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Alonso W, Vandeberg P, Lang J, Yuziuk J, Silverstein R, Stokes K, McBride D, Cruz M, Burns D, Merritt WK, Willis T, Jorquera JI. Immune globulin subcutaneous, human 20% solution (Xembify®), a new high concentration immunoglobulin product for subcutaneous administration. Biologicals 2020; 64:34-40. [PMID: 32085977 DOI: 10.1016/j.biologicals.2020.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/19/2019] [Accepted: 01/10/2020] [Indexed: 12/19/2022] Open
Abstract
Immune globulin subcutaneous, human 20% solution (IGSC-C 20%, Xembify®)-a new 20% immunoglobulin (IgG) liquid product for subcutaneous (SC) administration-has been developed by Grifols. The IGSC-C 20% formulation is based on knowledge acquired from the formulation of Immune Globulin Injection (Human),10% Caprylate/Chromatography Purified (IGIV-C 10%, Gamunex®-C). The protein concentration was increased from 10% to 20% to provide a smaller volume for SC administration. The IGSC-C 20% manufacturing process employs the same caprylate/chromatography purification steps as IGIV-C 10%, with the addition of an ultrafiltration step so that the product can be formulated at a higher protein concentration. IGSC-C 20% has been produced at full industrial scale to support clinical studies and licensure. These batches were characterized using a comprehensive panel of analytical testing. The new IGSC-C 20% product maintains the same composition, neutralizing activity, purity, and quality characteristics found in IGIV-C 10%.
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Affiliation(s)
- William Alonso
- Grifols Bioscience Research Group, 85 TW Alexander Drive, Research Triangle Park, NC, 27709, USA.
| | - Pete Vandeberg
- Grifols Bioscience Research Group, 85 TW Alexander Drive, Research Triangle Park, NC, 27709, USA
| | - John Lang
- Grifols Bioscience Research Group, 85 TW Alexander Drive, Research Triangle Park, NC, 27709, USA
| | - Jeffrey Yuziuk
- Grifols Bioscience Research Group, 85 TW Alexander Drive, Research Triangle Park, NC, 27709, USA
| | - Rebecca Silverstein
- Grifols Bioscience Research Group, 85 TW Alexander Drive, Research Triangle Park, NC, 27709, USA
| | - Kenya Stokes
- Grifols Bioscience Research Group, 85 TW Alexander Drive, Research Triangle Park, NC, 27709, USA
| | - Dennis McBride
- Grifols Bioscience Research Group, 85 TW Alexander Drive, Research Triangle Park, NC, 27709, USA
| | - Maria Cruz
- Grifols Bioscience Research Group, 85 TW Alexander Drive, Research Triangle Park, NC, 27709, USA
| | - Doug Burns
- Grifols Therapeutics LLC, 8368 US 70 Business Hwy West, Clayton, NC, 27520, USA
| | - W Keither Merritt
- Grifols Bioscience Research Group, 85 TW Alexander Drive, Research Triangle Park, NC, 27709, USA
| | - Todd Willis
- Grifols Bioscience Research Group, 85 TW Alexander Drive, Research Triangle Park, NC, 27709, USA
| | - Juan I Jorquera
- Grifols Bioscience Research Group, 85 TW Alexander Drive, Research Triangle Park, NC, 27709, USA
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Ochs HD, Melamed I, Borte M, Moy JN, Pyringer B, D Kobayashi AL, Knutsen AP, Smits W, Pituch-Noworolska A, Kobayashi RH. Intravenous immunoglobulin 10% in children with primary immunodeficiency diseases. Immunotherapy 2018; 10:1193-1202. [PMID: 30088423 DOI: 10.2217/imt-2018-0074] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To assess the safety and efficacy of an intravenous immunoglobulin (IVIG) 10% preparation (Panzyga®; Octapharma AG, Lachen, Switzerland) in predominantly antibody-deficient children with primary immunodeficiency disease. METHODS Data from two prospective, open-label and noncontrolled multicenter Phase III studies of IVIG 10% that included 25 patients <16 years of age were analyzed for efficacy, pharmacokinetics and safety. RESULTS The rate of serious bacterial infections was 0.04/patient-year. A maximal infusion rate of 0.14 ml/kg/min was achieved in 82% of pediatric patients (n = 9). Infusions of immunoglobulin G trough levels between infusions remained ≥5-6 g/l; median half-life was 32.79-36.62 days. Abdominal pain, headache and chills were the most common treatment-related adverse events. CONCLUSION IVIG 10% is safe and effective for the treatment of predominantly antibody-deficient children.
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Affiliation(s)
- Hans D Ochs
- Department of Pediatrics, University of Washington & Seattle Children's Research Institute, 1900 Ninth Avenue, Seattle, WA 98101, USA
| | - Isaac Melamed
- IMMUNOe Research Centers, 6801 South Yosemite Street, Centennial, CO 80112, USA
| | - Michael Borte
- Klinik für Kinder- und Jugendmedizin, Klinikum St. Georg gGmbH, Delitzscher Str. 141, 04129 Leipzig, Germany
| | - James N Moy
- Division of Pediatric Allergy/Immunology, Stroger Hospital of Cook County, 1901 W. Harrison Street, Chicago, IL 60612, USA
| | - Barbara Pyringer
- Octapharma Pharmazeutika Produktionsges.m.b.H., Oberlaaer Str. 235, 1100 Vienna, Austria
| | - Ai Lan D Kobayashi
- Midlands Pediatrics PC, 401 E. Gold Coast Road, Suite 325, Papillion, NE 68046, USA
| | - Alan P Knutsen
- Cardinal Glennon Children's Hospital, Saint Louis University, 1 N Grand Blvd, St Louis, MO 63103, USA
| | - William Smits
- The Allergy & Asthma Center, 7222 Engle Rd, Fort Wayne, IN 46804, USA
| | - Anna Pituch-Noworolska
- Department of Pediatrics, University Children Hospital, Jagiellonian University, Wielicka st 265, 30-663 Kraków, Poland
| | - Roger H Kobayashi
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, UCLA School of Medicine, Los Angeles, CA 90095, USA
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Melamed IR, Borte M, Trawnicek L, Kobayashi AL, Kobayashi RH, Knutsen A, Gupta S, Smits W, Pituch-Noworolska A, Strach M, Pulka G, Ochs HD, Moy JN. Pharmacokinetics of a novel human intravenous immunoglobulin 10% in patients with primary immunodeficiency diseases: Analysis of a phase III, multicentre, prospective, open-label study. Eur J Pharm Sci 2018. [PMID: 29522908 DOI: 10.1016/j.ejps.2018.03.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Intravenous immunoglobulin (IVIG) therapy is commonly used to treat patients with primary antibody deficiency. This prospective, open-label, non-randomised, multicentre, phase III trial investigated the pharmacokinetics of a new 10% liquid IVIG product (panzyga®; Octapharma) in 51 patients aged 2-75 years with common variable immunodeficiency (n = 43) or X-linked agammaglobulinaemia (n = 8). Patients were treated with IVIG 10% every 3 (n = 21) or 4 weeks (n = 30) at a dose of 200-800 mg/kg for 12 months. Total immunoglobulin G (IgG) and subclass concentrations approximately doubled from pre- to 15 min post-infusion. The maximum concentration of total IgG (mean ± SD) was 21.82 ± 5.83 g/L in patients treated 3-weekly and 17.42 ± 3.34 g/L in patients treated 4-weekly. Median trough IgG concentrations were nearly constant over the course of the study, remaining between 11.0 and 12.2 g/L for patients on the 3-week schedule and between 8.10 and 8.65 g/L for patients on the 4-week schedule. The median terminal half-life of total IgG was 36.1 (range 18.5-65.9) days, with generally similar values for the IgG subclasses (26.7-38.0 days). Median half-lives for specific antibodies ranged between 21.3 and 51.2 days for anti-cytomegalovirus, anti-Haemophilus influenzae, anti-measles, anti-tetanus toxoid, anti-varicella zoster virus antibodies, and anti-Streptococcus pneumoniae subtype antibodies. Overall, IVIG 10% demonstrated pharmacokinetic properties similar to those of other commercial IVIG 10% preparations and 3- or 4-weekly administration achieved sufficient concentrations of IgG, IgG subclasses, and specific antibodies, exceeding the recommended level needed to effectively prevent serious bacterial infections.
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Affiliation(s)
- Isaac R Melamed
- IMMUNOe Research Center, 6801 S. Yosemite street, Centennial, CO 80112, USA.
| | - Michael Borte
- Klinik für Kinder- und Jugendmedizin, Klinikum St. Georg gGmbH, Leipzig, Germany.
| | - Laurenz Trawnicek
- Octapharma Pharmazeutika Produktionsges.m.b.H, Oberlaaer Straße 235, 1100 Vienna, Austria.
| | | | | | - Alan Knutsen
- Saint Louis University, 1 N Grand Blvd, St Louis, MO 63103, USA.
| | - Sudhir Gupta
- University of California, C240 Med Sci I, Irvine, CA 92697, USA.
| | - William Smits
- The Allergy and Asthma Center, 7222 Engle Rd, Fort Wayne, IN 46804, USA
| | | | - Magdalena Strach
- Jagiellonian University Medical College, Świętej Anny 12, 31-008 Kraków, Poland.
| | - Grazyna Pulka
- Jagiellonian University Medical College, Świętej Anny 12, 31-008 Kraków, Poland.
| | - Hans D Ochs
- Department of Pediatrics, University of Washington and Seattle Children's Research Institute, Seattle, WA 98195, USA.
| | - James N Moy
- Division of Pediatric Allergy/Immunology, John H. Stroger, Jr. Hospital of Cook County, 1969 W. Ogden Ave., Chicago, IL 60612, USA; Rush University Medical Center, 1653 W. Congress Parkway, Chicago, IL 60612, USA.
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Comparative Study of Two ELISA Kits for Estimation of Antibodies to Hepatitis B Virus in Human Normal Immunoglobulin and Specific Immunoglobulin Intended for Intravenous or Intramuscular Use. Indian J Clin Biochem 2017; 32:243-245. [DOI: 10.1007/s12291-016-0590-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 06/19/2016] [Indexed: 10/21/2022]
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Impact of Site of Care on Infection Rates Among Patients with Primary Immunodeficiency Diseases Receiving Intravenous Immunoglobulin Therapy. J Clin Immunol 2017; 37:180-186. [PMID: 28160239 PMCID: PMC5325835 DOI: 10.1007/s10875-017-0371-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 01/18/2017] [Indexed: 01/31/2023]
Abstract
Purpose Patients with primary immunodeficiency diseases (PIDD) are at increased risk of infection and may require lifelong immunoglobulin G (IgG) replacement. Infection incidence rates were determined for patients with PIDD receiving intravenously administered IgG (IGIV) in a home or hospital outpatient infusion center (HOIC). Methods Data were extracted from a large, US-based, employer-sponsored administrative database. Patients were eligible for analysis if they had ≥1 inpatient or emergency room claim or ≥2 outpatient claims with a PIDD diagnosis between January 2002 and March 2013, 12 months of continuous health plan enrollment prior to index date (i.e., first IGIV infusion date), and 6 months of continuous IGIV at the same site of care after the index date. Incidences of pneumonia (bacterial or viral) and bronchitis (all types) within 7 days of IGIV infusion were retrospectively determined and compared between sites of care. Results A total of 1076 patients were included in the analysis; 51 and 49% received IGIV at home and at an HOIC, respectively. The event/patient-year of pneumonia was significantly lower in patients receiving IGIV at home compared to an outpatient hospital (0.102 vs. 0.216, p = 0.0071). Similarly, the event/patient-year of bronchitis was significantly lower among patients infusing at home compared to an HOIC (0.150 vs. 0.288, p < 0.0001). Conclusions PIDD patients experienced incidence rates for pneumonia and bronchitis that were lower for patients receiving home-based IGIV treatment versus HOIC-based IGIV treatment. The lower infection rates in the home setting suggest that infection risk may be an important factor in site of care selection.
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Lucas M, Lee M, Oksenhendler E, Chapel H. The ratio of mean daily IgG increment/mean daily dose in immunoglobulin replacement therapy in primary antibody deficiencies. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:998-1000.e2. [DOI: 10.1016/j.jaip.2015.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 06/30/2015] [Accepted: 07/01/2015] [Indexed: 11/29/2022]
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McClelland M, Crombez MM, Crombez C, Wenz C, Lisius M, Mattia A, Marku S. Implications for Advanced Practice Nurses When Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections (PANDAS) Is Suspected: A Qualitative Study. J Pediatr Health Care 2015; 29:442-52. [PMID: 25895693 DOI: 10.1016/j.pedhc.2015.03.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 03/15/2015] [Accepted: 03/16/2015] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS) is a relatively new but controversial diagnosis affecting hundreds of children and their families. It is generally thought to be an autoimmune disorder resulting from a streptococcal infection that causes significant and bizarre behavioral changes in children. Currently no definitive diagnostic or treatment modalities exist, which has led to misdiagnoses, ineffective treatments, and delayed care. METHODS A qualitative study was conducted that included 60 families with at least one child diagnosed with PANDAS. The purpose was to explore how families experience the disorder and what nurses can do to provide effective care. RESULTS Using paradigmatic analysis of transcribed interviews, three themes were identified: fear, frustration, and not being heard. DISCUSSION Results from this study suggest that more information is needed to better understand this challenging phenomenon from both medical and nursing perspectives. The study also reaffirms the importance of practicing the art of nursing, especially when the science is not yet established.
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Romberg V, Hoefferer L, El Menyawi I. Effects of the manufacturing process on the anti-A isoagglutinin titers in intravenous immunoglobulin products. Transfusion 2015; 55 Suppl 2:S105-9. [DOI: 10.1111/trf.13115] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 02/19/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Val Romberg
- Research & Development; CSL Behring LLC; King of Prussia Pennsylvania
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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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Buehler AM, Flato UP, Ferri CP, Fernandes JG. Is there evidence for recommending specific intravenous immunoglobulin formulations? A systematic review of head-to-head randomized controlled trials. Eur J Pharmacol 2015; 747:96-104. [DOI: 10.1016/j.ejphar.2014.11.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 11/11/2014] [Accepted: 11/12/2014] [Indexed: 11/27/2022]
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Molinaro I, Barbano B, Rosato E, Cianci R, Di Mario F, Quarta S, Sardo L, Salsano F, Amoroso A, Gigante A. Safety and infectious prophylaxis of intravenous immunoglobulin in elderly patients with membranous nephropathy. Int J Immunopathol Pharmacol 2014; 27:305-8. [PMID: 25004844 DOI: 10.1177/039463201402700220] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A variety of infections has been recognized as an important cause of morbidity and mortality in patients with nephrotic syndrome, and membranous nephropathy is a common cause of this in the elderly. The reasons for infection risk are due to oedema complications, urinary loss of factor B and D of the alternative complement pathway, cellular immunity, granulocyte chemotaxis, hypogammaglobulinemia with serum IgG levels below 600 mg/dL, and secondary effects of immunosuppressive therapy. Many different prophylactic interventions have been used for reducing the risks of infection in these patients but recommendations for routine use are still lacking. We report two membranous nephropathy cases in the elderly in which Intravenous immunoglobulin were useful in long-term infectious prophylaxis, showing safety in renal function. During immunosuppressant therapy in membranous nephropathy, intravenous immunoglobulin without sucrose are a safe therapeutic option as prophylaxis in those patients with nephrotic syndrome and IgG levels below 600 mg/dL. The long-term goal of infection prevention in these patients is to reduce mortality, prolong survival and improve quality of life.
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Affiliation(s)
- I Molinaro
- Department of Clinical Medicine, Clinical Immunology Unit, Scleroderma Center, Sapienza University of Rome, Italy
| | - B Barbano
- Department of Clinical Medicine, Nephrology Unit, Sapienza University of Rome, Italy
| | - E Rosato
- Department of Clinical Medicine, Clinical Immunology Unit, Scleroderma Center, Sapienza University of Rome, Italy
| | - R Cianci
- Department of Clinical Medicine, Nephrology Unit, Sapienza University of Rome, Italy
| | - F Di Mario
- Department of Clinical Medicine, Sapienza University of Rome, Italy
| | - S Quarta
- Department of Clinical Medicine, Clinical Immunology Unit, Scleroderma Center, Sapienza University of Rome, Italy
| | - L Sardo
- Department of Clinical Medicine, Sapienza University of Rome, Italy
| | - F Salsano
- Department of Clinical Medicine, Clinical Immunology Unit, Scleroderma Center, Sapienza University of Rome, Italy
| | - A Amoroso
- Department of Clinical Medicine, Sapienza University of Rome, Italy
| | - A Gigante
- Department of Clinical Medicine, Sapienza University of Rome, Italy
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Saeedian M, Randhawa I. Immunoglobulin Replacement Therapy: A Twenty-Year Review and Current Update. Int Arch Allergy Immunol 2014; 164:151-66. [DOI: 10.1159/000363445] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Laursen IA, Blou L, Sullivan JS, Bang P, Balstrup F, Houen G. Development, manufacturing and characterization of a highly purified, liquid immunoglobulin g preparation from human plasma. Transfus Med Hemother 2014; 41:205-12. [PMID: 25053934 DOI: 10.1159/000357982] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 05/14/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The use of plasma-derived immunoglobulin G (IgG) is increasing, and the number of diseases, including immunodeficiencies, neurological diseases and autoimmune conditions, treated with intravenous IgG (IVIG) is expanding. Consequently, there is a great need for high-yield production processes for plasma-derived IgG. The aim of this work was to develop a high-yield process leading to a highly purified, liquid, ready-to-use IgG for intravenous use. METHODS Plasma from healthy, voluntary, non-remunerated donors was fractionated by ethanol precipitation. IgG was extracted from fraction II + III using a phosphate/acetate buffer, pH 4, and purified by chromatography. RESULTS Precipitation with 6% polyethylene glycol at pH 7 removed high molecular-weight contaminating proteins, aggregates and contaminating viruses. Ion exchange chromatography at pH 5.7 on serially connected anion and cation exchange columns allowed for elution of IgG from the cation exchange column in good yield and high purity. Further safety was achieved by solvent/detergent treatment and repeated ion exchange chromatography. The product consisted of essentially only IgG monomers and dimers, and had a high purity with very low levels of IgM and IgA. CONCLUSION A process providing highly purified IVIG in good yield was developed.
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Affiliation(s)
- Inga A Laursen
- Department of Clinical Biochemistry and Immunology, Statens Serum Institut, Copenhagen, Denmark
| | - Lene Blou
- Department of Clinical Biochemistry and Immunology, Statens Serum Institut, Copenhagen, Denmark
| | | | - Peter Bang
- Department of Clinical Biochemistry and Immunology, Statens Serum Institut, Copenhagen, Denmark
| | - Flemming Balstrup
- Department of Clinical Biochemistry and Immunology, Statens Serum Institut, Copenhagen, Denmark
| | - Gunnar Houen
- Department of Clinical Biochemistry and Immunology, Statens Serum Institut, Copenhagen, Denmark
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St-Amour I, Paré I, Alata W, Coulombe K, Ringuette-Goulet C, Drouin-Ouellet J, Vandal M, Soulet D, Bazin R, Calon F. Brain bioavailability of human intravenous immunoglobulin and its transport through the murine blood-brain barrier. J Cereb Blood Flow Metab 2013; 33:1983-92. [PMID: 24045402 PMCID: PMC3851908 DOI: 10.1038/jcbfm.2013.160] [Citation(s) in RCA: 122] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 07/31/2013] [Accepted: 08/15/2013] [Indexed: 11/09/2022]
Abstract
Intravenous immunoglobulin (IVIg) is currently evaluated in clinical trials for the treatment of various disorders of the central nervous system. To assess its capacity to reach central therapeutic targets, the brain bioavailability of IVIg must be determined. We thus quantified the passage of IVIg through the blood-brain barrier (BBB) of C57Bl/6 mice using complementary quantitative and qualitative methodologies. As determined by enzyme-linked immunosorbent assay, a small proportion of systemically injected IVIg was detected in the brain of mice (0.009±0.001% of injected dose in the cortex) whereas immunostaining revealed localization mainly within microvessels and less frequently in neurons. Pharmacokinetic analyses evidenced a low elimination rate constant (0.0053 per hour) in the cortex, consistent with accumulation within cerebral tissue. In situ cerebral perfusion experiments revealed that a fraction of IVIg crossed the BBB without causing leakage. A dose-dependent decrease of brain uptake was consistent with a saturable blood-to-brain transport mechanism. Finally, brain uptake of IVIg after a subchronic treatment was similar in the 3xTg-AD mouse model of Alzheimer disease compared with nontransgenic controls. In summary, our results provide evidence of BBB passage and bioavailability of IVIg into the brain in the absence of BBB leakage and in sufficient concentration to interact with the therapeutic targets.
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Affiliation(s)
- Isabelle St-Amour
- 1] Centre de Recherche du CHU de Québec, Quebec, Canada [2] Faculté de Pharmacie, Université Laval, Centre Hospitalier de l'Université Laval (CHUL) Research Center, Quebec, Canada [3] Département de Recherche et Développement, Héma-Québec, Quebec, Canada
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Nursing guidelines for administration of immunoglobulin replacement therapy. JOURNAL OF INFUSION NURSING 2012; 36:58-68. [PMID: 23271153 DOI: 10.1097/nan.0b013e3182798af8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Immunoglobulin (Ig) replacement therapy, given as regular infusions of pooled human Ig, is the recognized treatment of humoral immunodeficiencies characterized by hypogammaglobulinemia and impaired antibody responses. It is a safe, effective therapy when delivered by nurses who have been educated to oversee and/or provide these infusions. Guidelines for administration have been developed by the Immune Deficiency Foundation Nurse Advisory Committee to provide a framework and guidance to those nurses administering this therapy.
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Schroeder HW, Dougherty CJ. Review of intravenous immunoglobulin replacement therapy trials for primary humoral immunodeficiency patients. Infection 2012; 40:601-11. [PMID: 22968971 PMCID: PMC3501191 DOI: 10.1007/s15010-012-0323-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Accepted: 08/17/2012] [Indexed: 11/26/2022]
Abstract
An available supply of intravenous immunoglobulin (IVIG) is essential for individuals with primary humoral immunodeficiency. A shortage in 1997 prompted the Food and Drug Administration (FDA) to revise guidelines for the licensure, production, and distribution of new IVIG products, including the standardization of United States clinical trials regarding endpoints for safety, efficacy, and pharmacokinetics. The following review is intended to present current information and results of clinical trials in patients with primary immunodeficiency treated with IVIG products currently licensed or awaiting licensure in the United States. The data presented are compiled from published clinical trials and prescribing information generated by manufacturers.
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Affiliation(s)
- H. W. Schroeder
- Department of Medicine, Division of Clinical Immunology and Rheumatology, The University of Alabama at Birmingham, Birmingham, AL USA
| | - C. J. Dougherty
- Clinical and Regulatory Affairs Department, Biotest Pharmaceuticals Corporation, Boca Raton, FL USA
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Impact of intravenous immunoglobulin on the dopaminergic system and immune response in the acute MPTP mouse model of Parkinson's disease. J Neuroinflammation 2012; 9:234. [PMID: 23046563 PMCID: PMC3520736 DOI: 10.1186/1742-2094-9-234] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 09/16/2012] [Indexed: 01/19/2023] Open
Abstract
Intravenous immunoglobulin (IVIg) is a blood-derived product, used for the treatment of immunodeficiency and autoimmune diseases. Since a range of immunotherapies have recently been proposed as a therapeutic strategy for Parkinson’s disease (PD), we investigated the effects of an IVIg treatment in a neurotoxin-induced animal model of PD. Mice received four injections of MPTP (15 mg/kg) at 2-hour intervals followed by a 14-day IVIg treatment, which induced key immune-related changes such as increased regulatory T-cell population and decreased CD4+/CD8+ ratio. The MPTP treatment induced significant 80% and 84% decreases of striatal dopamine concentrations (P < 0.01), as well as 33% and 40% reductions in the number of nigral dopaminergic neurons (P < 0.001) in controls and IVIg-treated mice, respectively. Two-way analyses of variance further revealed lower striatal tyrosine hydroxylase protein levels, striatal homovanillic acid concentrations and nigral dopaminergic neurons (P < 0.05) in IVIg-treated animals. Collectively, our results fail to support a neurorestorative effect of IVIg on the nigrostriatal system in the MPTP-treated mice and even suggest a trend toward a detrimental effect of IVIg on the dopaminergic system. These preclinical data underscore the need to proceed with caution before initiating clinical trials of IVIg in PD patients.
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Bleasel K, Heddle R, Hissaria P, Stirling R, Stone C, Maher D. Pharmacokinetics and safety of Intragam 10 NF, the next generation 10% liquid intravenous immunoglobulin, in patients with primary antibody deficiencies. Intern Med J 2012; 42:252-9. [DOI: 10.1111/j.1445-5994.2011.02712.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Mark SM. Comparison of Intravenous Immunoglobulin Formulations: Product Formulary, and Cost Considerations. Hosp Pharm 2011. [DOI: 10.1310/hpj4609-668] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose A review of the different formulations of intravenous immunoglobulin (IVIG) replacement therapy for primary immunodeficiency and other severe diseases, focusing on the comparative efficacy, safety, and tolerability of these formulations. This review discusses the manufacturing processes, physicochemical properties, and other attributes of IVIG therapy that affect its clinical utility. Summary IVIG therapy is a preferred treatment for patients with certain types of primary immunodeficiency, neuroimmunologic, and autoimmune hematologic disorders, as well as for immunomodulation in bone marrow and some solid organ transplants. The IVIG products available in the United States include lyophilized, 5% liquid, and 10% ready-to-use liquid formulations. Differences among these formulations in their manufacturing processes, excipients, pH, and physicochemical properties may be reflected as differences in clinical efficacy, safety, and tolerability. For example, compared with lyophilized and 5% liquid IVIG formulations, 10% ready-to-use IVIG liquid formulations may be associated with better tolerability because of lower IgA concentrations, optimal pH, use of glycine or proline stabilizers, low sodium content, and less osmolality. Liquid formulations (both 5% and 10%) may provide greater convenience than lyophilized formulations for both patients and health care providers, because they do not require further dilution before administration and have shorter infusion times. Conclusion Before selecting an IVIG product for a hospital formulary, pharmacists should be knowledgeable about the product's concentration to ensure delivery of the proper dosage, the staff training needed for proper administration, the potential benefits and problems of brand substitution, the safety and efficacy of each formulation, the hospital's policies on off-label use of IVIG, and the impact of reimbursement.
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Affiliation(s)
- Scott M. Mark
- West Penn Allegheny Health System, One Allegheny Center, 6th Floor, Pittsburgh, PA 15212
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Moy JN, Scharenberg AM, Stein MR, Suez D, Roberts RL, Levy RJ, Ballow M, Fasano MB, Dash CH, Leach SJ. Efficacy and safety of a new immunoglobulin G product, Gammaplex(®), in primary immunodeficiency diseases. Clin Exp Immunol 2011; 162:510-5. [PMID: 21070209 DOI: 10.1111/j.1365-2249.2010.04247.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
This open-label multi-centre study evaluated a new intravenous immunoglobulin, Gammaplex®, in the treatment of 50 patients with primary immunodeficiency and significant hypogammglobulinaemia. Patients treated previously with other intravenous immunoglobulins received Gammaplex® on their same infusion schedule for 1 year; 22 were on a 21-day and 28 on a 28-day regimen (300-800 mg/kg/infusion). There were no serious, acute bacterial infections, whereas six subjects (12·0%) had at least one such infection in the 6 months before enrollment. Forty subjects (80·0%) had at least one non-serious infection; the median number of infective episodes per subject per year was 3·07. Antibiotics were taken by 38 subjects therapeutically and prophylactically by 16 at some time. Fewer than half (46·0%) missed any time off work or school because of infection or other illness. Trough immunoglobulin (Ig)G levels were above 6·00 g/l in all subjects at all assessments after 15 weeks with two exceptions. Overall, 21·2% of infusions were associated with an adverse event up to 72 h after infusion. The frequency of adverse events increased with infusion rate. Headache was the most common product-related adverse event (7·5% of 703 infusions). In conclusion, Gammaplex® is effective in primary immunodeficiency and is well tolerated.
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Affiliation(s)
- J N Moy
- Rush University Medical Center, Chicago, IL, USA
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Wasserman RL, Irani AM, Tracy J, Tsoukas C, Stark D, Levy R, Chen J, Sorrells S, Roberts R, Gupta S. Pharmacokinetics and safety of subcutaneous immune globulin (human), 10% caprylate/chromatography purified in patients with primary immunodeficiency disease. Clin Exp Immunol 2011; 161:518-26. [PMID: 20550549 DOI: 10.1111/j.1365-2249.2010.04195.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Subcutaneous administration of intravenous immunoglobulin G (IgG) preparations provides an additional level of patient convenience and more options for patients with poor venous access or a history of intravenous IgG reactions. An open-label, pharmacokinetic trial (n = 32) determined the non-inferiority of the subcutaneous versus intravenous route of 10% caprylate/chromatography purified human immune globulin intravenous (IGIV-C; Gamunex®) administration by comparing the steady-state area under the concentration-versus-time curve (AUC) of total plasma IgG in patients with primary immunodeficiency disease. Patients on stable IGIV-C received two intravenous infusions (administered 3 or 4 weeks apart). Seven to 10 days after the second intravenous infusion, all patients switched to a weekly infusion of subcutaneous IGIV-C, with the dose equal to 137% of the previous weekly equivalent intravenous dose, for up to 24 weeks. Samples for pharmacokinetic analysis were collected during steady state for intravenous and subcutaneous IGIV-C treatments. The AUC(0-) τ geometric least-squares mean ratio was 0·89 (90% confidence interval, 0·86-0·92) and met the criteria for non-inferiority. The overall mean steady-state trough concentration of plasma total IgG with subcutaneous IGIV-C was 11·4 mg/ml, 18·8% higher than intravenous IGIV-C (9·6 mg/ml). Subcutaneous IGIV-C was safe and well tolerated. Subcutaneous IGIV-C infusion-site reactions were generally mild/moderate and the incidence decreased over time. No serious bacterial infections were reported. Weekly subcutaneous IGIV-C infusion using 137% of the weekly equivalent intravenous immunoglobulin dose provides an AUC comparable to intravenous administration, thus allowing patients to maintain the same IgG preparation/formulation if switching between intravenous and subcutaneous infusions.
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Cunningham-Rundles C. How I treat common variable immune deficiency. Blood 2010; 116:7-15. [PMID: 20332369 PMCID: PMC2904582 DOI: 10.1182/blood-2010-01-254417] [Citation(s) in RCA: 196] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Accepted: 03/12/2010] [Indexed: 01/04/2023] Open
Abstract
Common variable immunodeficiency is a rare immune deficiency, characterized by low levels of serum immunoglobulin G, A, and/or M with loss of antibody production. The diagnosis is most commonly made in adults between the ages of 20 and 40 years, but both children and older adults can be found to have this immune defect. The range of clinical manifestations is broad, including acute and chronic infections, inflammatory and autoimmune disease, and an increased incidence of cancer and lymphoma. For all these reasons, the disease phenotype is both heterogeneous and complex. Contributing to the complexity is that patient cohorts are generally small, criteria used for diagnosis vary, and the doses of replacement immune globulin differ. In addition, routines for monitoring patients over the years and protocols for the use of other biologic agents for complications have not been clarified or standardized. In the past few years, data from large patient registries have revealed that both selected laboratory markers and clinical phenotyping may aid in dissecting groups of subjects into biologically relevant categories. This review presents my approach to the diagnosis and treatment of patients with common variable immunodeficiency, with suggestions for the use of laboratory biomarkers and means of monitoring patients.
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Affiliation(s)
- Charlotte Cunningham-Rundles
- Department of Medicine, Mount Sinai School of Medicine, Mount Sinai Medical Center, 1425 Madison Ave, New York, NY 10029, USA.
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23
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The Use of Immunoglobulin Therapy for Patients With Primary Immune Deficiency: An Evidence-Based Practice Guideline. Transfus Med Rev 2010; 24 Suppl 1:S28-50. [DOI: 10.1016/j.tmrv.2009.09.011] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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24
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Misbah S, Sturzenegger MH, Borte M, Shapiro RS, Wasserman RL, Berger M, Ochs HD. Subcutaneous immunoglobulin: opportunities and outlook. Clin Exp Immunol 2009; 158 Suppl 1:51-9. [PMID: 19883424 PMCID: PMC2801034 DOI: 10.1111/j.1365-2249.2009.04027.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Immunoglobulin (Ig) administration via the subcutaneous (s.c.) route has become increasingly popular in recent years. The method does not require venous access, is associated with few systemic side effects and has been reported to improve patients' quality of life. One current limitation to its use is the large volumes which need to be administered. Due to the inability of tissue to accept such large volumes, frequent administration at multiple sites is necessary. Most studies conducted to date have investigated the use of subcutaneous immunoglobulin (SCIg) in patients treated previously with the intravenous (i.v.) formulation. New data now support the use of s.c. administration in previously untreated patients with primary immunodeficiencies. SCIg treatment may further be beneficial in the treatment of autoimmune neurological conditions, such as multi-focal motor neuropathy; however, controlled trials directly comparing the s.c. and i.v. routes are still to be performed for this indication. New developments may further improve and facilitate the s.c. administration route. For example, hyaluronidase-facilitated administration increases the bioavailability of SCIg, and may allow for the administration of larger volumes at a single site. Alternatively, more concentrated formulations may reduce the volume required for administration, and a rapid-push technique may allow for shorter administration times. As these developments translate into clinical practice, more physicians and patients may choose the s.c. administration route in the future.
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Affiliation(s)
- S Misbah
- John Radcliffe Hospital, Oxford, UK.
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25
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Cunningham-Rundles C. Lung disease, antibodies and other unresolved issues in immune globulin therapy for antibody deficiency. Clin Exp Immunol 2009; 157 Suppl 1:12-6. [PMID: 19630864 PMCID: PMC2715435 DOI: 10.1111/j.1365-2249.2009.03952.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2009] [Indexed: 01/12/2023] Open
Abstract
Defects of antibody production are the most common of the primary immune defects of man. While these defects have been described in clinical terms for more than five decades, in most cases, the pathogenesis is still poorly understood. The most common clinically important of these is common variable immune deficiency. However there is no strict definition of this defect and the criteria for initiating immune globulin therapy are not standardized, leading to wide variation in treatment practices. In addition there has been no clear means to adequate assess progression of lung disease or elucidate the causes of progressive pulmonary inflammation found in some subjects. Moreover, there are still questions such as what are the best predictors of chronic lung disease and how can we prevent this disorder. Other complications such as autoimmunity, granulomatous disease, gastrointestinal inflation, are similarly poorly understood although treatment with various biological agents has been used with some success. A few bio-markers for assessing clinical and immunologic status have been proposed, and some have proved to be useful, but additional methods to gauge the benefits of therapy, predict outcomes, and harmonize treatment practices are needed. Aside from Ig replacement, additional means of prevention of lung disease may need consideration to reduce lung damage apart from prophylactic antibiotics. These might include using macrolides as anti-inflammatory agents, inhaled corticosteroids, bronchodilators, mucolytics or mechanical or rehabilitative respiratory methods.
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26
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Moore ML, Quinn JM. Subcutaneous immunoglobulin therapy in pediatric primary antibody deficiency. ACTA ACUST UNITED AC 2009. [DOI: 10.2217/phe.09.17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Subcutaneous immunoglobulin (SCIG) therapy is recognized as a standard treatment for primary antibody deficiency. SCIG is efficacious for the prevention of infections and is associated with a lower risk of systemic side effects, improved quality of life for patients and families and is preferred by children when compared with intravenous immunoglobulin replacement. For pediatric patients, SCIG is an ideal treatment modality that affords children and families more freedom and less disruption of important childhood activities. This article reviews the characteristics of SCIG to provide the pediatric practitioner with an understanding of the experiences their patients receiveing SCIG may encounter.
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Affiliation(s)
- Meredith L Moore
- Department of Allergy & Immunology, Wilford Hall Medical Center, San Antonio, TX, USA
| | - James M Quinn
- Department of Allergy & Immunology, Wilford Hall Medical Center, San Antonio, TX, USA
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Burnouf T, A. Sayed M, Radosevich M, El-Ekiaby M. Comparative removal of solvent and detergent viral inactivating agents from human intravenous immunoglobulin G preparations using SDR HyperD and C18 sorbents. Anal Biochem 2009; 389:69-73. [DOI: 10.1016/j.ab.2009.03.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Revised: 03/16/2009] [Accepted: 03/16/2009] [Indexed: 11/27/2022]
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Wasserman RL, Church JA, Peter HH, Sleasman JW, Melamed I, Stein MR, Bichler J. Pharmacokinetics of a new 10% intravenous immunoglobulin in patients receiving replacement therapy for primary immunodeficiency. Eur J Pharm Sci 2009; 37:272-8. [PMID: 19491015 DOI: 10.1016/j.ejps.2009.02.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2008] [Revised: 02/13/2009] [Accepted: 02/21/2009] [Indexed: 10/21/2022]
Abstract
Intravenous immunoglobulin (IVIg) is used in treating immunodeficiencies and autoimmune or inflammatory disorders. As manufacturing processes and storage can alter IgG molecules, pharmacokinetic assessments are important for new preparations. Thus, we studied pharmacokinetics of IgPro10, a new 10% liquid IVIg product stabilised with l-proline, in patients with common variable immunodeficiency (CVID) and X-linked agammaglobulinaemia (XLA). Patients received IgPro10 for >or=4 months (median dose of 444mg/kg, at 3- or 4-week intervals). Median total IgG serum concentrations increased from 10.2g/l pre-infusion to 23.2g/l at infusion end. Serum IgG concentrations decreased in a biphasic manner; median terminal half-life was 36.6 days. Median half-lives were 33.2 for IgG(1), 36.3 for IgG(2), 25.9 for IgG(3) and 36.4 days for IgG(4). Specific antibody concentrations (anti-CMV, anti-Hemophilus influenzae type B, anti-tetanus toxoid and anti-Streptococcus pneumoniae) decreased with median half-lives of 22.3-30.5 days. IgPro10 pharmacokinetics were similar in patients with CVID and XLA, although patients with CVID showed higher levels of anti-tetanus and anti-S. pneumoniae antibodies than patients with XLA, suggesting residual specific antibody production. IgPro10 pharmacokinetics fulfilled expectations for and were similar to intact IgG products. Administration of IgPro10 at 3- or 4-week intervals achieved sufficient plasma concentrations of total IgG, IgG subclasses and antibodies specific to important pathogens.
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29
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Bonilla FA. Pharmacokinetics of immunoglobulin administered via intravenous or subcutaneous routes. Immunol Allergy Clin North Am 2009; 28:803-19, ix. [PMID: 18940575 DOI: 10.1016/j.iac.2008.06.006] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This article reviews pharmacokinetic studies of IgG administration by intravenous and subcutaneous routes. Intravenous immunoglobulin pharmacokinetics have been studied during replacement therapy for primary and secondary immunodeficiencies and other special circumstances (eg, infection prophylaxis in neonates). Subcutaneous immunoglobulin pharmacokinetics have been studied only during replacement therapy for primary immunodeficiency. Published studies vary greatly with respect to the nature of the patients studied, dose regimens, sampling schedules, and pharmacokinetic models, making comparisons difficult. With either route of administration, there is large variation in individual IgG elimination rates. Periodic measurement of serum IgG concentration is critical to monitor the adequacy of replacement during therapy.
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Affiliation(s)
- Francisco A Bonilla
- Division of Immunology, Children's Hospital Boston, Fegan Building, 6th Floor, 300 Longwood Avenue, Boston, MA 02115, USA.
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30
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Moore ML, Quinn JM. Subcutaneous immunoglobulin replacement therapy for primary antibody deficiency: advancements into the 21st century. Ann Allergy Asthma Immunol 2008; 101:114-21; quiz 122-3, 178. [PMID: 18727465 DOI: 10.1016/s1081-1206(10)60197-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To provide a review of the world literature and discuss the clinical role of subcutaneous immunoglobulin (SCIG) therapy for primary antibody deficiency. DATA SOURCES English-language publications on SCIG therapy were identified through MEDLINE and through the reference list of the initially identified publications. STUDY SELECTION Articles pertaining to SCIG for the treatment of immunodeficiency, particularly primary antibody deficiency, were selected. RESULTS SCIG therapy has been shown to be effective and safe for the treatment of primary immunodeficiency. The risk of systemic reactions during infusion is generally reported to be less than 1%. Many patients prefer SCIG over conventional intravenous immunoglobulin therapy because of increased convenience and independence associated with SCIG therapy. Publications show SCIG therapy to be advantageous in selected patient populations, such as children, pregnant women, and patients with poor intravenous access. CONCLUSION SCIG therapy has been widely used in some European countries for a number of years, but a Food and Drug Administration-approved product was only recently introduced into the United States in 2006. SCIG therapy offers unique advantages that are applicable to many patients receiving immunoglobulin therapy for primary immunodeficiency.
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Affiliation(s)
- Meredith L Moore
- Allergy/Immunology Clinic, Wilford Hall Medical Center, San Antonio, Texas 78236, USA.
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31
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Principles of and advances in immunoglobulin replacement therapy for primary immunodeficiency. Immunol Allergy Clin North Am 2008; 28:413-37, x. [PMID: 18424340 PMCID: PMC7127239 DOI: 10.1016/j.iac.2008.01.008] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
During the last 2 decades, the continued development and the large-scale production of polyclonal immune serum globulin (ISG) preparations with improved safety and tolerability profiles have allowed treatment to focus on quality of life and long-term freedom from the complications of primary immune deficiency disease, rather than just on freedom from severe acute infections and survival. Available ISG preparations allow routine therapy by a variety of routes and regimens that can be tailored to suit individual patients. Continued vigilance is required, however, because problems with emerging diseases, and the costs and availability of ISG are likely to present continuing challenges.
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Shah SR. A newer immunoglobulin intravenous (IGIV) – Gammagard®liquid 10%: Evaluation of efficacy, safety, tolerability and impact on patient care. Expert Opin Biol Ther 2008; 8:799-804. [DOI: 10.1517/14712598.8.6.799] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Gustafson R, Gardulf A, Hansen S, Leibl H, Engl W, Lindén M, Müller A, Hammarström L. Rapid subcutaneous immunoglobulin administration every second week results in high and stable serum immunoglobulin G levels in patients with primary antibody deficiencies. Clin Exp Immunol 2008; 152:274-9. [PMID: 18341618 DOI: 10.1111/j.1365-2249.2008.03620.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Subcutaneous immunoglobulin G (SCIG) infusions as life-long replacement therapy in patients with primary antibody deficiences (PAD) is being applied increasingly. However, only a few published pharmacokinetic studies are available for this route of administration. Therefore, the pharmacokinetics of a 16% immunoglobulin G (IgG) preparation intended for subcutaneous use were investigated in patients with common variable immunodeficiency and X-linked agammaglobulinaemia. SCIG infusions (200 mg/kg body weight) were administered to 12 adult patients every 14 days for 24 weeks (total of 144 infusions). Pharmacokinetic parameters were determined based on serum IgG trough levels and antibody levels against tetanus. The median half-life of the total serum IgG and for the tetanus antibodies was 40.6 and 23.3 days respectively. Median in vivo recovery of serum IgG and tetanus immunoglobulins were 36% and 46% respectively. Median, preinfusion serum IgG trough levels per patient were high without major variations between infusions and ranged from 7.24 to 7.86 g/l. Safety, in terms of adverse events including systemic adverse reactions and local tissue reactions at infusions sites, was monitored throughout the study. Six mild, local tissue reactions were observed during the study in one patient. No systemic adverse reactions related to the study drug were observed and no serious other adverse event occurred during the study. It is concluded that the bi-weekly SCIG therapy was well tolerated in the study and that it results in high and stable serum IgG levels, offering an alternative therapy regimen to patients suffering from PAD.
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Affiliation(s)
- R Gustafson
- Immunodeficiency Unit, Karolinska University Hospital, Huddinge, Stockholm, and Baxter Medical AB, Kista, Stockholm, Sweden.
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Aghaie A, Pourfathollah AA, Bathaie SZ, Moazzeni SM, Khorsand Mohammad Pour H, Banazadeh S. Structural study on immunoglobulin G solution after pasteurization with and without stabilizer. Transfus Med 2008; 18:62-70. [DOI: 10.1111/j.1365-3148.2007.00778.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Wood P, Stanworth S, Burton J, Jones A, Peckham DG, Green T, Hyde C, Chapel H. Recognition, clinical diagnosis and management of patients with primary antibody deficiencies: a systematic review. Clin Exp Immunol 2007; 149:410-23. [PMID: 17565605 PMCID: PMC2219316 DOI: 10.1111/j.1365-2249.2007.03432.x] [Citation(s) in RCA: 142] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The primary purpose of this systematic review was to produce an evidence-based review of the literature as a means of informing current clinical practice in the recognition, diagnosis and management of patients with suspected primary antibody deficiency. Randomized controlled trials (RCTs) were identified from a search of MEDLINE, EMBASE, The Cochrane Library, DARE (CRD website) and CINAHL by combining the search strategies with The Cochrane Collaboration's validated RCT filter. In addition, other types of studies were identified in a separate search of MEDLINE and EMBASE. Patients at any age with recurrent infections, especially in the upper and lower respiratory tracts, should be investigated for possible antibody deficiency. Replacement therapy with immunoglobulin in primary antibody deficiencies increases life expectancy and reduces infection frequency and severity. Higher doses of immunoglobulin are associated with reduced infection frequency. Late diagnosis and delayed institution of immunoglobulin replacement therapy results in increased morbidity and mortality. A wide variety of organ-specific complications can occur in primary antibody deficiency syndromes, including respiratory, gastroenterological, hepatic, haematological, neurological, rheumatological and cutaneous. There is an increased risk of malignancy. Some of these complications appear to be related to diagnostic delay and inadequate therapy. High-quality controlled trial data on the therapy of these complications is generally lacking. The present study has identified a number of key areas for further research, but RCT data, while desirable, is not always obtained easily for rare conditions. Few data from registries or large case-series have been published in the past 5 years and a greater focus on international collaboration and pooling of data is needed.
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Affiliation(s)
- P Wood
- Department of Clinical Immunology, St James's University Hospital, Leeds, UK.
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36
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Lambert M. Atelier SNFMI du jeudi 7 décembre 2006. Les immunoglobulines sous-cutanées pourquoi et comment? Exemple de Vivaglobin. Rev Med Interne 2007; 28:436-40. [PMID: 17459535 DOI: 10.1016/j.revmed.2007.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- M Lambert
- MCU-PH, Service de Médecine Interne, Hôpital Huriez, CHRU de Lille, France.
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37
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Elluru S, Duong Van Huyen JP, Prost F, Delignat S, Bayry J, Ephrem A, Siberil S, Misra N, Lacroix-Desmzes S, Kazatchkine MD, Kaveri SV. Comparative study of the anti-inflammatory effect of two intravenous immunoglobulin preparations manufactured by different processes. Immunol Lett 2006; 107:58-62. [PMID: 16952403 DOI: 10.1016/j.imlet.2006.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2006] [Revised: 07/27/2006] [Accepted: 07/28/2006] [Indexed: 11/17/2022]
Abstract
Intravenous immunoglobulin (IVIG) is increasingly used in the treatment of diverse immune-mediated disorders. Since several preparations of IVIG are available for therapy, it is possible that different manufacturing processes might influence clinical efficacy of IVIG. An insight into the mechanisms of action of such different IVIG preparations is therefore necessary that will provide further guidelines for the utility of IVIG preparations in autoimmune and inflammatory diseases. Since endothelial cells (EC) influence the inflammatory process via production of cytokines, chemokines and expression of adhesive molecules, we analyzed the anti-inflammatory effect on EC of two IVIG preparations: caprylated IVIG (IVIG-C) versus solvent/detergent-treated IVIG (IVIG-SD) preparation. We found that both IVIG preparations inhibit in an equivalent manner, the expression of different pro-inflammatory factors such as IL-6, IL-8, GM-CSF, IL-1beta and TNF-alpha and the adhesion molecules ICAM-1 and VCAM-1. Our results thus suggest that the caprylate while inactivating the virus and enhancing the yield of IgG during IVIG formulation, does not modulate the immunomodulatory properties of IVIG at EC level and that the two preparations show similar anti-inflammatory effects.
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Affiliation(s)
- Sriramulu Elluru
- INSERM U681, Université Pierre et Marie Curie, UPMC, Paris 6, Institut des Cordeliers, 15 Rue de l'Ecole de Médecine, 75006 Paris, France
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38
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Abstract
BACKGROUND Intravenous immunoglobulin (IGIV) is used in the treatment of a wide variety of immune disorders. To our knowledge, no comprehensive or systematic review on the pharmacokinetics of IGIV has been published despite the availability of many published individual studies. OBJECTIVE To systematically review published studies of the pharmacokinetics of IGIV. METHODOLOGY We conducted a search of PubMed/MEDLINE from January 1966-September 2005 and EMBASE from January 1980-September 2005 for English-language articles on the pharmacokinetics of IGIV. This search was supplemented by a bibliographic review of all relevant articles. RESULTS Data elements extracted from these articles included study design, number of study subjects, indication for IGIV therapy, IGIV treatment regimen (formulation, dosage, and duration), pharmacokinetic parameters (clearance, volume of distribution, elimination rate constant, and half-life), analytic methodology, pharmacokinetic model, and blood sampling times. The United States Preventive Services Task Force rating scale was used to categorize the 50 pertinent citations identified in our literature search. According to the rating scale, 12 studies were level I (prospective, randomized, controlled studies), 3 were level II-1 (prospective, nonrandomized, controlled studies), 30 were level II-2 (prospective, nonrandomized, uncontrolled [cohort] studies), and 5 were level III (case reports or descriptive studies). CONCLUSION The pharmacokinetics of IGIV shows considerable intra- and interpopulation variability among patients with normal immunoglobulin levels, patients with primary immunodeficiency diseases, bone marrow transplant recipients, patients with immune deficiency due to chronic lymphocytic leukemia or multiple myeloma, very low birth weight neonates, neonates with suspected sepsis, high-risk infants in the neonatal intensive care unit, high-risk infants with cardiopulmonary disease, children with cryptogenic West or Lennox-Gastaut syndrome, women and infants with fetal alloimmune thrombocytopenia, and women with recurrent spontaneous abortions. Despite the large number of studies characterizing the pharmacokinetics of IGIV, major literature gaps include lack of information on IGIV clearance or area under the curve parameters and target serum immunoglobulin G concentrations. Further study is needed to rigorously characterize the pharmacokinetic properties of IGIV in a range of patient populations.
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Affiliation(s)
- Tamar Koleba
- Division of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, University of British Columbia, and the Department of Pharmacy, Children's and Women's Health Centre of British Columbia, Vancouver, British Columbia, Canada
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Church JA, Leibl H, Stein MR, Melamed IR, Rubinstein A, Schneider LC, Wasserman RL, Pavlova BG, Birthistle K, Mancini M, Fritsch S, Patrone L, Moore-Perry K, Ehrlich HJ. Efficacy, safety and tolerability of a new 10% liquid intravenous immune globulin [IGIV 10%] in patients with primary immunodeficiency. J Clin Immunol 2006; 26:388-95. [PMID: 16705486 DOI: 10.1007/s10875-006-9025-3] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2005] [Accepted: 04/13/2006] [Indexed: 11/24/2022]
Abstract
The present clinical study was designed to evaluate the efficacy, pharmacokinetics and safety of a new 10% liquid intravenous immune globulin in patients with primary immunodeficiency diseases. Sixty-one adults and children with primary immuno-deficiency diseases received doses of 300-600 mg/kg body weight every 21-28 days for 12 months. No validated acute serious bacterial infections were reported. The 95% confidence interval for the annualized rate of acute serious bacterial infections (primary endpoint) was 0-0.060. A total of four predefined validated other bacterial infections commonly occurring in primary immunodeficiency disease subjects were observed; none were serious, severe or resulted in hospitalization. The median elimination half-life of IgG was 35 days. Median total IgG trough levels varied from 9.6 to 11.2 g/L. Temporally associated adverse experiences were determined for 72 h after each infusion and the most common adverse experience was headache, which was associated with 6.9% of infusions. The study met the primary endpoint for efficacy and demonstrated excellent tolerability of the new 10% liquid intravenous imunoglobulin preparation.
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Affiliation(s)
- Joseph A Church
- Childrens Hospital Los Angeles, Los Angeles, California, USA
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Reid B, Van Allen D, LaGrange CA, Boissonneault N. Protocol Recommendations for Administration of Intravenous Immunoglobulin in Canada. JOURNAL OF INFUSION NURSING 2006; 29:158-64. [PMID: 16878858 DOI: 10.1097/00129804-200605000-00006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A group of Canadian nurses and transfusion safety officers developed 10 recommendations for the infusion of intravenous immunoglobulin (IVIG) in acute care hospitals and clinics. The recommendations address issues related to documentation, patient consent, difference among IVIG brands, selection of a brand on the basis of patients' risk factors, contraindications, needs, action plans for adverse events, rapid infusion protocols, and setup of infusion pumps, tubing, and filter equipment. The Canadian group encouraged institutions to include nurses on committees that examine infusion protocols.
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Affiliation(s)
- Brenda Reid
- The Hospital for Sick Children, Toronto, Ontario, Canada.
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Björkander J, Nikoskelainen J, Leibl H, Lanbeck P, Wallvik J, Lumio JT, Braconier JH, Pavlova BG, Birthistle K, Engl W, Walter S, Ehrlich HJ. Prospective open-label study of pharmacokinetics, efficacy and safety of a new 10% liquid intravenous immunoglobulin in patients with hypo- or agammaglobulinemia. Vox Sang 2006; 90:286-93. [PMID: 16635071 DOI: 10.1111/j.1423-0410.2006.00764.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND OBJECTIVES The aim of this study was to evaluate the pharmacokinetics, efficacy and safety of a newly developed 10% liquid immunoglobulin preparation in patients with primary immunodeficiency diseases. This new preparation for intravenous use includes three dedicated virus clearance steps in its manufacturing process to ensure a high margin of viral safety. MATERIALS AND METHODS This was a prospective, open-label, non-controlled, multicentre study. Twenty-two subjects with primary immunodeficiency were treated initially with three infusions of a licensed intravenous immunoglobulin to standardize the immunoglobulin G (IgG) replacement therapy of all subjects to the same intravenous product. A total of nine infusions of the new 10% liquid preparation were subsequently administered. RESULTS The median terminal half-life of total IgG following administration of the new preparation was 30.1 days. Median terminal half-lives for IgG subclasses IgG(1), IgG(2), IgG(3) and IgG(4) were 28.3, 31.3, 20.9 and 24.2 days, respectively. The median total serum IgG steady-state trough level was 8.51 g/l. No severe infection episodes started after initiation of treatment with the new preparation. The median rate of mild or moderate infection episodes was 0.48 per month. A total of 194 infusions with the new 10% liquid immunoglobulin preparation were administered. The mean dose per infusion was 0.41 g/kg body weight and the maximum infusion rates recorded were 8 ml/kg/h. Adverse experiences were mostly mild and unrelated to the study drugs. Only 4% of infusions with the new product were followed by one or more related adverse experiences. CONCLUSION The new 10% liquid immunoglobulin preparation was well tolerated and shown to have an excellent pharmacokinetic, efficacy and safety profile. The liquid formulation provides convenience to patients and healthcare professionals.
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Roifman CM, Schroeder H, Berger M, Sorensen R, Ballow M, Buckley RH, Gewurz A, Korenblat P, Sussman G, Lemm G. Comparison of the efficacy of IGIV-C, 10% (caprylate/chromatography) and IGIV-SD, 10% as replacement therapy in primary immune deficiency. A randomized double-blind trial. Int Immunopharmacol 2003; 3:1325-33. [PMID: 12890430 DOI: 10.1016/s1567-5769(03)00134-6] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
A novel method of large-scale chromatography has been developed to improve recovery and purity of immunoglobulin G (IgG) from pooled plasma. The current study compares safety, toxicity and efficacy of two intravenous immunoglobulin products: a novel formulation, IGIV caprylate/chromatography (IGIV-C; Gamunex, 10%) and a licensed solvent/detergent-treated product, Gamimune N, 10% (IGIV-SD). The study, a randomized, double-blind, parallel group, therapeutic equivalence trial, was conducted at 25 treatment centers in Canada and the United States. Patients (n=172) having confirmed chronic primary immunodeficiency (PID), aged 1-75 years, and receiving IGIV therapy were enrolled. For 9 months, patients were treated with IGIV-C or IGIV-SD in accordance with the patient's individualized treatment regimen utilized before study entry. The primary endpoint was the proportion of patients with >or=1 validated acute sinopulmonary infection during the treatment period. Secondary endpoints included the proportion of patients with all infections, time to first infection, annual infection rates, lung function parameters, infusion-related safety and viral safety. The annual validated infection rate in the IGIV-C group was 0.18 compared to 0.43 in the IGIV-SD group (p=0.023). Nine patients receiving IGIV-C experienced validated infections, compared to 17 patients in IGIV-SD group (p=0.06). Acute sinusitis (validated plus clinically defined) was less frequent in the IGIV-C group (p=0.012). Presence of bronchiectasis did not affect efficacy. Adverse reactions were similar in frequency and severity in both groups. No evidence of viral transmission was observed. IGIV-C appears to be superior to IGIV-SD in preventing validated sinopulmonary infections, especially acute sinusitis, in patients with PID.
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Affiliation(s)
- Chaim M Roifman
- Division of Immunology/Allergy, Hospital for Sick Children, Toronto, ON, Canada M5G 1X8.
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Lebing W, Remington KM, Schreiner C, Paul HI. Properties of a new intravenous immunoglobulin (IGIV-C, 10%) produced by virus inactivation with caprylate and column chromatography. Vox Sang 2003; 84:193-201. [PMID: 12670368 DOI: 10.1046/j.1423-0410.2003.00285.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Current manufacture of intravenous immunoglobulin (Gamimune N) uses four cold-ethanol precipitation steps and solvent-detergent treatment. Our objective was to design a new manufacturing process to maximize immunoglobulin G (IgG) purity, achieve robust viral safety, preserve all the biological activities of antibody and avoid unnecessary protein loss. MATERIALS AND METHODS The new process combines multiple functions in single steps. Caprylate is added to precipitate non-IgG proteins and to inactivate enveloped viruses. Two successive anion-exchange columns are used to purify IgG and remove caprylate. The new product, IGIV-C (Gamunex, 10%) is formulated with glycine at 100 mg/ml IgG, pH 4.25. Vials are incubated for 21 days at 23-27 degrees C in a final virus-inactivation step. RESULTS Compared with the process for production of Gamimune N, that for IGIV-C requires a shorter production time, achieves more robust virus inactivation, increases IGIV yield from plasma, improves physiological IgG subclass distribution (resulting in higher levels of IgG4), and improves purity, with lower levels of IgA (40 microg/ml), IgM (< 2 microg/ml) and albumin (< 20 microg/ml). Antibody binding, opsonization and protective activities are similar. CONCLUSIONS Compared with the current commercial process, the new IGIV-C manufacturing process produces a more highly purified preparation that contains slightly higher levels of IgG4 and retains antibody activities required for clinical efficacy.
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Affiliation(s)
- W Lebing
- Technology Department, Bayer Health Care, Biological Products Division, Clayton, North Carolina 27520, USA.
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