Decision to use or omit premedications in an individual receiving IVIG

IVIG: intravenous immune globulin; NSAID: nonsteroidal antiinflammatory drug; SCIG: subcutaneous immune globulin; IgA: immunoglobulin A.

* We generally avoid premedication in individuals who have not previously received IVIG or those who have not had an allergic or other mild reaction, as many individuals will tolerate IVIG without premedications, and this practice avoids unnecessary medications in many cases. An alternative approach, also reasonable, is to give premedications with the first dose, and, if no reaction occurs, omit them with subsequent doses. Patient values and preferences should be assessed.

¶ When premedications are used, we generally start with an NSAID, acetaminophen, and/or an antihistamine. Migraine prophylaxis may be reasonable for certain individuals. Glucocorticoids may also be reasonable; however, we generally avoid glucocorticoids, especially in individuals with immunodeficiency, reserving them for individuals for whom other approaches are ineffective. For individuals receiving regular IVIG infusions with premedications, it may be reasonable to reevaluate the need for premedications periodically.

• Using a slower initial infusion rate.
• Switching to an SCIG product if appropriate.
• Changing IVIG products.
• In some cases with low or absent IgA and a prior reaction, switching to a low IgA product such as Gammagard SD may be reasonable.
• If the reaction was in the distant past (eg, years prior) it may be reasonable to reevaluate the need for premedications, either by performing a test dose without premedications or by gradually decreasing premedications and observing closely for a reaction.