Practice Guidelines

Prescribing intravenous immunoglobulin: summary of Department of Health guidelines

BMJ 2008; 337 doi: http://dx.doi.org/10.1136/bmj.a1831 (Published 20 October 2008) Cite this as: BMJ 2008;337:a1831
  1. Drew Provan, consultant haematologist1,
  2. Helen M Chapel, consultant immunologist2,
  3. W A Carrock Sewell, consultant immunologist and visiting professor of immunology3,
  4. Denise O’Shaughnessy, senior medical adviser4
  5. on behalf of the UK Immunoglobulin Expert Working Group
  1. 1Department of Haematology, Barts and the London NHS Trust, The Royal London Hospital, London E1 2ES
  2. 2Nuffield Department of Medicine, University of Oxford, and Oxford Radcliffe Hospitals NHS Trust, Oxford OX3 9DU
  3. 3Scunthorpe General Hospital, North Lincolnshire and Goole NHS Trust, North Lincolnshire DN15 7BH
  4. 4Blood Policy Unit, Department of Health, London SE1 6LH
  1. Correspondence to: D Provan a.provan{at}virgin.net
  • Accepted 9 August 2008

Why read this summary?

Therapeutic immunoglobulin, a preparation of normal human polyclonal immunoglobulin G derived from pooled human plasma, has become an important treatment option in a range of medical conditions beyond its use in immune deficiencies, particularly autoimmune and acute inflammatory diseases.1 For some time, concern has been expressed over the availability of immunoglobulin. Severe global supply shortages began in the late 1990s, when demand exceeded supply by up to 30%,2 and production problems specific to the United Kingdom have curtailed supply. This supply shortage has been compounded by increasing use in established indications3 and widespread off-label prescribing.4 To ensure that supply is maintained, even in times of acute shortage, for the patients considered to be the highest priority because of a risk to life without treatment, potential prescribers of immunoglobulin need help in identifying treatment indications for which its use is appropriate. This article summarises the most recent Department of Health guidelines on prescribing intravenous immunoglobulin, published in May 2008.5

Recommendations

Recommendations are based on systematic review of evidence based guidelines and Cochrane reviews, supplemented by expert opinion. The level of evidence for each indication is indicated as Ia, Ib, IIa, IIb, III, or IV; the grade of recommendation is given as A, B, C, or D. Our approach was adapted from the system used by the Agency for Healthcare Policy and Research (US Department of Health and Human Services).6

Recommendations are colour coded to reflect treatment prioritisation. Red indicates conditions for which treatment is considered the highest priority because of a risk to life without treatment, and blue indicates conditions for which, although the evidence base is reasonable, the priority is moderate because other treatments are available (see figure). Box 1 lists those conditions for which the evidence base is weak (these are known as …

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