ASHP Midyear: Optimizing IVIG Therapy for BK Nephropathy in Kidney Transplant Patients Can Improve Outcomes

Pharmacists play a crucial role in optimizing IVIG treatment for BK nephropathy in kidney transplant recipients, according to Ashton Coker, PharmD, PGY 1 resident from the Medical University of South Carolina. They can provide education to health care providers on the conflicting evidence supporting the use of intravenous immunoglobulin (IVIG), and discuss trends observed in medication use evaluations, such as patients with higher weights or lower baseline BK viral loads being more likely to clear the virus with IVIG. Pharmacists can also ensure appropriate reductions in immunosuppression medications are made prior to and during IVIG therapy. Additionally, pharmacists can collaborate with nephrologists and other providers to determine the most suitable patients for IVIG, and ensure proper dosing, infusion rates, and durations are used. Importantly, pharmacists can educate nurses on monitoring patients for common infusion reactions like headache, nausea, and fever, and the appropriate use of pre-medications like acetaminophen and diphenhydramine.

Pharmacy Times: How can pharmacists help to optimize the use of IVIG in kidney transplant recipients with BK nephropathy?

Ashton Coker: So pharmacists can help optimize IVIG treatment for BK nephropathy in our kidney transplant recipients by providing an education to our providers regarding the conflicting evidence supporting its use. So in our medication use evaluation at the Medical University of South Carolina, some trends that we discovered is patients that were treated with IVIG were more likely to clear the virus if they were of higher weights or had lower baseline BK viral loads. So this information can be discussed with our providers in order to make a shared clinical decision on if the therapy is appropriate. Another way is we as pharmacists can also ensure that appropriate reduction of immunosuppression medications are done prior to completed IVIG therapy.

Pharmacy Times: What are the key monitoring parameters for patients receiving IVIG therapy, and how can pharmacists help identify and manage potential adverse effects?

Coker: A common adverse effect of IVIG therapy are infusion reactions. So this provides an opportunity for pharmacists to educate nurses on how to appropriately monitor these patients. So the key monitoring parameters are going to be our vital signs. So typically, vital signs should be monitored prior to the infusion, and then every 15-to-30 minutes throughout the infusion, and patients should also be monitored for at least an hour after completing the infusion. Some size of infusion reactions include headache, nausea, muscle aches, flushing, and fever. So typically, these infusions require pre medication with acetaminophen and diphenhydramine. Some hospital protocols may also recommend the use of prophylactic steroids prior to IVIG administration. Usually for the first administration of the infusion, patients will receive a less concentrated formulation infused at a slower rate, and then once a patient is able to show that they tolerate the infusion, then a more concentrated formulation and higher or increased infusion rates can be used for future doses.

Pharmacy Times: How can pharmacists collaborate with nephrologists and other health care providers to optimize IVIG therapy?

Coker: So pharmacists can collaborate with nephrologists and other health care providers in order to determine the most appropriate patient for IVIG therapy. Pharmacists can also ensure that appropriate doses, infusion rates, concentrations and duration of therapy are used., and then, as previously highlighted, pharmacists should also collaborate to ensure that appropriate immunosuppression reduction is done prior to and in conjunction with IVIG therapy.