How to Use the IG Side Effects Card
By Marianna Herrera, RN, BSN, IgCN - July 21, 2023

Prior to an infusion visit, we ask nurses to contact patients 12 -24 hours before and complete our Pre-Infusion Checklist (IVIG Pre-Infusion Checklist / SCIG Pre-Infusion Checklist). Nufactor developed the checklist to help the nurse and patient plan for a successful infusion. The list is a great tool and helps nurses guide their patients using a standardized check-off format. The list provides tips to give to the patient the day prior to, the day of, and the day after an infusion.

Nufactor believes patients should have a better quality of life when receiving specialty infusion treatments at home. Screening for side effects is included on the checklist. Teaching our patients to understand and mitigate their side effects is a top priority. Nufactor also created simple color-coded Immune Globulin Side Effects Charts, included in the patient's welcome booklet on page 13. These can be used during every visit to keep the patient informed about possible side effects, including whether they are common and minor, or rare and severe, and serve as a guide on what steps to take to help resolve adverse side effects.

Mild side effects are symptoms that do not interfere with daily activities, and they can be managed at home. Here are a few of the most commonly experienced side effects and ways patients can be taught to manage them at home. These side effects should subside within 72 hours after receiving Immune Globulin therapy.

Possible mild side effects for patients receiving IVIG:

1. Headache (pain rated 1-4 on a 0–10 scale) — This is the most common side effect reported by patients receiving IVIG therapy.
1. Hydration is key for mitigating a headache. Encourage the patient to hydrate with water, non-caffeinated, or low-sugar drinks to ensure proper hydration so as not to reverse the effect with diuresis.
2. If a headache is experienced during an infusion, the effect may be rate related. Assess the patient with both verbal and non-verbal cues and vital signs. If the patient voices any pain, slow down the infusion. Decrease the infusion rate by half and infuse for no less than 15 minutes and re-assess the patient. If the patient's headache decreases, attempt to increase the rate and adjust accordingly. Always document properly and communicate with the pharmacy to ensure a plan of care can be initiated if needed.
3. Pre-medications can be used as indicated on the label. TYLENOL^® should be used as needed for pain every 4-6 hours.
4. Proper rest/sleep should also be recommended. Receiving IG can be very taxing on the patient and simply resting or getting a good night's sleep the day before, the day of, and the day after will help the body recover faster, minimizing the opportunity to develop a headache.
5. Patients with a history of chronic headaches/migraines should take additional precautions and prepare more heavily with additional hydration, possibly with electrolytes, and ensure they have their regular medication for stronger headaches or migraine attacks on hand.
2. Mild nausea
1. Eating small, healthy meals on the day of infusion can help decrease nausea.
2. Avoid trying new foods and spicy foods.
3. Don't take daily or pre-medications on an empty stomach, which can cause an upset stomach.
4. Don't skip meals during infusions.
3. General fatigue
1. Rest during infusion. Advise the patient to use the infusion time to rest and recover to prevent the patient from feeling overly tired or fatigued days after infusion.
2. Pre-medications can be used as indicated on the label.
4. Flu-like symptoms
1. If these effects are felt during infusion, advise the patient to keep you informed on any worsening effects and slow down infusion as mentioned above.
2. Pre-medications can be used as indicated on the label.
5. Diarrhea
1. Proper hydration will help in the event that diarrhea is experienced.
2. Avoid trying new foods or spicy foods.
3. Don't take daily or pre-medications on an empty stomach, which can cause an upset stomach.
6. Low-grade temperature (<101° F)
1. Slow down infusion—changes in vital signs could mean the patient is not tolerating the rate of infusion.
2. Pre-medications can be used as indicated on the label. Ensure the patient is properly hydrated.
3. Ensure the home environment is not too warm or the patient isn't heavily dressed.
7. Rash/itchy skin
1. This can be a mild histamine response. Check the time on antihistamine medication and repeat the dose if needed.
2. Pre-medications can be used as indicated on the label.
3. Proper hydration.
8. Mild back or leg pain/achiness
1. Rest during infusion. Advise the patient to use the infusion time to rest and recover to prevent the patient from feeling overly tired or fatigued days after infusion.
2. Pre-medications can be used as indicated on the label.

Possible mild side effects for patients receiving SCIG:

1. Mild local needle site reaction
1. Ensure the patient is taught and is using the "dry-stick" method—approximately 2 inches from the tip of the subcutaneous needle.
1. IG is well tolerated in the subcutaneous tissue, but it activates a histamine response on the dermal layers = warm, pink itchy skin.
2. Over-the-counter anti-itch creams and ice/cool packs can be used in case the patient experiences localized reactions.
3. Pre-medications can be used as indicated on the label.
4. Addressing technique issues may resolve these side effects.

Moderate side effect symptoms affect daily activities. These side effects are NOT expected and need to be reported to a Nufactor pharmacist as soon as possible. Please educate the patient to call (800) 323-6832 to have their current treatment reviewed and possibly revised. Medical attention may be needed for some of these side effects.

Moderate side effects for patients receiving IVIG:

1. Headache (pain rated 5-7 on a 0–10 scale) lasting more than 24 hours. This is the most common side effect reported by patients receiving IVIG therapy when not addressed promptly.
1. All recommendations mentioned above can help the patient keep headaches at bay. However, if pain increases and lasts longer than 24 hours, please have the patient notify Nufactor.
2. Nausea/vomiting, diarrhea lasting more than 24 hours
1. Ensure the patient understands these side effects are NOT expected and must be addressed.
2. Proper hydration continues to be essential; follow all medical directives to help address symptoms.
3. Fatigue affecting daily activities
1. Feeling extremely fatigued post-infusion is NOT expected and needs to be discussed with the pharmacy to explore treatment options with their doctor.
4. Temperature between 101° F-104° F
1. Ensure the patient is hydrating properly to prevent dehydration.
2. Continue all recommendations stated above.
3. Patients need to dress appropriately and follow the doctor's instructions to bring down their temperature and keep it from rising.

Moderate side effects for patients receiving SCIG:

1. Hives/rash lasting more than 72 hours. If the infusion sites look irritated or tender and are not resolving, it may be indicative of a delayed response to the medication. Inform the patient that Nufactor needs to be contacted to discuss treatment options with their doctor.

Severe to serious side effects require immediate medical attention.

Education is key for these patients to identify emergent situations and how to handle them properly. Nufactor includes a guide for emergency planning. Use the My Anaphylaxis Management Plan on page 23 of the New Patient Welcome Packet to plan and keep patients prepared. Patients can experience symptoms that may need to be evaluated by a local emergency department. Depending on the severity of symptoms, educate the patient to either call 911 or have a family member/caregiver drive them to the ER. Once the patient is stable, they need to report these side effects to a Nufactor pharmacist as soon as possible at (800) 323-6832.

1. Shortness of breath
1. Can be indicative of anaphylaxis if followed by angioedema, wheezing, and swelling of the eyelids or lips.
2. My Anaphylaxis Management Plan can be initiated.
3. Requires immediate medical attention.
2. Severe headache with pain reported as "intolerable" (pain rated 8–10 on a 0–10 scale) and/or severe headache (with neck stiffness, sensitivity to light, painful eye movement, or visual disturbances)
1. May indicate aseptic meningitis and requires immediate medical attention.
3. Temperature <104° F
1. Can cause further issues if not controlled and requires immediate medical attention.
4. Uncontrollable vomiting/diarrhea
1. Can cause severe dehydration and requires immediate medical attention.
5. Decreased urine output and/or dark urine
1. May indicate significant kidney injury and requires medical attention.
6. Sudden weight gain, new onset of swelling in feet
1. May indicate heart failure and requires medical attention.
7. Chest pain, shortness of breath, lower leg swelling/pain, and mental status changes such as confusion, slurred speech, drooling, and unresponsiveness.
1. IG has a black label warning of possible clotting. If these symptoms are present, immediate medical attention is required.

Providing all this information in written form can quickly throw a patient into information overload. Nufactor created the easy-to-use side effects chart nurses can use to guide patients on what to do and when. Education is key to successful outcomes. Use the side effects chart with every visit and know your patient and/or their caregiver will be able to tackle IG side effects appropriately, whether big or small.