lymphocyte immune globulin (antithymocyte globulin equine, ATG, ATG equine, LIG)
Pharmacologic class: Immunoglobulin
Therapeutic class: Immunosuppressant
Pregnancy risk category C
FDA Box Warning
• Give drug under supervision of physician experienced in immunosuppressive therapy for treatment of renal transplant or asplastic anemia patients, in facility with adequate laboratory and supportive resources
Unknown. Thought to inhibit cell-mediated immune response by altering function of or eliminating T lymphocytes in circulation.
Injection: 50 mg/ml in 5-ml ampules
Indications and dosages
➣ To prevent acute renal allograft rejection
Adults and children: 15 mg/kg/day I.V. for 14 days, then switch to alternate-day dosing for 14 days (for a total of 21 doses in 28 days). Give first dose within 24 hours of transplantation.
➣ Acute renal allograft rejection
Adults and children: 10 to 15 mg/kg/day I.V. for 14 days, then may switch to alternate-day dosing for 14 days (for a total of 21 doses in 28 days). Start therapy at first sign of rejection.
➣ Aplastic anemia in patients ineligible for bone marrow transplantation
Adults and children: 10 to 20 mg/kg/day I.V. for 8 to 14 days; then may give additional alternate-day doses for a total of up to 21 doses in 28 days
• Bone marrow, liver, and heart transplantation
• Multiple sclerosis
• Myasthenia gravis
• History of severe systemic reaction to lymphocyte immune globulin or other equine preparation
Use cautiously in:
• severe renal or hepatic disease
• pregnant or breastfeeding patients
☞ Know that drug should be given only by health care professionals experienced in immunosuppressive therapy for treating aplastic anemia or renal transplant patients, in facilities equipped and staffed with adequate laboratory and supportive resources.
☞ Because of high risk of anaphylaxis, perform intradermal skin test before first dose. Inject 0.1-ml dose of 1:1,000 dilution of LIG intradermally; a control test using 0.9% sodium chloride injection is injected contralaterally. Observe site every 15 to 20 minutes during first hour after injection, and monitor patient for systemic manifestations. Local reaction of 10 mm or greater with wheal, erythema, or both (with or without pseudopod formation and itching or marked local swelling) indicates positive test (which warrants consideration of alternate therapy). Systemic reaction (such as tachycardia, dyspnea, hypotension, or anaphylaxis) precludes LIG therapy.
• Premedicate with antipyretic, antihistamine, or corticosteroid, as prescribed, to minimize reactions.
• For I.V. infusion, dilute prescribed dose in 250 to 1,000 ml of 0.45% or 0.9% sodium chloride injection. (Don't dilute in dextrose solutions or highly acidic solutions.) Final concentration shouldn't exceed 4 mg/ml. Infuse total daily dose over at least 4 hours.
• When adding drug to infusion container, invert container so air doesn't enter. Gently swirl or rotate container to mix solution.
• Using in-line filter with pore size of 0.2 to 1 micron, infuse into central vein, shunt, or arteriovenous fistula over at least 4 hours.
• Be aware that drug is usually given concurrently with azathioprine and corticosteroids when used for allograft rejection.
CNS: malaise, agitation, headache, dizziness, weakness, syncope, encephalitis, seizures
CV: hypotension, hypertension, chest pain, bradycardia, tachycardia, cardiac irregularities, phlebitis, myocarditis, thrombophlebitis, heart failure
EENT: periorbital edema
GI: nausea, vomiting, diarrhea, stomatitis
Hematologic: leukopenia, agranulocytosis, thrombocytopenia, aplastic anemia
Musculoskeletal: joint pain or stiffness, myalgia, back pain
Respiratory: dyspnea, pleural effusion
Skin: rash, pruritus, urticaria, diaphoresis, night sweats
Other: burning soles and palms, fever, chills, pain at infusion site, edema, lymphadenopathy, hypersensitivity reactions including serum sickness and anaphylaxis
Drug-diagnostic tests. Creatinine, glucose, hepatic enzymes: increased values
Hemoglobin, platelets, white blood cells: decreased values
Kidney and liver function tests: abnormal results
☞ During infusion, watch for signs and symptoms of hypersensitivity reaction, such as rash, respiratory distress, or chest, flank, or back pain. Be aware that this reaction may occur even with a negative skin test.
☞ Discontinue drug if renal transplant patient develops signs or symptoms of anaphylaxis or severe thrombocytopenia or leukopenia.
• Be aware that product derives from equine and human blood components and may transmit infections.
• Monitor for signs and symptoms of infection, such as fever, malaise, and sore throat (caused by immunosuppression).
☞ Tell patient to immediately report adverse reactions during infusion (such as pain at infusion site) as well as systemic complaints (such as easy bruising or bleeding or signs of hypersensitivity reaction).
• Instruct patient to avoid sources of infection, such as people with known infections. Tell him to promptly report signs or symptoms of infection.
☞ Advise patient to immediately report evidence of serum sickness, including fever, joint pain, nausea, vomiting, lymphadenopathy, and rash.
☞ Caution female patient not to take drug if she is pregnant.
• Tell female patient to inform prescriber if she is breastfeeding.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the tests mentioned above.
lymphocyte immune globulin(lim-foe-site im-myoon glo-byoo-lin) ,
antilymphocyte globulin(trade name),
Pharmacologic: immune globulins
Time/action profile (decreased circulating T lymphocytes)
Adverse Reactions/Side Effects
Central nervous system
- chest pain
- dermatologic reactions (most frequent)
- leukopenia (most frequent)
- thrombocytopenia (most frequent)
- pain/phlebitis at IV site
- allergic reactions including anaphylaxis (life-threatening)
- chills (most frequent)
- fever (most frequent)
- serum sickness–like reactions (most frequent)
- clotted AV fistula
- night sweats
Drug-Drug interactionConcurrent use of corticosteroids and immunosuppressants may mask some adverse reactions.
- Assess patient for hypersensitivity reaction (respiratory distress; hypotension; pain in chest, flank, or back) continuously throughout administration. Keep epinephrine, antihistamines, corticosteroids, syringes, and an airway at bedside at all times. If a reaction occurs, stop infusion immediately; administer 0.3 mL aqueous epinephrine 1:1000 IM. Administer corticosteroids and resuscitative measures as needed. Do not resume therapy.
- Monitor vital signs frequently throughout administration. Medication frequently causes chills, fever, itching, and erythema. Prophylactic administration of antihistamines and corticosteroids usually controls these symptoms.
- Lab Test Considerations: Monitor CBC and platelets throughout therapy. May cause leukopenia and thrombocytopenia. Thrombocytopenia is usually transient and does not normally require discontinuation of therapy or transfusion.
- May also cause hemolysis. Treatment includes transfusion of erythrocytes and administration of mannitol, furosemide, sodium bicarbonate, and fluids, if necessary.
Potential Nursing DiagnosesRisk for infection (Indications, Side Effects)
- Medication should be used only by physicians experienced in immunosuppressive therapy and management of renal transplant patients and should be administered only in facilities equipped and staffed with adequate laboratory and medical resources.
- Patients with aplastic anemia may need a transfusion of platelets before administration to maintain platelets at a clinically acceptable level.
- Test Dose: Administer an intradermal injection of 0.1 mL of a 1:1000 dilution in 0.9% NaCl and a 0.9% NaCl control. If a wheal or erythema >10 mm forms with or without a pseudopod and itching or a marked local swelling occurs, administer infusion with caution. If a systemic reaction (generalized rash, tachycardia, dyspnea, hypotension, anaphylaxis) occurs, do not administer infusion. Allergic reactions may occur in patients with a negative reaction to test dose.
- Intermittent Infusion: Diluent: Dilute total daily dose in 0.45% NaCl or 0.9% NaCl. Concentration: Not to exceed 1 mg/mL. Invert IV saline bottle so that undiluted drug does not come in contact with the air inside. May be infused through an in-line filter with a pore size of 0.2–1 micron. Refrigerate diluted solution if prepared before administration. Do not freeze; discard if frozen. Stable for 24 hr, including infusion time, if refrigerated.
- Administer through large veins to minimize phlebitis and thrombosis.
- Rate: Administer over at least 4 hr.
- Explain the purpose of the medication to the patient.
- Instruct patient to notify health care professional promptly if fever; chills; cough; sore throat; signs of infection; bleeding gums; bruising; petechiae; blood in stools, urine, or emesis; numbness, tingling, or burning pain in hands, arms, legs, feet, or lips; increased fatigue; confusion; dizziness; weakness; dyspnea; tachycardia; or orthostatic hypotension occurs. Caution patient to avoid crowds and persons with known infections. Instruct patient to use soft toothbrush and electric razor and to avoid falls. Caution patient not to drink alcoholic beverages or take medication containing aspirin or NSAIDs, because these may precipitate gastric bleeding.
- Instruct patient to notify health care professional immediately if signs of hypersensitivity reaction (itching or hives, swelling in your face or hands, swelling or tingling in your mouth or throat, chest tightness, trouble breathing) occur.
- Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult health care professional before taking any new medications.
- Advise female patients to notify health care professional if pregnancy is planned or suspected or if breastfeeding.
- Advise patient to the importance of follow up lab tests.
- Prevention or management of allograft rejection in renal transplant patients.
- Treatment of moderate to severe aplastic anemia.