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Kapoor M, Khoo A, Lunn MPT, Reddel S, Carr AS. Immunoglobulin use in neurology: a practical approach. Pract Neurol 2024:pn-2022-003655. [PMID: 39097408 DOI: 10.1136/pn-2022-003655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2024] [Indexed: 08/05/2024]
Abstract
Human immunoglobulin, delivered either intravenously (IVIg) or subcutaneously, is used to treat a range of immune-mediated neurological disorders. It has a role in acute or subacute inflammatory disease control and as a maintenance therapy in chronic disease management. This review considers mechanisms of IVIg action and the evidence for IVIg in neurological conditions. We use Guillain-Barré syndrome and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) as frameworks to demonstrate an approach to IVIg use in acute and chronic dysimmune neurological conditions across two different healthcare systems: the UK and Australia. We highlight the benefits and limitations of IVIg and focus on practical considerations such as informed consent, managing risks and adverse effects, optimal dosing and monitoring response. We use these basic clinical practice principles to discuss the judicious use of an expensive and scarce blood product with international relevance.
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Affiliation(s)
- Mahima Kapoor
- Neuroscience / FMNHS / School of Translational Medicine, Monash University, Melbourne, Victoria, Australia
| | - Anthony Khoo
- Flinders University College of Medicine and Public Health, Adelaide, South Australia, Australia
- Department of Neurology, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Michael P T Lunn
- Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
- UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Stephen Reddel
- ANZAC Research Institute, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Aisling S Carr
- UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
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Cook M, Pasnoor M, Ajroud-Driss S, Brannagan TH, Dimachkie MM, Allen JA. CIDP prognosis in patients with IVIG treatment-related fluctuations. Muscle Nerve 2023; 67:69-73. [PMID: 36330716 PMCID: PMC10098814 DOI: 10.1002/mus.27746] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 10/22/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION/AIMS Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an acquired immune-mediated peripheral nerve disorder with variable prognosis and long-term dependence on immunotherapy. Frequent assessment of grip strength can be a useful tool to identify intravenous immunoglobulin (IVIG) treatment-related fluctuations (TRFs) and optimize IVIG treatment in real-time, but the long-term implications of TRFs are unknown. We aimed to explore the impact that real-time TRFs had on long-term CIDP prognosis, strength impairment, and disability. METHODS This retrospective observational cohort study analyzed standard of care clinical and treatment outcomes in patients who participated in a published prospective study of intra-IVIG-cycle grip strength quantification. Patients were analyzed based upon the presence or absence of TRFs, as determined in the initial prospective study. RESULTS Data were available for 23 CIDP patients with a mean follow-up period of 44.7 mo. There were no differences in baseline or follow-up strength, disability, or IVIG usage in patients with a low number of fluctuations compared to those with a high number of fluctuations. In both groups, drug-free remission was achieved in about one-third of patients. DISCUSSION TRFs are important to identify in order to optimize treatment in real time, but poorly predict long-term disease activity status. The presence of minor TRFs are unlikely to result in substantial accumulation of disability over time. Periodic IVIG optimization trials using objective outcomes are encouraged in all CIDP patients receiving chronic IVIG treatment as a means to identify the lowest effective IVIG dose and frequency.
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Affiliation(s)
- Melissa Cook
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mamatha Pasnoor
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Senda Ajroud-Driss
- Department of Neurology, Northwestern University, Chicago, Illinois, USA
| | - Thomas H Brannagan
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Mazen M Dimachkie
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jeffrey A Allen
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
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Keh RYS, Shah S, Lilleker JB, Lavin T, Morrow J, Carr AS, Lunn MP. Pragmatic guide to peripheral nerve disease and the role of clinical biomarkers. Pract Neurol 2022; 22:pn-2022-003438. [PMID: 35850979 DOI: 10.1136/pn-2022-003438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2022] [Indexed: 11/03/2022]
Abstract
In clinical neurology practice, there are few sensitive, specific and responsive serological biomarkers reflecting pathological processes affecting the peripheral nervous system. Instead, we rely on surrogate multimodality biomarkers for diagnosis and management. Correct use and interpretation of the available tests is essential to ensure that appropriate treatments are used and adjusted in a timely fashion. The incorrect application or interpretation of biomarkers can result in misdiagnosis and delays in appropriate treatment. Here, we discuss the uses and limitations of such biomarkers and discuss possible future developments.
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Affiliation(s)
- Ryan Yann Shern Keh
- Centre for Neuromuscular Diseases, National Hospital of Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - Sachit Shah
- Lysholm Department of Neuroradiology, National Hospital of Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | - James B Lilleker
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester, UK
- Division of Musculoskeletal and Dermatological, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Tim Lavin
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - Jasper Morrow
- Centre for Neuromuscular Diseases, National Hospital of Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
- Lysholm Department of Neuroradiology, National Hospital of Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | - Aisling S Carr
- Centre for Neuromuscular Diseases, National Hospital of Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
- Institute of Neurology, University College London, London, UK
| | - Michael P Lunn
- Centre for Neuromuscular Diseases, National Hospital of Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
- Institute of Neurology, University College London, London, UK
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van Veen R, Wieske L, Lucke I, Adrichem ME, Merkies ISJ, van Schaik IN, Eftimov F. Assessing deterioration using impairment and functional outcome measures in chronic inflammatory demyelinating polyneuropathy: a post-hoc analysis of the IOC trial. J Peripher Nerv Syst 2022; 27:144-158. [PMID: 35507446 PMCID: PMC9321849 DOI: 10.1111/jns.12497] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/05/2022] [Accepted: 04/10/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS It is unclear whether frequently used cut-off values for outcome measures defining minimal clinically important differences (MCIDs) can accurately identify meaningful deterioration in chronic inflammatory demyelinating polyneuropathy (CIDP). METHODS We used data from the IOC trial, in which sixty clinically stable CIDP patients were randomized to IVIg withdrawal or continuation. We calculated change scores of the Inflammatory Rasch-Built Overall Disability Scale (I-RODS), grip strength, and MRC sum score (MRC-SS) and classified visits based on a treatment anchor (i.e. decision to restart/increase treatment after reaching a predefined early endpoint of deterioration). The variability of scores in patients without deterioration was calculated using the limits of agreement. We defined optimized MCIDs for deterioration and specific combinations of MCIDs from different outcome measures, and subsequently calculated the accuracies of the (combined) MCIDs. RESULTS Substantial variability was found in scores of the I-RODS, grip strength and MRC-SS in patients without deterioration over time, and most MCIDs were within the limits of the variability observed in patients without deterioration. Some MCID cut-offs were insensitive but highly specific for detecting deterioration, e.g. the MCID-SE of -1.96 of the I-RODS and -2 point on the MRC-SS. Others were sensitive, but less specific, e.g. -4 centiles of the I-RODS. Some combined MCIDs resulted in high specificities and moderate sensitivities. INTERPRETATION Our results suggest that clinically important deterioration cannot be distinguished from variability over time with currently used MCIDs on the individual level. Combinations of MCIDs might improve the accuracy of determining deterioration, but this needs validation.
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Affiliation(s)
- Robin van Veen
- Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Luuk Wieske
- Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Department of Clinical Neurophysiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Ilse Lucke
- Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Max E Adrichem
- Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Ingemar S J Merkies
- Maastricht Academic Medical Centre, Maastricht, the Netherlands.,Curaçao Medical Centre, Willemstad, Curacao
| | - Ivo N van Schaik
- Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Spaarne Gasthuis, Haarlem, the Netherlands
| | - Filip Eftimov
- Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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