Immunology nursing in the Czech republic today Teplá Ilona Králíčková Pavlína Institute of Allergy and Clinical Immunology University Hospital Hradec Kralove Czech Republic sources: foto oficial pages in the Internet

Introduction sources : oficial pages in the Internet / foto learning centre of the University Hospital Hradec Kralove

The main points Statistical survey of our patients in the Czech PID database Practical aspects in the administration Immunoglobulin supplementation therapy and comparison IVIG x SCIG Most frequent questions/difficulties with the administration Conclusion Discussion

Statistical survey of PID patients /Czech republic/ Actual status • general descriptions of database / immunoglobulin therapy/ • comparison of status in particular centres /referential values/ Czech PID registry, export of data 09/2014

Statistical survey of PID patients /Czech republic number of patients % of valid cases Total evidence 684 88,6% Actual monitored 664 88,7% Centre Number of patients valid FNUSA Brno - Ústav klin. imunolog. a alergolog. 156 98,0% FN Motol - Ústav imunologie 151 92,4% FNHK - ÚKIA 79 93,7% VFN Praha - Ústav imunologie a mikrobiologie 59 100,0% FN Plzeň - Ústav imunologie a alergologie 43 64,3% ZÚ ÚnL - Odd. klin. imunologie a alergologie 35 97,0% IKEM Praha - Klinická a transplantační medicína 29 86,2% FN Olomouc - Odd. alergologie a klin. imunologie 21 Nemocnice České Budějovice - Imunologické oddělení 18 88,9% Zlín - Plicní oddělení, KNTB a.s. 14 ZÚ Ostrava - Oddělení imunologie a alergologie FN Brno - Pediatrická klinika 13 91,7% FNHK - Klinika dětského lékařství 11 FNKV Praha - Odd.alergologie a klin. imunologie 90,9% FN Olomouc a LF UP - Dětská klinika 3 66,7% Tábor-Kasmed s.r.o., alerg., imunolog, neurolog. FN Ostrava - Alergologie 2 50,0% Krnov SSZ - interní oddělení

Statistical survey of PID patients /Czech republic/ N=664 (Currently monitored) Male (N=300) Female (N=364)

Basic characteristics

Replacement therapy

Practical aspects in the administration Optimal IgG doses and target trough levels are individual (clinical symptoms, comorbidities, genetic factors) The route of administration could be the result of discussion (patient X nurse X doctor) Negative influence - financial conditions in hospital - statement of insurance company - economical tender of immunoglobulin preparation

Practical aspects in the administration IVIG therapy Advantages - cheaper in the Czech Rep. - administration ones/twice a month - more often checking of clinical status and laboratory results Disadvantages - administration at outpatient department (traveling, day off work) - higher risk of adverse events - more often intolerance of administered preparation - necessary good venous access

Practical aspects in the administration SCIG therapy Advantages - home therapy with independence - comfort, flexibility - less frequent visits at the doctor - better tolerance of Ig preparations - low side effect profile (no severe systemic) - alternative for patients with poor venous access - benefit in case of gastrointestinal losses, malnutrition - flexibility of dosing and ease of administration

Practical aspects in the administration SCIG therapy Practical aspects in the administration Disadvantages/limitations - fear from the inject or the needle - administrations 1-3 times a week - intolerance (local skin reactions, scars, stretch marks) - risk of lower compliance

SCIG therapy It is important to doing difference between methods of subcutaneous administrations, preparations Individual approach to each patient Choose areas from recommended sites for the administration /abdomen, outer/ inner thighs, hips, upper arms/ Specific role of trained nurses in the education of patients It depends on the constitution of the patient, the thickness of the subcutis and type of needles

SCIG therapy Subcutaneous administration method rapid push /patient can adjust the rate of the infusion according to his tolerance without using the infusion pump/ ….Rapid push significantly higher infusion rate (60ml/h x 20ml/h) ….Patients with 10ml and less per one site prefer rapid push by the infusion pump /there should keep recommended rate of the infusion/ ….Infusion pumps provide pharmaceutical firms ….Comparable efficacy and tolerability

Our own experience – centre Hradec Kralove, Czech Rep. 47 patients regularly on Ig substitution therapy 27/47 IVIG 20/47 SCIG SCIG with pump since … 2007 to Oct 2014: 9 patients (3 died, 1 switched to IVIG – medication intolerance) Rapid push since …2012 to Oct 2014: 11 patients (2 switched to IVIG – 1 case patient preference, one case unsatisfactory IgG level and patients reluctance to increase Ig doses)

Side effects – pump x rapid push No serious systemic reaction • including patient experienced moderate systemic reaction - IgA antibodies • 1 case - intolerance of two different preparations (fatigue) Local reactions: Pump: infrequently haematoma Rapid push: → 2/11 mild itching, erythema → 2/11 pain during administration (change of the injection site to the inner thigh)

Often problems with administration / by patients and nurse´s view

a view on our daily centre /outpatient ward/

Practical experience Giving enough practical information to the patient by a nurse-specialist Explanation of the whole procedure (initiation of SCIG therapy) or providing an instructional video Demonstration of administration Reassurance of the patient (patient in home therapy after regaining certainty in the administration)

Question 1: There are enlarged pores, which are usually disappear for a day, the area is painful. Shall I continue with the application? There is the skin apparently attenuated (stretch marks, etc.) … You will try to change the site. We choose a different area from the recommended injection sites. Mainly it depends on the tolerance of the patient .. We had same patient in our department with this problem and she solved it just changing of the injection site. She started to administer to the inner side of thigh and she was satisfy.

Practical experience - possibility of the administration

Question/difficulties 2: There are stretch marks around the abdomen and it is very limited the choice to other site. outside stretch marks (scars) it depends again on the constitution of the patient, the thickness of the subcutis

Question 3: The injection site is after the infusion leakage or wet … There was probably made too shallow the introducing of the needle. The needle was only a little bent or it was just a poor implementation. We have tested for example bending the needle to the angle of 90 degrees /method rapid push/, the introduction of the needle is deep enough to the preparation is well absorbed and well tolerated by the patient. the bending of the needle to 90°degrees is recommended in the administration to the abdomen (special type of the needle) and there is stronger thickness of the subcutis

Practical experience - possibilty of administration

Question 4: The injection site is after administration indurated and painful and it has been disappear for a long time..… The dose of the liquid is probably too large on the thickness of the subcutis. We will try to divide the dose into two or more administrations. New sites should be at lest 2 inches apart. We should have been always consulted with the doctor.

Conclusion Immunoglobulin supplementation therapy represents a corner stone in the treatment of patients with disturbance of specific antibody production. The correctly guided treatment leads to decrease of severe illnesses and improve the quality of life. I am glad that I can participate in it. There were used information from the official websites www. hizentra.com and the Internet .

Discussion

Immunology nursing in the Czech republic today Thank you for your attention. sources : foto oficial pages in the Internet