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Sütçü M, Kara EM, Yıldız F, Gül D, Yıldız R, Yılmaz D, Atik F, Özkaya O. MIS-C Treatment: Is glucocorticoid monotherapy enough for mild cases? Am J Emerg Med 2024; 83:95-100. [PMID: 39002497 DOI: 10.1016/j.ajem.2024.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 06/23/2024] [Accepted: 06/24/2024] [Indexed: 07/15/2024] Open
Abstract
BACKGROUND The effectiveness of using only glucocorticoids (GCs) in mild multisystem inflammatory syndrome (MIS-C) cases was compared with combined treatment [GCs + Intravenous immune globulin (IVIG)]. METHODS This retrospective cohort study was conducted between June 1, 2020, and June 1, 2022, in a tertiary care center in Istanbul, Turkey. Clinical and investigational data of the MIS-C patients were analyzed. The patients were divided into two groups: those who received only GCs and those who received the GCs + IVIG combination. The primary outcome focused on assessing the deterioration of the patient's clinical condition, the occurrence of shock, admission to the pediatric intensive care unit (PICU), and the need for additional immunosuppressive medication. Secondary outcomes included evaluating the course of cardiovascular and infection-related complications observed at the one-year follow-up. RESULTS Ninety-seven MIS-C patients with a median age of 41 (3- 214) months were enrolled. Fifty-six (57.7%) patients were male. All the patients had fever at admission with a temperature of 39 °C (37.5 °C-40.1 °C). Thirty-two patients (33%) had cardiac findings on echocardiography [left ventricular dysfunction (n= 13, 13.5%), coronary artery involvement (n= 11, 11.3%), and dilation of cardiac cavities and/or increased cardiac muscle thickness (n= 8, 8.2%)]. Thirteen patients (13.5%) required intensive care. All patients received GCs [only GCs (group I; n= 65, 67%)], and 32 patients (33%) with severe manifestations and/or cardiac involvement received GCs + IVIG (group II). No mortality was observed. None of the patients had any complaints at the one-year follow-up, and all echocardiography findings were normal. CONCLUSION This study provides preliminary evidence that GC monotherapy is a safe treatment alternative for mild MIS-C cases without cardiac involvement.
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Affiliation(s)
- Murat Sütçü
- Istinye University Faculty of Medicine, Bahçeşehir Liv Hospital, Department of Pediatric Infectious Diseases, Istanbul, Turkey
| | - Emine Manolya Kara
- Yeditepe University Faculty of Medicine, Department of Pediatric Infectious Diseases, Istanbul, Turkey
| | - Funda Yıldız
- Istinye University Faculty of Medicine, Bahçeşehir Liv Hospital, Department of Pediatrics, Istanbul, Turkey
| | - Doruk Gül
- Istinye University Faculty of Medicine, Bahçeşehir Liv Hospital, Department of Pediatrics, Istanbul, Turkey
| | - Raif Yıldız
- Basaksehir Cam Sakura Training and Research Hospital, University of Health Sciences, Department of Pediatric Emergency, Turkey
| | - Duygu Yılmaz
- Yeditepe University Faculty of Medicine, Department of Pediatrics, Istanbul, Turkey.
| | - Fatih Atik
- Istinye University Faculty of Medicine, Bahçeşehir Liv Hospital, Department of Pediatric Cardiology, Istanbul, Turkey
| | - Ozan Özkaya
- Istinye University Faculty of Medicine, Bahçeşehir Liv Hospital, Department of Pediatric Rheumatology, Istanbul, Turkey
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2
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Ramachandram DS, Kow CS, Hasan SS, Thiruchelvam K. Effect of intravenous immunoglobulin on mortality in hospitalized patients with COVID-19: A systematic review and meta-analysis of randomized controlled trials. Health Sci Rep 2024; 7:e2239. [PMID: 38983684 PMCID: PMC11230917 DOI: 10.1002/hsr2.2239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 06/18/2024] [Accepted: 06/25/2024] [Indexed: 07/11/2024] Open
Abstract
Background and Aims We performed a meta-analysis of randomized controlled trials (RCTs) to summarize the overall effect of intravenous immunoglobulin (IVIG) on mortality outcomes among hospitalized coronavirus disease 2019 (COVID-19) patients. Methods We systematically searched electronic databases up to June 1, 2023. Pooled odds ratio (OR) of mortality with a 95% confidence interval (CI) was generated using a random-effects model. The risk of bias was appraised using the Cochrane risk-of-bias Version 2 tool for randomized trials. Results Nine RCTs were included: three RCTs had an overall low risk of bias, four RCTs had some concerns in the overall risk of bias, and two RCTs trials had an overall high risk of bias. The use of IVIG indicated a significant reduction in the odds of mortality (pooled OR = 0.69; 95% CI 0.50-0.96) relative to nonuse of IVIG. Subgroup analysis in patients with a severe course of COVID-19 revealed no significant reduction in the odds of mortality (pooled OR = 0.58; 95% CI 0.29-1.16). Conclusions We suggest exercising caution when interpreting effectiveness of IVIG in reducing mortality among hospitalized patients with COVID-19. Our findings emphasize for larger trials with rigorous study designs to better understand the impact of IVIG, particularly in those with severe COVID-19.
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Affiliation(s)
| | - Chia Siang Kow
- School of PharmacyIMU UniversityKuala LumpurMalaysia
- School of Applied SciencesUniversity of HuddersfieldHuddersfieldUnited Kingdom
| | - Syed Shahzad Hasan
- School of Applied SciencesUniversity of HuddersfieldHuddersfieldUnited Kingdom
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3
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KC O, Subedi A, Sharma R. Intravenous Immunoglobulin-Associated Severe Hemolytic Anemia. J Med Cases 2023; 14:227-231. [PMID: 37560548 PMCID: PMC10409536 DOI: 10.14740/jmc4126] [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: 06/09/2023] [Accepted: 06/26/2023] [Indexed: 08/11/2023] Open
Abstract
Intravenous immunoglobulin (IVIG) is used to treat immunodeficiency conditions, neuro-immunological, infection-related, autoimmune, and inflammatory disorders and is typically well tolerated. A hematological adverse reaction such as hemolytic anemia and neutropenia is known to occur with IVIG, which is usually transient and subclinical. However, severe hemolytic anemia is known to occur in some cases. We present a case of a 66-year-old man who developed severe symptomatic hemolytic anemia after receiving IVIG for acute inflammatory demyelinating polyneuropathy (AIDP). The patient had known risk factors such as non-O blood group, high cumulative dose of IVIG, and underlying autoimmune condition, which would have put him at high risk for developing hemolytic anemia after IVIG. Therefore, it is prudent for clinicians to have increased awareness regarding the potential for severe hemolysis and closely monitor these patients with risk factors after treatments to identify this adverse reaction before more severe complications occur.
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Affiliation(s)
- Ojbindra KC
- Department of Hospital Medicine, Faith Regional Health Services, Norfolk, NE, USA
| | - Ananta Subedi
- Department of Hospital Medicine, Avera McKennan Hospital and University Health Center, Sioux Falls, SD, USA
| | - Rakshya Sharma
- Department of Hospital Medicine, Avera McKennan Hospital and University Health Center, Sioux Falls, SD, USA
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4
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Konovalova A, Gerula N, Hartmane I, Upeniece I, Ščerbuks M, Bernāte K, Reinberga L, Mikažāns I. Intravenous Immunoglobulin Therapy-Induced Erythema Multiforme in a Patient with Chronic Lymphocytic Leukemia. Case Rep Dermatol 2023; 15:182-189. [PMID: 37899943 PMCID: PMC10601765 DOI: 10.1159/000533987] [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: 05/31/2023] [Accepted: 08/30/2023] [Indexed: 10/31/2023] Open
Abstract
This case report discusses immunoglobulin-induced erythema multiforme (EM), a rare and understudied condition that requires further investigation. The report presents the case of a 69-year-old woman with a history of chronic lymphocytic leukemia who developed an acute hypersensitivity reaction to intravenous gamma globulin medication. The patient received intravenous immunoglobulin (IVIG) to normalize and stabilize her immunoglobulin levels and reduce the risk of recurrent infections due to her immunodeficiency with predominantly antibody defects. However, after the second administration of the medication, the patient experienced an acute skin rash and was admitted to the hospital for treatment. The treatment plan included systemic desensitizing therapy, systemic antihistamine therapy, corticosteroid therapy, and local therapy. After a course of therapy, the patient's skin condition improved, and her overall well-being improved. However, due to the acute hypersensitivity reaction, the IVIG therapy was discontinued. The multidisciplinary team of specialists concluded that the patient had developed EM. The discussion provides an overview of EM, including its causes, clinical presentation, diagnostic tools, and therapy principles. The discussion also describes the use of human IVIG preparations in treating various immunodeficient and inflammatory diseases, highlighting the importance of monitoring patients for adverse effects. The case of this patient underscores the potential risks associated with immunoglobulin therapy and emphasizes the need for healthcare providers to remain vigilant for adverse reactions. By promptly diagnosing and treating EM, healthcare providers can minimize its impact on patients' overall well-being.
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Affiliation(s)
- Angelina Konovalova
- Riga Stradins University, Riga, Latvia
- Department of Dermatology and Venereology, Pauls Stradiņš Clinical University Hospital, Riga, Latvia
| | - Natālija Gerula
- Riga Stradins University, Riga, Latvia
- Dermatology and STI Clinic, Riga 1st Hospital, Riga, Latvia
| | - Ilona Hartmane
- Riga Stradins University, Riga, Latvia
- Department of Dermatology and Venereology, Pauls Stradiņš Clinical University Hospital, Riga, Latvia
| | - Ilze Upeniece
- Riga Stradins University, Riga, Latvia
- Department of Dermatology and Venereology, Pauls Stradiņš Clinical University Hospital, Riga, Latvia
| | | | | | - Lelde Reinberga
- Riga Stradins University, Riga, Latvia
- Department of Dermatology and Venereology, Pauls Stradiņš Clinical University Hospital, Riga, Latvia
| | - Ingmārs Mikažāns
- Riga Stradins University, Riga, Latvia
- Department of Dermatology and Venereology, Pauls Stradiņš Clinical University Hospital, Riga, Latvia
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5
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Klemencic Kozul T, Yudina A, Donovan C, Pinto A, Osman C. Cost-minimisation analysis of plasma exchange versus IVIg in the treatment of autoimmune neurological conditions. BMC Health Serv Res 2022; 22:904. [PMID: 35831856 PMCID: PMC9277970 DOI: 10.1186/s12913-022-08210-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: 12/01/2021] [Accepted: 06/07/2022] [Indexed: 11/30/2022] Open
Abstract
Background Plasma exchange (PLEX) is an effective treatment for antibody-mediated neurological disorders and has been shown to be equally efficacious to intravenous immunoglobulin (IVIg) with comparable adverse event profiles. IVIg has traditionally been the preferred treatment option due to its ease of use. However, advancing technology has allowed PLEX to be performed with a centrifugal system via peripheral access as opposed to central access via a membrane filter. Methods We prospectively collected data from a cohort of patients who underwent PLEX at the Wessex Neurological Centre, UK, to perform a cost-minimisation analysis comparing PLEX to IVIg, the standard of care, between May 2019 and May 2020. Data obtained included indication, admission type (inpatient, daycase or intensive care), access (peripheral or central), number of PLEX cycles, exchange volume, patient weight, complications and clinical outcomes. The cost of PLEX delivered in an outpatient setting for an average 80kg person was calculated and compared to the equivalent cost of delivering IVIg by means of a cost-minimization model. Results The provision of PLEX was roughly half as costly when compared to what it would have been for IVIg (£886 per exchange vs £1778 per infusion or £4432 per cycle of 5 exchanges vs £8890 per cycle of 5 infusions). Our cohort included a total of 44 patients who received a total of 357 PLEX exchanges during the 12-month period (the majority of which were in a daycase setting). We calculated an annual cost saving for PLEX over IVIg of £318,589. The robustness of this result was confirmed by a one-way deterministic sensitivity analysis, showing the cost-effectiveness of PLEX. Conclusion Our findings demonstrate that PLEX is more cost-effective than IVIg in this setting. Our study supports the economic case for development of plasma exchange centres in regional neurology units, a case made all the more relevant in the context of constrained supplies of IVIg. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08210-z.
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Affiliation(s)
| | - Anna Yudina
- Terumo Blood and Cell Technologies Europe, Zaventem, Belgium
| | - Carley Donovan
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ashwin Pinto
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Chinar Osman
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Burnouf T, Gathof B, Bloch EM, Bazin R, de Angelis V, Patidar GK, Rastvorceva RMG, Oreh A, Goel R, Rahimi-Levene N, Hindawi S, Al-Riyami AZ, So-Osman C. Production and Quality Assurance of Human Polyclonal Hyperimmune Immunoglobulins against SARS-CoV-2. Transfus Med Rev 2022; 36:125-132. [PMID: 35879213 PMCID: PMC9183240 DOI: 10.1016/j.tmrv.2022.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/01/2022] [Accepted: 06/02/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Thierry Burnouf
- College of Biomedical Engineering, Graduate Institute of Biomedical Materials and Tissue Engineering, Taipei Medical University, Taipei, Taiwan; International PhD Program in Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan.
| | - Birgit Gathof
- Department of Transfusion Medicine, University Hospital of Cologne, Köln, Germany.
| | - Evan M Bloch
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Renée Bazin
- Héma-Québec, Medical Affairs and Innovation, Québec, Canada
| | | | - Gopal Kumar Patidar
- Department of Transfusion Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rada M Grubovic Rastvorceva
- Institute for Transfusion Medicine of RNM, Skopje, North Macedonia; Faculty of Medical Sciences, University Goce Delcev, Štip, North Macedonia
| | - Adaeze Oreh
- Department of Planning, Research and Statistics, National Blood Service Commission, Federal Ministry of Health, Abuja, Nigeria
| | - Ruchika Goel
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Division of Hematology/Oncology, Simmons Cancer Institute at SIU School of Medicine and ImpactLife Blood Center, Springfield, IL, USA
| | | | - Salwa Hindawi
- Haematology Department, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Arwa Z Al-Riyami
- Department of Hematology, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Cynthia So-Osman
- Department of Haematology, Erasmus Medical Centre, Rotterdam, The Netherlands; Unit Transfusion Medicine, Sanquin Blood Supply Foundation, Amsterdam, The Netherlands
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Kampouri E, Walti CS, Gauthier J, Hill JA. Managing Hypogammaglobulinemia in Patients Treated with CAR-T-cell Therapy: Key Points for Clinicians. Expert Rev Hematol 2022; 15:305-320. [PMID: 35385358 DOI: 10.1080/17474086.2022.2063833] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The unprecedented success of chimeric antigen receptor (CAR)-T-cell therapy in the management of B-cell malignancies comes with a price of specific side effects. Healthy B-cell depletion is an anticipated 'on-target' 'off-tumor' side effect and can contribute to severe and prolonged hypogammaglobulinemia. Evidence-based guidelines for the use of immunoglobulin replacement therapy (IGRT) for infection prevention are lacking in this population. AREAS COVERED This article reviews the mechanisms and epidemiology of hypogammaglobulinemia and antibody deficiency, association with infections, and strategies to address these issues in CD19- and BCMA-CAR-T-cell recipients. EXPERT OPINION CD19 and BCMA CAR-T-cell therapy result in unique immune deficits due to depletion of specific B-lineage cells and may require different infection prevention strategies. Hypogammaglobulinemia before and after CAR-T-cell therapy is frequent, but data on the efficacy and cost-effectiveness of IGRT are lacking. Monthly IGRT should be prioritized for patients with severe or recurrent bacterial infections. IGRT may be more broadly necessary to prevent infections in BCMA-CAR-T-cell recipients and children with severe hypogammaglobulinemia irrespective of infection history. Vaccinations are indicated to augment humoral immunity and can be immunogenic despite cytopenias; re-vaccination(s) may be required. Controlled trials are needed to better understand the role of IGRT and vaccines in this population.
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Affiliation(s)
- Eleftheria Kampouri
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Carla S Walti
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Infectious Disease and Hospital Epidemiology Division, University Hospital Basel, Basel, Switzerland
| | - Jordan Gauthier
- Department of Medicine, University of Washington, Seattle, Washington, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Joshua A Hill
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
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Keddie S, Eftimov F, van den Berg LH, Brassington R, de Haan RJ, van Schaik IN. Immunoglobulin for multifocal motor neuropathy. Cochrane Database Syst Rev 2022; 1:CD004429. [PMID: 35015296 PMCID: PMC8751207 DOI: 10.1002/14651858.cd004429.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Multifocal motor neuropathy (MMN) is a rare, probably immune-mediated disorder characterised by slowly progressive, asymmetric, distal weakness of one or more limbs with no objective loss of sensation. It may cause prolonged periods of disability. Treatment options for MMN are few. People with MMN do not usually respond to steroids or plasma exchange. Uncontrolled studies have suggested a beneficial effect of intravenous immunoglobulin (IVIg). This is an update of a Cochrane Review first published in 2005, with an amendment in 2007. We updated the review to incorporate new evidence. OBJECTIVES To assess the efficacy and safety of intravenous and subcutaneous immunoglobulin in people with MMN. SEARCH METHODS We searched the following databases on 20 April 2021: the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, and WHO ICTRP for randomised controlled trials (RCTs) and quasi-RCTs, and checked the reference lists of included studies. SELECTION CRITERIA We considered RCTs and quasi-RCTs examining the effects of any dose of IVIg and subcutaneous immunoglobulin (SCIg) in people with definite or probable MMN for inclusion in the review. Eligible studies had to have measured at least one of the following outcomes: disability, muscle strength, or electrophysiological conduction block. We used studies that reported the frequency of adverse effects to assess safety. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed the literature searches to identify potentially relevant trials, assessed risk of bias of included studies, and extracted data. We followed standard Cochrane methodology. MAIN RESULTS Six cross-over RCTs including a total of 90 participants were suitable for inclusion in the review. Five RCTs compared IVIg to placebo, and one compared IVIg to SCIg. Four of the trials comparing IVIg versus placebo involved IVIg-naive participants (induction treatment). In the other two trials, participants were known IVIg responders receiving maintencance IVIg at baseline and were then randomised to maintenance treatment with IVIg or placebo in one trial, and IVIg or SCIg in the other. Risk of bias was variable in the included studies, with three studies at high risk of bias in at least one risk of bias domain. IVIg versus placebo (induction treatment): three RCTs including IVIg-naive participants reported a disability measure. Disability improved in seven out of 18 (39%) participants after IVIg treatment and in two out of 18 (11%) participants after placebo (risk ratio (RR) 3.00, 95% confidence interval (CI) 0.89 to 10.12; 3 RCTs, 18 participants; low-certainty evidence). The proportion of participants with an improvement in disability at 12 months was not reported. Strength improved in 21 out of 27 (78%) IVIg-naive participants treated with IVIg and one out of 27 (4%) participants who received placebo (RR 11.00, 95% CI 2.86 to 42.25; 3 RCTs, 27 participants; low-certainty evidence). IVIg treatment may increase the proportion of people with resolution of at least one conduction block; however, the results were also consistent with no effect (RR 7.00, 95% CI 0.95 to 51.70; 4 RCTs, 28 participants; low-certainty evidence). IVIg versus placebo (maintenance treatment): a trial that included participants on maintenance IVIg treatment reported an increase in disability in 17 out of 42 (40%) people switching to placebo and seven out of 42 (17%) remaining on IVIg (RR 2.43, 95% CI 1.13 to 5.24; 1 RCT, 42 participants; moderate-certainty evidence) and a decrease in grip strength in 20 out of 42 (48%) participants after a switch to placebo treatment compared to four out of 42 (10%) remaining on IVIg (RR 0.20, 95% CI 0.07 to 0.54; 1 RCT, 42 participants; moderate-certainty evidence). Adverse events, IVIg versus placebo (induction or maintenance): four trials comparing IVIg and placebo reported adverse events, of which data from two studies could be meta-analysed. Transient side effects were reported in 71% of IVIg-treated participants versus 4.8% of placebo-treated participants in these studies. The pooled RR for the development of side effects was 10.33 (95% CI 2.15 to 49.77; 2 RCTs, 21 participants; very low-certainty evidence). There was only one serious side effect (pulmonary embolism) during IVIg treatment. IVIg versus SCIg (maintenance treatment): the trial that compared continuation of IVIg maintenance versus SCIg maintenance did not measure disability. The evidence was very uncertain for muscle strength (standardised mean difference 0.08, 95% CI -0.84 to 1.00; 1 RCT, 9 participants; very low-certainty evidence). The evidence was very uncertain for the number of people with side effects attributable to treatment (RR 0.50, 95% CI 0.18 to 1.40; 1 RCT, 9 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS Low-certainty evidence from three small RCTs shows that IVIg may improve muscle strength in people with MMN, and low-certainty evidence indicates that it may improve disability; the estimate of the magnitude of improvement of disability has wide CIs and needs further studies to secure its significance. Based on moderate-certainty evidence, it is probable that most IVIg responders deteriorate in disability and muscle strength after IVIg withdrawal. SCIg might be an alternative treatment to IVIg, but the evidence is very uncertain. More research is needed to identify people in whom IVIg withdrawal is possible and to confirm efficacy of SCIg as an alternative maintenance treatment.
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Affiliation(s)
- Stephen Keddie
- Faculty of Brain Sciences, Institute of Neurology, London, UK
| | - Filip Eftimov
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Leonard H van den Berg
- Department of Neurology, University Medical Center Utrecht, Brain Center Rudolf Magnus, Utrecht, Netherlands
| | - Ruth Brassington
- Queen Square Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Rob J de Haan
- Clinical Research Unit, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Ivo N van Schaik
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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Johnson AF, LaRock CN. Antibiotic Treatment, Mechanisms for Failure, and Adjunctive Therapies for Infections by Group A Streptococcus. Front Microbiol 2021; 12:760255. [PMID: 34803985 PMCID: PMC8601407 DOI: 10.3389/fmicb.2021.760255] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 09/28/2021] [Indexed: 11/13/2022] Open
Abstract
Group A Streptococcus (GAS; Streptococcus pyogenes) is a nearly ubiquitous human pathogen responsible for a significant global disease burden. No vaccine exists, so antibiotics are essential for effective treatment. Despite a lower incidence of antimicrobial resistance than many pathogens, GAS is still a top 10 cause of death due to infections worldwide. The morbidity and mortality are primarily a consequence of the immune sequelae and invasive infections that are difficult to treat with antibiotics. GAS has remained susceptible to penicillin and other β-lactams, despite their widespread use for 80 years. However, the failure of treatment for invasive infections with penicillin has been consistently reported since the introduction of antibiotics, and strains with reduced susceptibility to β-lactams have emerged. Furthermore, isolates responsible for outbreaks of severe infections are increasingly resistant to other antibiotics of choice, such as clindamycin and macrolides. This review focuses on the challenges in the treatment of GAS infection, the mechanisms that contribute to antibiotic failure, and adjunctive therapeutics. Further understanding of these processes will be necessary for improving the treatment of high-risk GAS infections and surveillance for non-susceptible or resistant isolates. These insights will also help guide treatments against other leading pathogens for which conventional antibiotic strategies are increasingly failing.
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Affiliation(s)
- Anders F Johnson
- Microbiology and Molecular Genetics Program, Graduate Division of Biological and Biomedical Sciences, Laney Graduate School, Emory University, Atlanta, GA, United States
| | - Christopher N LaRock
- Microbiology and Molecular Genetics Program, Graduate Division of Biological and Biomedical Sciences, Laney Graduate School, Emory University, Atlanta, GA, United States.,Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA, United States.,Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States.,Emory Antibiotic Resistance Center, Atlanta, GA, United States
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10
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Suresh J, Kyle BD. Clinical false positives resulting from recent intravenous immunoglobulin therapy: case report. BMC Infect Dis 2021; 21:288. [PMID: 33743628 PMCID: PMC7981890 DOI: 10.1186/s12879-021-05986-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 03/15/2021] [Indexed: 05/31/2023] Open
Abstract
Background Many clinicians are aware that certain therapies administered to their patients can have downstream consequences in the form of clinical laboratory test interferences. This is particularly true of laboratory tests that depend on, or directly involve the use of, antibody-based methodology. Intravenously-administered immunoglobulin therapy is one such treatment that can in theory directly impact the results of particular tests in the area of viral serology. This study can help serve as a reference for clinicians researching the impact of intravenously-administered immunoglobulin therapy in the context of positive results that do not reflect the clinical background of the patient. Case presentation We describe a case whereby an intravenously-administered immunoglobulin therapy led to a series of clinical false positives in viral serology, inconsistent with the known patient history as well as recent laboratory results. The patient presented to hospital with petechiae-type bleeding rashes and was investigated for thrombocytopenia after initial blood investigations indicated very low platelets. Subsequent testing of the potential causes for low-platelet involved several viral serology investigations, including hepatitis, cytomegalovirus and human immunodeficiency virus. Initial testing indicated patient exhibited negative status for all viral antibodies and antigens (except immunity for hepatitis B surface antigen antibody). As part of the thrombocytopenia treatment, intravenously-administered immunoglobulin therapy was administered, and subsequent viral serology was ordered. These investigations indicated a positive status for several hepatitis antibodies as well as cytomegalovirus. Conclusions This case study illustrates the potential for improper diagnosis of previous or ongoing infection status in patients administered IVIg therapy. Caution should be exercised particularly when interpreting results involving cytomegalovirus and hepatitis.
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Affiliation(s)
- Janarthanee Suresh
- Department of Pathology and Laboratory Medicine, College of Medicine, University of Saskatchewan, Saskatoon, S7N 0W8, Canada
| | - Barry D Kyle
- Department of Pathology and Laboratory Medicine, College of Medicine, University of Saskatchewan, Saskatoon, S7N 0W8, Canada.
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11
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D'Mello RJ, Hsu CD, Chaiworapongsa P, Chaiworapongsa T. Update on the Use of Intravenous Immunoglobulin in Pregnancy. Neoreviews 2021; 22:e7-e24. [PMID: 33386311 DOI: 10.1542/neo.22-1-e7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Intravenous immunoglobulin (IVIG) was first administered to humans in the 1980s. The mechanism of action of IVIG is still a subject of debate but the pharmacokinetics have been well characterized, albeit outside of pregnancy. IVIG has been used in pregnancy to treat several nonobstetrical and obstetrical-related conditions. However, current evidence suggests that IVIG use during pregnancy can be recommended for 1) in utero diagnosis of neonatal alloimmune thrombocytopenia; 2) gestational alloimmune liver disease; 3) hemolytic disease of the fetus and newborn for early-onset severe intrauterine disease; 4) antiphospholipid syndrome (APS) when refractory to or contraindicated to standard treatment, or in catastrophic antiphospholipid syndrome; and 5) immune thrombocytopenia when standard treatment is ineffective or rapid increase of platelet counts is needed. All recommendations are based on case series and cohort studies without randomized trials usually because of the rare prevalence of the conditions, the high incidence of adverse outcomes if left untreated, and ethical concerns. In contrast, IVIG therapy cannot be recommended for recurrent pregnancy loss, and the use of IVIG in subgroups of those with recurrent pregnancy loss requires further investigations. For non-obstetrical-related conditions, we recommend using IVIG as indicated for nonpregnant patients. In conclusion, the use of IVIG during pregnancy is an effective treatment in some obstetrical-related conditions with rare serious maternal side effects. However, the precise mechanisms of action and the long-term immunologic effects on the fetus and neonate are poorly understood and merit further investigations.
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Affiliation(s)
- Rahul J D'Mello
- Department of Obstetrics and Gynecology, Detroit Medical Center, Detroit, MI
| | - Chaur-Dong Hsu
- Department of Obstetrics and Gynecology and.,Department of Physiology, Wayne State University School of Medicine, Detroit, MI
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Saldarriaga Rivera LM, Fernández Ávila D, Molano WB, Jaramillo Arroyave D, Ramírez AJB, Díaz Maldonado A, Izquierdo JH, Jáuregui E, Latorre Muñoz MC, Restrepo JP, Segura Charry JS. Recommendations on the management of adult patients with rheumatic diseases in the context of SARS-CoV-2/COVID-19 infection. Colombian Association of Rheumatology. REUMATOLOGÍA CLÍNICA (ENGLISH EDITION) 2020. [PMCID: PMC7546262 DOI: 10.1016/j.reumae.2020.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective To produce recommendations for patients with rheumatological diseases receiving immunomodulatory and immunosuppressive therapies (conventional drugs, biologicals, and small molecules) during the COVID-19 pandemic. Materials and methods The recommendations were determined using the Delphi method as an agreement tool. A panel of experts was formed, with academic backgrounds and research experience in rheumatology. A literature search was conducted and 42 questions were generated. The level of agreement was made with 80% of approval by the participants. Results A group of eleven rheumatologists from 7 cities in the country participated. The response rate was 100% for the three consultation rounds. In the first round, agreement was reached on 35 questions, on 37 in the second round, and on 42 questions in the third round. Conclusion The recommendation for the majority of the pharmacological treatments used in rheumatology is to continue with immunomodulatory or immunosuppressive therapies in patients who do not have the infection, and to suspend it in patients with a diagnosis of SARS-CoV-2/COVID-19.
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13
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Saldarriaga Rivera LM, Fernández Ávila D, Bautista Molano W, Jaramillo Arroyave D, Bautista Ramírez AJ, Díaz Maldonado A, Hernán Izquierdo J, Jáuregui E, Latorre Muñoz MC, Restrepo JP, Segura Charry JS. Recommendations on the management of adult patients with rheumatic diseases in the context of SARS-CoV-2/COVID-19 infection. Colombian Association of Rheumatology. ACTA ACUST UNITED AC 2020; 16:437-446. [PMID: 32800760 PMCID: PMC7386365 DOI: 10.1016/j.reuma.2020.06.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/10/2020] [Indexed: 12/16/2022]
Abstract
Objetivo Generar las recomendaciones para la atención de pacientes con enfermedades reumáticas que reciben terapias inmunomoduladoras e inmunosupresoras (fármacos convencionales, biológicos y moléculas pequeñas) durante la pandemia por COVID-19. Materiales y métodos Las recomendaciones se realizaron utilizando el método Delphi como herramienta de acuerdo. Se conformó un panel de expertos con trayectoria académica y experiencia en investigación en reumatología. Se realizó la búsqueda de la literatura y se generó el cuestionario del ejercicio Delphi conformado por 42 preguntas. El grado de acuerdo se logró con el 80% de aprobación de los participantes. Resultados Se conformó un grupo de 11 reumatólogos de 7 ciudades del país. La tasa de respuesta fue del 100% para las 3 rondas de consulta. En la primera ronda se logró acuerdo en 35 preguntas, en la segunda ronda 37 y en la tercera ronda se logró el acuerdo de las 42 preguntas. Conclusión La recomendación para la mayoría de los tratamientos inmunomoduladores utilizados en reumatología es continuar con las terapias en pacientes que no tengan la infección y suspenderlas en aquellos con diagnóstico de SARS-CoV-2/COVID-19.
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Affiliation(s)
- Lina María Saldarriaga Rivera
- Departamento de Medicina Interna, Unidad de Reumatología, Facultad de Medicina, Universidad Tecnológica de Pereira. Hospital Universitario San Jorge, Clínica Los Rosales, Pereira, Colombia.
| | - Daniel Fernández Ávila
- Departamento de Medicina Interna, Unidad de Reumatología, Facultad de Medicina, Pontificia Universidad Javeriana. Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Wilson Bautista Molano
- Sección de Reumatología, Hospital Universitario Fundación Santa Fe de Bogotá, Universidad el Bosque, Bogotá, Colombia
| | | | | | - Adriana Díaz Maldonado
- Unidad de Reumatología Pediátrica, Care for Kids, Fundación HOMI, Instituto Roosevelt, Bogotá, Colombia
| | | | - Edwin Jáuregui
- Unidad de Reumatología, Epidemiología Clínica, Riesgo de Fractura S.A-CAYRE IPS, Bogotá, Colombia
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14
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Saldarriaga Rivera LM, Fernández Ávila D, Bautista Molano W, Jaramillo Arroyave D, Bautista Ramírez AJ, Díaz Maldonado A, Hernán Izquierdo J, Jáuregui E, Latorre Muñoz MC, Restrepo JP, Segura Charry JS. Recomendaciones sobre el manejo de pacientes adultos con enfermedades reumáticas en el contexto de la infección por SARS-CoV-2/COVID-19. Asociación Colombiana de Reumatología. ACTA ACUST UNITED AC 2020. [PMCID: PMC7290203 DOI: 10.1016/j.rcreu.2020.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objetivo Generar las recomendaciones para la atención de pacientes con enfermedades reumáticas que reciben terapias inmunomoduladoras e inmunosupresoras (fármacos convencionales, biológicos y moléculas pequeñas) durante la pandemia por COVID-19. Materiales y métodos Las recomendaciones se realizaron utilizando el método Delphi como herramienta de acuerdo. Se conformó un panel de expertos con trayectoria académica y experiencia en investigación en reumatología. Se realizó la búsqueda de la literatura y se generó el cuestionario del ejercicio Delphi conformado por 42 preguntas. El grado de acuerdo se logró con el 80% de aprobación de los participantes. Resultados Se conformó un grupo de 11 reumatólogos de 7 ciudades del país. La tasa de respuesta fue del 100% para las 3 rondas de consulta. En la primera ronda se logró acuerdo en 35 preguntas, en la segunda ronda 37 y en la tercera ronda se logró el acuerdo de las 42 preguntas. Conclusión La recomendación para la mayoría de los tratamientos inmunomoduladores utilizados en reumatología es continuar con las terapias en pacientes que no tengan la infección y suspenderlas en aquellos con diagnóstico de SARS-CoV-2/COVID-19.
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15
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Recommendations on the management of adult patients with rheumatic diseases in the context of SARS-CoV-2/COVID-19 infection. Colombian Association of Rheumatology. REVISTA COLOMBIANA DE REUMATOLOGÍA (ENGLISH EDITION) 2020. [PMCID: PMC7547567 DOI: 10.1016/j.rcreue.2020.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objective To produce recommendations for patients with rheumatological diseases receiving immunomodulatory and immunosuppressive therapies (conventional drugs, biologicals, and small molecules) during the COVID-19 pandemic. Materials and methods The recommendations were determined using the Delphi method as an agreement tool. A panel of experts was formed, with academic backgrounds and research experience in rheumatology. A literature search was conducted and 42 questions were generated. The level of agreement was made with 80% of approval by the participants. Results A group of eleven rheumatologists from 7 cities in the country participated. The response rate was 100% for the three consultation rounds. In the first round, agreement was reached on 35 questions, on 37 in the second round, and on 42 questions in the third round. Conclusion The recommendation for the majority of the pharmacological treatments used in rheumatology is to continue with immunomodulatory or immunosuppressive therapies in patients who do not have the infection, and to suspend it in patients with a diagnosis of SARS-CoV-2/COVID-19.
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Abstract
OBJECTIVES To determine demographic features of patients provided intravenous immunoglobulin (IVIG) excluding replacement therapy in the inpatient services and to evaluate indications for IVIG, and side effects related to therapy. Methods: Patients who received IVIG therapy between January 2016 and August 2018 were retrospectively identified. The demographic features, diagnosis, IVIG dose, number of days they underwent IVIG therapy, and whether or not they experienced IVIG-related side effects were recorded. Results: A total of 186 patients were included in this study, and of these, 89 (47.8%) were females. The median age of all of the patients was 48.5 months old (range 13-120 months). When the IVIG indications were examined, the hematological disease group had the highest number of patients (n=73, 39.2%). The US Food and Drug Administration (FDA) labeled use rate was 45.7%. Side effects were seen in 15 (3.81%) of the 394 IVIG infusions, 2 of which were acute kidney failure and nausea/vomiting as delayed onset side effects. The rapid onset side effects included fever (n=5), headache (n=3), rash and redness (n=2), and pain in the infusion area, hypotension, and hypertension (n=1). Conclusion: Intravenous immunoglobulin preparations are used for the treatment of many diseases due to their immunoregulatory effects. In recent years, the use of IVIGs without FDA approval has been increasing.
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Affiliation(s)
- Ali Güngör
- Department of Pediatrics, University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Anakara, Turkey. E-mail.
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Han DJ. Complication from Desensitization. KIDNEY TRANSPLANTATION IN SENSITIZED PATIENTS 2020. [PMCID: PMC7122531 DOI: 10.1007/978-981-10-7046-4_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Sensitization to human leukocyte antigens (HLAs) has been one of the major clinical challenges for successful kidney transplantation. In end-stage renal disease, kidney transplantation provides benefits compared with dialysis in terms of improved patient survival better quality of life, and lower ongoing costs after the first year. Living donor kidney transplantation has an advantage with improved allograft survival, and performed earlier and electively compared with deceased donor transplantation. However sensitized patients are increasing in number on transplant waiting lists, and their prospect of getting a transplant is less than nonsensitized patients due to immunological incompatibility with the donor. Strategy for sensitized patients are listing for a compatible deceased donor transplant or, if they have a living donor, either selecting a kidney exchange program or undergoing a desensitization procedure. Desensitization procedures may be undertaken to increase access to either living or deceased donor transplants, and in some situations may also be employed to facilitate participation in a kidney exchange, in less immunological barrier to be overcome. The question of whether individuals are better off with a desensitization treatment followed by HLA-incompatible living donor transplantation or waiting on the deceased donor kidney transplant list for a compatible transplant has recently been addressed by two large multicenter studies, with conflicting results. A multicenter study from the United States published in the New England Journal of Medicine [365;318 326.2011] concluded that there was a strong survival benefit for sensitized patients undergoing desensitization followed by HLA-incompatible living donor kidney transplant compared with those remaining on the waiting list. Of interest, a second study, published in the Lancet, [389;727 734.2017] found no significant survival advantage for desensitized patients compared with similar patients remaining on the waiting list in the United Kingdom. Controversies still remain regarding how desensitization can be achieved and which techniques are effective and safe. In this chapter various complications from the desensitization will be dealt with in current use of medications or armamentum.
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Madsen MB, Bergsten H, Norrby-Teglund A. Treatment of Necrotizing Soft Tissue Infections: IVIG. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1294:105-125. [DOI: 10.1007/978-3-030-57616-5_8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Wabnitz H, Khan R, Lazarus AH. The use of IVIg in fetal and neonatal alloimmune thrombocytopenia- Principles and mechanisms. Transfus Apher Sci 2019; 59:102710. [PMID: 31926738 DOI: 10.1016/j.transci.2019.102710] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a rare neonatal disorder that is caused by alloimmunization against platelet antigens during pregnancy. Although rare, affecting only 1 in 1000 live births, it can cause intracranial hemorrhage and other bleeding complications that can lead to miscarriage, stillbirth and life-long neurological complications. One of the gold-standard therapies for at risk pregnancies is the administration of IVIg. Although IVIg has been used in a variety of different disorders for over 40 years, its exact mechanism of action is still unknown. In FNAIT, the majority of its therapeutic effect is thought the be mediated through the neonatal Fc receptor, however other mechanisms cannot be excluded. Due to safety, supply and other concerns that are associated with IVIg use, alternative therapies that could replace IVIg are additionally being investigated. This includes the possibility of a prophylaxis regimen for FNAIT, similarly to what has been successfully used in hemolytic disease of the fetus and newborn for over 50 years.
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Affiliation(s)
- Hanna Wabnitz
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, M5S 1A8, Canada; Keenan Research Centre, Department of Laboratory Medicine, St. Michael's Hospital, Toronto, ON, M5B 1W8, Canada; Toronto Platelet Immunobiology Group (TPIG), Toronto, ON, M5B 1T8, Canada
| | - Ramsha Khan
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, M5S 1A8, Canada; Keenan Research Centre, Department of Laboratory Medicine, St. Michael's Hospital, Toronto, ON, M5B 1W8, Canada; Toronto Platelet Immunobiology Group (TPIG), Toronto, ON, M5B 1T8, Canada; Canadian Blood Services, Centre for Innovation, Ottawa, ON, K1G 4J5, Canada
| | - Alan H Lazarus
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, M5S 1A8, Canada; Keenan Research Centre, Department of Laboratory Medicine, St. Michael's Hospital, Toronto, ON, M5B 1W8, Canada; Toronto Platelet Immunobiology Group (TPIG), Toronto, ON, M5B 1T8, Canada; Canadian Blood Services, Centre for Innovation, Ottawa, ON, K1G 4J5, Canada; Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, M5S 1A8, Canada.
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20
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Balch A, Wilkes J, Thorell E, Pavia A, Sherwin CMT, Enioutina EY. Changing trends in IVIG use in pediatric patients: A retrospective review of practices in a network of major USA pediatric hospitals. Int Immunopharmacol 2019; 76:105868. [PMID: 31487613 DOI: 10.1016/j.intimp.2019.105868] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/06/2019] [Accepted: 08/27/2019] [Indexed: 01/19/2023]
Abstract
The use of immunoglobulins is gradually increasing. Intravenous immunoglobulins (IVIG) are used as replacement therapy for primary and secondary immune deficiencies, and as an anti-inflammatory and immunomodulatory medication for the treatment of neurologic, dermatologic, and rheumatologic diseases. The objective of this study was to analyze trends in the IVIG use in pediatric patients hospitalized to 47 US-based children's hospitals from 2007 to 2014. IVIG was used for the treatment of >2300 primary diagnoses in 53,648 unique patients. The number of IVIG admissions increased by 30.2% during the study period, while the mean rate of IVIG admissions/100,000 admissions increased only 5.8%. Most patients receiving IVIG were children and adolescents. IVIG was frequently used off-label or for the treatment of FDA-approved indications in children under two years of age and BMT patients <20 years of age. Primary immune deficiencies represented only 1.2% of all IVIG admissions. Pediatric patients with mucocutaneous lymph node syndrome (Kawasaki disease, KD) and idiopathic thrombocytopenic purpura (ITP) were two primary consumers of the IVIG. Another top-ranked indications were acute infectious polyneuritis (Guillain-Barré syndrome, GBS) and prophylaxis of infections in patients receiving antineoplastic chemotherapy. IVIG usage is a dynamic process guided by emerging evidence and FDA approval for new indications. IVIG was mostly prescribed for treatment of diseases with pathologic immune responses to foreign of self-antigens. These indications usually, require higher amounts of IVIG per admission. More studies are needed to understand whether IVIG treatments of off-label indications are effective and cost-efficient.
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Affiliation(s)
- Alfred Balch
- Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jacob Wilkes
- Intermountain Healthcare, Salt Lake City, UT, USA
| | - Emily Thorell
- Division of Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Andrew Pavia
- Division of Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Catherine M T Sherwin
- Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton Children's Hospital, Dayton, OH, USA
| | - Elena Y Enioutina
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA.
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21
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Waheed W, Ayer GA, Jadoo CL, Badger GJ, Aboukhatwa M, Brannagan TH, Tandan R. Safety of intravenous immune globulin in an outpatient setting for patients with neuromuscular disease. Muscle Nerve 2019; 60:528-537. [PMID: 31443119 DOI: 10.1002/mus.26678] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 08/16/2019] [Accepted: 08/20/2019] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Although intravenous immune globulin (IVIg) is used to treat patients in the outpatient setting, there is limited documentation addressing the safety of this practice. METHODS Retrospective analysis of 438 patients with neuromuscular diseases receiving IVIg in an outpatient setting. RESULTS Adverse events (AE) overall occurred in 16.9% of patients. Headache was the most common AE, noted in 11.6% of patients. Serious AEs occurred in 0.91% of patients; aseptic meningitis was the only one noted. Multivariate analyses identified the following risk factors for AEs: first-lifetime course of IVIg, higher dose per course of IVIg, diagnosis of myasthenia gravis, women, and younger age. DISCUSSION Intravenous immune globulin is generally safe to administer in an outpatient setting. Women, myasthenia gravis patients, and those receiving their first course or a higher total dose of IVIg are at an increased risk of experiencing an AE.
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Affiliation(s)
- Waqar Waheed
- Department of Neurological Sciences, University of Vermont, Robert Larner MD College of Medicine, Burlington, Vermont.,Department of Neurological Sciences, University of Vermont Medical Center, Burlington, Vermont
| | | | | | - Gary J Badger
- Department of Medical Biostatistics, University of Vermont, Burlington, Vermont
| | - Marwa Aboukhatwa
- Pharmacotherapy Service, University of Vermont Medical Center, Burlington, Vermont.,Pharmacology Department, Medical Division, National Research Center, Cairo, Egypt
| | | | - Rup Tandan
- Department of Neurological Sciences, University of Vermont, Robert Larner MD College of Medicine, Burlington, Vermont.,Department of Neurological Sciences, University of Vermont Medical Center, Burlington, Vermont
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22
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Hill JA, Giralt S, Torgerson TR, Lazarus HM. CAR-T - and a side order of IgG, to go? - Immunoglobulin replacement in patients receiving CAR-T cell therapy. Blood Rev 2019; 38:100596. [PMID: 31416717 DOI: 10.1016/j.blre.2019.100596] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/22/2019] [Accepted: 08/06/2019] [Indexed: 12/15/2022]
Abstract
The development and regulatory approval of chimeric antigen receptor T cell (CAR-T) therapies targeting the B-lineage surface antigen CD19 represents a major milestone in cancer immunotherapy. This treatment also results in depletion of normal CD19+ B cells and is associated with hypogammaglobulinemia. These on-target, off-tumor toxicities may result in an increased risk for infection, particularly for encapsulated bacteria. Data regarding the efficacy and cost-effectiveness of prophylactic IgG replacement in CD19-targeted CAR-T cell therapy recipients is lacking, and current expert recommendations are extrapolated from the data for individuals with primary immune deficiencies. This article reviews CAR-T cell therapies targeting B-lineage lymphocytes, associated side effects, and considerations for the approach to management of hypogamaglobulinemia in this patient population. Studies are needed to establish evidence-based approaches to prophylactic immunoglobulin administration in this context, and strategies may differ by patient and CAR-T cell product characteristics.
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Affiliation(s)
- Joshua A Hill
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA.
| | - Sergio Giralt
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Troy R Torgerson
- Department of Pediatrics, University of Washington, Seattle, WA, USA; Seattle Children's Research Institute, Seattle, WA, USA
| | - Hillard M Lazarus
- Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
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23
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Abstract
Intravenous immunoglobulin (IVIg) is used in the treatment of autoimmune diseases, including immune-mediated central and peripheral nervous system disorders. This article will review the indications, proposed mechanism of actions, and administration of immunoglobulin treatment in various neuropathies, neuromuscular junction disorders, and myopathies. IVIg may have more than one mechanism of action to alter the pathogenesis of underlying neuromuscular disease. IVIg treatment has been used as a first-line treatment in Guillain-Barre syndrome, chronic inflammatory demyelinating polyradiculoneuropathy, multifocal motor neuropathy, and second-line off-label treatment in medically refractory cases of polymyositis, dermatomyositis, and myasthenia gravis. IVIg is a well-tolerated and effective treatment for these neuromuscular diseases. With this review article, we hope to increase clinicians' awareness of the indications and efficiencies of IVIg in a broad spectrum of neuromuscular diseases.
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Affiliation(s)
- Ahmet Z Burakgazi
- Department of Internal Medicine, Neuroscience Section, Virginia Tech Carilion School of Medicine, Carilion Clinic Neurology, Roanoke, VA
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24
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Gomes JP, Santos L, Shoenfeld Y. Intravenous immunoglobulin (IVIG) in the vanguard therapy of Systemic Sclerosis. Clin Immunol 2018; 199:25-28. [PMID: 30543921 DOI: 10.1016/j.clim.2018.12.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Systemic Sclerosis (SSc) is a rare autoimmune disease that is characterized by a progressive skin fibrosis, an obliteration of the microvasculature and an exaggerated extracellular matrix deposition, which lead to a multisystemic dysfunction. Various pathogenetic mechanisms were described. The lack of a successful therapy make SSc a disease with a poor prognosis. The intravenous immunoglobulin (IVIG) has been used for a long time in different autoimmune diseases, and firstly used in SSc patients in 2000. IVIG has multiple non-specific mechanisms of action and, beyond an impressive improvement in muscle symptoms, a French nationwide cohort demonstrated that IVIG ameliorates the skin disease and systemic inflammation, and helps the daily dose corticosteroid's tapering at the end of the treatment. The benefits on gastrointestinal symptoms of IVIG was reported by a recent English article, in which the patients consistently reported a decrease in the gastro-esophageal reflux disease symptoms and their frequencies. The impact on the lung involvement still remains unclear. One of the advantages of IVIG is its safe profile. Few adverse effects were reported and most of them are mild, and can be managed and usually they do not relapse. Harmful effects were described, but they can be avoid with cautious and judicious use of this therapy.
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Affiliation(s)
- João Pedro Gomes
- Zabludowicz Center for Autoimmune Disease, Sheba Medical Center, Tel Hashomer, Israel; Department A of Internal Medicine, Hospital and University Centre of Coimbra, Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Portugal.
| | - Lèlita Santos
- Department A of Internal Medicine, Hospital and University Centre of Coimbra, Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Portugal.
| | - Yehuda Shoenfeld
- Sackler Faculty of Medicine, Tel Aviv University, Israel; Zabludowicz Center for Autoimmune Disease, Sheba Medical Center, Tel Hashomer, Israel.
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A Retrospective Analysis of the Safety Profile of Intravenous Immunoglobulin in 1176 Patients Receiving Home Infusion Therapy. J Clin Neuromuscul Dis 2018; 19:181-195. [PMID: 29794573 DOI: 10.1097/cnd.0000000000000201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
OBJECTIVES This analysis assessed the safety of intravenous immunoglobulin (IVIg) in the treatment of patients with neuroimmunological and immunological disorders in a home-based setting. METHODS Adverse reactions (ARs) were assessed in a retrospective review of 1176 patients receiving 28,677 home-based IVIg infusions between 1996 and 2013. RESULTS Of 1176 patients, 648 (55.1%) experienced IVIg-related ARs; 536 (45.6%) were mild, 78 (6.6%) moderate, and 34 (2.9%) severe. Thirty-seven (3.1%) patients were hospitalized because of ARs; of these, headache was most common (51.4%). Mean number of ARs per patient increased from 1.4 (low dose) to 3.6 (high dose). Incidence of ARs increased from 41% in the first 5-year moving average in 2003 to 65% in 2008. The number of ARs correlated with the number of infusions (ρ = 0.24; P < 0.001) and the average IVIg dose (ρ = 0.10; P < 0.001). CONCLUSIONS Low- and high-dose IVIg were safe and well tolerated with a few serious ARs in patients with neuroimmunological and immunological disorders.
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26
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Alsina L, Mohr A, Montañés M, Oliver X, Martín E, Pons J, Drewe E, Papke J, Günther G, Chee R, Gompels M. Surveillance study on the tolerability and safety of Flebogamma ® DIF (10% and 5% intravenous immunoglobulin) in adult and pediatric patients. Pharmacol Res Perspect 2018; 5. [PMID: 28971614 PMCID: PMC5625155 DOI: 10.1002/prp2.345] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 07/20/2017] [Indexed: 11/29/2022] Open
Abstract
Direct comparisons of tolerability and safety of concentrated intravenous immunoglobulin (IVIG) versus less concentrated products are scarce. In this postauthorization, prospective, observational, multicenter study, a systematic comparison of 10% and 5% concentrations of Flebogamma® DIF IVIG was performed in both adult and pediatric patients treated with the studied IVIG products according to the approved indications under routine conditions. Dose of product administered, adverse events (AEs), physical assessments, laboratory tests, and concomitant therapy were analyzed. Patient recruitment in the 10% and 5% product groups was, respectively, 34 (32 analyzed, 13 of them children, receiving 130 IVIG infusions) and 35 (34 analyzed, receiving 135 IVIG infusions). Twenty‐four infusions (18.5%; 95% CI: 11.8, 25.1) with the 10% product and 3 (2.2%; 95% CI: −0.3, 4.7) with the 5% product were associated with potentially treatment‐related AEs (P < 0.0001). Nine patients (28.1%) infused with the 10% product and 3 (8.8%) infused with the 5% product presented, respectively, 33 and 8 treatment‐related AEs (of which 7 and 6, respectively, were serious AEs, experienced by only three hypersensitive patients). The profile of AEs occurring with the infusion of 10% and 5% products were comparable. The most frequent treatment‐related AEs were headache (n = 17, 3 patients; 15 episodes, 1 patient) and pyrexia (n = 6, 4 patients). In conclusion, no unpredictable risk was detected for both Flebogamma DIF 10% and 5% concentrations, which were therefore deemed as safe and well‐tolerated IVIG in the studied population. The frequency of infusions associated with treatment‐related AEs was lower with the 5% concentration.
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Affiliation(s)
- Laia Alsina
- Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Institut de Recerca Pediàtrica Hospital Sant Joan de Déu, Passeig de Sant, Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
| | - Andreas Mohr
- Hematology and Oncology, OncoResearch Lerchenfeld, Lerchenfeld 14, 22081, Hamburg, Germany
| | - Maria Montañés
- Pharmacovigilance Department, Instituto Grifols S.A., Avinguda de la Generalitat 152-158, 08174, Sant Cugat del Vallès, Barcelona, Spain
| | - Xènia Oliver
- Pharmacovigilance Department, Instituto Grifols S.A., Avinguda de la Generalitat 152-158, 08174, Sant Cugat del Vallès, Barcelona, Spain
| | - Esperanza Martín
- Pneumology Service, Hospital Sant Joan de Déu, Fundació Althaia. Carrer Dr. Joan Soler, s/n, 08243, Manresa, Spain
| | - Jaime Pons
- Immunology Service, Hospital Son Espases, Carrer de Valldemossa 79, 07120, Palma de Mallorca, Spain
| | - Elizabeth Drewe
- Clinical Immunology and Allergy Department, Nottingham University Hospitals - QMC Campus, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Jens Papke
- Practice and Day Clinic for Internal Medicine and Oncology, Rosa-Luxemburg-Straße 6, 01844, Neustadt in Sachsen, Germany
| | - Georg Günther
- Medical Healthcare Centre for Blood and Cancer Diseases, Kurfürstenstraße 20, D-14467, Potsdam, Germany
| | - Ronnie Chee
- Clinical Immunology Department, Royal Free London NHS Foundation Trust, 17 Lyndhurst Gardens, London, NW3 5NU, UK
| | - Mark Gompels
- Immunology and Allergy Department, Southmead Hospital, Dorian Way, Westbury-on-Trym, Bristol, BS10 5NB, UK
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Burnouf T. What can be learned in the snake antivenom field from the developments in human plasma derived products? Toxicon 2018; 146:77-86. [PMID: 29621528 DOI: 10.1016/j.toxicon.2018.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 03/20/2018] [Accepted: 04/01/2018] [Indexed: 10/17/2022]
Abstract
Human plasma-derived medicinal products and snake antivenom immunoglobulins are unique and complex therapeutic protein products. Human plasma products are obtained by fractionating large pools of plasma collected from blood plasma donors. They comprise a wide range of protein products, including polyvalent and hyperimmune immunoglobulins, coagulation factors, albumin, and various protease inhibitors that are transfused to patients affected by congenital or acquired protein deficiencies, immunological disorders, or metabolic diseases. Snake antivenoms are manufactured from pools of plasma collected from animals, typically horses, which have been immunized against snake venoms. Transfusing antivenoms is the cornerstone therapy to treat patients affected by snakebite envenoming. Over the last thirty years, much technical and regulatory evolution has been implemented to ensure that this class of biologicals meets modern quality requirements. The purpose of this review is to compare the main developments that took place in plasma production, protein fractionation, pathogen safety, quality control, preclinical and clinical studies, and regulations of these products. We also analyze whether both fields have been influencing and cross-fertilizing each other technically and in regulatory aspects to reach modern safety and efficacy standards at global levels, and how experience in the human plasma fractionation industry can further impact the manufacture of snake antivenom and that of other animal-derived antisera.
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Affiliation(s)
- Thierry Burnouf
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan, ROC; International PhD Program in Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan, ROC.
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Impact of organizational interventions on reducing inappropriate intravenous immunoglobulin (IVIG) usage: A systematic review and meta-analysis. Transfus Apher Sci 2018; 57:215-221. [PMID: 29439921 DOI: 10.1016/j.transci.2018.01.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 01/21/2018] [Accepted: 01/23/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND With increasing global use of intravenous immunoglobulin (IVIG), there is interest in its appropriate usage. Efforts to regulate IVIG usage have primarily taken the form of organizational interventions implemented in hospitals to monitor and improve physician prescribing. Similar interventions have proven effective in reducing the inappropriate and total hospital usage of other blood products, but their efficacy on IVIG use is less understood. Thus, we performed a systematic review of studies reporting the change in inappropriate IVIG use following such interventions in hospitals or regions. METHODS A systematic search was carried out using MEDLINE and EMBASE (1966-June 2016) for English language studies if they 1) were primary research, 2) described an organizational intervention to target plasma, IVIG, or albumin, and 3) reported appropriateness of usage and total usage preand post-intervention. Review Manager v5.0 was utilized to perform a random-effects meta-analysis on eligible IVIG studies, where the risk ratio (RR) of inappropriate IVIG transfusion comparing pre- and postintervention periods was calculated with 95% confidence intervals (CI). RESULTS Our search retrieved three retrospective cohort studies, where metaanalysis encompassing 2100 episodes of IVIG transfusion demonstrated no decrease in inappropriate IVIG use (RR 1.55, 95% CI 0.78-3.07). Heterogeneity between studies was considerable (I2 = 89%). CONCLUSION Organizational interventions were ineffective at changing inappropriate IVIG use, but more high-quality studies describing the effects of these interventions are required before any conclusions can be drawn. Futureresearch efforts should also be directed at evolving evidence-based IVIGguidelines to improve patient safety and burdens on healthcare systems.
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Zhu J, Kirkham HS, Ayer G, Chen CC, Wade RL, Karkare SU, Robson CH, Orange JS. Clinical and economic outcomes of a "high-touch" clinical management program for intravenous immunoglobulin therapy. Clinicoecon Outcomes Res 2018; 10:1-12. [PMID: 29296090 PMCID: PMC5741071 DOI: 10.2147/ceor.s142239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objective To compare clinical and economic outcomes of patients who received intravenous immunoglobulin (IVIG) therapies and were managed by a clinical management program vs the outcomes of matched controls using administrative claim data. Methods This retrospective cohort study used the PharMetrics Plus™ claim database between September 1, 2011 and June 30, 2014. Patients in the intervention group were from a “high-touch” IVIG clinical management program administered by a home infusion specialty pharmacy. A greedy propensity score matching algorithm was used to identify a control group from non-program patients. Generalized estimating equation models were employed to evaluate differences between cohorts who were followed for 1 year. Results Clinical outcomes were measured as infections and infusion-related adverse events. The proportion of patients who had serious bacterial infections was significantly lower (4.13% vs 7.75%, P=0.049) in the intervention group (n=242) compared to the control group (n=968). Other clinical outcomes assessed were not different between cohorts (P>0.050). The economic outcomes were measured as healthcare costs. The annual adjusted mean total health care costs of patients in the program were $26,522 lower compared to matched controls, representing a 20% lower cost ($109,476 vs $135,998, P=0.002). A major contribution to this difference ($17,269) was IVIG-related total outpatient cost (intervention vs control groups: $64,080 vs $81,349, P=0.001). Conclusion The patients in this high-touch IVIG clinical management program appeared to have comparable infections or adverse event rates and significantly lower total health costs compared to their matched controls.
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Affiliation(s)
| | | | | | | | | | | | | | - Jordan S Orange
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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30
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Sridhar G, Ekezue BF, Izurieta HS, Forshee RA, Selvam N, Mintz PD, Anderson SA, Menis MD. Occurrence of hemolytic reactions on the same day as immune globulin product administrations during 2008 to 2014. Transfusion 2017; 58:70-80. [DOI: 10.1111/trf.14384] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 08/24/2017] [Accepted: 08/24/2017] [Indexed: 11/26/2022]
Affiliation(s)
| | | | - Hector S. Izurieta
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration; Silver Spring Maryland
| | - Richard A. Forshee
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration; Silver Spring Maryland
| | | | - Paul D. Mintz
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration; Silver Spring Maryland
| | - Steven A. Anderson
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration; Silver Spring Maryland
| | - Mikhail D. Menis
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration; Silver Spring Maryland
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Ekezue BF, Sridhar G, Forshee RA, Izurieta HS, Selvam N, Mintz PD, Anderson SA, Menis MD. Occurrence of acute renal failure on the same day as immune globulin product administrations during 2008 to 2014. Transfusion 2017; 57:2977-2986. [PMID: 29027208 DOI: 10.1111/trf.14330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 07/21/2017] [Accepted: 07/26/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Acute renal failure (ARF) is a rare serious adverse event after immune globulin (IG) use. Our large claims-based study evaluated occurrence of same-day ARF after administration of different IGs and ascertained potential risk factors, during the 2008 to 2014 study period. STUDY DESIGN AND METHODS A retrospective cohort study was conducted using a large commercial administrative database. The cohort included individuals exposed to IG products as identified by procedure codes. ARF was ascertained using ICD-9-CM diagnoses. Unadjusted same-day ARF rates (per 1000 persons exposed) were estimated overall and by age, sex, and IG products. Regression analyses were conducted to control for confounding and assess potential risk factors. RESULTS Of 20,440 persons exposed, 163 (7.97 per 1000) had a recorded same-day ARF. The unadjusted nonzero same-day ARF rates (per 1000) ranged from 1.92 (95% confidence interval [CI], 0.05-10.69) for Hizentra to 16.97 (95% CI, 11.36-24.37) for Privigen and differed by sex. In multivariate analyses, compared to Gammagard Liquid, no significantly elevated ARF risks were identified with any IGs. A significantly lower odds ratio was identified with Gamunex, 0.53 (95% CI, 0.30-0.93). Age 45 and over, prior renal impairment, hypertension, and other factors were associated with increased risk of same-day ARF. CONCLUSION The study showed variation in the risk of IG-related ARF by age, sex, and IG products. The study results suggest the importance of recipient factors, such as older age and underlying health conditions. Variations in ARF occurrence may also be explained by product dosage, administration route and rate, and manufacturing processes, which warrant further evaluation.
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Affiliation(s)
| | | | - Richard A Forshee
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Hector S Izurieta
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | | | - Paul D Mintz
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Steven A Anderson
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Mikhail D Menis
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
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Frankovich J, Swedo S, Murphy T, Dale RC, Agalliu D, Williams K, Daines M, Hornig M, Chugani H, Sanger T, Muscal E, Pasternack M, Cooperstock M, Gans H, Zhang Y, Cunningham M, Bernstein G, Bromberg R, Willett T, Brown K, Farhadian B, Chang K, Geller D, Hernandez J, Sherr J, Shaw R, Latimer E, Leckman J, Thienemann M, PANS/PANDAS Consortium. Clinical Management of Pediatric Acute-Onset Neuropsychiatric Syndrome: Part II-Use of Immunomodulatory Therapies. J Child Adolesc Psychopharmacol 2017; 27:574-593. [PMID: 36358107 PMCID: PMC9836706 DOI: 10.1089/cap.2016.0148] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Introduction: Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) is a clinically heterogeneous disorder with a number of different etiologies and disease mechanisms. Inflammatory and postinfectious autoimmune presentations of PANS occur frequently, with some clinical series documenting immune abnormalities in 75%-80% of patients. Thus, comprehensive treatment protocols must include immunological interventions, but their use should be reserved only for PANS cases in which the symptoms represent underlying neuroinflammation or postinfectious autoimmunity, as seen in the PANDAS subgroup (Pediatric Autoimmune Neuropsychiatric Disorders associated with Streptococcal infections). Methods: The PANS Research Consortium (PRC) immunomodulatory task force is comprised of immunologists, rheumatologists, neurologists, infectious disease experts, general pediatricians, psychiatrists, nurse practitioners, and basic scientists with expertise in neuroimmunology and PANS-related animal models. Preliminary treatment guidelines were created in the Spring of 2014 at the National Institute of Health and refined over the ensuing 2 years over conference calls and a shared web-based document. Seven pediatric mental health practitioners, with expertise in diagnosing and monitoring patients with PANS, were consulted to create categories in disease severity and critically review final recommendations. All authors played a role in creating these guidelines. The views of all authors were incorporated and all authors gave final approval of these guidelines. Results: Separate guidelines were created for the use of immunomodulatory therapies in PANS patients with (1) mild, (2) moderate-to-severe, and (3) extreme/life-threatening severity. For mildly impairing PANS, the most appropriate therapy may be "tincture of time" combined with cognitive behavioral therapy and other supportive therapies. If symptoms persist, nonsteroidal anti-inflammatory drugs and/or short oral corticosteroid bursts are recommended. For moderate-to-severe PANS, oral or intravenous corticosteroids may be sufficient. However, intravenous immunoglobulin (IVIG) is often the preferred treatment for these patients by most PRC members. For more severe or chronic presentations, prolonged corticosteroid courses (with taper) or repeated high-dose corticosteroids may be indicated. For PANS with extreme and life-threatening impairment, therapeutic plasma exchange is the first-line therapy given either alone or in combination with IVIG, high-dose intravenous corticosteroids, and/or rituximab. Conclusions: These recommendations will help guide the use of anti-inflammatory and immunomodulatory therapy in the treatment of PANS.
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Affiliation(s)
- Jennifer Frankovich
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California.,Pediatric Allergy, Immunology, and Rheumatology, Stanford University School of Medicine, Palo Alto, California
| | - Susan Swedo
- Pediatrics and Developmental Neuroscience Branch, National Institute of Mental Health, Bethesda, Maryland
| | - Tanya Murphy
- Rothman Center for Pediatric Neuropsychiatry, Pediatrics and Psychiatry, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Russell C. Dale
- Paediatrics and Child Health, Institute for Neuroscience and Muscle Research, the Children's Hospital at Westmead, University of Sydney, Sydney, Australia
| | - Dritan Agalliu
- Pathology and Cell Biology (in Neurology and Pharmacology), Columbia University, New York, New York
| | - Kyle Williams
- Pediatric Neuropsychiatry and Immunology Program in the OCD and Related Disorders Program, Harvard Medical School, Boston, Massachusetts
| | - Michael Daines
- Allergy, Immunology, and Rheumatology, The University of Arizona College of Medicine Tuscon, Tuscon, Arizona
| | - Mady Hornig
- Epidemiology, Center for Infection and Immunity, Columbia University Medical Center, New York, New York
| | - Harry Chugani
- Pediatric Neurology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Terence Sanger
- Neurology, University of Southern California Pediatric Movement Disorders Center, Children's Hospital of Los Angeles, Los Angeles, California
| | - Eyal Muscal
- Pediatric Rheumatology, Baylor College of Medicine, Houston, Texas
| | - Mark Pasternack
- Pediatric Infectious Disease, Harvard Medical School, Boston, Massachusetts
| | - Michael Cooperstock
- Pediatric Infectious Diseases, University of Missouri School of Medicine, Columbia, Missouri
| | - Hayley Gans
- Pediatric Infectious Diseases, Stanford University School of Medicine, Stanford, California
| | - Yujuan Zhang
- Pediatric Rheumatology, Tufts University School of Medicine, Boston, Massachusetts
| | - Madeleine Cunningham
- Microbiology and Immunology, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Gail Bernstein
- Child and Adolescent Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Reuven Bromberg
- Pediatric Rheumatology, Miami Rheumatology, LLC, Miami, Florida
| | - Theresa Willett
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Kayla Brown
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California.,Pediatric Allergy, Immunology, and Rheumatology, Stanford University School of Medicine, Palo Alto, California
| | - Bahare Farhadian
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Kiki Chang
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California.,Psychiatry and Behavioral Sciences, Child and Adolescent Psychiatry, Stanford University School of Medicine, Palo Alto, California
| | - Daniel Geller
- Pediatric OCD and Tic Disorder Program, Harvard Medical School, Boston, Massachusetts
| | - Joseph Hernandez
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California.,Pediatric Allergy, Immunology, and Rheumatology, Stanford University School of Medicine, Palo Alto, California
| | - Janell Sherr
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California.,Pediatric Allergy, Immunology, and Rheumatology, Stanford University School of Medicine, Palo Alto, California
| | - Richard Shaw
- Psychiatry and Behavioral Sciences, Child and Adolescent Psychiatry, Stanford University School of Medicine, Palo Alto, California
| | - Elizabeth Latimer
- Pediatric Neurology, Georgetown University Hospital, Washington, District of Columbia
| | - James Leckman
- Child Psychiatry, Psychiatry, Psychology and Pediatrics, Yale Child Study Center, Yale School of Medicine, New Haven, Connecticut
| | - Margo Thienemann
- Stanford PANS Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California.,Psychiatry and Behavioral Sciences, Child and Adolescent Psychiatry, Stanford University School of Medicine, Palo Alto, California
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Mielke O, Fontana S, Goranova-Marinova V, Shebl A, Spycher MO, Wymann S, Durn BL, Lawo JP, Hubsch A, Salama A. Hemolysis related to intravenous immunoglobulins is dependent on the presence of anti-blood group A and B antibodies and individual susceptibility. Transfusion 2017; 57:2629-2638. [PMID: 28840942 DOI: 10.1111/trf.14289] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 06/14/2017] [Accepted: 06/25/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patients treated with intravenous immunoglobulins (IVIG) rarely experience symptomatic hemolysis. Although anti-A and anti-B isoagglutinins from the product are involved in most cases, the actual mechanisms triggering hemolysis are unclear. STUDY DESIGN AND METHODS A prospective, open-label, multicenter, single-arm clinical trial in 57 patients with immune thrombocytopenia treated with IVIG (Privigen, CSL Behring) was conducted. RESULTS Twenty-one patients received one infusion (1 g/kg) and 36 received two infusions (2 × 1 g/kg) of IVIG. After a study duration of more than 2 years, no cases of clinically significant hemolysis as defined in the protocol were identified. Data of patients with mild hematologic and biochemical changes were analyzed in more detail. Twelve cases (10/23 patients with blood group A1 and 2/11 patients with blood group B, all having received 2 g/kg IVIG) were adjudicated as mild hemolysis (median hemoglobin [Hb] decrease, -3.0 g/dL); Hb decreases were transient, with partial or full recovery achieved by last visit. Eighteen patients (31.6%), all with non-O blood group, of whom 16 (88.9%) received 2 g/kg IVIG, fulfilled post hoc criteria for hemolytic laboratory reactions. Red blood cell (RBC) eluates of all direct antiglobulin test-positive samples were negative for non-ABO blood group antibodies. Blood groups A and B antigen density on RBCs appeared to be a risk factor for hemolytic laboratory reactions. Platelet response to treatment was observed in 42 patients (74%); eight of 12 patients with complete response had blood group A1. CONCLUSION Isoagglutinins are involved in clinically nonsignificant hemolysis after treatment with IVIG, but individual susceptibility varies greatly.
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Affiliation(s)
| | - Stefano Fontana
- Interregional Blood Transfusion Service SRC, Bern, Switzerland
| | | | | | | | | | | | | | | | - Abdulgabar Salama
- Institut für Transfusionsmedizin, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Immune Gamma Globulin Therapeutic Indications in Immune Deficiency and Autoimmunity. Curr Allergy Asthma Rep 2017; 16:55. [PMID: 27401913 DOI: 10.1007/s11882-016-0632-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Immune gamma globulin (IgG) has a long history in the treatment of both primary immune deficiency and autoimmune disorders. Disease indications continue to expand and new-generation products increase the versatility of delivery. This review encompasses a historical perspective as well as current and future implications of human immune globulin for the treatment of immune-mediated illness.
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Clementi N, Cappelletti F, Criscuolo E, Castelli M, Mancini N, Burioni R, Clementi M. Role and potential therapeutic use of antibodies against herpetic infections. Clin Microbiol Infect 2017; 23:381-386. [DOI: 10.1016/j.cmi.2016.12.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 12/14/2016] [Accepted: 12/24/2016] [Indexed: 11/30/2022]
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Dubruc E, Nadaud B, Ruchelli E, Heissat S, Baruteau J, Broué P, Debray D, Cordier MP, Miossec P, Russo P, Collardeau-Frachon S. Relevance of C5b9 immunostaining in the diagnosis of neonatal hemochromatosis. Pediatr Res 2017; 81:712-721. [PMID: 28085791 DOI: 10.1038/pr.2017.8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 12/04/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Neonatal hemochromatosis caused by a gestational alloimmune mechanism or gestational alloimmune liver disease (GALD) is a rare perinatal disorder characterized by intra- and extrahepatic iron overload. It is believed to result from complement-mediated liver injury, in which the classical complement pathway is activated by maternal antibody/fetal antigen complexes, leading to hepatocyte lysis by the membrane attack complex C5b9. According to some authors, C5b9 expression in more than 75% of liver parenchyma is specific for GALD. METHODS We conducted a retrospective multicentric immunohistochemical study with anti-C5b9 in GALD cases (n = 25) and non-GALD cases with iron overload (n = 36) and without iron overload (n = 18). RESULTS C5b9 was expressed in 100% of GALD cases but involved more than 75% of the liver parenchyma in only 26% of the cases. C5b9 was detected in 26.75% of the non-GALD cases with more than 75% of positive parenchyma in maternal erythrocytic alloimmunization, herpes and enterovirus hepatitis, bile acid synthetic defect, DGUOK mutation, Gaucher disease, cystic fibrosis, and giant-cell hepatitis with autoimmune hemolytic anemia. CONCLUSION Diagnosis and therapeutic management of GALD cannot only be based on C5b9 expression in liver samples as it is not specific of this disease.
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Affiliation(s)
- Estelle Dubruc
- Department of pathology, Hôpital Femme-Mère-Enfant, CHU de Lyon, France
| | - Béatrice Nadaud
- Department of pathology, Hôpital Femme-Mère-Enfant, CHU de Lyon, France
| | - Eduardo Ruchelli
- Department of pathology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sophie Heissat
- Department of pediatrics, Hôpital Femme-Mère-Enfant, CHU de Lyon, France
| | - Julien Baruteau
- Pediatric Hepatology and Inborn Metabolic Diseases Unit, University Children's Hospital, Toulouse, France
| | - Pierre Broué
- Pediatric Hepatology and Inborn Metabolic Diseases Unit, University Children's Hospital, Toulouse, France
| | - Dominique Debray
- Department of Pediatric Surgery, Hepatology, and Transplantation, Necker Enfants Malades Hospital, Paris, France
| | | | - Pierre Miossec
- Department of immunology, Hôpital Edouard Herriot, CHU de Lyon, France.,Université Claude Bernard Lyon 1, France
| | - Pierre Russo
- Department of pathology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sophie Collardeau-Frachon
- Department of pathology, Hôpital Femme-Mère-Enfant, CHU de Lyon, France.,Université Claude Bernard Lyon 1, France.,SOFFOET, Société Française de Foetopathologie, Paris, France
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Prise en charge des événements indésirables chez les patients sous traitement par immunoglobulines : recommandations pour la pratique clinique. Rev Med Interne 2017; 38:312-319. [DOI: 10.1016/j.revmed.2016.10.390] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 09/25/2016] [Accepted: 10/20/2016] [Indexed: 12/29/2022]
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38
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Shih AW, Jamula E, Diep C, Lin Y, Armali C, Heddle NM, Traore A, Doherty J, Shah N, Hillis CM. Audit of provincial IVIG Request Forms and efficacy documentation in four Ontario tertiary care centres. Transfus Med 2017; 27:122-131. [PMID: 28144996 DOI: 10.1111/tme.12391] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/29/2016] [Accepted: 12/30/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Retrospective audit of IVIG Request Forms in four Ontario tertiary care centres: to determine the case mix of new IVIG requests, to authenticate information provided, and to determine documentation of clinical efficacy. AIMS To understand contributors to increases in IVIG utilisation and to determine whether IVIG is being used and monitored appropriately. INTRODUCTION Intravenous immunoglobulin (IVIG) use in Canada is high compared with other developed countries. We performed a retrospective audit of new IVIG Request Forms across four tertiary care centres in Ontario, one with an active surveillance programme, to determine the case mix, authenticate information provided and assess documentation of efficacy. METHODS Consecutive adult patients with a first-time IVIG request in 2014 were included. The ordering physician specialty, form completeness, documentation of diagnostic criteria for the medical condition and indication for IVIG use and documentation of efficacy were assessed by form and chart review. RESULTS Of 178 patients, the most common indications for IVIG were immune thrombocytopenia (24.2%) and secondary immune deficiency (20.2%). The most frequent prescribers were haematologists (37.6%) and neurologists (10.7%). Other conditions not listed on the form represented 24.2% of cases, with most not indicated in current guidelines. A total of 32.6% of cases overall lacked verification of diagnostic criteria and 51.7% lacked verification for IVIG utilisation criteria, with the number of cases meeting criteria based on documentation being higher at the active surveillance site (P = 0.005). A total of 19.1% of cases had a discrepancy between the indication written on the form and the documented clinical diagnosis. A total of 18.7% of clinic notes following IVIG had no mention of efficacy. CONCLUSION Our audit demonstrates a lack of compliance with IVIG Request Form requirements, a lack of documentation of diagnostic criteria and efficacy, and suggests inappropriate use of IVIG. Current implementation of the form may not be sufficient as a strategy for improving appropriate IVIG use.
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Affiliation(s)
- A W Shih
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - E Jamula
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - C Diep
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Y Lin
- Department of Clinical Pathology, Sunnybrook Health Sciences Centre and Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - C Armali
- Department of Clinical Pathology, Sunnybrook Health Sciences Centre and Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - N M Heddle
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada.,Centre for Innovation, Canadian Blood Services, Ottawa, Ontario, Canada
| | - A Traore
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - J Doherty
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - N Shah
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - C M Hillis
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada.,Department of Oncology, McMaster University, Hamilton, Ontario, Canada
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Kovaleva L, Apte S, Damodar S, Ramanan V, Loriya S, Navarro-Puerto J, Khojasteh A. Safety and efficacy of a 10% intravenous immunoglobulin preparation in patients with immune thrombocytopenic purpura: results of two international, multicenter studies. Immunotherapy 2016; 8:1371-1381. [PMID: 27817251 DOI: 10.2217/imt-2016-0088] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
AIM To assess safety and efficacy of a 10% intravenous immunoglobulin in patients with primary immune thrombocytopenic purpura (ITP). PATIENTS & METHODS ITP patients in two multicenter studies (Trials A/B) were treated with 2 g/kg Flebogamma® 10% DIF (over 2-5 days) and were followed up to 1-3 months. RESULTS 18 patients in Trial A and 58 in Trial B were enrolled (12 children in Trial B). The response rate (platelet count ≥50 × 109/l) was 72.2% (Trial A) and 76.1/100% (adults/children; Trial B). Most patients improved bleedings (83.3% Trial A; 88.9% Trial B). Potential treatment-related adverse events were reported by 38.9% (Trial A) and 30.4/83.3% (adults/children; Trial B) of patients. All serious adverse events (five patients) resolved without sequelae. CONCLUSION Flebogamma 10% DIF was effective and safe in patients with primary ITP.
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Affiliation(s)
- Lidia Kovaleva
- Hematology Research Centre of Russian Academy of Medical Science, Moscow, Russia
| | | | - Sharat Damodar
- Narayana Hrudayalaya Hospitals, Bangalore, Karnataka, India
| | | | - Svetlana Loriya
- Federal Research Clinical Centre of Pediatric Hematology, Oncology & Immunology, Moscow, Russia
| | | | - Ali Khojasteh
- Columbia Comprehensive Cancer Care Clinic & Research Institute, 1705 Christy Dr. Suite 214, Jefferson City, MO 65101, USA
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Cantarini L, Rigante D, Vitale A, Napodano S, Sakkas LI, Bogdanos DP, Shoenfeld Y. Intravenous immunoglobulins (IVIG) in systemic sclerosis: a challenging yet promising future. Immunol Res 2015; 61:326-37. [PMID: 25550086 DOI: 10.1007/s12026-014-8615-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The etiology and pathogenesis of systemic sclerosis are still largely unknown, but a variety of humoral and cellular autoimmune phenomena have been documented. In addition, the rarity of the disease, the broad spectrum of clinical manifestations, and the relevant risk of severe complications as well as the highly variable disease course render its management a major challenge. Some immunomodulatory agents have been used, but no single agent has given a convincing proof of effectiveness, and treatment has remained largely symptomatic through recent years. Novel therapies are currently being tested and may have the potential of modifying the disease process and overall clinical outcome. Efficacy of intravenous immunoglobulins (IVIG) in different regimens (1-2 g/kg of body weight, administered over 2-5 consecutive days) has been described in a limited number of trials and small case series, showing benefits in skin, articular, and lung interstitial disease symptoms. However, studies on IVIG in systemic sclerosis still remain few, and further randomized controlled trials should be undertaken to assess their clinical effectiveness or define the optimal dosage and times of administration.
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Affiliation(s)
- Luca Cantarini
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy,
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Management of adverse events in the treatment of patients with immunoglobulin therapy: A review of evidence. Autoimmun Rev 2015; 15:71-81. [PMID: 26384525 DOI: 10.1016/j.autrev.2015.09.002] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 09/08/2015] [Indexed: 12/12/2022]
Abstract
Immunoglobulin (IG) therapy is actually used for a broad range of diseases including primary and secondary immunodeficiency disorders, and autoimmune diseases. This therapy is available for intravenous (IV) and subcutaneous (SC) administration. The efficacy of the IG therapy has been demonstrated in numerous studies and across different diseases. Generally, IG infusions are well tolerated; however some well-known adverse reactions, ranging from mild to severe, are associated with the therapy. The most common adverse reactions including headache, nausea, myalgia, fever, chills, chest discomfort, skin and anaphylactic reactions, could arise immediately during or after the infusion. Delayed events could be more severe and include migraine headaches, aseptic meningitis, haemolysis renal impairment and thrombotic events. This paper reviews all the potential adverse events related to IG therapy and establishes a comprehensive guideline for the management of these events. Moreover it resumes the opinions and clinical experience of expert endorsers on the utilization of the treatment. Published data were classified into levels of evidence and the strength of the recommendation was given for each intervention according to the GRADE system.
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Tufekci S, Coban A, Bor M, Yasa B, Nisli K, Ince Z. Cardiac rhythm abnormalities during intravenous immunoglobulin G(IVIG) infusion in two newborn infants: coincidence or association? Clin Case Rep 2015; 3:731-4. [PMID: 26401276 PMCID: PMC4574787 DOI: 10.1002/ccr3.329] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Accepted: 04/30/2015] [Indexed: 11/10/2022] Open
Abstract
We report the occurrence of supraventricular tachycardia during intravenous immunoglobulin (IVIG) infusion. Supraventricular tachycardia was observed in two newborn patients during IVIG infusion. Both of the babies responded to adenosine treatment. Cardiorespiratory monitoring during IVIG infusion can be recommended because of the possibility of this potentially lifethreatening adverse effect.
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Affiliation(s)
- Sinan Tufekci
- Division of Neonatology, Department of Pediatrics, Istanbul Medical Faculty, Istanbul University Istanbul, Turkey
| | - Asuman Coban
- Division of Neonatology, Department of Pediatrics, Istanbul Medical Faculty, Istanbul University Istanbul, Turkey
| | - Meltem Bor
- Division of Neonatology, Department of Pediatrics, Istanbul Medical Faculty, Istanbul University Istanbul, Turkey
| | - Beril Yasa
- Division of Neonatology, Department of Pediatrics, Istanbul Medical Faculty, Istanbul University Istanbul, Turkey
| | - Kemal Nisli
- Division of Pediatric Cardiology, Department of Pediatrics, Istanbul Medical Faculty, Istanbul University Istanbul, Turkey
| | - Zeynep Ince
- Division of Neonatology, Department of Pediatrics, Istanbul Medical Faculty, Istanbul University Istanbul, Turkey
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Luban NL, Wong EC, Henrich Lobo R, Pary P, Duke S. Intravenous immunoglobulin-related hemolysis in patients treated for Kawasaki disease. Transfusion 2015; 55 Suppl 2:S90-4. [DOI: 10.1111/trf.13089] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Naomi L.C. Luban
- Division of Laboratory Medicine; Children's National Medical Center; Washington DC
- Department of Pediatrics; Washington DC
- Department of Pathology; the George Washington University School of Medicine and Health Sciences; Washington DC
| | - Edward C.C. Wong
- Division of Laboratory Medicine; Children's National Medical Center; Washington DC
- Department of Pediatrics; Washington DC
- Department of Pathology; the George Washington University School of Medicine and Health Sciences; Washington DC
| | - Rodolfo Henrich Lobo
- Department of Pathology; the George Washington University School of Medicine and Health Sciences; Washington DC
| | - Philippe Pary
- Division of Laboratory Medicine; Children's National Medical Center; Washington DC
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Kalariya N, Twigg A, Brassil K. Nursing Management of Sustained Rigors and Recurrent Fever as Symptoms of Filgrastim Hypersensitivity: A Case Report. Oncol Nurs Forum 2015; 42:415-9. [PMID: 26148322 DOI: 10.1188/15.onf.415-419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Alyssa Twigg
- University of Texas MD Anderson Cancer Center in Houston
| | - Kelly Brassil
- University of Texas MD Anderson Cancer Center in Houston
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Sehgal VN, Pandhi D, Khurana A. Biologics in dermatology: adverse effects. Int J Dermatol 2015; 54:1442-60. [PMID: 26147909 DOI: 10.1111/ijd.12802] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 01/13/2014] [Accepted: 06/25/2014] [Indexed: 12/13/2022]
Abstract
Biologics are a group of drugs that precisely affect certain specific steps in the immune response and are an extremely useful group when used in an appropriate setting. However, their use can often be a double-edged sword. Careful patient selection and thorough knowledge of adverse effects is a key to their successful use in various disorders. The initial enthusiasm has gradually given way to a more cautious approach wherein a balance is sought between clinical usefulness and expected side effects. The adverse effects of the biologics most commonly used in dermatology have been carefully listed for ready reference. The plausible causes of the adverse reactions are succinctly outlined along with their incriminating factor(s). Besides, in brief, the attention has been focused on their management. The content should provide an essential didactic content for educating the practitioner.
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Affiliation(s)
- Virendra N Sehgal
- Dermato-Venereology (Skin/VD) Center, Sehgal Nursing Home, Delhi, India
| | - Deepika Pandhi
- Department of Dermatology and STD, University College of Medical Sciences, and Associated Guru Teg Bahadur Hospital, Shahdara, Delhi, India
| | - Ananta Khurana
- Department of Dermatology and STD, Dr RML hospital and PGIMER, New Delhi, India
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Stein MR. The New Generation of Liquid Intravenous Immunoglobulin Formulations in Patient Care: A Comparison of Intravenous Immunoglobulins. Postgrad Med 2015; 122:176-84. [DOI: 10.3810/pgm.2010.09.2214] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Berger M, Allen JA. Optimizing IgG therapy in chronic autoimmune neuropathies: a hypothesis driven approach. Muscle Nerve 2015; 51:315-26. [PMID: 25418426 PMCID: PMC4357394 DOI: 10.1002/mus.24526] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2014] [Indexed: 12/22/2022]
Abstract
Prolonged intravenous immunoglobulin (IVIG) therapy is used for the chronic autoimmune neuropathies chronic idiopathic demyelinating polyneuropathy and multifocal motor neuropathy, but the doses and treatment intervals are usually chosen empirically due to a paucity of data from dose-response studies. Recent studies of the electrophysiology and immunology of these diseases suggest that antibody-induced reversible dysfunction of nodes of Ranvier may play a role in conduction block and disability which responds to immunotherapy more rapidly than would be expected for demyelination or axonal damage per se. Clinical reports suggest that in some cases, the effects of each dose of IVIG may be transient, wearing-off before the next dose is due. These observations lead us to hypothesize that that therapeutic IgG acts by competing with pathologic autoantibodies and that individual patients may require different IgG levels for optimal therapeutic effects. Frequent IVIG dosing and weekly subcutaneous IgG have been tried as ways of continuously maintaining high serum IgG levels, resulting in stabilization of neuromuscular function in small case series. Frequent grip strength and disability measurements, performed by the patient at home and reported electronically, can be used to assess the extent and duration of responses to IgG doses. Individualization of IgG treatment regimens may optimize efficacy, minimize disability, and identify nonresponders.
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Affiliation(s)
- Melvin Berger
- CSL Behring, LLC., 1040 First Avenue, King of PrussiaPennsylvania, USA 19406
| | - Jeffrey A Allen
- University of MinnesotaMinneapolis, Minnesota, USA
- Northwestern UniversityChicago, Illinois, USA
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The Canadian Choosing Wisely campaign: the Canadian Hematology Society’s top five tests and treatments. Ann Hematol 2015; 94:541-5. [DOI: 10.1007/s00277-015-2304-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 01/21/2015] [Indexed: 01/08/2023]
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Heissat S, Collardeau-Frachon S, Baruteau J, Dubruc E, Bouvier R, Fabre M, Cordier MP, Broué P, Guigonis V, Debray D. Neonatal hemochromatosis: diagnostic work-up based on a series of 56 cases of fetal death and neonatal liver failure. J Pediatr 2015; 166:66-73. [PMID: 25444000 DOI: 10.1016/j.jpeds.2014.09.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 08/14/2014] [Accepted: 09/18/2014] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To define an algorithm to improve diagnosis of neonatal hemochromatosis (NH) related to gestational alloimmune liver disease (GALD), which is diagnosed by immunohistochemistry demonstrating activated complement at hepatocytes (IDACH). STUDY DESIGN We assessed 56 instances of fetal death or neonatal liver failure (NLF; 2006-2009), 29 (7 stillborns, 22 NLF) with NH, and 27 (5 stillborns, 22 NLF) without NH (non-NH). Immunohistochemistry was retrospectively performed in 21 cases. Cases were grouped as follows: (1) GALD as demonstrated by IDACH (n = 17); (2) indeterminate for GALD (n = 28); or (3) alternate diagnosis found (n = 11). We compared cases of immunohistochemically proven GALD with those with an alternate diagnosis. RESULTS Of the 12 stillborns, 7 had NH because of GALD (NH-GALD), one was undeterminate, and 4 had alternate diagnoses (GALD excluded). Of the 22 newborns with NH, 6 had NH-GALD, one had mitochondrial respiratory chain disorder (MRCD), and 15 were indeterminate for GALD. Of 22 non-NH newborns, extrahepatic siderosis (EHS) was not assessed in 13 (3 GALD, 1 alternate diagnosis [MRCD] and 9 indeterminate GALD) and excluded in 9 (5 alternate diagnoses and 4 indeterminate GALD). The only clinical features found to be associated with GALD were intrafamilial recurrence, prematurity, and EHS. CONCLUSIONS In unexplained fetal death or NLF, the diagnosis of subsets of NH requires tissue analysis (autopsy) to assess EHS. In patients with NH, if MRCD is ruled out, NH-GALD is likely. The rate of IDACH in the diagnosis of GALD in cases without NH requires further study.
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Affiliation(s)
- Sophie Heissat
- Department of Pediatric Gastroenterology and Hepatology, Hôpital Femme Mère Enfant, Hospices Civils de Lyon et Université Lyon 1, Lyon, France.
| | - Sophie Collardeau-Frachon
- Department of Pathology, Hôpital Femme Mère Enfant, Hospices Civils de Lyon et Université Lyon 1, Lyon, France
| | - Julien Baruteau
- Department of Pediatric Hepatology and Metabolic Diseases, CHU Toulouse, Toulouse, France
| | - Estelle Dubruc
- Department of Pathology, Hôpital Femme Mère Enfant, Hospices Civils de Lyon et Université Lyon 1, Lyon, France
| | - Raymonde Bouvier
- Department of Pathology, Hôpital Femme Mère Enfant, Hospices Civils de Lyon et Université Lyon 1, Lyon, France
| | | | | | - Pierre Broué
- Department of Pediatric Hepatology and Metabolic Diseases, CHU Toulouse, Toulouse, France
| | - Vincent Guigonis
- Department of Pediatrics, Hôpital Mère et Enfant, CHU Limoges, Limoges, France
| | - Dominique Debray
- Medical-Surgical Center, Hepatology, and Transplantation AP-HP, Hôpital Necker Enfants Malades, Paris, France
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