P53 A review of the use of intravenous immunoglobulin (IVIG) in paediatric neurology patients at a children’s hospital from April 2017 to April 2019
Authors: Stillwagon Olivia 
Published: August 2020

Aim

To determine if the use of IVIG in neurology patients at a children’s hospital was appropriate according to local1 and national guidance2 3.

Method

All paediatric neurology patients supplied with IVIG from the hospital pharmacy from April 2017 to April 2019 were identified retrospectively using the pharmacy dispensing system. The standards were based on local and national guidelines from the Department of Health (DoH). Patients’ details, for example indication and dose, were recorded and analysed on Microsoft Excel.

Standards

100% of patients will have an IVIG request form completed.

100% of patients will have IVIG prescribed for indications approved by the DoH.

100% of patients will have panel approval before being supplied with IVIG.

100% of patients will have the appropriate dose and duration of IVIG for the corresponding indication according to guidelines.

Results

A total of 20 patients were identified for this audit with 4 patients from 2017/18 and 16 from 2018/19. Standard 1 was met by 100% of patients. 8 patients (40%) were given IVIG for indications that do not have automatic approval from the DoH guidelines, i.e. for indications under ‘grey’ or ‘black’ categories. 2 patients (10%) did not have panel approval and both of these patients had acute flaccid myelitis, which is a ‘black’ indication. 16 (80%) patients were prescribed IVIG at a dose or duration advised by local and DoH guidelines.

Conclusion and Discussion

During the study period the method for completing the IVIG request forms changed to a new electronic system. The two patients with acute flaccid myelitis were incorrectly approved by the IVIG panel due to an error in the new electronic request form. The approval system was updated to prevent this error from reoccurring. All other patients that did not have automatic approval from the DoH guideline were approved by the local IVIG panel before use. Overall cost and usage increased significantly from 2017/18 to 2018/19; approximately £9,300 and £57,000 respectively. One patient was given a higher dose over a shorter period but the total dose for each course was the same. The shortened regimen meant that doses were rounded to the nearest vial size, which reduced wastage. The demand for IVIG is increasing and due to its limited availability and high cost, it is important that IVIG is only given to patients that meet the specified requirements.

Recommendations

Ensure patients are only supplied with IVIG if the above standards are met

Neurology pharmacist to re-audit data annually to ensure that IVIG is being given according to guidelines

References

Pharmacists in a children’s hospital. 2017. Clinical guideline: human intravenous immunoglobulin (Privigen 100 mg/ml).

Department of Health. Clinical Guidelines for Immunoglobulin Use. 2011. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/216671/dh_131107.pdf

Department of Health. Updated Commissioning Criteria for the use of therapeutic immunoglobulin (Ig) in immunology, haematology, neurology and infectious diseases in England January 2019. Available from: http://igd.mdsas.com/wp-content/uploads/Ig-PWG-Guidance-for-the-use-of-Ig-V1.3-12022019.pdf