Special considerations with the use of intravenous immunoglobulin in older persons

There are currently six labelled indications in the US for intravenous immunoglobulin (IVIG) and over 150 unlabelled uses, ranging from some of the most studied indications through to those mentioned only in anecdotal reports. A downstream effect of the varied uses of IVIG is its increased utilization for disease processes that significantly affect the older population. In general, IVIG is considered a safe therapy, and the common adverse events (AEs) associated with IVIG administration are mild and transient. Serious AEs are fortunately uncommon with IVIG infusion. However, most safety data are collated from case reports and case series, with a modest amount of data from well controlled clinical studies that have limited power to detect uncommon AEs. Among the reported serious AEs, older patients appear to be particularly at risk of acute renal failure and arterial and venous thrombosis. The incidence of AEs appears to vary with the IVIG product composition, rate of infusion, the study population's disease process and underlying co-morbidities. Approaches to minimizing AEs, particularly in the older patient population, include ensuring sufficient hydration prior to infusion of IVIG, using the minimal effective dose possible during infusion, considering use of preparations with lower concentrations of sucrose, and monitoring renal function. Research is expanding to inform possible uses of a subcutaneous formulation of IVIG that, if proven to be effective, offers a potential reduction in AEs and lower cost of administration.