Single-Center Experience of Outcomes and Prescribing Patterns of IV Immunoglobulin Use in Critically Ill Patients

Heather Torbic; Sinan Samir Abdul-Wahab; Sravanthi Ennala; Nagamani Guduguntla; Xiaozhen Han; Xiaofeng Wang; Abhijit Duggal; Sudhir Krishnan

doi:10.1097/CCE.0000000000000314

Single-Center Experience of Outcomes and Prescribing Patterns of IV Immunoglobulin Use in Critically Ill Patients

Crit Care Explor. 2021 Jan 11;3(1):e0314. doi: 10.1097/CCE.0000000000000314. eCollection 2021 Jan.

Authors

Heather Torbic¹, Sinan Samir Abdul-Wahab², Sravanthi Ennala³, Nagamani Guduguntla⁴, Xiaozhen Han⁵, Xiaofeng Wang⁵, Abhijit Duggal⁶, Sudhir Krishnan⁶

Affiliations

¹ Department of Pharmacy, Cleveland Clinic, Cleveland, OH.
² Department of Internal Medicine, Mountainview Regional Medical Center, Las Cruces, New Mexico.
³ Department of Internal Medicine, Cleveland Clinic, Cleveland, OH.
⁴ Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, OH.
⁵ Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH.
⁶ Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH.

Abstract

Previous literature has not compared prescribing practices of IV immunoglobulin in medical ICU survivors and nonsurvivors. The objective of this study was to study IV immunoglobulin use in patients admitted to a medical ICU evaluating differences between hospital survivors and nonsurvivors in regards to level of evidence supporting use, prescribing patterns, and cost.

Design: Retrospective, observational study.

Setting: Single, academic medical center medical ICU.

Patients: Adults who received greater than or equal to 1 dose of IV immunoglobulin during their medical ICU admission from 2011 to 2018.

Interventions: Prescribing patterns, level of evidence supporting use, and cost.

Measurements and main results: A total of 389 patients received greater than or equal to 1 dose of IV immunoglobulin for 46 discrete indications and 36.5% of indications had low-quality data supporting use of IV immunoglobulin. The primary indication for IV immunoglobulin was hypogammaglobulinemia (35.5%) followed by antibody-mediated lung transplant rejection (15.4%). Nonsurvivors received lower median dosing (g/kg) and number of doses compared with survivors (0.4 g/kg [0.4-1 g/kg] vs 0.5 g/kg [0.4-1 g/kg] [p = 0.0003] and 1.0 [1-2] vs 2 [1-3] doses [p = 0.0001], respectively). Dosing was based on ideal body weight in 258 patients (66%). High-quality data supported IV immunoglobulin use in 15 patients (4%). The median cost per dose of IV immunoglobulin in nonsurvivors was $4,893 ($4,078-$8,155) versus $5,709 ($4,078-$10,602) in survivors (p = 0.04).

Conclusions: IV immunoglobulin is prescribed for many indications in the medical ICU with low-quality evidence supporting its use and dosing regimens are variable. Hospital survivors received a higher dose and greater number of doses of IV immunoglobulin compared with nonsurvivors. National guidelines are needed to help inform IV immunoglobulin utilization and reduce healthcare costs.

Keywords: critical care; intravenous immunoglobulin; mortality; prescribing patterns.