1
|
Geerts M, de Greef BTA, Sopacua M, van Kuijk SMJ, Hoeijmakers JGJ, Faber CG, Merkies ISJ. Intravenous Immunoglobulin Therapy in Patients With Painful Idiopathic Small Fiber Neuropathy. Neurology 2021; 96:e2534-e2545. [PMID: 33766992 PMCID: PMC8205474 DOI: 10.1212/wnl.0000000000011919] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 02/24/2021] [Indexed: 11/18/2022] Open
Abstract
Objective This is the first double-blind randomized controlled trial evaluating the efficacy and safety of IV immunoglobulin (IVIG) vs placebo in patients with idiopathic small fiber neuropathy (I-SFN). Methods Between July 2016 and November 2018, 60 Dutch patients with skin biopsy–proven I-SFN randomly received a starting dose of IVIG (2 g/kg body weight) or matching placebo (0.9% saline). Subsequently, 3 additional infusions of IVIG (1 g/kg) or placebo were administered at 3-week intervals. The primary outcome was a 1-point change in Pain Intensity Numerical Rating Scale score at 12 weeks compared to baseline. Results Thirty patients received IVIG, and 30 received placebo. In both groups, 29 patients completed the trial. In 40% of patients receiving IVIG, the mean average pain was decreased by at least 1 point compared to 30% of the patients receiving placebo (p = 0.588, odds ratio 1.56, 95% confidence interval 0.53–4.53). No significant differences were found on any of the other prespecified outcomes, including general well-being, autonomic symptoms, and overall functioning and disability. Conclusions This randomized controlled trial showed that IVIG treatment had no significant effect on pain in patients with painful I-SFN. Trial Registration Information ClinicalTrials.gov Identifier: NCT02637700, EudraCT 2015-002624-31. Classification of Evidence This study provides Class I evidence that for patients with painful I-SFN, IVIG did not significantly reduce pain compared to placebo.
Collapse
Affiliation(s)
- Margot Geerts
- From the Department of Neurology (M.G., B.T.A.d.G., M.S., J.G.J.H., C.G.F., I.S.J.M.), School of Mental Health and Neuroscience, and Department of Clinical Epidemiology and Medical Technology Assessment (S.M.J.v.K.), Maastricht University Medical Center+; Department of Rehabilitation Adelante/Maastricht University Medical Center+ (M.S.), the Netherlands; and Department of Neurology (I.S.J.M.), Curaçao Medical Center, Willemstad, Curaçao
| | - Bianca T A de Greef
- From the Department of Neurology (M.G., B.T.A.d.G., M.S., J.G.J.H., C.G.F., I.S.J.M.), School of Mental Health and Neuroscience, and Department of Clinical Epidemiology and Medical Technology Assessment (S.M.J.v.K.), Maastricht University Medical Center+; Department of Rehabilitation Adelante/Maastricht University Medical Center+ (M.S.), the Netherlands; and Department of Neurology (I.S.J.M.), Curaçao Medical Center, Willemstad, Curaçao
| | - Maurice Sopacua
- From the Department of Neurology (M.G., B.T.A.d.G., M.S., J.G.J.H., C.G.F., I.S.J.M.), School of Mental Health and Neuroscience, and Department of Clinical Epidemiology and Medical Technology Assessment (S.M.J.v.K.), Maastricht University Medical Center+; Department of Rehabilitation Adelante/Maastricht University Medical Center+ (M.S.), the Netherlands; and Department of Neurology (I.S.J.M.), Curaçao Medical Center, Willemstad, Curaçao
| | - Sander M J van Kuijk
- From the Department of Neurology (M.G., B.T.A.d.G., M.S., J.G.J.H., C.G.F., I.S.J.M.), School of Mental Health and Neuroscience, and Department of Clinical Epidemiology and Medical Technology Assessment (S.M.J.v.K.), Maastricht University Medical Center+; Department of Rehabilitation Adelante/Maastricht University Medical Center+ (M.S.), the Netherlands; and Department of Neurology (I.S.J.M.), Curaçao Medical Center, Willemstad, Curaçao
| | - Janneke G J Hoeijmakers
- From the Department of Neurology (M.G., B.T.A.d.G., M.S., J.G.J.H., C.G.F., I.S.J.M.), School of Mental Health and Neuroscience, and Department of Clinical Epidemiology and Medical Technology Assessment (S.M.J.v.K.), Maastricht University Medical Center+; Department of Rehabilitation Adelante/Maastricht University Medical Center+ (M.S.), the Netherlands; and Department of Neurology (I.S.J.M.), Curaçao Medical Center, Willemstad, Curaçao
| | - Catharina G Faber
- From the Department of Neurology (M.G., B.T.A.d.G., M.S., J.G.J.H., C.G.F., I.S.J.M.), School of Mental Health and Neuroscience, and Department of Clinical Epidemiology and Medical Technology Assessment (S.M.J.v.K.), Maastricht University Medical Center+; Department of Rehabilitation Adelante/Maastricht University Medical Center+ (M.S.), the Netherlands; and Department of Neurology (I.S.J.M.), Curaçao Medical Center, Willemstad, Curaçao.
| | - Ingemar S J Merkies
- From the Department of Neurology (M.G., B.T.A.d.G., M.S., J.G.J.H., C.G.F., I.S.J.M.), School of Mental Health and Neuroscience, and Department of Clinical Epidemiology and Medical Technology Assessment (S.M.J.v.K.), Maastricht University Medical Center+; Department of Rehabilitation Adelante/Maastricht University Medical Center+ (M.S.), the Netherlands; and Department of Neurology (I.S.J.M.), Curaçao Medical Center, Willemstad, Curaçao
| |
Collapse
|
2
|
Meregalli C, Monza L, Chiorazzi A, Scali C, Guarnieri C, Fumagalli G, Alberti P, Pozzi E, Canta A, Ballarini E, Rodriguez-Menendez V, Oggioni N, Cavaletti G, Marmiroli P. Human Intravenous Immunoglobulin Alleviates Neuropathic Symptoms in a Rat Model of Paclitaxel-Induced Peripheral Neurotoxicity. Int J Mol Sci 2021; 22:ijms22031058. [PMID: 33494384 PMCID: PMC7865319 DOI: 10.3390/ijms22031058] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/17/2021] [Accepted: 01/18/2021] [Indexed: 01/07/2023] Open
Abstract
The onset of chemotherapy-induced peripheral neurotoxicity (CIPN) is a leading cause of the dose reduction or discontinuation of cancer treatment due to sensory symptoms. Paclitaxel (PTX) can cause painful peripheral neuropathy, with a negative impact on cancer survivors' quality of life. While recent studies have shown that neuroinflammation is involved in PTX-induced peripheral neurotoxicity (PIPN), the pathophysiology of this disabling side effect remains largely unclear and no effective therapies are available. Therefore, here we investigated the effects of human intravenous immunoglobulin (IVIg) on a PIPN rat model. PTX-treated rats showed mechanical allodynia and neurophysiological alterations consistent with a severe sensory axonal polyneuropathy. In addition, morphological evaluation showed a reduction of intra-epidermal nerve fiber (IENF) density and evidenced axonopathy with macrophage infiltration, which was more prominent in the distal segment of caudal nerves. Three weeks after the last PTX injection, mechanical allodynia was still present in PTX-treated rats, while the full recovery in the group of animals co-treated with IVIg was observed. At the pathological level, this behavioral result was paralleled by prevention of the reduction in IENF density induced by PTX in IVIg co-treated rats. These results suggest that the immunomodulating effect of IVIg co-treatment can alleviate PIPN neurotoxic manifestations, probably through a partial reduction of neuroinflammation.
Collapse
Affiliation(s)
- Cristina Meregalli
- Experimental Neurology Unit, School of Medicine and Surgery, and NeuroMI (Milan Center for Neuroscience), University of Milano-Bicocca, 20900 Monza, Italy; (C.M.); (L.M.); (A.C.); (G.F.); (P.A.); (E.P.); (A.C.); (E.B.); (V.R.-M.); (N.O.); (P.M.)
| | - Laura Monza
- Experimental Neurology Unit, School of Medicine and Surgery, and NeuroMI (Milan Center for Neuroscience), University of Milano-Bicocca, 20900 Monza, Italy; (C.M.); (L.M.); (A.C.); (G.F.); (P.A.); (E.P.); (A.C.); (E.B.); (V.R.-M.); (N.O.); (P.M.)
| | - Alessia Chiorazzi
- Experimental Neurology Unit, School of Medicine and Surgery, and NeuroMI (Milan Center for Neuroscience), University of Milano-Bicocca, 20900 Monza, Italy; (C.M.); (L.M.); (A.C.); (G.F.); (P.A.); (E.P.); (A.C.); (E.B.); (V.R.-M.); (N.O.); (P.M.)
| | - Carla Scali
- Global Medical and R&D Department, Kedrion S.p.A., Località Ai Conti, Castelvecchio Pascoli, 55051 Lucca, Italy; (C.S.); (C.G.)
| | - Chiara Guarnieri
- Global Medical and R&D Department, Kedrion S.p.A., Località Ai Conti, Castelvecchio Pascoli, 55051 Lucca, Italy; (C.S.); (C.G.)
| | - Giulia Fumagalli
- Experimental Neurology Unit, School of Medicine and Surgery, and NeuroMI (Milan Center for Neuroscience), University of Milano-Bicocca, 20900 Monza, Italy; (C.M.); (L.M.); (A.C.); (G.F.); (P.A.); (E.P.); (A.C.); (E.B.); (V.R.-M.); (N.O.); (P.M.)
| | - Paola Alberti
- Experimental Neurology Unit, School of Medicine and Surgery, and NeuroMI (Milan Center for Neuroscience), University of Milano-Bicocca, 20900 Monza, Italy; (C.M.); (L.M.); (A.C.); (G.F.); (P.A.); (E.P.); (A.C.); (E.B.); (V.R.-M.); (N.O.); (P.M.)
| | - Eleonora Pozzi
- Experimental Neurology Unit, School of Medicine and Surgery, and NeuroMI (Milan Center for Neuroscience), University of Milano-Bicocca, 20900 Monza, Italy; (C.M.); (L.M.); (A.C.); (G.F.); (P.A.); (E.P.); (A.C.); (E.B.); (V.R.-M.); (N.O.); (P.M.)
| | - Annalisa Canta
- Experimental Neurology Unit, School of Medicine and Surgery, and NeuroMI (Milan Center for Neuroscience), University of Milano-Bicocca, 20900 Monza, Italy; (C.M.); (L.M.); (A.C.); (G.F.); (P.A.); (E.P.); (A.C.); (E.B.); (V.R.-M.); (N.O.); (P.M.)
| | - Elisa Ballarini
- Experimental Neurology Unit, School of Medicine and Surgery, and NeuroMI (Milan Center for Neuroscience), University of Milano-Bicocca, 20900 Monza, Italy; (C.M.); (L.M.); (A.C.); (G.F.); (P.A.); (E.P.); (A.C.); (E.B.); (V.R.-M.); (N.O.); (P.M.)
| | - Virginia Rodriguez-Menendez
- Experimental Neurology Unit, School of Medicine and Surgery, and NeuroMI (Milan Center for Neuroscience), University of Milano-Bicocca, 20900 Monza, Italy; (C.M.); (L.M.); (A.C.); (G.F.); (P.A.); (E.P.); (A.C.); (E.B.); (V.R.-M.); (N.O.); (P.M.)
| | - Norberto Oggioni
- Experimental Neurology Unit, School of Medicine and Surgery, and NeuroMI (Milan Center for Neuroscience), University of Milano-Bicocca, 20900 Monza, Italy; (C.M.); (L.M.); (A.C.); (G.F.); (P.A.); (E.P.); (A.C.); (E.B.); (V.R.-M.); (N.O.); (P.M.)
| | - Guido Cavaletti
- Experimental Neurology Unit, School of Medicine and Surgery, and NeuroMI (Milan Center for Neuroscience), University of Milano-Bicocca, 20900 Monza, Italy; (C.M.); (L.M.); (A.C.); (G.F.); (P.A.); (E.P.); (A.C.); (E.B.); (V.R.-M.); (N.O.); (P.M.)
- Correspondence:
| | - Paola Marmiroli
- Experimental Neurology Unit, School of Medicine and Surgery, and NeuroMI (Milan Center for Neuroscience), University of Milano-Bicocca, 20900 Monza, Italy; (C.M.); (L.M.); (A.C.); (G.F.); (P.A.); (E.P.); (A.C.); (E.B.); (V.R.-M.); (N.O.); (P.M.)
- Department of Biotechnology and Biosciences, University of Milano-Bicocca, 20126 Milan, Italy
| |
Collapse
|
3
|
Chang MC, Park D. Effectiveness of Intravenous Immunoglobulin for Management of Neuropathic Pain: A Narrative Review. J Pain Res 2020; 13:2879-2884. [PMID: 33209055 PMCID: PMC7669498 DOI: 10.2147/jpr.s273475] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/13/2020] [Indexed: 12/15/2022] Open
Abstract
Administrations of intravenous immunoglobulin (IVIG), an immune-modulating blood-derived product, may be beneficial for managing neuropathic pain. Here, we review previous studies to investigate the effectiveness of IVIG in managing neuropathic pain due to various neurological disorders. The electronic databases PubMed, Scopus, Embase, and the Cochrane Library were searched for studies published up to February 2020. Two reviewers independently assessed the studies using strict inclusion criteria. Ten studies were included and qualitatively analyzed. The review included patients with pain due to complex regional pain syndrome (CRPS), diabetic polyneuropathy, and others, such as postherpetic neuralgia and trigeminal neuralgia. We found that IVIG may be one of the beneficial options for managing neuropathic pain from various neurological disorders. In the four articles reviewed, no major adverse effects were reported, and the trend was toward a positive pain-reducing effect in eight articles. However, to confirm the benefits of IVIG on reducing neuropathic pain, more high-quality studies are required.
Collapse
Affiliation(s)
- Min Cheol Chang
- Department of Rehabilitation Medicine, College of Medicine, Yeungnam University, Daegu, Republic of Korea
| | - Donghwi Park
- Department of Physical Medicine and Rehabilitation, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| |
Collapse
|
4
|
Han CL, Sheng YC, Wang SY, Chen YH, Kang JH. Serum proteome profiles revealed dysregulated proteins and mechanisms associated with fibromyalgia syndrome in women. Sci Rep 2020; 10:12347. [PMID: 32704114 PMCID: PMC7378543 DOI: 10.1038/s41598-020-69271-w] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 06/30/2020] [Indexed: 12/20/2022] Open
Abstract
Fibromyalgia syndrome (FM) is a multifactorial disorder whose pathogenesis and diagnosis are poorly understood. This study investigated differential serum proteome profiles in patients with FM and healthy pain-free controls and explored the association between serum proteome and clinical profiles in patients with FM. Twenty patients with FM (according to the American College of Rheumatology criteria, 2010) and 20 healthy pain-free controls were recruited for optimized quantitative serum proteomics analysis. The levels of pain, pressure pain threshold, sleep, anxiety, depression, and functional status were evaluated for patients with FM. We identified 22 proteins differentially expressed in FM when compared with healthy pain-free controls and propose a panel of methyltransferase-like 18 (METTL18), immunoglobulin lambda variable 3–25 (IGLV3–25), interleukin-1 receptor accessory protein (IL1RAP), and IGHV1OR21-1 for differentiating FM from controls by using a decision tree model (accuracy: 0.97). In addition, we noted several proteins involved in coagulation and inflammation pathways with distinct expression patterns in patients with FM. Novel proteins were also observed to be correlated with the levels of pain, depression, and dysautonomia in patients with FM. We suggest that upregulated inflammation can play a major role in the pathomechanism of FM. The differentially expressed proteins identified may serve as useful biomarkers for diagnosis and evaluation of FM in the future.
Collapse
Affiliation(s)
- Chia-Li Han
- Master Program in Clinical Pharmacogenomics and Pharmacoproteomics, College of Pharmacy, Taipei Medical University, Taipei, 11031, Taiwan
| | - Yung-Ching Sheng
- Department of Chemistry, National Taiwan University, Taipei, 10617, Taiwan
| | - San-Yuan Wang
- Master Program in Clinical Pharmacogenomics and Pharmacoproteomics, College of Pharmacy, Taipei Medical University, Taipei, 11031, Taiwan
| | - Yi-Hsuan Chen
- Master Program in Clinical Pharmacogenomics and Pharmacoproteomics, College of Pharmacy, Taipei Medical University, Taipei, 11031, Taiwan
| | - Jiunn-Horng Kang
- Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital, Taipei, 11031, Taiwan. .,Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, 250 Wuxing St., Taipei, 11031, Taiwan. .,Research Center of Artificial Intelligence in Medicine, Taipei Medical University, Taipei, 11031, Taiwan.
| |
Collapse
|
5
|
Ornello R, Frattale I, Pistoia F, Sacco S, Notturno F. Erenumab Plus Subcutaneous Immunoglobulin in a Patient With Comorbid Chronic Migraine and Myasthenia Gravis. Headache 2020; 60:787-788. [DOI: 10.1111/head.13779] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/26/2020] [Accepted: 01/27/2020] [Indexed: 12/28/2022]
Affiliation(s)
- Raffaele Ornello
- Neuroscience Section Department of Applied Clinical Sciences and Biotechnology University of L’Aquila L’Aquila Italy
| | - Ilaria Frattale
- Neuroscience Section Department of Applied Clinical Sciences and Biotechnology University of L’Aquila L’Aquila Italy
| | - Francesca Pistoia
- Neuroscience Section Department of Applied Clinical Sciences and Biotechnology University of L’Aquila L’Aquila Italy
| | - Simona Sacco
- Neuroscience Section Department of Applied Clinical Sciences and Biotechnology University of L’Aquila L’Aquila Italy
- Department of Neurology ‘SS. Filippo e Nicola’ Hospital Avezzano (L’Aquila) Italy
| | - Francesca Notturno
- Department of Neurology ‘SS. Filippo e Nicola’ Hospital Avezzano (L’Aquila) Italy
| |
Collapse
|
6
|
Eldufani J, Elahmer N, Blaise G. A medical mystery of complex regional pain syndrome. Heliyon 2020; 6:e03329. [PMID: 32149194 PMCID: PMC7033333 DOI: 10.1016/j.heliyon.2020.e03329] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 12/31/2019] [Accepted: 01/27/2020] [Indexed: 12/12/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a condition of neuropathic pain, which is characterized by significant autonomic and inflammatory features. CRPS occurs in patients who have limb surgery, limb fractures, or trauma. Many patients may have pain resolve within twelve months of the inciting incident; however, a small subset progresses to the chronic form. This transitional process often happens by changing from warm CRPS with dominant inflammatory phase to cold CRPS, in which autonomic characteristics or manifestations dominate. Several peripheral and central mechanisms are involved, which might vary among individuals over a period of time. Other contributors include peripheral and central sensitization, autonomic alterations, inflammatory and immune changes, neurochemical changes, and psychological and genetic factors. Although effective management of the chronic CRPS form is often challenging, there are a few high quality randomized controlled trials that support the efficacy of the most commonly used therapeutic approaches.
Collapse
Affiliation(s)
- Jabril Eldufani
- Department of Medicine, Faculty of Medicine, Elmergib University, El-khums, Libya
- Department of Medicine and Anesthesia, Faculty of Medicine, University of Montréal, Montreal, Quebec, Canada
| | - Nyruz Elahmer
- Department of Pharmacology and Physiology, Faculty of Medicine, University of Montréal, Montreal, Quebec, Canada
| | - Gilbert Blaise
- Department of Medicine and Anesthesia, Faculty of Medicine, University of Montréal, Montreal, Quebec, Canada
- Department of Anesthesiology and Pain Management, Centre hospitalier de l’Université de Montréal (CHUM), Montreal, Quebec, Canada
| |
Collapse
|
7
|
Conti P, Gallenga CE, Caraffa A, Ronconi G, Kritas SK. Impact of mast cells in fibromyalgia and low-grade chronic inflammation: Can IL-37 play a role? Dermatol Ther 2019; 33:e13191. [PMID: 31837249 DOI: 10.1111/dth.13191] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 12/11/2019] [Indexed: 12/20/2022]
Abstract
Fibromyalgia (FM) is a disease characterized by chronic widespread pain, fatigue, aches, joint stiffness, depression, cognitive dysfunction, and nonrestorative sleep. In FM, neurotransmission and glial activation can occur with an increase in inflammatory cytokines and involvement of mast cells (MCs) in the skin. FM skin biopsies show an increase in the number of MCs, as well as the production of corticotropin releasing hormone and substance P (SP) by the neurons, which in turn activate MCs to release neurosensitizing proinflammatory substances, such as cytokines, secreted preformed mediators, and lipids, which can exacerbate low-grade inflammation. In fact, certain proinflammatory cytokines are higher in FM and mediate muscle pain, the mechanism of which is not yet clear. MC-derived tumor necrosis factor (TNF) induces nerve growth factor (NGF) and participates in nerve fiber elongation in skin hypersensitivity. IL-37 is an inhibitor of proinflammatory IL-1 family members, which are generated and released by MCs. The goal of this article is to demonstrate that inflammatory cytokines and MC products play a role in FM and that inflammation may be inhibited by IL-37. Here, we propose IL-37 as a cytokine that contributes to improve the pathogenesis of FM by blocking IL-1 family members.
Collapse
Affiliation(s)
- Pio Conti
- Immunology Division, Postgraduate Medical School, University of Chieti-Pescara, Chieti, Italy
| | - Carla Enrica Gallenga
- Department of Biomedical Sciences and Specialist Surgery, Section of Ophthalmology, University of Ferrara, Italy
| | | | - Gianpaolo Ronconi
- UOS Clinica dei Pazienti del Territorio, Policlinico Gemelli, Rome, Italy
| | - Spyros K Kritas
- Department of Microbiology and Infectious Diseases, Aristotle University of Thessaloniki, Macedonia, Greece
| |
Collapse
|
8
|
Tan W, Song Y, Mo C, Jiang S, Wang Z. Analysis of gene expression profile microarray data in complex regional pain syndrome. Mol Med Rep 2017; 16:3371-3378. [DOI: 10.3892/mmr.2017.6950] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 03/16/2017] [Indexed: 11/06/2022] Open
|
9
|
Perez EE, Orange JS, Bonilla F, Chinen J, Chinn IK, Dorsey M, El-Gamal Y, Harville TO, Hossny E, Mazer B, Nelson R, Secord E, Jordan SC, Stiehm ER, Vo AA, Ballow M. Update on the use of immunoglobulin in human disease: A review of evidence. J Allergy Clin Immunol 2016; 139:S1-S46. [PMID: 28041678 DOI: 10.1016/j.jaci.2016.09.023] [Citation(s) in RCA: 376] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 09/12/2016] [Accepted: 09/23/2016] [Indexed: 12/20/2022]
Abstract
Human immunoglobulin preparations for intravenous or subcutaneous administration are the cornerstone of treatment in patients with primary immunodeficiency diseases affecting the humoral immune system. Intravenous preparations have a number of important uses in the treatment of other diseases in humans as well, some for which acceptable treatment alternatives do not exist. We provide an update of the evidence-based guideline on immunoglobulin therapy, last published in 2006. Given the potential risks and inherent scarcity of human immunoglobulin, careful consideration of its indications and administration is warranted.
Collapse
Affiliation(s)
- Elena E Perez
- Allergy Associates of the Palm Beaches, North Palm Beach, Fla.
| | - Jordan S Orange
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Francisco Bonilla
- Department of Pediatrics, Clinical Immunology Program, Children's Hospital Boston and Harvard Medical School, Boston, Mass
| | - Javier Chinen
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Ivan K Chinn
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Morna Dorsey
- Department of Pediatrics, Allergy, Immunology and BMT Division, Benioff Children's Hospital and University of California, San Francisco, Calif
| | - Yehia El-Gamal
- Department of Pediatrics, Pediatric Allergy and Immunology Unit, Children's Hospital and Ain Shams University, Cairo, Egypt
| | - Terry O Harville
- Departments of Pathology and Laboratory Services and Pediatrics, University of Arkansas, Little Rock, Ark
| | - Elham Hossny
- Department of Pediatrics, Pediatric Allergy and Immunology Unit, Children's Hospital and Ain Shams University, Cairo, Egypt
| | - Bruce Mazer
- Department of Pediatrics, Allergy and Immunology, Montreal Children's Hospital and McGill University, Montreal, Quebec, Canada
| | - Robert Nelson
- Department of Medicine and Pediatrics, Division of Hematology and Oncology and Stem Cell Transplantation, Riley Hospital, Indiana University School of Medicine and the IU Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - Elizabeth Secord
- Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Detroit, Mich
| | - Stanley C Jordan
- Nephrology & Transplant Immunology, Kidney Transplant Program, David Geffen School of Medicine at UCLA and Cedars-Sinai Medical Center, Los Angeles, Calif
| | - E Richard Stiehm
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - Ashley A Vo
- Transplant Immunotherapy Program, Comprehensive Transplant Center, Kidney Transplant Program, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Mark Ballow
- Department of Pediatrics, Division of Allergy & Immunology, University of South Florida, Morsani College of Medicine, Johns Hopkins All Children's Hospital, St Petersburg, Fla
| |
Collapse
|
10
|
de Greef BTA, Geerts M, Hoeijmakers JGJ, Faber CG, Merkies ISJ. Intravenous immunoglobulin therapy for small fiber neuropathy: study protocol for a randomized controlled trial. Trials 2016; 17:330. [PMID: 27439408 PMCID: PMC4955261 DOI: 10.1186/s13063-016-1450-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 06/15/2016] [Indexed: 01/02/2023] Open
Abstract
Background Small fiber neuropathy is the most common cause of neuropathic pain in peripheral neuropathies, with a minimum prevalence of 53/100,000. Patients experience excruciating pain, and currently available anti-neuropathic and other pain drugs do not relieve the pain substantially. Several open-label studies have suggested an immunological basis in small fiber neuropathy and have reported efficacy of treatment with intravenous immunoglobulin. Therefore, immunological mechanisms conceivably may play a role in small fiber neuropathy. To date, no randomized controlled study with intravenous immunoglobulin in patients with small fiber neuropathy has been performed. Methods/design This study is a randomized, double-blind, placebo-controlled, clinical trial in patients with idiopathic small fiber neuropathy. The primary objective is to investigate the efficacy of intravenous immunoglobulin versus placebo on pain alleviation. A 1-point change in the PI-NRS compared to baseline is considered the minimum clinically important difference. In the IVIg-treated group, we assume a response rate of approximately 60 % based on the criteria composed by the IMMPACT group for measurement of pain. Based on this, a sample size of 60 patients is needed. Eligible patients fulfilling the inclusion/exclusion criteria will be randomized to receive either intravenous immunoglobulin or placebo (0.9 % saline). The treatment regimen will start with a loading dose of 2 g/kg body weight over 2–4 consecutive days, followed by a maintenance dose of 1 g/kg body weight over 1–2 consecutive days given three times at a 3-week interval. The primary endpoint is the comparison of the percentage of responder subjects between the two treatment groups from the first randomization during the 12 weeks of treatment. A responder is defined as ≥ 1-point Pain Intensity Numerical Rating Scale improvement on the mean weekly peak pain relative to baseline. The secondary outcomes are pain intensity, pain qualities, other small fiber neuropathy-related complaints, daily and social functioning, as well as quality of life. In addition, safety assessments will be performed for adverse events, vital signs, and laboratory values outside the normal range. Responders during the 12-week treatment period will be followed during a 3-month extension phase. Discussion This is the first randomized, double-blind, placebo-controlled clinical trial with intravenous immunoglobulin in patients with idiopathic small fiber neuropathy. Positive findings will result in a new treatment option for small fiber neuropathy and support an immunological role in this condition. Trial registration ClinicalTrials.gov, NCT02637700. Registered on 16 December 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1450-x) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Bianca T A de Greef
- Department of Neurology, School of Mental Health and Neuroscience, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - Margot Geerts
- Department of Neurology, School of Mental Health and Neuroscience, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Janneke G J Hoeijmakers
- Department of Neurology, School of Mental Health and Neuroscience, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Catharina G Faber
- Department of Neurology, School of Mental Health and Neuroscience, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Ingemar S J Merkies
- Department of Neurology, School of Mental Health and Neuroscience, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands.,Department of Neurology, St. Elisabeth Hospital, Willemstad, Curaçao
| |
Collapse
|
11
|
Xu J, Yang J, Lin P, Rosenquist E, Cheng J. Intravenous Therapies for Complex Regional Pain Syndrome: A Systematic Review. Anesth Analg 2016; 122:843-856. [PMID: 26891396 DOI: 10.1213/ane.0000000000000999] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Complex regional pain syndrome (CRPS) remains a challenging clinical pain condition. Multidisciplinary approaches have been advocated for managing CRPS. Compared with spinal cord stimulation and intrathecal targeted therapy, IV treatments are less invasive and less costly. We aimed to systemically review the literature on IV therapies and determine the level of evidence to guide the management of CRPS. We searched PubMed, Embase, Scopus, and the Cochrane databases for articles published on IV therapies of CRPS up through February 2015. The search yielded 299 articles, of which 101 were deemed relevant by reading the titles and 63 by reading abstracts. All these 63 articles were retrieved for analysis and discussion. We evaluated the relevant studies and provided recommendations according to the level of evidence. We conclude that there is evidence to support the use of IV bisphosphonates, immunoglobulin, ketamine, or lidocaine as valuable interventions in selected patients with CRPS. However, high-quality studies are required to further evaluate the safety, efficacy, and cost-effectiveness of IV therapies for CRPS.
Collapse
Affiliation(s)
- Jijun Xu
- From the Departments of Pain Management and Pediatric Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | | | | | | | | |
Collapse
|
12
|
Goebel A, Shenker N, Padfield N, Shoukrey K, McCabe C, Serpell M, Sanders M, Murphy C, Ejibe A, Milligan H, Kelly J, Ambler G. Low-dose intravenous immunoglobulin treatment for complex regional pain syndrome (LIPS): study protocol for a randomized controlled trial. Trials 2014; 15:404. [PMID: 25344328 PMCID: PMC4226877 DOI: 10.1186/1745-6215-15-404] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 08/28/2014] [Indexed: 11/12/2022] Open
Abstract
Background Longstanding complex regional pain syndrome (CRPS) is refractory to treatment with established analgesic drugs in most cases, and for many patients, alternative pain treatment approaches, such as with neuromodulation devices or rehabilitation methods, also do not work. The development of novel, effective treatment technologies is, therefore, important. There are preliminary data suggesting that low-dose immunoglobulin treatment may significantly reduce pain from longstanding CRPS. Methods/Design LIPS is a multicentre (United Kingdom), double-blind, randomised parallel group, placebo-controlled trial, designed to evaluate the efficacy, safety, and tolerability of intravenous immunoglobulin (IVIg) 0.5 g/kg plus standard treatment, versus matched placebo plus standard treatment in 108 patients with longstanding complex regional pain syndrome. Participants with moderate or severe CRPS of between 1 and 5 years duration will be randomly allocated to receive IVIg 0.5 g/kg (IntratectTM 50 g/l solution for infusion) or matching placebo administered day 1 and day 22 after randomisation, followed by two optional doses of open-label medication on day 43 after randomisation and on day 64 after randomisation. The primary outcome is the patients’ pain intensity in the IVIG group compared with the placebo group, between 6 and 42 days after randomisation. The primary trial objective is to confirm the efficacy and confidently determine the effect size of the IVIG treatment technology in this group of patients. Trial registration ISRCTN42179756 (Registered 28 June 13). Electronic supplementary material The online version of this article (doi:10.1186/1745-6215-15-404) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Andreas Goebel
- The University of Liverpool, Brownlow Hill, L69 7ZX Liverpool, UK.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Tzekou A, Fehlings MG. Treatment of spinal cord injury with intravenous immunoglobulin G: preliminary evidence and future perspectives. J Clin Immunol 2014; 34 Suppl 1:S132-8. [PMID: 24722853 PMCID: PMC4050295 DOI: 10.1007/s10875-014-0021-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 03/19/2014] [Indexed: 01/18/2023]
Abstract
Neuroinflammation plays an important role in the secondary pathophysiological mechanisms of spinal cord injury (SCI) and can exacerbate the primary trauma and thus worsen recovery. Although some aspects of the immune response are beneficial, it is thought that leukocyte recruitment and activation in the acute phase of injury results in the production of cytotoxic substances that are harmful to the nervous tissue. Therefore, suppression of excessive inflammation in the spinal cord could serve as a therapeutic strategy to attenuate tissue damage. The immunosuppressant methylprednisolone has been used in the setting of SCI, but there are complications which have attenuated the initial enthusiasm. Hence, there is interest in other immunomodulatory approaches, such as intravenous Immunoglobulin G (IVIg). Importantly, IVIg is used clinically for the treatment of several auto-immune neuropathies, such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy (CIPD) and Kawasaki disease, with a good safety profile. Thus, it is a promising treatment candidate for SCI. Indeed, IVIg has been shown by our team to attenuate the immune response and result in improved neurobehavioral recovery following cervical SCI in rats through a mechanism that involves the attenuation of neutrophil recruitment and reduction in the levels of cytokines and cytotoxic enzymes Nguyen et al. (J Neuroinflammation 9:224, 2012). Here we review published data in the context of relevant mechanisms of action that have been proposed for IVIg in other conditions. We hope that this discussion will trigger future research to provide supporting evidence for the efficiency and detailed mechanisms of action of this promising drug in the treatment of SCI, and to facilitate its clinical translation.
Collapse
Affiliation(s)
- Apostolia Tzekou
- Toronto Western Research Institute and Krembil Neuroscience Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Michael G. Fehlings
- Toronto Western Research Institute and Krembil Neuroscience Centre, University Health Network, University of Toronto, Toronto, Canada
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst St. Suite 4WW-449, Toronto, ON M5T2S8 Canada
| |
Collapse
|
14
|
Tamburin S, Borg K, Caro XJ, Jann S, Clark AJ, Magrinelli F, Sobue G, Werhagen L, Zanette G, Koike H, Späth PJ, Vincent A, Goebel A. Immunoglobulin g for the treatment of chronic pain: report of an expert workshop. PAIN MEDICINE 2014; 15:1072-82. [PMID: 24422915 DOI: 10.1111/pme.12319] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The treatment of chronic pain is still unsatisfactory. Despite the availability of different drugs, most patients with chronic pain do not receive satisfactory pain relief or report side effects. Converging evidence implicates involvement of the immune system in the pathogenesis of different types of nociceptive and neuropathic chronic pain. DESIGN At a workshop in Liverpool, UK (October 2012), experts presented evidence suggesting immunological involvement in chronic pain and recent data supporting the concept that the established immune-modulating drug, polyvalent immunoglobulin G (IgG), either given intravenously (IVIg) or subcutaneously (SCIg), may reduce pain in some peripheral neuropathies and a range of other pain disorders. Workshop's attendees discussed the practicalities of using IVIg and SCIg in these disorders, including indications, cost-effectiveness, and side effects. RESULTS IgG may reduce pain in a range of nociceptive and neuropathic chronic pain conditions, including diabetes mellitus, Sjögren's syndrome, fibromyalgia, complex regional pain syndrome, post-polio syndrome, and pain secondary to pathological autoantibodies. CONCLUSIONS IgG is a promising treatment in several chronic pain conditions. IgG is a relatively safe therapeutic strategy, with uncommon and mild side effects but high costs. Randomized, controlled trials and predictive tests are needed to better support the use of IgG for refractory chronic pain.
Collapse
Affiliation(s)
- Stefano Tamburin
- Department of Neurological and Movement Sciences, University of Verona, Verona, Verona, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Abstract
Subcutaneous administration of IgG (SCIG) has become widely used in primary immune deficiency diseases but it has only recently been studied for maintenance therapy in autoimmune peripheral neuropathies, such as chronic idiopathic demyelinating polyneuropathy and multifocal motor neuropathy. Weekly self-administration of SCIG is safe and well-tolerated, and results in steady-state serum IgG levels, as contrasted with the peaks and troughs of monthly immune globulin (human) for intravenous use. Freedom from the need for venous access or medical personnel for infusions, flexibility in scheduling, convenience of home therapy, and improved clinical stability due to the steady-state IgG levels, lead many patients to prefer SCIG to immune globulin (human) for intravenous use. Long-term studies are needed to determine if the constant IgG levels and clinical stability translate into better long-term outcomes.
Collapse
Affiliation(s)
- Melvin Berger
- Immunology Research & Development, CSL Behring, LLC, 1020 First Avenue, King of Prussia, PA 19406, USA and Pediatrics & Pathology, Case Western Reserve University, Cleveland, OH, USA
| |
Collapse
|
16
|
Tamburin S, Magrinelli F, Favaro F, Briani C, Zanette G. Long-term response of neuropathic pain to intravenous immunoglobulin in relapsing diabetic lumbosacral radiculoplexus neuropathy. A case report. Pain Pract 2013; 14:E85-90. [PMID: 24152254 DOI: 10.1111/papr.12133] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Accepted: 08/21/2013] [Indexed: 12/12/2022]
Abstract
Diabetic lumbosacral radiculoplexus neuropathy (DLRPN) is a rare painful peripheral neuropathic complication of diabetes mellitus. The clinical features of DLRPN include severe neuropathic pain, weakness, atrophy, and sensory loss in the lower limbs with asymmetrical distribution. Nerve ischemia due to inflammation and microvasculitis has been suggested as the pathophysiological mechanism for DLRPN. Analgesics and drugs for neuropathic pain often cannot achieve adequate pain control in DLRPN. Some reports suggest that intravenous immunoglobulin (IVIg) may reduce pain in DLRPN, but the mechanisms of this effect are unclear. We report a patient with relapsing DLRPN who was followed up for 8 years and whose pain improved after IVIg on nine occasions. We measured serum cytokines before and after IVIg; serum tumor necrosis factor α was increased when the patient reported pain and normalized after IVIg in parallel with pain improvement. Our data extend the notion that some types of pain, including peripheral neuropathic pain, may respond to IVIg and give some clue on the mechanism of this therapeutic effect. They are also consistent with the suggested role of the immune system in the pathophysiology of neuropathic pain and offer support to the hypothesis that cytokines may contribute to the pathogenesis of neuropathic pain.
Collapse
Affiliation(s)
- Stefano Tamburin
- Department of Neurological and Motor Sciences, University of Verona, Verona, Italy
| | | | | | | | | |
Collapse
|
17
|
Jann S, Francia A, Fruguglietti ME, De Toni Franceschini L, Sterzi R. Efficacy and Safety of Intravenous Immunoglobulin as Adjuvant Treatment for Refractory Neuropathic Pain. Results of an Open-Label, Multicenter Study. PAIN MEDICINE 2012; 13:1334-41. [DOI: 10.1111/j.1526-4637.2012.01478.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
18
|
Binkley KE. Improving the diagnosis and treatment of CRPS: insights from a clinical immunologist's personal experience with an underrecognized neuroinflammatory disorder. J Neuroimmune Pharmacol 2012; 8:477-88. [PMID: 22588663 DOI: 10.1007/s11481-012-9376-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Accepted: 05/07/2012] [Indexed: 10/28/2022]
Abstract
Complex regional pain syndrome is a neuroinflammatory condition associated with overactive glial cells that can be challenging to diagnose and treat. Early recognition and treatment are thought to be critical for good outcomes, yet many patients experience a delay in diagnosis and have difficulty accessing expert medical care. While there are no universally effective treatments, there are several promising new therapies, but these are not widely available. Some of the specific barriers to diagnosis and treatment are reviewed, with suggestions as to how they might be eliminated, leading to better care for all patients with CRPS.
Collapse
Affiliation(s)
- Karen E Binkley
- Division of Clinical Immunology and Allergy, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|