SUBCUTANEOUS IMMUNOGLOBULINS IN CHRONIC LYMPHOCYTIC LEUKAEMIA WITH SECONDARY ANTIBODY DEFICIENCY. A MONOCENTRIC EXPERIENCE DURING COVID‐19 PANDEMICS

Prevention and management of infectious complications in patients with chronic lymphocytic leukemia (CLL) treated with BTK and BCL-2 inhibitors, focus on current guidelines

CLL is associated with an increased risk of infectious complications. Treatment with BTK or BCL-2 inhibitors does not seem to increase significantly the risk of opportunistic infections, but the role of combination therapies including BTK and/or BCL-2 inhibitors remains to be established. Various infectious complications can be successfully prevented with appropriate risk management strategies. In this paper we reviewed the international guidelines on prevention and management of infectious complications in patients with CLL treated with BTK or BCL-2 inhibitors. Universal pharmacological anti-herpes, antibacterial or antifungal prophylaxis is not warranted. Reactivation of HBV should be prevented in HBsAg-positive subjects. For HBsAg-negative/HBcAb-positive patients recommendations differ, but in case of combination treatment should follow those for other, particularly anti-CD20, agent. Immunization should be provided preferably before the onset of treatment. Immunoglobulin therapy has favourable impact on morbidity but not mortality in patients with hypogammaglobulinemia and severe or recurrent infections. Lack of high-quality data and heterogeneity of patients or protocols included in the studies might explain differences among the main guidelines. Better data collection is warranted.

A Retrospective Study on the Efficacy of Subcutaneous Immunoglobulin as Compared to Intravenous Formulation in Patients with Chronic Lymphocytic Leukemia and Secondary Antibody Deficiency

Secondary antibody deficiency (SAD) is a common complication in chronic lymphocytic leukemia (CLL) which favors the development of life-threatening infections. Subcutaneous immunoglobulins (IG) (SCIG) have been proven to be as effective as intravenous immunoglobulin (IVIG) in primary immunodeficiencies. Since only a few studies investigated SCIG in secondary antibody deficiency, the aim of this study was to assess the efficacy and safety of SCIG or IVIG in CLL patients with secondary antibody deficiency. One hundred and sixteen CLL patients were recruited, 63% were males, and the median age was 68 years; 44% had bronchiectasis and 76% never smoked. Forty-nine patients received IVIG and 88 SCIG, including 28 patients who shifted from IVIG to SCIG. Despite similar baseline IgG levels, patients receiving SCIG achieved higher IgG after at least +6 months (p = 0.0009). We observed that SCIG can decrease the cumulative incidence of first (HR 0.39 p < 0.0001) and second (HR 0.56 p = 0.0411) infection more than IVIG. The effect was remarkable in that patients were able to reach at least 6 g/L of IgG after 6 months of treatments (p < 0.0001). Replacement therapies were well tolerated with less adverse events and a lower discontinuation rate in patients was managed with SCIG than IVIG. In this study we describe the clinical features of a large cohort of CLL with secondary antibody deficiency receiving IG. We demonstrated that SCIG are active and well tolerated drugs that allows to reach higher IgG levels and decrease the rate of infections better than IVIG, in particular when IgG levels reach 6 g/L.

Immunomodulation mediated by polyclonal IgG replacement in patients with CLL may be important in infection prevention

We read with interest the article by Idanna Innocenti and colleagues where a fixed dose of 10g hyaluronidase-free SCIg (subcutaneous immunoglobulin IgG) was administered every two weeks for one year to 10 patients with chronic lymphocytic leukaemia (CLL) and was highly effective in preventing infections [1]. It is generally accepted that frequency of infusions with hyaluronidase-free SCIg preparations are once weekly to maintain 'adequate' trough IgG [2], but this has been extrapolated from use in primary immunodeficient patients who typically have a complete antibody deficiency in contrast to the deficit observed in CLL This article is protected by copyright. All rights reserved.

Current perspectives regarding SARS-CoV-2 vaccination in chronic lymphocytic leukemia

In immunocompetent people, the mRNA vaccines BNT162b2 and mRNA‐1273 have been shown to be safe and effective against coronavirus disease of 2019 (COVID‐19). However, results of cohort studies and meta‐analyses have indicated that the degree of humoral response to SARS‐CoV‐2 vaccines in patients with chronic lymphocytic leukemia (CLL) appears to be lower than that observed in the general population. These inadequate responses are mainly related to the disease itself and to the immunosuppressive effect of therapies administered. In the specific context of CLL, enrolling patients with sub‐optimal vaccine‐response in pivotal vaccine trials could be considered as an appropriate approach to improve response to the COVID‐19 vaccine. These clinical trials should also address the issues of regularity and timing of vaccine booster doses or re‐vaccinations, especially in patients undergoing therapy with pathway‐targeting agents and anti‐CD20 monoclonal antibodies. However, since hypogammaglobulinemia is a serious consequence of CLL, patients who do not have a detectable antibody response should be natural candidates for preventive antibody therapy.