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Noto A, Cassin R, Mattiello V, Bortolotti M, Reda G, Barcellini W. Should treatment of hypogammaglobulinemia with immunoglobulin replacement therapy (IgRT) become standard of care in patients with chronic lymphocytic leukemia? Front Immunol 2023; 14:1062376. [PMID: 37122737 PMCID: PMC10140292 DOI: 10.3389/fimmu.2023.1062376] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 03/13/2023] [Indexed: 05/02/2023] Open
Abstract
Hypogammaglobulinemia (HGG) is a frequent finding in patients with hematological malignancies, and is commonly described in chronic lymphocytic leukemia (CLL) before or after treatment. We reviewed published literature available online in the last thirty years through Medline search of indexed articles focusing on the main differences and advantages of the products now available on the market, namely intravenous Ig (IVIg) and subcutaneous Ig (SCIg) preparations. IgRT is effective and safe in the prophylaxis of infections in a selected group of patients with CLL and hypogammaglobulinemia and is therefore a valuable tool for clinicians in the everyday management of infectious risk. We encourage the use of SCIg formulations as they appear to have similar efficacy but better cost-effectiveness and tolerability.
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Affiliation(s)
- Alessandro Noto
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ramona Cassin
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Veronica Mattiello
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marta Bortolotti
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Hematology Oncology, Faculty of Medicine and Surgery, University of Milan, Milan, Italy
| | - Gianluigi Reda
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- *Correspondence: Gianluigi Reda,
| | - Wilma Barcellini
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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2
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Otani IM, Lehman HK, Jongco AM, Tsao LR, Azar AE, Tarrant TK, Engel E, Walter JE, Truong TQ, Khan DA, Ballow M, Cunningham-Rundles C, Lu H, Kwan M, Barmettler S. Practical guidance for the diagnosis and management of secondary hypogammaglobulinemia: A Work Group Report of the AAAAI Primary Immunodeficiency and Altered Immune Response Committees. J Allergy Clin Immunol 2022; 149:1525-1560. [PMID: 35176351 DOI: 10.1016/j.jaci.2022.01.025] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 12/31/2021] [Accepted: 01/21/2022] [Indexed: 11/17/2022]
Abstract
Secondary hypogammaglobulinemia (SHG) is characterized by reduced immunoglobulin levels due to acquired causes of decreased antibody production or increased antibody loss. Clarification regarding whether the hypogammaglobulinemia is secondary or primary is important because this has implications for evaluation and management. Prior receipt of immunosuppressive medications and/or presence of conditions associated with SHG development, including protein loss syndromes, are histories that raise suspicion for SHG. In patients with these histories, a thorough investigation of potential etiologies of SHG reviewed in this report is needed to devise an effective treatment plan focused on removal of iatrogenic causes (eg, discontinuation of an offending drug) or treatment of the underlying condition (eg, management of nephrotic syndrome). When iatrogenic causes cannot be removed or underlying conditions cannot be reversed, therapeutic options are not clearly delineated but include heightened monitoring for clinical infections, supportive antimicrobials, and in some cases, immunoglobulin replacement therapy. This report serves to summarize the existing literature regarding immunosuppressive medications and populations (autoimmune, neurologic, hematologic/oncologic, pulmonary, posttransplant, protein-losing) associated with SHG and highlights key areas for future investigation.
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Affiliation(s)
- Iris M Otani
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, UCSF Medical Center, San Francisco, Calif.
| | - Heather K Lehman
- Division of Allergy, Immunology, and Rheumatology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
| | - Artemio M Jongco
- Division of Allergy and Immunology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
| | - Lulu R Tsao
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, UCSF Medical Center, San Francisco, Calif
| | - Antoine E Azar
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore
| | - Teresa K Tarrant
- Division of Rheumatology and Immunology, Duke University, Durham, NC
| | - Elissa Engel
- Division of Hematology and Oncology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Jolan E Walter
- Division of Allergy and Immunology, Johns Hopkins All Children's Hospital, St Petersburg, Fla; Division of Allergy and Immunology, Morsani College of Medicine, University of South Florida, Tampa; Division of Allergy and Immunology, Massachusetts General Hospital for Children, Boston
| | - Tho Q Truong
- Divisions of Rheumatology, Allergy and Clinical Immunology, National Jewish Health, Denver
| | - David A Khan
- Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas
| | - Mark Ballow
- Division of Allergy and Immunology, Morsani College of Medicine, Johns Hopkins All Children's Hospital, St Petersburg
| | | | - Huifang Lu
- Department of General Internal Medicine, Section of Rheumatology and Clinical Immunology, The University of Texas MD Anderson Cancer Center, Houston
| | - Mildred Kwan
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill
| | - Sara Barmettler
- Allergy and Immunology, Massachusetts General Hospital, Boston.
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3
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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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4
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Benbrahim O, Viallard JF, Choquet S, Royer B, Bauduer F, Decaux O, Crave JC, Fardini Y, Clerson P, Lévy V. The use of octagam and gammanorm in immunodeficiency associated with hematological malignancies: a prospective study from 21 French hematology departments. Hematology 2018; 24:173-182. [DOI: 10.1080/10245332.2018.1538001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Omar Benbrahim
- Hôpital de La Source, Centre Hospitalier Régionale Orléans, Orléans, France
| | | | - Sylvain Choquet
- Hématologie, GH Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Bruno Royer
- Hématologie Clinique, CHU Amiens – Sud, Amiens, France
| | | | | | | | | | | | - Vincent Lévy
- URC/CRC Groupe Hospitalier Paris Seine Saint Denis, APHP, Hôpital Avicenne, France
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5
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Sarmiento E, Cifrian J, Calahorra L, Bravo C, Lopez S, Laporta R, Ussetti P, Sole A, Morales C, de Pablos A, Jaramillo M, Ezzahouri I, García S, Navarro J, Lopez-Hoyos M, Carbone J. Monitoring of early humoral immunity to identify lung recipients at risk for development of serious infections: A multicenter prospective study. J Heart Lung Transplant 2018; 37:1001-1012. [DOI: 10.1016/j.healun.2018.04.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 03/12/2018] [Accepted: 04/03/2018] [Indexed: 12/13/2022] Open
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Benbrahim O, Viallard JF, Choquet S, Royer B, Bauduer F, Decaux O, Crave JC, Fardini Y, Clerson P, Lévy V. A French observational study describing the use of human polyvalent immunoglobulins in hematological malignancy-associated secondary immunodeficiency. Eur J Haematol 2018; 101:48-56. [DOI: 10.1111/ejh.13078] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2018] [Indexed: 01/25/2023]
Affiliation(s)
- Omar Benbrahim
- Hématologie; Hôpital de La Source; CHR Orléans; Orléans France
| | | | - Sylvain Choquet
- Hématologie; GH Pitié Salpêtrière; Assistance Publique-Hôpitaux de Paris; Paris France
| | - Bruno Royer
- Hématologie Clinique; CHU Amiens - Sud; Amiens France
| | | | | | | | | | | | - Vincent Lévy
- URC/CRC Groupe Hospitalier Paris Seine Saint Denis; APHP, Hôpital Avicenne; Bobigny France
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7
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Vacca A, Melaccio A, Sportelli A, Solimando AG, Dammacco F, Ria R. Subcutaneous immunoglobulins in patients with multiple myeloma and secondary hypogammaglobulinemia: a randomized trial. Clin Immunol 2017; 191:110-115. [PMID: 29191714 DOI: 10.1016/j.clim.2017.11.014] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 10/13/2017] [Accepted: 11/27/2017] [Indexed: 11/29/2022]
Abstract
Multiple myeloma is commonly associated with a reduction of non-paraprotein immunoglobulins, resulting in a higher risk of infections that represent the leading cause of the patients' death. Therefore, immunoglobulin replacement therapy appears a logical approach. A total number of 46 myeloma patients were randomly enrolled: 24 of them were assigned to receive subcutaneous immunoglobulins, and 22 were controls. The primary endpoint was the evaluation of the annual rate of severe infections in immunoglobulins-receiving patients as compared with those untreated. Subcutaneous immunoglobulins-treated patients showed a significantly lower number of severe infections per year. Adverse events were limited to the site of infusion and were easily manageable. Health-related quality of life was significantly better in subcutaneous immunoglobulins-receiving patients. By decreasing the rate of infections, the prophylactic administration of SCIg improves both adherence to chemotherapy and health-related quality of life, and is cost-effective by reducing the need of hospitalization and the use of antibiotics.
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Affiliation(s)
- Angelo Vacca
- Department of Biomedical Sciences and Human Oncology, Section of Internal Medicine and Clinical Oncology, University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Assunta Melaccio
- Department of Biomedical Sciences and Human Oncology, Section of Internal Medicine and Clinical Oncology, University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Azzurra Sportelli
- Department of Biomedical Sciences and Human Oncology, Section of Internal Medicine and Clinical Oncology, University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Antonio G Solimando
- Department of Biomedical Sciences and Human Oncology, Section of Internal Medicine and Clinical Oncology, University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Franco Dammacco
- Department of Biomedical Sciences and Human Oncology, Section of Internal Medicine and Clinical Oncology, University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Roberto Ria
- Department of Biomedical Sciences and Human Oncology, Section of Internal Medicine and Clinical Oncology, University of Bari "Aldo Moro" Medical School, Bari, Italy.
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8
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Windegger TM, Lambooy CA, Hollis L, Morwood K, Weston H, Fung YL. Subcutaneous Immunoglobulin Therapy for Hypogammaglobulinemia Secondary to Malignancy or Related Drug Therapy. Transfus Med Rev 2017; 31:45-50. [DOI: 10.1016/j.tmrv.2016.06.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 06/28/2016] [Indexed: 01/20/2023]
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9
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Hoffman TW, van Kessel DA, van Velzen-Blad H, Grutters JC, Rijkers GT. Antibody replacement therapy in primary antibody deficiencies and iatrogenic hypogammaglobulinemia. Expert Rev Clin Immunol 2015; 11:921-33. [DOI: 10.1586/1744666x.2015.1049599] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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10
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Florescu DF. Solid organ transplantation: hypogammaglobulinaemia and infectious complications after solid organ transplantation. Clin Exp Immunol 2015; 178 Suppl 1:54-6. [PMID: 25546761 DOI: 10.1111/cei.12510] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- D F Florescu
- Transplant Infectious Diseases Division, Transplant Surgery Division, University of Nebraska Medical Center, Omaha, NE, USA
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11
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Compagno N, Malipiero G, Cinetto F, Agostini C. Immunoglobulin replacement therapy in secondary hypogammaglobulinemia. Front Immunol 2014; 5:626. [PMID: 25538710 PMCID: PMC4259107 DOI: 10.3389/fimmu.2014.00626] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 11/24/2014] [Indexed: 12/02/2022] Open
Abstract
Immunoglobulin (Ig) replacement therapy dramatically changed the clinical course of primary hypogammaglobulinemias, significantly reducing the incidence of infectious events. Over the last two decades its use has been extended to secondary antibody deficiencies, particularly those related to hematological disorders as lymphoproliferative diseases (LPDs) and multiple myeloma. In these malignancies, hypogammaglobulinemia can be an intrinsic aspect of the disease or follow chemo-immunotherapy regimens, including anti-CD20 treatment. Other than in LPDs the broadening use of immunotherapy (e.g., rituximab) and immune-suppressive therapy (steroids, sulfasalazine, and mycophenolate mofetil) has extended the occurrence of iatrogenic hypogammaglobulinemia. In particular, in both autoimmune diseases and solid organ transplantation Ig replacement therapy has been shown to reduce the rate of infectious events. Here, we review the existing literature about Ig replacement therapy in secondary hypogammaglobulinemia, with special regard for subcutaneous administration route, a safe, effective, and well-tolerated treatment approach, currently well established in primary immunodeficiencies and secondary hypogammaglobulinemias.
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Affiliation(s)
- Nicolò Compagno
- Department of Medicine, Clinical Immunology and Hematology, University of Padova , Padova , Italy
| | - Giacomo Malipiero
- Department of Medicine, Clinical Immunology and Hematology, University of Padova , Padova , Italy
| | - Francesco Cinetto
- Department of Medicine, Clinical Immunology and Hematology, University of Padova , Padova , Italy
| | - Carlo Agostini
- Department of Medicine, Clinical Immunology and Hematology, University of Padova , Padova , Italy
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12
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Sarmiento E, Navarro J, Fernandez-Yañez J, Palomo J, Muñoz P, Carbone J. Evaluation of an immunological score to assess the risk of severe infection in heart recipients. Transpl Infect Dis 2014; 16:802-12. [PMID: 25179534 DOI: 10.1111/tid.12284] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 03/14/2014] [Accepted: 06/18/2014] [Indexed: 01/27/2023]
Abstract
BACKGROUND We previously reported how specific humoral and cellular immunological markers that are readily available in clinical practice can be used to identify heart transplant recipients (HTR) at risk of developing severe infections. In this study, we perform an extended analysis to identify immunological profiles that could prove to be superior to individual markers in assessing the risk of infection early after heart transplantation. METHODS In a prospective follow-up study, we evaluated 100 HTR at 1 week after transplantation. Laboratory tests included determination of immunoglobulin (Ig) levels (IgG, IgA, IgM), complement factors (C3 and C4), and lymphocyte subsets (CD3+, CD4+, CD8+ T cells, B cells, and natural killer [NK] cells). The prevalence of infection during the first 3 months was registered at scheduled visits after transplantation. Severe infections were defined as all infections requiring hospitalization and intravenous antimicrobial therapy. RESULTS During follow-up, 33 patients (33%) developed severe infections. The individual risk factors of severe infection, according to the Cox regression analysis, were as follows: IgG <600 mg/dL (hazard ratio [HR], 2.41; 95% confidence interval [CI], 1.21-4.78; P = 0.012), C3 <80 mg/dL (HR, 4.65; 95% CI, 2.31-9.38; P < 0.0001), C4 <18 mg/dL (HR 2.30, 95% CI, 1.15-4.59; P = 0.018), NK count <30 cells/μL (HR 4.07, 95% CI, 1.76-9.38; P = 0.001), and CD4 count <350 cells/μL (HR, 3.04; 95% CI, 1.47-6.28; P = 0.0027). An immunological score was created. HRs were used to determine the number of points assigned to each of the 5 previously mentioned individual risk factors. The score was obtained from the sum of these factors. In the multivariate Cox regression analysis, the immunological score was useful for identifying patients at risk of infection and was the only variable that maintained a significant association with the development of infection, after adjustment for the 5 individual factors. CONCLUSION Patients with an immunological score ≥13 were at the highest risk of severe infections (HR, 9.29; 95% CI, 4.57-18.90; P < 0.0001). This score remained significantly associated with the risk of severe infection after adjustment for clinical risk factors of infection. An immunological score was useful for identifying HTR at risk of developing severe infections. If this score is validated in multicenter studies, it could be easily introduced into clinical practice.
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Affiliation(s)
- E Sarmiento
- Clinical Immunology Department, University Hospital Gregorio Marañon, Madrid, Spain
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