Practical Aspects of Transitioning from Intravenous to Subcutaneous Immunoglobulin Therapy in Neuromuscular Disorders

ABSTRACT: Recent evidence shows that subcutaneous immunoglobulin (SCIG) is as efficacious as intravenous immunoglobulin (IVIG) and has a better safety profile and acceptance rate among patients with neuromuscular disorders who require maintenance IVIG treatment. Awareness of the practical aspects of patient selection, enrollment, dose calculation, administration, and follow-up would help physicians coordinate a smooth and seamless transition from IVIG to SCIG. SCIG is ideally offered to patients having intolerable side effects during IVIG or wearing-off effect and in those keen for treatment autonomy. The weekly dose of SCIG is calculated by multiplying the maintenance dose of IVIG by the dose adjustment factor and dividing by the interval between IVIG in weeks and is initiated 1 week after the last dose of IVIG. The physician places the order for the SCIG and the clinic nurse or the physician refers the patient to the home care nursing program for further education and training. The necessary supplies are dispatched to the patient who would also collect the SCIG from the transfusion center of the nearest hospital. The patient is educated on assembling and administering the infusion, and home visits are continued until the patient or caregiver is confident. Regular follow-up with the patient is maintained to assess treatment response and side effects if any. With a smooth transition, most patients have excellent tolerance to SCIG and in our experience seldom request switching back to IVIG. Transitioning patients from IVIG to SCIG offers several advantages and thus, in general, is preferable for multiple stakeholders.

[1]  V. Bril,et al.  Chronic immunoglobulin maintenance therapy in myasthenia gravis , 2020, European journal of neurology.

[2]  N. Rashid,et al.  Intravenous versus Subcutaneous Immunoglobulin in Primary Immunodeficiency: Real-World Evaluation of Safety, Efficacy, and Patient Perceptions , 2020 .

[3]  H. Hartung,et al.  Long-term safety and efficacy of subcutaneous immunoglobulin IgPro20 in CIDP , 2019, Neurology: Neuroimmunology & Neuroinflammation.

[4]  H. Hartung,et al.  Feasibility of switching from intravenous to subcutaneous immunoglobulin in CIDP: PATH trial and clinical experience , 2019, Clinical Neurophysiology.

[5]  L. Vaughan.  Managing cost of care and healthcare utilization in patients using immunoglobulin agents. , 2019 .

[6]  Xuefeng Wang,et al.  Adverse Effects of Immunoglobulin Therapy , 2018, Front. Immunol..

[7]  G. L. Masson,et al.  Subcutaneous immunoglobulin for maintenance treatment in chronic inflammatory demyelinating polyneuropathy (PATH): a randomised, double-blind, placebo-controlled, phase 3 trial , 2018, The Lancet Neurology.

[8]  Z. Siddiqi,et al.  Subcutaneous immunoglobulin in myasthenia gravis exacerbation , 2017, Neurology.

[9]  V. Bril,et al.  High-Dose Subcutaneous Immunoglobulin in Patients With Multifocal Motor Neuropathy: A Nursing Perspective , 2017, Journal of infusion nursing : the official publication of the Infusion Nurses Society.

[10]  S. Misbah,et al.  Assessment of Local Adverse Reactions to Subcutaneous Immunoglobulin (SCIG) in Clinical Trials , 2017, Journal of Clinical Immunology.

[11]  L. Sposato,et al.  Subcutaneous versus intravenous immunoglobulin for chronic autoimmune neuropathies: A meta‐analysis , 2017, Muscle & nerve.

[12]  Ivan K. Chinn,et al.  Update on the use of immunoglobulin in human disease: A review of evidence , 2017, The Journal of allergy and clinical immunology.

[13]  G. Krishnarajah,et al.  Evaluating dose ratio of subcutaneous to intravenous immunoglobulin therapy among patients with primary immunodeficiency disease switching to 20% subcutaneous immunoglobulin therapy. , 2016, The American journal of managed care.

[14]  P. Bourque,et al.  Subcutaneous Immunoglobulin Therapy in the Chronic Management of Myasthenia Gravis: A Retrospective Cohort Study , 2016, PloS one.

[15]  R. Jaussaud,et al.  Does the route of immunoglobin replacement therapy impact quality of life and satisfaction in patients with primary immunodeficiency? Insights from the French cohort “Visages” , 2016, Orphanet Journal of Rare Diseases.

[16]  Hosein Shabaninejad,et al.  A Comparative Study of Intravenous Immunoglobulin and Subcutaneous Immunoglobulin in Adult Patients with Primary Immunodeficiency Diseases: A Systematic Review and Meta-Analysis , 2016, Expert review of clinical immunology.

[17]  W. Deeb,et al.  Safety and Efficacy of Subcutaneous Immunoglobulin in the Treatment of Neuromuscular Disorders , 2016, Journal of clinical neuromuscular disease.

[18]  C. João,et al.  The Production Processes and Biological Effects of Intravenous Immunoglobulin , 2016, Biomolecules.

[19]  J. Lawo,et al.  Quantitative Evidence of Wear-Off Effect at the End of the Intravenous IgG (IVIG) Dosing Cycle in Primary Immunodeficiency , 2016, Journal of Clinical Immunology.

[20]  S. H. Sindrupb,et al.  Subcutaneous immunoglobulin as first-line therapy in treatment-naive patients with chronic inflammatory demyelinating polyneuropathy : randomized controlled trial study , 2016 .

[21]  T. Torgerson,et al.  Health-related quality of life in patients with primary immunodeficiency disease , 2015, Allergy, Asthma & Clinical Immunology.

[22]  R. Hadden,et al.  Switch from intravenous to subcutaneous immunoglobulin in CIDP and MMN: improved tolerability and patient satisfaction , 2015, Therapeutic advances in neurological disorders.

[23]  M. Berger.  Subcutaneous IgG in neurologic diseases. , 2014, Immunotherapy.

[24]  Tin Tran,et al.  Calculating the dose of subcutaneous immunoglobulin for primary immunodeficiency disease in patients switched from intravenous to subcutaneous immunoglobulin without the use of a dose-adjustment coefficient. , 2013, P & T : a peer-reviewed journal for formulary management.

[25]  R. Schellenberg,et al.  Economic benefits of subcutaneous rapid push versus intravenous immunoglobulin infusion therapy in adult patients with primary immune deficiency , 2012, Transfusion medicine.

[26]  L. Kobrynski.  Subcutaneous immunoglobulin therapy: a new option for patients with primary immunodeficiency diseases , 2012, Biologics : targets & therapy.

[27]  J. Orange,et al.  Evaluation of correlation between dose and clinical outcomes in subcutaneous immunoglobulin replacement therapy , 2012, Clinical and experimental immunology.

[28]  E. Haddad,et al.  Higher Doses of Subcutaneous IgG Reduce Resource Utilization in Patients with Primary Immunodeficiency , 2011, Journal of Clinical Immunology.

[29]  R. Nelson,et al.  Pharmacokinetics of Subcutaneous IgPro20 in Patients with Primary Immunodeficiency , 2011, Clinical pharmacokinetics.

[30]  M. Rojavin,et al.  Pharmacokinetics of subcutaneous immunoglobulin and their use in dosing of replacement therapy in patients with primary immunodeficiencies. , 2011, Clinical immunology.

[31]  S. Jacob,et al.  Current Proposed Mechanisms of Action of Intravenous Immunoglobulins in Inflammatory Neuropathies , 2009, Current neuropharmacology.

[32]  F. Bonilla.  Pharmacokinetics of immunoglobulin administered via intravenous or subcutaneous routes. , 2008, Immunology and allergy clinics of North America.

[33]  B. Grimbacher,et al.  Patients' Attitude to Subcutaneous Immunoglobulin Substitution as Home Therapy , 2006, Journal of Clinical Immunology.

[34]  Ó. Asensio,et al.  Rapid Subcutaneous IgG Replacement Therapy is Effective and Safe in Children and Adults with Primary Immunodeficiencies—A Prospective, Multi-National Study , 2006, Journal of Clinical Immunology.

[35]  H. Ochs,et al.  Conversion from Intravenous to Subcutaneous Immunolgobulin Therapy: Relationship Between Dose, Serum Trough IgG Concentration and Infection Rate in Patients with Primary Immune Deficiency Diseases , 2006 .

[36]  P E Blackerby,et al.  Professional Education. , 1959, American journal of public health and the nation's health.