Preparation and administration Intravenous immunoglobulin

Immunoglobulin preparations have been available for therapeutic parenteral use for over four decades, although those suitable for intravenous use (IVIg) have only been manufactured for the last 10 years. These are therapeutic preparations of normal polyspecific immunoglobulin G (IgG) extracted from pooled donor plasma by cold ethanol fractionation. Pepsin treatment at low pH, polyethyleneglycol precipitation, or chromatographic methods can then be used to purify the IgG which is further stabilized to prevent the formation of IgG aggregates. In order to minimize the risk of viral transmission, IgG preparations also undergo a viral inactivation step. The antibody profile reflects the serological responses to endemic pathogens and immunization status of the donor population. They are expensive to produce and this is reflected in the cost. A 2-g/kg course can cost at least $3000 (£2000) depending on the product.

The mechanism of immunomodulatory action is poorly understood in most conditions for which IVIg has been used, but it alters the immune system in a variety of ways, any or all which may be responsible for its efficacy. Its main effects are reticuloendothelial blockade, suppression of antibody synthesis, and via anti-idiotype antibodies.

Recommended doses for antibody replacements vary from low doses of 0.4 g/kg every 2 to 3 weeks to the high dose of 1 g/kg for 2 days for the treatment of cytomegalovirus infection following bone marrow transplantation. The high dose is used for immunomodulation, although historically in immune thrombocytic purpura the total of 2 g/kg is usually given as 0.4 g/kg for 5 days.

Intramuscular immunoglobulin

Intramuscular immunoglobulin (IMIg) is mainly used when a specific antibody is required to provide short-term protection against infection or as immunotherapy (e.g. in the prevention of Rh isoimmunization). Therefore it is produced as hyperimmune preparations fractionated from donors with high titers of the specific antibody.

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