For the past several decades, immunoglobulin replacement therapy (abbreviated IgRT) has provided effective treatment for a variety of primary immunodeficiencies (abbreviated PI or PID), and the survival rate of patients with antibody deficiencies has increased dramatically since its introduction.1,2,3
|A quick reference for commonly used acronyms|
|PI or PID||Primary Immunodeficiency (Disease)|
|IgRT||Immunoglobulin Replacement Therapy|
|IgG||Purified Immunoglobulin Type G|
|QoL||Quality of Life|
Typically, IgRT therapy is administered either intravenously (through a vein, abbreviated IVIg) or subcutaneously (through the skin, abbreviated SCIg). A third route, intramuscular infusion (into a muscle, abbreviated IMIg) is no longer recommended because of its high rate of harmful infusion-related side effects (called adverse events).4 Both intravenous immunoglobulin and subcutaneous immunoglobulin therapies are viable for the treatment of patients with PI, and both administration routes have had a positive impact on reduction of doctor visits, hospital stays, and days missed from work or school because of illness.3,5
Each method of infusion has unique qualities that may be considered advantages or disadvantages, depending on the patient’s individual circumstances. Each patient’s response to treatment, unique medical needs, and lifestyle all play a role in determining which method of infusion is best for them. Take the time to talk to your healthcare provider to choose which administration route is best for you. Continue reading to learn more about how each route of administration might affect your particular quality of life (QoL).
Patients with antibody deficiencies are particularly vulnerable to bacterial infections, which can lead to a range of chronic illnesses.6 In addition to the burden of coping with these illnesses, PI diseases often also impose a significant burden on the quality of life of patients, including limitations on their work, sports, or regular physical activities.6 Time spent on doctor’s visits, taking antibiotics, and even stays in hospital because of infections represent one set of challenges.7 Managing therapy, tracking health, and coping with everyday life represent a second set of lifestyle challenges for the PI patient.
IgRT is often the therapy of choice for most PI-affected patients and has been found to have a positive effect on their health-related QoL, including less fear of future infections.8,9 However, these treatments do require significant lifestyle adjustments—and are usually required for life.6,8 For example, IVIg is typically administered by a nurse, either at home or in a healthcare setting, once every 3 to 4 weeks over 2 to 6 hours.9,10 SCIg is usually self-administered at home once or twice a week over 1 to 2 hours.9,10
Therefore, choosing the right product and route of administration is of utmost importance not only to suit your unique personal and medical needs but also for your overall quality of life.
The following are decision points you should consider and discuss with your healthcare provider when evaluating which route of administration is right for you.
Which form of Ig administration a patient prefers is an important factor that healthcare providers often consider when choosing between IVIg and SCIg.2 However, the options available for where a patient would prefer to receive their infusions (called the site of care) are also an essential factor when choosing the right product.2 Some options for site of care include:2
Although home-based treatment is an option for both IVIg and SCIg therapies, only SCIg offers the benefit of self-administration, which eliminates the need for a nurse’s supervision.2 Data from patient surveys show that many patients prefer the convenience and independence associated with the at-home, self-infusion options offered with SCIg.9
Being able to self-infuse at home is a unique benefit of SCIg; however, prescribers usually consider a range of factors before determining which site of care and route of administration is best for the patient. These specifics can include:2
The choice of which product to administer and where to administer it often depends on a joint decision-making process, where the prescriber’s judgement and patient’s preferences, medical, or individual needs, and sometimes insurance coverage, are all taken into account.8
Because with IVIg the full monthly dose of immunoglobulin is administered all at once directly into the patient’s bloodstream, it can often lead to a rapid and high rise in IgG concentration levels (called a peak), followed by a rapid fall over the next few days (called a trough).2,9 These peaks and troughs can be associated with mild to moderate unwanted side effects, called adverse events, and a drop in energy (fatigue) as the IVIg “wears off.”9,11 This “wear-off” is often a reason why some patients prefer SCIg over IVIg.11
Conversely, SCIg regimens that are given under the skin are associated with smaller and more frequent doses. This alternative dosing schedule can reduce the risks of the systemic adverse events (meaning harmful side effects that occur inside the body) typically associated with IVIg.9 The smaller doses and more regular intervals of SCIg can result in higher and more stable IgG trough levels than with IVIg, helping to avoid “wear off”.9 The downside to these regimens, however, is that the underlying skin tissue cannot accommodate large volumes of SCIg fluid.9 This requires that patients infuse smaller volumes, more often, and at more injection sites than is needed with IVIg administration.9 The amount of needle sticks and number of injection sites typically required to administer a full dose of SCIg can often lead to local adverse reactions (unwanted side effects that happen at the site of the injection).9
During an IVIg treatment session, a nurse who is trained in the administration of IVIg will use a single needle (called a catheter) to infuse the full monthly dose of prepared Ig formulation all at once directly into a patient’s vein.10
During an SCIg infusion, a patient or patient’s caregiver will use a needle set explicitly designed for SC infusions to inject the prepared dose under the skin.2,7 Depending on the patient’s individual tolerance to the therapy, these infusions can be given daily, weekly, biweekly, or every 3 to 4 weeks until the full monthly dose is infused.2,4,7 Multiple SC sites can be injected simultaneously into the skin on the belly, inner thighs, outer buttocks, upper arms, or lower back.7 Where to stick the needles and how many needles sticks will be required, depend on how much SCIg is going to be infused that day. Sometimes, only one injection site is required; other times, many sites are needed at once.7
Not all routes of administration are appropriate for all patients. For example, patients who may have difficulty accessing a vein may not be viable candidates for IVIg.2 Patients who do not have cognitive or fine motor abilities, or who may have a fear of needles, may not be able to self-infuse, so SCIg may not be the right option for them.2,8
Although each route of administration has unique qualities that may be advantages or disadvantages and may not be appropriate for every patient, the ultimate decision remains a patient-specific choice.2
Determining which method of IgRT administration is best for any given patient requires an assessment not only of the benefits of the therapy and preferences of the patient, but also of the risks. While the typical long-term safety of Ig preparations has been well established, and both IVIg and SCIg are well-tolerated and considered safe for most patients, adverse events can occur.2,5,7,12
Adverse events in patients undergoing IVIg therapy tend to be systemic (throughout the body) and are observed more often in patients who are new to IgRT.2 The most common systemic reaction reported in the literature is mild or moderate headache, which can occur either during or after an infusion.7,9,14 Other reactions can also include fatigue, fever, chills, or “flu-like” symptoms.14 On the other hand, systemic adverse events are rare with SCIg and most adverse reactions tend to be mild local site reactions that decrease over time, including localized swelling, redness, itching, and soreness.2,7,9,12,13
Check out our article comparing side effects of SCIg and IVIg routes of administration for additional details.
IgRT is the most widely encountered treatment option for patients with PI. There is good evidence that the therapy prolongs survival and reduces morbidity (or sickness).2,9 Both IVIg and SCIg have been shown to protect patients from serious bacterial infections and improve their health-related QoL.8,9
That said, several studies indicate that many patients prefer the autonomy and perceived health benefits associated with SCIg therapy.7 They reference preferences for:
However, SCIg is not for everyone. Those who prefer IVIg therapy cite dissatisfaction with several aspects of SCIg treatment:
Below (Table 1) is an overview of some of the primary differences between SCIg and IVIg therapies.
Table 1: A simplified overview of SCIg and IVIg therapies
|Who (lifestyle)2||Self-administered or administered by a caregiver
|Administered by a healthcare provider
|Where2||At home (or office, vacation, etc.)||At home or in a healthcare facility with nurse supervision|
|When2,4,7||Daily, weekly, biweekly, or every 3 to 4 weeks||Usually every 3 to 4 weeks|
|Administration (challenges)2||Subcutaneous (under the skin)
(Fear of self-administration; problematic if cognitive or fine motor ability are lacking)
|Intravenous (into a vein)
(Self-administration is not an option; problematic if venous access is difficult)
|Time to Infuse9,10||1 to 2 hours||2 to 6 hours|
|Absorption Rate2||Slow (Ig first has to diffuse through subcutaneous space into lymphatic system before entering the circulatory system via the thoracic duct)||Fast (Ig is administered directly into the circulatory system via a vein)|
|Ig Levels2||Steady state Ig levels||Peaks and troughs in Ig levels|
|Systemic Side Effects13||Infrequent||Common|
|Local Site Reactions13||Common||Infrequent|
Whether you choose IVIg or SCIg, the success of your Ig therapy experience not only depends on the knowledge, expertise, and support of your medical team but also your spirit of collaboration and participation.2 Although either route of Ig administration is appropriate for patients with PI, each one has its unique advantages and disadvantages. In the end, however, the choice of which route of Ig administration you would prefer will be up to you.2 Be sure to talk to your healthcare provider about your IgRT options and how each could affect the quality of your life.
The page contains general medical information that cannot safely be applied to any individual case. Medical knowledge and practice can change rapidly. Therefore, this page should not be used as a substitute for professional medical advice.
1. Perez EE, Orange JS, Bonilla F, et al. Update on the use of immunoglobulin in human disease: A review of evidence. J Allergy Clin Immunol. 2017;139(3):S1-S46.
2. Ness S. Differentiating characteristics and evaluating intravenous and subcutaneous immunoglobulin. Am J Care. 2019;25:S98-S104.
3. McCusker C, Upton J, Warrington R. Primary immunodeficiency. Allergy Asthma Clin Immunol. 2018;14(Suppl 2):61-71.
4. Perez EE. Immunoglobulin use in immune deficiency and autoimmune disease states. Am J Manag Care. 2019 Jun;25(6 Suppl):S92-S97.
5. Chapel H, Prevot J, Gaspar HB, et al. Primary immune deficiencies – principles of care. Front Immunol. 2014;5(627):1-12.
6. Routes J, Costa-Carvalho BT, Grimbacher B, et al. Health-related quality of life and health resource utilization in patients with primary immunodeficiency disease prior to and following 12 months of immunoglobulin G treatment. J Clin Immunol. 2016;36:450-461.
7. Kobrynski L. Subcutaneous immunoglobulin therapy: a new option for patients with primary immunodeficiency diseases. Biologics. 2012;6:277-287.
8. Zuizewind CA, van Kessel P, Kramer CM, et al. Home-based treatment with immunoglobulins: an evaluation from the perspective of patients and healthcare professionals. J Clin Immunol. 2018;38:876-885.
9. Espanol T, Prevot J, Drabbwell J, et al. Improving current immunoglobulin therapy for patients with primary immunodeficiency: quality of life and views on treatment. Patient Prefer Adherence. 2014;8:621-629.
10. Immune Deficiency Foundation. IDF Guide to IG Therapy. Epland K, Perez EE. Townson, MD: Immune Deficiency Foundation; 2018.
11. Anterasian C, Duong R, Gruenemeier P, et al. Quality of life differences for primary immunodeficiency patients on home SCIG versus IVIG. J Clin Immunol. 2019;39:814-822.
12. Wasserman RL. Common infusion-related reactions to subcutaneous immunoglobulin therapy: managing patient expectations. Patient Prefer Adherence. 2008(2):163-166.
13. Skoda-Smith, Torgerson, Ochs. Subcutaneous immunoglobulin replacement therapy in the treatment of patients with primary immunodeficiency disease. Ther Clin Risk Manag. 2010;6:1-10.
14. Bonilla FA. Intravenous immunoglobulin: adverse reactions and management. J Allergy Clin Immunol. 2008;122:1238-1239.