Twinrab: Anti rabies monoclonal antibody cocktail

Twinrab is a drug containing antibody cocktail for post exposure prophylaxis. Rabies is a deadly disease and it is spread from animals to humans when infected animals bite humans. It contains monoclonal antibodies against rabies namely docaravimab and miromavimab. It is marketed by Zydus.

There is no cure for this disease. Death is almost certain when someone suffers from the rabies disease. Rabies vaccination is the only thing that can prevent Rabies disease.

The animal can be asymptomatic at the time of the bite but may be carrying a virus in the saliva. It can also spread the virus by scratch also.

In which form Twinrab is available?

Twinrab is available in the form of ready to inject sterile liquid for injection.

  • 3000 IU in 10 ml vial.
  • 3000 IU in 5 ml vial
  • 1500 IU in 2.5 ml vial
  • 600 IU in 1 ml vial

How to store the Twinrab vaccine?

Store Twinrab at temperature range 2 – 8 degree Celsius as recommended by the manufacturer.

Maintain the temperature range at all stages of transport and storage using cold chains. Strictly maintain temperature range. 

Discard if frozen accidentally.

While discarding this product all the local biomedical waste management protocols should be followed to protect the environment.

How to reconstitute Twinrab?

Twinrab is ready to inject vial and the required dose is sucked into the sterile syringe depending on weight of the patient.

How is the Twinrab vaccine given?

Give Twinrab anti rabies antibodies by injection.

In small children, give it on the thigh anterolateral aspect.

In adolescents and adults, give it in the deltoid muscle.

The dose of 40 IU/kg body weight is given to cat 3 wound and immunocompromised patients cat 2 and cat 3 wound.

Half the calculated dose should be given into the animal bite wound and give half systemically.

Follow all the safety injection precautions while injection.

Discard the disposables per the biomedical waste management protocols.

Do not use expired vaccines and discard it as per biomedical waste management protocol to protect the environment.

What is the schedule for Twinrab Anti Rabies antibodies?

For post exposure prophylaxis, give injection in the following schedule. The need of the Rabieshield vaccine together depends upon the category of bite wound.

CategoryType of contactType of exposureRecommended post exposure prophylaxis
ITouching or feeding of animalsLicks on intact skinNoneNone if reliable case history is available.
IINibbling on uncovered skinMinor scratches or abrasion without bleedingMinorWound management and antirabies vaccine.
IISingle or multiple trans-dermal bites or scratches, licks on broken skin Contamination of the mucous membrane with saliva.SevereWound management + Antirabies immunoglobulin + Antirabies vaccine

Category of dog bite wound

  • For intradermal route, Administer 4 doses, 2 injections of 0.1 ml at 2 different sites as per the updated thai red cross regimen (2-2-2-0-2) as given above.
  • In those previously immunized by complete vaccination schedule (pre or post exposure prophylaxis), give 2 doses of 0.5 ml by intramuscular route or 2 doses of 0.1 ml by intradermal route on day 0 and 3.
  • In cases of category 3 exposures and of category 2 exposure in immunodeficient patients, human rabies immunoglobulin or equine rabies immunoglobulin should be given with Twinrab vaccine.
  • Do not administer immunoglobulin later than 7 days after the first vaccination since later administered would result in interference with immune response of the vaccine.
RouteDoseNumber of dosesSchedule
Intramuscular0.5 ml5Day 0, 3, 7, 14 and 28
Intradermal0.1 ml+0.1 ml4Day 0, 3, 7 and 28

Post exposure prophylaxis

What are side effects of the Twinrab anti rabies antibodies?

Twinrab vaccine prevents deadly rabies disease. The side effects are usually milder and usually self resolving and can be managed at home.

  • Fever.
  • Injection site pain.
  • Irritability.
  • Headache.
  • Asthenia.
  • Shivering.
  • Dizziness.
  • Myalgia.
  • Nausea.
  • Abdominal pain.
  • Arthralgia.
  • Like every other vaccine anaphylaxis allergic reaction can occur after this vaccine though extremely rare I should be managed swiftly. The necessary skilled personnel, drugs and equipment should be available at the time of the vaccination.

What are the warnings and precautions while taking the Twinrab vaccine?

  • Corticosteroids, chloroquine and other immunosuppressive treatments can interfere with the immune response of vaccines and lead to failure of the vaccination.
  • Administer Twinrab anti rabies antibody at different sites than that from vaccines.
  • Do not exceed the recommended dose of Twinrab.
  • Do not administer repeated doses of the Anti rabies antibody once the vaccination course has been started.
  • Higher dose of immunoglobulin could interfere with the immune response to rabies vaccine.
  • The person who is hypersensitive may get anaphylaxis reaction with these antibodies though it contains a very small amount of neomycin. The vaccine should be given with precaution in such a person as rabies is deadlier.
  • The safety of Twinrab in pregnancy is not known but it is used as Rabies disease is itself lethal.

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