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Wonnaparhown A, Hilal T, Squire J, Freeman C, Fonseca R. IgG replacement in multiple myeloma. Blood Cancer J 2024; 14:124. [PMID: 39054331 PMCID: PMC11272770 DOI: 10.1038/s41408-024-01107-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 07/15/2024] [Accepted: 07/17/2024] [Indexed: 07/27/2024] Open
Abstract
T cell engagers (TCE) such as chimeric antigen receptor (CAR) T cell therapy and bispecific antibodies (BiAbs) for the treatment of multiple myeloma (MM) have significantly improved clinical outcomes, but have also raised awareness for ensuing post-treatment secondary immunodeficiency and hypogammaglobulinemia (HG). As patients with MM live longer, recurrent infections become a significant component of therapy-associated morbidity and mortality. Treatment of HG with immunoglobulin G replacement therapy (IgG-RT) has been a mainstay of the primary immunodeficiency (PI) world, and extrapolation to MM has recently started to show promising clinical outcomes. However, IgG-RT initiation, dosing, route, timing, monitoring, and management in MM has not been standardized in the setting of TCE. Progress in MM treatment will involve greater recognition and screening of underlying secondary immunodeficiency, identification of risk-stratification markers, optimizing IgG-RT management, and implementing other approaches to decrease the risk of infection. In this review, we summarize infection risk, risk of HG, and management strategies for IgG-RT in patients with relapsed MM after TCE.
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Affiliation(s)
- Alex Wonnaparhown
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Phoenix, AZ, USA.
| | - Talal Hilal
- Division of Hematology and Medical Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Jacqueline Squire
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Jacksonville, FL, USA
| | - Catherine Freeman
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Phoenix, AZ, USA
| | - Rafael Fonseca
- Division of Hematology and Medical Oncology, Mayo Clinic, Phoenix, AZ, USA
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Svačina MKR, Meißner A, Schweitzer F, Ladwig A, Pitarokoili K, Kofler DM, Sprenger‐Svačina A, Schneider C, Kohle F, Klein I, Wüstenberg H, Lehmann HC. Immunomodulatory effects of intravenous and subcutaneous immunoglobulin in chronic inflammatory demyelinating polyneuropathy: An observational study. Eur J Neurol 2024; 31:e16079. [PMID: 37789648 PMCID: PMC11235934 DOI: 10.1111/ene.16079] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/23/2023] [Accepted: 09/14/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND AND PURPOSE It is not known whether the route of administration affects the mechanisms of action of therapeutic immunoglobulin in chronic inflammatory demyelinating polyneuropathy (CIDP). The aim of this study, therefore, was to compare the immunomodulatory effects of intravenous (IVIg) and subcutaneous immunoglobulin (SCIg) in patients with CIDP and in IVIg-treated common variable immunodeficiency (CVID) patients. METHODS Serum and peripheral blood mononuclear cell samples were obtained from 30 CIDP patients receiving IVIg, 10 CIDP patients receiving SCIg, and 15 patients with CVID receiving IVIg. Samples and clinical data were obtained prior to IVIg/SCIg and at 3 days, 7 days, and, in CIDP patients receiving IVIg, 21 days post-administration. Serum cytokines were assessed by Luminex-based multiplex assay and enzyme-linked immunosorbent assay. Immune cells were characterized by flow cytometry. RESULTS Immune cell profiles of CIDP and CVID patients differed in frequencies of myeloid dendritic cells and cytotoxic natural killer cells. During treatment with IVIg or SCIg in CIDP patients, cellular immunomarkers were largely similar. CIDP patients receiving IVIg had higher macrophage inflammatory protein (MIP)-1α (p = 0.01), interleukin (IL)-4 (p = 0.04), and IL-33 (p = 0.04) levels than SCIg recipients. IVIg treatment more broadly modulated cytokines in CIDP than SCIg treatment. CONCLUSIONS Our study demonstrates that the modulation of cellular immunomarkers in CIDP is independent of the application route of therapeutic immunoglobulin. Minor differences were observed between CIDP and CVID patients. In contrast, cytokines were differentially modulated by IVIg and SCIg in CIDP.
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Affiliation(s)
- Martin K. R. Svačina
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | - Anika Meißner
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | - Finja Schweitzer
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | - Anne Ladwig
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | | | - David M. Kofler
- Medical Clinic I, Department of Immunology and RheumatologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | - Alina Sprenger‐Svačina
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | - Christian Schneider
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
- Department of NeurologySt. Katharinen HospitalFrechenGermany
| | - Felix Kohle
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | - Ines Klein
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | - Hauke Wüstenberg
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | - Helmar C. Lehmann
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
- Department of NeurologyClinic of Leverkusen gGmbHLeverkusenGermany
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Gupta S, DeAngelo J, Melamed I, Walter JE, Kobayashi AL, Bridges T, Sublett JW, Bernstein JA, Koterba A, Manning M, Maltese J, Hoeller S, Turpel-Kantor E, Kreuwel H, Kobayashi RH. Subcutaneous Immunoglobulin 16.5% (Cutaquig®) in Primary Immunodeficiency Disease: Safety, Tolerability, Efficacy, and Patient Experience with Enhanced Infusion Regimens. J Clin Immunol 2023:10.1007/s10875-023-01509-4. [PMID: 37160610 PMCID: PMC10169187 DOI: 10.1007/s10875-023-01509-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/03/2023] [Indexed: 05/11/2023]
Abstract
PURPOSE To achieve reductions in infusion time, infusion sites, and frequency, a prospective, open-label, multicenter, Phase 3 study evaluated the safety, efficacy, and tolerability of subcutaneous immunoglobulin (SCIG) 16.5% (Cutaquig®, Octapharma) at enhanced infusion regimens. METHODS Three separate cohorts received SCIG 16.5% evaluating volume, rate, and frequency: Cohort 1) volume assessment/site: up to a maximum 100 mL/site; Cohort 2) infusion flow rate/site: up to a maximum of 100 mL/hr/site or the maximum flow rate achievable by the tubing; Cohort 3) infusion frequency: every other week at twice the patient's weekly dose. RESULTS For Cohort 1 (n = 15), the maximum realized volume per site was 108 mL/site, exceeding the currently labeled (US) maximum (up to 40 mL/site for adults). In Cohort 2 (n = 15), the maximum realized infusion flow rate was 67.5 mL/hr/site which is also higher than the labeled (US) maximum (up to 52 mL/hr/site). In Cohort 3 (n = 34), the mean total trough levels for every other week dosing demonstrated equivalency to weekly dosing (p value = 0.0017). All regimens were well tolerated. There were no serious bacterial infections (SBIs). Most patients had mild (23.4%) or moderate (56.3%) adverse events. The majority of patients found the new infusion regimens to be better or somewhat better than their previous regimens and reported that switching to SCIG 16.5% was easy. CONCLUSIONS SCIG 16.5% (Cutaquig®), infusions are efficacious, safe, and well tolerated with reduced infusion time, fewer infusion sites, and reduced frequency. Further, the majority of patients found the new infusion regimens to be better or somewhat better than their previous regimens.
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Affiliation(s)
| | | | | | | | | | - Tracy Bridges
- Allergy and Asthma Clinics of Georgia, Albany, GA, USA
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Gupta S, Kobayashi RH, Litzman J, Cherwin L, Hoeller S, Kreuwel H. Subcutaneous immunoglobulin 16.5% for the treatment of pediatric patients with primary antibody immunodeficiency. Expert Rev Clin Immunol 2023; 19:7-17. [PMID: 36346032 DOI: 10.1080/1744666x.2023.2144836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Human immunoglobulin (IG) administered intravenously (IVIG) or subcutaneously (SCIG) is used to prevent infections in patients with primary immunodeficiency diseases (PIDDs) such as primary antibody immunodeficiencies. AREAS COVERED This review provides an overview of PIDD with a focus on SCIG treatment, including the properties and clinical trial results of a new SCIG 16.5% (Cutaquig, Octapharma) in pediatric patients. We also discuss the various benefits of SCIG including stable serum immunoglobulin G levels, high tolerability with fewer systemic side effects, and the flexibility of self-administration. EXPERT OPINION Individualized treatment for PIDD in children is necessary given the different factors that affect administration of SCIG. Variables such as the dose, dosing interval, administration sites, and ancillary equipment can be adjusted to impact the long-term satisfaction with SCIG administration in pediatric patients. The successful work that has been conducted by both professional and patient organizations to increase awareness of PIDD, especially in pediatric patients, is substantial and ongoing. The importance of early diagnosis and treatment in the pediatric patient population cannot be overstated. The safety, efficacy, and tolerability of SCIG 16.5% have been demonstrated in pediatric patients with PIDDs providing an additional therapeutic option in this vulnerable population.
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Affiliation(s)
- Sudhir Gupta
- Division of Basic and Clinical Immunology, University of California, Irvine, Irvine, CA, USA
| | - Roger H Kobayashi
- School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jiří Litzman
- Department of Clinical Immunology and Allergology, St. Anne's University in Brno, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Laurel Cherwin
- Scientific and Medical Affairs, Octapharma AG, Paramus, NJ, USA
| | - Sonja Hoeller
- Scientific and Medical Affairs, Octapharma AG, Paramus, NJ, USA
| | - Huub Kreuwel
- Scientific and Medical Affairs, Octapharma AG, Paramus, NJ, USA
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Epland K, Suez D, Paris K. A clinician's guide for administration of high-concentration and facilitated subcutaneous immunoglobulin replacement therapy in patients with primary immunodeficiency diseases. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2022; 18:87. [PMID: 36180928 PMCID: PMC9526304 DOI: 10.1186/s13223-022-00726-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 09/07/2022] [Indexed: 11/27/2022]
Abstract
Immunoglobulin replacement therapy is the standard-of-care treatment for patients with primary immunodeficiency diseases who have impaired antibody production and function. Clinicians and patients may consider intravenous immunoglobulin (IVIG) or subcutaneous immunoglobulin (SCIG) options, and each route may offer different benefits for the individual. IVIG requires fewer infusion sites and less frequent infusions than some formulations of SCIG. However, SCIG does not require venous access, is associated with fewer systemic adverse infusion reactions than IVIG, and can independently be self-administered at home. Importantly, tailoring treatment experiences to the needs of the individual may improve treatment adherence and quality of life for patients with primary immunodeficiency diseases who often rely on long-term or lifelong treatment. This review aims to educate United States (US) healthcare providers on the administration process of SCIG, with a focus on more concentrated formulations of SCIG and facilitated SCIG. It provides practical guidance on initiating, optimizing, and monitoring SCIG therapy. The advantages and disadvantages of the different treatment options are also presented for discussion between the patient and clinician.
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Affiliation(s)
| | - Daniel Suez
- Allergy, Asthma and Immunology Clinic, PA, Irving, TX, USA
| | - Kenneth Paris
- Division of Pediatric Allergy and Immunology, LSU Health Sciences Center New Orleans and Children's Hospital New Orleans, 200 Henry Clay Avenue, New Orleans, LA, USA.
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Consensus guidelines and recommendations for infection prevention in multiple myeloma: a report from the International Myeloma Working Group. Lancet Haematol 2022; 9:e143-e161. [DOI: 10.1016/s2352-3026(21)00283-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 08/26/2021] [Accepted: 09/07/2021] [Indexed: 12/14/2022]
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Kobayashi RH, Litzman J, Rizvi S, Kreuwel H, Hoeller S, Gupta S. Overview of subcutaneous immunoglobulin 16.5% in primary and secondary immunodeficiency diseases. Immunotherapy 2022; 14:259-270. [PMID: 34986666 DOI: 10.2217/imt-2021-0313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Most primary immunodeficiency diseases, and select secondary immunodeficiency diseases, are treated with immunoglobulin (IG) therapy, administered intravenously or subcutaneously (SCIG). The first instance of IG replacement for primary immunodeficiency disease was a 16.5% formulation administered subcutaneously in 1952. While most SCIG products are now a 10 or 20% concentration, this review will focus on SCIG 16.5% products with a historical overview of development, including the early pioneers who initiated and refined IG replacement therapy, as well as key characteristics, manufacturing and clinical studies. In determining an appropriate IG regimen, one must consider specific patient needs, characteristics and preferences. There are advantages to SCIG, such as stable serum immunoglobulin G levels, high tolerability and the flexibility of self-administered home treatment.
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Affiliation(s)
| | - Jiří Litzman
- Department of Clinical Immunology & Allergology, St. Anne's University in Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | | | | | - Sonja Hoeller
- Octapharma Pharm. ProduduktionsgesmbH, Vienna, Austria
| | - Sudhir Gupta
- Division of Basic & Clinical Immunology, University of California, Irvine, CA, USA
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Safarzadeh Kozani P, Safarzadeh Kozani P, Rahbarizadeh F. Optimizing the Clinical Impact of CAR-T Cell Therapy in B-Cell Acute Lymphoblastic Leukemia: Looking Back While Moving Forward. Front Immunol 2021; 12:765097. [PMID: 34777381 PMCID: PMC8581403 DOI: 10.3389/fimmu.2021.765097] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/07/2021] [Indexed: 12/13/2022] Open
Abstract
Chimeric antigen receptor T-cell (CAR-T) therapy has been successful in creating extraordinary clinical outcomes in the treatment of hematologic malignancies including relapsed or refractory (R/R) B-cell acute lymphoblastic leukemia (B-ALL). With several FDA approvals, CAR-T therapy is recognized as an alternative treatment option for particular patients with certain conditions of B-ALL, diffuse large B-cell lymphoma, mantle cell lymphoma, follicular lymphoma, or multiple myeloma. However, CAR-T therapy for B-ALL can be surrounded by challenges such as various adverse events including the life-threatening cytokine release syndrome (CRS) and neurotoxicity, B-cell aplasia-associated hypogammaglobulinemia and agammaglobulinemia, and the alloreactivity of allogeneic CAR-Ts. Furthermore, recent advances such as improvements in media design, the reduction of ex vivo culturing duration, and other phenotype-determining factors can still create room for a more effective CAR-T therapy in R/R B-ALL. Herein, we review preclinical and clinical strategies with a focus on novel studies aiming to address the mentioned hurdles and stepping further towards a milestone in CAR-T therapy of B-ALL.
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Affiliation(s)
- Pouya Safarzadeh Kozani
- Department of Medical Biotechnology, Faculty of Paramedicine, Guilan University of Medical Sciences, Rasht, Iran.,Student Research Committee, Medical Biotechnology Research Center, School of Nursing, Midwifery, and Paramedicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Pooria Safarzadeh Kozani
- Department of Medical Biotechnology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Fatemeh Rahbarizadeh
- Department of Medical Biotechnology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran.,Research and Development Center of Biotechnology, Tarbiat Modares University, Tehran, Iran
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9
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Bus SRM, Wieske L, Keddie S, van Schaik IN, Eftimov F. Subcutaneous immunoglobulin for chronic inflammatory demyelinating polyradiculoneuropathy. Hippokratia 2021. [DOI: 10.1002/14651858.cd014542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Sander RM Bus
- Department of Neurology, Amsterdam Neuroscience; Amsterdam UMC, University of Amsterdam; Amsterdam Netherlands
| | - Luuk Wieske
- Department of Neurology, Amsterdam Neuroscience; Amsterdam UMC, University of Amsterdam; Amsterdam Netherlands
| | - Stephen Keddie
- Faculty of Brain Sciences; Institute of Neurology; London UK
| | - Ivo N van Schaik
- Department of Neurology, Amsterdam Neuroscience; Amsterdam University Medical Centers, location AMC, University of Amsterdam; Amsterdam Netherlands
| | - Filip Eftimov
- Department of Neurology, Amsterdam Neuroscience; Amsterdam UMC, University of Amsterdam; Amsterdam Netherlands
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Gul Y, Kapakli H, Guner SN, Alan HB, Hazar E, Keles S, Reisli I. Long-Term Experience of Subcutaneous Immunoglobulin Therapy in Pediatric Primary Immunodeficient Patients with Low and Normal Body Weight. J Clin Immunol 2021; 42:64-71. [PMID: 34617265 DOI: 10.1007/s10875-021-01144-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 09/27/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE The aim was to review the compliance, side effects and effectiveness of subcutaneous immunoglobulin (SCIG) supplementation in patients with primary immunodeficiencies (PID) who had previously received intravenous immunoglobulin (IVIG) therapy and subsequently switched to SCIG, as well as to compare these parameters in patients while considering body weight. METHODS Demographic data, clinical and laboratory findings, SCIG dose, and side effects of 87 patients were retrospectively obtained from patient files. In patients who first received IVIG and then SCIG, the monthly SCIG dose was calculated by multiplying the IVIG dose by 1.37. The total monthly SCIG dose was distributed via injection across three or four doses per month, thus every 7 or 10 days. RESULTS Of the 87 patients aged between one and 22 years, 50 were male (57.5%) and 37 were female (42.5%). The serum IgG levels of the SCIG group were higher and more stable than those of the IVIG group. The number of hospitalizations and infections decreased significantly after initiation of SCIG. Thirteen patients (14.9%) had low body weight (LBW) for their age, seven of whom were male (53.8%). Serum IgG levels of the LBW cohort were significantly elevated and more stable during the SCIG period than the IVIG period. Mild, local side effects were detected in 153 administrations (3.3%) in 30 patients with normal body weight, while no local reactions were recorded in the patients with LBW. CONCLUSION SCIG supplementation is an effective treatment for pediatric patients with PID. The preliminary data from the present study suggest that such treatment is also safe for LBW children. The numbers of patient hospitalizations and family visits to clinics were reduced, allowing our patients and their parents to live more normal lives.
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Affiliation(s)
- Yahya Gul
- Meram Medical School, Division of Pediatric Allergy and Immunology, Necmettin Erbakan University, Beyşehir Yolu, 42080, Konya, Turkey.
| | - Hasan Kapakli
- Balıkesir City Hospital, Pediatric Allergy and Immunology Clinic, Balıkesir, Turkey
| | - Sukru Nail Guner
- Meram Medical School, Division of Pediatric Allergy and Immunology, Necmettin Erbakan University, Beyşehir Yolu, 42080, Konya, Turkey
| | - Havva Bozkurt Alan
- Meram Medical School, Division of Pediatric Allergy and Immunology, Necmettin Erbakan University, Beyşehir Yolu, 42080, Konya, Turkey
| | - Esra Hazar
- Alanya Training and Research Hospital Pediatric Allergy and Immunology Unit, Antalya, Turkey
| | - Sevgi Keles
- Meram Medical School, Division of Pediatric Allergy and Immunology, Necmettin Erbakan University, Beyşehir Yolu, 42080, Konya, Turkey
| | - Ismail Reisli
- Meram Medical School, Division of Pediatric Allergy and Immunology, Necmettin Erbakan University, Beyşehir Yolu, 42080, Konya, Turkey
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11
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Li Z, Dumas T, Seth Berry N, McCoy B, Yel L. Population pharmacokinetic simulation of varied Immune Globulin Subcutaneous (Human), 20% solution (Ig20Gly) loading and maintenance dosing regimens in immunoglobulin-naïve patients with primary immunodeficiency diseases. Int Immunopharmacol 2021; 100:108044. [PMID: 34601202 DOI: 10.1016/j.intimp.2021.108044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/29/2021] [Accepted: 08/01/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The pharmacokinetics of Ig20Gly, a 20% subcutaneous immunoglobulin (IG) therapy, is well characterized in IG-experienced patients with primary immunodeficiency diseases (PID). Data from IG-naïve patients are limited. OBJECTIVE Simulate serum total immunoglobulin G (IgG) pharmacokinetic profiles in IG-naïve patients with PID for different Ig20Gly initiation and maintenance dosing regimens. METHODS A population pharmacokinetic model developed with data from pivotal phase 2/3 trials of weekly Ig20Gly in PID (NCT01412385, NCT01218438) was used to simulate pharmacokinetic profiles of IgG in various scenarios with 400- or 800-mg/kg total loading doses (administered as split doses over 1-2 weeks) and corresponding 100- or 200-mg/kg weekly maintenance doses, respectively. Endogenous baseline IgG levels (1.5, 2.0, 4.0, 6.0 g/L) were evaluated for each scenario; time to putative therapeutic target IgG trough level (7 g/L) was determined. RESULTS Serum IgG levels reached steady-state by approximately Week 12 for all scenarios and baseline endogenous IgG levels. Time to target trough level generally occurred sooner with 1-week versus 2-week loading schemes. Endogenous baseline IgG levels <4 g/L required a 1-week 800-mg/kg total loading dose to achieve target levels within 2 weeks. Both maintenance regimens sustained serum IgG above target level. CONCLUSIONS Simulations indicated IG-naïve patients with PID can achieve protective serum IgG levels within 1-3 weeks using appropriate Ig20Gly loading regimens. Patients with low endogenous IgG may benefit most from an 800-mg/kg/month loading dose. 400- or 800-mg/kg/month Ig20Gly maintenance regimens appeared adequate to maintain stable IgG levels. Serum IgG monitoring and clinical status can guide dosing parameters.
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Affiliation(s)
- Zhaoyang Li
- Takeda Development Center Americas, Inc, Cambridge, MA, USA.
| | | | | | - Barbara McCoy
- Baxalta Innovations GmbH, a Takeda Company, Vienna, Austria.
| | - Leman Yel
- Takeda Development Center Americas, Inc, Cambridge, MA, USA.
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12
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Goyal NA, Karam C, Sheikh KA, Dimachkie MM. Subcutaneous immunoglobulin treatment for chronic inflammatory demyelinating polyneuropathy. Muscle Nerve 2021; 64:243-254. [PMID: 34260074 PMCID: PMC8457117 DOI: 10.1002/mus.27356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 06/11/2021] [Accepted: 06/15/2021] [Indexed: 12/15/2022]
Abstract
Immunoglobulin G (IgG) therapy is an established long‐term treatment in chronic inflammatory demyelinating polyneuropathy (CIDP) that is commonly administered intravenously (IVIg). The subcutaneous immunoglobulin (SCIg) administration route is a safe and effective alternative option, approved by the United States Food and Drug Administration (FDA) in 2018, for maintenance treatment of adults with CIDP. Physicians and patients alike need to be aware of all their treatment options in order to make informed decisions and plan long‐term treatment strategies. In this review, we collate the evidence for SCIg in CIDP from all published studies and discuss their implications and translation to clinical practice. We also provide guidance on the practicalities of how and when to transition patients from IVIg to SCIg and ongoing patient support. Evidence suggests that IVIg and SCIg have comparable long‐term efficacy in CIDP. However, SCIg can provide additional benefits for some patients, including no requirement for venous access or premedication, and reduced frequency of systemic adverse events. Local‐site reactions are more common with SCIg than IVIg, but these are mostly well‐tolerated and abate with subsequent infusions. Data suggest that many patients prefer SCIg following transition from IVIg. SCIg preference may be a result of the independence and flexibility associated with self‐infusion, whereas IVIg preference may be a result of familiarity and reliance on a healthcare professional for infusions. In practice, individualizing maintenance dosing based on disease behavior and determining the minimally effective IgG dose for individuals are key considerations irrespective of the administration route chosen.
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Affiliation(s)
- Namita A Goyal
- Department of Neurology, MDA ALS and Neuromuscular Center, University of California, Irvine, California, USA
| | - Chafic Karam
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kazim A Sheikh
- Department of Neurology, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Mazen M Dimachkie
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
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Steady-State Serum IgG Trough Levels Are Adequate for Pharmacokinetic Assessment in Patients with Immunodeficiencies Receiving Subcutaneous Immune Globulin. J Clin Immunol 2021; 41:1331-1338. [PMID: 34036490 PMCID: PMC8310849 DOI: 10.1007/s10875-021-00990-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 02/04/2021] [Indexed: 11/01/2022]
Abstract
Patients with primary immunodeficiency diseases often require lifelong immunoglobulin (IG) therapy. Most clinical trials investigating IG therapies characterize serum immunoglobulin G (IgG) pharmacokinetic (PK) profiles by serially assessing serum IgG levels. This retrospective analysis evaluated whether steady-state serum IgG trough level measurement alone is adequate for PK assessment. Based on individual patient serum IgG trough levels from two pivotal trials (phase 2/3 European [NCT01412385] and North American [NCT01218438]) of weekly 20% subcutaneous IG (SCIG; Cuvitru, Ig20Gly), trough level-predicted IgG AUC (AUCτ,tp) were calculated and compared with the reported AUC calculated from serum IgG concentration-time profiles (AUCτ). In both studies, mean AUCτ,tp values for Ig20Gly were essentially equivalent to AUCτ with point estimates of geometric mean ratio (GMR) of AUCτ,tp/AUCτ near 1.0 and 90% CIs within 0.80-1.25. In contrast, for IVIG, 10%, mean AUCτ,tp values were lower than AUCτ by >20%, (GMR [90% CI]: 0.74 [0.70-0.78] and 0.77 [0.73-0.81] for the two studies, respectively). Mean AUCτ,tp values calculated for 4 other SCIG products (based on mean IgG trough levels reported in the literature/labels) were also essentially equivalent to the reported AUCτ (differences <10% for all except HyQvia, a facilitated SCIG product), while differences for IVIG products were >20%. In conclusion, steady-state serum IgG levels following weekly SCIG remain stable, allowing for reliable prediction of AUC over the dosing interval using trough IgG levels. These findings indicate that measuring steady-state serum IgG trough levels alone may be adequate for PK assessment of weekly SCIG.
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Practical Aspects of Transitioning from Intravenous to Subcutaneous Immunoglobulin Therapy in Neuromuscular Disorders. Can J Neurol Sci 2021; 49:161-167. [PMID: 33766159 DOI: 10.1017/cjn.2021.56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Recent evidence shows that subcutaneous immunoglobulin (SCIG) is as efficacious as intravenous immunoglobulin (IVIG) and has a better safety profile and acceptance rate among patients with neuromuscular disorders who require maintenance IVIG treatment. Awareness of the practical aspects of patient selection, enrollment, dose calculation, administration, and follow-up would help physicians coordinate a smooth and seamless transition from IVIG to SCIG. SCIG is ideally offered to patients having intolerable side effects during IVIG or wearing-off effect and in those keen for treatment autonomy. The weekly dose of SCIG is calculated by multiplying the maintenance dose of IVIG by the dose adjustment factor and dividing by the interval between IVIG in weeks and is initiated 1 week after the last dose of IVIG. The physician places the order for the SCIG and the clinic nurse or the physician refers the patient to the home care nursing program for further education and training. The necessary supplies are dispatched to the patient who would also collect the SCIG from the transfusion center of the nearest hospital. The patient is educated on assembling and administering the infusion, and home visits are continued until the patient or caregiver is confident. Regular follow-up with the patient is maintained to assess treatment response and side effects if any. With a smooth transition, most patients have excellent tolerance to SCIG and in our experience seldom request switching back to IVIG. Transitioning patients from IVIG to SCIG offers several advantages and thus, in general, is preferable for multiple stakeholders.
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15
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Cinetto F, Neri R, Vianello F, Visentin A, Barilà G, Gianese S, Lanciarotta A, Milito C, Rattazzi M, Piazza F, Trentin L, Zambello R, Agostini C, Scarpa R. Subcutaneous immunoglobulins replacement therapy in secondary antibody deficiencies: Real life evidence as compared to primary antibody deficiencies. PLoS One 2021; 16:e0247717. [PMID: 33661940 PMCID: PMC7932095 DOI: 10.1371/journal.pone.0247717] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 02/12/2021] [Indexed: 12/31/2022] Open
Abstract
Secondary antibody deficiencies (SAD) may require immunoglobulin replacement therapy (IgRT). While the intravenous route (IVIG) is broadly considered effective in SAD, the use of subcutaneous immunoglobulins (SCIG) is mainly adopted from the experience in primary antibody deficiencies (PAD), where SCIG have been shown to perform as effective as IVIG. However, evidence-based data on SCIG administration in SAD patients are still insufficient. Herein we retrospectively evaluated the efficacy and safety profile of SCIG treatment in 131 SAD patients as compared to a group of 102 PAD patients. We found SCIG being equally effective in reducing annual infectious rate both in SAD and PAD patients. However, SAD patients required lower SCIG dosage and lower IgG through level to achieve similar biological effect in terms of infection burden, at the steady state. SAD patients also showed better correlation between SCIG dose and serum IgG achieved value. Furthermore, within SAD, SCIG were found to work irrespective of the underlying disease. Especially in Non-Hodgkin Lymphoma patients, whose indication to IgRT is still not included in all guidelines and for whom evidence-based data are still lacking, SCIG were as effective as in Chronic Lymphocytic Leukemia or Multiple Myeloma patients, and SCIG discontinuation, without evidence of B cell recovery, led to IgG decline and relapsed infections. Finally, treatment tolerance in SAD patients was comparable to the PAD cohort. Globally, our data suggest that SCIG, as already appreciated in PAD, represent a valuable option in SAD patients, independent on the disease leading to antibody deficiency.
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Affiliation(s)
- Francesco Cinetto
- Department of Medicine–DIMED, University of Padua, Padua, Italy
- Formerly Haematology and Clinical Immunology Unit, University of Padua, Padua, Italy
- Regional Center for Rare Immunological Diseases, Internal Medicine 1, Treviso Hospital, University of Padua, Padua, Italy
| | - Raffaella Neri
- Department of Medicine–DIMED, University of Padua, Padua, Italy
- Formerly Haematology and Clinical Immunology Unit, University of Padua, Padua, Italy
- Regional Center for Rare Immunological Diseases, Internal Medicine 1, Treviso Hospital, University of Padua, Padua, Italy
| | - Fabrizio Vianello
- Department of Medicine–DIMED, University of Padua, Padua, Italy
- Haematology and Clinical Immunology Unit, University of Padua, Padua, Italy
| | - Andrea Visentin
- Department of Medicine–DIMED, University of Padua, Padua, Italy
- Haematology and Clinical Immunology Unit, University of Padua, Padua, Italy
| | - Gregorio Barilà
- Department of Medicine–DIMED, University of Padua, Padua, Italy
- Haematology and Clinical Immunology Unit, University of Padua, Padua, Italy
| | - Sabrina Gianese
- Department of Medicine–DIMED, University of Padua, Padua, Italy
- Regional Center for Rare Immunological Diseases, Internal Medicine 1, Treviso Hospital, University of Padua, Padua, Italy
| | - Alison Lanciarotta
- Department of Medicine–DIMED, University of Padua, Padua, Italy
- Regional Center for Rare Immunological Diseases, Internal Medicine 1, Treviso Hospital, University of Padua, Padua, Italy
| | - Cinzia Milito
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Marcello Rattazzi
- Department of Medicine–DIMED, University of Padua, Padua, Italy
- Regional Center for Rare Immunological Diseases, Internal Medicine 1, Treviso Hospital, University of Padua, Padua, Italy
| | - Francesco Piazza
- Department of Medicine–DIMED, University of Padua, Padua, Italy
- Haematology and Clinical Immunology Unit, University of Padua, Padua, Italy
| | - Livio Trentin
- Department of Medicine–DIMED, University of Padua, Padua, Italy
- Haematology and Clinical Immunology Unit, University of Padua, Padua, Italy
| | - Renato Zambello
- Department of Medicine–DIMED, University of Padua, Padua, Italy
- Haematology and Clinical Immunology Unit, University of Padua, Padua, Italy
| | - Carlo Agostini
- Department of Medicine–DIMED, University of Padua, Padua, Italy
- Formerly Haematology and Clinical Immunology Unit, University of Padua, Padua, Italy
- Regional Center for Rare Immunological Diseases, Internal Medicine 1, Treviso Hospital, University of Padua, Padua, Italy
- * E-mail:
| | - Riccardo Scarpa
- Department of Medicine–DIMED, University of Padua, Padua, Italy
- Formerly Haematology and Clinical Immunology Unit, University of Padua, Padua, Italy
- Regional Center for Rare Immunological Diseases, Internal Medicine 1, Treviso Hospital, University of Padua, Padua, Italy
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16
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Fileccia E, Rinaldi R, Minicuci G, D'Angelo R, Bartolomei L, Liguori R, Donadio V. Subcutaneous immunoglobulin for maintenance therapy in stiff-person syndrome: One-year follow-up in two patients. Neuromuscul Disord 2020; 30:921-924. [DOI: 10.1016/j.nmd.2020.09.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 10/23/2022]
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17
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Stino AM, Naddaf E, Dyck PJ, Dyck PJB. Chronic inflammatory demyelinating polyradiculoneuropathy-Diagnostic pitfalls and treatment approach. Muscle Nerve 2020; 63:157-169. [PMID: 32914902 DOI: 10.1002/mus.27046] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 08/07/2020] [Accepted: 08/11/2020] [Indexed: 12/19/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is characterized by progressive weakness and sensory loss, often affecting patients' ability to walk and perform activities of daily living independently. With the lack of a diagnostic biomarker, the diagnosis relies on clinical suspicion, clinical findings, and the demonstration of demyelinating changes on electrodiagnostic (EDx) testing and nerve pathology. As a result, patients can often be misdiagnosed with CIDP and unnecessarily treated with immunotherapy. Interpreting the EDx testing and cerebrospinal fluid findings in light of the clinical phenotype, recognizing atypical forms of CIDP, and screening for CIDP mimickers are the mainstays of the approach to patients suspected of having CIDP, and are detailed in this review. We also review the currently available treatment options, including intravenous immunoglobulin (IVIg), corticosteroids (CCS), and plasma exchange (PE), and discuss how to approach treatment-refractory cases. Finally, we emphasize the need to adopt objective outcome measures to monitor treatment response.
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Affiliation(s)
- Amro M Stino
- Division of Neuromuscular Medicine, Department of Neurology, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Elie Naddaf
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter J Dyck
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - P James B Dyck
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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18
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Hanitsch L, Baumann U, Boztug K, Burkhard-Meier U, Fasshauer M, Habermehl P, Hauck F, Klock G, Liese J, Meyer O, Müller R, Pachlopnik-Schmid J, Pfeiffer-Kascha D, Warnatz K, Wehr C, Wittke K, Niehues T, von Bernuth H. Treatment and management of primary antibody deficiency: German interdisciplinary evidence-based consensus guideline. Eur J Immunol 2020; 50:1432-1446. [PMID: 32845010 DOI: 10.1002/eji.202048713] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/25/2020] [Accepted: 08/20/2020] [Indexed: 12/13/2022]
Abstract
This evidence-based clinical guideline provides consensus-recommendations for the treatment and care of patients with primary antibody deficiencies (PADs). The guideline group comprised 20 clinical and scientific expert associations of the German, Swiss, and Austrian healthcare system and representatives of patients. Recommendations were based on results of a systematic literature search, data extraction, and evaluation of methodology and study quality in combination with the clinical expertise of the respective representatives. Consensus-based recommendations were determined via nominal group technique. PADs are the largest clinically relevant group of primary immunodeficiencies. Most patients with PADs present with increased susceptibility to infections, however immune dysregulation, autoimmunity, and cancer affect a significant number of patients and may precede infections. This guideline therefore covers interdisciplinary clinical and therapeutic aspects of infectious (e.g., antibiotic prophylaxis, management of bronchiectasis) and non-infectious manifestations (e.g., management of granulomatous disease, immune cytopenia). PADs are grouped into disease entities with definitive, probable, possible, or unlikely benefit of IgG-replacement therapy. Summary and consensus-recommendations are provided for treatment indication, dosing, routes of administration, and adverse events of IgG-replacement therapy. Special aspects of concomitant impaired T-cell function are highlighted as well as clinical data on selected monogenetic inborn errors of immunity formerly classified into PADs (APDS, CTLA-4-, and LRBA-deficiency).
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Affiliation(s)
- Leif Hanitsch
- Institute for Medical Immunology, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Ulrich Baumann
- Department of Paediatric Pulmonology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany
| | - Kaan Boztug
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Department of Pediatrics and Adolescent Medicine and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | | | - Maria Fasshauer
- ImmunoDeficiencyCenter Leipzig (IDCL), Hospital St. Georg gGmbH Leipzig, Academic Teaching Hospital of the University of Leipzig, Leipzig, Germany
| | | | - Fabian Hauck
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Gerd Klock
- Technische Universität Darmstadt, Clemens-Schöpf-Institut für Organische Chemie & Biochemie, Darmstadt, Germany
| | - Johannes Liese
- Pediatric Immunology, Department of Pediatrics, University Hospital Würzburg, Würzburg, Germany
| | - Oliver Meyer
- Institute of Transfusion Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Rainer Müller
- Klinik und Poliklinik für HNO-Heilkunde, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Jana Pachlopnik-Schmid
- Division of Immunology, University Children's Hospital Zurich and University of Zurich, Switzerland
| | | | - Klaus Warnatz
- Department of Rheumatology and Clinical Immunology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Center for Chronic Immunodeficiency, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Claudia Wehr
- Center for Chronic Immunodeficiency, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kirsten Wittke
- Institute for Medical Immunology, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Tim Niehues
- Department of Pediatrics, Helios Klinikum Krefeld, Krefeld, Germany
| | - Horst von Bernuth
- Department of Immunology, Labor Berlin Charité - Vivantes GmbH, Berlin, Germany.,Berlin Center for Regenerative Therapies (BCRT), Charité Universitätsmedizin Berlin, Berlin, Germany.,Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
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19
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Correlations Among Subcutaneous Immunoglobulin Dosage, Immunoglobulin G Serum Pre-infusional Levels and Body Mass Index in Primary Antibody Deficiency Patients: A Pooled Analysis from the SHIFT/IBIS Studies. Clin Drug Investig 2020; 40:279-286. [PMID: 32036588 PMCID: PMC7035227 DOI: 10.1007/s40261-020-00885-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background and Objective In recent years, two Italian non-interventional studies evaluated subcutaneous immunoglobulin (SCIG) treatment in patients affected by primary antibody deficiency (PAD). The SHIFT study considered patients who were treated with intravenous immunoglobulin (IVIG) or SCIG 16% (Vivaglobin®) and then replaced this therapy with weekly treatments of SCIG 20% (Hizentra®). The IBIS study evaluated patients previously taking a weekly SCIG 20% regimen, who instead began therapy with biweekly SCIG 20% to assess the correlation between the dose of immunoglobulin G (IgG) administered and the body mass index (BMI) of patients, determine if there is a need for dosage adjustments on a BMI basis, and identify the predictors of serum IgG trough levels in our cohort. Methods In this study, we analyzed the pooled data of 109 PAD patients enrolled in the SHIFT and IBIS studies. Only prospective phases were considered. Results The total monthly SCIG dose showed comparable trends among weight categories, except for underweight patients. When we considered the monthly SCIG dosage per kilogram of body weight, a significant decreasing trend according to BMI was observed. Data on IgG trough levels were available for 88 patients, with a mean IgG serum level of 8.4 ± 1.6 g/L. A stepwise regression model revealed that the mean monthly dosage of SCIG 20% (p = 0.04248) and the mean monthly dosage of IgG per kilogram of body weight were the only two independent predictors associated with IgG trough levels. No association was found between BMI and IgG trough levels. Conclusions These findings support the concept that the cumulative monthly dose of SCIG and the dose of SCIG per kilogram of body weight affect IgG trough levels in PAD patients, irrespective of BMI.
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20
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Angelotti F, Capecchi R, Giannini D, Mazzarella O, Rocchi V, Migliorini P. Long-term efficacy, safety, and tolerability of recombinant human hyaluronidase-facilitated subcutaneous infusion of immunoglobulin (Ig) (fSCIG; HyQvia( ®)) in immunodeficiency diseases: real-life data from a monocentric experience. Clin Exp Med 2020; 20:387-392. [PMID: 32385734 DOI: 10.1007/s10238-020-00633-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 05/01/2020] [Indexed: 10/24/2022]
Abstract
Humoral immunodeficiency diseases represent a heterogeneous group of disorders that require long-term therapies. Thus, the treatment provided must not only be effective but also safe and well tolerated. In this paper, we report our data on the efficacy, safety, and tolerability of recombinant human hyaluronidase-facilitated subcutaneous infusion of immunoglobulin (Ig) (fSCIG; HyQvia(®)) in immunodeficiency patients. We collected retrospective data from 30 patients with primary and secondary immunodeficiency diseases in therapy with fSCIG from September 2014 to December 2019. We evaluated the efficacy of the therapy, taking into account serum IgG values during follow-up and the number of annual infectious events and serious bacterial infections reported by patients. Safety was assessed on the basis of the number and intensity of adverse events (AEs) and local reactions reported. Our real-life data suggest that long-term repeated self-administration of recombinant human hyaluronidase-facilitated subcutaneous infusion of immunoglobulins results in a reduced rate of infectious events if compared to the pre-treatment rate. Both AEs and local reactions are mild to moderate and were never reasons for treatment discontinuation. Therapy with HyQvia shows prolonged efficacy and good tolerability; these aspects, together with the possibility of self-administration at home, minimize the impact the illness has on patients.
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Affiliation(s)
- Francesca Angelotti
- Clinical Immunology Unit, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliera Universitaria Pisana, Via Roma 67, 56126, Pisa, Italy
| | - Riccardo Capecchi
- Clinical Immunology Unit, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliera Universitaria Pisana, Via Roma 67, 56126, Pisa, Italy
| | - Daiana Giannini
- Clinical Immunology Unit, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliera Universitaria Pisana, Via Roma 67, 56126, Pisa, Italy
| | - Ornella Mazzarella
- Clinical Immunology Unit, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliera Universitaria Pisana, Via Roma 67, 56126, Pisa, Italy
| | - Valeria Rocchi
- Clinical Immunology Unit, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliera Universitaria Pisana, Via Roma 67, 56126, Pisa, Italy
| | - Paola Migliorini
- Clinical Immunology Unit, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliera Universitaria Pisana, Via Roma 67, 56126, Pisa, Italy.
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21
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Arnold DE, Maude SL, Callahan CA, DiNofia AM, Grupp SA, Heimall JR. Subcutaneous immunoglobulin replacement following CD19-specific chimeric antigen receptor T-cell therapy for B-cell acute lymphoblastic leukemia in pediatric patients. Pediatr Blood Cancer 2020; 67:e28092. [PMID: 31793170 DOI: 10.1002/pbc.28092] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 10/07/2019] [Accepted: 10/26/2019] [Indexed: 01/02/2023]
Abstract
Twenty-eight patients were maintained on subcutaneous immunoglobulin replacement for persistent B-cell aplasia and agammaglobulinemia following CD19-targeted chimeric antigen receptor T-cell therapy for B-cell lymphoblastic leukemia. Patients were transitioned from intravenous to subcutaneous immunoglobulin replacement at a median of 11.5 months (range, 4-20). Increasing serum IgG level was significantly associated with a lower rate of sinopulmonary infection (P = 0.0072). The median serum IgG level during infection-free periods was 1000 mg/dL (range, 720-1430), which was significantly higher than IgG levels in patients with sinopulmonary infections. As such, we recommend maintaining a goal IgG level > 1000 mg/dL to provide optimal protection.
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Affiliation(s)
- Danielle E Arnold
- Children's Hospital of Philadelphia, Division of Allergy and Immunology, Philadelphia, Pennsylvania
| | - Shannon L Maude
- Children's Hospital of Philadelphia, Division of Oncology, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Colleen A Callahan
- Children's Hospital of Philadelphia, Division of Oncology, Philadelphia, Pennsylvania
| | - Amanda M DiNofia
- Children's Hospital of Philadelphia, Division of Oncology, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephan A Grupp
- Children's Hospital of Philadelphia, Division of Oncology, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer R Heimall
- Children's Hospital of Philadelphia, Division of Allergy and Immunology, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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22
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Immunoglobulin administration for the treatment of CIDP: IVIG or SCIG? J Neurol Sci 2019; 408:116497. [PMID: 31765922 DOI: 10.1016/j.jns.2019.116497] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 08/20/2019] [Accepted: 09/17/2019] [Indexed: 01/08/2023]
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is an acquired neurological disorder characterized clinically by weakness and impaired sensory function evolving over 2 months or more, loss or significant decrease in deep tendon reflexes, and by electrophysiological evidence of peripheral nerve demyelination. Expeditious diagnosis and treatment of CIDP early in the disease course is critical such that irreversible disability can be avoided. Intravenous immunoglobulin (IVIG) is one first-line and maintenance therapy option for CIDP. The US Food & Drug Administration's (FDA's) approval of subcutaneous immunoglobulin (SCIG) in 2018 provides patients with CIDP more treatment options for maintenance therapy. The different options for administration of IG treatment create the need for information to assist clinicians and patients in choosing the optimal therapeutic approach. Considerations for pharmacokinetics, administration procedures, adverse events, patient variables, and cost will all be discussed in this article.
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23
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van Schaik IN, Mielke O, Bril V, van Geloven N, Hartung HP, Lewis RA, Sobue G, Lawo JP, Praus M, Durn BL, Cornblath DR, Merkies ISJ. Long-term safety and efficacy of subcutaneous immunoglobulin IgPro20 in CIDP: PATH extension study. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 6:e590. [PMID: 31355323 PMCID: PMC6624149 DOI: 10.1212/nxi.0000000000000590] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 05/16/2019] [Indexed: 11/18/2022]
Abstract
Objective To investigate the long-term safety and efficacy of weekly subcutaneous IgPro20 (Hizentra, CSL Behring) in chronic inflammatory demyelinating polyneuropathy (CIDP). Methods In a 48-week open-label prospective extension study to the PATH study, patients were initially started on 0.2 g/kg or on 0.4 g/kg weekly and-if clinically stable-switched to 0.2 g/kg weekly after 24 weeks. Upon CIDP relapse on the 0.2 g/kg dose, 0.4 g/kg was (re)initiated. CIDP relapse was defined as a deterioration by at least 1 point in the total adjusted Inflammatory Neuropathy Cause and Treatment score. Results Eighty-two patients were enrolled. Sixty-two patients initially received 0.4 g/kg, 20 patients 0.2 g/kg weekly. Seventy-two received both doses during the study. Sixty-six patients (81%) completed the 48-week study duration. Overall relapse rates were 10% in 0.4 g/kg-treated patients and 48% in 0.2 g/kg-treated patients. After dose reduction from 0.4 to 0.2 g/kg, 51% (27/53) of patients relapsed, of whom 92% (24 of 26) improved after reinitiation of the 0.4 g/kg dose. Two-thirds of patients (19/28) who completed the PATH study without relapse remained relapse-free on the 0.2 g/kg dose after dose reduction in the extension study. Sixty-two patients had adverse events (AEs) (76%), of which most were mild or moderate with no related serious AEs. Conclusions Subcutaneous treatment with IgPro20 provided long-term benefit at both 0.4 and 0.2 g/kg weekly doses with lower relapse rates on the higher dose. Long-term dosing should be individualized to find the most appropriate dose in a given patient. Classification of evidence This study provides Class IV evidence that for patients with CIDP, long-term treatment with SCIG beyond 24 weeks is safe and efficacious.
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Affiliation(s)
- Ivo N van Schaik
- Department of Neurology (I.N.S.), Amsterdam University Medical Centers, University of Amsterdam, The Netherlands; Spaarne Gasthuis (I.N.S.), Haarlem, The Netherlands; CSL Behring (O.M., M.P., B.L.D.), Marburg, Germany and King of Prussia, PA; Department of Medicine (Neurology) (V.B.), University Health Network, University of Toronto, Canada; Medical Statistics (N.G.), Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (G.S.), Nagoya University Graduate School of Medicine, Japan; Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (I.S.J.M.), Maastricht University Medical Center, The Netherlands
| | - Orell Mielke
- Department of Neurology (I.N.S.), Amsterdam University Medical Centers, University of Amsterdam, The Netherlands; Spaarne Gasthuis (I.N.S.), Haarlem, The Netherlands; CSL Behring (O.M., M.P., B.L.D.), Marburg, Germany and King of Prussia, PA; Department of Medicine (Neurology) (V.B.), University Health Network, University of Toronto, Canada; Medical Statistics (N.G.), Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (G.S.), Nagoya University Graduate School of Medicine, Japan; Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (I.S.J.M.), Maastricht University Medical Center, The Netherlands
| | - Vera Bril
- Department of Neurology (I.N.S.), Amsterdam University Medical Centers, University of Amsterdam, The Netherlands; Spaarne Gasthuis (I.N.S.), Haarlem, The Netherlands; CSL Behring (O.M., M.P., B.L.D.), Marburg, Germany and King of Prussia, PA; Department of Medicine (Neurology) (V.B.), University Health Network, University of Toronto, Canada; Medical Statistics (N.G.), Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (G.S.), Nagoya University Graduate School of Medicine, Japan; Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (I.S.J.M.), Maastricht University Medical Center, The Netherlands
| | - Nan van Geloven
- Department of Neurology (I.N.S.), Amsterdam University Medical Centers, University of Amsterdam, The Netherlands; Spaarne Gasthuis (I.N.S.), Haarlem, The Netherlands; CSL Behring (O.M., M.P., B.L.D.), Marburg, Germany and King of Prussia, PA; Department of Medicine (Neurology) (V.B.), University Health Network, University of Toronto, Canada; Medical Statistics (N.G.), Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (G.S.), Nagoya University Graduate School of Medicine, Japan; Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (I.S.J.M.), Maastricht University Medical Center, The Netherlands
| | - Hans-Peter Hartung
- Department of Neurology (I.N.S.), Amsterdam University Medical Centers, University of Amsterdam, The Netherlands; Spaarne Gasthuis (I.N.S.), Haarlem, The Netherlands; CSL Behring (O.M., M.P., B.L.D.), Marburg, Germany and King of Prussia, PA; Department of Medicine (Neurology) (V.B.), University Health Network, University of Toronto, Canada; Medical Statistics (N.G.), Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (G.S.), Nagoya University Graduate School of Medicine, Japan; Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (I.S.J.M.), Maastricht University Medical Center, The Netherlands
| | - Richard A Lewis
- Department of Neurology (I.N.S.), Amsterdam University Medical Centers, University of Amsterdam, The Netherlands; Spaarne Gasthuis (I.N.S.), Haarlem, The Netherlands; CSL Behring (O.M., M.P., B.L.D.), Marburg, Germany and King of Prussia, PA; Department of Medicine (Neurology) (V.B.), University Health Network, University of Toronto, Canada; Medical Statistics (N.G.), Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (G.S.), Nagoya University Graduate School of Medicine, Japan; Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (I.S.J.M.), Maastricht University Medical Center, The Netherlands
| | - Gen Sobue
- Department of Neurology (I.N.S.), Amsterdam University Medical Centers, University of Amsterdam, The Netherlands; Spaarne Gasthuis (I.N.S.), Haarlem, The Netherlands; CSL Behring (O.M., M.P., B.L.D.), Marburg, Germany and King of Prussia, PA; Department of Medicine (Neurology) (V.B.), University Health Network, University of Toronto, Canada; Medical Statistics (N.G.), Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (G.S.), Nagoya University Graduate School of Medicine, Japan; Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (I.S.J.M.), Maastricht University Medical Center, The Netherlands
| | - John-Philip Lawo
- Department of Neurology (I.N.S.), Amsterdam University Medical Centers, University of Amsterdam, The Netherlands; Spaarne Gasthuis (I.N.S.), Haarlem, The Netherlands; CSL Behring (O.M., M.P., B.L.D.), Marburg, Germany and King of Prussia, PA; Department of Medicine (Neurology) (V.B.), University Health Network, University of Toronto, Canada; Medical Statistics (N.G.), Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (G.S.), Nagoya University Graduate School of Medicine, Japan; Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (I.S.J.M.), Maastricht University Medical Center, The Netherlands
| | - Michaela Praus
- Department of Neurology (I.N.S.), Amsterdam University Medical Centers, University of Amsterdam, The Netherlands; Spaarne Gasthuis (I.N.S.), Haarlem, The Netherlands; CSL Behring (O.M., M.P., B.L.D.), Marburg, Germany and King of Prussia, PA; Department of Medicine (Neurology) (V.B.), University Health Network, University of Toronto, Canada; Medical Statistics (N.G.), Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (G.S.), Nagoya University Graduate School of Medicine, Japan; Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (I.S.J.M.), Maastricht University Medical Center, The Netherlands
| | - Billie L Durn
- Department of Neurology (I.N.S.), Amsterdam University Medical Centers, University of Amsterdam, The Netherlands; Spaarne Gasthuis (I.N.S.), Haarlem, The Netherlands; CSL Behring (O.M., M.P., B.L.D.), Marburg, Germany and King of Prussia, PA; Department of Medicine (Neurology) (V.B.), University Health Network, University of Toronto, Canada; Medical Statistics (N.G.), Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (G.S.), Nagoya University Graduate School of Medicine, Japan; Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (I.S.J.M.), Maastricht University Medical Center, The Netherlands
| | - David R Cornblath
- Department of Neurology (I.N.S.), Amsterdam University Medical Centers, University of Amsterdam, The Netherlands; Spaarne Gasthuis (I.N.S.), Haarlem, The Netherlands; CSL Behring (O.M., M.P., B.L.D.), Marburg, Germany and King of Prussia, PA; Department of Medicine (Neurology) (V.B.), University Health Network, University of Toronto, Canada; Medical Statistics (N.G.), Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (G.S.), Nagoya University Graduate School of Medicine, Japan; Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (I.S.J.M.), Maastricht University Medical Center, The Netherlands
| | - Ingemar S J Merkies
- Department of Neurology (I.N.S.), Amsterdam University Medical Centers, University of Amsterdam, The Netherlands; Spaarne Gasthuis (I.N.S.), Haarlem, The Netherlands; CSL Behring (O.M., M.P., B.L.D.), Marburg, Germany and King of Prussia, PA; Department of Medicine (Neurology) (V.B.), University Health Network, University of Toronto, Canada; Medical Statistics (N.G.), Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (G.S.), Nagoya University Graduate School of Medicine, Japan; Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (I.S.J.M.), Maastricht University Medical Center, The Netherlands
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24
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Gelbmann N, Zöchling A, Pichotta A, Schmidt T, Murányi A, Ernegger T, Pock K, Römisch J. Octanorm [cutaquig®], a new immunoglobulin (human) subcutaneous 16.5% solution for injection (165 mg/mL) – Biochemical characterization, pathogen safety, and stability. Biologicals 2019; 60:60-67. [DOI: 10.1016/j.biologicals.2019.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/15/2019] [Accepted: 05/02/2019] [Indexed: 01/14/2023] Open
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25
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Immunoglobulin Therapy. Clin Immunol 2019. [DOI: 10.1016/b978-0-7020-6896-6.00084-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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26
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Berger M, Harbo T, Cornblath DR, Mielke O. IgPro20, the Polyneuropathy and Treatment with Hizentra® study (PATH), and the treatment of chronic inflammatory demyelinating polyradiculoneuropathy with subcutaneous IgG. Immunotherapy 2018; 10:919-933. [DOI: 10.2217/imt-2018-0036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Subcutaneous IgG (SCIG) administration may be preferred over the intravenous route (IVIG) in chronic inflammatory demyelinating polyneuropathy (CIDP) because it minimizes ‘end of cycle’ treatment-related fluctuations, reduces systemic adverse effects, improves convenience/quality of life and potentially lowers overall costs. Early reports of the use of highly concentrated SCIG preparations suggested they were effective and well-tolerated in chronic inflammatory demyelinating polyneuropathy. This was confirmed in the Polyneuropathy and Treatment with Hizentra® study of 172 subjects randomized to receive maintenance therapy with placebo or one of two doses of IgPro20 (20% IgG stabilized with L-Proline) for 6 months. Risk of relapse was reduced by SCIG in a dose-related manner as compared with placebo. A total of 88% of polyneuropathy and treatment with hizentra subjects felt the subcutaneous method was ‘easy to learn’. Local adverse events were mostly mild or moderate, and systemic adverse events were infrequent. Some patients may prefer maintenance therapy with SCIG over IVIG.
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Affiliation(s)
| | - Thomas Harbo
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - David R Cornblath
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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27
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Guo Y, Tian X, Wang X, Xiao Z. Adverse Effects of Immunoglobulin Therapy. Front Immunol 2018; 9:1299. [PMID: 29951056 PMCID: PMC6008653 DOI: 10.3389/fimmu.2018.01299] [Citation(s) in RCA: 186] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 05/24/2018] [Indexed: 01/09/2023] Open
Abstract
Immunoglobulin has been widely used in a variety of diseases, including primary and secondary immunodeficiency diseases, neuromuscular diseases, and Kawasaki disease. Although a large number of clinical trials have demonstrated that immunoglobulin is effective and well tolerated, various adverse effects have been reported. The majority of these events, such as flushing, headache, malaise, fever, chills, fatigue and lethargy, are transient and mild. However, some rare side effects, including renal impairment, thrombosis, arrhythmia, aseptic meningitis, hemolytic anemia, and transfusion-related acute lung injury (TRALI), are serious. These adverse effects are associated with specific immunoglobulin preparations and individual differences. Performing an early assessment of risk factors, infusing at a slow rate, premedicating, and switching from intravenous immunoglobulin (IVIG) to subcutaneous immunoglobulin (SCIG) can minimize these adverse effects. Adverse effects are rarely disabling or fatal, treatment mainly involves supportive measures, and the majority of affected patients have a good prognosis.
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Affiliation(s)
- Yi Guo
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
| | - Xin Tian
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
| | - Xuefeng Wang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
| | - Zheng Xiao
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
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28
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Allen JA, Berger M, Querol L, Kuitwaard K, Hadden RD. Individualized immunoglobulin therapy in chronic immune-mediated peripheral neuropathies. J Peripher Nerv Syst 2018; 23:78-87. [PMID: 29573033 PMCID: PMC6033159 DOI: 10.1111/jns.12262] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 03/12/2018] [Accepted: 03/14/2018] [Indexed: 12/11/2022]
Abstract
Despite the well-recognized importance of immunoglobulin therapy individualization during the treatment of chronic inflammatory demyelinating polyneuropathy (CIDP), the pathway to best achieve optimization is unknown. There are many pharmacokinetic and immunobiologic variables that can potentially influence the appropriateness of any individual therapy. Although identification of specific autoantibodies and their targets has only been accomplished in a minority of patients with CIDP, already the diagnostic and treatment implications of specific autoantibody detection are being realized. Individual variability in IgG pharmacokinetic properties including IgG catabolic rates and distribution, as well as the IgG level necessary for disease control also require consideration during the optimization process. For optimization to be successful there must be a measure of treatment response that has a clinically meaningful interpretation. There are currently available well-defined and validated clinical assessment tools and outcome measures that are well suited for this purpose. While there remains much to learn on how best to manipulate immunopathology and immunoglobulin pharmacokinetics in the most favorable way, there currently exists an understanding of these principles to a degree sufficient to begin to develop rational and evidence-based treatment optimization strategies.
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Affiliation(s)
- Jeffrey A Allen
- Department of Neurology, University of Minnesota, Minneapolis, MN, USA
| | - Melvin Berger
- Immunology Research and Development, CSL Behring, King of Prussia, PA, USA
| | - Luis Querol
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro para la Investigación Biomédica en Red en Enfermedades Raras (CIBERER), Madrid, Spain
| | - Krista Kuitwaard
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Neurology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Robert D Hadden
- Department of Neurology, King's College Hospital, London, UK
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29
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Melamed IR, Borte M, Trawnicek L, Kobayashi AL, Kobayashi RH, Knutsen A, Gupta S, Smits W, Pituch-Noworolska A, Strach M, Pulka G, Ochs HD, Moy JN. Pharmacokinetics of a novel human intravenous immunoglobulin 10% in patients with primary immunodeficiency diseases: Analysis of a phase III, multicentre, prospective, open-label study. Eur J Pharm Sci 2018. [PMID: 29522908 DOI: 10.1016/j.ejps.2018.03.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Intravenous immunoglobulin (IVIG) therapy is commonly used to treat patients with primary antibody deficiency. This prospective, open-label, non-randomised, multicentre, phase III trial investigated the pharmacokinetics of a new 10% liquid IVIG product (panzyga®; Octapharma) in 51 patients aged 2-75 years with common variable immunodeficiency (n = 43) or X-linked agammaglobulinaemia (n = 8). Patients were treated with IVIG 10% every 3 (n = 21) or 4 weeks (n = 30) at a dose of 200-800 mg/kg for 12 months. Total immunoglobulin G (IgG) and subclass concentrations approximately doubled from pre- to 15 min post-infusion. The maximum concentration of total IgG (mean ± SD) was 21.82 ± 5.83 g/L in patients treated 3-weekly and 17.42 ± 3.34 g/L in patients treated 4-weekly. Median trough IgG concentrations were nearly constant over the course of the study, remaining between 11.0 and 12.2 g/L for patients on the 3-week schedule and between 8.10 and 8.65 g/L for patients on the 4-week schedule. The median terminal half-life of total IgG was 36.1 (range 18.5-65.9) days, with generally similar values for the IgG subclasses (26.7-38.0 days). Median half-lives for specific antibodies ranged between 21.3 and 51.2 days for anti-cytomegalovirus, anti-Haemophilus influenzae, anti-measles, anti-tetanus toxoid, anti-varicella zoster virus antibodies, and anti-Streptococcus pneumoniae subtype antibodies. Overall, IVIG 10% demonstrated pharmacokinetic properties similar to those of other commercial IVIG 10% preparations and 3- or 4-weekly administration achieved sufficient concentrations of IgG, IgG subclasses, and specific antibodies, exceeding the recommended level needed to effectively prevent serious bacterial infections.
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Affiliation(s)
- Isaac R Melamed
- IMMUNOe Research Center, 6801 S. Yosemite street, Centennial, CO 80112, USA.
| | - Michael Borte
- Klinik für Kinder- und Jugendmedizin, Klinikum St. Georg gGmbH, Leipzig, Germany.
| | - Laurenz Trawnicek
- Octapharma Pharmazeutika Produktionsges.m.b.H, Oberlaaer Straße 235, 1100 Vienna, Austria.
| | | | | | - Alan Knutsen
- Saint Louis University, 1 N Grand Blvd, St Louis, MO 63103, USA.
| | - Sudhir Gupta
- University of California, C240 Med Sci I, Irvine, CA 92697, USA.
| | - William Smits
- The Allergy and Asthma Center, 7222 Engle Rd, Fort Wayne, IN 46804, USA
| | | | - Magdalena Strach
- Jagiellonian University Medical College, Świętej Anny 12, 31-008 Kraków, Poland.
| | - Grazyna Pulka
- Jagiellonian University Medical College, Świętej Anny 12, 31-008 Kraków, Poland.
| | - Hans D Ochs
- Department of Pediatrics, University of Washington and Seattle Children's Research Institute, Seattle, WA 98195, USA.
| | - James N Moy
- Division of Pediatric Allergy/Immunology, John H. Stroger, Jr. Hospital of Cook County, 1969 W. Ogden Ave., Chicago, IL 60612, USA; Rush University Medical Center, 1653 W. Congress Parkway, Chicago, IL 60612, USA.
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30
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Cocito D, Romagnolo A, Peci E, Rosso M, Lopiano L, Milla P, Merola A. Subcutaneous vs. intravenous immunoglobulin in CIDP: pharmacokinetic and clinical response. J Peripher Nerv Syst 2018; 21:114-6. [PMID: 27251938 DOI: 10.1111/jns.12168] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 02/10/2016] [Accepted: 02/20/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Dario Cocito
- Department of Neuroscience, University of Turin, Turin, Italy
| | | | - Erdita Peci
- Department of Neuroscience, University of Turin, Turin, Italy
| | - Michela Rosso
- Department of Neuroscience, University of Turin, Turin, Italy
| | | | - Paola Milla
- Department of Drug Science and Technology, University of Turin, Turin, Italy
| | - Aristide Merola
- Department of Neuroscience, University of Turin, Turin, Italy
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van Schaik IN, Bril V, van Geloven N, Hartung HP, Lewis RA, Sobue G, Lawo JP, Praus M, Mielke O, Durn BL, Cornblath DR, Merkies ISJ, Sabet A, George K, Roberts L, Carne R, Blum S, Henderson R, Van Damme P, Demeestere J, Larue S, D'Amour C, Bril V, Breiner A, Kunc P, Valis M, Sussova J, Kalous T, Talab R, Bednar M, Toomsoo T, Rubanovits I, Gross-Paju K, Sorro U, Saarela M, Auranen M, Pouget J, Attarian S, Le Masson G, Wielanek-Bachelet A, Desnuelle C, Delmont E, Clavelou P, Aufauvre D, Schmidt J, Zschuentssch J, Sommer C, Kramer D, Hoffmann O, Goerlitz C, Haas J, Chatzopoulos M, Yoon R, Gold R, Berlit P, Jaspert-Grehl A, Liebetanz D, Kutschenko A, Stangel M, Trebst C, Baum P, Bergh F, Klehmet J, Meisel A, Klostermann F, Oechtering J, Lehmann H, Schroeter M, Hagenacker T, Mueller D, Sperfeld A, Bethke F, Drory V, Algom A, Yarnitsky D, Murinson B, Di Muzio A, Ciccocioppo F, Sorbi S, Mata S, Schenone A, Grandis M, Lauria G, Cazzato D, Antonini G, Morino S, Cocito D, Zibetti M, Yokota T, Ohkubo T, Kanda T, Kawai M, Kaida K, Onoue H, Kuwabara S, Mori M, Iijima M, Ohyama K, Baba M, Tomiyama M, Nishiyama K, Akutsu T, Yokoyama K, Kanai K, van Schaik I, Eftimov F, Notermans N, Visser N, Faber C, Hoeijmakers J, Rejdak K, Chyrchel-Paszkiewicz U, Casanovas Pons C, Alberti Aguiló M, Gamez J, Figueras M, Marquez Infante C, Benitez Rivero S, Lunn M, Morrow J, Gosal D, Lavin T, Melamed I, Testori A, Ajroud-Driss S, Menichella D, Simpson E, Chi-Ho Lai E, Dimachkie M, Barohn R, Beydoun S, Johl H, Lange D, Shtilbans A, Muley S, Ladha S, Freimer M, Kissel J, Latov N, Chin R, Ubogu E, Mumfrey S, Rao T, MacDonald P, Sharma K, Gonzalez G, Allen J, Walk D, Hobson-Webb L, Gable K. Subcutaneous immunoglobulin for maintenance treatment in chronic inflammatory demyelinating polyneuropathy (PATH): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet Neurol 2018; 17:35-46. [DOI: 10.1016/s1474-4422(17)30378-2] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 09/28/2017] [Accepted: 10/02/2017] [Indexed: 10/18/2022]
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33
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Goudouris ES, Rego Silva AMD, Ouricuri AL, Grumach AS, Condino-Neto A, Costa-Carvalho BT, Prando CC, Kokron CM, Vasconcelos DDM, Tavares FS, Silva Segundo GR, Barreto IC, Dorna MDB, Barros MA, Forte WCN. II Brazilian Consensus on the use of human immunoglobulin in patients with primary immunodeficiencies. EINSTEIN-SAO PAULO 2017; 15:1-16. [PMID: 28444082 PMCID: PMC5433300 DOI: 10.1590/s1679-45082017ae3844] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 01/04/2017] [Indexed: 12/18/2022] Open
Abstract
In the last few years, new primary immunodeficiencies and genetic defects have been described. Recently, immunoglobulin products with improved compositions and for subcutaneous use have become available in Brazil. In order to guide physicians on the use of human immunoglobulin to treat primary immunodeficiencies, based on a narrative literature review and their professional experience, the members of the Primary Immunodeficiency Group of the Brazilian Society of Allergy and Immunology prepared an updated document of the 1st Brazilian Consensus, published in 2010. The document presents new knowledge about the indications and efficacy of immunoglobulin therapy in primary immunodeficiencies, relevant production-related aspects, mode of use (routes of administration, pharmacokinetics, doses and intervals), adverse events (major, prevention, treatment and reporting), patient monitoring, presentations available and how to have access to this therapeutic resource in Brazil.
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Affiliation(s)
| | | | | | | | | | | | | | - Cristina Maria Kokron
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | | | | | - Mayra de Barros Dorna
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Myrthes Anna Barros
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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34
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Ballow M. Practical aspects of immunoglobulin replacement. Ann Allergy Asthma Immunol 2017; 119:299-303. [PMID: 28958372 DOI: 10.1016/j.anai.2017.07.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 07/14/2017] [Accepted: 07/19/2017] [Indexed: 02/08/2023]
Affiliation(s)
- Mark Ballow
- Division of Allergy & Immunology, Department of Pediatrics, University of South Florida Morsani College of Medicine, and Johns Hopkins All Children's Hospital, St Petersburg, Florida.
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35
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Bonagura VR, Kaplan B, Jongco AM. Management of primary antibody deficiency syndromes. Ann Allergy Asthma Immunol 2017; 117:620-626. [PMID: 27979019 DOI: 10.1016/j.anai.2016.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 08/16/2016] [Accepted: 08/16/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Vincent R Bonagura
- Laboratory of Host Defense, Center for Immunology and Inflammation, Feinstein Institute for Medical Research, Manhasset, New York; Division of Allergy and Immunology, Hofstra Northwell School of Medicine, Great Neck, New York.
| | - Blanka Kaplan
- Division of Allergy and Immunology, Hofstra Northwell School of Medicine, Great Neck, New York
| | - Artemio M Jongco
- Laboratory of Host Defense, Center for Immunology and Inflammation, Feinstein Institute for Medical Research, Manhasset, New York; Division of Allergy and Immunology, Hofstra Northwell School of Medicine, Great Neck, New York
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36
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The Role of Immunoglobulin in the Treatment of Immune-Mediated Peripheral Neuropathies. JOURNAL OF INFUSION NURSING 2017; 40:375-379. [DOI: 10.1097/nan.0000000000000248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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37
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Markvardsen LH, Harbo T. Subcutaneous immunoglobulin treatment in CIDP and MMN. Efficacy, treatment satisfaction and costs. J Neurol Sci 2017; 378:19-25. [PMID: 28566163 DOI: 10.1016/j.jns.2017.04.039] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 04/21/2017] [Accepted: 04/22/2017] [Indexed: 10/19/2022]
Abstract
Subcutaneous administration of immunoglobulin (SCIG) in chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy (MMN) has been reported in several case reports and in a few randomized trials during the last decade. In this review we present the studies on SCIG in CIDP and MMN with special focus on the clinical effects. Moreover, the effect on quality of life, side effects to SCIG and the health economic perspectives are reviewed. Nine case studies, three randomized trials and six long-term, follow-up studies were identified. Most of the studies are conducted in patients switched from regular IVIG to SCIG treatment; one study involves treatment-naïve patients. The review shows that none of the studies have been powered to demonstrate an effect on disability. SCIG can maintain muscle strength for a period of 1 to 2years and ability seems preserved for a similar period. Quality of life is generally unchanged or improved after switch to SCIG and generalized side-effects seem fewer, whereas local reactions at the injection site occur. Health economic analyses favour SCIG at the doses used in the reviewed studies.
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Affiliation(s)
| | - Thomas Harbo
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
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38
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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.
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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
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Safety and Efficacy of Subcutaneous Immunoglobulin in the Treatment of Neuromuscular Disorders. J Clin Neuromuscul Dis 2016; 17:110-9. [PMID: 26905911 DOI: 10.1097/cnd.0000000000000105] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Many neuromuscular diseases may be treated with immunoglobulins. In the United States, the major form of immunoglobulin used is intravenous (IV). Recently, there has been an increased interest in research regarding the use of subcutaneous immunoglobulin (SCIg), mainly for improved patient quality of life, convenience, potential for fewer systemic adverse events, and avoiding wear-off. The widespread use of the subcutaneous formulation in neurology has been affected by some limitations, mainly the smaller volume and higher frequency of infusions compared to IV administration. Also, there are different pharmacokinetic properties that should be considered to evaluate whether they change the immunomodulatory effect. There are several formulations available that address some limitations. Several studies have assessed efficacy, safety, and quality of life of SCIg in neurology. This review article summarizes the current evidence for the use of SCIg in neuromuscular diseases. It also addresses the pharmacokinetic differences and the different formulations available. The current available preliminary evidence indicates that SCIg is at least as effective as the IV formulations.
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Cocito D, Merola A, Romagnolo A, Peci E, Toscano A, Mazzeo A, Gentile L, Russo M, Fazio R, Filosto M, Siciliano G, Schirinzi E, Nobile-Orazio E, Lopiano L. Subcutaneous immunoglobulin in CIDP and MMN: a different long-term clinical response? J Neurol Neurosurg Psychiatry 2016; 87:791-3. [PMID: 26109674 DOI: 10.1136/jnnp-2014-310280] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 06/04/2015] [Indexed: 11/04/2022]
Affiliation(s)
- Dario Cocito
- Department of Neuroscience, University of Turin, Torino, Italy
| | - Aristide Merola
- Department of Neuroscience, University of Turin, Torino, Italy
| | | | - Erdita Peci
- Department of Neuroscience, University of Turin, Torino, Italy
| | - Antonio Toscano
- Department of Neuroscience, Psychiatry and Anesthesiology, A.O.U. Policlinico "G. Martino", Messina, Italy
| | - Anna Mazzeo
- Department of Neuroscience, Psychiatry and Anesthesiology, A.O.U. Policlinico "G. Martino", Messina, Italy
| | - Luca Gentile
- Department of Neuroscience, Psychiatry and Anesthesiology, A.O.U. Policlinico "G. Martino", Messina, Italy
| | - Massimo Russo
- Department of Neuroscience, Psychiatry and Anesthesiology, A.O.U. Policlinico "G. Martino", Messina, Italy
| | | | - Massimiliano Filosto
- Neuromuscular Diseases and Neuropathies Section, University and Neurological Clinic, A.O "Spedali Civili" of Brescia, Brescia, Italy
| | - Gabriele Siciliano
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Erica Schirinzi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Eduardo Nobile-Orazio
- Department of Translational Medicine, Neurology 2, University of Milano, IRCCS Istituto Clinico Humanitas, Rozzano, Milano, Italy
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Heimall J, Chen J, Church JA, Griffin R, Melamed I, Kleiner GI. Pharmacokinetics, Safety, and Tolerability of Subcutaneous Immune Globulin Injection (Human), 10 % Caprylate/Chromatography Purified (GAMUNEX®-C) in Pediatric Patients with Primary Immunodeficiency Disease. J Clin Immunol 2016; 36:600-9. [DOI: 10.1007/s10875-016-0311-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 06/08/2016] [Indexed: 10/21/2022]
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Spadaro G, Pecoraro A, De Renzo A, Della Pepa R, Genovese A. Intravenous versus subcutaneous immunoglobulin replacement in secondary hypogammaglobulinemia. Clin Immunol 2016; 166-167:103-4. [PMID: 27063866 DOI: 10.1016/j.clim.2016.04.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 04/04/2016] [Indexed: 12/29/2022]
Abstract
In this study, we compared intravenous immunoglobulins (IVIG) and subcutaneous immunoglobulins (SCIG) in terms of serum IgG concentration and incidence of infections in patients with hypogammaglobulinemia secondary to chemo-immunotherapy regimens including the anti-CD20 monoclonal antibody rituximab. Fourteen patients with a B-cell lymphoproliferative disease treated for at least six months with a rituximab-including chemo-immunotherapy regimen were recruited. Mean serum levels of IgG were higher during replacement therapy than at the end of rituximab treatment (p<0.001). Moreover, serum IgG level was higher during replacement therapy with SCIG than with IVIG (p<0.001). No differences in the incidence of infections were observed. Although the non-randomized design and the small number of patients do not allow definitive conclusions to be drawn, study results suggest that higher mean serum IgG levels are reached when using the subcutaneous route after a switch from the intravenous regimen, and that IVIG and SCIG offer comparable protection against infections.
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Affiliation(s)
- Giuseppe Spadaro
- Department of Translational Medical Sciences, Allergy and Clinical Immunology, University of Naples Federico II, Naples, Italy.
| | - Antonio Pecoraro
- Department of Translational Medical Sciences, Allergy and Clinical Immunology, University of Naples Federico II, Naples, Italy
| | - Amalia De Renzo
- Department of Clinical Medicine and Surgery, Haematology, University of Naples Federico II, Naples, Italy
| | - Roberta Della Pepa
- Department of Clinical Medicine and Surgery, Haematology, University of Naples Federico II, Naples, Italy
| | - Arturo Genovese
- Department of Translational Medical Sciences, Allergy and Clinical Immunology, University of Naples Federico II, Naples, Italy
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Živković S. Intravenous immunoglobulin in the treatment of neurologic disorders. Acta Neurol Scand 2016; 133:84-96. [PMID: 25997034 DOI: 10.1111/ane.12444] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2015] [Indexed: 12/17/2022]
Abstract
Intravenous immunoglobulins (IVIGs) are often used in the treatment of autoimmune disorders and immunodeficiencies, and it has been estimated that neurologic indications can account for up to 43% of IVIG used in clinical practice. In neurologic clinical practice, IVIG is used for acute therapy of newly diagnosed autoimmune disorders or exacerbations of pre-existing conditions, or as long-term maintenance treatment for chronic disorders. IVIG exerts its effects on humoral and cell-based immunity through multiple pathways, without a single dominant mechanism. Clinical use of IVIG has been supported by guidelines from American Academy of Neurology and European Federation of Neurologic Societies. IVIG is generally recommended for the treatment of Guillain-Barre syndrome and chronic inflammatory demyelinating polyneuropathy in adults, multifocal motor neuropathy and myasthenia gravis, and should be considered as a treatment option for dermatomyositis in adults and Lambert-Eaton myasthenic syndrome. Additional potential indications include stiff person syndrome, multiple sclerosis during pregnancy or while breastfeeding, refractory autoimmune epilepsy, and paraneoplastic disorders. Clinical use of IVIG is mostly safe but few adverse effects may still occur with potentially severe complications, including aseptic meningitis and thromboembolism. In addition to intravenous route (IVIG), subcutaneous immunoglobulins have been used as an alternative treatment option, especially in patients with limited intravenous access. Treatment with IVIG is effective in various autoimmune diseases, but its broader use is constrained by limited supply. This review evaluates the use of immunoglobulins in treatment of neurologic diseases.
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Affiliation(s)
- S. Živković
- Department of Neurology; University of Pittsburgh Medical Center; Pittsburgh PA USA
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44
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Lünemann JD, Quast I, Dalakas MC. Efficacy of Intravenous Immunoglobulin in Neurological Diseases. Neurotherapeutics 2016; 13:34-46. [PMID: 26400261 PMCID: PMC4720677 DOI: 10.1007/s13311-015-0391-5] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Owing to its anti-inflammatory efficacy in various autoimmune disease conditions, intravenous immunoglobulin (IVIG)-pooled IgG obtained from the plasma of several thousands individuals-has been used for nearly three decades and is proving to be efficient in a growing number of neurological diseases. IVIG therapy has been firmly established for the treatment of Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy, either as first-line therapy or adjunctive treatment. IVIG is also recommended as rescue therapy in patients with worsening myasthenia gravis and is beneficial as a second-line therapy for dermatomyositis and stiff-person syndrome. Subcutaneous rather than intravenous administration of IgG is gaining momentum because of its effectiveness in patients with primary immunodeficiency and the ease with which it can be administered independently from hospital-based infusions. The demand for IVIG therapy is growing, resulting in rising costs and supply shortages. Strategies to replace IVIG with recombinant products have been developed based on proposed mechanisms that confer the anti-inflammatory activity of IVIG, but their efficacy has not been tested in clinical trials. This review covers new developments in the immunobiology and clinical applications of IVIG in neurological diseases.
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Affiliation(s)
- Jan D Lünemann
- Institute of Experimental Immunology, Laboratory of Neuroinflammation, University of Zürich, Winterthurerstrasse 190, Zürich, Switzerland.
- Department of Neurology, University Hospital of Basel, Basel, Switzerland.
| | - Isaak Quast
- Institute of Experimental Immunology, Laboratory of Neuroinflammation, University of Zürich, Winterthurerstrasse 190, Zürich, Switzerland
| | - Marinos C Dalakas
- Neuroimmunology Unit, University of Athens Medical School, Athens, Greece
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
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Abstract
Peripheral neuropathies are frequent in association with systemic diseases as well as isolated disorders. Recent advances in the therapy of specific neuropathies led to the approval of new drugs/treatments. This review selected those peripheral neuropathies where the most recent approvals were provided and revised the potential future developments in diabetic and toxic-induced neuropathies, although they do not have a currently available causal therapy in view of their epidemiological and social relevance. Data have been extracted from the most important published trials and from clinical experience. In addition, data from the Food and Drug Administration and European Medicine Agency indications on the treatment of the selected peripheral neuropathies and from recently updated international guidelines have also been included. The website of the U.S. National Institutes of Health www.clinicaltrials.gov registry has been used as the reference database for phase III clinical trials not yet published or ongoing. This review gives a general overview of the most recent advances in the treatment of amyloid, inflammatory, and paraproteinemic peripheral neuropathies. Moreover, it briefly describes the unmet medical need in disabling and frequent conditions, such as diabetic and chemotherapy-induced neuropathy, highlighting the most promising therapeutic approaches to their treatment.
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Affiliation(s)
- Paola Marmiroli
- a Experimental Neurology Unit, School of Medicine and Surgery and Milan Center for Neuroscience , University of Milano-Bicocca , Monza , Italy
| | - Guido Cavaletti
- a Experimental Neurology Unit, School of Medicine and Surgery and Milan Center for Neuroscience , University of Milano-Bicocca , Monza , Italy
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46
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Berger M. Efficient Utilization of IgG for Antibody Replacement Therapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2015; 3:1001-1002. [PMID: 26553622 DOI: 10.1016/j.jaip.2015.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 07/24/2015] [Indexed: 06/05/2023]
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Lucas M, Lee M, Oksenhendler E, Chapel H. The ratio of mean daily IgG increment/mean daily dose in immunoglobulin replacement therapy in primary antibody deficiencies. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:998-1000.e2. [DOI: 10.1016/j.jaip.2015.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 06/30/2015] [Accepted: 07/01/2015] [Indexed: 11/29/2022]
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Niebur HB, Duff CM, Shear GF, Nguyen D, Alberdi TK, Dorsey MJ, Sleasman JW. Efficacy and tolerability of 16% subcutaneous immunoglobulin compared with 20% subcutaneous immunoglobulin in primary antibody deficiency. Clin Exp Immunol 2015; 181:441-50. [PMID: 25761372 PMCID: PMC4557380 DOI: 10.1111/cei.12623] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2015] [Indexed: 11/27/2022] Open
Abstract
Multiple subcutaneous immunoglobulin (SCIG) products are available to treat primary antibody deficiency (PAD). The efficacy and tolerability of 16% SCIG (Vivaglobin(®) ) was compared with 20% SCIG (Hizentra(®) ) in PAD subjects. The study was a prospective, single-centre, open-label study of PAD subjects transitioning Vivaglobin to equivalent Hizentra doses, rounded to the nearest vial size. Comparisons included immunoglobulin (Ig)G levels; tetanus, varicella and Streptococcus pneumoniae titres; adverse events (AEs), annual infection rate and quality of life during 8 weeks of Vivaglobin and 24 weeks of Hizentra. Thirty-two subjects (aged 2-75 years) participated. Rounding to the nearest Hizentra vial size resulted in a 12·8% (± 2·9%) increase in SCIG dose. Median immunoglobulin (Ig)G level following 8 weeks of Vivaglobin was similar to 24 weeks of Hizentra (1050 versus 1035 mg/dl, respectively; P = 0·77). Both products had similar protective titres to tetanus, varicella and serotypes of S. pneumoniae, which were variable but well above protective levels. After 12 weeks of Hizentra, subjects reported fewer local site reactions compared with Vivaglobin. Switching products resulted in increased systemic AEs in some subjects but, overall, not significantly higher than during Vivaglobin treatment. Average infusion time decreased from 104·7 min (3·3 sites) with Vivaglobin to 70·7 min (2·2 sites) with Hizentra (P = 0·0005). Acute serious bacterial infections were similar. Treatment satisfaction was superior with Hizentra. Hizentra and Vivaglobin have similar pharmacokinetics and efficacy. Although transition to a different SCIG product initially increased AEs, Hizentra is well tolerated and can be infused more rapidly and with fewer sites compared to Vivaglobin.
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Affiliation(s)
- H B Niebur
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, University of South Florida, St Petersburg, FL, USA
| | - C M Duff
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, University of South Florida, St Petersburg, FL, USA
| | - G F Shear
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, University of South Florida, St Petersburg, FL, USA
| | - D Nguyen
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, University of South Florida, St Petersburg, FL, USA
| | - T K Alberdi
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, University of South Florida, St Petersburg, FL, USA
| | - M J Dorsey
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, University of South Florida, St Petersburg, FL, USA
| | - J W Sleasman
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, University of South Florida, St Petersburg, FL, USA
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Dash C, Gascoigne E, Gillanders K, Gooi H. Experience with Subgam, a Subcutaneously Administered Human Normal Immunoglobulin (ClinicalTrials.gov--NCT02247141). PLoS One 2015. [PMID: 26222441 PMCID: PMC4519338 DOI: 10.1371/journal.pone.0131565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background and Objectives A multi-centre, non-comparative study examining the efficacy and safety of Subgam, a normal immunoglobulin (IgG) given weekly as a rapid subcutaneous infusion to patients with primary immune deficiency (PID), is reported. Also included is a summary of adverse drug reactions associated with the use of marketed Subgam in the UK. Materials and Methods 50 patients with stable PID on IgG therapy were enrolled: Stage 1 included three infusions with prior IgG product followed by 6 months with Subgam, Stage 2 involved long-term Subgam therapy up to 4 years. Results Stage 1, 85% of the subjects aged >12 years and 93% of the subjects aged <12 years achieved IgG levels ≥6 and ≥4 g/L, respectively at all observations. There were 3.62 infections/patient/year during Subgam treatment. The most common product-related events were infusion site reactions (50% of patients). Recent post-hoc pharmacokinetics analysis of the post-infusion serum total IgG concentration indicated that the mean dose-normalised incremental IgG AUCτ following intravenous dosing (120.5 g.day/L) was 1.64-fold that of the dose-normalised mean incremental IgG AUCτ following subcutaneous dosing (73.6 g.day/L), corresponding to an estimated IgG bioavailability for subcutaneous dosing of 61%. Only 34 post-licensing adverse reactions have been received in 30 patients over a period of 10 years; fourteen were classed as serious as defined by the ICH guidelines on good clinical practice. The most common post-licensing adverse reaction was infusion site reaction (7 reports). There were 7 reports of flu-like symptoms (pyrexia/shivering/rigors/feeling hot or cold), 2 other reports of combined flu-like symptoms and infusion site reactions, 5 reports of generalised skin reactions, and 3 reports of combined infusion site and skin reactions. There were also reports of anaphylaxis (2 reports) and 8 other adverse events (including headache). In conclusion, Subgam is effective and well tolerated in the treatment of PID. Trial Registration ClinicalTrials.gov NCT02247141
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Affiliation(s)
- Clive Dash
- CD Consultants, St Albans, United Kingdom
| | - Ernie Gascoigne
- Medical Department, Bio Products Laboratory Limited (BPL), Elstree, Hertfordshire (Herts.), United Kingdom
| | - Kate Gillanders
- Medical Department, Bio Products Laboratory Limited (BPL), Elstree, Hertfordshire (Herts.), United Kingdom
- * E-mail:
| | - Hock Gooi
- Department of Clinical Immunology and Allergy, King's College Hospital, London, United Kingdom
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