IVIg vs. SCIg

Immunoglobulin replacement therapy is generally administered either intravenously (IVIg), or subcutaneously (SCIg). IVIg administration every 3 to 4 weeks and weekly SCIg are regarded as therapeutically equivalent treatments for PIDD and CIDP. The healthcare provider and patient or caregiver should discuss which route of administration is most appropriate for each patient.¹

IVIg

Intravenous Immunoglobulin (IVIg) infusions are given by a medical professional through an IV cannula in the arm every 3-4 weeks at a specific, prescribed dose. These treatments must be scheduled in advance and are typically done in an infusion suite, physician office, or at home. For patients with poor venous access, subcutaneous immunoglobulin (SCIg) should be the considered route of Ig administration.

Some common side effects of IVIg include headache, nausea, fever and chills, flushing, wheezing, vomiting, backache, muscle aches, joint aches, or chest tightness. In most cases, these side effects are related to the rate of the infusion.²

SCIg

Subcutaneous Immunoglobulin (SCIg) infusions are given by slowly administering immunoglobulin into fatty tissue (subcutaneous layer) just underneath the skin using an electronic or mechanical infusion pump (such as our Freedom syringe drivers) or by manual push by hand with a syringe. Typical infusion sites are the abdomen, thighs, or outer buttocks. Local site reactions are the most common side effects of SCIg.²

The total monthly dose, number of infusion sites (needles) and flow rate tubing is calculated by the pharmacist or other health care provider depending on the body weight, volume and the concentration of the SCIg medication to be infused.

SCIg is typically self-administered and can be done at home, thus eliminating the need for monthly hospital or infusion center visits. This allows patients more flexibility and promotes independence.² 

Deciding What’s Best for You

If you are new to treatment, make sure you talk to your healthcare provider when deciding which option is best for you. Here is a breakdown of the differences between IVIg and SCIg.⁴

References:

1. Institute of Allergy and Infectious Diseases. Primary immune deficiency diseases (PIDDs). niaid.nih.gov/diseases-conditions/primary-immune-deficiency-diseases-PIDDs. Accessed Aug 19, 2020
2. Immune Deficiency Foundation. IDF Guide to IG Therapy, 6th Edition. 2018. primaryimmune.org
3. Shrestha et al. Impact of IVIG vs. SCIG on IgG trough level and infection incidence in primary immunodeficiency diseases: A systematic review and meta-analysis of clinical studies. World Allergy Organization Journal (2019) 12: 10068
4. Shapiro R. Subcutaneous Immunoglobulin. Immunol Allergy Clin NA. 2020. In press.

Related Publications

Subcutaneous immunoglobulin replacement in primary immunodeficiencies

Quantitative Evidence of Wear-Off Effect at the End of the Intravenous IgG (IVIG) Dosing Cycle in Primary Immunodeficiency

Impact of IVIG vs. SCIG on IgG Trough Level and Infection Incidence in Primary Immunodeficiency Diseases: A Systematic Review and Meta-Analysis of Clinical Studies

Poster: Patient IVIg to SCIg Case Study

Optimizing Infusions

Several variables involved with SCIg allow optimization of the infusion experience for patients. Some of these variables include number of needle-sticks, infusion sites, volume infused/site, needle length and pump type.

SCIg is delivered using a small needle attached to tubing and a syringe that is placed in a mechanical pump or an electronic programmable pump. Both pumps are portable. Several needle and tubing sizes are available for mechanical pumps and troubleshooting problems with SCIg often involves reviewing that the equipment being used, such as needle sets, tubing, and pump are appropriate for the individual receiving the therapy.

Choosing an Infusion Device

There are different options when it comes to infusion pumps and devices, the main two being electronic pumps (constant flow systems) and mechanical pumps (constant pressure systems).

Constant Flow Systems	Constant Pressure Systems (KORU Freedom systems)
Electronic devices	Mechanical devices
Programmed to a specific flow rate	No programming
Respond to tissue saturation by increasing pressure	Respond to tissue saturation by slowing down the infusion to maintain the same safe pressure throughout the infusion

Dynamic Equilibrium

Our Freedom infusion systems are designed to function based on how well the patient's body absorbs medication. This benefit, known as DynEQ® (Dynamic Equilibrium), means that the system responds to building pressure in the subcutaneous tissue during SCIg infusions, by slowing down the infusion to ensure a balanced infusion.

Selecting the Right Infusion Device

Secrets to Finding the Best Infusion Sites

Infusion Pump Design for SCIg

Needle Design

If the patient is having local site reactions, the healthcare provider can consider changing the needle type before changing the medication. Compared with tricuspid needles, lancet-type needles may cause more coring of the skin, resulting in increased bleeding and tissue trauma.  The tricuspid needle tip design of HigH-Flo Subcutaneous Safety Needle Sets™ minimizes damage and scarring, resulting in less site reactions.¹

 Importance of Ancillary Supplies for Subcutaneous Immunoglobulin Infusion

Troubleshooting SCIg Site Reactions

When patients are trained correctly, site reactions could become a rare occurrence. When site reactions do occur, patients can experience redness, irritation, drug leakage, itching, pain, and discomfort.

Flow Rate

Selecting the correct flow rate tubing is important when starting SCIg therapy. It may be trial and error to find which flow rate works best for you/your patients. For patients who experience site reactions, a slower flow rate tubing set is recommended.

The Freedom infusion systems slow down the infusion automatically if the resistance in the tissue increases. However, by choosing the slower flow rate, it is possible to minimize or prevent the tissue saturation.

Needle Length

Choosing the correct needle length is very important when getting started on SCIg. Every ‘body’ is different but generally: infants use 4 mm, children (up to age 9) and patient sites with extremely low body fat use 6 mm, over age 9 and adults use 9 mm and/or 12 mm, and very large adults use 14 mm.¹

Incidence of Drug Leakage When Giving SCIg and fSCIg Treatments

Short needles can cause:

Leaking from the sites

Bumps around the sites

Needle site discomfort

Extended infusion times 

Dry Priming

It is recommended to insert the needles dry, as drug leaking needles can cause irritation to the site.³

Reducing Incidences of Local Infusion Site Reactions

Drug Volume

Volume per site is a key factor to consider, especially because every body-type is different. Patients with more adipose/fatty tissue will be able to accept Ig easier. Thinner patients may experience longer infusion times and more substantial site reactions. The volume per site needs to be weighed against the subcutaneous tissue available. Many times, spreading the volume out to more sites will help keep volume per site low and can eliminate site reactions.²

Site Location

The abdomen is the most common place to infuse, but the upper buttocks/side of upper hips, the outer side of the thighs, and the back of the upper arms are also used. It is important that the site(s) chosen has a good amount of subcutaneous tissue. Some medications require that sites be 2+ inches (5 cm) apart, and that the needles are inserted at a 90° angle. If and how to rotate infusion sites should be a subject for discussion between the patient and healthcare provider. You may achieve better results by periodically returning to sites that have worked well in the past.³

Adhesive Dressing

The dressing used can make a difference. 3M Tegaderm™ dressing, provided with every HIgH-Flo subcutaneous needle set, provides gentle adhesion without building to excessive levels over time, for easy removal.⁴ To release the adhesive, pull and stretch it out horizontally parallel to the skin. Any redness to skin should be only temporary.

References:

1. Duff et al. Importance of Ancillary Supplies for Subcutaneous Immunoglobulin Infusion. J Infus Nurs. 2013; 36:384-390
2. Younger ME et al. Nursing Guidelines for Administration of Immunoglobulin Replacement Therapy. J Inf Nurs. 2013; 36:58-64
3. Duff et al. Nuts and Bolts of Subcutaneous Therapy. Immunol Allergy Clin N Am 2020; 40:527-537
4. 3M, 3M™ Tegaderm™ Transparent Film Dressings Product Profile, https://multimedia.3m.com/mws/media/447983O/tegaderm-transparent-film-dressing-brochure.pdf Accessed Aug 19, 2020.

Related Publications

Importance of ancillary supplies for subcutaneous immunoglobulin infusion: management of the local infusion site

Nursing guidelines for administration of immunoglobulin replacement therapy

Nuts and Bolts of Subcutaneous Therapy

Quality Improvement Study to Evaluate Patient-Centered Outcomes and Infusion Parameters Using the HIgH-Flo Super26