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Roth K, Darwish C, Keller MD, Hammer B, Ahmed-Winston S, Escalante E, Madrigal V, Patrick D, Diab Y, Grant C, Hanisch B, Kahn I, Khan S, Moudgil A, Wistinghausen B. Implementation of a tier system for IVIG indications to address IVIG shortage at a tertiary care pediatric medical center. Pediatr Blood Cancer 2024; 71:e30871. [PMID: 38279890 DOI: 10.1002/pbc.30871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 12/15/2023] [Accepted: 01/02/2024] [Indexed: 01/29/2024]
Abstract
BACKGROUND Drug shortages are a common issue that healthcare systems face and can result in adverse health outcomes for patients requiring inferior alternate treatment. The United States recently experienced a national drug shortage of intravenous immunoglobulin (IVIG). Several reported strategies to address the IVIG and other drug shortages have been proposed; however, there is a lack of evidence-based methods for protocol development and implementation. OBJECTIVE To evaluate the efficacy of introducing a multidisciplinary task force and tier system of indications and to minimize adverse effects during a shortage of IVIG. METHODS Faculty members across disciplines with expertise in IVIG use were invited to participate in a task force to address the shortage and ensure adequate supply for emergent indications. A tier system of IVIG indications was established according to the severity of diagnosis, urgency of indication, and quality of supporting evidence. Based on inventory, indications in selected tiers were auto-approved. Orders that could not be automatically approved were escalated for task force review. RESULTS Overall, there were 342 distinct requests for IVIG during the study period (August 1, 2019 to December 31, 2019). All Tier 1 indications were approved. Of all requests, only 2.6% (9) of requests were denied, none of which resulted in adverse effects based on retrospective chart review. Seven patients who regularly receive IVIG had possible adverse effects due to dose reduction or spacing of treatment; however, each complication was multifactorial and not attributed to the shortage or tier system implementation alone. CONCLUSION Implementation of a multidisciplinary task force and tier system to appropriately triage high-priority indications for limited pharmaceutical agents should be considered in health institutions faced with a drug shortage.
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Affiliation(s)
- Kristina Roth
- Department of Pediatrics, Children's National Hospital, Washington, District of Columbia, USA
| | - Christina Darwish
- Department of Pediatrics, Children's National Hospital, Washington, District of Columbia, USA
| | - Michael D Keller
- Division of Allergy & Immunology, Children's National Hospital, Washington, District of Columbia, USA
| | - Benjamin Hammer
- Department of Pharmacy, Children's National Hospital, Washington, District of Columbia, USA
| | - Sameeva Ahmed-Winston
- Division of Blood and Marrow Transplantation, Children's National Hospital, Washington, District of Columbia, USA
| | - Enrique Escalante
- Division of Hospital Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Vanessa Madrigal
- Division of Intensive Care, Children's National Hospital, Washington, District of Columbia, USA
| | - DiAnthia Patrick
- Department of Pediatrics, Children's National Hospital, Washington, District of Columbia, USA
| | - Yaser Diab
- Division of Hematology & Oncology, Children's National Hospital, Washington, District of Columbia, USA
| | - Christina Grant
- Division of Genetics, Children's National Hospital, Washington, District of Columbia, USA
| | - Benjamin Hanisch
- Division of Infectious Diseases, Children's National Hospital, Washington, District of Columbia, USA
| | - Ilana Kahn
- Division of Neurology, Children's National Hospital, Washington, District of Columbia, USA
| | - Sairah Khan
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia, USA
| | - Asha Moudgil
- Division of Nephrology, Children's National Hospital, Washington, District of Columbia, USA
| | - Birte Wistinghausen
- Division of Blood and Marrow Transplantation, Children's National Hospital, Washington, District of Columbia, USA
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Lee JL, Mohd Saffian S, Makmor-Bakry M, Islahudin F, Alias H, Ali A, Mohamed Shah N. Prescribing Practices of Intravenous Immunoglobulin in Tertiary Care Hospitals in Malaysia: A Need for a National Guideline for Immunoglobulin Use. Front Pharmacol 2022; 13:879287. [PMID: 35754485 PMCID: PMC9218597 DOI: 10.3389/fphar.2022.879287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 05/20/2022] [Indexed: 11/13/2022] Open
Abstract
Rational use of drug involves the use of medicine as per clinical guidelines. Given the steady increase in the clinical utility of intravenous immunoglobulin (IVIG) either as licensed or off-label use, concerns are being raised about the possibility of supply shortages that could significantly impact patient care. Therefore, there is a need to regulate and to promote the rational use of this valuable medication. This cross-sectional chart review study attempts to evaluate the prescribing patterns of IVIG at two tertiary hospitals in Malaysia. Patients’ medical files and dispensing records were examined and compared with current guidelines. A total of 348 prescriptions for IVIG were written during the 1-year study period. The highest usage of IVIG was for neurological (47.9%), immunological (27.5%), and hematological conditions (20%). The number of prescriptions with the US Food and Drug Administration (FDA) licensed indications and off-label indications was 148 (42.5%) and 200 (57.5%), respectively. Age (OR: 1.02, 95% CI: 1.01–1.03, p = 0.003) and those admitted to the critical care units (OR: 11.11, 95% CI: 5.60–22.05, p < 0.001) were significant factors for receiving IVIG for an off-label indication. Most prescriptions (79%) had appropriate dosing. Significant factors associated with receiving inappropriate dose of IVIG include age (OR: 0.93, 95% CI: 0.89–0.97, p = 0.001) and those admitted to the critical care units (OR: 10.15, 95% CI: 3.81–27.06, p < 0.001). This study advocates the development and implementation of evidence-based clinical guidelines with prioritization protocol to ensure rational use of IVIG.
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Affiliation(s)
- Jian Lynn Lee
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia.,Department of Pharmacy, Tengku Ampuan Rahimah Hospital, Ministry of Health Malaysia, Selangor Darul Ehsan, Malaysia
| | - Shamin Mohd Saffian
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Mohd Makmor-Bakry
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Farida Islahudin
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Hamidah Alias
- Department of Pediatrics, UKM Medical Centre, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Adli Ali
- Department of Pediatrics, UKM Medical Centre, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Noraida Mohamed Shah
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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Choo SJ, Ng CZ, Ong YJ, Kamarul Baharin KS, Chang CT. Intravenous human immunoglobulin utilization patterns and cost analysis in a Malaysian tertiary referral hospital. J Pharm Policy Pract 2022; 15:31. [PMID: 35473939 PMCID: PMC9040375 DOI: 10.1186/s40545-022-00430-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/13/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction While intravenous human immunoglobulin therapy is potentially lifesaving for rare diseases, the significant costs associated with its usage warrant due attention. This study evaluated the costs and prescribing patterns of IVIg. Methods This was a retrospective analysis of medical records in a tertiary hospital. The evidence category IIA and below, as well as strength of recommendations level B and below were classified as lower evidence category and lower strength of recommendation, respectively. Patients’ demographic data, indications, dosing regimen, physician specialty were retrieved from medical records, while the cost was derived based on total prescribed doses. Results Out of 78 patients, more than half of the patients were prescribed with off-label IVIg based on MOHM Formulary (52, 66.7%), FDA indications (52, 66.7%) and EMA indications (46, 59.0%). 37 (47.4%) cases used IVIg for indications with lower evidence category and 52 (66.7%) cases with lower strength of recommendation. The total cost of IVIg use within the 2-year period was RM 695,426.36, with RM267,993.40 (38.5%) spent for indications with lower evidence category. Immunoglobulin use in rheumatology and neurology cases were associated with lower evidence category (p < 0.001). Conclusions A high proportion of off-label immunoglobulin use was observed. A timely update of prescribing policy, standardization of prescribing guidelines may promote appropriate immunoglobulin prescribing and justify expenses. Supplementary Information The online version contains supplementary material available at 10.1186/s40545-022-00430-2.
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Wang S, Tang Z, Zheng X, Deng J, Wang Z. Efficacy of human immunoglobulin injection and effects on serum inflammatory cytokines in neonates with acute lung injury. Exp Ther Med 2021; 22:931. [PMID: 34306200 PMCID: PMC8281239 DOI: 10.3892/etm.2021.10363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 10/15/2020] [Indexed: 12/02/2022] Open
Abstract
The present study aimed to explore the efficacy of intravenous immunoglobulin (IVIG) injection in neonates with acute lung injury (ALI) and assess its effects on serum inflammatory cytokine levels. The research subjects were 140 neonates with ALI who were evenly distributed into a control group (COG) and a study group (STG). The COG patients were treated routinely, whereas patients in the STG were administered IVIG in addition to the standard treatment received by the COG. The arterial partial pressure of oxygen (PaO2), PaO2/fraction of inspired oxygen (FIO2), mechanical ventilation time and hospitalization time were compared between the two groups. ELISA was used to determine the levels of interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) in the patients before treatment and at 12, 24 and 36 h after treatment. The Kaplan-Meier method was used to analyze the survival of the patients, including their survival for 30 days after treatment. The patients were divided into high and low cytokine expression groups based on their mean expression levels of serum IL-6 and TNF-α before treatment. After treatment, PaO2 and PaO2/FiO2 were significantly higher and mechanical ventilation and hospitalization time were reduced in the STG in comparison with the COG (all P<0.001). At 12, 24 and 36 h after treatment, serum IL-6 and TNF-α levels in the STG were lower than those in the COG (both P<0.05). The 30-day survival rate after treatment was not significantly different between the two groups (P>0.05). The 30-day survival rate in the high IL-6 and high TNF-α expression COG was lower than that in the low IL-6 and low TNF-α expression COG (both P<0.05). The results of the present study indicate that IVIG may improve pulmonary gas exchange, shorten the course of disease and reduce the inflammatory response in neonates with ALI.
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Affiliation(s)
- Shaohua Wang
- Neonatal Intensive Care Unit, Women and Children Health Institute of Futian, University of South China, Shenzen, Guangdong 518033, P.R. China
| | - Zanmei Tang
- Neonatal Intensive Care Unit, Women and Children Health Institute of Futian, University of South China, Shenzen, Guangdong 518033, P.R. China
| | - Xuemei Zheng
- Neonatal Intensive Care Unit, Women and Children Health Institute of Futian, University of South China, Shenzen, Guangdong 518033, P.R. China
| | - Jian Deng
- Neonatal Intensive Care Unit, Women and Children Health Institute of Futian, University of South China, Shenzen, Guangdong 518033, P.R. China
| | - Zhangxing Wang
- Neonatal Intensive Care Unit, Longhua People's Hospital, Shenzhen, Guangdong 518109, P.R. China
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