Utilization Management Guidelines
Best Practice Recommendations
For Immune Globulin (IG) stewardship in Ontario, it is crucial to follow these key recommendations when providing patient care:
IG is only prescribed where there is evidence to support use, and
- Alternative therapies have failed or are not feasible / available
- IG dose is prescribed as per adjusted body weight calculator criteria
- Use should be discontinued if benefit is not demonstrated
- For continued use (i.e., maintenance therapy) the evaluation of clinical effectiveness must:
- Be performed 6 months after initiation of therapy and at minimum annually thereafter
- Include adjustment to the lowest effective dose and/or greatest treatment interval
- Consider trials of alternative therapies where appropriate
ORBCoN is funded by the Ontario Ministry of Health to develop, distribute, promote and educate users on blood utilization management, including IG utilization best practices. The list of medical conditions found on this page is per version 5.0 of the Ontario Immune Globulin Utilization Management (IGUM) document. (The full version document can be downloaded from the link on the right side of this page) The additional indications incorporated within version (5.0) are largely adopted with permission from the Criteria for the Clinical Use of Immune Globulin document. This document was the output of the Prairie Collaborative Immune Globulin Utilization Management Framework Project, a collaboration of an Inter-Provincial Medical Expert Committee, the Institute of Health Economics of Alberta, the Alberta Ministry of Health, Shared Health Manitoba, and the Saskatchewan Ministry of Health.
This summary of medical conditions and information on IG utilization has been prepared specifically for use in Ontario, based on the input from the Ontario IG Advisory Panel. There may be new evidence to support IG use in other medical conditions since publication of the Prairie Collaborative document that has not been included in the Ontario IGUM version (5.0) document. New evidence will be evaluated in the future comprehensive revision of the Criteria for the Clinical Use of Immune Globulin document.
This information is intended as supportive for prescribers of IG seeking clarification on the common and clinically appropriate uses of IG. Unless specifically indicated, use applies to both Intravenous (IVIG) and Subcutaneous (SCIG) forms of IG. The use of SCIG should be evaluated based on patient medical condition as well as ability to tolerate and self administer.
The MOH request forms for IVIG (neurology and non-neurology) and SCIG
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DownloadIn instances when longer term or repeat treatment is required, continued use of IG should be based on objective measures of effectiveness established at the outset of treatment. These measures should be assessed no later than 6 months after initiation of long-term treatment and at least annually thereafter. If clinical effectiveness has not been achieved or sustained, IG should be discontinued.
In instances when longer term or repeat treatment is required, continued use of IG should be based on objective measures of effectiveness established at the outset of treatment. These measures should be assessed no later than 6 months after initiation of treatment and at least annually thereafter. If clinical effectiveness has not been achieved, IG should be discontinued.
Hematopoietic stem cell transplant (HSCT), allogeneic, Cytomegalovirus (CMV)-induced pneumonitis
H7-HCST
Vaccine induced immune thrombotic thrombocytopenia (VITT) / vaccine induced prothrombotic immune thrombocytopenia (VIPIT)
H13-VITT
Aim to use the dose that achieves a significant reduction in the number of infections. SCIG and IVIG are equally effective. Continued use of IG should be based on objective measures of effectiveness established at the outset of treatment. These measures should be assessed no later than 6 months after initiation of treatment and at least annually thereafter by a physician with recognized expertise in immunodeficiency disorders.
In instances when longer term treatment is required, continued use of IG should be based on objective measures of effectiveness established at the outset of treatment. These measures should be assessed no later than 6 months after initiation of treatment and at least annually thereafter. If clinical effectiveness has not been achieved, IG should be discontinued.
Autoimmune encephalitis mediated by antibodies (AMAE) targeting cell-surface antigens
N2-AMAE
Multiple Sclerosis (MS) – Relapsing remitting multiple sclerosis (RRMS), short-term therapy
Myelin Oligodendrocyte Glycoprotein antibody-associated disorders (MOGAD) – pediatric
N9-MOGAD
Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS)
N16- PANDAS
Polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, skin changes (POEMS) syndrome
Vasculitic neuropathy as part of a systemic disorder (systemic vasculitis affecting the peripheral nervous system)
N15-VN
In instances when longer term treatment is required, continued use of IG should be based on objective measures of effectiveness established at the outset of treatment. These measures should be assessed no later than 6 months after initiation of treatment (unless specifically indicated) and at least annually thereafter. If clinical effectiveness has not been achieved, IG should be discontinued.
Juvenile Idiopathic Inflammatory Myopathy (J-IIM)(Previously Juvenile Dermatomyositis)
R5-JIIM
Multisystem inflammatory syndrome in children (MIS-C) associated with SARS-CoV-2/COVID-19 infection
R8-MISC
In instances when longer term treatment is required, continued use of IG should be based on objective measures of effectiveness established at the outset of treatment. These measures should be assessed no later than 6 months after initiation of treatment (unless specifically indicated) and at least annually thereafter. If clinical effectiveness has not been achieved, IG should be discontinued.
Community-acquired respiratory virus (CARV), upper respiratory tract infection (URTI) in high-risk patients
T1-CARV/URTI
Solid organ transplant, active antibody-mediated rejection (ABMR) prevention and management
T3-ABMR
Solid organ transplant, ongoing desensitization, prevention or treatment of graft rejection
T4-DGR
In instances when longer term treatment is required, continued use of IG should be based on objective measures of effectiveness established at the outset of treatment. These measures should be assessed no later than 6 months after initiation of treatment (unless specifically indicated) and at least annually thereafter. If clinical effectiveness has not been achieved, IG should be discontinued.
