Anti-Human thymocyte globulin (ATG) Administration Guidelines for Allogeneic Transplantation and Severe Aplastic Anemia
Introduction Horse anti-thymocyte globulin (H-ATG) is a gamma globulin protein obtained from hyperimmune serum of horses immunized with human thymus lymphocytes. It is an antilymphocytic immunosuppressant which alters the function of T-cell (thymus dependent) lymphocytes. It is used as a preparative drug for marrow transplant, immunosuppressive therapy in aplastic anemia, and GVHD treatment.
Dosage Usual ATG dosage for GVHD treatment is 15mg/kg every other day times 6 doses. ATG doses are specified in each protocol. Use adjusted ideal body weight for markedly obese patients.
Skin tests Perform skin tests prior to first dose of ATG.
Anaphylaxis precaution During the administration of the skin test, have diphenhydramine (苯海拉明50mg I.V.) and epinephrine 1:1000 (肾上腺素1ml) available at the bedside in case of allergic reaction.
Administration of skin test Skin tests should be performed by P.A.(physician\"s assistant) or M.D.(medical doctors) and reaction confirmed with them. Two intradermal tests are routinely done. Both are administered at the same time and reactions noted. To prepare:
1. Control: Use 0.1 ml of NS.
2. Horse ATG: A 1:1000 dilution is used for skin testing (0.1 ml/test)
Mark test sites NS or ATG with pen. The patient and specifically the skin test should be observed at one hour after intradermal injection. A local reaction of 10 mm or greater with a wheal or erythema, or both, with or without pseudopod formation and itching or a marked local swelling should be considered a positive test. Allergic reactions such as anaphylaxis have occurred in patients whose skin test in negative. In the presence of a locally positive skin test to ATG, serious consideration to alternative forms of therapy should be given. A positive test shall be noted if any of the following is present: ①Systemic reaction Urticaria; Generalized itching or rash; Tachycardia; Dyspnea; Hypotension; Anaphylaxis (shock) ②Local reaction Local symptoms (observe 1 hour): Induration (wheal) and/or erythema more than 10 mm with pseudopod formation and itching to ATG or marked local swelling of the extremity ③Positive reaction Patients with a positive skin test or systemic reaction should not receive ATG unless approved by the attending physician or principal investigator.
Preparation of ATG Horse ATG is manufactured in 250mg/5ml vials. ATG, once diluted, is physically and chemically stable for up to 24 hours at concentrations of up to 4 mg/ml in NS, ½NS, D5¼NS and D5½NS. The use of high-flow veins will minimize the occurrence of phlebitis and thrombosis. If a peripheral vein is being used, a dilution of 1 mg/ml should be used to prevent phlebitis. Dilution is D5W is not recommended as low salt concentrations can cause precipitation. Highly acidic solutions can also contribute to physical instability over time. Diluted ATG should be stored in the refrigerator if prepared prior to the time of infusion. The total time in dilution should not exceed 24 hours (including infusion time).
ATG administration Horse ATG should be administered alone and not run piggyback with any other solution. Always use a filter (in-line) when administering ATG to the patient (i.e. 1 micron).
Infusion schedule Epinephrine 1:10000, diphenhydramine 50mg I.V. and hydrocortisone 100mg I.V. should be at bedside. In order to assess potential toxicity, a gradually increasing dose rate is recommended for the initial infusion, e.g. 50mg ATG over 1 hour, 100 mg ATG over the next hour. Remaining calculated dose can be infused over 4-10 hours as tolerated by patient. Initial infusion aliquots proportionate to dose should be estimated for pediatric patients. For patients receiving ATG as part of conditioning, 1 mg/kg of methylprednisolone should be given before every dose.
Toxicities and treatments
Major toxicity Any toxicity considered by the physician to be a major threat to the patient mandates discontinuation of the ATG.
Chills and Fever Chills and fever commonly occur in patients receiving ATG. Minor toxicities can usually be managed by symptomatic treatment and temporary slowing of the infusion. If during infusion the patient develops fever and/or chills, (s)he should be medicated with diphenhydramine 25-50mg I.V. (pediatric 1 mg/kg) and an antipyretic, e.g. acetaminophen (对乙酰氨基酚，扑热息痛), 300-600mg (pediatric 10-15 mg/kg) p.o. q6-8 hours prn. For severe fever and chills meperidine (哌替啶) 25-50 mg (pediatric 1 mg/kg) I.V. q 4-6 hours prn may also be required.
Purities Itching and erythema occasionally develop. Symptoms are generally controlled with diphenhydramine.
Respiratory distress Respiratory distress may be a sign of anaphylaxis. Infusion should be discontinued. If reaction persists, diphenhydramine, epinephrine and/or hydrocortisone should be administered. Pain is chest, flank or back may be a sign of anaphylaxis or hemolysis. Infusion should be discontinued.
Hypotension Hypotension occurs rarely and may be a sign of anaphylaxis. Discontinue infusion and treat accordingly.
Serum sickness Syndrome of fevers, arthralgias, fluid weight gain, and rash may occur. Treat with steroids.
Phlebitis Can be caused by infusion of ATG through peripheral veins. This can be avoided by infusion of ATG into a high flow vein.
骨髓移植和造血干细胞移植是一个概念吗？ 骨髓移植和造血干细胞移植是一个概念吗？ 请问；骨髓移植和造血干细胞移植是一个概念吗？
MDS MDS需换骨髓 因为这里的医生建议骨髓移植，我想问一下是骨髓移植还是造血干细胞移植呢？
重型再障，保守治疗17月，骨髓配型半相合 重型再障配型半相合是否可以做骨髓移植 在兰州军区总院做的骨髓配型，结果显示为半相合，该种情况可以做骨髓移植手术吗？如可以，成功的几率有多大，费用需要多少钱？如果不建议做骨髓移植手术，该如何治疗？
急重型再障 造血干细胞移植？ 是否可以考虑造血干细胞移植
骨髓移植后 造血干细胞移植后 像我这种情况可以治疗吗