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Recent advances to achieve remission induction in antineutrophil cytoplasmic antibody-associated vasculitis. Curr Opin Rheumatol 2010; 22:37-42. [PMID: 19770660 DOI: 10.1097/bor.0b013e328331cfeb] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Significant advances in the treatment of antineutrophil cytoplasmic antibody-associated vasculitis have been made in the past 10 years. This review aims to detail advances in treatment aimed at induction of remission. RECENT FINDINGS Cyclophosphamide-based regimes remain the standard of care, at least in generalized disease. Safer therapeutic regimes with reduced cumulative dose of cyclophosphamide have been developed such as the use of pulsed cyclophosphamide. Preliminary data are available, suggesting rituximab may be an alternative to cyclophosphamide, but additional safety data are required. Evidence suggests that plasma exchange should be added to those with more severe disease and it is acceptable to use methotrexate as an induction agent for those with limited or early systemic disease. Using current regimens, remission is achieved in over 90% of patients, but toxicity remains an important issue. Attention should be paid to reducing treatment toxicity. SUMMARY Findings of recent clinical trials should change clinical practice and improve outcome of patients with antineutrophil cytoplasmic antibody-associated vasculitis.
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202
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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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203
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Arnson Y, Shoenfeld Y, Amital H. Intravenous immunoglobulin therapy for autoimmune diseases. Autoimmunity 2009; 42:553-60. [DOI: 10.1080/08916930902785363] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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204
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Damianovich M, Blank M, Raiter A, Hardy B, Shoenfeld Y. Anti-vascular endothelial growth factor (VEGF) specific activity of intravenous immunoglobulin (IVIg). Int Immunol 2009; 21:1057-63. [PMID: 19625382 DOI: 10.1093/intimm/dxp070] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Intravenous immunoglobulins (IVIg) preparations can be beneficial therapeutic agents for the treatment of tumor metastases as has been shown in both human and animal studies. Operating mechanisms have not yet been completely elucidated. Some of the mechanisms proposed entail the stimulation of the production of IL-12, a cytokine that exhibits anti-angiogenic activities, as well as inhibition of endothelial cells proliferation and vascular endothelial growth factor (VEGF) secretion. The aim of the present study was to investigate whether in an IVIg preparation there are natural antibodies directed against VEGF with the potential to affect angiogenesis. Using both sandwich and direct ELISA assays, IVIg was found to specifically recognize and bind VEGF in a dose-dependent manner. The binding specificity was confirmed by inhibition of IVIg binding to VEGF by VEGF as an inhibitor, as shown by ELISA and immunoblot. A mouse hind limb ischemia model was employed to evaluate the in vivo IVIg-induced inhibition of angiogenesis. IVIg was found to exhibit inhibitory effect on VEGF-mediated blood perfusion in the ischemic limb. The present study shows a presence of anti-VEGF fraction in IVIg preparation.
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Affiliation(s)
- Maya Damianovich
- Department of Medicine B, Center for Autoimmune Diseases, Sheba Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Hashomer, Israel
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205
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Katz U, Kishner I, Magalashvili D, Shoenfeld Y, Achiron A. Long term safety of IVIg therapy in multiple sclerosis: 10 years experience. Autoimmunity 2009; 39:513-7. [PMID: 17060031 DOI: 10.1080/08916930600825867] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Multiple sclerosis (MS) is a chronic demyelinating disease of the central nervous system. The majority of MS patients have a relapsing-remitting course with progressive neurological disability that accumulates over the years. Intravenous Immunoglobulin (IVIg) has demonstrated benefit in the treatment of some patients with relapsing-remitting MS. Concerns about adverse events of IVIg, mainly acute renal failure and thromboembolic events have been raised in the medical literature. We examined the adverse events profile of IVIg treatment in a large cohort of 293 relapsing-remitting MS patients treated with an initial loading dose of IVIg (0.4 g/Kg body weight/day, for 5 consecutive days) and additional booster dose infusions (0.4 g/Kg body weight/booster dose, every 6 weeks) as a maintenance treatment. A total of 9281 IVIg infusions were administered within a mean treatment period of 3.8 +/- 3.5 years (3 months-10 years). The main adverse event during the loading dose period was headache, occurring in 12.6% of the patients. The annual rate of any adverse event during the IVIg maintenance period was 4.4% during the first year and had a trend to decrease with every passing year of treatment. Adverse events during the loading dose did not predict adverse events during the maintenance phase. No severe adverse events were recorded. We conclude that IVIg is a safe therapy in MS either for short or for long-term periods.
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Affiliation(s)
- Uriel Katz
- Department of Internal Medicine B, Center for Autoimmune Diseases, The Chaim Sheba Medical Center, Tel HaShomer, 52621, Israel
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206
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Petrov R, Elbahloul O, Gallichio MH, Stellrecht K, Conti DJ. Monthly screening for polyoma virus eliminates BK nephropathy and preserves renal function. Surg Infect (Larchmt) 2009; 10:85-90. [PMID: 19298172 DOI: 10.1089/sur.2008.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Polyoma BK virus nephropathy is a serious complication after renal transplantation and is associated with a high rate of allograft failure. Progressive infection with BK virus in immunocompromised renal transplant recipients occurs in detectable stages: Viruria, viremia, then nephropathy. METHODS In January, 2006, we initiated a plasma screening policy for all new transplant recipients, with monthly blood testing for BK virus by polymerase chain reaction (PCR). Between January 1, 2006, and February 28, 2007, 66 renal transplants were performed at our center. The 11 patients with a positive plasma BK PCR test underwent prompt reduction in baseline immunotherapy consisting of a 50% daily dose reduction (n = 6) or complete discontinuation of therapy with mycophenolate mofetil (n = 5). RESULTS After reduction or discontinuation of mycophenolate mofetil, 10 patients became negative for BK virus in the plasma within 6 months. Progression to BK nephropathy has not occurred, and renal transplant dysfunction secondary to acute cellular rejection developed in only 1 patient (9%). One year post-transplant, the mean serum creatinine values for these 11 patients remained stable at 1.5 mg/dL. CONCLUSION Monthly plasma screening for BK virus by PCR together with immunosuppressive regimen reduction prevents BK nephropathy. In addition, this intensive screening protocol is associated with a low rate of acute rejection and excellent preservation of renal function.
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Affiliation(s)
- Roman Petrov
- Department of Surgery, Albany Medical College, Albany, New York 12208, USA
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207
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Bucciarelli S, Erkan D, Espinosa G, Cervera R. Catastrophic antiphospholipid syndrome: treatment, prognosis, and the risk of relapse. Clin Rev Allergy Immunol 2009; 36:80-4. [PMID: 19051065 DOI: 10.1007/s12016-008-8107-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The "catastrophic" variant of the antiphospholipid syndrome (APS) is characterized by multiple vascular occlusive events, usually affecting small vessels and developing over a short period of time. Although patients with catastrophic APS represent less than 1% of all patients with APS, they are usually in a life-threatening situation with a 50% mortality rate. The purpose of this paper is to review the treatment strategies and prognostic factors in patients with catastrophic APS. A detailed description of the clinical and laboratory features of the syndrome can be found in the other articles of this issue.
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208
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Arumugam TV, Woodruff TM, Lathia JD, Selvaraj PK, Mattson MP, Taylor SM. Neuroprotection in stroke by complement inhibition and immunoglobulin therapy. Neuroscience 2009; 158:1074-89. [PMID: 18691639 PMCID: PMC2639633 DOI: 10.1016/j.neuroscience.2008.07.015] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2008] [Revised: 07/08/2008] [Accepted: 07/08/2008] [Indexed: 12/18/2022]
Abstract
Activation of the complement system occurs in a variety of neuroinflammatory diseases and neurodegenerative processes of the CNS. Studies in the last decade have demonstrated that essentially all of the activation components and receptors of the complement system are produced by astrocytes, microglia, and neurons. There is also rapidly growing evidence to indicate an active role of the complement system in cerebral ischemic injury. In addition to direct cell damage, regional cerebral ischemia and reperfusion (I/R) induces an inflammatory response involving complement activation and generation of active fragments, such as C3a and C5a anaphylatoxins, C3b, C4b, and iC3b. The use of specific inhibitors to block complement activation or their mediators such as C5a, can reduce local tissue injury after I/R. Consistent with therapeutic approaches that have been successful in models of autoimmune disorders, many of the same complement inhibition strategies are proving effective in animal models of cerebral I/R injury. One new form of therapy, which is less specific in its targeting of complement than monodrug administration, is the use of immunoglobulins. Intravenous immunoglobulin (IVIG) has the potential to inhibit multiple components of inflammation, including complement fragments, pro-inflammatory cytokine production and leukocyte cell adhesion. Thus, IVIG may directly protect neurons, reduce activation of intrinsic inflammatory cells (microglia) and inhibit transendothelial infiltration of leukocytes into the brain parenchyma following an ischemic stroke. The striking neuroprotective actions of IVIG in animal models of ischemic stroke suggest a potential therapeutic potential that merits consideration for clinical trials in stroke patients.
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Affiliation(s)
- T V Arumugam
- Department of Pharmaceutical Sciences, School of Pharmacy, Texas Tech University Health Sciences Center, 1300 Coulter Drive, Amarillo, TX 79106, USA.
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Abstract
The provision of antibodies to prevent and treat infection began with the application of "curative serum" in the first years of the last century. After the process of large-scale plasma fractionation was developed in the 1940s, the general use of immunoglobulin expanded. Intravenous immunoglobulin products became available in the 1970s, and their only use for the provision of antibodies governed the opinion of experts over the next decade. Modulation of inflammation and immunosuppression were introduced in treatment of inflammatory and autoimmune diseases and became accepted indications. The history of adverse events of treatment and their management are outlined in this article. Consensus indications and evidence-based off-label uses are discussed.
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Affiliation(s)
- Martha M Eibl
- Medical University of Vienna, Center for Physiology, Pathophysiology and Immunology, Institute of Immunology, Borschkegasse 8a, 1090 Vienna, Austria.
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210
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Choo KJL, Simons FER, Sheikh A. Glucocorticoids for the treatment of anaphylaxis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2009. [DOI: 10.1002/14651858.cd007596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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211
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Martinez V, Cohen P, Pagnoux C, Vinzio S, Mahr A, Mouthon L, Sailler L, Delaunay C, Sadoun A, Guillevin L. Intravenous immunoglobulins for relapses of systemic vasculitides associated with antineutrophil cytoplasmic autoantibodies: results of a multicenter, prospective, open-label study of twenty-two patients. ACTA ACUST UNITED AC 2008; 58:308-17. [PMID: 18163506 DOI: 10.1002/art.23147] [Citation(s) in RCA: 124] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To evaluate at 9 months and 24 months the safety and efficacy of intravenous immunoglobulins (IVIGs) administered for 6 months to treat relapses of Wegener's granulomatosis (WG) or microscopic polyangiitis (MPA) occurring either under treatment or during the year following discontinuation of corticosteroids and/or immunosuppressants. METHODS Patients received IVIGs (0.5 gm/kg/day for 4 days) as additional therapy administered monthly for 6 months and were assessed every 3-6 months. Corticosteroids could be maintained or reintroduced at the time of relapse; immunosuppressants could be continued but could not be reintroduced. At months 9 (end point) and 24 (followup), the following information was collected: complete or partial remission, relapse as assessed with the Birmingham Vasculitis Activity Score (BVAS) 2005, and tolerance and safety of IVIG therapy. RESULTS Twenty-two Caucasian patients (7 men and 15 women) were studied: 19 had WG, and 3 had MPA. Their median age was 53 years (range 19-75 years), and their median duration of systemic vasculitis was 27 months (range 7-109 months). Their median BVAS 2005 score was 11 (range 3-25). At study entry, 21 patients were ANCA positive, and 21 patients were taking steroids and/or immunosuppressants. All patients experiencing relapse were treated with the same drug(s) plus IVIGs. All patients initially responded to IVIG therapy. By month 9, 13 patients had complete remission, 1 had partial remission, 7 had relapse, and 1 had treatment failure. In 8 of the 14 patients who had remission, the response persisted at month 24. Seven patients experienced minor side effects. CONCLUSION IVIGs induced complete remissions of relapsed ANCA-associated vasculitides in 13 of 22 patients at month 9. Because of the good safety and tolerance profiles of IVIGs, these agents can be included in a therapeutic strategy with other drugs used to treat relapses of WG or MPA.
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Affiliation(s)
- Valérie Martinez
- Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Université Paris Descartes, Paris, France
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212
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Davé S, Hagan J. Myocardial infarction during intravenous immunoglobulin infusion in a 65-year-old man with common variable immunodeficiency and subsequent successful repeated administration. Ann Allergy Asthma Immunol 2008; 99:567-70. [PMID: 18219840 DOI: 10.1016/s1081-1206(10)60388-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Intravenous immunoglobulin (IVIG) may cause thromboembolic events. Although such events are usually associated with large IVIG doses administered to treat neurologic diseases, thromboembolic events may also occur with standard immunodeficiency doses. OBJECTIVE We describe a 65-year-old man with common variable immunodeficiency (CVID) who experienced angina and myocardial infarction with IVIG infusion. METHODS The patient's electronic medical record was reviewed. RESULTS The patient developed substernal chest pain during a scheduled 40-g (400-mg/kg) infusion. The infusion was discontinued, and a cardiac evaluation was initiated. The patient was found to have elevated troponin T and creatine kinase MB levels, signifying cardiac injury. Heart catheterization revealed severe vessel disease, and surgical revascularization was subsequently performed. Three weeks after revascularization, an IVIG dose of 200 mg/kg was cautiously readministered. This dose was increased in 2 weeks to 300 mg/kg, which was tolerated every 3 to 4 weeks without any adverse thrombotic events in the subsequent 12 months. CONCLUSIONS This case demonstrates not only angina and myocardial infarction associated with IVIG infusion in a patient with CVID but also the successful reinitiation of IVIG infusion after surgical revascularization. This case also underscores the importance of caution with IVIG infusion in patients with CVIDand known coronary artery disease.
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Affiliation(s)
- Shoban Davé
- Division of Allergic Diseases, Department of Medicine. Mayo Clinic, Rochester, Minnesota 55905, USA.
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213
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Piguet D, Tosi C, Lüthi JM, Andresen I, Juge O. Redimune NF Liquid, a ready-to-use, high-concentration intravenous immunoglobulin therapy preparation, is safe and typically well tolerated in the routine clinical management of a broad range of conditions. Clin Exp Immunol 2008; 152:45-9. [PMID: 18241226 DOI: 10.1111/j.1365-2249.2008.03597.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
In clinical practice, intravenous immunoglobulin therapy (IVIG) is used in the management of a wide variety of medical conditions. Observational studies examining IVIG use in routine clinical practice are therefore an important means of validating findings from more strictly randomized controlled trials of patients with specific conditions. In this observational study, we examined the tolerability of a high-concentration (12%) ready-to-use liquid IVIG (Redimune NF Liquid) when used in the standard management of a diverse range of conditions (including primary immunodeficiency diseases, neurology conditions, oncology conditions and immune thrombocytopaenic purpura). IVIG regimen and dose were selected by the physician based on the summary of product characteristics. During the study, 193 infusions were administered to 51 patients in 153 infusion cycles (per infusion cycle: one to five infusions; mean dose, 347.6 mg/kg; mean duration, 202.4 min). The mean maximum infusion rate per cycle was 2.9 mg/kg/min, demonstrating that the infusion rate was often higher than that recommended in the summary of product characteristics. Redimune NF Liquid was well tolerated: there were 36 adverse reactions (at least probably associated with IVIG) in 10 patients (19.6% of sample, 0.24 per infusion cycle, 0.19 per infusion). The most common adverse reaction was headache (50% of reactions), followed by chills (13.8%). Most reactions (69%) were mild and there were no serious or unexpected reactions. In conclusion, in routine clinical practice involving patients with many different conditions, Redimune NF Liquid was well tolerated by the majority of patients.
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Affiliation(s)
- D Piguet
- Haematology-Oncology, Neuchatel, Switzerland
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214
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Samuel S, Azar Y, Corchia N, Or R. Improved Immune Function with Donor B-cell Infusion after Semi-Allogeneic Bone Marrow Transplantation in Mice. Arch Med Res 2008; 39:61-8. [DOI: 10.1016/j.arcmed.2007.06.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2007] [Accepted: 06/25/2007] [Indexed: 11/25/2022]
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215
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Schachter J, Katz U, Mahrer A, Barak D, David LZB, Nusbacher J, Shoenfeld Y. Efficacy and safety of intravenous immunoglobulin in patients with metastatic melanoma. Ann N Y Acad Sci 2007; 1110:305-14. [PMID: 17911445 DOI: 10.1196/annals.1423.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
We have previously reported studies performed both in vitro and in laboratory animals, as well as a case study in humans, suggesting that intravenous immunoglobulin (IVIG) may be beneficial in the treatment of malignancies, including metastatic melanoma. As part of a phase II open label trial, we have administered IVIG to nine patients with metastatic melanoma who had been heavily treated. In two of nine (22%) patients treated every 3 weeks with IVIG (1 g/kg body weight), the disease stabilized. One patient had stable disease for 8 months; the other for 3 months. No serious adverse events (AEs) attributable to IVIG were observed. We conclude that IVIG therapy may be useful for the treatment of metastatic melanoma. Furthermore, we suggest that the effects of IVIG therapy might be enhanced by its use as an adjuvant in patients without evidence of disease following surgery.
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Affiliation(s)
- Jacob Schachter
- Institute of Oncology, Department of Medicine B, Sheba Medical Center, Tel-HaShomer 52621, Ramat Gan, Israel
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216
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Barsheshet A, Marai I, Appel S, Zimlichman E. Acute ST elevation myocardial infarction during intravenous immunoglobulin infusion. Ann N Y Acad Sci 2007; 1110:315-8. [PMID: 17911446 DOI: 10.1196/annals.1423.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Intravenous immunoglobulin (IVIG) preparations are increasingly being used in the treatment of autoimmune disorders. This treatment is regarded as generally safe, and most of the adverse effects associated with IVIG administration are mild and transient. This paper reports a 72-year-old patient with known ischemic heart disease admitted for a Guillain-Barré syndrome variant, who developed acute ST elevation myocardial infarction (MI) during the first hours of IVIG infusion. The literature on acute MI during IVIG treatment is reviewed. Evaluation of each patient for cardiovascular risk prior to IVIG treatment is recommended as is the assessment of risk versus benefit. If IVIG is prescribed, we propose close monitoring and slow infusion rate.
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Affiliation(s)
- Alon Barsheshet
- Heart Institute, Sheba Medical Center, and Sackler Faculty of Medicine, Tel-Aviv University, Israel
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217
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Abstract
Nephropathy from BK virus (BKV) infection is an evolving challenge in kidney transplant recipients. It is the consequence of modern potent immunosuppression aimed at reducing acute rejection and improving allograft survival. Untreated BKV infections lead to kidney allograft dysfunction or loss. Decreased immunosuppression is the principle treatment but predisposes to acute and chronic rejection. Screening protocols for early detection and prevention of symptomatic BKV nephropathy have improved outcomes. Although no approved antiviral drug is available, leflunomide, cidofovir, quinolones, and intravenous Ig have been used. Retransplantation after BKV nephropathy has been successful.
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Affiliation(s)
- Daniel L Bohl
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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218
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Arumugam TV, Tang SC, Lathia JD, Cheng A, Mughal MR, Chigurupati S, Magnus T, Chan SL, Jo DG, Ouyang X, Fairlie DP, Granger DN, Vortmeyer A, Basta M, Mattson MP. Intravenous immunoglobulin (IVIG) protects the brain against experimental stroke by preventing complement-mediated neuronal cell death. Proc Natl Acad Sci U S A 2007; 104:14104-9. [PMID: 17715065 PMCID: PMC1955802 DOI: 10.1073/pnas.0700506104] [Citation(s) in RCA: 160] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2007] [Indexed: 11/18/2022] Open
Abstract
Stroke is among the three leading causes of death worldwide and the most frequent cause of permanent disability. Brain ischemia induces an inflammatory response involving activated complement fragments. Here we show that i.v. Ig (IVIG) treatment, which scavenges complement fragments, protects brain cells against the deleterious effects of experimental ischemia and reperfusion (I/R) and prevents I/R-induced mortality in mice. Animals administered IVIG either 30 min before ischemia or after 3 h of reperfusion exhibited a 50-60% reduction of brain infarct size and a 2- to 3-fold improvement of the functional outcome. Even a single low dose of IVIG given after stroke was effective. IVIG was protective in the nonreperfusion model of murine stroke as well and did not exert any peripheral effects. Human IgG as well as intrinsic murine C3 levels were significantly higher in the infarcted brain region compared with the noninjured side, and their physical association was demonstrated by immuno-coprecipitation. C5-deficient mice were significantly protected from I/R injury compared with their wild-type littermates. Exposure of cultured neurons to oxygen/glucose deprivation resulted in increased levels of C3 associated with activation of caspase 3, a marker of apoptosis; both signals were attenuated with IVIG treatment. Our data suggest a major role for complement-mediated cell death in ischemic brain injury and the prospect of using IVIG in relatively low doses as an interventional therapy for stroke.
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Affiliation(s)
- Thiruma V. Arumugam
- *Laboratory of Neurosciences, National Institute on Aging Intramural Research Program, 5600 Nathan Shock Drive, Baltimore, MD 21224
- Department of Pharmaceutical Sciences, Texas Tech University Health Sciences Center 1400 Wallace Boulevard, Amarillo, TX 79106
| | - Sung-Chun Tang
- *Laboratory of Neurosciences, National Institute on Aging Intramural Research Program, 5600 Nathan Shock Drive, Baltimore, MD 21224
- Department of Neurology, National Taiwan University Hospital, Yun-Lin Branch, Yun-Lin 640, Taiwan
| | - Justin D. Lathia
- *Laboratory of Neurosciences, National Institute on Aging Intramural Research Program, 5600 Nathan Shock Drive, Baltimore, MD 21224
| | - Aiwu Cheng
- *Laboratory of Neurosciences, National Institute on Aging Intramural Research Program, 5600 Nathan Shock Drive, Baltimore, MD 21224
| | - Mohamed R. Mughal
- *Laboratory of Neurosciences, National Institute on Aging Intramural Research Program, 5600 Nathan Shock Drive, Baltimore, MD 21224
| | - Srinivasulu Chigurupati
- *Laboratory of Neurosciences, National Institute on Aging Intramural Research Program, 5600 Nathan Shock Drive, Baltimore, MD 21224
| | - Tim Magnus
- *Laboratory of Neurosciences, National Institute on Aging Intramural Research Program, 5600 Nathan Shock Drive, Baltimore, MD 21224
| | - Sic L. Chan
- *Laboratory of Neurosciences, National Institute on Aging Intramural Research Program, 5600 Nathan Shock Drive, Baltimore, MD 21224
- Biomolecular Science Center, University of Central Florida, Orlando, FL 32816
| | - Dong-Gyu Jo
- *Laboratory of Neurosciences, National Institute on Aging Intramural Research Program, 5600 Nathan Shock Drive, Baltimore, MD 21224
| | - Xin Ouyang
- *Laboratory of Neurosciences, National Institute on Aging Intramural Research Program, 5600 Nathan Shock Drive, Baltimore, MD 21224
| | - David P. Fairlie
- Centre for Drug Design and Development, Institute for Molecular Bioscience, University of Queensland, Brisbane, Qld 4072, Australia
| | - Daniel N. Granger
- Department of Molecular and Cellular Physiology, Louisiana State University Health Sciences Center, Shreveport, LA 71130
| | - Alexander Vortmeyer
- **Neurosurgical Division, National Institute for Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892; and
| | | | - Mark P. Mattson
- *Laboratory of Neurosciences, National Institute on Aging Intramural Research Program, 5600 Nathan Shock Drive, Baltimore, MD 21224
- Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD 21205
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219
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Tufan F, Kamali S, Erer B, Gul A, Inanc M, Ocal L, Konice M, Aral O. Safety of high-dose intravenous immunoglobulin in systemic autoimmune diseases. Clin Rheumatol 2007; 26:1913-5. [PMID: 17636363 DOI: 10.1007/s10067-007-0694-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2007] [Revised: 06/21/2007] [Accepted: 06/22/2007] [Indexed: 01/22/2023]
Abstract
It is reported that the usage of high-dose intravenous immunoglobulin (HD-IVIG) in systemic autoimmune diseases is associated with various adverse events in a wide range of severity. We aimed to investigate the frequency and profile of adverse events in a group of patients with diffuse connective tissue diseases and Wegener's granulomatosis (WG) who were administrated HD-IVIG for different indications. We recorded the data of 38 patients (25 females and 13 males) aged 38 +/- 15 (12-75) years who were followed up with the diagnosis of systemic autoimmune diseases between 1994 and 2006 according to a predefined protocol. Patients with active disease were treated with HD-IVIG and standard immunosuppressives concomitantly. We evaluated the occurrence of allergy, acute renal failure, thromboembolic events, neutropenia, hemolytic anemia, aseptic meningitis, and vasculitis during infusion therapy of HD-IVIG and in the following 3 weeks. We commenced a total of 130 infusions of HD-IVIG. Patients were administrated 1-12 (3.4 +/- 2.6) infusions of HD-IVIG as needed. Indications for HD-IVIG were unresponsiveness or partial response to standard treatment, severe infections along with disease activity, and severe thrombocytopenia in the preoperative period in 97, 23, and 5% of patients, respectively. Minor adverse events were seen in two patients during HD-IVIG infusions. One patient with WG developed rapidly progressive renal failure during severe disease flare between HD-IVIG infusions. Another patient with WG developed recurrence of deep-vein thrombosis during severe disease flare 3 months after HD-IVIG. Both events were attributed to severe disease activity. Adverse events like allergy, acute renal failure, thromboembolic events, hematological problems, aseptic meningitis, and vasculitis are reported in different frequencies (1-81%) in patients who were administered HD-IVIG for systemic autoimmune diseases. HD-IVIG is considered a safe treatment in selected patients assuring adequate infusion precautions.
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Affiliation(s)
- Fatih Tufan
- Department of Internal Medicine, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey.
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Berger M, Cunningham-Rundles C, Bonilla FA, Melamed I, Bichler J, Zenker O, Ballow M. Carimune NF Liquid is a safe and effective immunoglobulin replacement therapy in patients with primary immunodeficiency diseases. J Clin Immunol 2007; 27:503-9. [PMID: 17479360 DOI: 10.1007/s10875-007-9096-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2006] [Accepted: 03/29/2007] [Indexed: 10/23/2022]
Abstract
Subjects with primary immune deficiency diseases treated with intravenous immunoglobulin (n=42) received intravenous infusions of Carimune NF Liquid every 3-4 weeks for 6 months without routine premedication. The mean dose/patient/infusion was 278.5-800.7 mg/kg. Also, 80.4% of infusions achieved maximum rates of >or=3.5 mg/kg/min; 32% of infusions were associated with adverse events during or within 48 h of their end (upper 95% confidence interval was 39.4%, meeting the Food and Drug Administration (FDA) criterion for acceptable tolerability), and 54.8% of subjects had at least one temporally associated adverse event considered at least possibly drug-related (headache: 35.7% of subjects, 12.4% of infusions; nausea: 14.3%, 3.5%; myalgia: 14.3%, 3.2%; fatigue: 11.9%, 5.7%). The frequencies of these were highest after the first infusion. There were no serious drug-related adverse events or acute serious bacterial infections. Serum IgG trough levels were unchanged from baseline. Carimune NF Liquid, a ready-to-use, high-concentration, liquid immunoglobulin preparation is safe and effective.
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Affiliation(s)
- Melvin Berger
- Rainbow Babies and Children's Hospital, Division of Allergy/Immunology, 111100 Euclid Avenue, Cleveland, Ohio 44106, USA.
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221
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Abstract
Intravenous immunoglobulin (IVIg) is administered both for the treatment of immunodeficiencies and for an expanding list of autoimmune diseases. Most adverse effects are mild and transient including headaches, flushing, fever, chills, fatigue, nausea, diarrhea, blood pressure changes and tachycardia. IgA deficiency-related anaphylactic reactions are largely preventable. Late adverse events are rare and include acute renal failure and thromboembolic events. Acute renal failure, usually oliguric and transient, occurs generally in insufficiently hydrated patients and with sucrose-stabilized products due to osmotic injury. Thromboembolic complications occur due to hyperviscosity especially in patients having risk factors including advanced age, previous thromboembolic events, immobilization, diabetes mellitus, hypertension, dyslipidemia or those receiving high-dose IVIg in a rapid infusion rate or excessive dose. Slow infusion rate and good hydration may prevent renal failure, thromboembolic events and aseptic meningitis. In our experience in more than 200 patients receiving IVIg for different autoimmune diseases and near 10000 infusions for relapsing-remitting multiple sclerosis patients, the occurrence of adverse effects was 24-36% after high dose IVIg, most were headaches and all were mild adverse events. We conclude that IVIg is a safe therapy when given in a slow infusion rate in well-hydrated patients, better avoiding patients with known risk factors.
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Affiliation(s)
- Uriel Katz
- Center for Autoimmune Diseases, Department of Internal Medicine B, The Chaim Sheba Medical Center, Tel HaShomer 52621, Israel
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Shin HJ, Bang IK, Choe BK, Hwang JB, Kim JS, Kim HS. Change of absolute neutrophil count after intravenous immunoglobulin administration for the children with idiopathic thrombocytopenic purpura. KOREAN JOURNAL OF PEDIATRICS 2007. [DOI: 10.3345/kjp.2007.50.10.982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Hyun Jung Shin
- Department of Pediatrics Keimyung University School of Medicine, Daegu, Korea
| | - In Kug Bang
- Department of Pediatrics Keimyung University School of Medicine, Daegu, Korea
| | - Byung Kyu Choe
- Department of Pediatrics Keimyung University School of Medicine, Daegu, Korea
| | - Jin-Bok Hwang
- Department of Pediatrics Keimyung University School of Medicine, Daegu, Korea
| | - Jun Sik Kim
- Department of Pediatrics Keimyung University School of Medicine, Daegu, Korea
| | - Heung Sik Kim
- Department of Pediatrics Keimyung University School of Medicine, Daegu, Korea
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Mignogna MD, Fortuna G, Ruoppo E, Adamo D, Leuci S, Fedele S. Variations in serum hemoglobin, albumin, and electrolytes in patients receiving intravenous immunoglobulin therapy: a real clinical threat? Am J Clin Dermatol 2007; 8:291-9. [PMID: 17902731 DOI: 10.2165/00128071-200708050-00004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND OBJECTIVE Intravenous immunoglobulin (IVIg) is a solution of globulins containing antibodies derived from pooled human plasma of donors and used in the treatment of a number of immune deficiencies and autoimmune diseases. However, several investigators have reported biochemical alterations with use of IVIg. The objective of this study was to evaluate the effects of IVIg therapy on selected biochemical and hematologic parameters in patients with autoimmune mucocutaneous blistering diseases (AMBDs). METHODS In this preliminary clinical study, ten patients with AMBDs (seven with pemphigus vulgaris and three with mucous membrane pemphigoid) received 133 cycles of IVIg for a total of 399 infusions. We evaluated the effects of IVIg therapy on serum hemoglobin (Hb), albumin, and electrolyte levels, including sodium (Na+), potassium (K+), chloride (Cl-) and calcium (Ca2+). Values of these parameters were measured 24 hours before, during, and 24 hours and 4 weeks after the 3-day infusion period. RESULTS The observed variations in serum electrolyte levels were physiologically and clinically negligible. Furthermore, 24 hours after the last infusion, mean electrolyte values had spontaneously returned to normal levels without the need for additional supplementation: Na+ 137.59+/-1.42 mmol/L (p=0.6091 vs baseline); K+ 3.97+/-0.5 mmol/L (p=0.2689); Cl- 103.4+/-2.69 mmol/L (p=0.0388); and Ca2+ 9.07+/-0.44 mg/dL (p=0.5332). Conversely, significant variations in mean Hb and albumin levels were observed. When measured 24 hours after the last infusion, mild/moderate decreases in Hb (11.62+/-2.12 g/dL; p=0.009 vs baseline) and/or albumin (mean 3.14+/-0.24 g/dL; p=0.0016 vs baseline) were evident. Such changes may, albeit very rarely, be of sufficient clinical significance in individual patients as to necessitate additional treatment. CONCLUSION In patients receiving intravenous IVIg for AMBDs, electrolyte values should be monitored but do not represent a real clinical threat. Hemoglobin and albumin values may be altered sufficiently to require additional treatment but this is a very rare occurrence. These findings confirm and extend previous reports of the safety of IVIg therapy.
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Affiliation(s)
- Michele D Mignogna
- Section of Oral Medicine, Department of Odontostomatological and Maxillofacial Sciences, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy.
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Gold R, Stangel M, Dalakas MC. Drug Insight: the use of intravenous immunoglobulin in neurology—therapeutic considerations and practical issues. ACTA ACUST UNITED AC 2007; 3:36-44. [PMID: 17205073 DOI: 10.1038/ncpneuro0376] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2006] [Accepted: 10/18/2006] [Indexed: 11/08/2022]
Abstract
Over the past few years, we have achieved increasing success in the treatment of a number of autoimmune-mediated disorders affecting nerves and muscles. This success is partly attributable to the use of high-dose polyclonal intravenous immunoglobulin (IVIg), which has dramatically changed our treatment options. On the basis of results from controlled, but non-FDA-approved, clinical trials, IVIg is now the treatment of choice for Guillain-Barré syndrome, chronic idiopathic inflammatory demyelinating polyneuropathy and multifocal motor neuropathy; IVIg offers rescue therapy for patients with rapidly worsening myasthenia gravis, and is a second-line therapy for dermatomyositis, stiff-person syndrome, and pregnancy-associated or postpartum multiple sclerosis attacks. The ability of IVIg to treat such immunologically diverse disorders effectively, coupled with its excellent safety profile, has led clinicians to use the drug more liberally, even in diseases for which the data are weak and not evidence-based and in patients with coexisting conditions. Use of IVIg for such indications can increase the risk of complications while raising the cost of the drug. Practical issues regarding dosing and frequency of infusions generate dilemmas in clinical practice. In this article, we review the current indications for IVIg treatment, address practical issues related to the use and costs of the drug, and summarize its mechanisms of action.
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Affiliation(s)
- Ralf Gold
- Department of Neurology at St Josef Hospital, University of Bochum, Germany.
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225
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Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a rapidly progressive life-threatening disease that causes multiple organ thromboses in the presence of antiphospholipid antibodies. High index of clinical suspicion and careful investigation are required to make an early diagnosis so that treatment with anticoagulation, corticosteroids, and plasma exchange or intravenous immunoglobulins can be initiated. Despite this multi-modal treatment, CAPS is associated with high mortality; evidence-based management recommendations do not exist due to the rarity of the condition and the lack of controlled studies. This article reviews the therapeutic and prognostic controversies that were addressed during the 1st International Symposium on CAPS.
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Affiliation(s)
- Doruk Erkan
- The Barbara Volcker Center for Women and Rheumatic Disease, Division of Rheumatology, Hospital for Special Surgery, Weill Medical College of Cornell University, 535 E70th Street, New York, NY 10021, USA.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2006. [DOI: 10.1002/pds.1181] [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]
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