1. Teresa Meenaghan RANP Haematology 16thOctober HAI

2. Disease Treatment

3. Conducted an Audit of patients on monthly IVIG 43 patients with secondary immune suppression Need Capacity issue Investigate alternative management

4. Attended conference in Dublin at the end of July 50% Haematology 50% Immunology Benefits Procedure Case reviews Reviewed

5. Dr Ogden Bruton, USA, published in 1952 the first case of proven PID (antibody deficiency) in a 4- year old boy He demonstrated the lack of antibodies in the boy and the normalized level after the initiation of the subcutaneous injections

7. Infusion of IgG into subcutaneous tissue using an ambulatory infusion pump or syringe driver Weekly dose = ¼ monthly IVIG dose Monthly Dose: Full monthly dose can be administered subcutaneously Can be self-administered

8. Letter for funding (patients name, address and date of birth. The most important information is if the patient has a medical card or a long term illness card or a drug payment scheme card. Need to write number of whichever card they have. Funding letter must be printed on Hospital headed paper and signed by referring consultant. Consultant letter optional Prescription (The prescription should state, name of drug dose per month, frequency (once a month, once every 3 weeks etc.)Length of prescription max is 6 months The funding letter can be faxed, emailed or posted back to Ms. Aoife Murphy, Homecare Services Co-Ordinator, Baxter Healthcare Ltd, Deansgrange Business Park, Deansgrange Co. Dublin Email: aoife_murphy@baxter.com Fax no: 012065583aoife_murphy@baxter.com.

9. Start fSCIG 1 week following last IVIG or SCIG dose fSCIG Infusion Number Dose of the Ig 10% Component of fSCIG Week 111-week dose Week 222-week dose Week 3No infusion Week 433-week dose Week 5No infusion Week 6No infusion Week 7 4 (If required) 4-week dose Once funding has been approved the homecare nurse will commence training one week after the last dose of IVIG. Training occurs over a period of 7 weeks. See example below of a training schedule for a patient receiving 40gs every 4 weeks.

10. Patient is then discharged home with home visit for next 2 doses While patient is been trained in hospital the pharmacy need to supply the drug for the training weeks and then the cost is taken over by local health board once they go home. All the pumps etc that the patient needs for infusion are supplied by the drug company. Deliveries are done every 12 weeks Some products are a fridge product so a fridge is also supply to the patient.

11. Infused using syringe drivers Initial speed: 10 mL/h/pump For each subsequent infusion speed can be increased Maximum speed: varies from country to country More than one pump can be used simultaneously; sites at least 10 cm apart

12. Butterfly or Thumb needles are used Placed under the skin at angles of 45 degrees for butterfly and thumb needles at 90 degrees. SCIG is infused into the abdominal wall or thigh The use of more than one syringe driver simultaneously can reduce infusion time.

13. 100 mL fSCIG Preinfusion50 mL fSCIG fSC 150 mL fSCIGG200 mL fSCIG 24 hours postinfusion

14. Immediately Post 1 st Infusion Infusion Sites: 1 Dose: 12.5g/125mls Needle: 12mm length Immediately Post 2 nd Infusion Infusion Sites: 1 Dose: 22.5g/225mls Needle: 12mm Length

15. Immediately post 3 rd Infusion Infusion Sites: 2 Dose: 37.5g/375mls Needle: 12mm length Immediately post 4 th Infusion Infusion Sites: 1 Dose: 45g/450mls Needle: 14mm Length

16. Proven to show that trough IgG concentration levels are comparable with those receiving IVIG Outbreaks of Hepatitis C has been associate with IV products but to date none has been reported with S/C administration

17. Possible Disadvantages Funding Weekly infusions Redness 5 itching at infusion sites (usually quickly resolves ) Possible advantages No venous access required Convenient & well tolerated Facilitates self infusion or home infusions Shorter infusion times Greater patient independence Often the choice for paediatric patients

18. SCIG a very real alternative to IV treatment Patient choice & control over their condition / treatment Higher doses not a problem Easy & quick for to teach Method of choice for home therapy in many countries

19. Birte, M., Bernatowska, H.D., Roifman, C.M. (2011) Efficacy and safety of home-based subcutaneous immunoglobulin replacement therapy in paediatric patients with primary immunodeficiencies. British Society for Immunology, Clinical and Experimental Immunology, 164(1)357-354. Framme, J.L.& Fasth, A. (2013) Subcutaneous Immunoglobulin for primary and Secondary Immunodeficiencies: an Evidence Based Review. Drugs, 73(1)1307-1319. Gaspar, J., Gerritsen, B. & Jones, A. (1998) Immunoglobulin replacement treatment by rapid subcutaneous infusion. British Medical Journal, 79(1)48-51.