True or False, Immunoglobulin is Free in Indonesia?

Immunoglobulin therapy, also known as normal human immunoglobulin (NHIG), is the use of a mixture of antibodies (immunoglobulins) to treat a number of health conditions.

These conditions include primary immunodeficiency, immune thrombocytopenic purpura, chronic inflammatory demyelinating polyneuropathy, Kawasaki disease, certain cases of HIV/AIDS and measles, Guillain-Barré syndrome, and in certain other infections when a more specific immunoglobulin is not available.

Depending on the formulation it can be given by injection into muscle, a vein, or under the skin. The effects last a few weeks. Common side effects include pain at the site of injection, muscle pain, and allergic reactions.

Other severe side effects include kidney problems, anaphylaxis, blood clots, and red blood cell breakdown. Use is not recommended in people with some types of IgA deficiency. Use appears to be relatively safe during pregnancy. Human immunoglobulin is made from human blood plasma. It contains antibodies against many viruses.

Human immunoglobulin therapy first occurred in the 1930s and a formulation for injection into a vein was approved for medical use in the United States in 1981. It is on the World Health Organization’s List of Essential Medicines, the safest and most effective medicines needed in a health system.

Each formulation of product is somewhat different. In the United Kingdom a dose cost the NHS between 11.20 and 1,200.00 pounds depending on the type and amount. A number of specific immunoglobulin formulations are also available including for hepatitis B, rabies, tetanus, varicella infection, and Rh positive blood exposure.

Immunoglobulin therapy is used in a variety of conditions, many of which involve decreased or abolished antibody production capabilities, which range from a complete absence of multiple types of antibodies, to IgG subclass deficiencies (usually involving IgG2 or IgG3), to other disorders in which antibodies are within a normal quantitative range, but lacking in quality – unable to respond to antigens as they normally should – resulting in an increased rate or increased severity of infections.

In these situations, immunoglobulin infusions confer passive resistance to infection on their recipients by increasing the quantity/quality of IgG they possess. Immunoglobulin therapy is also used for a number of other conditions, including in many autoimmune disorders such as dermatomycosis in an attempt to decrease the severity of symptoms.

Immunoglobulin therapy is also used in some treatment protocols for secondary immune deficiencies such as human immunodeficiency virus (HIV), some autoimmune disorders (such as immune thrombocytopenia and Kawasaki disease), some neurological diseases (multifocal motor neuropathy, stiff person syndrome, multiple sclerosis and myasthenia gravis) some acute infections and some complications of organ transplantation. Immunoglobulin therapy is especially useful in some acute infection cases such as pediatric HIV infection and is also considered the standard of treatment for some autoimmune disorders such as Guillain–Barré syndrome. The high demand which coupled with the difficulty of producing immunoglobulin in large quantities has resulted in increasing global shortages, usage limitations and rationing of immunoglobulin. Different national bodies and medical associations have established varying standards for the use of immunoglobulin therapy.

Although immunoglobulin is frequently used for long periods of time and is generally considered safe, immunoglobulin therapy can have severe adverse effects, both localized and systemic. Subcutaneous administration of immunoglobulin is associated with a lower risk of both systemic and localized risk when compared to intravenous administration (hyaluronidase-assisted subcutaneous administration is associated with a greater frequency of adverse effects than traditional subcutaneous administration but still a lower frequency of adverse effects when compared to intravenous administration.

Patients who are receiving immunoglobulin and experience adverse events are sometimes recommended to take acetaminophen and diphenhydramine before their infusions to reduce the rate of adverse effects. Additional premedication may be required in some instances (especially when first getting accustomed to a new dosage), prednisone or another oral steroid.

Local side effects of immunoglobulin infusions most frequently include an injection site reaction (reddening of the skin around the injection site), itching, rash, and hives. Less serious systemic side effects to immunoglobulin infusions include an increased heart rate, hyper or hypotension, an increased body temperature, diarrhea, nausea, abdominal pain, vomiting, arthralgia or myalgia, dizziness, headache, fatigue, fever, and pain.

Serious side effects of immunoglobulin infusions include chest discomfort or pain, myocardial infarction, tachycardia hyponatremia, hemolysis, hemolytic anemia, thrombosis, hepatitis, anaphylaxis, backache, aseptic meningitis, acute kidney injury, hypokalemic nephropathy, pulmonary embolism, and transfusion related acute lung injury. There is also a small chance that even given the precautions taken in preparing immunoglobulin preparations, an immunoglobulin infusion may pass a virus to its recipient.

Some immunoglobulin solutions also contain isohemagglutinins, which in rare circumstances can cause hemolysis by the isohemagglutinins triggering phagocytosis.

In the case of less serious side effects, a patient’s infusion rate can be adjusted downwards until the side effects become tolerable, while in the case of more serious side effects, emergency medical attention should be sought.

Immunoglobulin therapy also interferes with the ability of the body to produce a normal immune response to an attenuated live virus vaccine for up to a year, can result in falsely elevated blood glucose levels, and can interfere with many of the IgG-based assays often used to diagnose a patient with a particular infection.

The precise mechanism by which immunoglobulin therapy suppresses harmful inflammation is likely multifactorial. For example, it has been reported that immunoglobulin therapy can block Fas-mediated cell death.

Perhaps a more popular theory is that the immunosuppressive effects of immunoglobulin therapy are mediated through IgG’s Fc glycosylation. By binding to receptors on antigen presenting cells, IVIG can increase the expression of the inhibitory Fc receptor, FcgRIIB and shorten the half-life of auto-reactive antibodies.

The ability of immunoglobulin therapy to suppress pathogenic immune responses by this mechanism is dependent on the presence of a sialylated glycan at position CH2-84.4 of IgG. Specifically, de-sialylated preparations of immunoglobulin lose their therapeutic activity and the anti-inflammatory effects of IVIG can be recapitulated by administration of recombinant sialylated IgG1 Fc.

There are several other proposed mechanisms of action and the actual primary targets of immunoglobulin therapy in autoimmune disease are still being elucidated. Some believe that immunoglobulin therapy may work via a multi-step model where the injected immunoglobulin first forms a type of immune complex in the patient. Once these immune complexes are formed, they can interact with Fc receptors on dendritic cells,  which then mediate anti-inflammatory effects helping to reduce the severity of the autoimmune disease or inflammatory state.

Other proposed mechanisms include the possibility that donor antibodies may bind directly with the abnormal host antibodies, stimulating their removal; the possibility that IgG stimulates the host’s complement system, leading to enhanced removal of all antibodies, including the harmful ones; and the ability of immunoglobulin to block the antibody receptors on immune cells (macrophages), leading to decreased damage by these cells, or regulation of macrophage phagocytosis.

Indeed, it is becoming more clear that immunoglobulin can bind to a number of membrane receptors on T cells, B cells, and monocytes that are pertinent to autoreactivity and induction of tolerance to self. A recent report stated that immunoglobulin application to activated T cells leads to their decreased ability to engage microglia. As a result of immunoglobulin treatment of T cells, the findings showed reduced levels of tumor necrosis factor-alpha and interleukin-10 in T cell-microglia co-culture. The results add to the understanding of how immunoglobulin may affect inflammation of the central nervous system in autoimmune inflammatory diseases.

In Indonesia, for immunoglobulin, you should have to pay to get the treatment. However, most of the immunoglobulin variants are covered by the insurance.

The government does not make the immunoglobulin free because of the high demand and lack of resources of the immunoglobulin itself.

If you are foreigner it is better for you to take the immunoglobulin back in your hometown because most of immunoglobulin don’t provide immunity until at least two weeks after they’re given, so visit a doctor four to eight weeks before departure. Ask your doctor for an International Certificate of Immunoglobulin (otherwise known as the yellow booklet), which will list all the vaccinations you’ve received.

It is difficult to find reliable medical care in rural areas especially in case of giving the immunoglobulin treatment, but most major cities now have clinics catering specifically to travelers and expats.

These clinics are usually more expensive than local medical facilities, but are worth utilizing, as they will offer a superior standard of care. Additionally, they understand the local system and are aware of the safest local hospitals and best specialists. They can also liaise with insurance companies should you require evacuation.

Local medical care in general is not yet up to international standards. Foreign doctors are not allowed to work in Indonesia, but some clinics (such as those in Bali and Jakarta) catering to foreigners have ‘international advisors’. Almost all Indonesian doctors work at government hospitals during the day and in private practices at night. This means that private hospitals often don’t have their best staff available during the day. Serious cases are evacuated to Australia, Bangkok or Singapore.

The cost of medical care in Indonesia remains cheap by international standards: a visit to the ER of a top hospital in a major city will start at around 500,000Rp for a minor treatment. So we can say that the treatment of immunoglobulin in Indonesia is not free. However, the hospital or clinics in Indonesia is still can offering you the insurance covered for your immunoglobulin treatment while you are travelling in Indonesia.

We suggest you to always do a double checking when you are want to take the immunoglobulin treatment, especially for the allergic reaction and the price of the immunoglobulin. Find the information as much as possible before taking the medication.

If you still want to learn more all about Immunoglobulin during your visit in Bali, you can go and contact Hydro Medical Bali. They will provide you the information that you needed for Immunoglobulin.

Also, they will provide you the immunoglobulin therapy when you needed it with the handling of their professional health care.

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