Optimizing Use of Intravenous Immunoglobulin

Jun 1, 2013
Optimizing the Use of Intravenous Immunoglobulin in Chronic Inflammatory Demyelinating Polyneuropathy. Presented at the 2013 American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting.

Purpose: Chronic inflammatory demyelinating polyneuropathy (CIDP) is an autoimmune disorder affecting the peripheral nerves with progressive weakness of upper and lower extremities. Intravenous immunoglobulin (IVIG) has been shown to improve neuromuscular impairment and reduce relapse in CIDP. Initial information suggests that many CIDP patients are not being prescribed optimal dosing. A therapy management program was developed to guide the assessment of CIDP patients and selection of an appropriate IVIG dosing regimen. The aim of this report is to evaluate the impact of the CIDP Optimal Regimen Evaluation (CORE) therapy management program on prescriber dosing and patient disease score.  

Methods: The CIDP program is an evidence-based, five-step algorithmic loop: dose assessment, patient initial assessment, physician engagement, patient reassessment, and physician re-engagement.  A retrospective review of CORE program records for patients receiving at least one dose of IVIG for CIDP between 1/1/2010- 2/25/2013 was performed. Patients were risk-ranked by dosing regimen per CORE rationale. Pharmacist-physician engagements followed CORE protocol: patients ranked as potential medium or high risk and a disease score greater than or equal to four generate a recommendation to increase dose/shorten interval; patients ranked as potential low risk with a disease score of less than four over two consecutive reassessment periods generate a recommendation to decrease dose/lengthen interval.  Follow-up disease scores were performed at a minimum of every 24 weeks and compared against previous assessment.

Results: The study sample included 772 CIDP patients under the CORE protocol.  A total of 349 (45%) patients reported initial disease score of greater than or equal to 4, with 33 (9.5%) of those patients requiring physician engagement to recommend an IVIG regimen increase. Two patients required physician engagement recommending regimen reduction (0.57%). Of the 35 total physician engagements to adjust the dosing regimen, 19 (54%) accepted the recommendation, while 16 (46%) declined.  Patient outcomes were assessed using the 35 patients potentially needing regimen changes.  Follow-up scores were available for all 35: of the 19 accepted dose change patients, 12 (63%) had an improved disease score of 1 or more over baseline, while only 4 (25%) patients in the group where regimen changes were rejected had similar improvement in disease scores at follow-up.

Conclusions: The CORE program effectively evaluates IVIG therapy in CIDP patients and supports physician prescribing for optimal dosing regimens.  Results demonstrated a tendency toward under-prescribing of IVIG dose or duration for CIDP.  When specifically reviewed by a pharmacist, in concert with disease score, approximately half of the recommended dose changes were accepted. In those patients where the recommendations were accepted versus not accepted, patient outcomes showed a trend towards improvement.