Ontario’s Immunoglobulin Advisory Panel: Ongoing stewardship of a valuable resource over the last 15 years.
Lois Shepherd, MDCM, FRCPC, Chair, IGAP
Laura Aseltine, MLT, BSc., Ontario Regional Blood Coordinating Network
The use of Immunoglobulin (IG) has been increasing on average, by approximately 10% per annum for more than the last two decades. It is the most expensive product issued by volume, accounting for almost half of the Canadian Blood Services budget. These costs are shared among the Provinces and Territories excluding Quebec.
Results of the first Ontario IG use audit undertaken by ORBCoN in 2007 were presented in 2008 to the Blood Program Coordinating Office of the Ministry of Health. Eight recommendations were generated, the first of which was to develop and adopt an Ontario provincial guideline for use of IVIG.
In 2009, ORBCoN launched the Ontario IVIG Utilization Management Guidelines (version 1.0) based on National Guidelines for the IVIG use in Hematology, Neurology, Immunology, and Solid Organ Transplant. A toolkit was also provided to assist hospitals with implementation.
In 2011, due to rising utilization and costs of both intravenous (IV) and subcutaneous (SC) IG the Immune Globulin Advisory Panel (IGAP) was convened as a subcommittee of the Ontario Blood Consultation Group to address these challenges. IGAP now serves as a broad-based advisory group to the Ministry of Health’s Provincial Utilization Management Strategy, managed through ORBCoN.
A second IG audit conducted in 2011, identified that only a minority of hospitals had adopted the 2009 guidelines and request form included in the toolkit, and concluded ongoing sub-optimal use of IG. The Ontario Ministry of Health and Long-Term Care (MOHLTC) then introduced its first Ontario IG Utilization Management Strategy in 2012. A third audit led by IGAP in 2015, demonstrated continued sub-optimal use of IG, lack of compliance with the request form, and insufficient documentation of diagnostic criteria to suggest desired patient outcome.
In 2017, an IG order screening pilot project was undertaken where all requests for neurological indications were submitted to a centralized team to determine approval. Any questionable / sub-optimal orders for IG were forwarded for adjudication by experts in this field. This project was a manual, paper-based process and was determined to be labour and resource intensive. However, the results of this project confirmed continued requests for indications and dosing not listed in the Ontario guidelines.
It has now been 6 years (2018) since version 4.0 of the guidelines was released. Since then, the National Shortage Plan for IG has been finalized, new indications for IG have emerged, and alternative therapies to IG have been identified for some clinical indications. In 2024, IGAP approached the Prairie Collaborative (Manitoba, Saskatchewan and Alberta) to explore reconciling Ontario’s current 2018 Guidelines with the Prairie’s 2022 edition of the Criteria for the Clinical Use of Immune Globulin as an initial step to standarding the way IG is used across the Provinces. The Prairie Collaborative generously agreed, and version 5.0 of the Ontario Guidelines will be available in early 2025. Future plans include collaboration with the Prairies in 2026 for their next formal revision.
Highlights of the Ontario Guidelines version 5.0 include:
- A colour coded categorization including a Do not Use category,
- Consistent use of the adjusted body weight IG dose calculator in all patients meeting height and weight criteria,
- Regular evaluation of patients for clinical effectiveness, exploration of alternatives, and the use of the lowest effective dose / longest treatment interval
- A visual aid for quick reference of all recommendations where IG can be used
In addition, a specific request form for the use of SCIG has also been developed.
IGAP and its dedicated committee members continue to work diligently to promote IG stewardship. This work ensures that this precious resource is used in the most appropriate way for the safety and benefit of our patients.
The following items reflect the core requirements from these strategies that are still valid in mitigating unsustainable increases in IG utilization:
- Intravenous Immune Globulin (IVIG) 2012 Audit Report: Ontario Regional Blood Coordinating Network; 2012.
- Audit of Intravenous Immune Globulin (IVIG) Indications and Effectiveness in Ontario Tertiary Care Centres: Ontario Regional Blood Coordinating Network; Dec 2015
- Shepherd, L, Lin, Y, Gagliardi, K. Ontario’s intravenous immune globulin (IVIG) utilization management strategy. Ontario Medical Review, p24-25. Jan 2013
- Immune Globulin Screening Pilot (IGSP) Final Report. Ministry of Health and Long-Term Care Provincial Programs Branch, Negotiations and Accountability management Division; Nov 2017
- The National Plan for Management of Shortages of Immunoglobulin (Ig) Products. National Advisory Committee on Blood and Bood Products. May 30, 2024. (Accessed: Dec 13, 2024)