Multifocal motor neuropathy Myasthenia gravis
B, III
A, II A, II A, I B, I A, I
A,I B,I A,III A,I
Level II: When in-house stores of IVIG are < 3,375 g† (< 55% of institution’s normal supply) Patients fitting criteria for Level I and Level II will receive IVIG in a preferential fashion BMT, Adult patients
Patients with CMV infection (reactivation only) Patients with other DNA virus infections (human herpes virus 6, herpes simplex virus, or herpes zoster virus) Patients with a history of encapsulated bacterial sepsis & who have chronic GVHD or have had a splenectomy Prophylactic IGIV in hypogammaglobulinemic patients after BMT
A, I
BMT, Pediatric patients
Allogenic BMT patient 3 to 6 months post-transplant Allogenic BMT patient first 2 months post-transplant Congenital immunodeficient patient with near normal level of immunoglobulin but who has an infection history
A,I
-
Neurology patients Inflammatory myopathies (e.g. polymyositis, inclusion body myositis, dermatomyositis) CIDP B,I A,I
Level III When in-house stores of IVIG are < 4,500 g† (< 75% of institution’s normal supply) Patients fitting the criteria for Level I, Level II, and Level III will receive IVIG in a preferential fashion BMT, Adult patients
Transfusion refractory thrombocytopenia Hemolytic uremic syndrome/thrombotic thrombocytopenia purpura associated with BMT
A,I
BMT, Pediatric patients
BMT patient with clinical manifestations of autoimmune disease
A,I
Neonatal Infection, prophylaxis for high risk premature infants every 2 weeks until 36 weeks post-conceptual age ITP patients (use alternative therapy first; WinRho for Rh-positive patients or corticosteroids) Neurology patients who do not meet the criteria for Level I or Level II, but in whom IVIG is reasonable therapy
C, I B,III
* Triage Plan: Based on Schrande, et. al. Preparing for Drug Shortages: One teaching hospital’s approach to the IVIG Shortage, Formulary 2001; 36:52-9. † Please Round dose to the nearest one-hundreth to avoid medication wastage
Contraindications Hypersensitivity or any component of hypersensitivity IgA Deficiency **Can utilize Polygam Antibodies to IgA
Florida Hospital Department of Pharmacy December 2, 2002