The role of immunoglobulin therapy in allergic diseases

Association of primary immune thrombocytopenia and common allergic diseases among children

BACKGROUND

Growing evidence has revealed a link between autoimmune and allergic diseases. However, few studies have assessed the relationship between allergic diseases and primary immune thrombocytopenia (ITP), an autoimmune disease frequently occurring in children. This population-based case-control study investigated the association between common allergic diseases and the subsequent risk of developing ITP during childhood.

METHODS

This study investigated 1,203 children younger than 18 y of age who were diagnosed with ITP between 1998 and 2008, as well as 4,812 frequency-matched controls. The odds ratios of the association between ITP and preexisting allergic diseases were calculated.

RESULTS

Children with every type of allergic disease examined in this study (except asthma) exhibited an increased risk of developing ITP; the lowest adjusted odds ratio (aOR) was 1.39 for allergic conjunctivitis (95% confidence interval (CI) = 1.09-1.79), whereas the greatest aOR was 1.84 for allergic rhinitis (95% CI = 1.49-2.27). The aORs increased with the number of concurrent allergic diseases to 2.89 (95% CI = 1.98-4.22) for children with at least three allergic diseases.

CONCLUSION

Children with atopic diathesis have a greater risk of subsequently developing ITP. The fundamental determinants of this relationship warrant further study.

Change of bronchial hyperresponsiveness in asthmatic children

INTRODUCTION

Bronchial hyperresponsiveness (BHR) is a factor in predicting bronchial asthma independently of inflammation markers.

OBJECTIVE

The aims were to determine the frequency and important predictive facts of BHR and the effect of prophylaxis by Global Initiative for Asthma (GINA) and National Asthma Education and Prevention Program (NAEPP) on BHR in asthmatic children.

METHODS

BHR in 106 children was evaluated by the bronchoprovocation test with methacholine.

RESULTS

The prevalence rate of symptomatic BHR is 18% for crucial point of PC20 = 4.1 +/- 3.03 mg/ml and PD20 = 3.22 +/- 2.59 micromol methacholine. On average asthmatic children express moderate BHR, which persists even two years after administering prophylaxis. After two years bronchial reactivity is significantly smaller, the change of FEV1 is significantly smaller, the velocity of change of slope dose response curve (sDRC) is faster and the provocative concentration of methacholine that causes wheezing is 2-3 times lower. A mild sDRC shows milder bronchoconstriction after two years. The fast change of bronchial reactivity in 41% of asthmatic children is contributed to aero-pollution with sulfur dioxide and/or, possible insufficient and/or inadequate treatment during two years of administering prophylaxis. A simultaneous effect of allergens from home environment and grass and tree pollens and of excessive aero-pollution on children's airways is important in the onset of symptomatic BHR. After two years of treatment by GINA and NAEPP children do not show asthma symptoms or show mild asthma symptoms, however bronchial sensitivity remains unchanged.

CONCLUSION

Optimal duration of anti-inflammatory treatment in asthmatic children who show moderate bronchial hyperresponsiveness should be longer than two years.

Modulation of lymphocyte phenotype and function by immunoglobulins

BACKGROUND

Immunoglobulins have immune-modulating capacities and are used for the treatment of different dermatological diseases. They have also been reported for the treatment of severe atopic dermatitis (AD).

OBJECTIVES

To determine the effects of immunoglobulins on the phenotype and function of peripheral T and B lymphocytes from patients with AD in comparison with healthy donors (HD) as controls.

METHODS

We studied lymphocyte activation and T-cell cytokine production from 12 patients with AD and 10 HD by multicolour flow cytometric analysis in the presence of immunoglobulins.

RESULTS

Immunoglobulins significantly inhibited T-cell activation (CD69), by 71% (AD) and by 62% (HD). Production of interferon-gamma and interleukin-4 was also significantly inhibited, by 44%/24% (AD) and 38%/10% (HD), respectively. In addition, CD86 expression on B lymphocytes was downregulated by 30% in AD and by 29% in HD, whereas CD23 expression was decreased without reaching statistical significance.

CONCLUSIONS

Our data demonstrate that, in vitro, immunoglobulins modulate the activation and cytokine production of peripheral blood lymphocytes from both HD and patients with AD.

IVIG--mechanisms of action

Intravenous immunoglobulin (IVIG) preparations are fractionated from a plasma pool of several thousand donors. IVIG contain immune antibodies and physiologic autoantibodies. Immune antibodies reflect the immunologic experience of the donor population. This fraction of IVIG preparations is useful for replacement therapy and passive immunisation. Natural autoantibodies are able to react with the immune system of the recipient of IVIG and are suggested to help to correct immune deregulation. Immunomodulatory and anti-inflammatory properties are based on multiple mechanisms of action which are described. These mechanisms are effective concomitantly and synergistically at every occasion of use of IVIG in inflammatory and autoimmune disorders.

Effect of intravenous immunoglobulin treatment on the Th1/Th2 balance in women with recurrent spontaneous abortions

PROBLEM

The way by which intravenous immunoglobulin (IvIg) acts to prevent immunlogically mediated recurrent spontaneous abortions (RSA) has not been clarified. In the present study, a possible effect of IvIg on the T helper cell (Th1/Th2) balance was investigated in abortions of either alloimmune or autoimmune abnormalities.

METHOD OF STUDY

The study included 21 women treated with IvIg before conception because of a history of RSA characterized by alloimmune abnormalities (n = 15) or associated with anti-phospholipid antibodies (APA) (n = 6). Peripheral blood samples, collected before and 5 days after the first IvIg infusion, were stimulated, and Th1 and Th2 cells were detected by flow-cytometric analysis using a combination of monoclonal antibodies against T-cell surface markers and intracellular interferon (IFN)-gamma and interleukin (IL)-4. The percentage of IFN-gamma-producing (Th1) and IL-4-producing (Th2) cells and the Th1/Th2 ratio were compared between pre- and post-infusion samples.

RESULTS

A decrease of Th1 percentage in 66.6% of the cases and a concurrent Th2 percentage increase (47.61%) resulted in a decrease in the Th1/Th2 ratio in most of the cases (76.1%) (p < 0.01). Similar results were found in Group A (Th1/Th2 decreased in 60% of the cases, p < 0.05), while in Group B the effect of IvIg was not clear (Th1/Th2 increased in three and decreased in another three cases).

CONCLUSION

Our finding suggests that IvIg administration in women with alloimmune RSA enhances Th2 polarization. This is not always the case with APA-associated abortions.

A randomized controlled evaluator-blinded trial of intravenous immunoglobulin in adults with severe atopic dermatitis

BACKGROUND

There is a need for alternative therapy in severe adult atopic dermatitis (AD). Intravenous immunoglobulin (IVIG) treatment has been shown to be beneficial in a few open observations, but evidence of effectiveness is still lacking.

OBJECTIVE

To investigate whether treatment with IVIG is effective in adults with severe AD.

METHODS

In a randomized evaluator-blinded trial, 10 patients with severe AD were randomized to immediate or delayed (by 1 month) treatment with IVIG 2 g kg-1. Patients received an 8-h infusion of 1 g kg-1 daily for two consecutive days. They were assessed clinically at days 15, 30, 60 and 90. The primary efficacy criterion was measurement of the severity scoring of AD (SCORAD) index at day 30.

RESULTS

The SCORAD values were not significantly different between the two groups at day 30. Similarly, global evaluation of disease severity by patients did not show any clinically significant change at day 30. In the cohort of 10 patients, the mean percentage decrease in SCORAD as compared with baseline was, respectively, 15%[95% confidence interval (CI) 6-24%] and 22% (95% CI 5-39%) at 30 and 60 days after IVIG infusion.

CONCLUSIONS

IVIG treatment was not associated with clinically significant improvement of AD signs and symptoms in this randomized study. Although this study may have been too small to detect a beneficial effect in a small subset of patients, the results do not support the common use of IVIG in refractory AD.

Treatment of refractory atopic dermatitis using 'wet-wrap' dressings and diluted corticosteroids: results of standardized treatment in both children and adults

BACKGROUND

'Wet-wrap' dressings with diluted corticosteroids form an alternative treatment in patients with refractory atopic dermatitis (AD).

OBJECTIVE

To evaluate a standardized treatment, using wet-wrap dressings with diluted corticosteroids, in patients with refractory AD.

METHODS

Results of treatment, complications and possible side effects were retrospectively evaluated in 14 children and 12 adults.

RESULTS

Skin lesions improved dramatically during 1 week of inpatient treatment. A significant decrease in early-morning serum cortisol levels was measured. Levels below the normal range were only observed after 1 week in 2 adults and on day 4 in 3 children. Suppression of the hypothalamus-pituitary-adrenal-cortex axis in 1 adult and a new exacerbation of AD in 2 children and 3 adults complicated long-term treatment at home. Additional complications included folliculitis, a Pseudomonas aeruginosa infection, a secondary bacterial infection and refractory skin lesions between bandages.

CONCLUSION

Wet-wrap dressings and diluted corticosteroids form an effective treatment in patients with refractory AD.

A review of high-dose intravenous immunoglobulin treatment for atopic dermatitis

Atopic dermatitis generally responds to topical therapy; however, small numbers of patients have severe resistant disease despite second line therapies. High-dose intravenous immunoglobulin (HdIVIg) which is being used increasingly for dermatological indications has been suggested to be of benefit in a small number of uncontrolled trials and case reports. The mode of action is via a number of immunomodulatory mechanisms and it is not associated with the many side-effects of steroids and other immunosuppressive agents. There are now reports of 32 atopic dermatitis patients treated with HdIVIg, and this review aims to make a critical assessment of the current data. These have been obtained from a Medline search of the English literature from 1966 to 2001 for intravenous immunoglobulin and atopic dermatitis/eczema. Taken together an improvement was observed in 61% of atopic dermatitis patients treated with HdIVIg. Adults appeared less likely to respond (48%) than children (90%) and the duration of response was also more prolonged in children. Adjunctive therapy in adults was more effective than monotherapy (59% vs 0%), whereas monotherapy was effective in 90% of children. HdIVIg may offer a safe potential therapeutic avenue for resistant cases of atopic dermatitis, particularly in children, but should be further assessed using double-blind placebo-controlled trials.

IVIG-pools: regulatory gifts--transiting from harmony toward harmonious immunoglobulins: why? and why not?

Based on 'initial conditions' which depend on each donors' exposure to a unique environment, a pooled intravenous immunoglobulin (IVIG) product transfers its immunoglobulin molecule repertoire, unchanged, to the altered host. The relay function of the cell-bound receptors, especially that of the inhibitory Fc(gamma)RIIB, may then allow sufficient amplification to make regulatory activity possible. To the clinician, IVIG may be considered a tool to promote reversal of the dysregulation causing autoimmune disease. Generically, IVIG may be seen as a promoter allowing a progression from harm by an inflammatory/fibrotic reaction, then down-regulating toward restitutio ad integrum. By modifying natural processes, IVIG may play minor roles in promoting defense against spontaneous bleeding and, perhaps, stimulating remyelination. The wide spectrum of IVIG specificities, by reflecting evolutionary epitope selection, may not further destabilize cell/molecule disarray in the affected host. Benefit to the patient by IVIG treatment cannot be predicted nor can potentially severe or even fatal accidents entirely be excluded. Important aspects of IVIG treatment still await clarification including dosage, timing and the isotype form. In the foreseeable future it does not seem that biotechnological advances will match the physiologic harmony of IVIG, leaving antibody characteristics aside.

Intravenous immunoglobulin therapy for the treatment of severe atopic dermatitis

Intravenous immunoglobulin (IVIg) is standard therapy for primary immunodeficiencies, Kawasaki Disease and idiopathic thrombocytopenic purpura. More recently, the use of high dose IVIg (2 g/kg in divided doses) has widened to include a number of inflammatory diseases, including atopic eczema. The mechanism of IVIg's anti-inflammatory action has yet to be fully understood. Proposed mechanisms include modulation of IgE responses and a reduction in inflammatory cytokines with a reduction in T-cell proliferation. Antibacterial and antitoxin effects may also play a role.

Intravenous immunoglobulin in autoimmune and inflammatory dermatoses. A review of proposed mechanisms of action and therapeutic applications

Off-label use of intravenous immunoglobulin (IVIG) at high doses has resulted in numerous anecdotal reports of its effectiveness in a variety of autoimmune and inflammatory conditions. Despite its growing acceptance as a viable therapeutic option in the management of several such disorders, the poorly defined mechanism of action of IVIG has stifled its rational therapeutic application. The lack of carefully designed prospective randomized clinical trials has further fueled controversy and mitigates against optimal application of this burgeoning therapy. Nevertheless, some standardization of IVIG therapy is slowly advancing that promises to support the use of this treatment for a growing number of autoimmune and inflammatory dermatoses.