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Soumerai JD, Yousif Z, Gift T, Desai R, Huynh L, Ye M, Banatwala A, Clear L, Pinaire M, Belsky G, Hsieh YG, Herrick C, Darnell EP, Duh MS, Sanchirico M, Murphy SN. IgG testing, immunoglobulin replacement therapy, and infection outcomes in patients with CLL or NHL: real-world evidence. Blood Adv 2024; 8:4239-4249. [PMID: 38904477 DOI: 10.1182/bloodadvances.2024013073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 05/03/2024] [Accepted: 05/05/2024] [Indexed: 06/22/2024] Open
Abstract
ABSTRACT Patients with chronic lymphocytic leukemia (CLL) and non-Hodgkin lymphoma (NHL) can develop hypogammaglobulinemia, a form of secondary immune deficiency (SID), from the disease and treatments. Patients with hypogammaglobulinemia with recurrent infections may benefit from immunoglobulin replacement therapy (IgRT). This study evaluated patterns of immunoglobulin G (IgG) testing and the effectiveness of IgRT in real-world patients with CLL or NHL. A retrospective, longitudinal study was conducted among adult patients diagnosed with CLL or NHL. Clinical data from the Massachusetts General Brigham Research Patient Data Registry were used. IgG testing, infections, and antimicrobial use were compared before vs 3, 6, and 12 months after IgRT initiation. Generalized estimating equation logistic regression models were used to estimate odds ratios, 95% confidence intervals, and P values. The study population included 17 192 patients (CLL: n = 3960; median age, 68 years; NHL: n = 13 232; median age, 64 years). In the CLL and NHL cohorts, 67% and 51.2% had IgG testing, and 6.5% and 4.7% received IgRT, respectively. After IgRT initiation, the proportion of patients with hypogammaglobulinemia, the odds of infections or severe infections, and associated antimicrobial use, decreased significantly. Increased frequency of IgG testing was associated with a significantly lower likelihood of severe infection. In conclusion, in real-world patients with CLL or NHL, IgRT was associated with significant reductions in hypogammaglobulinemia, infections, severe infections, and associated antimicrobials. Optimizing IgG testing and IgRT are warranted for the comprehensive management of SID in patients with CLL or NHL.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Aged
- Middle Aged
- Male
- Female
- Immunoglobulin G/blood
- Lymphoma, Non-Hodgkin/therapy
- Lymphoma, Non-Hodgkin/complications
- Retrospective Studies
- Infections/etiology
- Agammaglobulinemia/complications
- Agammaglobulinemia/therapy
- Agammaglobulinemia/etiology
- Treatment Outcome
- Longitudinal Studies
- Aged, 80 and over
- Adult
- Immunization, Passive/methods
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Affiliation(s)
- Jacob D Soumerai
- Center for Lymphoma, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Zaid Yousif
- Takeda Pharmaceuticals USA, Inc, Lexington, MA
- Division of Clinical Pharmacy, University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA
| | - Thais Gift
- Takeda Pharmaceuticals USA, Inc, Lexington, MA
| | | | | | | | | | | | | | - Gregory Belsky
- Mass General Brigham, Research Information Science and Computing, Somerville, MA
| | - Yichuan Grace Hsieh
- Mass General Brigham, Research Information Science and Computing, Somerville, MA
| | - Christopher Herrick
- Mass General Brigham, Research Information Science and Computing, Somerville, MA
| | - Eli P Darnell
- Center for Lymphoma, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
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2
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An J, Zhao J, Zou P, Zhang Y, Wei J, Tian W, Wei J. Infections associated with CAR-T cell therapy in patients with relapsed refractory multiple myeloma: Risks and prevention strategies. Cancer Med 2024; 13:e7372. [PMID: 38923216 PMCID: PMC11196838 DOI: 10.1002/cam4.7372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 05/13/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Chimeric antigen receptor T (CAR-T) cell therapy has emerged as a potent treatment for relapsed or refractory multiple myeloma, demonstrating significant clinical efficacy. Despite these advances, treatment-related toxicities, particularly infections, pose a significant challenge to patient safety. METHODS This review synthesizes current knowledge on the mechanisms underlying post-CAR-T therapy infections, focusing on the interplay between immune dysfunction, host factors, and treatment-induced toxicity. It provides a comprehensive analysis of the temporal and individual variability in infection characteristics and the confounding clinical presentation of cytokine release syndrome. RESULTS The review identifies that patients receiving CAR-T cells are at increased risk of concurrent infections due to the heterogeneity in infection characteristics across different time periods, individuals, and patient groups. It highlights the diagnostic and therapeutic complexities introduced by the overlapping symptoms of infection and cytokine release syndrome. CONCLUSION To enhance the infection control post-CAR-T therapy, this review proposes preventive strategies tailored to the early and long-term management of patients. It underscores the need for a nuanced understanding of infection mechanisms and the importance of personalized prevention plans to improve clinical outcomes in multiple myeloma treatment.
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Affiliation(s)
- Jing An
- Department of Hematology, Shanxi Bethune Hospital, Shanxi Academy of Medical SciencesThird Hospital of Shanxi Medical University, Tongji Shanxi HospitalTaiyuanShanxiChina
- School of Public HealthShanxi Medical UniversityTaiyuanShanxiChina
| | - Jie Zhao
- Department of Hematology, Shanxi Bethune Hospital, Shanxi Academy of Medical SciencesThird Hospital of Shanxi Medical University, Tongji Shanxi HospitalTaiyuanShanxiChina
- Sino‐German Joint Oncological Research LaboratoryShanxi Bethune Hospital, Shanxi Academy of Medical SciencesTaiyuanShanxiChina
| | - Ping Zou
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhanChina
| | - Yicheng Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
- Immunotherapy Research Center for Hematologic Diseases of Hubei ProvinceWuhanHubeiChina
| | - Junni Wei
- School of Public HealthShanxi Medical UniversityTaiyuanShanxiChina
| | - Weiwei Tian
- Department of Hematology, Shanxi Bethune Hospital, Shanxi Academy of Medical SciencesThird Hospital of Shanxi Medical University, Tongji Shanxi HospitalTaiyuanShanxiChina
- School of Public HealthShanxi Medical UniversityTaiyuanShanxiChina
- Sino‐German Joint Oncological Research LaboratoryShanxi Bethune Hospital, Shanxi Academy of Medical SciencesTaiyuanShanxiChina
| | - Jia Wei
- Department of Hematology, Shanxi Bethune Hospital, Shanxi Academy of Medical SciencesThird Hospital of Shanxi Medical University, Tongji Shanxi HospitalTaiyuanShanxiChina
- Sino‐German Joint Oncological Research LaboratoryShanxi Bethune Hospital, Shanxi Academy of Medical SciencesTaiyuanShanxiChina
- Department of Hematology, Tongji Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
- Immunotherapy Research Center for Hematologic Diseases of Hubei ProvinceWuhanHubeiChina
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3
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Kim JJY, Dennett L, Ospina MB, Hicks A, Vliagoftis H, Adatia A. Effectiveness of immunoglobulin replacement therapy in preventing infections in patients with chronic obstructive pulmonary disease: a systematic review. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2024; 20:30. [PMID: 38600554 PMCID: PMC11005196 DOI: 10.1186/s13223-024-00886-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 03/12/2024] [Indexed: 04/12/2024]
Abstract
PURPOSE Immunoglobulin replacement therapy is a standard treatment for patients with antibody production deficiencies, which is of interest in patients with chronic obstructive pulmonary disease (COPD). This systematic review, registered with PROSPERO (CRD42021281118), assessed the current literature regarding immunoglobulin replacement therapy on COPD clinical outcomes in patients with low immunoglobulin G (IgG) serum concentrations. METHODS Literature searches conducted from inception to August 23, 2021, in databases including MEDLINE, EMBASE, and CINAHL. Population (sex, age, comorbidities), baseline clinical characteristics (pulmonary function testing results, IgG levels), and outcome (hospitalizations, emergency department visits) were extracted after title/abstract and full text screening. The Cochrane risk of bias assessment form was used for risk of bias assessment of randomized controlled trials and the National Heart, Lung, and Blood Institute (NHLBI) assessment was used for pre and post studies. RESULTS A total of 1381 studies were identified in the preliminary search, and 874 records were screened after duplicates were removed. Screening 77 full texts yielded four studies that were included in the review. CONCLUSION It is unclear whether immune globulin replacement therapy reduces acute exacerbation frequency and severity in COPD. Current evidence suggests that it is worth considering, but better developed protocols for administration of immune globulin supplementation is required for future randomized controlled trials.
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Affiliation(s)
- Justin J Y Kim
- Faculty of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Liz Dennett
- Sperber Health Sciences Library University of Alberta, Edmonton, AB, Canada
| | - Maria B Ospina
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Anne Hicks
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
- Alberta Respiratory Centre, University of Alberta, Edmonton, AB, Canada
| | - Harissios Vliagoftis
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
- Alberta Respiratory Centre, University of Alberta, Edmonton, AB, Canada
| | - Adil Adatia
- Department of Medicine, University of Alberta, Edmonton, AB, Canada.
- Alberta Respiratory Centre, University of Alberta, Edmonton, AB, Canada.
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Angarola E, Peuchot VA, Warley F, Liberatore DI. Secondary hypogammaglobulinemia in adults-A large retrospective cohort study. Med Clin (Barc) 2024; 162:170-178. [PMID: 37980212 DOI: 10.1016/j.medcli.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 10/05/2023] [Accepted: 10/07/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUND AND OBJECTIVE IgG replacement therapy (IgG-RT) has radically changed the clinical evolution of primary immunodeficiencies, yet the information regarding secondary hypogammaglobulinemia (SHG) is insufficient or conflicting. We aim to describe clinical features, evolution and treatment of SHG patients in our center. METHODS Dynamic retrospective cohort between January 2001 and July 2021 of adults with gamma globulin fraction <0.6g/dL in a serum protein electrophoresis and a coincident decrease of IgG levels - with a disease-related SHG or treatment that reduces serum immunoglobulins. RESULTS We included 1012 patients with SHG with a median follow-up of 5 years (IQR 2-8). Hematological diseases were identified in 95% of the patients and 61% received drugs related to SHG. Sixty five percent had more than one etiological factor associated with SHG. Infectious diseases were present in 69% of the patients, 48% had respiratory infections and 17% had severe infections. There was statistical association between respiratory and severe infections with multiple myeloma (MM), lymphoma and rituximab. MGUS had less infections and death compared with other etiologies. IgG-RT was indicated in 18.7% of the patients and 4.6% received it for more than 6 months with variable intervals. Among the latter group, there was a significant reduction of all-type infections and respiratory infections with IgG-RT (p<0.001), and it was consistent with similar findings in lymphoma, MM and all IgG levels subgroups. CONCLUSION SHG was associated with more than one etiological factor and a high frequency of infections. IgG-RT indication was irregular yet still effective. It is relevant to consider IgG levels screening, monitoring and accurate indication of IgG-RT.
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Affiliation(s)
- Ernestina Angarola
- Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | | | - Fernando Warley
- Hematology Section, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Ar MC, El Fakih R, Gabbassova S, Alhuraiji A, Nasr F, Alsaeed A, Sayinalp N, Marashi M. Management of humoral secondary immunodeficiency in hematological malignancies and following hematopoietic stem cell transplantation: Regional perspectives. Leuk Res 2023; 133:107365. [PMID: 37643508 DOI: 10.1016/j.leukres.2023.107365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 07/17/2023] [Accepted: 07/25/2023] [Indexed: 08/31/2023]
Abstract
Secondary immunodeficiency (SID) can occur as a result of multiple factors, including hematological malignancies, hematopoietic stem cell transplantation (HSCT), immunosuppressive treatment, biologics, and anti-inflammatory drugs. SID includes disorders resulting from impairment of both cellular and humoral immunity. This review focuses on the current risk factors, implications, and challenges in managing SID patients with impaired humoral immunity, which includes quantitative (hypogammaglobulinemia) and/or functional antibody and B-cell deficiencies specifically related to hematological malignancies and post-HSCT. Increased physician awareness is needed surrounding the disease presentation and early risk factors, as SID may be caused by several etiologies. Careful clinical assessment is then required to optimize management, which encompasses close monitoring of clinical parameters, vaccination, antibiotic prophylaxis, and immunoglobulin replacement therapy (IGRT). Novel methods of IGRT administration are associated with enhanced pharmacokinetics, IgG trough level stability, no need for venous access, as well as fewer systemic adverse events and better administration flexibility compared with traditional methods. Published international guidelines supported by observations from clinical data are broadly followed; however, best practices within each country have nuances that underline the need to tailor treatment plans to the individual patient.
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Affiliation(s)
- Muhlis Cem Ar
- Division of Hematology, Department of Internal Medicine, Cerrahpaşa School of Medicine, Istanbul University, Cerrahpaşa, Istanbul, Turkey
| | - Riad El Fakih
- Oncology Center, Section of Stem Cell Transplant and Cellular Therapy, King Faisal Hospital and Research Center, Riyadh, Saudi Arabia
| | - Saule Gabbassova
- Center for Hematology and Bone Marrow Transplantation, Kazakh Scientific Research Institute of Oncology and Radiology, Almaty, Kazakhstan; Al-Farabi Kazakh National University, Almaty, Kazakhstan
| | - Ahmad Alhuraiji
- Department of Hematology, Kuwait Cancer Control Center, Kuwait City, Kuwait
| | - Fady Nasr
- Department of Hemato-Oncology, Hôtel-Dieu de France Hospital, Faculty of Medicine, Saint-Joseph University of Beirut, Beirut, Lebanon
| | - Ahmad Alsaeed
- Princess Noorah Oncology Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia; College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Nilgun Sayinalp
- Department of Hematology, Hacettepe University Medical School, Ankara, Turkey
| | - Mahmoud Marashi
- Department of Hematology, Mediclinic City Hospital, Dubai, United Arab Emirates.
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Jowik K, Marciniak-Stępak P, Derwich K. Clinical use of polyvalent intravenous immunoglobulins during intensive polychemotherapy in children with acute lymphoblastic leukemia. Minerva Pediatr (Torino) 2023; 75:583-589. [PMID: 31264396 DOI: 10.23736/s2724-5276.19.05494-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Acute lymphoblastic leukemia (ALL) is seen in almost 30% of cases of cancer among children. Drop in absolute neutrophil count (ANC) and immunosuppression during chemotherapy are causing the significant increase in the risk of other complications, which can lead to prolonged hospitalization, higher costs of therapy and increased mortality. METHODS The analysis concerned 78 patients treated for ALL at the Department of Pediatric Oncology, Hematology and Transplantology. The indications for the use of immunoglobulins, the regimen of administration, the dose and adverse reactions were analyzed. RESULTS Intravenous immunoglobulins (IVIGs) were used in 66 (85%) of 78 patients. The standard risk group (SR) was represented by 10 (15%) patients, intermediate (IR) - 29 (44%), and high (HR) - 27 (41%). The most common were 1 and 2-day administrations - 60% and 28%, respectively, of transfusions. The spread of the IVIG doses used ranged from 43 mg to 882 mg/kg body weight. In the SR and IR groups, preparations were transfused at the reinduction stage, while in the HR-consolidation. Among the indications for IVIG, the most common was hypogammaglobulinemia-117 (42%), neutropenia-69 (25%) and infection-62 (22%). During the implementation of 279 patterns of immunoglobulin preparations, 8 (3%) post-transfusion reactions were registered. CONCLUSIONS The vast majority of ALL patients required immunoglobulin substitution during polychemotherapy. The supply of preparations is safe, however, there are no unambiguous guidelines regarding their dosage.
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Affiliation(s)
- Katarzyna Jowik
- Department of Pediatric Oncology Hematology and Transplantology, University of Medical Sciences of Poznan, Poznan, Poland -
| | - Patrycja Marciniak-Stępak
- Department of Pediatric Oncology Hematology and Transplantology, University of Medical Sciences of Poznan, Poznan, Poland
| | - Katarzyna Derwich
- Department of Pediatric Oncology Hematology and Transplantology, University of Medical Sciences of Poznan, Poznan, Poland
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7
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Ishino Y, Fukasawa H, Kitamoto S, Nakagami D, Kaneko M, Yasuda H, Furuya R. A survival case of visceral disseminated varicella zoster virus infection in a patient with systemic lupus erythematosus. BMC Nephrol 2023; 24:164. [PMID: 37291486 PMCID: PMC10251651 DOI: 10.1186/s12882-023-03223-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/31/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Visceral disseminated varicella zoster virus (VZV) infection is a rare but life-threatening complication in immunosuppressed patients. Herein, we report a survival case of visceral disseminated VZV infection in a patient with systemic lupus erythematosus (SLE). CASE PRESENTATION A 37-year-old woman was diagnosed as SLE and initial induction therapy was started. Two months after starting the immunosuppressive therapy consisting of 40 mg of prednisolone (PSL) and 1500 mg of mycophenolate mofetil (MMF) daily, she suddenly developed strong abdominal pain, which was required opioid analgesics, followed by systemic skin blisters, which were diagnosed as varicella. Laboratory findings showed rapid exacerbation of severe liver failure, coagulation abnormalities and increased numbers of blood VZV deoxyribonucleic acid (DNA). Therefore, she was diagnosed as visceral disseminated VZV infection. Multidisciplinary treatment with acyclovir, immunoglobulin and antibiotics was started, the dose of PSL was reduced, and MMF was withdrawn. By their treatment, her symptoms were resolved and she finally discharged. CONCLUSIONS Our case highlights the importance of a clinical suspicion of visceral disseminated VZV infections, and the necessity of immediate administration of acyclovir and reduced doses of immunosuppressant to save patients with SLE.
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Affiliation(s)
- Yuri Ishino
- Renal Division, Department of Internal Medicine, Iwata City Hospital, 512-3 Ohkubo, Iwata, Shizuoka, 438-8550, Japan
| | - Hirotaka Fukasawa
- Renal Division, Department of Internal Medicine, Iwata City Hospital, 512-3 Ohkubo, Iwata, Shizuoka, 438-8550, Japan.
| | - Shuhei Kitamoto
- Renal Division, Department of Internal Medicine, Iwata City Hospital, 512-3 Ohkubo, Iwata, Shizuoka, 438-8550, Japan
| | - Daisuke Nakagami
- Renal Division, Department of Internal Medicine, Iwata City Hospital, 512-3 Ohkubo, Iwata, Shizuoka, 438-8550, Japan
| | - Mai Kaneko
- Renal Division, Department of Internal Medicine, Iwata City Hospital, 512-3 Ohkubo, Iwata, Shizuoka, 438-8550, Japan
| | - Hideo Yasuda
- First Department of Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Ryuichi Furuya
- Renal Division, Department of Internal Medicine, Iwata City Hospital, 512-3 Ohkubo, Iwata, Shizuoka, 438-8550, Japan
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Lutz C, Feiten S, Chakupurakal G, Heymanns J, Thomalla J, van Roye C, Weide R. Patients with indolent lymphomas are at high risk of infections: experience from a German outpatient clinic. BMC Immunol 2023; 24:2. [PMID: 36631764 PMCID: PMC9833869 DOI: 10.1186/s12865-022-00536-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 12/23/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Patients with indolent B-cell non-Hodgkin lymphomas (B-NHLs) have an increased risk of infections which is caused by pathomechanisms of the diseases itself but also as a result of anti-tumor therapy. Especially the effects of anti-CD20 antibodies are well understood as these lead to decreased antibody production. Most studies regarding immunodeficiency in B-NHLs were conducted with multiple myeloma and chronic lymphocytic leukemia patients. As these studies not always represent the general population we collected and analyzed real world data from patients with indolent lymphomas and a control group (CG). RESULTS Patients with B-NHLs undergoing therapy or who were regularly monitored in a watch and wait approach had, over the time of one year, an increased rate of infections compared to the CG of 145 healthy volunteers (mean: 11.66 vs. 7.13 infections per 1000 days). Consistent with this finding B-NHL patients received more antibiotic treatment (mean: 11.17 vs. 6.27 days) and were more often hospitalized than persons from the CG (mean: 5.19 vs. 0.99 days per 1000 days). Lymphoma patients without immunodeficiency had a lower infection rate than patients with non-symptomatic and symptomatic immunodeficiency (mean: 10.91 vs. 12.07 and 12.36 per 1000 days). The number of infections differed statistically significant for the subgroups and CG (7.13 per 1000 days). Patients with symptomatic immunodeficiency were mostly treated with regular immunoglobulin substitutions and infection rates were comparable to those of patients with asymptomatic immunodeficiency. CONCLUSIONS Our data suggest the use of an approach with regular immune monitoring including the measurement of immunoglobulin levels and regular appointments for clinical assessment of all indolent lymphoma patients in order to identify patients with increased risk of infections. It also raises the question if patients with immunodeficiency should be treated more often with regular immunoglobulin substitution, but so far more studies are necessary to answer this question.
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Affiliation(s)
- Christoph Lutz
- Praxis für Hämatologie und Onkologie Koblenz, Neversstr. 5, 56068, Koblenz, Germany.
| | - Stefan Feiten
- grid.488965.eInstitut für Versorgungsforschung in der Onkologie, Koblenz, Germany
| | - Geothy Chakupurakal
- grid.477753.50000 0004 0560 2414Praxis für Hämatologie und Onkologie Koblenz, Neversstr. 5, 56068 Koblenz, Germany
| | - Jochen Heymanns
- grid.477753.50000 0004 0560 2414Praxis für Hämatologie und Onkologie Koblenz, Neversstr. 5, 56068 Koblenz, Germany
| | - Jörg Thomalla
- grid.477753.50000 0004 0560 2414Praxis für Hämatologie und Onkologie Koblenz, Neversstr. 5, 56068 Koblenz, Germany
| | - Christoph van Roye
- grid.477753.50000 0004 0560 2414Praxis für Hämatologie und Onkologie Koblenz, Neversstr. 5, 56068 Koblenz, Germany
| | - Rudolf Weide
- grid.477753.50000 0004 0560 2414Praxis für Hämatologie und Onkologie Koblenz, Neversstr. 5, 56068 Koblenz, Germany
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Shah N, Mustafa SS, Vinh DC. Management of secondary immunodeficiency in hematological malignancies in the era of modern oncology. Crit Rev Oncol Hematol 2023; 181:103896. [PMID: 36528276 DOI: 10.1016/j.critrevonc.2022.103896] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 11/29/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022] Open
Abstract
Secondary immunodeficiency (SID) in patients with B-cell hematological malignancies is a common condition that presents with recurrent infection. SID is due to both the inherent immune defects due to the malignancy, as well as secondary to cancer therapies, many of which have B-cell depleting properties. The early diagnosis of SID and the optimization of intervention strategies are key to delivering the most effective cancer treatments and reducing infection-related morbidity and mortality. This review discusses current practice, recommendations, and challenges for SID diagnosis, based on the evaluation of clinical history and laboratory assessments, and the effectiveness of specific vaccines and immunoglobulin replacement therapy in reducing the frequency and recurrence of infections in patients with SID, and the healthcare system-associated costs.
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Affiliation(s)
- Nina Shah
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States.
| | - S Shahzad Mustafa
- Rochester Regional Health, Rochester, NY, United States; Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
| | - Donald C Vinh
- Department of Medicine, McGill University Health Centre, Montreal, Canada
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10
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Lahue BJ, Mallick R, Zhang X, Heidt J, Song Y, Koenig AS, Espinoza G. Reduced risk of infections with the intravenous immunoglobulin, IgPro10, in patients at risk of secondary immunodeficiency-related infections. Immunotherapy 2022; 14:1245-1261. [PMID: 35971794 DOI: 10.2217/imt-2022-0142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Aim: Patients with secondary immunodeficiency (SID) are at increased risk of infections and may be treated with immunoglobulin replacement therapy (IgRT). Despite growing efficacy evidence for IgRT in infection prevention in SID, treatment guidelines are not aligned. Materials & methods: A retrospective database analysis was conducted to assess treatment patterns and infection rates in patients at risk of SID-related infections, with or without IgRT (IgPro10) exposure, to evaluate real-world effectiveness of IgRT in infection prevention. Results: Of 11,448 patients included, 222 received IgPro10. B-cell malignancies and solid organ transplants were the predominant underlying conditions. Despite being sicker at baseline, the IgPro10 cohort demonstrated fewer infections post-index than the non-IgRT cohort. Conclusion: IgPro10 may be an effective option for infection prevention in SID.
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Sun C. EXABS-181-CLL Infection Prophylaxis in Chronic Lymphocytic Leukemia. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22 Suppl 2:S83-S84. [PMID: 36164243 DOI: 10.1016/s2152-2650(22)00673-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Clare Sun
- Hematology Branch, National Heart, Lung, and Blood Institute, Bethesda, MD 20892, USA
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12
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Hipogammaglobulinemia crónica postrasplante de precursores hematopoyéticos y su tratamiento con gammaglobulina subcutánea en pacientes pediátricos. An Pediatr (Barc) 2022. [DOI: 10.1016/j.anpedi.2021.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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13
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Serra Font S, López-Granados L, Sisinni L, Serna Berna JV, Martínez Martínez L, Fernández de Gamarra-Martínez E, de la Calle Martín O, Badell Serra I. Chronic hypogammaglobulinemia after allogeneic stem cell transplantation and their treatment with subcutaneous immunoglobulin in pediatric patients. An Pediatr (Barc) 2022; 97:103-111. [PMID: 35869014 DOI: 10.1016/j.anpede.2021.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 08/25/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Hypogammaglobulinemia in the first months after allogeneic hematopoietic stem cell transplantation (HSCT) is common in paediatric patients. During this phase, replacement therapy with human immunoglobulin must be administered parenterally to prevent infections. In some cases, this hypogammaglobulinemia persists over time, which forces further treatment when the patient is usually no longer a carrier of a central line, making them ideal candidates for subcutaneous replacement therapy. There is little published literature describing the use of this method in paediatric patients undergoing HSCT, widely described in replacement treatment in children with primary immunodeficiencies with very good results. PATIENTS AND METHODS An observational, descriptive, longitudinal and retrospective study is carried out. During the years 2008-2019, we evaluated all paediatric patients undergoing HSCT in our center with persistent chronic hypogammaglobulinemia (for over a year). The treatment phase with intravenous immunoglobulin (Privigen®) and the first four years of treatment with subcutaneous immunoglobulin (Hizentra®) are evaluated using a questionnaire. RESULTS During the years 2008-2019, 175 patients underwent HSCT, 143 (82%) of whom exceeded three months after transplantation. Three (2%) of them had persistent hypogammaglobulinemia. All three share factors described in the literature involved in immune reconstitution. After analysing the questionnaire, it is observed that switching from intravenous to subcutaneous gammaglobulin has involved a great improvement in their quality of life. CONCLUSIONS The origin of chronic hypogammaglobulinemia in our patients shows different factors and cannot be attributed to a single cause. Due to the limited number of patients no conclusions can be drawn at the population level. We have been able to observe that replacement treatment with Hizentra 20% has been as effective as the intravenous administration without evidence of an increase in bacterial infections. Furthermore, it has also led to an improvement in quality of life and increased comfort, as the patients themselves have stated.
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Affiliation(s)
- Sara Serra Font
- Unidad Pediátrica De Hematología, Oncología y Trasplante Hematopoyético, Hospital De La Santa Creu i Sant Pau, Barcelona, Spain.
| | - Lucía López-Granados
- Unidad Pediátrica De Hematología, Oncología y Trasplante Hematopoyético, Hospital De La Santa Creu i Sant Pau, Barcelona, Spain
| | - Luisa Sisinni
- Unidad Pediátrica De Hematología, Oncología y Trasplante Hematopoyético, Hospital De La Santa Creu i Sant Pau, Barcelona, Spain
| | - José Vicente Serna Berna
- Unidad Pediátrica De Hematología, Oncología y Trasplante Hematopoyético, Hospital De La Santa Creu i Sant Pau, Barcelona, Spain; Instituto De Investigaciones Biomédicas Sant Pau (IIB Sant Pau), Universidad Autónoma De Barcelona, Barcelona, Spain
| | - Laura Martínez Martínez
- Instituto De Investigaciones Biomédicas Sant Pau (IIB Sant Pau), Universidad Autónoma De Barcelona, Barcelona, Spain; Servicio De Inmunología, Hospital De La Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Oscar de la Calle Martín
- Instituto De Investigaciones Biomédicas Sant Pau (IIB Sant Pau), Universidad Autónoma De Barcelona, Barcelona, Spain; Servicio De Inmunología, Hospital De La Santa Creu i Sant Pau, Barcelona, Spain
| | - Isabel Badell Serra
- Unidad Pediátrica De Hematología, Oncología y Trasplante Hematopoyético, Hospital De La Santa Creu i Sant Pau, Barcelona, Spain; Instituto De Investigaciones Biomédicas Sant Pau (IIB Sant Pau), Universidad Autónoma De Barcelona, Barcelona, Spain
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14
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Wudhikarn K, Perales MA. Infectious complications, immune reconstitution, and infection prophylaxis after CD19 chimeric antigen receptor T-cell therapy. Bone Marrow Transplant 2022; 57:1477-1488. [PMID: 35840746 PMCID: PMC9285870 DOI: 10.1038/s41409-022-01756-w] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/24/2022] [Accepted: 06/30/2022] [Indexed: 12/15/2022]
Abstract
CD19-targeted chimeric antigen receptor (CAR) T-cell becomes a breakthrough therapy providing excellent remission rates and durable disease control for patients with relapsed/refractory (R/R) hematologic malignancies. However, CAR T-cells have several potential side effects including cytokine release syndrome, neurotoxicities, cytopenia, and hypogammaglobulinemia. Infection has been increasingly recognized as a complication of CAR T-cell therapy. Several factors predispose CAR T-cell recipients to infection. Fortunately, although studies show a high incidence of infection post-CAR T-cells, most infections are manageable. In contrast to patients who undergo hematopoietic stem cell transplant, less is known about post-CAR T-cell immune reconstitution. Therefore, evidence regarding antimicrobial prophylaxis and vaccination strategies in these patients is more limited. As CAR T-cell therapy becomes the standard treatment for R/R B lymphoid malignancies, we should expect a larger impact of infections in these patients and the need for increased clinical attention. Studies exploring infection and immune reconstitution after CAR T-cell therapy are clinically relevant and will provide us with a better understanding of the dynamics of immune function after CAR T-cell therapy including insights into appropriate strategies for prophylaxis and treatment of infections in these patients. In this review, we describe infections in recipients of CAR T-cells, and discuss risk factors and potential mitigation strategies.
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Affiliation(s)
- Kitsada Wudhikarn
- Division of Hematology and Research Unit in Translational Hematology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
| | - Miguel-Angel Perales
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
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15
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Wo S, Levavi H, Mascarenhas J, Kremyanskaya M, Navada S, Bar-Natan M, Kim SS. Immunoglobulin repletion during blinatumomab therapy does not reduce the rate of secondary hypogammaglobulinemia and associated infectious risk. Blood Res 2022; 57:135-143. [PMID: 35551109 PMCID: PMC9242831 DOI: 10.5045/br.2022.2021163] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 01/09/2022] [Accepted: 04/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background Blinatumomab has demonstrated efficacy in minimal residual disease (MRD) positive and relapsed/refractory B-cell acute lymphoblastic leukemia (B-ALL) by inciting rapid and sustained B-cell depletion. Methods Owing to its effect on B-cells, blinatumomab is associated with a higher rate of secondary hypogammaglobulinemia compared to chemotherapy. To mitigate blinatumomab-induced hypogammaglobulinemia, patients were pre-emptively repleted with intravenous immune globulin (IVIG) during blinatumomab therapy. In this retrospective study, we compared outcomes of 23 blinatumomab treated adults with ALL. Seventeen patients routinely received IVIG and 6 patients were in the control cohort. Results Our findings demonstrated no difference between the two cohorts in immunoglobulin G (IgG) nadir (338 mg/dL vs. 337 mg/dL, P=0.641), days to IgG nadir (120.5 vs. 85.5 days, P=0.13), infection rate (82.4% vs. 66.7%, P=0.58), infections requiring ICU admission (23.5% vs. 16.7%, P=1), and infection related mortality (17.6% vs. 16.7%, P=1). Conclusion Pre-emptive IVIG repletion during blinatumomab did not prevent hypogammaglobulinemia and associated infection risk.
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Affiliation(s)
- Stephanie Wo
- Department of Pharmacy, The Mount Sinai Hospital, New York, NY, USA
| | - Hannah Levavi
- Division of Hematology/Oncology, Icahn School of Medicine at The Mount Sinai Hospital, New York, NY, USA
| | - John Mascarenhas
- Division of Hematology/Oncology, Icahn School of Medicine at The Mount Sinai Hospital, New York, NY, USA
| | - Marina Kremyanskaya
- Division of Hematology/Oncology, Icahn School of Medicine at The Mount Sinai Hospital, New York, NY, USA
| | - Shyamala Navada
- Division of Hematology/Oncology, Icahn School of Medicine at The Mount Sinai Hospital, New York, NY, USA
| | - Michal Bar-Natan
- Division of Hematology/Oncology, Icahn School of Medicine at The Mount Sinai Hospital, New York, NY, USA
| | - Sara S Kim
- Department of Pharmacy, The Mount Sinai Hospital, New York, NY, USA
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16
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Scarpa R, Dell'Edera A, Felice C, Buso R, Muscianisi F, Finco Gambier R, Toffolo S, Grossi U, Giobbia M, Barberio G, Landini N, Facchini C, Agostini C, Rattazzi M, Cinetto F. Impact of Hypogammaglobulinemia on the Course of COVID-19 in a Non-Intensive Care Setting: A Single-Center Retrospective Cohort Study. Front Immunol 2022; 13:842643. [PMID: 35359947 PMCID: PMC8960988 DOI: 10.3389/fimmu.2022.842643] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 02/01/2022] [Indexed: 12/11/2022] Open
Abstract
Background Severity and mortality of COVID-19 largely depends on the ability of the immune system to clear the virus. Among various comorbidities potentially impacting on this process, the weight and the consequences of an antibody deficiency have not yet been clarified. Methods We used serum protein electrophoresis to screen for hypogammaglobulinemia in a cohort of consecutive adult patients with COVID-19 pneumonia, hospitalized in non-intensive care setting between December 2020 and January 2021. The disease severity, measured by a validated score and by the need for semi intensive (sICU) or intensive care unit (ICU) admission, and the 30-day mortality was compared between patients presenting hypogammaglobulinemia (HYPO) and without hypogammaglobulinemia (no-HYPO). Demographics, comorbidities, COVID-19 specific treatment during the hospital stay, disease duration, complications and laboratory parameters were also evaluated in both groups. Results We enrolled 374 patients, of which 39 represented the HYPO cohort (10.4%). In 10/39 the condition was previously neglected, while in the other 29/39 hematologic malignancies were common (61.5%); 2/39 were on regular immunoglobulin replacement therapy (IgRT). Patients belonging to the HYPO group more frequently developed a severe COVID-19 and more often required sICU/ICU admission than no-HYPO patients. IgRT were administered in 8/39 during hospitalization; none of them died or needed sICU/ICU. Among HYPO cohort, we observed a significantly higher prevalence of neoplastic affections, of active oncologic treatment and bronchiectasis, together with higher prevalence of viral and bacterial superinfections, mechanical ventilation, convalescent plasma and SARS-CoV-2 monoclonal antibodies administration during hospital stay, and longer disease duration. Multivariate logistic regression analysis and Cox proportional hazard regression confirmed the impact of hypogammaglobulinemia on the COVID-19 severity and the probability of sICU/ICU admission. The analysis of the mortality rate in the whole cohort showed no significant difference between HYPO and no-HYPO. Conclusions Hypogammaglobulinemia, regardless of its cause, in COVID-19 patients hospitalized in a non-intensive care setting was associated to a more severe disease course and more frequent admission to s-ICU/ICU, particularly in absence of IgRT. Our findings emphasize the add-value of routine serum protein electrophoresis evaluation in patients admitted with COVID-19 to support clinicians in patient care and to consider IgRT initiation during hospitalization.
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Affiliation(s)
- Riccardo Scarpa
- Internal Medicine I, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy.,Department of Medicine, University of Padova, Padua, Italy
| | - Alessandro Dell'Edera
- Internal Medicine I, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy.,Department of Medicine, University of Padova, Padua, Italy
| | - Carla Felice
- Internal Medicine I, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy.,Department of Medicine, University of Padova, Padua, Italy
| | - Roberta Buso
- Internal Medicine I, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy
| | - Francesco Muscianisi
- Internal Medicine I, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy.,Department of Medicine, University of Padova, Padua, Italy
| | - Renato Finco Gambier
- Internal Medicine I, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy.,Department of Medicine, University of Padova, Padua, Italy
| | - Sara Toffolo
- Internal Medicine I, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy.,Department of Medicine, University of Padova, Padua, Italy
| | - Ugo Grossi
- Department of Surgery, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy
| | - Mario Giobbia
- Infectious Diseases Unit, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy
| | - Giuseppina Barberio
- Laboratory Medicine, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy
| | - Nicholas Landini
- Radiology Unit, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy
| | - Cesarina Facchini
- Internal Medicine I, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy
| | - Carlo Agostini
- Internal Medicine I, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy.,Department of Medicine, University of Padova, Padua, Italy
| | - Marcello Rattazzi
- Internal Medicine I, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy.,Department of Medicine, University of Padova, Padua, Italy
| | - Francesco Cinetto
- Internal Medicine I, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy.,Department of Medicine, University of Padova, Padua, Italy
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17
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Immunoglobulin substitution in patients with secondary antibody deficiency in chronic lymphocytic leukemia and multiple myeloma: a representative analysis of guideline adherence and infections. Support Care Cancer 2022; 30:5187-5200. [PMID: 35257229 PMCID: PMC9046374 DOI: 10.1007/s00520-022-06920-y] [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: 08/10/2021] [Accepted: 02/12/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION In secondary immunodeficiency, immunoglobulin replacement therapy (IgRT) is recommended by guidelines (GL) for patients with IgG level < 4 g/l and more than 3 infections or a severe infection. IgRT may be appropriate if IgG level < 4 g/l and/or 1-3 less severe infections (≤ grade 2). METHODS This was a retrospective sample analysis representative for practices and hospitals in Germany. The treatments and infection data were collected from patients with chronic lymphocytic leukemia (CLL) and multiple myeloma (MM). GL adherence (GLAD) was analyzed. RESULTS Data from 1086 patients (CLL 490, MM 596) were collected from 86 centers. Of all patients, 34.8% developed IgG deficiency during therapy (CLL 35.5%; MM 34.2%). IgRT was given in 23.5% of CLL and 14.4% of MM patients. GLAD in hypogammaglobulinemia and indication to IgRT was 23.3% of 86 CLL and 22.1% of 77 MM patients. Without GLAD, the hazard ratio (HR) for any infection was 4.49 (95% CI 3.72-5.42; p < 0.001) and for severe infections (grade ≥ 3) 10.64 (95% CI 7.54-15.00; p < 0.001). Significant independent risk factors for infections were a higher Charlson Comorbidity Index, IgG deficiency, and 3rd + line treatment, as well as therapy with BTK inhibitors or chemotherapy in CLL. Multivariable analysis showed a significantly lower risk of severe infections after start of IgRT with a HR of 0.47 (95% CI 0.28-0.77; p = 0.003). CONCLUSIONS Guideline adherence correlated with fewer and less severe infections but was low in patients with indication to IgRT. Risk factors for infection can be identified. Risk of severe infections was significantly lower in patients with IgRT.
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18
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Smets I, Giovannoni G. Derisking CD20-therapies for long-term use. Mult Scler Relat Disord 2021; 57:103418. [PMID: 34902761 DOI: 10.1016/j.msard.2021.103418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/15/2021] [Accepted: 11/20/2021] [Indexed: 11/16/2022]
Abstract
Anti-CD20 have quickly become the mainstay in the treatment of multiple sclerosis (MS) and other neuroinflammatory conditions. However, when they are used as a maintenance therapy the balance between risks and benefits changes. In this review, we suggested six steps to derisk anti-CD20. Firstly and secondly, adequate infectious screening followed by vaccinations before starting anti-CD20 are paramount. Third, family planning needs to be discussed upfront with every woman of childbearing age. Fourth, infusion reactions should be adequately managed to avoid treatment interruption. After repeated infusions, it becomes important to detect and prevent anti-CD20-related adverse events. Fifth, we recommended measuring immunoglobulin levels and reviewing vaccinations annually as well as counselling adequate fever management. For female patients, we emphasised the importance to engage with the local breast cancer screening programs. Sixth, to fundamentally derisk anti-CD20 therapies, we need evidence-based approaches to reduce dosing intervals and guide retreatment.
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Affiliation(s)
- Ide Smets
- Blizard Institute, Centre for Neuroscience, Surgery and Trauma, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark St, Whitechapel, London E1 2AT, United Kingdom; Clinical Board Medicine (Neuroscience), Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom
| | - Gavin Giovannoni
- Blizard Institute, Centre for Neuroscience, Surgery and Trauma, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark St, Whitechapel, London E1 2AT, United Kingdom; Clinical Board Medicine (Neuroscience), Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1FR, United Kingdom.
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19
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Nath K, Wong T, Ahluwalia A, Colquhoun S, Clark PJ, Taylor K, Cherian S. Hepatitis B in haematology patients receiving intravenous immunoglobulin: highlighting a core issue. Intern Med J 2021; 51:1981-1982. [PMID: 34796622 DOI: 10.1111/imj.15573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/18/2021] [Accepted: 09/29/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Karthik Nath
- Icon Cancer Centre, Brisbane, Queensland, Australia.,Mater Private Hospital, Brisbane, Queensland, Australia
| | - Thomas Wong
- Icon Cancer Centre, Brisbane, Queensland, Australia
| | | | - Scott Colquhoun
- Department of Microbiology, Sullivan Nicolaides Pathology, Brisbane, Queensland, Australia
| | - Paul J Clark
- Mater Private Hospital, Brisbane, Queensland, Australia.,Department of Gastroenterology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Department of Gastroenterology, Mater Public Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Kerry Taylor
- Icon Cancer Centre, Brisbane, Queensland, Australia.,Mater Private Hospital, Brisbane, Queensland, Australia
| | - Sarah Cherian
- Department of Microbiology, Sullivan Nicolaides Pathology, Brisbane, Queensland, Australia
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20
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Jolles S, Smith BD, Vinh DC, Mallick R, Espinoza G, DeKoven M, Divino V. Risk factors for severe infections in secondary immunodeficiency: a retrospective US administrative claims study in patients with hematological malignancies. Leuk Lymphoma 2021; 63:64-73. [PMID: 34702119 DOI: 10.1080/10428194.2021.1992761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Real-world data are lacking to identify patients with secondary immunodeficiency (SID) who may benefit most from anti-infective interventions. This retrospective analysis used the IQVIA PharMetrics® Plus database to assess baseline characteristics associated with risk of severe infections post-SID diagnosis in patients with hematological malignancies. In 4066 patients included, the mean number of any and severe infections per patient in the one-year pre-SID diagnosis period was 9.5 and 0.7, respectively. Post-SID diagnosis, the mean annualized number of any and severe infections was 19.1 and 1.5, respectively. Receiver operating characteristic curve analysis identified a threshold (cutoff) of three bacterial infections at baseline as optimally predictive of severe infections post-SID diagnosis. Multivariate analysis indicated that hospitalizations, infections (≥3), or antibiotic use pre-SID diagnosis were predictive of severe infections post-SID diagnosis. Evaluation of these risk factors could inform clinical decisions regarding which patients may benefit from prophylactic anti-infective treatment, including immunoglobulin replacement if warranted.
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Affiliation(s)
| | - B Douglas Smith
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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21
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Allegra A, Tonacci A, Musolino C, Pioggia G, Gangemi S. Secondary Immunodeficiency in Hematological Malignancies: Focus on Multiple Myeloma and Chronic Lymphocytic Leukemia. Front Immunol 2021; 12:738915. [PMID: 34759921 PMCID: PMC8573331 DOI: 10.3389/fimmu.2021.738915] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 09/29/2021] [Indexed: 12/19/2022] Open
Abstract
Secondary immunodeficiency is reported in most patients with hematological malignancies such as chronic lymphocytic leukemia and multiple myeloma. The aim of our review was to evaluate the existing literature data on patients with hematological malignancies, with regard to the effect of immunodeficiency on the outcome, the clinical and therapeutic approach, and on the onset of noninfectious complications, including thrombosis, pleural effusion, and orofacial complications. Immunodeficiency in these patients has an intense impact on their risk of infection, in turn increasing morbidity and mortality even years after treatment completion. However, these patients with increased risk of severe infectious diseases could be treated with adequate vaccination coverage, but the vaccines' administration can be associated with a decreased immune response and an augmented risk of adverse reactions. Probably, immunogenicity of the inactivated is analogous to that of healthy subjects at the moment of vaccination, but it undertakes a gradual weakening over time. However, the dispensation of live attenuated viral vaccines is controversial because of the risk of the activation of vaccine viruses. A particular immunization schedule should be employed according to the clinical and immunological condition of each of these patients to guarantee a constant immune response without any risks to the patients' health.
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MESH Headings
- Animals
- Humans
- Immunocompromised Host
- Immunogenicity, Vaccine
- Immunologic Deficiency Syndromes/epidemiology
- Immunologic Deficiency Syndromes/immunology
- Immunologic Deficiency Syndromes/therapy
- Incidence
- Leukemia, Lymphocytic, Chronic, B-Cell/epidemiology
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Multiple Myeloma/epidemiology
- Multiple Myeloma/immunology
- Multiple Myeloma/therapy
- Opportunistic Infections/epidemiology
- Opportunistic Infections/immunology
- Opportunistic Infections/prevention & control
- Risk Factors
- Vaccination
- Vaccine Efficacy
- Vaccines/administration & dosage
- Vaccines/adverse effects
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Affiliation(s)
- Alessandro Allegra
- Division of Hematology, Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, University of Messina, Messina, Italy
| | - Alessandro Tonacci
- Clinical Physiology Institute, National Research Council of Italy (IFC-CNR), Pisa, Italy
| | - Caterina Musolino
- Division of Hematology, Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, University of Messina, Messina, Italy
| | - Giovanni Pioggia
- Institute for Biomedical Research and Innovation (IRIB), National Research Council of Italy (CNR), Messina, Italy
| | - Sebastiano Gangemi
- School of Allergy and Clinical Immunology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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22
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Secondary Dysgammaglobulinemia in Children with Hematological Malignancies Treated with Targeted Therapies. Paediatr Drugs 2021; 23:445-455. [PMID: 34292515 DOI: 10.1007/s40272-021-00461-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2021] [Indexed: 10/20/2022]
Abstract
Targeted therapies have emerged as innovative treatments for patients whose disease does not respond to conventional chemotherapy, and their use has widely expanded in the field of pediatric hematologic malignancies in the last decade. While they carry the promise of improved disease control and survival and are currently investigated in first-line treatment protocols for patients with poor prognostic markers, they are associated with a considerable incidence of specific toxicities, including cytokine-release syndrome, neurotoxicity, hepatotoxicity, nephrotoxicity, cardiotoxicity, endocrine adverse events, and infectious complications. Iatrogenic or secondary dysgammaglobulinemia is a main consequence of targeted therapies using monoclonal antibodies and other antibody-derived treatments that target specific antigens on lymphoid cells (blinatumomab, inotuzumab ozogamicin, rituximab), chimeric antigen receptor T cells, tyrosine kinase inhibitors (imatinib, dasatinib, nilotinib) and, to a lesser extent, checkpoint inhibitors (pembrolizumab, nivolumab). This review discusses the diagnosis and incidence of secondary or iatrogenic dysgammaglobulinemia in children treated with targeted therapies for leukemias and lymphomas, and options for monitoring and treatment.
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23
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Qi CZ, Bollu V, Yang H, Dalal A, Zhang S, Zhang J. Cost-Effectiveness Analysis of Tisagenlecleucel for the Treatment of Patients With Relapsed or Refractory Diffuse Large B-Cell Lymphoma in the United States. Clin Ther 2021; 43:1300-1319.e8. [PMID: 34380609 DOI: 10.1016/j.clinthera.2021.06.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/03/2021] [Accepted: 06/23/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE To assess the cost-effectiveness and cost-effective price of tisagenlecleucel, a novel, effective chimeric antigen receptor T-cell therapy, versus salvage chemotherapy (SC) for the treatment of relapsed or refractory diffuse large B-cell lymphoma (r/r DLBCL) using a willingness-to-pay (WTP) threshold of $150,000 per quality-adjusted life year (QALY) gained from a US third-party payer's perspective. METHODS A three-state (progression-free survival, progressive disease, and death), responder-based partitioned survival model with a lifetime horizon and 3% annual discount rate was developed. Overall survival (OS) and progression-free survival of tisagenlecleucel were estimated separately for patients with and without an overall response (OR), using data from JULIET ( Study of Efficacy and Safety of CTL019 in Adult DLBCL Patients). OS of SC was informed by SCHOLAR-1 (Retrospective Non-Hodgkin Lymphoma Research). Mixture cure models were used to inform the survival of tisagenlecleucel responders, supported by JULIET. The median OS was 11.1 months in all tisagenlecleucel-treated patients but not reached for responders; no progression or death occurred among responders since month 22 of treatment. For tisagenlecleucel nonresponders and SC, survival was based on standard parametric models until month 60and the survival of DLBCL long-term survivors thereafter. The model prediction validated well against the observed trial data. Costs and utilities were from the literature; utilities depended on health states and were used to estimate QALYs. Total costs, QALYs, and incremental cost per QALY gained were estimated. A cost-effective price range was estimated for all tisagenlecleucel-treated patients, OR responders, and complete response (CR) responders. Deterministic sensitivity and scenario analyses and a probabilistic sensitivity analysis were performed. All costs were reported in or inflated to 2020 US dollars. FINDINGS Tisagenlecleucel was associated with 3.35 QALYs gained versus SC.,The estimated incremental costs per QALY gained versus SC were $78,652 using the wholesale acquisition cost of $373,000 for tisagenlecleucel. The estimated cost-effective price of tisagenlecleucel in all treated patients was $612,270 at the WTP threshold of $150,000. Tisagenlecleucel OR and CR responders had an increase of 7.82 and 9.34 QALYs versus SC, with cost-effective prices estimated at $1,281,456 and $1,551,974, respectively. Sensitivity analysis results supported the base case findings. IMPLICATIONS Tisagenlecleucel is a cost-effective treatment versus SC for r/r DLBCL from the perspective of a US third-party payer. The estimated cost-effective prices ranged from $612,270 (all tisagenlecleucel-treated patients) to up to $1.5 million (patients achieving CR). Limitations include the use of single-arm trials due to data availability. (Clin Ther. 2021;43:XXX-XXX) © 2021 Elsevier HS Journals, Inc.
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Affiliation(s)
| | - Vamsi Bollu
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Anand Dalal
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Su Zhang
- Analysis Group, Inc, Boston, MA, USA
| | - Jie Zhang
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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24
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Perreault S, Schiffer M, Clinchy-Jarmoszko V, Bocchetta N, Barbarotta L, Abdelghany O, Foss F, Huntington S, Seropian S, Isufi I. Mitigating the risk of COVID-19 exposure by transitioning from clinic-based to home-based immune globulin infusion. Am J Health Syst Pharm 2021; 78:1112-1117. [PMID: 33617630 PMCID: PMC7929449 DOI: 10.1093/ajhp/zxab072] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Intravenous immune globulin (IVIG) therapy is used in patients with hypogammaglobulinemia to lower the risk of infections. IVIG and subcutaneous IVIG (SCIG) therapy have been to shown to be safe and effective when administered as clinic-based infusions. Concern from both patients and providers for increased transmission of the coronavirus disease 2019 (COVID-19) virus to immunosuppressed patients with scheduled medical visits and procedures made it necessary for us to reassess our process of how we manage patient care in general and chronic clinic infusions in particular. Here we describe our experience of transitioning patients from clinic-based to home based IVIG and/or SCIG infusions to decrease the risk of COVID-19 exposure. METHODS Criteria were developed to identify high-risk immunosuppressed patients who would be appropriate candidates for potential conversion to home based IVIG infusions. Data were collected via chart review, and cost analysis was performed using Medicare Part B reimbursement data. A patient outcome questionnaire was developed for administration through follow-up phone calls. RESULTS From March to May 2020, 45 patients met criteria for home-based infusion, with 27 patients (60%) agreeing to home-based infusion. Posttransition patient outcomes assessment, conducted in 26 patients (96%), demonstrated good patient understanding of the home-based infusion process. No infusion-related complications were reported, and 24 patients (92%) had no concerns about receiving future IVIG and/or SCIG doses at home. No patient tested positive for COVID-19 during the study period. Clinic infusion visits decreased by 26.6 visits per month, resulting in a total of 106 hours of additional available infusion chair time per month and associated cost savings of $12,877. CONCLUSION Transition of clinic based to home based IVIG/SCIG infusion can be successfully done to decrease potential exposure during a pandemic in a high-risk immunosuppressed population, with no impact on patient satisfaction, adherence, or efficacy. The home-based infusion initiative was associated with a reduction in costs to patients and an increase in available chair time in the infusion clinic.
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Affiliation(s)
- Sarah Perreault
- Department of Pharmacy, Yale New Haven Health, New Haven, CT, USA
| | - Molly Schiffer
- Department of Pharmacy, Yale New Haven Health, New Haven, CT, USA
| | | | - Nicole Bocchetta
- Department of Nursing, Yale New Haven Health, New Haven, CT, USA
| | - Lisa Barbarotta
- Department of Nursing, Yale New Haven Health, New Haven, CT, USA
| | - Osama Abdelghany
- Department of Pharmacy, Yale New Haven Health, New Haven, CT, USA
| | - Francine Foss
- Department of Hematology, Yale School of Medicine, New Haven, CT, and Yale New Haven Health, New Haven, CT, USA
| | - Scott Huntington
- Department of Hematology, Yale School of Medicine, New Haven, CT, and Yale New Haven Health, New Haven, CT, USA
| | - Stuart Seropian
- Department of Hematology, Yale School of Medicine, New Haven, CT, and Yale New Haven Health, New Haven, CT, USA
| | - Iris Isufi
- Department of Hematology, Yale School of Medicine, New Haven, CT, and Yale New Haven Health, New Haven, CT, USA
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25
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Rituximab-induced hypogammaglobulinemia and infection risk in pediatric patients. J Allergy Clin Immunol 2021; 148:523-532.e8. [PMID: 33862010 DOI: 10.1016/j.jaci.2021.03.041] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 03/03/2021] [Accepted: 03/05/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Rituximab is a B-cell depleting agent used in B-cell malignancies and autoimmune diseases. A subset of adult patients may develop prolonged and symptomatic hypogammaglobulinemia following rituximab treatment. However, this phenomenon has not been well delineated in the pediatric population. OBJECTIVES This study sought to determine the prevalence, risk factors, and clinical significance of hypogammaglobulinemia following rituximab therapy in children. METHODS This was a multicenter, retrospective cohort study that extracted clinical and immunological data from pediatric patients who received rituximab. RESULTS The cohort comprised 207 patients (median age, 12.0 years). Compared to baseline values, there was a significant increase in hypogammaglobulinemia post-rituximab therapy, with an increase in prevalence of hypo-IgG (28.7%-42.6%; P = .009), hypo-IgA (11.1%-20.4%; P = .02), and hypo-IgM (20.0%-62.0%; P < .0001). Additionally, low IgG levels at any time post-rituximab therapy were associated with a higher risk of serious infections (34.4% vs 18.9%; odds ratio, 2.3; 95% CI, 1.1-4.8; P = .03). Persistent IgG hypogammaglobulinemia was observed in 27 of 101 evaluable patients (26.7%). Significant risk factors for persistent IgG hypogammaglobulinemia included low IgG and IgA levels pre-rituximab therapy. Nine patients (4.3%) within the study were subsequently diagnosed with a primary immunodeficiency, 7 of which received rituximab for autoimmune cytopenias. CONCLUSIONS Hypogammaglobulinemia post-rituximab treatment is frequently diagnosed within the pediatric population. Low IgG levels are associated with a significant increase in serious infections, and underlying primary immunodeficiencies are relatively common in children receiving rituximab, thus highlighting the importance of immunologic monitoring both before and after rituximab therapy.
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26
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Almaghlouth I, Johnson SR, Pullenayegum E, Gladman D, Urowitz M. Immunoglobulin levels in systemic lupus erythematosus: A narrative review. Lupus 2021; 30:867-875. [PMID: 33779380 DOI: 10.1177/09612033211004714] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Immunoglobulins play a fundamental role in the protection of the human body against internal and external threats. They also contribute to the immune system homeostasis and maintenance of self-tolerance. Hypogammaglobulinemia is occasionally encountered in routine clinical practice by rheumatologists. Low levels of immunoglobulins can occur as primary or secondary issues and may predispose patients to various forms of infection. However, the impact of the low immunoglobulin level abnormality varies with the underlying condition. In this narrative review, we shed light on the overall types and functions of immunoglobulins for clinicians. We discuss important principles of immunoglobulin measurements. We then consider the primary and secondary causes of low immunoglobulins with a special focus on hypogammaglobulinemia in patients with systemic lupus erythematosus (SLE).
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Affiliation(s)
- Ibrahim Almaghlouth
- Division of Rheumatology, Department of Medicine, Toronto Western Hospital, Mount Sinai Hospital, University of Toronto and the Schroeder Arthritis Institute, University Health Network, Toronto, Canada.,Rheumatology Unit, Department of Medicine, King Saud University, Riyadh, Saudi Arabia.,College of Medicine Research Center, King Saud University, Riyadh, Saudi Arabia
| | - Sindhu R Johnson
- Division of Rheumatology, Department of Medicine, Toronto Western Hospital, Mount Sinai Hospital, University of Toronto and the Schroeder Arthritis Institute, University Health Network, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Eleanor Pullenayegum
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Program in Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Canada
| | - Dafna Gladman
- Division of Rheumatology, Department of Medicine, Toronto Western Hospital, Mount Sinai Hospital, University of Toronto and the Schroeder Arthritis Institute, University Health Network, Toronto, Canada.,Centre for Prognosis in Rheumatic Diseases, University Health Network, Toronto, Canada
| | - Murray Urowitz
- Division of Rheumatology, Department of Medicine, Toronto Western Hospital, Mount Sinai Hospital, University of Toronto and the Schroeder Arthritis Institute, University Health Network, Toronto, Canada.,Centre for Prognosis in Rheumatic Diseases, University Health Network, Toronto, Canada
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27
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Cost Effectiveness Analysis of Tisagenlecleucel for the Treatment of Adult Patients with Relapsed or Refractory Diffuse Large B Cell Lymphoma in Japan. Transplant Cell Ther 2021; 27:506.e1-506.e10. [PMID: 33823168 DOI: 10.1016/j.jtct.2021.03.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/04/2021] [Accepted: 03/02/2021] [Indexed: 12/31/2022]
Abstract
There are limited treatment options and substantial unmet needs for adult patients with relapsed or refractory diffuse large B cell lymphoma (r/r DLBCL) in Japan. In 2019, tisagenlecleucel, a CD19-directed chimeric antigen receptor T cell therapy, was approved for r/r DLBCL in Japan. The efficacy and safety of tisagenlecleucel were demonstrated in the pivotal phase II single-arm JULIET trial. The objective of the current study was to assess the cost-effectiveness of tisagenlecleucel treatment strategy versus current standard of care (salvage chemotherapy treatment strategy) for the treatment of patients with r/r DLBCL in Japan. A three-state partitioned survival model was constructed from a Japanese public healthcare payer's perspective, with the following three health states: progression-free survival, progressive/relapsed disease, and death. Because the tisagenlecleucel arm included patients who did or did not receive the infusion, a decision-tree structure was used to partition patients based on their infusion status. Treatment efficacy and costs were based on tisagenlecleucel-infused patients for those who received the infusion; for non-infused patients, they were based on standard salvage chemotherapy. The efficacy inputs for tisagenlecleucel-infused patients and salvage chemotherapy were based on observed data in the JULIET trial and the international SCHOLAR-1 meta-analysis, respectively, before year 3. Afterward, all patients were assumed to have no further progression and to incur the mortality risk of long-term DLBCL survivors. The base case analysis explored a lifetime horizon (44 years), with costs and effectiveness discounted 2.0% annually, and it used a monthly model cycle. Direct costs were considered in the base case, composed of pretreatment costs, treatment costs, adverse events management costs, follow-up costs before progression, subsequent SCT costs, post-progression costs, and terminal care costs. Total incremental costs, life years (LYs), and quality-adjusted life years (QALYs) were compared for tisagenlecleucel versus salvage chemotherapy. The incremental cost-effectiveness ratio (ICER) was estimated as the costs per QALY gained, and a threshold of ¥7.5 million was used to assess whether tisagenlecleucel is cost effective. Deterministic and probabilistic sensitivity analyses were performed. The total LYs (discounted) for tisagenlecleucel and salvage chemotherapy were 7.24 and 4.35 years, respectively; the corresponding QALYs were 5.42 and 2.57 years, respectively. The discounted incremental LYs and QALYs comparing tisagenlecleucel to salvage chemotherapy were estimated as 2.89 and 2.85 years, respectively. Over a lifetime horizon, the model estimated that tisagenlecleucel had a total incremental cost of ¥15,590,335 (discounted) versus salvage chemotherapy. Tisagenlecleucel was associated with an ICER of ¥5,476,496 per QALY gained compared to salvage chemotherapy. Extensive sensitivity analyses supported the base-case findings. Tisagenlecleucel is a cost-effective treatment strategy for r/r DLBCL compared to salvage chemotherapy treatment strategy from a Japanese public healthcare payer's perspective.
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28
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Cinetto F, Neri R, Vianello F, Visentin A, Barilà G, Gianese S, Lanciarotta A, Milito C, Rattazzi M, Piazza F, Trentin L, Zambello R, Agostini C, Scarpa R. Subcutaneous immunoglobulins replacement therapy in secondary antibody deficiencies: Real life evidence as compared to primary antibody deficiencies. PLoS One 2021; 16:e0247717. [PMID: 33661940 PMCID: PMC7932095 DOI: 10.1371/journal.pone.0247717] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 02/12/2021] [Indexed: 12/31/2022] Open
Abstract
Secondary antibody deficiencies (SAD) may require immunoglobulin replacement therapy (IgRT). While the intravenous route (IVIG) is broadly considered effective in SAD, the use of subcutaneous immunoglobulins (SCIG) is mainly adopted from the experience in primary antibody deficiencies (PAD), where SCIG have been shown to perform as effective as IVIG. However, evidence-based data on SCIG administration in SAD patients are still insufficient. Herein we retrospectively evaluated the efficacy and safety profile of SCIG treatment in 131 SAD patients as compared to a group of 102 PAD patients. We found SCIG being equally effective in reducing annual infectious rate both in SAD and PAD patients. However, SAD patients required lower SCIG dosage and lower IgG through level to achieve similar biological effect in terms of infection burden, at the steady state. SAD patients also showed better correlation between SCIG dose and serum IgG achieved value. Furthermore, within SAD, SCIG were found to work irrespective of the underlying disease. Especially in Non-Hodgkin Lymphoma patients, whose indication to IgRT is still not included in all guidelines and for whom evidence-based data are still lacking, SCIG were as effective as in Chronic Lymphocytic Leukemia or Multiple Myeloma patients, and SCIG discontinuation, without evidence of B cell recovery, led to IgG decline and relapsed infections. Finally, treatment tolerance in SAD patients was comparable to the PAD cohort. Globally, our data suggest that SCIG, as already appreciated in PAD, represent a valuable option in SAD patients, independent on the disease leading to antibody deficiency.
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Affiliation(s)
- Francesco Cinetto
- Department of Medicine–DIMED, University of Padua, Padua, Italy
- Formerly Haematology and Clinical Immunology Unit, University of Padua, Padua, Italy
- Regional Center for Rare Immunological Diseases, Internal Medicine 1, Treviso Hospital, University of Padua, Padua, Italy
| | - Raffaella Neri
- Department of Medicine–DIMED, University of Padua, Padua, Italy
- Formerly Haematology and Clinical Immunology Unit, University of Padua, Padua, Italy
- Regional Center for Rare Immunological Diseases, Internal Medicine 1, Treviso Hospital, University of Padua, Padua, Italy
| | - Fabrizio Vianello
- Department of Medicine–DIMED, University of Padua, Padua, Italy
- Haematology and Clinical Immunology Unit, University of Padua, Padua, Italy
| | - Andrea Visentin
- Department of Medicine–DIMED, University of Padua, Padua, Italy
- Haematology and Clinical Immunology Unit, University of Padua, Padua, Italy
| | - Gregorio Barilà
- Department of Medicine–DIMED, University of Padua, Padua, Italy
- Haematology and Clinical Immunology Unit, University of Padua, Padua, Italy
| | - Sabrina Gianese
- Department of Medicine–DIMED, University of Padua, Padua, Italy
- Regional Center for Rare Immunological Diseases, Internal Medicine 1, Treviso Hospital, University of Padua, Padua, Italy
| | - Alison Lanciarotta
- Department of Medicine–DIMED, University of Padua, Padua, Italy
- Regional Center for Rare Immunological Diseases, Internal Medicine 1, Treviso Hospital, University of Padua, Padua, Italy
| | - Cinzia Milito
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Marcello Rattazzi
- Department of Medicine–DIMED, University of Padua, Padua, Italy
- Regional Center for Rare Immunological Diseases, Internal Medicine 1, Treviso Hospital, University of Padua, Padua, Italy
| | - Francesco Piazza
- Department of Medicine–DIMED, University of Padua, Padua, Italy
- Haematology and Clinical Immunology Unit, University of Padua, Padua, Italy
| | - Livio Trentin
- Department of Medicine–DIMED, University of Padua, Padua, Italy
- Haematology and Clinical Immunology Unit, University of Padua, Padua, Italy
| | - Renato Zambello
- Department of Medicine–DIMED, University of Padua, Padua, Italy
- Haematology and Clinical Immunology Unit, University of Padua, Padua, Italy
| | - Carlo Agostini
- Department of Medicine–DIMED, University of Padua, Padua, Italy
- Formerly Haematology and Clinical Immunology Unit, University of Padua, Padua, Italy
- Regional Center for Rare Immunological Diseases, Internal Medicine 1, Treviso Hospital, University of Padua, Padua, Italy
- * E-mail:
| | - Riccardo Scarpa
- Department of Medicine–DIMED, University of Padua, Padua, Italy
- Formerly Haematology and Clinical Immunology Unit, University of Padua, Padua, Italy
- Regional Center for Rare Immunological Diseases, Internal Medicine 1, Treviso Hospital, University of Padua, Padua, Italy
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29
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Jolles S, Michallet M, Agostini C, Albert MH, Edgar D, Ria R, Trentin L, Lévy V. Treating secondary antibody deficiency in patients with haematological malignancy: European expert consensus. Eur J Haematol 2021; 106:439-449. [PMID: 33453130 DOI: 10.1111/ejh.13580] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 01/12/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Secondary antibody deficiency (SAD), associated with severe, recurrent or persistent infections, is common in patients with haematological malignancies (HM), but unifying guidance on immunoglobulin replacement therapy (IgRT) in these patients is lacking. We aimed to develop consensus statements for the use of IgRT in patients with HM. METHODS A Delphi exercise was employed to test the level of agreement on statements developed by a Task Force based on available data and their clinical experience. In Round 1, an Expert Panel, comprising specialist EU physicians caring for patients with HM, helped to refine the statements. In Round 2, experts rated their agreement with the statements. In Round 3, experts who had scored their agreement as ≤4 were invited to review their agreement based on the overall feedback. RESULTS Three definitions and 20 statements were formulated and tested for consensus, covering measurement of IgG levels, initiation and discontinuation of IgRT, dosing, and the use of subcutaneous IgG. Consensus (agreement ≥70% on Likert-type scale) was reached for all three definitions and 18 statements. CONCLUSIONS Recommendations have been developed with the aim of providing guidance for the use of IgRT to prevent severe, recurrent or persistent infections in patients with HM and SAD.
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Affiliation(s)
- Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | | | - Carlo Agostini
- Ca' Foncello Internal Medicine 1st and Centre for Immunologic and Respiratory Rare Diseases, Padua University, Padua, Italy
| | - Michael H Albert
- Dr. von Hauner Children's Hospital, University Hospital, LMU, Munich, Germany
| | - David Edgar
- St James's Hospital & Trinity College Dublin, Dublin, Ireland
| | - Roberto Ria
- Department of Biomedical Science and Human Oncology, University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Livio Trentin
- Department of Medicine-DIMED, University of Padua, Padua, Italy
| | - Vincent Lévy
- Département de Recherche Clinique, Avicenne Hospital, Sorbonne Paris Nord University, Bobigny, France
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30
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Wang XJ, Wang YH, Li SCT, Gkitzia C, Lim ST, Koh LP, Lim FLWI, Hwang WYK. Cost-effectiveness and budget impact analyses of tisagenlecleucel in adult patients with relapsed or refractory diffuse large B-cell lymphoma from Singapore's private insurance payer's perspective. J Med Econ 2021; 24:637-653. [PMID: 33904359 DOI: 10.1080/13696998.2021.1922066] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patients experiencing relapsed or refractory diffuse large B-cell lymphoma (r/r DLBCL) have limited treatment options and poor prognosis. Tisagenlecleucel (TIS) has shown improved clinical outcomes, but at a high upfront cost. Singapore has a multi-payer healthcare system where private insurance is one of the major payers. This study evaluated the cost-effectiveness and budget impact of TIS against salvage chemotherapy regimen (SCR) for treating r/r DLBCL patients who have failed ≥2 lines of systemic therapy from Singapore's private insurance payer's perspective. METHODS Over a life-time horizon, a partitioned survival model with three health-states was developed to evaluate the cost-effectiveness of TIS vs. SCR with or without hematopoietic stem cell transplantation (HSCT). Efficacy inputs for TIS and SCR were based on 43 months of observation data from pooled JULIET and UPenn trials, and CORAL extension studies respectively. Direct costs for pre-treatment, treatment, adverse events, follow-up, subsequent-HSCT, relapse, and terminal care were included. Incremental cost-effectiveness ratios (ICERs) were calculated as the total incremental costs per quality-adjusted life-year (QALY) gained. Additionally, the financial implication of introducing TIS in Singapore from a private payer's perspective was analyzed, comparing the current treatment pathway (without TIS) with a future scenario (with TIS) over 5 years. RESULTS Compared with SCR, TIS was the dominant option, with cost savings of S$8,477 alongside an additional gain of 2.78 QALYs in privately insured patients who shifted from private to public hospitals for TIS treatment. Scenario analyses for patients starting in public hospitals show ICERs of S$99,623 (no subsidy) and S$133,261 (50% subsidy for SCR treatment, no subsidy for TIS), supporting the base case. The projected annual budget impact ranges from S$850,000 to S$3.4 million during the first 5 years. CONCLUSIONS TIS for treating r/r DLBCL patients who have failed ≥2 lines of systemic therapies, is likely to be cost effective with limited budget impact.
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Affiliation(s)
| | - Yi-Ho Wang
- Novartis Singapore Pte Ltd., Singapore, Singapore
| | | | | | - Soon Thye Lim
- National Cancer Centre Singapore, Singapore, Singapore
| | - Liang Piu Koh
- National University Cancer Institute, Singapore, Singapore
| | | | - William Ying Khee Hwang
- National University Cancer Institute, Singapore, Singapore
- Singapore General Hospital, Singapore, Singapore
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31
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Maus MV, Alexander S, Bishop MR, Brudno JN, Callahan C, Davila ML, Diamonte C, Dietrich J, Fitzgerald JC, Frigault MJ, Fry TJ, Holter-Chakrabarty JL, Komanduri KV, Lee DW, Locke FL, Maude SL, McCarthy PL, Mead E, Neelapu SS, Neilan TG, Santomasso BD, Shpall EJ, Teachey DT, Turtle CJ, Whitehead T, Grupp SA. Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immune effector cell-related adverse events. J Immunother Cancer 2020; 8:jitc-2020-001511. [PMID: 33335028 PMCID: PMC7745688 DOI: 10.1136/jitc-2020-001511] [Citation(s) in RCA: 139] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2020] [Indexed: 12/20/2022] Open
Abstract
Immune effector cell (IEC) therapies offer durable and sustained remissions in significant numbers of patients with hematological cancers. While these unique immunotherapies have improved outcomes for pediatric and adult patients in a number of disease states, as 'living drugs,' their toxicity profiles, including cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS), differ markedly from conventional cancer therapeutics. At the time of article preparation, the US Food and Drug Administration (FDA) has approved tisagenlecleucel, axicabtagene ciloleucel, and brexucabtagene autoleucel, all of which are IEC therapies based on genetically modified T cells engineered to express chimeric antigen receptors (CARs), and additional products are expected to reach marketing authorization soon and to enter clinical development in due course. As IEC therapies, especially CAR T cell therapies, enter more widespread clinical use, there is a need for clear, cohesive recommendations on toxicity management, motivating the Society for Immunotherapy of Cancer (SITC) to convene an expert panel to develop a clinical practice guideline. The panel discussed the recognition and management of common toxicities in the context of IEC treatment, including baseline laboratory parameters for monitoring, timing to onset, and pharmacological interventions, ultimately forming evidence- and consensus-based recommendations to assist medical professionals in decision-making and to improve outcomes for patients.
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Affiliation(s)
- Marcela V Maus
- Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Sara Alexander
- Cancer Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael R Bishop
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | | | - Colleen Callahan
- Cancer Immunotherapy Program, Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Marco L Davila
- Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida, USA
| | - Claudia Diamonte
- Cellular Therapeutics Center, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jorg Dietrich
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Julie C Fitzgerald
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew J Frigault
- Bone Marrow Transplant and Cellular Immunotherapy Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Terry J Fry
- Pediatric Hematology/Oncology/BMT, Children's Hospital Colorado and University of Colorado Anschutz School of Medicine, Aurora, Colorado, USA
| | - Jennifer L Holter-Chakrabarty
- Department of Hematology/Oncology/Bone Marrow Transplant and Cellular Therapy, The University of Oklahoma Stephenson Cancer Center, Oklahoma City, Oklahoma, USA
| | - Krishna V Komanduri
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
| | - Daniel W Lee
- Department of Pediatrics, University of Virginia Cancer Center, Charlottesville, Virginia, USA
| | - Frederick L Locke
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida, USA
| | - Shannon L Maude
- Cancer Immunotherapy Program, Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Philip L McCarthy
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Elena Mead
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Sattva S Neelapu
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tomas G Neilan
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bianca D Santomasso
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Elizabeth J Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David T Teachey
- Cancer Center, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cameron J Turtle
- Clinical Research Division, Fred Hutchinson Cancer Research Center Division of Medical Oncology, University of Washington, Seattle, Washington, USA
| | - Tom Whitehead
- Emily Whitehead Foundation, Phillipsburg, Pennsylvania, USA
| | - Stephan A Grupp
- Cancer Immunotherapy Program, Division of Oncology, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Monleón Bonet C, Waser N, Cheng K, Tzivelekis S, Edgar JDM, Sánchez-Ramón S. A systematic literature review of the effects of immunoglobulin replacement therapy on the burden of secondary immunodeficiency diseases associated with hematological malignancies and stem cell transplants. Expert Rev Clin Immunol 2020; 16:911-921. [PMID: 32783541 DOI: 10.1080/1744666x.2020.1807328] [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] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Secondary immunodeficiency diseases (SID) caused by hematological malignancies (HMs), stem cell transplant (SCT), and associated therapies are mainly characterized by the presence of hypogammaglobulinemia or antibody production deficits. AREAS COVERED The authors summarized the scientific literature on disease burden of SIDs in patients who had HMs or SCT. Systematic searches were conducted to identify English-language articles from 1994-2020, reporting on clinical, humanistic, and economic burdens of SID due to HMs or SCT. Definitions of SID and serum immunoglobulin G thresholds varied across 24 eligible studies. In most (n = 16) studies, patients received immunoglobulin replacement therapy (IGRT). Several studies found IGRT was associated with significant reductions in rates of infection and antimicrobial use. However, 1 study found no statistically significant difference in antibiotic use with IGRT. Only 3 studies reported on quality of life, and no economic studies were identified. EXPERT OPINION Overall, the findings show several beneficial effects of IGRT on clinical outcomes and quality of life; however, disparate definitions, infrequent reporting of statistical significance, and scarcity of clinical trial data after the 1990s present areas for further investigation. This paucity indicates an unmet need of current evidence to assess the benefits of IGRT in SID.
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Affiliation(s)
- Clara Monleón Bonet
- Global Evidence and Outcomes, Immunology, Takeda Pharmaceuticals International AG , Zurich, Switzerland
| | - Nathalie Waser
- Real World Evidence Strategy and Analytics, ICON Plc , Vancouver, Canada
| | - Karen Cheng
- formerly in Global Medical Affairs, Rare Immunology, Takeda Pharmaceuticals International AG , Zurich, Switzerland
| | | | - J David M Edgar
- Department of Immunology, St James's Hospital and Trinity College Dublin , Dublin, Ireland
| | - Silvia Sánchez-Ramón
- Departmento de Inmunologia Clinica, Hospital Clinico San Carlos and Universidad Complutense of Madrid , Madrid, Spain
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Grywalska E, Zaborek M, Łyczba J, Hrynkiewicz R, Bębnowska D, Becht R, Sosnowska-Pasiarska B, Smok-Kalwat J, Pasiarski M, Góźdź S, Roliński J, Niedźwiedzka-Rystwej P. Chronic Lymphocytic Leukemia-Induced Humoral Immunosuppression: A Systematic Review. Cells 2020; 9:E2398. [PMID: 33147729 PMCID: PMC7693361 DOI: 10.3390/cells9112398] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/30/2020] [Accepted: 11/01/2020] [Indexed: 12/22/2022] Open
Abstract
Secondary immunodeficiency is observed in all patients with chronic lymphocytic leukemia (CLL) in varying degrees. The aim of the study was to review the available literature data on patients with CLL, with particular regard to the pathogenesis of the disease and the impact of humoral immunity deficiency on the clinical and therapeutic approach. A systematic literature review was carried out by two independent authors who searched PubMed databases for studies published up to January 2020. Additionally, Google Scholar was used to evaluate search results and support manual research. The search resulted in 240 articles eligible for analysis. After all criteria and filters were applied, 22 studies were finally applied to the analysis. The data analysis showed that the clinical heterogeneity of CLL patients correlates with the diversity of molecular abnormalities determining the clinical picture of the disease, the analysis of which enables setting therapeutic targets. Additionally, in improving the therapeutic method, it is worth introducing supportive therapies with the use of vaccines, antibiotics and/or immunoglobins. Moreover, humoral immunodeficiency in CLL has a strong influence on the risk of infection in patients for whom infections are a major cause of morbidity and mortality.
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Affiliation(s)
- Ewelina Grywalska
- Department of Clinical Immunology and Immunotherapy, Medical University of Lublin, 20-093 Lublin, Poland; (E.G.); (M.Z.); (J.Ł.); (J.R.)
| | - Monika Zaborek
- Department of Clinical Immunology and Immunotherapy, Medical University of Lublin, 20-093 Lublin, Poland; (E.G.); (M.Z.); (J.Ł.); (J.R.)
| | - Jakub Łyczba
- Department of Clinical Immunology and Immunotherapy, Medical University of Lublin, 20-093 Lublin, Poland; (E.G.); (M.Z.); (J.Ł.); (J.R.)
| | - Rafał Hrynkiewicz
- Institute of Biology, University of Szczecin, Felczaka 3c, 71-412 Szczecin, Poland; (R.H.); (D.B.)
| | - Dominika Bębnowska
- Institute of Biology, University of Szczecin, Felczaka 3c, 71-412 Szczecin, Poland; (R.H.); (D.B.)
| | - Rafał Becht
- Clinical Department of Oncology, Chemotherapy and Cancer Immunotherapy, Pomeranian Medical University of Szczecin, Unii Lubelskiej 1, 71-252 Szczecin, Poland;
| | | | - Jolanta Smok-Kalwat
- Department of Clinical Oncology, Holy Cross Cancer Centre, 25-734 Kielce, Poland; (J.S.-K.); (S.G.)
| | - Marcin Pasiarski
- Department of Immunology, Faculty of Health Sciences, Jan Kochanowski University, 25-317 Kielce, Poland;
- Department of Hematology, Holy Cross Cancer Centre, 25-734 Kielce, Poland
| | - Stanisław Góźdź
- Department of Clinical Oncology, Holy Cross Cancer Centre, 25-734 Kielce, Poland; (J.S.-K.); (S.G.)
- Faculty of Medicine and Health Sciences, The Jan Kochanowski University, 25-516 Kielce, Poland
| | - Jacek Roliński
- Department of Clinical Immunology and Immunotherapy, Medical University of Lublin, 20-093 Lublin, Poland; (E.G.); (M.Z.); (J.Ł.); (J.R.)
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Roberts MB, Fishman JA. Immunosuppressive Agents and Infectious Risk in Transplantation: Managing the "Net State of Immunosuppression". Clin Infect Dis 2020; 73:e1302-e1317. [PMID: 32803228 DOI: 10.1093/cid/ciaa1189] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Indexed: 12/14/2022] Open
Abstract
Successful solid organ transplantation reflects meticulous attention to the details of immunosuppression, balancing risks for graft rejection against risks for infection. The 'net state of immune suppression' is a conceptual framework of all factors contributing to infectious risk. Assays which measure immune function in the immunosuppressed transplant recipient relative to infectious risk and allograft function are lacking. The best measures of integrated immune function may be quantitative viral loads to assess the individual's ability to control latent viral infections. Few studies address adjustment of immunosuppression during active infections. Thus, confronted with infection in solid organ recipients, the management of immunosuppression is based largely on clinical experience. This review examines known measures of immune function and the immunologic effects of common immunosuppressive drugs and available studies reporting modification of drug regimens for specific infections. These data provide a conceptual framework for the management of immunosuppression during infection in organ recipients.
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Affiliation(s)
- Matthew B Roberts
- Transplant Infectious Disease and Compromised Host Program and Transplant Center, Massachusetts General Hospital, Boston MA
| | - Jay A Fishman
- Transplant Infectious Disease and Compromised Host Program and Transplant Center, Massachusetts General Hospital, Boston MA.,Harvard Medical School, Boston, MA
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Corbingi A, Innocenti I, Tomasso A, Pasquale R, Visentin A, Varettoni M, Flospergher E, Autore F, Morelli F, Trentin L, Reda G, Efremov DG, Laurenti L. Monoclonal gammopathy and serum immunoglobulin levels as prognostic factors in chronic lymphocytic leukaemia. Br J Haematol 2020; 190:901-908. [PMID: 32712965 DOI: 10.1111/bjh.16975] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 05/31/2020] [Indexed: 12/17/2022]
Abstract
The relationship between chronic lymphocytic leukaemia (CLL) and qualitative/quantitative gammaglobulin abnormalities is well established. Nevertheless, in order to better understand this kind of connection, we examined 1505 patients with CLL and divided them into four subgroups on the basis of immunoglobulin (Ig) aberrations at diagnosis. A total of 73 (4·8%), 149 (10%), 200 (13·2%) and 1083 (72%) patients were identified with IgM monoclonal gammopathy (IgM/CLL), IgG monoclonal gammopathy (IgG/CLL), hypogammaglobulinaemia (hypo-γ) and normal Ig levels (γ-normal) respectively. IgM paraprotein was significantly associated with a more advanced Binet/Rai stage and del(17p)/TP53 mutation, while IgG abnormalities correlated with a higher occurrence of trisomy 12. Patients with any type of Ig abnormality had shorter treatment-free survival (TFS) but no significant impact affecting overall survival (OS) compared to those with normal Ig levels.
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Affiliation(s)
- Andrea Corbingi
- Department of Hematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Idanna Innocenti
- Department of Hematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Annamaria Tomasso
- Department of Hematology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Raffaella Pasquale
- Department of Hematology, Fondazione IRCCS Ca'Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Visentin
- Hematology and Clinical Immunology Unit, Department of Medicine, Università degli Studi di Padova, Padova, Italy
| | - Marzia Varettoni
- Department of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Elena Flospergher
- Department of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Francesco Autore
- Department of Hematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesca Morelli
- Department of Hematology, Università degli Studi di Firenze, Florence, Italy
| | - Livio Trentin
- Hematology and Clinical Immunology Unit, Department of Medicine, Università degli Studi di Padova, Padova, Italy
| | - Gianluigi Reda
- Department of Hematology, Fondazione IRCCS Ca'Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Dimitar G Efremov
- Molecular Haematology, International Centre for Genetic Engineering and Biotechnology, Trieste, Italy
| | - Luca Laurenti
- Department of Hematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Hematology, Università Cattolica del Sacro Cuore, Rome, Italy
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Patel V, Cowan J. Discontinuation of immunoglobulin replacement therapy in patients with secondary antibody deficiency. Expert Rev Clin Immunol 2020; 16:711-716. [PMID: 32588670 DOI: 10.1080/1744666x.2020.1788939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Secondary immunodeficiency is becoming a greater medical concern as the usage of immunosuppressive and biological treatments has increased. Individuals with certain medical conditions, such as hematological malignancies, can also have secondary immunodeficiency. Immunoglobulin replacement therapy (IGRT), which has been used for decades in inherited or primary immunodeficiency, provides some protection to patients with acquired and predominant antibody deficiency, i.e. secondary antibody deficiency (SAD). However, IGRT is costly, and supplies are limited. Although there are clinical guidelines on when to initiate IGRT, there is no guideline on when to discontinue it. AREAS COVERED The authors reviewed existing literature and provided an overview of the current state of knowledge regarding IGRT discontinuation in SAD patients. EXPERT OPINION Long-term supplementary immunoglobulin may not be necessary. Although it is possible to successfully transition away from IGRT in individuals with SAD, evidence-based practices are limited. Without clear guidelines and reliable prognostic markers, IGRT discontinuation practices are restricted to clinical judgment. For this reason, additional research should be conducted to identify markers that indicate the recovery of humoral immunity. Furthermore, the derivation and validation of a set of combined clinical and laboratory criteria to allow safe and timely IGRT discontinuation is warranted.
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Affiliation(s)
- Vishesh Patel
- Faculty of Medicine, University of Ottawa , Ottawa, Canada
| | - Juthaporn Cowan
- Division of Infectious Diseases, Department of Medicine, University of Ottawa , Ottawa, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute , Ottawa, Canada.,Department of Biochemistry, Microbiology and Immunology, University of Ottawa , Ottawa, Canada.,Centre for Infection, Immunity and Inflammation (CI3), University of Ottawa , Ottawa, Canada
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IgA levels at diagnosis predict for infections, time to treatment, and survival in chronic lymphocytic leukemia. Blood Adv 2020; 3:2188-2198. [PMID: 31324639 DOI: 10.1182/bloodadvances.2018026591] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 06/01/2019] [Indexed: 01/29/2023] Open
Abstract
To better understand the relationship between baseline immunoglobulin measurements and subsequent clinical outcomes in chronic lymphocytic leukemia (CLL), we performed a retrospective analysis on 660 patients with CLL (72%), monoclonal B-cell lymphocytosis (MBL) (13%), and small lymphocytic lymphoma (SLL) (14%), diagnosed between 2005 and 2014 at CancerCare Manitoba. Of 511 patients who had their first immunoglobulin level determined within 3 months of diagnosis, abnormal (either increased or decreased) immunoglobulin M (IgM), IgG, and IgA values were observed in 58% of patients with CLL, 27% of patients with MBL, and 20% of patients with SLL. Immunoglobulin deviances were similar for MBL and CLL Rai stage 0 and for SLL and Rai stages I and II; for CLL, IgG and IgA abnormalities occurred with increasing frequency with advancing Rai stage. In contrast, the frequency of IgM abnormalities was similar in all patient groups. IgA abnormalities significantly correlated with high β2-microglobulin (B2M) expression, whereas abnormal IgG and IgA levels were associated with the use of IGHV1-69, 3-21, and 3-49 subtypes. Increases in IgG or IgM were commonly associated with the presence of a CLL-type M-band, whereas oligoclonal bands were frequently observed with increased IgA levels. Although abnormal levels of IgG and IgA at diagnosis were independent predictors for future immunoglobulin replacement, only abnormal IgA levels were associated with shorter time to first treatment and overall survival. These findings indicate that both reduced and elevated levels of IgG and IgA at diagnosis are important and independent prognostic markers for infection in CLL, with IgA being more relevant as a marker of disease progression and survival.
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38
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Weide R, Schnell R, Schardt C, Koenigsmann M, Otremba B, Zahn MO, Wierecky J, Braun U, Hensel M, Klausmann M, Fleckenstein D, Ehscheidt P, Feiten S. Health status and infections in patients with symptomatic primary and secondary immunoglobulin G (IgG) deficiencies receiving intravenous IgG replacement. BMC Immunol 2020; 21:39. [PMID: 32600256 PMCID: PMC7325170 DOI: 10.1186/s12865-020-00368-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 06/17/2020] [Indexed: 11/16/2022] Open
Abstract
Background The effects of intravenous immunoglobulin G replacement on perceived health and infection susceptibility of patients suffering from immunoglobulin G (IgG) deficiencies should be evaluated in a prospective analysis. Methods Patients with symptomatic primary or secondary IgG deficiencies were interviewed prior to the first IgG infusion (t0) and over the course of their treatment (t1 - t6). The respondents rated their current health using a 100 point scale (EQ-5D-5L), ranging from 0 (‘worst imaginable health’) to 100 (‘best imaginable health’). The patients also provided information on the frequency of infections and of infections requiring antibiotics in the past 8 weeks. A healthy control group (CG) without oncologic diseases answered the questions once. Results One hundred six patients with a median age of 65 years (21–85 years) were investigated. The median serum IgG concentration changed from 500 mg/dl (t0) to 772 mg/dl (t6). The mean number of infections and of infections requiring antibiotics decreased during IgG replacement significantly. Current health according to EQ-5D-5L improved from 57 (t0) to 68 (t6), compared to 73 in the CG. Conclusion During the course of IgG replacement patients reported fewer and less severe infections. Their health assessment improved but still was inferior to the healthy CG.
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Affiliation(s)
- Rudolf Weide
- Praxis für Hämatologie und Onkologie Koblenz, Neversstr. 5, 56068, Koblenz, Germany.
| | - Roland Schnell
- pioh - Praxis Internistischer Onkologie und Hämatologie, Frechen, Germany
| | - Christof Schardt
- Onkologische Gemeinschaftspraxis und Tagesklinik, Gelsenkirchen, Germany
| | | | | | | | - Jan Wierecky
- Überörtliche Gemeinschaftspraxis, Dres. Verpoort, Wierecky & Brandl, Schwerpunkt Onkologie & Hämatologie, Hamburg, Germany
| | - Ute Braun
- Gemeinschaftspraxis für Hämatologie und Onkologie, Ludwigshafen, Germany
| | | | | | | | | | - Stefan Feiten
- Institut für Versorgungsforschung in der Onkologie, Koblenz, Germany
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Angelotti F, Capecchi R, Giannini D, Mazzarella O, Rocchi V, Migliorini P. Long-term efficacy, safety, and tolerability of recombinant human hyaluronidase-facilitated subcutaneous infusion of immunoglobulin (Ig) (fSCIG; HyQvia( ®)) in immunodeficiency diseases: real-life data from a monocentric experience. Clin Exp Med 2020; 20:387-392. [PMID: 32385734 DOI: 10.1007/s10238-020-00633-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 05/01/2020] [Indexed: 10/24/2022]
Abstract
Humoral immunodeficiency diseases represent a heterogeneous group of disorders that require long-term therapies. Thus, the treatment provided must not only be effective but also safe and well tolerated. In this paper, we report our data on the efficacy, safety, and tolerability of recombinant human hyaluronidase-facilitated subcutaneous infusion of immunoglobulin (Ig) (fSCIG; HyQvia(®)) in immunodeficiency patients. We collected retrospective data from 30 patients with primary and secondary immunodeficiency diseases in therapy with fSCIG from September 2014 to December 2019. We evaluated the efficacy of the therapy, taking into account serum IgG values during follow-up and the number of annual infectious events and serious bacterial infections reported by patients. Safety was assessed on the basis of the number and intensity of adverse events (AEs) and local reactions reported. Our real-life data suggest that long-term repeated self-administration of recombinant human hyaluronidase-facilitated subcutaneous infusion of immunoglobulins results in a reduced rate of infectious events if compared to the pre-treatment rate. Both AEs and local reactions are mild to moderate and were never reasons for treatment discontinuation. Therapy with HyQvia shows prolonged efficacy and good tolerability; these aspects, together with the possibility of self-administration at home, minimize the impact the illness has on patients.
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Affiliation(s)
- Francesca Angelotti
- Clinical Immunology Unit, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliera Universitaria Pisana, Via Roma 67, 56126, Pisa, Italy
| | - Riccardo Capecchi
- Clinical Immunology Unit, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliera Universitaria Pisana, Via Roma 67, 56126, Pisa, Italy
| | - Daiana Giannini
- Clinical Immunology Unit, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliera Universitaria Pisana, Via Roma 67, 56126, Pisa, Italy
| | - Ornella Mazzarella
- Clinical Immunology Unit, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliera Universitaria Pisana, Via Roma 67, 56126, Pisa, Italy
| | - Valeria Rocchi
- Clinical Immunology Unit, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliera Universitaria Pisana, Via Roma 67, 56126, Pisa, Italy
| | - Paola Migliorini
- Clinical Immunology Unit, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliera Universitaria Pisana, Via Roma 67, 56126, Pisa, Italy.
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Irons EE, Punch PR, Lau JTY. Blood-Borne ST6GAL1 Regulates Immunoglobulin Production in B Cells. Front Immunol 2020; 11:617. [PMID: 32391003 PMCID: PMC7190976 DOI: 10.3389/fimmu.2020.00617] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 03/18/2020] [Indexed: 12/14/2022] Open
Abstract
Humoral immunity is an effective but metabolically expensive defense mechanism. It is unclear whether systemic cues exist to communicate the dynamic need for antigen presentation and immunoglobulin production. Here, we report a novel role for the liver-produced, acute phase reactant ST6GAL1 in IgG production. B cell expression of ST6GAL1, a sialyltransferase mediating the attachment of α2,6-linked sialic acids on N-glycans, is classically implicated in the dysregulated B cell development and immunoglobulin levels of St6gal1-deficient mice. However, the blood-borne pool of ST6GAL1, upregulated during systemic inflammation, can also extrinsically modify leukocyte cell surfaces. We show that B cell independent, extracellular ST6GAL1 enhances B cell IgG production and increases blood IgG titers. B cells of mice lacking the hepatocyte specific St6gal1 promoter have reduced sialylation of cell surface CD22 and CD45 and produce less IgG upon stimulation. Sialylation of B cells by extracellular ST6GAL1 boosts expression of IgM, IgD, and CD86, proliferation, and IgG production in vitro. In vivo, elevation of blood ST6GAL1 enhances B cell development and systemic IgG in a CD22-dependent manner. Our data point to a function of an extracellular glycosyltransferase in promoting humoral immunity. Manipulation of systemic ST6GAL1 may represent an effective therapeutic approach for humoral insufficiency.
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Affiliation(s)
- Eric E Irons
- Department of Molecular and Cellular Biology, Roswell Park Comprehensive Cancer Center, University at Buffalo, Buffalo, NY, United States
| | - Patrick R Punch
- Department of Molecular and Cellular Biology, Roswell Park Comprehensive Cancer Center, University at Buffalo, Buffalo, NY, United States
| | - Joseph T Y Lau
- Department of Molecular and Cellular Biology, Roswell Park Comprehensive Cancer Center, University at Buffalo, Buffalo, NY, United States
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Jablonka A, Etemadi H, Adriawan IR, Ernst D, Jacobs R, Buyny S, Witte T, Schmidt RE, Atschekzei F, Sogkas G. Peripheral Blood Lymphocyte Phenotype Differentiates Secondary Antibody Deficiency in Rheumatic Disease from Primary Antibody Deficiency. J Clin Med 2020; 9:jcm9041049. [PMID: 32272789 PMCID: PMC7230453 DOI: 10.3390/jcm9041049] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/02/2020] [Accepted: 04/06/2020] [Indexed: 02/07/2023] Open
Abstract
The phenotype of primary immunodeficiency disorders (PID), and especially common variable immunodeficiency (CVID), may be dominated by symptoms of autoimmune disorders. Furthermore, autoimmunity may be the first manifestation of PID, frequently preceding infections and the diagnosis of hypogammaglobulinemia, which occurs later on. In this case, distinguishing PID from hypogammaglobulinemia secondary to anti-inflammatory treatment of autoimmunity may become challenging. The aim of this study was to evaluate the diagnostic accuracy of peripheral blood lymphocyte phenotyping in resolving the diagnostic dilemma between primary and secondary hypogammaglobulinemia. Comparison of B and T cell subsets from patients with PID and patients with rheumatic disease, who developed hypogammaglobulinemia as a consequence of anti-inflammatory regimes, revealed significant differences in proportion of naïve B cells, class-switched memory B cells and CD21low B cells among B cells as well as in CD4+ memory T cells and CD4+ T follicular cells among CD4+ T cells. Identified differences in B cell and T cell subsets, and especially in the proportion of class-switched memory B cells and CD4+ T follicular cells, display a considerable diagnostic efficacy in distinguishing PID from secondary hypogammaglobulinemia due to anti-inflammatory regimens for rheumatic disease.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Faranaz Atschekzei
- Correspondence: (F.A.); (G.S.); Tel.: +49-(0)-511-532-3871 (F.A.); +49-(0)-511-532-3799 (G.S.)
| | - Georgios Sogkas
- Correspondence: (F.A.); (G.S.); Tel.: +49-(0)-511-532-3871 (F.A.); +49-(0)-511-532-3799 (G.S.)
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Wijetilleka S, Jayne DR, Mukhtyar C, Ala A, Bright PD, Chinoy H, Harper L, Kazmi MA, Kiani-Alikhan S, Li CK, Misbah SA, Oni L, Price-Kuehne FE, Salama AD, Workman S, Wrench D, Karim MY. Recommendations for the management of secondary hypogammaglobulinaemia due to B cell targeted therapies in autoimmune rheumatic diseases. Rheumatology (Oxford) 2020; 58:889-896. [PMID: 30590695 DOI: 10.1093/rheumatology/key394] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 11/01/2018] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES The association of B cell targeted therapies with development of hypogammaglobulinaemia and infection is increasingly recognized. Our aim was to develop consensus recommendations for immunoglobulin replacement therapy for management of hypogammaglobulinaemia following B cell targeted therapies in autoimmune rheumatic diseases. METHODS A modified Delphi exercise involved a 17-member Taskforce committee, consisting of immunologists, rheumatologists, nephrologists, haematologists, a gastroenterologist, an immunology specialist nurse and a patient representative. The first round identified the most pertinent topics to address in the recommendations. A search string was agreed upon for the identification of publications in PubMed focusing on these areas, for a systematic literature review. Original data was presented from this review to the Taskforce committee. Recommendations from the British Society for Rheumatology, the UK Department of Health, EULAR, the ACR, and the American Academy of Allergy, Asthma, and Immunology were also reviewed. The evidence was discussed in a face-to-face meeting to formulate recommendation statements. The levels of evidence and statements were graded according to Scottish Intercollegiate Guidelines Network methodology. RESULTS Three overarching principles, eight recommendation statements and a research agenda were formulated. The Taskforce committee voted on these statements, achieving 82-100% agreement for each recommendation. The strength of the recommendations was restricted by the low quality of the available evidence, with no randomized controlled trial data. The recommendations cover risk factors, monitoring, referral for hypogammaglobulinaemia; indications, dosage and discontinuation of immunoglobulin replacement therapy. CONCLUSION These are the first recommendations specifically formulated for B cell targeted therapies related to hypogammaglobulinaemia in autoimmune rheumatic diseases. The recommendations are to aid health-care professionals with clinical decision making for patients with hypogammaglobulinaemia.
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Affiliation(s)
| | - David R Jayne
- Department of Medicine, University of Cambridge, Cambridge
| | - Chetan Mukhtyar
- Department of Rheumatology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich
| | - Aftab Ala
- Department of Gastroenterology and Hepatology, Royal Surrey County Hospital NHS Foundation Trust, Guildford
| | | | - Hector Chinoy
- Department of Rheumatology, Salford Royal NHS Foundation Trust, Salford
| | - Lorraine Harper
- Department of Nephrology, Institute of Clinical Sciences-University of Birmingham, Birmingham
| | - Majid A Kazmi
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust
| | | | - Charles K Li
- Department of Rheumatology, Royal Surrey County Hospital NHS Foundation Trust, Guildford
| | - Siraj A Misbah
- Department of Immunology, Oxford University Hospitals, Oxford
| | - Louise Oni
- Department of Paediatric Nephrology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool
| | - Fiona E Price-Kuehne
- Department of Paediatrics, University of Cambridge School of Clinical Medicine, Cambridge
| | - Alan D Salama
- Department of Nephrology, University College London Centre for Nephrology
| | - Sarita Workman
- Department of Immunology, Royal Free London NHS Foundation Trust, London, UK
| | - David Wrench
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust
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43
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Rundgren IM, Ryningen A, Anderson Tvedt TH, Bruserud Ø, Ersvær E. Immunomodulatory Drugs Alter the Metabolism and the Extracellular Release of Soluble Mediators by Normal Monocytes. Molecules 2020; 25:molecules25020367. [PMID: 31963193 PMCID: PMC7024334 DOI: 10.3390/molecules25020367] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/10/2020] [Accepted: 01/13/2020] [Indexed: 12/14/2022] Open
Abstract
Immunomodulatory drugs (IMiDs) are used in the treatment of hematological malignancies, especially multiple myeloma. IMiDs have direct anticancer effects but also indirect effects via cancer-supporting stromal cells. Monocytes are a stromal cell subset whose metabolism is modulated by the microenvironment, and they communicate with neighboring cells through extracellular release of soluble mediators. Toll-like receptor 4 (TLR4) is then a common regulator of monocyte metabolism and mediator release. Our aim was to investigate IMiD effects on these two monocyte functions. We compared effects of thalidomide, lenalidomide, and pomalidomide on in vitro cultured normal monocytes. Cells were cultured in medium alone or activated by lipopolysaccharide (LPS), a TLR4 agonist. Metabolism was analyzed by the Seahorse XF 96 cell analyzer. Mediator release was measured as culture supernatant levels. TLR4 was a regulator of both monocyte metabolism and mediator release. All three IMiDs altered monocyte metabolism especially when cells were cultured with LPS; this effect was strongest for lenalidomide that increased glycolysis. Monocytes showed a broad soluble mediator release profile. IMiDs decreased TLR4-induced mediator release; this effect was stronger for pomalidomide than for lenalidomide and especially thalidomide. To conclude, IMiDs can alter the metabolism and cell–cell communication of normal monocytes, and despite their common molecular target these effects differ among various IMiDs.
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Affiliation(s)
- Ida Marie Rundgren
- Department of Biomedical Laboratory Scientist Education and Chemical Engineering, Faculty of Engineering and Natural Sciences, Western Norway University of Applied Sciences, 5020 Bergen, Norway; (I.M.R.); (A.R.); (E.E.)
- Department of Clinical Science, University of Bergen, 5020 Bergen, Norway
| | - Anita Ryningen
- Department of Biomedical Laboratory Scientist Education and Chemical Engineering, Faculty of Engineering and Natural Sciences, Western Norway University of Applied Sciences, 5020 Bergen, Norway; (I.M.R.); (A.R.); (E.E.)
| | | | - Øystein Bruserud
- Department of Clinical Science, University of Bergen, 5020 Bergen, Norway
- Section for Hematology, Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway;
- Correspondence:
| | - Elisabeth Ersvær
- Department of Biomedical Laboratory Scientist Education and Chemical Engineering, Faculty of Engineering and Natural Sciences, Western Norway University of Applied Sciences, 5020 Bergen, Norway; (I.M.R.); (A.R.); (E.E.)
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44
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Barrés-Fernández A, Piolatti-Luna A, Bretón-Martínez JR, Crehuá-Gaudiza E, Quiñones-Torrelo C, Moscardó-Navarro A, Fuertes-Latasa C, Martínez-Costa C. Case Report: Primary Peritonitis as the Onset of Pediatric Ménétrier's Disease. Front Pediatr 2020; 8:589853. [PMID: 33520889 PMCID: PMC7838494 DOI: 10.3389/fped.2020.589853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 12/07/2020] [Indexed: 11/20/2022] Open
Abstract
Introduction: Primary peritonitis (PP) and Ménétrier's Disease (MD) are both rare conditions among pediatric population. Although about 150 MD cases have been described in the scientific literature to date, its onset with a PP is an unusual condition. Case Presentation: We present a case of an 11-year-old boy who was admitted to our unit because of abdominal pain and distension. Complementary tests showed ascites, bilateral pleural effusion, leukocytosis, increased acute phase reactants and hypoproteinemia with hypoalbuminemia. Laparoscopy ruled out appendicitis or visceral perforations and exposed purulent peritoneal fluid, compatible with PP. Biochemical stool analysis showed increased clearance of alpha-1-antitrypsin, which was consistent with a protein-losing enteropathy. Gastroscopy findings were compatible with MD. The clinical course was favorable and he had no recurrence after 12 months of follow-up. Conclusion: PP can be the first clinical manifestation of pediatric MD. Knowledge of MD and its generally benign nature in children is important in order to avoid excessive testing and unnecessary treatment.
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Affiliation(s)
| | | | - José Rafael Bretón-Martínez
- Pediatric Department, Hospital Clínico Universitario, Valencia, Spain.,Department of Pediatrics, University of Valencia, Valencia, Spain
| | - Elena Crehuá-Gaudiza
- Pediatric Department, Hospital Clínico Universitario, Valencia, Spain.,Department of Pediatrics, University of Valencia, Valencia, Spain
| | - Carmen Quiñones-Torrelo
- Clinic Biochemistry and Molecular Pathology Department, Hospital Clínico Universitario, Valencia, Spain
| | | | | | - Cecilia Martínez-Costa
- Pediatric Department, Hospital Clínico Universitario, Valencia, Spain.,Department of Pediatrics, University of Valencia, Valencia, Spain
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45
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Silver JN, Ashbaugh CD, Miles JJ, Wu H, Marecki GT, Hwang JK, Jiao JA, Abrams M, Sullivan EJ, Wesemann DR. Deployment of Transchromosomal Bovine for Personalized Antimicrobial Therapy. Clin Infect Dis 2019; 66:1116-1119. [PMID: 29272362 DOI: 10.1093/cid/cix977] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 11/08/2017] [Indexed: 11/12/2022] Open
Abstract
For decades, intravenous immunoglobulin (IVIg) has provided safe and effective therapy for immunodeficient patients. This proof-of-principle study describes a novel approach to generate personalized IVIg for chronic, antibiotic-resistant infection in real time.
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Affiliation(s)
- Jared N Silver
- Department of Medicine, Division of Infectious Diseases, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Cameron D Ashbaugh
- Department of Medicine, Division of Infectious Diseases, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Hua Wu
- SAb Biotherapeutics Inc, Sioux Falls, South Dakota
| | - Gregory T Marecki
- Department of Medicine, Division of Infectious Diseases, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Joyce K Hwang
- Department of Medicine, Division of Infectious Diseases, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jin-An Jiao
- SAb Biotherapeutics Inc, Sioux Falls, South Dakota
| | - Mark Abrams
- Department of Medicine, Division of Infectious Diseases, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Duane R Wesemann
- Department of Medicine, Division of Infectious Diseases, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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46
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Cowan J, Do TL, Desjardins S, Ramotar K, Corrales-Medina V, Cameron DW. Prevalence of Hypogammaglobulinemia in Adult Invasive Pneumococcal Disease. Clin Infect Dis 2019; 66:564-569. [PMID: 29401274 DOI: 10.1093/cid/cix836] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 09/17/2017] [Indexed: 11/14/2022] Open
Abstract
Background Patients with humoral immune deficiency are susceptible to invasive pneumococcal disease (IPD). This study estimates the prevalence of underlying hypogammaglobulinemia in admitted IPD cases and examines whether IPD cases had received preventative treatment. Methods All adult IPD cases (Streptococcus pneumoniae in blood or cerebrospinal fluid) admitted to The Ottawa Hospital (TOH) from January 2013 to December 2015 were identified through the Eastern Ontario Regional Laboratory. Documented clinical demographics, S. pneumoniae serotype, serum immunoglobulins measured previously or in convalescence, and vaccination status of the cases were collected retrospectively for descriptive analyses. Results There were 134 IPD in 133 patients (47.4% male; mean age 63, standard deviation [SD] = 15.6 years) during a 3-year observation period. All-cause mortality rate was 22.6% over a mean follow-up time of 362, SD = 345 days. Fifty-seven patients (42.9%) had serum immunoglobulin levels measured. Eighteen were either found to have hypogammaglobulinemia in convalescence (8/18) or previously known to have hypogammaglobulinemia (10/18). None of the known hypogammaglobulinemic patients had received antibiotic prophylaxis and/or immunoglobulin replacement therapy within 4 months prior to IPD. The high and low estimates of prevalence of hypogammaglobulinemia were 31.6% (of all measured) and 13.5% (of all cases). Among 18 patients with hematological malignancies in our cohort, 13 had hypogammaglobulinemia. Many isolates were vaccine serotypes; however, only 8 had documented previous pneumococcal vaccination. Conclusions IPD has high mortality, and hypogammaglobulinemia was present in at least 13.5% of IPD cases. Secondary hypogammaglobulinemia is especially common in cases with hematological malignancy and IPD.
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Affiliation(s)
- Juthaporn Cowan
- Department of Medicine, The Ottawa Hospital and University of Ottawa.,Ottawa Hospital Research Institute
| | - Thuy Linh Do
- Department of Medicine, The Ottawa Hospital and University of Ottawa
| | - Sacha Desjardins
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ontario, Canada
| | - Karamchand Ramotar
- Department of Pathology and Laboratory Medicine, The Ottawa Hospital and University of Ottawa, Ontario
| | - Vicente Corrales-Medina
- Department of Medicine, The Ottawa Hospital and University of Ottawa.,Ottawa Hospital Research Institute
| | - Donald William Cameron
- Department of Medicine, The Ottawa Hospital and University of Ottawa.,Ottawa Hospital Research Institute.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ontario, Canada
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47
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Dinh T, Oh J, Cameron DW, Lee SH, Cowan J. Differential immunomodulation of T-cells by immunoglobulin replacement therapy in primary and secondary antibody deficiency. PLoS One 2019; 14:e0223861. [PMID: 31613907 PMCID: PMC6793872 DOI: 10.1371/journal.pone.0223861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 09/30/2019] [Indexed: 11/18/2022] Open
Abstract
Patients with primary or secondary antibody deficiency (PAD or SAD) are at increased risk of recurrent infections that can be alleviated by immunoglobulin replacement therapy (IRT). In addition to replenishing antibody levels, IRT has been suggested to modulate immune response in patients with antibody deficiency. Although both commonly treated with IRT, the underlying causes of PAD and SAD vary greatly, suggesting differential modulation of T-cell function that may lead to different responses to IRT. To explore this, peripheral blood mononuclear cells (PBMCs) were sampled from 17 PAD and 14 SAD patients before and 2–10 months after initiation of IRT, and analyzed for changes in T-cell phenotype and function. Proportions of CD4, CD8, Treg, or memory T-cells did not significantly change post-IRT compared to pre-IRT. However, we report distinct modulation in T-cell function between PAD and SAD patients post-IRT. Upon α-CD3/CD28 stimulation, proportion of IFN-γ+ CD4 and CD8 T-cells increased in SAD (p = 0.005) but not PAD patients post-IRT compared to baseline. Interestingly, total T-cell proliferation was reduced post-IRT in both PAD and SAD patients, although the reduction in proliferation was primarily due to reduced CD4 T-cell proliferation in PAD (p = 0.025) in contrast to CD8 T-cells in SAD (p = 0.042). In summary, even though IRT provides patients with passive humoral immunity-mediated protection in PAD and SAD, our findings suggest that IRT immunomodulation of T-cells is different in T-cell subsets depending on underlying immunodeficiency.
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Affiliation(s)
- Tri Dinh
- Department of Biochemistry, Microbiology, and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jun Oh
- Department of Biochemistry, Microbiology, and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Donald William Cameron
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Seung-Hwan Lee
- Department of Biochemistry, Microbiology, and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- * E-mail: (SHL); (JC)
| | - Juthaporn Cowan
- Department of Biochemistry, Microbiology, and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- * E-mail: (SHL); (JC)
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48
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Abdallah HM, Zhu AZX. A Minimal Physiologically-Based Pharmacokinetic Model Demonstrates Role of the Neonatal Fc Receptor (FcRn) Competition in Drug-Disease Interactions With Antibody Therapy. Clin Pharmacol Ther 2019; 107:423-434. [PMID: 31449666 DOI: 10.1002/cpt.1619] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 08/05/2019] [Indexed: 12/11/2022]
Abstract
Disease trajectories following antibody therapy can have a significant impact on the pharmacokinetics of the antibody. Although this phenomenon can often be explained by reduced target-expressing cells, other mechanisms may play a role. We use a novel minimal physiologically-based pharmacokinetic model to evaluate an alternative drug-disease interaction mechanism involving competitive inhibition of neonatal Fc receptor (FcRn)-mediated Immunoglobulin G recycling by paraproteins. The model is validated with clinical data from the anti-FcRn antibody M281 and is used to conduct a scenario test to quantify the interaction among M-protein, the characteristic paraprotein of multiple myeloma (MM), and the anti-CD38 antibody daratumumab indicated for MM treatment. Simulations predict up to a 3.6-fold increase in daratumumab half-life following M-protein reduction, which lends credence to the hypothesis that FcRn competition in MM can manifest as time-dependent reduction of clearance for daratumumab. This model can inform optimal dosing strategies for antibodies in MM and other pathologies of paraprotein excess.
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Affiliation(s)
| | - Andy Z X Zhu
- Takeda Pharmaceutical Company Limited, Cambridge, Massachusetts, USA
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49
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Gupta S, Pattanaik D, Krishnaswamy G. Common Variable Immune Deficiency and Associated Complications. Chest 2019; 156:579-593. [PMID: 31128118 DOI: 10.1016/j.chest.2019.05.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 05/05/2019] [Accepted: 05/13/2019] [Indexed: 12/25/2022] Open
Abstract
Common variable immunodeficiency disorders refer to a relatively common primary immune deficiency group of diseases that present with infectious and inflammatory complications secondary to defects in antibody production and sometimes in cellular immunity. The disorder often presents in middle age or later with recurrent sinopulmonary infections, bronchiectasis, or a plethora of noninfectious complications such as autoimmune disorders, granulomatous interstitial lung disease, GI diseases, malignancies (including lymphoma), and multisystem granulomatous disease resembling sarcoidosis. Infusion of immunoglobulin by IV or subcutaneous is the mainstay of therapy. Management of complications is often difficult as immune suppression may be necessary in these conditions and entails the use of medications and biologicals which may further increase the risk for infections. Specifically, bronchiectasis, granulomatous lymphocytic interstitial lung disease, repeated sinopulmonary infections, and malignancies are sequelae of antibody deficiency that may present to the pulmonologist. This review will provide an updated understanding of the molecular aspects, differential diagnosis, presentations, and the management of common variable immunodeficiency disorders.
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Affiliation(s)
- Siddhi Gupta
- Department of Medicine, Division of Infectious Disease, Wake Forest School of Medicine, Winston Salem, NC
| | - Debendra Pattanaik
- Division of Allergy, Immunology and Rheumatology, University of Tennessee Health Science Center, Memphis TN
| | - Guha Krishnaswamy
- Department of Medicine, Division of Infectious Disease, Wake Forest School of Medicine, Winston Salem, NC; Division of Infectious Disease, Pulmonary, Allergy and Immunology, Wake Forest School of Medicine, Winston Salem, NC; Department of Medicine, Division of Allergy and Immunology, W.G. (Bill) Hefner VA Medical Center, Salisbury, NC.
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50
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Pecoraro A, Crescenzi L, Galdiero MR, Marone G, Rivellese F, Rossi FW, de Paulis A, Genovese A, Spadaro G. Immunosuppressive therapy with rituximab in common variable immunodeficiency. Clin Mol Allergy 2019; 17:9. [PMID: 31080365 PMCID: PMC6501382 DOI: 10.1186/s12948-019-0113-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 04/11/2019] [Indexed: 12/23/2022] Open
Abstract
Common variable immunodeficiency (CVID) is the most frequent symptomatic primary antibody deficiency in adulthood and is characterized by the marked reduction of IgG and IgA serum levels. Thanks to the successful use of polyvalent immunoglobulin replacement therapy to treat and prevent recurrent infections, non-infectious complications, including autoimmunity, polyclonal lymphoproliferation and malignancies, have progressively become the major cause of morbidity and mortality in CVID patients. The management of these complications is particularly challenging, often requiring multiple lines of immunosuppressive treatments. Over the last 5–10 years, the anti-CD20 monoclonal antibody (i.e., rituximab) has been increasingly used for the treatment of both autoimmune and non-malignant lymphoproliferative manifestations associated with CVID. This review illustrates the evidence on the use of rituximab in CVID. For this purpose, first we discuss the mechanisms proposed for the rituximab mediated B-cell depletion; then, we analyze the literature data regarding the CVID-related complications for which rituximab has been used, focusing on autoimmune cytopenias, granulomatous lymphocytic interstitial lung disease (GLILD) and non-malignant lymphoproliferative syndromes. The cumulative data suggest that in the vast majority of the studies, rituximab has proven to be an effective and relatively safe therapeutic option. However, there are currently no data on the long-term efficacy and side effects of rituximab and other second-line therapeutic options. Further randomized controlled trials are needed to optimize the management strategies of non-infectious complications of CVID.
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Affiliation(s)
- Antonio Pecoraro
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Ludovica Crescenzi
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Maria Rosaria Galdiero
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Giancarlo Marone
- 2Department of Public Health, University of Naples Federico II, Naples, Italy.,3Monaldi Hospital Pharmacy, Naples, Italy
| | - Felice Rivellese
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy.,4Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Francesca Wanda Rossi
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Amato de Paulis
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Arturo Genovese
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Giuseppe Spadaro
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
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