A Canadian perspective on the use of immunoglobulin therapy to reduce infectious complications in chronic lymphocytic leukemia

Supportive Care in Older Lymphoma Patients to Reduce Toxicity and Preserve Quality of Life

The treatment paradigm in older patients with malignant hemopathies is the choice between an effective conservative treatment that preserves quality of life and an intensive, potentially curative treatment with more toxicities. For each patient, it is important to determine the risk/benefit ratio. The patient should be involved in the discussion, sufficiently informed and able to express himself and his expectations in terms of quality of life. However, this informed consent is conditioned by the ability of the patient to understand the risks and benefits of the treatment. Decline in quality of life is an important parameter for older patients with cancer and many prospective trials have now confirmed the impact of different side effects of treatment, such as recurrent hospitalization, loss of autonomy in daily activities, loss of contact with grandchildren and loss of cognitive functions. Interventions oriented to vulnerabilities detected in the older patients (by comprehensive geriatric assessment) and an optimal approach, including preventive measures to reduce treatment-related toxicity and mortality, are directly correlated to improvement in quality of life.

Should treatment of hypogammaglobulinemia with immunoglobulin replacement therapy (IgRT) become standard of care in patients with chronic lymphocytic leukemia?

Hypogammaglobulinemia (HGG) is a frequent finding in patients with hematological malignancies, and is commonly described in chronic lymphocytic leukemia (CLL) before or after treatment. We reviewed published literature available online in the last thirty years through Medline search of indexed articles focusing on the main differences and advantages of the products now available on the market, namely intravenous Ig (IVIg) and subcutaneous Ig (SCIg) preparations. IgRT is effective and safe in the prophylaxis of infections in a selected group of patients with CLL and hypogammaglobulinemia and is therefore a valuable tool for clinicians in the everyday management of infectious risk. We encourage the use of SCIg formulations as they appear to have similar efficacy but better cost-effectiveness and tolerability.

Management of secondary immunodeficiency in hematological malignancies in the era of modern oncology

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.

Immunoglobulin replacement therapy in chronic lymphocytic leukaemia patients with hypogammaglobulinaemia and infection

OBJECTIVES

To analyse total national utilisation of immunoglobulin (Ig) replacement therapy (IgRT) for Chronic Lymphocytic Leukaemia patients with acquired hypogammaglobulinaemia and severe and/or recurrent bacterial infections.

METHODS

In 2007, the National Blood Authority first published Criteria for the clinical use of intravenous immunoglobulin in Australia. The Australian Red Cross Lifeblood assessed, approved, and recorded all supply with patient demographics, distribution data, intravenous Ig (IVIg) volumes and treatment episodes. IVIg was the sole product used in Australia from 2008-2013 inclusive.

RESULTS

From 2008 to 2013 across Australia, 2734 individual CLL patients received 48,870 treatment episodes using a total 1,324,926 g of IVIg therapy. Six IVIg products were available, with domestically manufactured Intragam^® P accounting for 89.7% of supply. The average age for first dose was 74 years. Males received 60.6% of the total treatment episodes representing 20% more than females. The average pre-treatment IgG level was 4.03 ± 2.03 g/L (range 0.30-10.50 g/L). A sustained average annual increased IVIg utilisation of 5.5% was observed. There was significant regional variation consistent with differences in prescriber preferences across states and territories.

CONCLUSION

This study provides a globally unique insight into IgRT supply and demand in CLL patients by analysis of total national use in Australia over a 6-year period.

Secondary Hypogammaglobulinemia in Patients with Chronic Lymphocytic Leukemia Receiving Ibrutinib Therapy

Secondary hypogammaglobulinemia (SHG) is characterized by a decrease in total serum immunoglobulin (Ig) levels and can lead to immunodeficiency associated with recurrent and severe infections and is a common complication of chronic lymphocytic leukaemia (CLL). SHG also increases with the treatment of CLL. Ibrutinib is one of these treatments and acts by inhibiting bruton tyrosine kinase. Twenty-seven patients with relapsed/refractory (R/R) CLL who received ibrutinib monotherapy were included. IgG levels, stage, bulky disease, previous treatments, genetics and laboratory features, overall survival (OS) and progression free survival (PFS) were compared with and without SHG. Nine patients (33.3%) had SHG and 18 patients (66.6%) didn't have SHG. The mean IgG levels after ibrutinib treatment first, third, 6th and 12th months were 684, 531.3, 452 and 360 mg/dL respectively in SHG arm (p < 0.001) and 1156, 1058.2, 1012.8 and 886.9 mg/dL respectively in without SHG arm (p < 0.001). All patients with SHG had ibrutinib related other adverse effects(AEs) but 2 (11.1%) patients without SHG had AEs (p < 0.001). In SHG arm 7 (77.7%) had complete and partial remission but in other arm only 6 (33.3%) had (p: 0.029). There was no significant difference in OS and PFS (p values 0.95 and 0.64, respectively). IgG levels at the beginning of ibrutinib treatment is the best predicted value for SHG development in our study (p = 0.001). As a result, we reported a significant decrease in IgG values after ibrutinib monotherapy in R/R CLL patients. This decrease occurs every month after ibrutinib use, but after a maximum of 1 year.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s12288-021-01466-1.

A Systematic Review on the Prevention and Control of Opportunistic Infections in Patients With Chronic Lymphocytic Leukemia Complicated by Richter’s Transformation

Chronic lymphocytic leukemia (CLL) is one of the most commonly occurring types of leukemia among the elderly population, contributing to an increased vulnerability to infections that are especially prolific in the immunosuppressed and the risk of rapid progression of the disease into a more aggressive manifestation of large cell lymphoma, a process called Richter’s Transformation (RT). CLL alone predisposes patients to develop infections; however, the additional complication of RT decreases survival and makes the prevention and control of infection for the CLL patient even more challenging. However, research that exists on preventing and controlling infection in CLL patients with RT is relatively limited. In most cases, studies have focused on the prevention of infection in CLL patients in general and with no reference to the progression of RT.

Considering the dearth of research on infection prevention and control for patients with CLL complicated by RT specifically, the following review examines existing research in addressing the prevention and control of infection in CLL patients with RT and patients in general. The authors explored multiple databases such as PubMed, Google Scholar, and Science Direct. The ultimate focus of this study was to lay a fundamental understanding in preventing and controlling infection in CLL patients. After analyzing several studies, it can be concluded that identifying infections, even if rare, is a crucial aspect of managing CLL patients. A broad range of differential diagnoses should be sought in cases presenting with refractory CLL as well and management of infections before, during, or after CLL treatment should be considered.

Subcutaneous immunoglobulin replacement for treatment of humoral immune dysfunction in patients with chronic lymphocytic leukemia

Background

Patients with chronic lymphocytic leukemia (CLL) experience hypogammaglobinemia and non-neutropenic infections. In this exploratory proof of concept study, our objective was to determine the prevalence of humoral immunodeficiency in patients with CLL and serum IgG ≥ 400 mg/dL, and to evaluate the efficacy of subcutaneous immunoglobulin (SCIG) in this population.

Patients and methods

Patients with CLL with serum IgG ≥ 400 mg/dL were evaluated for serum IgG, IgM, IgA, along with pre/post vaccine IgG titers to diphtheria, tetanus, and Streptococcus pneumoniae. Patients with evidence of humoral dysfunction were treated with SCIG with Hizentra every 7±2 days for 24 weeks.

Results

Fifteen patients enrolled with median IgG = 782 mg/dL [IQR: 570 to 827], and 6/15 (40%) responded to vaccination with Td, while 5/15 (33%) responded to vaccination with PPV23. 14/15 (93.3%) demonstrated humoral immunodeficiency as evidenced by suboptimal vaccine responses, and were treated with SCIG. In patients treated with SCIG, serum IgG increased from 670 mg/dL [IQR: 565 to 819] to 1054 mg/dL [IQR: 1040 to 1166] after 24 weeks (95% CI: 271–540). For streptococcus pneumoniae, the median protective serotypes at baseline was 8 [IQR: 4 to 9] and increased to 17 [IQR: 17 to 19] after 24 weeks (95% CI: 6.93–13.72). Non-neutropenic infections (NNI) decreased from 14 to 5 during treatment with SCIG.

Conclusions

Patients with CLL demonstrate humoral immunodeficiency despite IgG > 400 mg/dL. For these patients, SCIG is well tolerated and efficacious in improving serum IgG, specific IgG to streptococcus pneumoniae, and may decrease reliance on antibiotics for the treatment of NNIs.

Clinical trials registration

NCT 03730129.

Can Immunocompetence Be Restored in Chronic Lymphocytic Leukemia?

Reversing or preventing immunodeficiency in patients with chronic lymphocytic leukemia (CLL) is of the highest priority. The past decade of research has met the challenge of treating CLL for most patients. Patients continue to struggle, however, with infections and second primary malignancies related to immunodeficiency. Strategies addressing this need currently are limited to vaccinations, with suboptimal efficacy, and immunoglobulin replacement. Correlative studies have provided insights into immunologic alterations on treatment. Understanding vulnerabilities in the immune system may help identify potential interventions to boost immunity. An emphasis on systematically testing such interventions is required to restore immunocompetence in patients with CLL.

Concurrent BK polyomavirus, adenovirus and cytomegalovirus infections in a patient treated for chronic lymphocytic leukaemia

A 58-year-old woman with chronic lymphocytic leukaemia (CLL) presented with 2 weeks of fever and haematuria following chemo-immunotherapy. CT scan showed thickening of her left urethra and bladder, suggesting pyleo-ureteritis with cystitis. The patient was initially treated for suspected bacterial urinary tract infection although repeated blood and urine cultures remained negative. She then received multiple transfusions for chemotherapy-induced pancytopenia while her urinary symptoms did not improve. Due to her immunocompromised status, she was tested for viral infection, which revealed, BK polyomavirus, adenovirus and cytomegalovirus in serum and urine. Cidofovir was initially administered to treat these infections while ganciclovir was used with filgrastim due to neutropenia. The patient subsequently improved. This case represents a diagnostic and therapeutic challenge due to the multiple concurrent viral infections causing haematuria as well as the combined post-chemo-immunotherapy and antiviral myelotoxicity in a CLL patient.

Discontinuation of immunoglobulin replacement therapy in patients with secondary antibody deficiency

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.

Management of chronic lymphocytic leukemia in Canada during the coronavirus pandemic

The emergence of the covid-19 disease pandemic caused by the 2019 novel coronavirus has required a re-evaluation of treatment practices for clinicians caring for patients with chronic lymphocytic leukemia (cll). The American Society for Hematology (ash) has provided a series of recommendations for the treatment of patients with cll during the pandemic, covering a range of topics, including testing for covid-19, cll treatment initiation and selection, use of immunoglobulin therapy, in-person monitoring, and treatment of patients with cll and covid-19. We summarize the ash recommendations and discuss their applicability as guidelines for the treatment of cll during the covid-19 pandemic in Canada.

Managing hypogammaglobulinaemia secondary to haematological malignancies in Australia and New Zealand: a clinician survey

BACKGROUND

Acquired hypogammaglobulinaemia secondary to haematological malignancies is associated with increased infection risk. Immunoglobulin (Ig) replacement reduces major infections but not mortality, and is costly. No prospective randomised trials have compared Ig replacement with prophylactic antibiotics.

AIMS

To identify variation in current practice regarding management of secondary hypogammaglobulinaemia in Australia and New Zealand, to identify barriers to best practice, and to inform the development of a clinical trial assessing antibiotic prophylaxis in secondary hypogammaglobulinaemia.

METHODS

We conducted an online survey of current clinical practice regarding management of secondary hypogammaglobulinaemia among haematologists in Australia and New Zealand.

RESULTS

Seventy-two haematologists responded; 89% of whom reported commencing Ig replacement for secondary hypogammaglobulinaemia in the setting of recurrent or severe infection. Most monitored trough immunoglobulin G levels, most often 3 monthly. Criteria for stopping Ig replacement varied. Most respondents recommended influenza and pneumococcal vaccination, while only 21% reported using antibiotic prophylaxis. Few respondents (3%) reported prescribing prophylactic antibiotics before commencing Ig replacement. Most reported an interest in recruiting patients to a clinical trial comparing Ig replacement with prophylactic antibiotics.

CONCLUSION

In comparison to limited international data, this survey finds variation in practice, which may be due to differences in local policies governing access to Ig. These findings highlight the need for research into the indications for Ig commencement and cessation, and will inform design of prospective trials of infection prevention in secondary hypogammaglobulinaemia.

Prevalence of Hypogammaglobulinemia in Adult Invasive Pneumococcal Disease

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.

Association of blood IgG with tumor necrosis factor-alpha and clinical course of chronic lymphocytic leukemia

The intrinsic humoral immunodeficiency of chronic lymphocytic leukemia (CLL) is often managed with immunoglobulin replacement therapy (IgRT) to maintain IgG levels in the low-normal range (6–8 g/L) but optimal targets for IgG and timing to commence IgRT are unclear. IgG levels fell near 6 g/L at rates of −0.85±0.14 g/L/year in 51 patients who required treatment for CLL within 4.5±0.4 years from initial diagnosis and − 0.27±0.04 g/L/year in 40 patients with progressive disease who remained untreated after 8.5±0.5 years. In contrast, endogenous IgG levels remained above 8 g/L in patients with highly indolent disease (n = 25) and TNFα and beta-2-microglobulin (β2M) in blood decreased when IgRT was used to increase IgG levels over 9 g/L. At 15 g/L but not 5 g/L, the IgRT product Hizentra® inhibited B cell receptor (BCR)-activation, TNFα production, and survival in vitro, particularly of CLL cells that spontaneously made little TNFα. These findings suggest deterioration of the humoral immune system is associated with progressive CLL and altering the dosing of IgRT to achieve higher than conventional IgG target levels may have therapeutic activity.

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Immunoglobulin levels decline at rates that reflect the clinical course of CLL.

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IgG levels over 10 g/L achieved with replacement therapy are associated with evidence of disease control in vivo and inhibition of BCR-mediated activation of CLL cells in vitro.

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Monitoring rates of decline of Ig levels in CLL patients gives biological information on disease severity.

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Appropriate IgG target levels for immunoglobulin replacement therapy in CLL may be much higher than for patients with other immunodeficiencies.

Management of patients with malignancies and secondary immunodeficiencies treated with immunoglobulins in clinical practice: Long-term data of the SIGNS study

OBJECTIVE

We aimed to describe the current management and outcomes of patients with secondary immunodeficiencies (SID) on intravenous (IV) or subcutaneous (SC) immunoglobulins (IG) as maintenance therapy to prevent infections.

METHODS

Non-interventional, prospective study (average follow-up 20.5 months).

RESULTS

Of the 307 SID patients (mean age 63.7±14.4 years, 52% males, in 31% IG newly initiated), 95.4% received IV IG (mean dosing interval 4.6 weeks, average dose 199 mg/kg per 4 weeks) and 4.6% were treated with SC IG (2.6 weeks, 343 mg/kg per 4 weeks). Median IG through level at first documentation was 5.8 g/L and did not differ between IV and SC treatment or between underlying malignancies. In 24.1% of patients, treatment was interrupted temporarily, over a mean of 11.6±6.3 months. In patients with newly initiated IG treatment the 82% overall infection rate prior to treatment dropped to 21% at 1 year.

CONCLUSIONS

Under clinical practice conditions, IG replacement therapy in SID patients was feasible, diminished infection rates and improved quality of life. Average IG doses were relatively low. Tolerability of IV IG treatment was excellent.

Thoracic Complications in Chronic Lymphocytic Leukemia

BACKGROUND

Chronic lymphocytic leukemia (CLL) is the most common lymphoproliferative disorder worldwide. Although thoracic complications are frequent in CLL, only limited data exist regarding the etiologies of these complications.

MATERIALS AND METHODS

A retrospective chart review was performed on all patients admitted to a tertiary care, CLL referral center, with CLL and a respiratory complaint from 2001 through 2013, to categorize pulmonary complaints and diagnoses.

RESULTS

There were 277 patients with CLL admitted on 409 occasions with respiratory complaints. The median age was 73 years, with a male to female ratio of 2:1. The majority of patients had a high-risk Rai classification and had received prior treatment. Common presenting symptoms included dyspnea, cough, and sputum production. The most common diagnoses were pneumonia (62.8%), with an identified organism in 44.7%, pleural effusions (31.8%), lung cancer (6.9%), and leukemic infiltrates (5.9%). Invasive procedures were performed 138 times: 70 bronchoscopies, 24 surgical lung biopsies, 10 computed tomography-guided lung biopsies, and 34 thoracenteses. In-hospital mortality was 24.9%. In a multivariable analysis, an elevated blood urea nitrogen level and creatinine, thrombocytopenia, and a presenting symptom of dyspnea correlated significantly with in-hospital mortality.

CONCLUSION

Thoracic manifestations in CLL are common among hospitalized patients. Although infectious pneumonia remains most common, unusual or opportunistic infections may be increasing, and direct lung damage owing to CLL itself or to newer biologic agents are being diagnosed with lung tissue sampling. Recognition of these complications will allow earlier diagnosis, which may change management including removal of offending biologic agents or augmentation of treatment for CLL when infiltrative leukemic cells are present.

Secondary immunodeficiency in lymphoproliferative malignancies

Secondary immunodeficiencies occur as a consequence of various diseases, including hematological malignancies, and the use of pharmacological therapies, such as immunosuppressive, anti-inflammatory, and biological drugs. Infections are the main cause of morbidity and mortality in multiple myeloma (MM) and chronic lymphocytic leukemia (CLL) patients. Recent advances in treatment have prolonged the duration of remission and the time between relapse phases in MM and CLL patients. However, managing multiple relapses and the use of salvage therapies can lead to cumulative immunosuppression and a higher risk of infections. The pathogenesis of immune deficiency secondary to lymphoproliferative malignancy is multifactorial including disease- and treatment-related factors. Supportive treatment, including early vaccination, anti-infective prophylaxis, and replacement immunoglobulin, plays a key role in preventing infections in MM and CLL. This article provides an overview of the basic immunology necessary to understand the pathogenesis of secondary immunodeficiency and the infectious complications in MM and CLL. We also discuss the evidence supporting the role of prophylactic replacement immunoglobulin treatment in patients with antibody failure secondary to MM and CLL and the indications for its use. Copyright © 2016 John Wiley & Sons, Ltd.