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Patel K, Bhanushali M, Muley SA. Management strategies in chronic inflammatory demyelinating polyradiculoneuropathy. Neurol India 2010; 58:351-60. [PMID: 20644261 DOI: 10.4103/0028-3886.65534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a chronic, proximal and distal, asymmetrical or symmetrical, motor and sensory demyelinating polyneuropathy with a progressive course for at least 2 months. The accurate diagnosis is crucial as CIDP is amenable to treatment. Recent advances have provided new strategies and options for management of this syndrome. In this article, we review the clinical and diagnostic features as well as discuss recent insights and treatment strategies along with our experience in the management of patients with CIDP.
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Affiliation(s)
- Kamakshi Patel
- Department of Neurology and Ophthalmology, Michigan State University, East Lansing, Michigan, USA
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52
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Eftimov F, Lunn MPT, Leeflang MM, van Schaik IN. Anti-GM1 antibody testing for multifocal motor neuropathy. Hippokratia 2010. [DOI: 10.1002/14651858.cd008595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Filip Eftimov
- Academic Medical Centre, University of Amsterdam; Department of Neurology; Meibergdreef 9 PO Box 22700 Amsterdam Netherlands 1100 DE
| | - Michael PT Lunn
- National Hospital for Neurology and Neurosurgery; Department of Neurology; Queen Square London UK WC1N 3BG
| | - Mariska M.G. Leeflang
- Academic Medical Center, J1B-207-1; Department of Clinical Epidemiology and Biostatistics; P.O. Box 22700 AMSTERDAM Netherlands 1100 DE
| | - Ivo N van Schaik
- Academic Medical Centre, University of Amsterdam; Department of Neurology; Meibergdreef 9 PO Box 22700 Amsterdam Netherlands 1100 DE
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Dacci P, Riva N, Scarlato M, Andresen I, Schmidt D, Comi G, Fazio R. Subcutaneous immunoglobulin therapy for the treatment of multifocal motor neuropathy: a case report. Neurol Sci 2010; 31:829-31. [DOI: 10.1007/s10072-010-0352-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Accepted: 06/01/2010] [Indexed: 11/28/2022]
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Blackhouse G, Gaebel K, Xie F, Campbell K, Assasi N, Tarride JE, O'Reilly D, Chalk C, Levine M, Goeree R. Cost-utility of Intravenous Immunoglobulin (IVIG) compared with corticosteroids for the treatment of Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) in Canada. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2010; 8:14. [PMID: 20565778 PMCID: PMC2903512 DOI: 10.1186/1478-7547-8-14] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2009] [Accepted: 06/17/2010] [Indexed: 11/18/2022] Open
Abstract
Objectives Intravenous immunoglobulin (IVIG) has demonstrated improvement in chronic inflammatory demyelinating polyneuropathy (CIDP) patients in placebo controlled trials. However, IVIG is also much more expensive than alternative treatments such as corticosteroids. The objective of the paper is to evaluate, from a Canadian perspective, the cost-effectiveness of IVIG compared to corticosteroid treatment of CIDP. Methods A markov model was used to evaluate the costs and QALYs for IVIG and corticosteroids over 5 years of treatment for CIDP. Patients initially responding to IVIG could remain a responder or relapse every 12 week model cycle. Non-responding IVIG patients were assumed to be switched to corticosteroids. Patients on corticosteroids were at risk of a number of adverse events (fracture, diabetes, glaucoma, cataract, serious infection) in each cycle. Results Over the 5 year time horizon, the model estimated the incremental costs and QALYs of IVIG treatment compared to corticosteroid treatment to be $124,065 and 0.177 respectively. The incremental cost per QALY gained of IVIG was estimated to be $687,287. The cost per QALY of IVIG was sensitive to the assumptions regarding frequency and dosing of maintenance IVIG. Conclusions Based on common willingness to pay thresholds, IVIG would not be perceived as a cost effective treatment for CIDP.
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Affiliation(s)
- Gord Blackhouse
- PATH Research Institute, McMaster University, Hamilton, Ontario, Canada.
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55
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Ruiz-Antorán B, Agustí Escasany A, Vallano Ferraz A, Danés Carreras I, Riba N, Mateu Escudero S, Costa J, Sánchez Santiago MB, Laredo L, Durán Quintana JA, Castillo JR, Abad-Santos F, Payares Herrera C, Sádaba Díaz de Rada B, Gómez Ontañón E. Use of non-specific intravenous human immunoglobulins in Spanish hospitals; need for a hospital protocol. Eur J Clin Pharmacol 2010; 66:633-41. [PMID: 20204337 DOI: 10.1007/s00228-010-0800-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2009] [Accepted: 02/08/2010] [Indexed: 11/29/2022]
Abstract
UNLABELLED Intravenous immunoglobulin (IVIG) use in non-approved indications, the increase in consumption and its high cost recommend rationalisation in its utilisation. AIMS To assess the use of IVIG in Spanish hospitals. METHODS An observational, prospective and multicentre drug utilisation study was conducted in 13 tertiary Spanish hospitals. Data were collected for 3 months in patients receiving any IVIG. Patient demographics, indication for IVIG use, dosage regimen and cost of treatment were collected. RESULTS Five hundred and fifty-four patients (mean age of 52 years) were included in the study. A total of 1,287 prescriptions were administered, and the average number of prescriptions per patient was 2.3. The mean daily dose was 24 g (range 0.6-90 g). Overall, IVIG was prescribed for authorised indications in 335 patients (60%) with 953 prescriptions (74%), for non-authorised indications with scientific evidentiary support in 86 patients (16%) with 137 prescriptions (11%), and non-authorised and non-accepted indications in 133 patients (24%) with 197 prescriptions (15%). The most frequent authorised indications were primary and secondary immunodeficiencies, and the most frequent non-authorised and non-accepted indications were multiple sclerosis and bullous dermatosis. The mean cost of IVIG per patient for authorised indications was 2,636.2 <euro>, non-authorised indications with scientific support 5,262.1 <euro> and non-accepted indications 3,555.8 <euro>. CONCLUSIONS IVIG is prescribed for a significant number of non-authorised and non-accepted indications with a notable cost. There is an important variability in IVIG prescriptions between hospitals, indicating room for improvement in IVIG use and the need for a consensus of protocol use.
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Affiliation(s)
- Belen Ruiz-Antorán
- Clinical Pharmacology Department, Puerta de Hierro Majadahonda University Hospital, C/ Manuel de Falla 1, 28222, Majadahonda, Madrid, Spain.
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56
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Hughes RAC, Dalakas MC, Cornblath DR, Latov N, Weksler ME, Relkin N. Clinical applications of intravenous immunoglobulins in neurology. Clin Exp Immunol 2010; 158 Suppl 1:34-42. [PMID: 19883422 DOI: 10.1111/j.1365-2249.2009.04025.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Intravenous immunoglobulin (IVIg) is used increasingly in the management of patients with neurological conditions. The efficacy and safety of IVIg treatment in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and Guillain-Barré syndrome (GBS) have been established clearly in randomized controlled trials and summarized in Cochrane systematic reviews. However, questions remain regarding the dose, timing and duration of IVIg treatment in both disorders. Reports about successful IVIg treatment in other neurological conditions exist, but its use remains investigational. IVIg has been shown to be efficacious as second-line therapy in patients with dermatomyositis and suggested to be of benefit in some patients with polymyositis. In patients with inclusion body myositis, IVIg was not shown to be effective. IVIg is also a treatment option in exacerbations of myasthenia gravis. Studies with IVIg in patients with Alzheimer's disease have reported increased plasma anti-Abeta antibody titres associated with decreased Abeta peptide levels in the cerebrospinal fluid following IVIg treatment. These changes at the molecular level were accompanied by improved cognitive function, and large-scale randomized trials are under way.
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Affiliation(s)
- R A C Hughes
- National Hospital for Neurology and Neurosurgery, Queens Square, London, UK.
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57
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Mouthon L, Bussone G, Kaveri S. Indications et mécanismes d’action des immunoglobulines intraveineuses dans les pathologies auto-immunes et inflammatoires systémiques. Rev Med Interne 2009; 30:H14-20. [DOI: 10.1016/s0248-8663(09)73168-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Misbah S, Sturzenegger MH, Borte M, Shapiro RS, Wasserman RL, Berger M, Ochs HD. Subcutaneous immunoglobulin: opportunities and outlook. Clin Exp Immunol 2009; 158 Suppl 1:51-9. [PMID: 19883424 PMCID: PMC2801034 DOI: 10.1111/j.1365-2249.2009.04027.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Immunoglobulin (Ig) administration via the subcutaneous (s.c.) route has become increasingly popular in recent years. The method does not require venous access, is associated with few systemic side effects and has been reported to improve patients' quality of life. One current limitation to its use is the large volumes which need to be administered. Due to the inability of tissue to accept such large volumes, frequent administration at multiple sites is necessary. Most studies conducted to date have investigated the use of subcutaneous immunoglobulin (SCIg) in patients treated previously with the intravenous (i.v.) formulation. New data now support the use of s.c. administration in previously untreated patients with primary immunodeficiencies. SCIg treatment may further be beneficial in the treatment of autoimmune neurological conditions, such as multi-focal motor neuropathy; however, controlled trials directly comparing the s.c. and i.v. routes are still to be performed for this indication. New developments may further improve and facilitate the s.c. administration route. For example, hyaluronidase-facilitated administration increases the bioavailability of SCIg, and may allow for the administration of larger volumes at a single site. Alternatively, more concentrated formulations may reduce the volume required for administration, and a rapid-push technique may allow for shorter administration times. As these developments translate into clinical practice, more physicians and patients may choose the s.c. administration route in the future.
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Affiliation(s)
- S Misbah
- John Radcliffe Hospital, Oxford, UK.
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59
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Immunomodulatory Therapies in Neurologic Critical Care. Neurocrit Care 2009; 12:132-43. [DOI: 10.1007/s12028-009-9274-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2009] [Accepted: 08/28/2009] [Indexed: 10/20/2022]
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Liumbruno GM, Bennardello F, Lattanzio A, Piccoli P, Rossettias G. Recommendations for the use of albumin and immunoglobulins. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2009; 7:216-34. [PMID: 19657486 PMCID: PMC2719274 DOI: 10.2450/2009.0094-09] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Giancarlo Maria Liumbruno
- UU.OO.CC. di Immunoematologia e Medicina Trasfusionale e Patologia Clinica, Ospedale San Giovanni Calibita Fatebenefratelli, Roma, Italy.
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Baumann A, Hess CW, Sturzenegger M. IVIg dose increase in multifocal motor neuropathy. J Neurol 2009; 256:608-14. [DOI: 10.1007/s00415-009-0130-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2008] [Revised: 09/13/2008] [Accepted: 10/23/2008] [Indexed: 10/20/2022]
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Harbo T, Andersen H, Hess A, Hansen K, Sindrup SH, Jakobsen J. Subcutaneous versus intravenous immunoglobulin in multifocal motor neuropathy: a randomized, single-blinded cross-over trial. Eur J Neurol 2009; 16:631-8. [PMID: 19236457 DOI: 10.1111/j.1468-1331.2009.02568.x] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE For treatment of multifocal motor neuropathy (MMN), we hypothesized that (i) infusion of equivalent dosages of subcutaneous immunoglobulin (SCIG) is as effective as intravenous immunoglobulin (IVIG) and that (ii) subcutaneous infusion at home is associated with a better quality of life. METHODS In a randomized single-blinded cross-over study, nine IVIG responsive patients were allocated to receive either SCIG or IVIG for a period equivalent to three IVIG treatment intervals and, subsequently, crossed over to the other treatment. Primary end-points were (i) dynamometric strength of affected muscles and (ii) the SF-36 quality of life questionnaire. RESULTS The two treatments were equally effective, the mean change in muscle strength after SCIG being 3.6% (95% CI -3.6% to 10.9%) vs. 4.3% (-1.3% to 10.0%) after IVIG (P = 0.86). One patient had sustained erythema and oedema at the injection sites for a few weeks. All other adverse effects during SCIG were mild and transient. No differences between treatments of health-related quality of life occurred. CONCLUSION In MMN, short-term subcutaneous infusion of immunoglobulin is feasible, safe and as effective as intravenous infusion. Subcutaneous administration is an alternative option that adds flexibility to the treatment schedule.
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Affiliation(s)
- T Harbo
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.
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Umapathi T, Hughes RAC, Nobile-Orazio E, Léger JM. Immunosuppressant and immunomodulatory treatments for multifocal motor neuropathy. Cochrane Database Syst Rev 2009:CD003217. [PMID: 19160219 DOI: 10.1002/14651858.cd003217.pub3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Multifocal motor neuropathy is characterised by progressive, predominantly distal, asymmetrical limb weakness and usually multiple partial motor nerve conduction blocks. Intravenous immunoglobulin is beneficial but the role of immunosuppressive agents is uncertain. OBJECTIVES To provide the best available evidence from randomised controlled trials on the role of immunosuppressive agents for the treatment of multifocal motor neuropathy. SEARCH STRATEGY For this update, we searched the Cochrane Neuromuscular Disease Group Trials Register (October 8 2008), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 4), MEDLINE (from January 1966 to October 8 2008), and EMBASE (from January 1980 to October 8 2008), for trials of multifocal motor neuropathy. SELECTION CRITERIA Randomised and quasi-randomised controlled trials were to be included and one was found. Prospective and retrospective case series and case reports were considered in the Discussion. DATA COLLECTION AND ANALYSIS Two review authors searched the titles and abstracts of the articles identified and extracted the data independently. MAIN RESULTS In this update, we found the first randomised controlled trial of multifocal motor neuropathy. This study, which randomised 28 patients, showed that mycophenolate mofetil did not significantly improve strength or function or reduce the need for intravenous immunoglobulin. We summarised the results of retrospective and prospective case series in the discussion. AUTHORS' CONCLUSIONS In the only randomised placebo-controlled trial of any immunosuppressive agent, mycophenolate mofetil did not produce significant benefit. Trials of other immunosuppressants should be undertaken.
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Affiliation(s)
- T Umapathi
- Department of Neurology, National Neuroscience Institute, 11 Jalan Tan, Tock Seng, Singapore, Singapore, 308433.
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Ringel I, Zettl UK. Intravenous immunoglobulin therapy in neurological diseases during pregnancy. J Neurol 2007; 253 Suppl 5:V70-4. [PMID: 16998758 DOI: 10.1007/s00415-006-5012-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Immunological changes during pregnancy influence the course of neurological autoimmune diseases in different ways. In case of pregnancy immunomodulatory standard therapies such as interferon-beta, glatiramer acetate,monoclonal antibodies and cytostatics mostly should be discontinued. In those cases intravenous immunoglobulin (IVIg) therapy might be an alternative. In some diseases, contemporary publications describe positive therapeutic effects on the course of disease during or after pregnancy.
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Gorshtein A, Levy Y. Intravenous immunoglobulin in therapy of peripheral neuropathy. Clin Rev Allergy Immunol 2006; 29:271-9. [PMID: 16391402 DOI: 10.1385/criai:29:3:271] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Peripheral neuropathy (PN) can be a manifestation of various neurological, infectious, metabolic, autoimmune, rheumatic, and malignant diseases. During the past decade, intravenous immunoglobulin (IVIg) has been increasingly used in the therapy of PN. Compared with other immunomodulatory therapies, IVIg has an excellent safety profile. IVIg is used today as a first-line therapy in the treatment of Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. Some small studies and reports of clinical cases presented in this article found benefit from IVIg in treating PN associated with diabetes, paraproteinemia, HIV, multisystem rheumatic diseases, and paraneoplastic PN. No clear recommendations can be made relating the use of IVIg in these conditions. Prospective, randomized trials are required to clarify this issue.
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