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Immunosuppressant (Polyclonal Anti-T-Cell Immunoglobulin)

Antithymocyte Immunoglobulin (Rabbit)

Brand names: Thymoglobulin, ATG-Fresenius S

Adult dose

Dose: Aplastic anaemia: 3.75 mg/kg/day IV for 5 days. Transplant rejection prophylaxis/treatment: 1.5 mg/kg/day for 3–5 days (Thymoglobulin). Doses vary by indication — refer to SmPC
Route: Intravenous infusion (via central line; long infusion time)
Frequency: Once daily for 3–5 days

Clinical pearls

  • Primary uses: (1) immunosuppression for aplastic anaemia (with ciclosporin and eltrombopag), (2) solid organ transplant rejection prophylaxis/treatment, (3) haematopoietic stem cell transplant (HSCT) conditioning
  • NICE NG234 (Aplastic anaemia, 2022): horse ATG (equine) preferred over rabbit ATG for treatment-naive severe aplastic anaemia (better response rates) — but rabbit ATG used when equine not available or second-line
  • Premedicate with IV corticosteroids, antihistamine, and paracetamol to reduce infusion reactions
  • CMV and fungal prophylaxis mandatory during and after treatment
  • Serum sickness: treat with prednisolone 1–2 mg/kg/day if occurs
  • Test dose (skin prick) recommended before full infusion to assess allergy

Contraindications

  • Severe infection that cannot be controlled
  • History of severe anaphylaxis to rabbit proteins
  • Hypersensitivity to excipients

Side effects

  • Infusion-related reactions: fever, chills, rigors, nausea (very common — due to cytokine release)
  • Serum sickness (7–14 days post-treatment): fever, arthralgia, rash, urticaria
  • Thrombocytopenia and leucopenia (due to T-cell depletion)
  • Increased susceptibility to infections (bacterial, viral, fungal)
  • CMV reactivation (require prophylaxis)
  • Anaphylaxis (rare)

Interactions

  • Other immunosuppressants — additive immunosuppression; increased infection risk
  • Live vaccines — contraindicated during immunosuppression

Monitoring

  • Full blood count (daily — CD3+ T-cell count and platelet/WBC monitoring)
  • Vital signs during infusion
  • CMV PCR weekly during and for 3 months after treatment
  • LFTs and renal function
  • Signs of serum sickness at 7–14 days

Reference: BNF; NICE NG234 (Aplastic anaemia: diagnosis and management, 2022); BSH Guidelines on aplastic anaemia (2015 updated); EBMT/EHA Guidelines; https://bnf.nice.org.uk/drugs/antithymocyte-immunoglobulin-rabbit/. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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