Prevention and/or treatment of acute allograft rejection (kidney, heart, skin, bone marrow, heart/lung, liver)
· Treatment of severe aplastic anemia
· Treatment of graft-versus-host disease (GVHD)
· Prevention of bone-marrow graft failure
- Available as a 50 mg/mL solution in 5 mL ampoules (250 mg/amp). Refrigerate ampoules; DO NOT FREEZE.
- Stable for only 24 hours refrigerated after dilution with IV solution (including infusion time)
- DO NOT use if precipitate present
· Available as a 25 mg powder for reconstitution. Refrigerate vial. Protect from light.
· Allow diluent and contents of vial to reach room temperature prior to reconstitution.
· Reconstitute 25 mg vial with 5 mL of sterile water for injection = 5 mg/mL solution
· Reconstituted vials are to be used within 4 hours if kept at room temperature.
· Reconstituted solutions should be clear and should not be used if discoloured or opaque or if particles are present.
Diluted solutions stable 24 hours at room temperature (including infusion time)
- Solutions compatible:
Equine ATG: 0.45% NaCl, NS and dextrose/saline combinations
Rabbit ATG: D5W and normal saline
Equine ATG: D5W alone
No information on compatibility with potassium chloride, morphine or TPN; run in dedicated line.
(For approved routes of administration by nursing personnel, refer to Policy for the Administration of Intravenous Medications.)
|SC||NO, test dose is intradermal|
|IV Intermittent Infusion||
Equine ATG: YES, preferably in a central line to minimize phlebitis, thrombosis and pain
Usual dilution: 1 mg/mL
Rabbit ATG:YES, preferably in a central line to minimize phlebitis, thrombosis and pain
Usual dilution: 0.5-2 mg/mL
Infusion time: 6-8 hours; Slow infusion rate over 8 hours if peripheral IV in order to avoid phlebitis. Increase infusion rate over 4 hours if previous doses have been tolerated without reaction.
NOTE: Use 0.22 micron in-line filter to infuse anti-thymocyte globulin rabbit
|IV Continuous Infusion||NO|
(For neonatal dosages, refer to Neonatal IV Drug Manual.)
NOTE: Doses of these agents are not equivalent. Rabbit ATG is 10 times the potency of equine ATG
Renal allograft recipients:
- Prevention of rejection: 15 mg/kg/24 hr x 14 days, then alternate days x 7
more doses (1st dose within 24 hrs of transplant)
- Treatment of rejection: 10-15 mg/kg/24 hr x 14 days, then alternate
days x 7 more doses
Prevention of bone marrow graft failure:
- Dose according to specific protocol
Treatment of aplastic anemia:
- 10-20 mg/kg/24 hr for 21 days OR 40 mg/kg/day once daily for 4 days,
then 10-30 mg/kg/dose every other day for 7 more doses
- 5 mcg intradermally (see below for preparation). A control test using NS
should be given contralaterally. Observe patient and skin test site every 15
minutes during the first hour following the test dose injection. A local reaction
>10 mm in diameter with a wheal (>3 mm) or erythema or both should be
considered a positive skin test.
· Aplastic anemia
3.5 mg/kg/day once daily for 5 days
· Bone marrow transplantation
1.5-3 mg/kg/day once daily for 4 consecutive days before transplantation
· Graft-versus-host disease
1.5 mg/kg/dose once daily or every other day
· Renal transplantation
Induction: 1-2 mg/kg/day once daily for 4-5 days initiated at time of transplant
Acute rejection: 1.5 mg/kg/day once daily for 7-14 days
Potential hazards of parenteral administration:
· Anaphylaxis is uncommon but serious. If anaphylaxis occurs, stop ATG; give epinephrine and steroids. Assist ventilation. Do not re-administer ATG
· Patients should be monitored continuously throughout an IV infusion of ATG for respiratory distress, hypotension and skin rash as these may be signs of anaphylaxis
· Keep anaphylaxis kit at bedside during administration of test dose and infusions
· Chills and fever are frequent during infusion; premedication with diphenhydramine, methylprednisilone and acetaminophen 1 hour prior to ATG may help
· Thrombocytopenia, leukopenia, hemolysis (may be severe)
· Itching, erythema (may be controlled with antihistamines)
· Serum sickness-like symptoms (fever, arthralgia, nausea, vomiting, lymphadenopathy, rash) have been noted in aplastic anemia patients
· Hypertension, tachycardia, peripheral edema
· Different anti-thymocyte globulins (rabbit and equine) are not interchangeable.
· Monitor WBC count (including lymphocytes), platelets and creatinine daily
· May cause direct antiglobulin test to become positive
- Preparation of 5 mcg test dose (to be prepared by Pharmacy)
- 0.1 mL of undiluted solution (50 mg/mL = 5 mg) + 9.9 mL normal saline (solution A = 500 mcg/mL)
- 0.1 mL solution A (50 mcg) + 0.9 mL normal saline (solution B = 50 mcg/mL)
- Test dose - 0.1 mL solution B (= 5 mcg/0.1 mL)