{"id":1599,"date":"2018-09-12T13:55:26","date_gmt":"2018-09-12T13:55:26","guid":{"rendered":"http:\/\/edren.org\/ren\/?page_id=1599"},"modified":"2024-11-08T12:41:04","modified_gmt":"2024-11-08T12:41:04","slug":"atg-anti-thymocyte-globulin","status":"publish","type":"page","link":"https:\/\/edren.org\/ren\/handbook\/transplant-handbook\/immunosuppressive-drugs\/atg-anti-thymocyte-globulin\/","title":{"rendered":"ATG (Anti-thymocyte Globulin)"},"content":{"rendered":"<h3><strong><span style=\"font-family: georgia, palatino, serif; color: #993300;\">Anti-Thymocyte Immunogloblin (ATG\/thymoglobin)<\/span><\/strong><\/h3>\n<p><strong><span style=\"font-family: georgia, palatino, serif; color: #993300;\">Indication:<\/span><\/strong><\/p>\n<ul style=\"margin-left: 40px; list-style-type: disc;\">\n<li><span style=\"font-family: georgia, palatino, serif;\">Induction therapy for high immunological risk recipients<\/span><\/li>\n<li><span style=\"font-family: georgia, palatino, serif;\">Treatment of vascular rejection or steroid resistant rejection (persistent biopsy proven rejection despite a course of methylprednisolone)<\/span><\/li>\n<\/ul>\n<p><strong><span style=\"font-family: georgia, palatino, serif; color: #993300;\">Contra-indications:<\/span><\/strong><\/p>\n<ul style=\"margin-left: 40px; list-style-type: disc;\">\n<li><span style=\"font-family: georgia, palatino, serif;\">known allergy to rabbit proteins<\/span><\/li>\n<li><span style=\"font-family: georgia, palatino, serif;\">acute illness<\/span><\/li>\n<li><span style=\"font-family: georgia, palatino, serif;\">previous anaphylaxis to <span style=\"color: #993300;\">ATG<\/span><\/span><\/li>\n<\/ul>\n<p><strong><span style=\"font-family: georgia, palatino, serif; color: #993300;\">Dosage and administration:<\/span><\/strong><\/p>\n<p><span style=\"font-family: georgia, palatino, serif;\">ATG is usually administered through a central line but may be given peripherally via a large bore cannula if necessary. In such circumstances, 1000 units heparin should be added directly to 0.9% NaCl infusion bag to prevent superficial thrombophlebitis. The combination of ATG, heparin and hydrocortisone in 5% dextrose should be avoided as precipitation has been reported. <\/span><span style=\"font-family: georgia, palatino, serif;\"><span style=\"color: #993300;\">ATG <\/span><span style=\"font-family: georgia, palatino, serif;\">should be administered through an in-line 0.22um filter.<\/span><\/span><\/p>\n<h3><span style=\"font-size: 24pt;\"><strong><span style=\"font-family: georgia, palatino, serif; color: #993300;\">Induction therapy<\/span><\/strong><\/span><\/h3>\n<p><span style=\"font-family: georgia, palatino, serif;\"><em>(<span style=\"color: #993300;\">NB:<\/span> Basiliximab is not given if using <span style=\"color: #993300;\">ATG<\/span> for induction)<\/em><\/span><\/p>\n<p><span style=\"font-family: georgia, palatino, serif;\">Dose: 1.5mg\/kg in 250mls 0.9% NaCl to run over a minimum of 6 hours for 4 days (Day 0,1,2,3) for a cumulative of 6mg\/kg. <\/span><span style=\"font-family: georgia, palatino, serif;\">No test dose is required<\/span><\/p>\n<ul style=\"margin-left: 40px; list-style-type: disc;\">\n<li><span style=\"font-family: georgia, palatino, serif;\"><strong><span style=\"color: #993300;\">Day 0:<\/span>\u00a0<\/strong>First dose should be administered intra-operatively, prior to allograft reperfusion but after 500mg methyl prednisolone has been given via CVP line. Premedication with 1g paracetamol PO and 10mg chlorpheniramine IV should also be given before ATG infusion. Significant first dose reactions are not common and do not tend to involve hypotension or bronchospasm. If a reaction occurs intra-operatively, the infusion should be stopped and consideration given for re-starting post-operatively.<\/span><\/li>\n<li><span style=\"font-family: georgia, palatino, serif;\"><strong><span style=\"color: #993300;\">Day 1:<\/span><\/strong> As for Day 0 (following second dose of 500mg methylprednisolone, with 1g paracetamol PO and 10mg chlorpheniramine IV)<\/span><\/li>\n<li><span style=\"font-family: georgia, palatino, serif;\"><strong><span style=\"color: #993300;\">Day 2,3:<\/span><\/strong> Premedication of Hydrocortisone 200mg IV, paracetamol 1g PO and chlorpheniramine 10mg IV before administering ATG.<\/span><\/li>\n<\/ul>\n<p><strong><span style=\"font-family: georgia, palatino, serif; color: #993300;\">Reduce the dose by half if total WCC &lt;3 x10<sup>9<\/sup>\/l &amp;\/or Platelets &lt;75 x10<sup>9<\/sup>\/l.<\/span><\/strong><\/p>\n<p><strong><span style=\"font-family: georgia, palatino, serif; color: #993300;\">Withhold dose if total WCC &lt; 2 x10<sup>9<\/sup>\/l or platelet count &lt; 50 x10<sup>9<\/sup>\/l.<\/span><\/strong><\/p>\n<p><span style=\"font-family: georgia, palatino, serif;\"><strong><span style=\"color: #993300;\">NB:<\/span> <\/strong>Tacrolimus, MMF prescribed as for standard immunosuppression. Omit oral prednisolone 20mg until day after ATG is completed.<\/span><\/p>\n<p><span style=\"font-size: 24pt;\"><strong><span style=\"font-family: georgia, palatino, serif; color: #993300;\">Treatment for acute rejection<\/span><\/strong><\/span><\/p>\n<ul style=\"margin-left: 40px; list-style-type: disc;\">\n<li><span style=\"font-family: georgia, palatino, serif; font-size: 14pt;\">The dosage of ATG is 1.5 mg\/kg\/day. <\/span><\/li>\n<li><span style=\"font-family: georgia, palatino, serif; font-size: 14pt;\">It is licensed for 7 &#8211; 14 days for AR treatment. For early or milder rejection episodes, it may resolve with even 5-7 days of treatment. Severe rejection may require up to 10-14 days of treatment.<\/span><\/li>\n<li><span style=\"font-family: georgia, palatino, serif; font-size: 14pt;\">Reduce the dose by half if total WCC &lt;3 x10<sup>9<\/sup>\/l and\/or Platelets &lt;75 x10<sup>9<\/sup>\/l. The dose should be withheld when total WCC &lt; 2 x10<sup>9<\/sup>\/l or platelet count &lt; 50 x10<sup>9<\/sup>\/l.<\/span><\/li>\n<li><span style=\"font-family: georgia, palatino, serif; font-size: 14pt;\">Premedication of Hydrocortisone 200mg IV (omit oral prednisolone), paracetamol 1g PO and chlorpheniramine 10mg IV before administering ATG.\u00a0<\/span><\/li>\n<li><span style=\"font-family: georgia, palatino, serif; font-size: 14pt;\"><strong><span style=\"color: #993300;\"><span style=\"color: #993300;\">A test dose is NOT needed for ATG treatment i<\/span><\/span><span style=\"color: #993300;\">n most cases.<\/span><\/strong> However, if the patient has had a previous reaction to ATG or has a history of close exposure to rabbits, it may be considered [5 mg ATG in 100 ml NaCl 0.9% infused through a peripheral vein over 1 hour]. Preparation of test dose:<\/span>\n<ul style=\"list-style-type: disc;\">\n<li><span style=\"font-size: 14pt; font-family: georgia, palatino, serif;\">Reconstitute 1 vial (25mg) with 5 ml water for injections, giving a solution of 5 mg ATG per ml.<\/span><\/li>\n<li><span style=\"font-size: 14pt; font-family: georgia, palatino, serif;\">Take 1 ml (5mg) of solution and add to 100 ml NaCl 0.9%.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<h3><span style=\"font-size: 18pt;\"><strong><span style=\"font-family: georgia, palatino, serif; color: #993300;\">First dose of ATG<\/span><\/strong><\/span><\/h3>\n<p><strong><span style=\"font-family: georgia, palatino, serif; color: #993300;\">Administration:<\/span><\/strong><\/p>\n<p><span style=\"font-family: georgia, palatino, serif;\"><span style=\"color: #993300;\">ATG<\/span> 1.5 mg\/kg in 0.9% NaCl given over 6 &#8211; 8 hours ideally via a central line, but\u00a0 a wide bore peripheral line may be used. Round the dose to the nearest 25 mg.<\/span><\/p>\n<p><strong><span style=\"font-family: georgia, palatino, serif; color: #993300;\">Preparation:<\/span><\/strong><\/p>\n<ul style=\"list-style-type: disc;\">\n<li><span style=\"font-family: georgia, palatino, serif;\">Reconstitute required number of vials with 5 ml dilutent per vial.<\/span><\/li>\n<li><span style=\"font-family: georgia, palatino, serif;\">Add contents of reconstituted vials to 0.9% NaCl, allowing 50 ml per vial (250 ml bag usually appropriate).<\/span><\/li>\n<\/ul>\n<p><strong><span style=\"font-family: georgia, palatino, serif; color: #993300;\">Observations:<\/span><\/strong><\/p>\n<table style=\"width: 80%; border-collapse: collapse; border-style: solid; border-color: #993300;\" border=\"2\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border-style: solid; border-color: #993300; background-color: #e6f7ed; text-align: center;\"><strong><span style=\"color: #993300;\">Time after dose<\/span><\/strong><\/td>\n<td style=\"width: 50%; border-style: solid; border-color: #993300; background-color: #e6f7ed; text-align: center;\"><strong><span style=\"color: #993300;\">Frequency of Observations<\/span><\/strong><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; text-align: center; border-style: solid; border-color: #993300;\">0 &#8211; 2 hours<\/td>\n<td style=\"width: 50%; text-align: center; border-style: solid; border-color: #993300;\">15 minutes<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; text-align: center; border-style: solid; border-color: #993300;\">2 &#8211; 4 hours<\/td>\n<td style=\"width: 50%; text-align: center; border-style: solid; border-color: #993300;\">30 minutes<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; text-align: center; border-style: solid; border-color: #993300;\">4 &#8211; 6 hours<\/td>\n<td style=\"width: 50%; text-align: center; border-style: solid; border-color: #993300;\">Hourly<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><strong><span style=\"font-family: georgia, palatino, serif; color: #993300;\">Side effects:<\/span><\/strong><\/p>\n<ul style=\"margin-left: 40px; list-style-type: disc;\">\n<li><span style=\"font-family: georgia, palatino, serif;\">Anaphylaxis, with a drop in arterial pressure, respiratory distress, fever and urticaria may appear during or just after the infusion.<\/span><\/li>\n<li><span style=\"font-family: georgia, palatino, serif;\">Other hypersensitivity reactions include rigors (1%), fever (4%), arthralgia (1%), erythema (1%) and pruritic skin eruptions (0.5%).<\/span><\/li>\n<li><span style=\"font-family: georgia, palatino, serif;\">Symptoms are most commonly seen after the first injection and decrease during the course of treatment.<\/span><\/li>\n<li><span style=\"font-family: georgia, palatino, serif;\">Other side effects include thrombocytopenia (approx. 5%), neutropenia, serum sickness (3%) and lymphoma.<\/span><\/li>\n<\/ul>\n<p><span style=\"font-family: georgia, palatino, serif;\"><strong><span style=\"color: #993300;\">Daily:\u00a0<\/span> <\/strong>FBC and U&amp;Es during course.<\/span><\/p>\n<p><strong><span style=\"font-family: georgia, palatino, serif; color: #993300;\">Maintenance immunosuppression:<\/span><\/strong><\/p>\n<ul style=\"margin-left: 40px; list-style-type: disc;\">\n<li><span style=\"font-family: georgia, palatino, serif; font-size: 14pt;\">Mycophenolate is generally withheld due to the risk of cytopaenias. <\/span><\/li>\n<li><span style=\"font-family: georgia, palatino, serif; font-size: 14pt;\">Prednisolone is withheld as hydrocortisone is being given. <\/span><\/li>\n<li><span style=\"font-family: georgia, palatino, serif; font-size: 14pt;\">A judgment call should be made regarding tacrolimus. Often it is felt desirable to continue tacrolimus as the rejection process is by definition severe.<\/span><\/li>\n<\/ul>\n<p><strong><span style=\"font-family: georgia, palatino, serif; color: #993300;\">Prophylaxis:<\/span><\/strong><\/p>\n<ul style=\"margin-left: 40px; list-style-type: disc;\">\n<li><span style=\"font-family: georgia, palatino, serif;\"><a href=\"https:\/\/edren.org\/ren\/handbook\/transplant-handbook\/infection-prophylaxis-and-treatment\/pneumocystis-jirovecii\/\">PJP prophylaxis<\/a> should generally be extended to 6 months post-ATG.<\/span><\/li>\n<li><span style=\"font-family: georgia, palatino, serif;\">CMV and HSV prophylaxis using valganciclovir for 6 months should also be used.<\/span><\/li>\n<\/ul>\n<p><strong><span style=\"font-family: georgia, palatino, serif; color: #993300;\">Ordering:<\/span><\/strong><\/p>\n<p><span style=\"font-family: georgia, palatino, serif;\">Mon-Fri 8.30 &#8211; 1700: contact unit pharmacist.<br \/>\n<\/span><span style=\"font-family: georgia, palatino, serif;\">Out of hours: contact resident pharmacist, bleep 2268<br \/>\n<\/span><span style=\"font-family: georgia, palatino, serif;\">Small stock held in pharmacy.<\/span><\/p>\n<p><strong><span style=\"font-family: georgia, palatino, serif; color: #993300;\">Storage:<\/span><\/strong><\/p>\n<p><span style=\"font-family: georgia, palatino, serif;\">Both the dry powder and reconstituted solution to be stored in fridge; protect from light.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Anti-Thymocyte Immunogloblin (ATG\/thymoglobin) Indication: Induction therapy for high immunological risk recipients Treatment of vascular rejection or steroid resistant rejection (persistent biopsy proven rejection despite a course of methylprednisolone) Contra-indications: known allergy to rabbit proteins acute illness previous anaphylaxis to ATG Dosage and administration: ATG is usually administered through a central\u2026<\/p>\n<p> <a class=\"continue-reading-link\" href=\"https:\/\/edren.org\/ren\/handbook\/transplant-handbook\/immunosuppressive-drugs\/atg-anti-thymocyte-globulin\/\"><span>Continue reading<\/span><i class=\"crycon-right-dir\"><\/i><\/a> <\/p>\n","protected":false},"author":2,"featured_media":0,"parent":1568,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_lmt_disableupdate":"no","_lmt_disable":"","footnotes":""},"class_list":["post-1599","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/1599","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/comments?post=1599"}],"version-history":[{"count":34,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/1599\/revisions"}],"predecessor-version":[{"id":6541,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/1599\/revisions\/6541"}],"up":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/1568"}],"wp:attachment":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/media?parent=1599"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}