1. health and fitness
2. disease

Medication Policy Manual
Policy No: dru020
Topic: Immune Globulin Replacement Therapy,
(IVIG, SCIG):
Bivigam®
Carimune® NF
Flebogamma® DIF
Gammagard®
®
Gammagard S/D
Gammaplex®
®
Gamunex-C
Hizentra™
Hyqvia®
Octagam®
®
Privigen
Date of Origin: January 1996
Committee Approval Date: February 17, 2015
Next Review Date: April 2015
Effective Date: March 1, 2015
IMPORTANT REMINDER
This Medical Policy has been developed through consideration of medical necessity, generally
accepted standards of medical practice, and review of medical literature and government
approval status.
Benefit determinations should be based in all cases on the applicable contract language. To the
extent there are any conflicts between these guidelines and the contract language, the contract
language will control.
The purpose of medical policy is to provide a guide to coverage. Medical Policy is not intended
to dictate to providers how to practice medicine. Providers are expected to exercise their medical
judgment in providing the most appropriate care.
Description
Intravenous immune globulin (IVIG) and subcutaneous immune globulin (SCIG; Hizentra® or
Hyqvia®) are preparations containing antibodies purified from human blood. They are used in
the treatment of many different conditions resulting from immune deficiencies or other
immunologic conditions.
© 2015 RegenceRx. All rights reserved.
dru020.21
Page 1 of 26
Policy/Criteria
I.
Most contracts require prior authorization approval of immune globulins prior to
coverage. Immune globulins may be considered medically necessary when criteria A
AND B below are met.
A.
Alternative Site of Care - for Washington, Oregon, and Idaho commercial,
fully insured members only (does not apply to Medicare)
Immune globulin replacement therapy is administered in a non-hospital outpatient
setting (also referred to as an “alternative site of care”; such as a provider’s office,
an infusion center, or home infusion), unless both of the following criteria 1 and 2
below are met:
1.
All non-hospital outpatient settings are greater than 10 miles further from
the member’s home than the hospital outpatient setting.
AND
2.
The member’s home is not eligible for home infusion services (such as
home is not within the service area or is deemed unsuitable for care by the
home infusion provider).
NOTE: Alternative Site of Care criteria will be waived for payment of the first
dose, to allow for adequate transition time to arrange for a non-hospital outpatient
setting for the infusion.
AND
B.
At least one of the following diagnostic criteria 1. through 5. below is met:
1.
Immunodeficiency (primary or acquired), as defined in criteria a. or b.:
a.
A diagnosis of one of the following and documented
hypogammaglobulinemia (a low baseline serum IgG level):
i.
Primary humoral immunodeficiency diseases (PID) (as
defined in Appendix I).
ii. HIV infected children (< 13 years of age) with
hypogammaglobulinemia.
iii. Hematologic malignancy-related hypogammaglobulinemia:
A. Post-allogeneic bone marrow transplant (BMT)
B. B-cell medicated cancer [e.g., chronic lymphocytic
leukemia (CLL), B-cell lymphoma]
iv. Hypogammaglobulinemic neonates, with a low birth weight
(less than 1500g) or in a setting with high baseline infection
rate or morbidity.
OR
© 2015 RegenceRx. All rights reserved.
dru020.21
Page 2 of 26
b.
Multiple myeloma in patients with stable disease and high risk of
recurrent infections despite prophylactic antibiotic therapy, patients
with poor IgG response to the pneumococcal vaccine, or have low
normal IgG levels during acute sepsis episodes.
OR
2.
Hematologic disorders (immune-mediated), not responding to
alternative therapies, or at high risk of bleeding:
a.
Acquired Factor VIII inhibitor, when conventional therapy is
ineffective or not tolerated. (e.g., immunosuppressive therapy with
cyclophosphamide, steroids, or azathioprine).
OR
b.
OR
c.
OR
d.
OR
e.
OR
f.
Autoimmune hemolytic anemia (AIHA) not responding to
alternative therapies (e.g., steroids, immunosuppressive agents,
plasmapheresis, rituximab and/or splenectomy).
Fetal (neonatal) alloimmune thrombocytopenia (FAIT) with
documented diagnosis.
Idiopathic thrombocytopenia purpura (acute; ITP), when a rapid
increase in platelet count is necessary, such as in an acute bleeding
episode or prior to surgery.
ITP (chronic), when the platelet count is dangerously low, defined
as a platelet count less than 30,000 cells/mm3 in children, less than
20,000 cells/mm3 in adults, or less than 30,000 cells/mm3 along
with signs/symptoms of bleeding in adults.
ITP in pregnancy, when at least one of the following criteria are
met:
i.
Platelet counts less than 10,000/mm3 in the third trimester,
despite an adequate course of corticosteroids, unless use of
steroids are contraindicated, or not tolerated.
OR
ii.
Platelet counts less than 30,000/mm3 associated with
bleeding before vaginal delivery or C-section.
OR
g.
OR
h.
Post-transfusion purpura (hemolytic transfusion reaction) in
severely affected patients.
Pure red cell aplasia (PRCA, viral) with documented parvovirus
B19 infection and severe anemia.
© 2015 RegenceRx. All rights reserved.
dru020.21
Page 3 of 26
OR
3.
Neuromuscular disorders, when significant functional impairment is
present:
a.
Acute inflammatory demyelinating polyneuropathy, including
Guillain-Barré syndrome (GBS), when one of criteria i. through iv.
below are met:
i.
Deteriorating pulmonary function tests.
OR
ii.
OR
iii.
OR
iv.
Rapid deterioration with symptoms for less than 2 weeks.
Rapidly deteriorating ability to ambulate.
Inability to walk independently for 10 meters.
OR
b.
Chronic inflammatory demyelinating polyneuropathy (CIDP)
when all of criteria i., ii., and iii. below are met:
i.
Significant functional disability.
AND
ii.
Documentation of slowing of nerve conduction velocity
on EMG/NCS.
AND
iii.
Documentation of elevated spinal fluid protein on lumbar
puncture OR a nerve biopsy confirming the diagnosis.
OR
c.
OR
d.
Dermatomyositis, with documented EMG abnormalities and/or
increased CPK levels, with associated severe disability when
steroid therapy is ineffective or not tolerated.
Lambert-Eaton myasthenic syndrome (LEMS) when other
treatment options are ineffective or not tolerated. (e.g.,
pyridostigmine bromide, azathioprine, and/or prednisone).
OR
e.
OR
f.
Multifocal motor neuropathy (MMN) in patients with conduction
block.
Myasthenia gravis for the treatment of acute crisis (e.g., respiratory
failure, swallowing difficulties) OR chronic decompensation, when
other treatments are ineffective or not tolerated (e.g.,
plasmapheresis, pyridostigmine, azathioprine, cyclosporine, and
cyclophosphamide).
© 2015 RegenceRx. All rights reserved.
dru020.21
Page 4 of 26
OR
g.
Paraneoplastic opsoclonus ataxia syndrome (Opsoclonusmyoclonus ataxia syndrome, OMS) in pediatric neuroblastoma
patients with significant functional impairment and not responding
to an adequate course of steroids (at least 3 to 7 days).
OR
h.
Pemphigoid, refractory immunobullous disease (e.g., bullous
pemphigoid, pemphigus foliaceus, pemphigus vulgaris) until
conventional treatment takes effect (e.g., immunosuppressive
agents and plasmapheresis).
OR
i.
Polymyositis in patients with severe active illness when other
treatments have been ineffective or not tolerated (e.g.,
corticosteroids, azathioprine, methotrexate, or cyclophosphamide).
OR
j.
Stiff-Person Syndrome when treatment with other agents is
ineffective or not tolerated. (e.g., diazepam, baclofen, clonazepam,
valproic acid, and clonidine).
OR
k.
Systemic lupus erythematosus, for severe active disease when
other interventions are ineffective or not tolerated (e.g.,
corticosteroids and immunosuppressive agents, such as
cyclophosphamide or azathioprine).
OR
4.
Transplant (solid organ), antibody-mediated rejection:
a.
Prevention of antibody (Ab)-mediated rejection: Prior to solid
organ transplant and in the peri-operative period, for patients at
high risk for Ab-mediated rejection, including highly sensitized
patients, and those receiving an ABO-incompatible organ.
OR
b.
Treatment of antibody-mediated rejection (a.k.a. vascular rejection,
humoral rejection): following solid organ transplant and confirmed
by either biopsy or presence of panel reactive antibodies (PRAs), if
used in combination with plasmapheresis.
OR
5.
Other Miscellaneous conditions, when criteria are met:
a.
Kawasaki syndrome, during the first ten days of diagnosis.
OR
© 2015 RegenceRx. All rights reserved.
dru020.21
Page 5 of 26
b.
II.
Pediatric intractable epilepsy in candidates for surgical resection or
when other interventions are ineffective or not tolerated. Examples
of other interventions include, but are not limited to, anticonvulsant
medications, ketogenic diets, and steroids. [85]
Administration, Quantity Limitations, and Authorization Period
A.
RegenceRx does not consider immune globulins to be self-administered
medications.
B.
When prior authorization is approved, immune globulins may be authorized in
quantities as follows:
1.
Initial Authorization: Immune globulins may be authorized for the period
defined in Table 1, based on diagnosis, in a non-hospital outpatient setting,
unless waived per criteria I.A. above.
NOTE: Alternative Site of Care criteria will be waived for payment of the
first dose, to allow for adequate transition time to arrange for a nonhospital outpatient setting for the infusion.
2.
C.
Continued Authorization: If the diagnosis is eligible for re-authorization
(as listed in Table 1), the maximum number of infusions that may be
authorized per year are based on the diagnosis being treated.
Authorization shall be reviewed as follows to confirm that current medical
necessity criteria are met and that the medication is effective.
1. Initial authorization shall be reviewed at the end of the initial authorization
period (as defined in Table 1).
2. Continued authorization (after the initial period) shall be reviewed at least
annually, and clinical documentation indicating that there is disease stability
or improvement must be provided (such as decrease in infections or
improvement of functional impairment from baseline). In addition, for
patients with immunodeficiency (on replacement therapy) documentation of a
current low/normal IgG trough level must be provided at least annually.
© 2015 RegenceRx. All rights reserved.
dru020.21
Page 6 of 26
Table 1. Initial Authorization
Frequency/Duration
Reauthorization Criteria/Duration
Indication
May be given no more frequently than:
Replacement Therapy - Immunodeficiency [with documented hypogammaglobulinemia (low IgG levels) or poor immune response (dysgammaglobulinemia)]
Primary humoral immunodeficiency disease (PID)
One dose per month x 12 months
Hematologic malignancy-related
hypogammaglobulinemia (e.g., CLL, post-BMT)
One dose per month x 12 months
HIV+ children with hypogammaglobulinemia
One dose per month x 12 months
Hypogammaglobulinemic neonates
One dose per month x 6 months
Documented current IgG levels that are in the low to normal range and
evidence of clinical improvement, such as decreased occurrence of
infections; x 12 months
Hematologic disorders (immune-mediated)
Acquired Factor VIII Inhibitor
One dose per month x 6 months
Documented initial response and continued presence of Factor VIII
inhibitor; x 12 months
Autoimmune hemolytic anemia, (AIHA)
One dose per month x 6 months
Documented initial response and recurrence of clinically significant,
symptomatic anemia; x 12 months
Fetal (neonatal) alloimmune thrombocytopenia
(FAIT)
One dose per week until the estimated
date of delivery.
No reauthorization
ITP (acute)
Up to four doses (authorization is for up
to a 6 month window).
May re-authorize under Chronic ITP; however, use of IVIG chronically is
generally discouraged, given the short duration of action. On a chronic basis,
IVIG may be indicated for intermittent use in patients with episodes of
acutely low platelets.
ITP (chronic)
One dose per month x 6 months. IVIG
treatment only covered until
conventional therapy takes effect.
Authorization x 6 months. Documented initial response to IVIG and:
-Continued thrombocytopenia, defined as a platelet count of < 20,000 OR
less than 30,000 cells/m3 and clinically significant bleeding. OR
-Patient is scheduled for an invasive procedure with high risk of bleeding.
ITP in pregnancy
One dose per month until the estimated
date of delivery.
May re-authorize under Chronic ITP
Post-transfusion purpura (hemolytic transfusion
reaction)
Up to two doses in 2 weeks (authorization is for up to a 2 week window)
No reauthorization
Pure red cell aplasia (PRCA), viral
One dose per month x 6 months
Documentation of initial response, parvovirus, and recurrence of significant
anemia; x 12 months
© 2015 RegenceRx. All rights reserved.
dru020.21
Page 7 of 26
Frequency/Duration
Indication
Reauthorization Criteria/Duration
May be given no more frequently than:
Neuroimmunologic disorders
Acute inflammatory demyelinating
polyneuropathy (including GBS)
One dose per month x 3 months
May re-authorize under Chronic IDP
Chronic inflammatory demyelinating
polyneuropathy (CIDP)
Dermatomyositis, refractory
One dose per month x 6 months
Documented functional improvement; x 12 months
One dose per month x 3 months.
Documented improvement in muscle strength and/or decreased
CPK levels; x 6 months
Lambert-Eaton myasthenic syndrome
One dose per month x 6 months
Multifocal motor neuropathy (MMN)
One dose per month x 6 months.
Myasthenia gravis (acute and chronic)
One dose per month x 6 months.
Paraneoplastic opsoclonus ataxia syndrome
One dose (authorization is for up to a 2 week window)
Documented functional improvement; x 6 months.
Polymyositis
One dose per month x 3 months.
Documented improvement in muscle strength and/or decreased
CPK levels; x 6 months
Pemphigoid, refractory
One dose per month x 6 months, until conventional therapy
takes effect.
No reauthorization
Stiff-Person syndrome
One dose per month x 3 months.
Documented functional improvement; x 6 months
Systematic lupus erythematosus
One dose per month x 6 months.
Documented improvement in muscle strength and/or decreased
CPK levels; x 6 months
Prevention of acute rejection (pre- and perioperative)
Up to 4 doses pre-transplant, then 1 dose weekly for 4
weeks post-transplant. (not to exceed 8 doses total;
authorization is for up to a 3 month window)
Further authorization may be considered under “Treatment of
Ab-mediated rejection”
Treatment of antibody (Ab)-mediated
(humoral) rejection
One dose, once per rejection episode (authorization is for
up to a 2 week window)
Documented improvement from previous course and
confirmation of another episode of rejection; one dose.
Kawasaki syndrome
Up to two doses given within 10 days of symptom onset
(authorization is up to a 2 week window)
No reauthorization
Pediatric intractable epilepsy
One dose per month x 6 months.
Documented of significantly reduced frequency and/or duration
of seizures; x 6 months
Documented improvement in muscle function/strength; x 12
months
Transplant (solid organ)
Other Miscellaneous disorders
© 2015 RegenceRx. All rights reserved.
dru020.21
Page 8 of 26
III.
Subcutaneous administration of immune globulin (SCIG) is considered an alternative to
intravenous administration of immune globulin and may be considered medically
necessary when one of the criteria in Section I is met.
IV.
For Washington, Oregon, and Idaho commercial, fully insured members only (does
not apply to Medicare)
Immune globulin replacement therapy is considered not medically necessary when
administered in a hospital outpatient setting when an alternative site of care (non-hospital
outpatient setting) is a treatment option (see Section I: Alternative Site of Care).
V.
IVIG/SCIG is considered investigational when used for all other conditions, including,
but not limited to:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
Acute disseminated encephalomyelitis (ADEM)
Acute lymphocytic leukemia
Acute renal failure
Adrenoleukodystrophy
Adult HIV infection
Alzheimer's disease
Aplastic anemia
Asthma
Atopic dermatitis
Autism
Behçet's syndrome (Behçet’s disease)
Cardiomyopathy, recent-onset dilated
Chronic fatigue syndrome
Clostridium difficile, recurrent
Cystic fibrosis
Diabetes
Diamond-Blackfan anemia
Endotoxemia
Heart block, congenital
Hemolytic anemia (other than autoimmune)
Hemophagocytic syndrome
Human T-lymphocyte virus-1 myelopathy
Hyper IgE syndrome
Immune mediated neutropenia
Inclusion body myositis
Infectious disease in high risk neonates and adults following surgery or trauma
Lumbosacral plexopathy
© 2015 RegenceRx. All rights reserved.
dru020.21
Page 9 of 26
28.
29.
30.
31.
32.
Multiple sclerosis
Narcolepsy/cataplexy
Neonatal hemochromatosis
Neonatal hemolytic disease
Nephropathy, membranous
33.
Nephrotic syndrome
34.
Ophthalmopathy, euthyroid
35.
Paraproteinemic neuropathy
36.
Post-polio syndrome
37.
Recurrent spontaneous abortion
38.
Rheumatoid arthritis
39.
Systemic Sclerosis, diffuse cutaneous (dcSS)
40.
Stevens-Johnson Syndrome
41.
Still's Disease (Systemic Juvenile Immune Arthritis, SJIA)
42.
Surgery or trauma
43.
Thrombocytopenia, nonimmune
44.
45.
Thrombotic Thrombocytopenic Purpura, including Hemolytic Uremic Syndrome
(TTP/HUS), neonatal autoimmune and transfusion refractory.
Tic disorder (Based on DSM Criteria)\
46.
Toxic epidermal necrolysis (TEN)
47.
Urticaria, delayed pressure
48.
Uveitis
49.
Vasculitic syndromes, systemic
50.
Von Willebrand’s syndromeWegener's granulomatosis
Position Statement
Summary
Intravenous immune globulin (IVIG)
-
All IVIG preparations are generally considered therapeutically interchangeable. [32-34]
Minor immunoglobulin A (IgA) and immunoglobulin G (IgG) subclass differences exist. [3234]
-
-
IVIG preparations with low IgA content are used to minimize reactions in patients with
hypogammaglobulinemia and concurrent IgA deficiency or when anti-IgA antibodies are
present in a recipient. [32-34]
Differences in formulation may guide product selection (e.g., pre-mixed liquid vs.
lyophilized powder, 5% vs. 10%, low sucrose, low osmolarity).
© 2015 RegenceRx. All rights reserved.
dru020.21
Page 10 of 26
Subcutaneous immune globulin (SCIG)
-
-
-
-
-
-
Hizentra® is an immune globulin product for subcutaneous use, approved for patients with
primary immune deficiency (PID). [81] It is available as a 20 % solution for weekly
subcutaneous infusion.
Hyqvia® is also an immune globulin product for subcutaneous use, approved for patients with
PID, and is available as a 10 % solution for every three to four week subcutaneous infusion.
[105]
Gammaked®, Gamunex-C®, and Gammagard liquid® are approved for both intravenous
and subcutaneous use for treatment of PID. [89-91] All three are available as a 10 % solution.
SCIG has a lower bioavailability than IVIG, so must be given in higher doses to achieve the
same serum IgG concentrations.
However, subcutaneous delivery may result in higher steady-state IgG levels due to less
variation in IgG levels.
Multiple injection sites (three to four) are necessary for weekly infusion (Hizentra,
Gammaked, Gamunex-C, Gammagard) for an average patient because of the volume that
must be infused, whereas Hyqvia may be infused monthly.
Hyqvia 10% is formulated with hyaluronidase, to allow for larger volume infusion at a single
injection site. Up to 600 mL (60 grams) may be given per injection site (for patients > 40 kg)
at an infusion rate up to 300 mL/hour. The recommended maximum dose per injection site
for Hizentra 20% is 25 mL (5 grams), given over a maximum of 25 mL/hour.
None of these products have been approved for SC administration for any other indications,
other than PID. Because other diagnoses usually require larger doses (based on grams per
kilogram) with a high volume per dose, subcutaneous administration is generally not feasible.
Injection site swelling, redness, and itching were reported in the majority of patients.
Dosing Considerations and Therapeutic Levels for Replacement Therapy for Treatment of
Immunodeficiency with Hypogammaglobulinemia
-
A plasma IgG level of 200 mg/dL is often a common minimum target for patients being
considered for IVIG replacement therapy. [4]
In patients with mild to moderate IgG deficiency with levels of 300 mg/dL-400mg/dL, the
decisions to treat are based on clinical symptoms and antigenic challenge. [31]
Dosing adjustment in replacement therapy is based on clinical response and IgG levels. [4]
* The trough or steady state IgG level is obtained before scheduled infusions and
frequently guides IVIG dose selection.
* The minimum serum concentration of IgG necessary for protection has not been firmly
established. However, maintenance of serum trough IgG levels above 500 mg/dL has
been considered a sufficient target to prevent most systemic infections. [4, 31] Some
patients may require an IgG level of 400-500 mg/dL above their baseline value for
protection.
* In patients with severe hypogammaglobulinemia, IgG levels (trough) should be checked
every three to six months in growing children and every six to twelve months in adults.
[56]
© 2015 RegenceRx. All rights reserved.
dru020.21
Page 11 of 26
-
-
Dosing of IVIG for conditions other than hypogammaglobulinemia do NOT require
monitoring of IgG levels. Efficacy in conditions other than hypogammaglobulinemia is based
on clinical response, including improvement or resolution of disease symptoms.
New technologies and pharmaceuticals allow therapeutic services, such as infusion therapy,
to be administered safely, effectively, and much less costly outside of the hospital outpatient
setting. Alternative sites of care (such as doctor’s offices, infusion centers, and home
infusion) are well-established, accepted by physicians, and reduce the overall cost of care.
Clinical Efficacy
IMMUNODEFICIENCY (Primary or Secondary) - Replacement Therapy for
Hypogammaglobulinemia [1, 4-5, 27, 34, 43]
Primary humoral immunodeficiency diseases
* All available immune globulin replacement products are FDA-approved for use in
primary immunodeficiency (PID). [94]
* X-linked agammaglobulinemia (congenital agammaglobulinemia) occurs in male infants,
usually presenting in the first 3 years of life.
* Common variable immunodeficiency (CVID; acquired hypogammaglobulinemia; adult
onset hypogammaglobulinemia; dysgammaglobulinemia) is characterized by low to
normal IgG levels and inability to produce an antibody response to protein (e.g., tetanus)
or carbohydrate antigens (e.g., Pneumovax). Most patients experience severe recurrent
and/or chronic infections.
* Combined immunodeficiency syndromes, including Wiskott-Aldrich syndrome, are rare,
inherited syndromes.
* Immunoglobulin reference ranges vary depending on the age of the patient and the
particular assay method used. The usual immune globulin maintenance dose is 100800mg/kg/month and therapy is usually life-long.
* Serum trough levels should be maintained at 400 – 600 mg/dl. Documentation of the
rationale should be provided in the event that a trough level greater than 600 mg/dl is
required. [72]
* Hypogammaglobulinemic neonates
o Treatment with IVIG is usually reserved for patients with recurrent severe infections,
not responding to antibiotic prophylaxis.
o The usual IVIG dose is 400 – 600 mg/kg/month, administered as a single dose, or up
to several months in duration. [67]
Acquired Deficiencies:
- Hematologic malignancy-related hypogammaglobulinemia (including B-cell cancers,
multiple myeloma, and post-bone marrow transplant (BMT)
© 2015 RegenceRx. All rights reserved.
dru020.21
Page 12 of 26
* Use of immune globulin replacement in hypogammaglobulinemic patients with B-cell
cancers (including CLL), multiple myeloma and post-allogeneic bone marrow transplant
(BMT) is supported by guidelines. [83, 100]
* IVIG therapy reduces the incidence of bacterial infections in patients with hematologic
malignancies to approximately 50% of the incidence without IVIG administration. [4, 34]
* Previously, use of IVIG prophylaxis post-BMT was common for prevention of graft
versus host disease (GVHD); however, with improved immunosuppressant regimens, the
use of routine IVIG prophylaxis is no longer supported. [100]
* Monthly IVIG infusions of 400 mg/kg are recommended to maintain the serum IgG level.
-
HIV-infected children < 13 years of age [92]
* Current guidelines recommend IVIG use among HIV-infected children who have
hypogammaglobulinemia (IgG <400 mg/dL), to prevent serious bacterial infections
(SBIs).
* IVIG is no longer recommended for primary prevention of SBIs in children, unless
hypogammaglobulinemia is present. During the pre-HAART (highly-active antiretroviral
therapy) era, IVIG was shown to decrease the frequency of bacterial infections and
hospitalization in children with AIDS, however only in those not receiving daily
Pneumocystis carinii pneumoniae (PCP) prophylaxis.
AUTOIMMUNE (IMMUNE-MEDIATED) DISORDERS
-
-
Pooled immune globulin (IVIG) has been studied and found to be useful in a variety of
autoimmune disorders, including hematologic, neuromuscular and infectious disease-related
diseases. However, given the rarity of many of these disorders, the evidence for safety and
efficacy in some diagnoses is insufficient at this time.
The mechanism of action of IVIG in autoimmune disorders is thought to include acute
neutralization of circulating autoantibodies, toxins, and cytokine modulation, as well as longterm reduction of antibody production and suppression of T-cell cytokines. [1]
Hematologic (immune-mediated) Disorders: [83]
Acquired Factor VIII inhibitor [21-25]
-
-
A sufficient treatment course is usually 6-12 weeks before attempting a different
immunosuppressive agent. Patients are generally treated until remission (elimination of the
inhibitor) occurs, which may take several months.
Treatment regimens of 1 gm/kg for 2 days or 400 mg/kg for 5 days have been studied. In one
study, only 6 of 19 patients responded to IVIG within 40 days of treatment. [60]
Fetal (neonatal) alloimmune thrombocytopenia (FAIT): [58, 83]
-
ACOG guidelines recommend IVIG as first line treatment for documented fetal
thrombocytopenia. [58]
© 2015 RegenceRx. All rights reserved.
dru020.21
Page 13 of 26
-
-
A trial comparing IVIG treatment with and without dexamethasone in siblings showed that:[2]
--
IVIG treatment was associated with an increase in mean platelet count of
69,000/mm3.
--
There were no instances of intracranial hemorrhages, although hemorrhage had
occurred previously in 10 untreated siblings.
The recommended dose of IVIG is 1 gm/kg/week, increasing to 2 gm/kg/week in refractory
cases. [59]
Idiopathic thrombocytopenia purpura (ITP) [5,83, 84]
-
-
Normal platelet count range is 115,000/mm3 to 440,000/mm3.
Acute ITP
* In various studies, 64% to 100% of IVIG recipients attained platelet counts greater than
100,000 cells/mm3 within 7 days. [4, 34]
* A maximum of 1 gm/kg/day for three or four doses of IVIG on alternate days is
recommended. Acute ITP is usually seen in children and typically resolves spontaneously
within 2 months.
Chronic ITP [4, 8-10]
* Current evidence does not support that IVIG alters the natural course of chronic ITP,
affects long-term morbidity/mortality, or increases the rate of long-term remission.
* IVIG is not indicated for the maintenance of platelet counts in chronic ITP; however,
IVIG maybe be used episodically in patients with chronic ITP, for acutely low platelet
levels.
* Steroids and/or splenectomy are considered the first-line treatment of choice for chronic
ITP. Although the use of IVIG may be considered as a steroid-sparing adjunctive therapy
for chronic ITP, [5,83,84] other therapies with a more durable response should be
considered, such as splenectomy, rituximab (Rituxan), eltrombopag (Promacta) or
romiplostim (Nplate). [5,84]
* IVIG may be considered in patients with dangerously low platelet counts (less than
10,000 to 20,000 per mm3 in adults or less than 30,000 per mm3 in children) or patients
undergoing an invasive procedure, and therefore may be at an increased risk for
significant bleeding, such as intracranial hemorrhage.
* The usual dose of IVIG is 1 to 2 gm/kg divided into equal amounts and given over 2 to 5
days.
-
ITP in pregnancy [44,83,84]
* The goal of therapy is to minimize the risk of bleeding complications due to
thrombocytopenia. [44]
* Platelet function is typically normal so it is not necessary to maintain platelet count in the
normal range.
* The first line of treatment is prednisone, usual dose 1-2mg/kg/day.
© 2015 RegenceRx. All rights reserved.
dru020.21
Page 14 of 26
* IVIG is useful in cases that are resistant to steroids and when a rapid rise in platelets is
necessary. A response typically occurs within 6 – 72 hours of IVIG treatment.
Post-transfusion purpura (hemolytic transfusion reaction)
-
Post-transfusion purpura is a rare condition that can occur in patients undergoing blood
transfusions. It typically develops approximately one-week after blood transfusion.
IVIG may be considered first-line therapy in severely affected patients. [1, 83]
The recommended dose of IVIG is 500 mg/kg/day for two consecutive days. Rapid platelet
recovery has been seen within days of treatment.
Pure Red Cell Aplasia (PRCA), Viral [83]
-
-
Parvovirus B19 infects and lyses red cell precursors, which can cause pure red cell aplasia.
IVIG therapy is usually reserved for patients with chronic parvovirus infection and chronic
anemia.
Chronic parvovirus infection with anemia usually occurs in immunocompromised patients. If
the immunodeficiency improves, the parvovirus and anemia may spontaneously resolve.
The usual dose of IVIG is 2-4 grams/kg, divided as 400 mg/kg/day for 5 – 10 days, 1
gm/kg/day for 3 days or 0.5 gm/kg weekly for 4 weeks. Initial treatment courses may be
indicated with recurrence of anemia and increase in parvovirus B19 DNA. [71,83]
Neuromuscular Disorders:
Inflammatory demyelinating polyneuropathy (IDP) [85, 86, 96]
-
-
Acute IDP, including Guillain-Barré syndrome (GBS) [57,97]
* IVIG appears to be effective in adult patients with Guillain-Barré syndrome when given
within 2 weeks of symptom onset.
* The recommended IVIG dose is 400 mg/kg/day for 5 days. If relapse occurs within 1-2
weeks of initial therapy, an additional treatment course of IVIG may be effective.
Further treatment does not improve outcomes and is not recommended.
Chronic IDP (CIDP)
* Treatment options include plasmapheresis, IVIG, and corticosteroids.
* The usual IVIG dose is 400 mg/kg/day for 5 days, repeated every 6 weeks.
Dermatomyositis (DM)
-
High-dose IVIG is a safe and effective treatment for refractory dermatomyositis
unresponsive to corticosteroid therapy. [5,7,27,33,36, 85,86,95]
The recommended IVIG dose is 2 gm/kg per month.
Lambert-Eaton myasthenic syndrome (LEMS) [39, 85-87]
-
LEMS is a rare acquired autoimmune disorder characterized by proximal weakness of
extremities, decreased reflexes, and dryness of mouth and eyes.
Patients reported improved limb, respiratory muscle, and bulbar muscle strength with IVIG,
compared to placebo in a small randomized crossover trial (n = 9). [73]
The recommended dose of IVIG is 2 gm/kg administered over 2 – 5 days.
© 2015 RegenceRx. All rights reserved.
dru020.21
Page 15 of 26
Multifocal motor neuropathy (MMN) [75-79, 85, 86]
-
Small controlled trials demonstrate significant increase in muscle strength associated with
IVIG administration, long-term benefits, and safety. [6,26]
The recommended IVIG dose is 2 gm/kg/month, administered over 2 – 5 days.
Conduction block is the hallmark of this disease. Additionally, patients with anti-GM1
antibodies show an increased chance of response to IVIG However, anti-GM antibodies are
present in only 30-80% of patients with MMN and are not specific to MMN. In addition,
patients who lack anti-GM1 antibodies may have a favorable response to IVIG; therefore the
clinical utility of monitoring anti-GM1 antibodies is uncertain. [75]
Myasthenia gravis (MG) [85, 86]
-
Randomized trials examining short-term treatment of myasthenia gravis with IVIG have
shown no difference between IVIG and plasma exchange or IVIG and methylprednisolone[69]
IVIG may be useful in treating patients with severe myasthenia gravis who fail to respond to
the maximum tolerated doses of corticosteroids and/or immunosuppressants. [70]
There is no evidence to determine whether IVIG improves function or reduces steroid
requirements for moderate to severe myasthenia gravis. [69]
The recommended dose of IVIG is 1 – 2 gm/kg/month administered over 2 – 5 days. [69]
Paraneoplastic opsoclonus ataxia syndrome (Opsoclonus-myoclonus) [85, 101]
-
-
-
Opsoclonus-myoclonus is a rare neurological syndrome characterized by an unsteady gait,
brief shock-like muscle spasms, and irregular rapid eye movements and can be a
paraneoplastic (e.g., with neuroblastoma) or non-paraneoplastic syndrome.
IVIG is a therapeutic option for pediatric neuroblastoma patients with paraneoplastic
opsoclonus ataxia syndrome, along with other immunologic treatments, including
glucocorticoids, cyclophosphamide, mycophenolate and plasma exchange. [85,101]
Evidence supporting the use of IVIG in this condition consists of retrospective chart reviews
and case reports. However, a randomized phase II trial is currently investigating the use of
IVIG in treating children with opsoclonus-myoclonus associated with neuroblastomas.
[73,74,102]
Refractory pemphigoid bullous (e.g., pemphigus foliaceus, pemphigus vulgaris) [27, 38, 88]
-
-
IVIG is typically given in combination with conventional treatments, such as
immunosuppressive agents and plasmapheresis, and is discontinued once conventional
treatment (such as corticosteroids, azathioprine, cyclophosphamide, etc.) takes effect. IVIG
is not considered a maintenance therapy for pemphigus foliaceus, pemphigus vulgaris or
other autoimmune mucocutaneous blistering diseases.
The usual dose of IVIG is 1-2 gm/kg administered over 3 days. This regimen may be
repeated every 3-4 weeks.
Polymyositis [85, 86, 95]
-
Polymyositis is an inflammatory myopathy with no unique clinical features. It is typically a
diagnosis of exclusion in patients with slowly progressive muscle weakness. Traditional
therapies include immunosuppressive medications or steroids.
© 2015 RegenceRx. All rights reserved.
dru020.21
Page 16 of 26
-
IVIG may be considered for patients not responding to first-line immunosuppression.
The recommended dose of IVIG is 2 gm/kg/month administered over 2 – 5 days.
Stiff Person Syndrome [37, 85]
-
-
Sixteen patients were randomized to IVIG or placebo for 3 months, and then crossed over to
the alternate treatment after a 1 month washout period. IVIG patients demonstrated decreased
stiffness scores, decreased frequency of falls, ability to walk more easily without assistance,
and improved ability to perform work-related tasks. Benefits lasted 6 weeks to 1 year without
additional treatment.
The usual dose of IVIG is 400 mg/kg/day for 3 – 5 days.
Systemic Lupus Erythematosus
-
Small case series suggest some benefit from treatment with IVIG when compared to
cyclophosphamide.
The usual dose of IVIG is 400 mg/kg/day for 5 days.
Transplant (Solid Organ) –
Antibody-mediated rejection [27, 98]
-
-
-
Acute allograft (organ) rejection may be cellular (T-cell mediated) or humoral (antibodymediated) (AHR, AMR).
Pre-treatment with IVIG (desensitization) may reduce the risk of AMR in highly sensitized
renal transplant patients. [27,98]
A randomized, double-blind trial comparing IVIG to placebo in 101 highly sensitized renal
transplant candidates concluded that IVIG is better than placebo in improving transplantation
rates. [68]
Acute humoral rejection (AHR) is also an AMR and can occur outside of the peri-operative
period, but most commonly within 6 months after transplant. The diagnosis is confirmed by a
renal biopsy. The goal of therapy is early antibody elimination with IVIG, pheresis or a
combination of modalities.
A variety of protocols have been developed for the use of IVIG in treating AMR after solid
organ transplant. [27,98]
Other Miscellaneous Disorders:
Kawasaki syndrome
-
-
IVIG in conjunction with aspirin given within the first 10 days of illness can reduce the
incidence of coronary artery abnormalities by 65% - 78%, compared with treatment with
aspirin alone. [4, 34-35,99] IVIG is not effective if more than ten days have elapsed from onset of
symptoms.
The usual dose of IVIG is 2 gm/kg as a single dose, but may be repeated if the patient fails to
defervesce. [99]
© 2015 RegenceRx. All rights reserved.
dru020.21
Page 17 of 26
INVESTIGATIONAL CONDITIONS [1, 5, 13-15, 17-20, 27, 46-52]
-
The University Hospital Consortium (UHC), an alliance of 68 academic health centers,
performed a critical assessment of off-label IVIG uses.
-
The UHC determined published data to be inadequate to support the use of IVIG in various
conditions. [1]
-
Asthma: Further trials in asthma patients are necessary to delineate patient subsets that would
best benefit from IVIG therapy, and define optimal dosing in this condition. [17-20]
-
HIV (adults): The use of IVIG in HIV-infected adults is not definitive to substantiate a
positive benefit on overall long-term health outcomes. [3]
-
Multiple sclerosis, progressive: There is not substantial evidence to support IVIG in the
treatment of chronic progressive multiple sclerosis. [28-30, 64]
-
Multiple sclerosis; relapsing-remitting type: IVIG may provide some benefit in reducing the
acute exacerbation rate in relapsing-remitting multiple sclerosis. [5, 27, 54]
*
Trials are generally limited to small numbers of patients and have lacked complete data
on clinical outcomes.
*
Current evidence suggests little benefit with regard to slowing disease progression.
*
The American Academy of Neurology does not consider IVIG to be a first-line therapy
in the treatment of relapsing-remitting multiple sclerosis.
-
Post-Polio: Two published trials of post-polio syndrome failed to demonstrate a statistically significant benefit compared to placebo in improvement of muscle strength. [65, 66]
-
Recurrent pregnancy loss, or recurrent spontaneous abortion (due to anti-phospholipid or
anti-cardiolipin antibodies):
*
Recurrent pregnancy loss is defined as three or more pregnancies resulting in
spontaneous abortion prior to 20 weeks of gestational age. These women often have
immunologic abnormalities, particularly antiphospholipid antibodies. [27]
*
IVIG has not been established as a safe or effective therapy to prevent recurrent
spontaneous abortion in women with immunologic abnormalities, such as elevated
natural killer cells, defective cytokines, or defective growth factors. [13-15, 62]
*
One randomized controlled trial comparing IVIG to thyroid replacement therapy for
the prevention of miscarriages found IVIG to be less effective. There was a
statistically significant higher rate of live birth among women treated with thyroid
replacement therapy. [61]
*
A small randomized controlled trial in 85 women with a history of three or more
spontaneous abortions before 10 weeks of gestation compared low molecular heparin
(LMW) plus aspirin with IVIG therapy. The percentage of live births in the LMW plus
aspirin versus the IVIG treatment group was 72.5% and 39.5%, respectively. [80]
*
A randomized controlled trial in 82 women with a history of idiopathic secondary
miscarriage compared live birth rates in those who received intravenous immune
© 2015 RegenceRx. All rights reserved.
dru020.21
Page 18 of 26
globulin versus placebo infusion (saline). There was no statistical difference between
treatment groups. [82]
*
-
ACOG recommendations state:
--
If results are positive for the same antibody on two consecutive tests 6 to 8
weeks apart, initiate heparin and low-dose aspirin with next pregnancy
attempt.
--
IVIG is not effective in preventing recurrent pregnancy loss. [55]
Additional conditions for which published data is determined to be inconclusive or
inadequate to support the use of IVIG include Alzheimer's disease, atopic dermatitis,
recurrent C. difficile, narcolepsy/cataplexy, neonatal hemochromatosis, chronic sinusitis,
tic disorder, delayed pressure urticaria, systemic sclerosis (diffuse cutaneous, dcSS) and
toxic epidermal necrolysis. [27, 46-52, 63,103, 104]
ALTERNATIVE SITE OF CARE:
-
-
-
-
-
Use of an alternative site of care, including non-hospital outpatient infusion centers and
home infusion services, is an accepted standard medical practice. These alternative sites
of care offer high-quality services for patients and reduce the overall cost of care, as
compared to a hospital-based infusion center.
All medications infused outside of a hospital setting (at an alternative site of care) have
undergone an evaluation for safe infusion and development of infusion standards,
including adverse drug reaction (ADR) management and reporting algorithms.
For use of an alternative site of care, every patient undergoes a patient assessment during
the intake process by the infusion provider, which includes evaluation of individual
clinical assessment parameters. These parameters may include, but are not limited to,
previous tolerance of products (such as IVIG), assessment of kidney function, risk factors
for developing thromboembolic events, and venous access.
For use of home infusion services, an assessment is conducted to determination whether
or not the home is a safe, appropriate site of care, with adequate support for infusion in
the home.
Because these “alternative site of care” providers need time to arrange for assessment and
coordinate the first dose of each new medication, the first dose of infused medications
may be covered in a hospital-based infusion center, if needed, to allow adequate time for
a seamless transition of care. This may include arranging for delivery of medications
and/or patient education, such as for self-administration of medications such as
subcutaneous immune globulin (SCIG).
© 2015 RegenceRx. All rights reserved.
dru020.21
Page 19 of 26
Cross References
BlueCross BlueShield Association Medical Policy # 8.01.05; Intravenous Immune Globulin
Therapy (6/2013)
Maximum Drug Dosage Policy, RegenceRx Medication Policy Manual, Policy No. dru237
Nplate®, romiplostim, RegenceRx Medication Policy Manual, Policy No. dru162
Promacta®, eltrombopag, RegenceRx Medication Policy Manual, Policy No. dru180
Rituxan®, rituximab, RegenceRx Medication Policy Manual, Policy No. dru214
Codes
Number
Description
CPT
9078090781
IV infusion for therapy
CPT
90284
Immune globulin (SCIg), human, for SC use
CPT
90283
Immune globulin (IVIG), human, for IV use
HCPCS
J1459
Injection, Immune Globulin (Privigen), IV, non-lyophilized (e.g., liquid)
500 MG
HCPCS
J1557
Injection, Immune Globulin (Gammaplex), IV, non-lyophilized (e.g.,
liquid) 500 MG
HCPCS
J1559
Injection, Immune Globulin (Hizentra), 100 mg
HCPCS
J1561
Injection, Immune Globulin, (Gamunex), IV, non-lyophilized, (e.g.,
liquid), 500 MG
HCPCS
J1566
Injection, Immune Globulin (Carimune), IV, lyophilized, 500 MG
HCPCS
J1568
HCPCS
J1569
HCPCS
J1572
Injection, Immune Globulin (Octagam), IV, non-lyophilized (e.g., liquid)
500 MG
Injection, Immune Globulin, (Gammagard), IV, non-lyophilized, (e.g.,
liquid), 500 MG
Injection, Immune Globulin, (Flebogamma), IV, non-lyophilized, (e.g.,
liquid), 500 MG
HCPCS
Unassigned
Immune Globulin, (BIVIGAM)
© 2015 RegenceRx. All rights reserved.
dru020.21
Page 20 of 26
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
Leong, H, Stachnik, J, Bonk, ME, Matuszewski, KA. Unlabeled uses of intravenous immune
globulin. Am J Health Syst Pharm. 2008 Oct 1;65(19):1815-24. PMID: 18796422.
Bussel JB et al. "Antenatal management of alloimmune thrombocytopenia with intravenous
immunoglobulin: A randomized trial of the addition of low dose steroid to intravenous
immunoglobulin." Am J Obstet Gynecol 1996;174:1414-23.
Kiehl MG et al. "A controlled trial of intravenous immune globulin for the prevention of serious
infections in adults with advanced human immunodeficiency virus infection." Arch Intern Med
1996;156:2545-50.
Immuno Facts®; May 2003 by Facts and Comparisons. p 213-20.
" Immune Globulin Therapy." BlueCross BlueShield Association (BCBSA) Medical Policy
Reference Manual, Policy No. 8.01.05, Last review date: June 2013.
Azulay JP et al. "Intravenous immunoglobulin treatment in patients with motor neuron syndromes
associated with anti-GM1 antibodies." Neurology 1994;44:429-32.
Dalakas MC et al. "A controlled trial of high-dose intravenous immunoglobulins infusions as
treatment for dermatomyositis." N Engl J Med 1993;329:1993-2000.
Chu Y-Waye et al. "Idiopathic thrombocytopenia purpura." Pediatrics Review 2000; 21(3):94105.
Laosombat V. "Intravenous gamma globulin for treatment of chronic idiopathic
thrombocytopenic purpura in children." J Med Assoc Thai 2000;83(2):160-8.
Medeiros, Desiree et al. "Current controversies in the management of idiopathic
thrombocytopenic purpura during childhood." Pediatric Clin N Amer 1996;43(3):757-73.
TEC Assessments 1998. "Intravenous Immune Globulin for Recurrent spontaneous Abortion."
Tab 14.
Daya S et al. "Mini symposium Analysis of therapies for anovulation and miscarriage: Critical
analysis of intravenous immunoglobulin therapy for recurrent miscarriage." Human Reproduction
Update 1999;5(5):475-82.
Daya S. "Intravenous immunoglobulin therapy for recurrent spontaneous abortion: a metaanalysis." Am J Reprod Immunol 1998;39(2):69-76.
A Perino et al. "Short-term therapy for recurrent abortion using intravenous immunoglobulins:
results of a double-blind placebo-controlled Italian study." Human Reproduction
1997;12(11):2388-92.
Stephenson MD et al. "Prevention of unexplained recurrent spontaneous abortion using
intravenous immunoglobulin: a prospective, randomized, double-blinded, placebo controlled
trial." Am J Reprod Immunology 1998;39:82-8.
Lee. Wintrobe's Clinical Hematology, 10th ed., Copyright © 1999 Lippincott Williams &
Wilkins, Inc. p. 2664.
Kishiyama JL et al. "A multicenter, randomized, double-blind, placebo-controlled trial of highdose intravenous immunoglobulin for oral corticosteroid-dependent asthma." Clinical
Immunology 1999;91(2):126-33.
Ballow Mark. "Is steroid-dependent asthma a disease treatable with intravenous
immunoglobulin?" Clinical Immunology 1999; 91(2):123-5.
Salmun LM et al. "Effect of intravenous immunoglobulin on steroid consumption in patients with
severe asthma: a double-blind, placebo-controlled, randomized trial." J All Clin Immunol 1999;
Copyright 1999 Mosby, Inc.
Landwehr LP et al. "Benefits of high-dose IV immunoglobulin in patients with severe steroiddependent asthma." Chest 1998;114:1349-56.
Lafferty TE et al. "Treatment of acquired factor VIII inhibitor using intravenous immunoglobulin
in two patients with systemic lupus erythematosus." Arthritis 1997; 40(4):775-8.
Crenier L. "Low response to high-dose intravenous immunoglobulin in the treatment of acquired
factor VIII inhibitor." Br J Haematol 1996;95(4):750-3.
Sultan Y. "Acquired hemophilia and its treatment." Blood Coagul Fibrinolysis 1997;8 (suppl
1):S15-8.
© 2015 RegenceRx. All rights reserved.
dru020.21
Page 21 of 26
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
Lusher JM. "Screening and diagnosis of coagulation disorders." American Journal of Obstetrics
Gynecol 1996;175(3):778-83.
Scott-Timperley LJ et al. "Life-threatening complications of autoimmune disease: Autoimmune
coagulation disorders." Rheum Dis Clin N Amer 1997;23(2):411-23.
Zulay JP et al. "Long term follow up of multifocal motor neuropathy with conduction block under
treatment." J Neurol 1997;62(4):391-4.
BlueCross BlueShield Association Medical Policy # 8.01.05; Intravenous Immune Globulin
Therapy, Last Reviewed December 2012.
Pehlau D et al. "Intravenous immunoglobulin (IVIG) treatment for patients with primary or
secondary progressive multiple sclerosis – outline of a double-blind randomized, placebocontrolled trial." Multiple Sclerosis 1997;149-52.
Cook S et al. "Intravenous gamma globulin in progressive MS." Acta Neurol Scand 1992;86:171175.
Francis G et al. "Failure of intravenous immunoglobulin to arrest progression of multiple
sclerosis: a clinical MRI based study." Multiple Sclerosis 1997;3:370-6.
Fauci AS et al. Harrison’s Principles of internal medicine, 14th edition. McGraw-Hill Companies,
Inc., New York, 1998, p. 1791.
Stiehm ER. "Immune globulin therapy." In: Mintz PD, editor. Transfusion therapy: clinical
principles and practice. Bethesda, MD:AABB Press; 199. P. 267-97.
Dalakais MC. "Intravenous immune globulin therapy for neurologic diseases." Ann Intern Med
1997;126(9):721-30.
USP-DI® Drug Information for the Health Care Professional, 22nd Edition, 2002.
Fasano MB. "Risks and benefits of intravenous immunoglobulin treatment in children." Curr
Opin Pediatr 1995;7:688-94.
Sansome A, Dubowitz V. "Intravenous immunoglobulin in juvenile dermatomyositis: four year
review of nine cases." Arch Dis Child 1995;72:25-8.
Dalakas MC et al. "High-dose intravenous immune globulin for stiff-person syndrome." N Engl J
Med 2001;345(26):1870-6.
Ahmed et al. "Intravenous immunoglobulin therapy for the treatment of refractory pemphigus
foliaceus." J Am Acad Dermatol 2002;46:42-9.
Bain PG et al. "Effects of intravenous immune globulin on muscle weakness and calcium-channel
autoantibodies in Lambert-Eaton myasthenic syndrome." Neurol 1996;47:678-83.
Triolo G et al. "Randomized study of subcutaneous low molecular weight heparin plus aspirin
versus intravenous immunoglobulin in the treatment of recurrent fetal loss associated with
antiphospholipid antibodies." Arthritis Rheum 2003;48(3):728-31.
Report of the WHO Scientific Group. "Primary immunodeficiency diseases". Clin Exper
Immunol 1997;109(suppl 1):1-28.
Harrison's Principles of Internal Medicine, 15th Edition, 2001.
American Hospital Formulary Service, Drug Information, 2002.
American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin,
Thrombocytopenia in Pregnancy, Number 6, September 1999 (reaffirmed 2012).
Petz LP. "Treatment of autoimmune hemolytic anemias". Curr Opin Hematol 2001;8:411-16.
Dodel RC et al. "Intravenous immunoglobulins containing antibodies against beta-amyloid for the
treatment of Alzheimer's disease". J Neurol Neurosurg Psychiatry 2004;75(10):1472-4.
Jolles S et al. "Adjunctive high-dose intravenous immunoglobulin treatment for resistant atopic
dermatitis: efficacy and effects on intracellular cytokine levels and CD4 counts." ACTA Derm
Venereol 2003;83(6):433-7.
Wilcox MH. "Descriptive study of intravenous immunoglobulin for the treatment of recurrent
Clostridium difficile diarrhea." J Antimicrob Chemother 2004;53(5):882-4.
Dauvilliers Y et al. "Successful management of cataplexy with intravenous immunoglobulins at
narcolepsy onset". Ann Neurol 2004:56(6):905-8.
Whitington PF et al. "High-dose immunoglobulin during pregnancy for recurrent neonatal
hemochromatosis." Lancet 2004;364(9446):1690-8.
© 2015 RegenceRx. All rights reserved.
dru020.21
Page 22 of 26
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
Hoekstra PJ et al. "Lack of effect of intravenous immunoglobulins on tics: a double-blind
placebo-controlled study". J Clin Psychiatry 2004;65(4):537-42.
Dawn G et al. "Effect of high-dose intravenous immunoglobulin in delayed pressure urticaria." Br
J Dermatol 2003;149(4):836-40.
Vivaglobin® (immune globulin subcutaneous) Prescribing Information. ZLB Behring GmbH,
Marburg, Germany. January 2006.
Goodin DS, et al. "Disease modifying therapies in multiple sclerosis: report of the Therapeutics
and Technology Assessment Subcommittee of the American Academy of Neurology and the MS
Council for Clinical Practice Guidelines." Neurology 2002;58:169-78.
American College of Obstetricians and Gynecologists (ACOG). Management of recurrent early
pregnancy loss. ACOG practice bulletin no. 24. Washington, DC: American College of
Obstetricians and Gynecologists (ACOG); 2001 Feb 12.
Bonilla FA, et al. "Practice parameter for the diagnosis and management of primary
immunodeficiency." Ann Allergy Asthma Imunol. 2005;94:S1-63.
Hughes RAC, et al. Practice parameter: immunotherapy for Guillain-Barre syndrome. Neurology
2003:61-736-40. Updated as of 3/27/2007.
American College of Obstetricians and Gynecologists (ACOG). Thrombocytopenia in pregnancy.
Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 1999 Sep. 12
p. (ACOG practice bulletin; no. 6). [72 references]
Rayment R, et al. Antenatal interventions for fetomaternal alloimmune thrombocytopenia.
Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No: CD004226.
Schwarz RS, et al. A prospective study of treatment of acquired (autoimmune) factor VIII
inhibitors with high-dose intravenous gammaglobulin. Blood 1995;86(2):797-804.
Vaquero E, et al. Mild thyroid abnormalities and recurrent spontaneous abortion: diagnostic and
therapeutical approach. American Journal of Reproductive Immunology 2000;43:204-08.
Porter TF, LaCoursiere Y, Scott JR. Immunotherapy for recurrent miscarriage. Cochrane
Database of Systematic Reviews 2006, Issue 2. Art. No.: CD000112.
Kaveri PP, et al. Skin immunoglobulin deposition following intravenous immunoglobulin therapy
in toxic epidermal necrolysis. Experimental Dermatology 2006;15:381-86.
Petereit HF, et al. No effect of intravenous immunoglobulins on cytokine-producing lymphocytes
in secondary progressive multiple sclerosis. Multiple Sclerosis 2006;12:66-71.
Kaponides G, et al. Effect of intravenous immunoglobulin in patients with post-polio syndrome –
an uncontrolled pilot study. J Rehabil Med 2006;38:138-40.
Gonzalez H, et al. Intravenous immunoglobulin for post-polio syndrome: a randomized controlled
trial. Lancet Neurol 2006;5:493-500.
Cano F et al. Absent specific viral antibodies in patients with transient hypogammaglobulinemia
of infancy. J Allergy Clin Immunol 1990 Feb;85(2):510-3.
Jordan SC, et al. Evaluation of intravenous immunoglobulin as an agent to lower allosensitization
and improve transplantation in highly sensitized adult patients with end-stage renal disease: report
of the NIH IG02 trial. J Am Soc Nephrol 2004 15:3256-62.
Gajdos P, et al. Intravenous immunoglobulin for myasthenia gravis. Cochrane Database of
Systematic Reviews 2006, Issue 2. Art. No.: CD002277. Last updated January 17, 2006.
Skeie GO et al. Guidelines for the treatment of autoimmune neuromuscular transmission
disorders. Eur Journ Neurol 2006;13:691-99.
UpToDate. Treatment and prevention of parvovirus B19 infection. Last updated May 14, 2006.
Available at:
http://www.utdol.com/utd/content/topic.do?topicKey=viralin/4441&type=A&selectedTitle=4~61.
Accessed: April 24, 2007.
Oregon Medicare Medical Policy, Intravenous Immune Globulin Therapy, Medical Policy
#10103, Review date: 01/01/06.
Feasby T, Banwell B, Benstead T, et al. Guidelines on the use of intravenous immune globulin
for neurologic conditions. Transfusion Medicine Reviews 2007;21:s57-107.
U.S. National Institutes of Health clinical trials registry. Available at:
http://www.clinicaltrials.gov/.
© 2015 RegenceRx. All rights reserved.
dru020.21
Page 23 of 26
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.
92.
93.
94.
Van Schaik IN, van den Berg LH, et al. Intravenous immunoglobulin for multifocal motor
neuropathy. Cochrane Database of Systemic Reviews 2005;(2): CD 004429.
European Federation of Neurological Societies/Peripheral Nerve Society Guideline on
management of multifocal motor neuropathy. Journal of the Peripheral Nervous System
2006;11:1-8.
Federuci O, Zochodne DW, et. al. Multifocal motor neuropathy improved by IVig: randomized,
double blind, placebo-controlled study. Neurology 2000;55(9):1256-62.
Kubori T, Mezaki T, et. al. The clinical usefulness of high-dose intravenous immunoglobulin
therapy for chronic inflammatory demyelinating polyneuropathy and multifocal motor
neuropathy. No To Shinkei 1999 Feb;51(2): 127-35.
Van den Berg RM, Franssen H, Wokke JH, et al. Multifocal motor neuropathy: diagnostic criteria
that predict the response to immunoglobulin treatment. Annals of Neurology 2000; 48(6): 919926.
Dendrinos S, Sakkas E, Makrakis E. Low-molecular-weight heparin versus intravenous
immunoglobulin for recurrent abortion associated with antiphospholipid antibody syndrome. Int J
Gynaecol Obstet. 2009;104(3):223-5.
Hizentra™ [package insert]. CSL Behring LLC: Kankakee, IL. March 2010.
Stephenson MD, Kutteh WH, Purkiss S, Librach C, Schultz P, et al. Intravenous immunoglobulin
and idiopathic secondary recurrent miscarriage: a multicentered randomized placebo-controlled
trial. Hum Reprod. 2010;25(9):2203-9. Epub 2010 Jul 15.
Anderson, D, Ali, K, Blanchette, V, et al. Guidelines on the use of intravenous immune globulin
for hematologic conditions. Transfus Med Rev. 2007 Apr;21(2 Suppl 1):S9-56. PMID: 17397769
Neunert, C, Lim, W, Crowther, M, et al. The American Society of Hematology (ASH) 2011
evidence-based practice guideline for immune thrombocytopenia. Blood. 2011 Apr
21;117(16):4190-207. PMID: 21325604
Elovaara, I, Apostolski, S, van Doorn, P, et al. European Federation of Neurological Societies
(EFNS) guidelines for the use of intravenous immunoglobulin in treatment of neurological
diseases: EFNS task force on the use of intravenous immunoglobulin in treatment of neurological
diseases. Eur J Neurol. 2008 Sep;15(9):893-908. PMID: 18796075
Patwa, HS, Chaudhry, V, Katzberg, H, Rae-Grant, AD, So, YT. Evidence-based guideline:
intravenous immunoglobulin in the treatment of neuromuscular disorders: report of the
Therapeutics and Technology Assessment Subcommittee of the American Academy of
Neurology (AAN). Neurology. 2012 Mar 27;78(13):1009-15. PMID: 22454268
Keogh, M, Sedehizadeh, S, Maddison, P. Treatment for Lambert-Eaton myasthenic syndrome.
Cochrane Database Syst Rev. 2011(2):CD003279. PMID: 21328260
Enk, A, European Dermatology Forum Guideline, S. Guidelines on the use of high-dose
intravenous immunoglobulin in dermatology. European journal of dermatology : EJD. 2009 JanFeb;19(1):90-8. PMID: 19171549
Gammaked® (immune globulin intravenous (Human) 10% solution) [package insert]. Cambridge,
MA: Kedrion Biopharma, Inc.; October 2010
Gamunex-C® (immune globulin intravenous (Human) 10% Caprylate/Chromatography Purified)
[package insert]. Research Triangle Park, NC: Grifols Therapeutics, Inc; June 2012
Gammagard liquid® (immune globulin intravenous (Human) 10% solution) [package insert].
Westlake Village, CA Baxter Healthcare Corporation; July 2012
Mofenson, LM, Brady, MT, Danner, SP, et al. Guidelines for the Prevention and Treatment of
Opportunistic Infections among HIV-exposed and HIV-infected children: recommendations from
CDC, the National Institutes of Health, the HIV Medicine Association of the Infectious Diseases
Society of America, the Pediatric Infectious Diseases Society, and the American Academy of
Pediatrics. MMWR Recomm Rep. 2009 Sep 4;58(RR-11):1-166. PMID: 19730409
Gammagard S/D® (immune globulin intravenous (Human) 5% solution) [package insert].
Westlake Village, CA Baxter Healthcare Corporation; December 2011
Facts & Comparisons 4.0 (electronic version, updated periodically). Wolters Kluwer Health, Inc.
© 2015 RegenceRx. All rights reserved.
dru020.21
Page 24 of 26
95.
96.
97.
98.
99.
100.
101.
102.
103.
104.
105.
Gordon, PA, Winer, JB, Hoogendijk, JE, Choy, EH. Immunosuppressant and immunomodulatory
treatment for dermatomyositis and polymyositis. Cochrane Database Syst Rev.
2012;8:CD003643. PMID: 22895935
Eftimov, F, Winer, JB, Vermeulen, M, de Haan, R, van Schaik, IN. Intravenous immunoglobulin
for chronic inflammatory demyelinating polyradiculoneuropathy. Cochrane Database Syst Rev.
2009(1):CD001797. PMID: 19160200
Hughes, RA, Swan, AV, van Doorn, PA. Intravenous immunoglobulin for Guillain-Barre
syndrome. Cochrane Database Syst Rev. 2012;7:CD002063. PMID: 22786476
Kälble T, Alcaraz A, et al. Guidelines on renal transplantation. Arnhem, The Netherlands:
European Association of Urology (EAU); 2009 Mar. [cited March 21, 2013]; Available from:
http://www.uroweb.org/fileadmin/tx_eauguidelines/2009/Full/Renal_Transplant.pdf
Newburger, JW, Takahashi, M, Gerber, MA, et al. Diagnosis, treatment, and long-term
management of Kawasaki disease: a statement for health professionals from the Committee on
Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the
Young, American Heart Association (AHA). Pediatrics. 2004 Dec;114(6):1708-33. PMID:
15574639
Dykewicz, CA, Centers for Disease, C, Prevention, Infectious Diseases Society of, A, American
Society of, B, Marrow, T. Summary of the Guidelines for Preventing Opportunistic Infections
among Hematopoietic Stem Cell Transplant Recipients. Clin Infect Dis. 2001 Jul 15;33(2):13944. PMID: 11418871
Dalmau, J. Opsoclonus myoclonus ataxia (Literature review current through May 2013). In:
Posner J, 21.4 (Ed). UpToDate, Waltham, MA, 2013.
Clinicaltrials.gov. “Cyclophosphamide and Prednisone With or Without Immunoglobulin in
Treating Abnormal Muscle Movement in Children With Neuroblastoma”. [cited 6/5/2013];
Available from: http://clinicaltrials.gov/ct2/show/NCT00033293
Dodel, R, Rominger, A, Bartenstein, P, et al. Intravenous immunoglobulin for treatment of mildto-moderate Alzheimer's disease: a phase 2, randomised, double-blind, placebo-controlled, dosefinding trial. Lancet neurology. 2013 Mar;12(3):233-43. PMID: 23375965
Takehara K, Ihn H, Sato S. A randomized, double-blind, placebo-controlled trial: intravenous
immunoglobulin treatment in patients with diffuse cutaneous systemic sclerosis. Clin Exp
Rheumatol. 2013 Mar-Apr;31(2 Suppl 76):151-6. Epub 2013 Jul 23. PubMed PMID: 23910617.
Hyqvia® [Immune Globulin Infusion 10% (Human) with Recombinant Human Hyaluronidase]
[package insert]. Westlake Village, CA Baxter Healthcare Corporation; September 2014.
© 2015 RegenceRx. All rights reserved.
dru020.21
Page 25 of 26
Appendix I: Primary Humoral Immunodeficiencies, as defined by the following diagnostic
criteria:
1. X-linked agammaglobulinemia (congenital agammaglobulinemia) diagnosis accompanied by
marked deficits or absence of all five immunoglobulin classes (IgG, IgM, IgA, IgE, and IgD),
decreased circulating B lymphocytes, and normal numbers of functioning T lymphocytes.
OR
2. Hypogammaglobulinemia (a general term describing serum levels of IgG which are below the
lower limits of normal).
OR
3. Common variable immunodeficiency (CVID; acquired hypogammaglobulinemia; adult onset
hypogammaglobulinemia; dysgammaglobulinemia) documented with low to normal IgG levels and
the inability to produce an antibody response to protein (e.g., tetanus) or carbohydrate antigens (e.g.,
Pneumovax).
OR
4. Immunoglobulin subclass deficiency (e.g., X-Linked immunodeficiency with hyper-IgM)
accompanied by very low serum concentrations of IgG, IgA, and IgE, with normal or, more
frequently, greatly elevated polyclonal IgM concentrations.
OR
5. Combined immunodeficiency syndromes, including Wiskott-Aldrich syndrome, accompanied by
marked deficits in IgG, IgA and IgM, low lymphocyte counts, and absent or below normal levels of
both B- and T-lymphocytes.
© 2015 RegenceRx. All rights reserved.
dru020.21
Page 26 of 26