What To Do When IVIG Doesn’t Work

Worried about what to do when intravenous immune globulin (IVIG) doesn’t work or fails to work as expected? Take a breath. You have several treatment options with comparable or even better outcomes. 

 

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Highlights

• When IVIG doesn’t work, your provider may recommend alternative treatments, such as plasmapheresis, corticosteroids, and immunosuppressive agents. 
• The choice of an alternative treatment is highly individualized.
• Alternative treatments depend on co-existing medical conditions, age, potential risks, and availability/cost.

IVIG is an effective treatment for numerous autoimmune, inflammatory, and infectious conditions. But, like all medications, not everyone responds to IVIG equally, and some may not respond at all. 

Several factors may determine the success or failure of IVIG therapy, such as:

• Individual patient factors
• Age 
• Adherence to treatment plan 

Likewise, studies show that the percentage of responders can vary depending on the condition being treated. In this article, we discuss the alternatives to IVIG specific for various medical conditions. 

Also Read: How To Tell if IVIG Is Working

 

IVIG Alternatives in Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)

Though IVIG is a first-line treatment for CIDP, about 1 in 4 people with CIDP don’t respond to it. When IVIG doesn’t work, your provider may prescribe immunosuppressive agents or monoclonal antibodies (mAbs) [1]. Additionally, some experts recommend switching from IVIG to SCIG (subcutaneous immunoglobulin).  

Immunosuppressive agents work by preventing the immune system from attacking the protective covering around nerve cells. Examples of immunosuppressives include azathioprine, mycophenolate mofetil, methotrexate, cyclosporine, and cyclophosphamide. 

Rituximab, a monoclonal antibody, improves CIDP symptoms in treatment-resistant cases according to a 2022 review [2].

 

IVIG Alternatives in Guillain Barre Syndrome (GBS)

IVIG is the primary treatment for GBS. Yet, about 25% of people who don’t respond to it need mechanical ventilation, and 20% of people cannot walk without support after 6 months [3].

When IVIG doesn’t work, your provider may switch you to plasmapheresis (plasma exchange) [4]. Plasmapheresis helps by removing the antibodies that attack your nerves. 

 

IVIG Alternatives in Kawasaki Disease (KD)

Though universal treatment guidelines are not available for KD, alternative treatments for IVIG-resistant KD include [4]:

• A corticosteroid called methylprednisolone
• A monoclonal antibody called infliximab (often considered the drug of choice)

 

IVIG Alternatives in Bleeding Disorders

If you have a bleeding disorder called immune thrombocytopenia (ITP), you are at risk of blood loss, especially during surgery. IVIG is commonly used before surgery to reduce the risk. 

A 2020 trial shows that an oral drug—eltrombopag—can be as effective as IVIG in people with ITP [5].

 

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IVIG Alternatives in Immune Deficiency

Emerging evidence suggests that SCIG (subcutaneous immunoglobulin) may be a better option for people with immune deficiency. 

Unlike IVIG, SCIG results in the slow release of antibodies from the subcutaneous tissues into the blood. This allows antibody levels in the blood to remain steady. However, with IVIG, the antibody levels in the blood are more erratic.

Moreover, SCIG is more convenient because you can inject your dose at home or anywhere else at any time of day after some training. Additionally, side effects are less common with SCIG compared to IVIG. 

 

What Can Be Used Instead of IVIG?

In general, SCIG causes fewer side effects than IVIG. You may choose SCIG over IVIG if you:

• Cannot tolerate IVIG side effects
• Have poor venous access
• Find SCIG more compatible with your lifestyle

Further Reading: SCIG vs. IVIG: Which Treatment Is Best for You?

 

 

REFERENCES:

1. Yoon, Min-Suk et al. “Standard and escalating treatment of chronic inflammatory demyelinating polyradiculoneuropathy.” Therapeutic advances in neurological disorders vol. 4,3 (2011): 193-200. doi:10.1177/1756285611405564
2. Hu, Jianian et al. “Efficacy of rituximab treatment in chronic inflammatory demyelinating polyradiculoneuropathy: a systematic review and meta-analysis.” Journal of neurology vol. 269,3 (2022): 1250-1263. doi:10.1007/s00415-021-10646-y
3. van Doorn, Pieter A et al. “IVIG treatment and prognosis in Guillain-Barré syndrome.” Journal of clinical immunology vol. 30 Suppl 1,Suppl 1 (2010): S74-8. doi:10.1007/s10875-010-9407-4
4. Hao Q, Grobelna A; Authors. Alternative Therapies to Immunoglobulin for Guillain-Barré Syndrome: CADTH Health Technology Review [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2023 May. Available from: https://www.ncbi.nlm.nih.gov/books/NBK594395/# 
5. Arnold, Donald M et al. “Perioperative oral eltrombopag versus intravenous immunoglobulin in patients with immune thrombocytopenia: a non-inferiority, multicentre, randomised trial.” The Lancet. Haematology vol. 7,9 (2020): e640-e648. doi:10.1016/S2352-3026(20)30227-1

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