IVIG Premedication: Essential Things to Know

Intravenous immunoglobulin (IVIG) premedication is one of the ways to minimize infusion-related side effects. 

Though intravenous immunoglobulin (IVIG) is well tolerated, some users may experience side effects such as flushing, headache, malaise, fever, chills, and fatigue. Rare and serious side effects can include:

• Renal impairment
• Thrombosis (blood clot inside a blood vessel)
• Arrhythmia (irregular heartbeat)
• Aseptic meningitis (swelling of the brain linings)
• Hemolytic anemia (a disorder of the blood cells)
• Transfusion-related acute lung injury (TRALI)

Some strategies to reduce the risk of side effects include:

• Slowing the infusion rate or lowering the dose
• Switching from IVIG to SCIG (subcutaneous immunoglobulin)
• Switching to other immunoglobulin preparations
  

What Is IVIG Premedication?

IVIG premedication involves the administration of one or more medications roughly 30 minutes before starting IVIG therapy. This is done to reduce the likelihood of side effects during your IVIG infusion. 

You may also receive premedication if you experience side effects during therapy. 

Before giving you premedication, your doctor will ask about any previous adverse events from IVIG therapy and assess for current risk of potential side effects.  

What Are the Most Frequently Used IVIG Premedications?

The following medicines are commonly used: 

Analgesics

Also called painkillers, these medicines relieve pain. Acetaminophen (Tylenol) is the most frequently used analgesic for IVIG premedication. The usual adult dose is 650 mg orally once. The oral dose for children depends on their body weight. 

Anti-inflammatory medicines called NSAIDs (non-steroidal anti-inflammatory drugs) may also be necessary. Examples include ibuprofen (Advil, Motrin) and naproxen (Aleve).

Antihistamines

These medicines treat symptoms of allergic reactions, such as rashes, swelling, or itching. Examples include:

• Diphenhydramine (Benadryl): The usual adult dose is 25 mg to 50 mg orally or through IV once. This is the most commonly prescribed antihistamine for premedication.
• Loratadine (Claritin): 10 mg orally once. 
• Cetirizine (Zyrtec): 10 mg orally once.
• Fexofenadine (Allegra): 180 mg orally once.

Corticosteroids

Also called steroids, these medicines help to reduce inflammation and swelling. The frequently used corticosteroids for IVIG premedication are:

• Dexamethasone (Decadron): The usual adult dose is 4 mg orally or through IV once.
• Methylprednisolone (Medrol): 20 mg to 60 mg IV once. 
• Hydrocortisone (Hydrocort): 50 mg to 200 mg IV once. 

Note: These steroids are not the same as the ones that some athletes abuse, which are referred to as anabolic steroids.

The choice of a drug and premedication protocol can vary according to your specific need, the co-occurrence of other medical conditions, and the medicines you take. It is also possible that your doctor may continue using the premedication at lower doses after your treatment if a side effect does occur during treatment.

In addition to premedication, staying well hydrated before IVIG therapy is crucial to preventing side effects. Your doctor may pre-hydrate you with normal saline (NS) which can help reduce the occurrence of headaches, renal impairment (kidney problems), and hemolysis (red blood cell destruction).

How Effective Is IVIG Premedication?

Appropriate premedication greatly reduces the frequency and severity of side effects [1].

In a 2016 review, authors noted that premedication with acetaminophen, diphenhydramine, or dexamethasone significantly reduced the occurrence of IVIG side effects [2]. 

Moreover, several international guidelines recommend the use of IVIG premedication. However, premedication is effective only in controlling mild-to-moderate symptoms. In severe cases, your doctor may decide to stop IVIG therapy. 

Do All Patients Need IVIG Premedication?

No, not all patients require premedication. However, while all patients do not require IVIG premedication, many are able to tolerate IVIG better with premedication.