Facilitated Subcutaneous Immunoglobulin Treatment in Patients with Immunodeficiencies: the FIGARO Study

Comparison of the frequency of viral infections in patients with inborn errors of immunity receiving immunoglobulin by different routes

Immunoglobulin replacement therapy (IRT) is the primary treatment for immunocompromised patients and can be administered via intravenous, subcutaneous, or facilitated subcutaneous routes. In this study, our objective was to compare the incidence of viral infections among patients receiving IRT via different administration routes during the winter season. Fifty-eight patients with primary immunodeficiency (PID) receiving immunoglobulin replacement therapy (IRT) were enrolled in the study. Patients were monitored for their immunoglobulin (Ig) levels, nasal swabs were studied with PCR monthly, and any viral infections were documented. The study included 58 patients with PID, with 33 males (56.8%) and 25 females (43.1%). The median age of the patients was 17 years (IQR, 28.5), and the median age at diagnosis was 11.5 years (IQR, 25.5). The most common IRT route was IVIG, used by 55.1% (n = 32) of patients, followed by cSCIG 27.5% (n = 16), and facilitated subcutaneous immunoglobulin (fSCIG) 17% (n = 10) of patients. The overall frequency of viral infections was 3.79%, distributed among IRT routes as follows: IVIG (n = 32, 4.2%), cSCIG (n = 16, 2.5%), and fSCIG (n = 10, 4.4%). The infection rate in the cSCIG route was significantly lower than in the IVIG and fSCIG routes (p < 0.05). The most common viral agents were adenovirus (21.8%), influenza A (16.4%), and human rhinovirus/enterovirus (16.4%).

CONCLUSION

 In a 3-month evaluation of patients, the infection rate was lower in the cSCIG route compared to the other IRT routes. cSCIG is a safe and viable treatment option that can effectively improve the quality of life for immunocompromised patients.

WHAT IS KNOWN

• Immunoglobulin replacement therapy (IRT) is the standard treatment for patients with primary immunodeficiencies (PID), aiming to prevent infections by maintaining adequate serum immunoglobulin levels. Limited research exists regarding the impact of IRT on the prevention of viral infections.

WHAT IS NEW

• This study reveals key insights into viral infections in PID patients receiving immunoglobulin replacement therapy (IRT) during winter. The overall viral infection rate was 3.79%, with IVIG at 4.2%, cSCIG at 2.5%, and fSCIG at 4.4%. Notably, the cSCIG group had a significantly lower infection rate than the IVIG and fSCIG groups (p0.05). These findings suggest that cSCIG may lower the risk of viral infections in PID patients during high-risk winter months.

Updates in the Understanding of Immunoglobulin Replacement Therapy in Primary Immune Deficiency Disorders: Function, Composition, and Role in Reconstitution and Immunomodulation

Clinical indications for immunoglobulin therapy can be broadly classified into replacement therapy for immunodeficiencies, immunomodulatory treatment of inflammatory conditions, and hyperimmune therapy against specific infectious agents. When starting immunoglobulin therapy, there are important considerations for the clinician including indication and function, composition, dosing, route, and safety. Immunoglobulin therapy should be tailored to an individual patient. This review discusses our current understanding and practical considerations for using immunoglobulin therapy for both humoral immune reconstitution and immunomodulation.

Patient-centered outcomes with subcutaneous immunoglobulin use for infection control in primary and secondary immunodeficiencies: data of a GEIE Spanish Registry

Background and aim

Subcutaneous immunoglobulin (SCIg) has emerged as an alternative to intravenous administration for patients with primary (PID) and secondary immunodeficiencies (SID), offering benefits such as fewer systemic adverse reactions and greater patient autonomy. However, comprehensive real-world data on SCIg use, including clinical and patient-centered outcomes, remain scarce. This study, conducted by expert immunodeficiency nursing teams, assesses the clinical characteristics, reported adverse effects, and quality-of-life outcomes associated with SCIg therapy with different formulations in patients with PID and SID across Spain.

Methods

A multicenter, cross-sectional study was conducted across 8 immunodeficiency nursing units in Spain, involving 223 adult patients treated with SCIg from 2004 to 2024. Data on demographics, comorbidities, SCIg treatment characteristics, reported adverse events, and quality-of-life metrics (EuroQol-5D-3L, Gijón Scale) were collected and analyzed.

Results

The cohort (61.4% female, mean age: 47.1 years) included 65% PID patients, with common variable immunodeficiency being the most frequent diagnosis (39.8%). SCIg demonstrated good tolerability overall, with no significant differences in global adverse event rates between facilitated 10% (fSCIg) and 20% formulations. However, 10% fSCIg was associated with higher reported frequencies of mild local rash (58.7% vs. 36.9%, p=0.002) and fever (10.6% vs. 1.7%, p=0.01). Quality-of-life scores indicated minimal limitations in mobility and self-care, with a mean subjective health rating of 72.7/100. Patients using 20% SCIg required fewer educational sessions for self-administration compared to the 10% group.

Conclusion

The different SCIg formulations in this large, multicenter cohort was effective and generally well-tolerated, supporting its use for maintaining adequate IgG levels and promoting patient independence in PID and SID. The study's findings advocate for tailored approaches that optimize patient satisfaction and address individual needs, emphasizing the critical role of dedicated immunodeficiency nursing teams in ensuring safe, effective, and patient-centered SCIg administration.

Real-World Effectiveness, Safety, and Tolerability of Facilitated Subcutaneous Immunoglobulin 10% in Secondary Immunodeficiency Disease: A Systematic Literature Review

Background: Secondary immunodeficiency disease (SID) is a complex, heterogeneous condition that occurs when extrinsic factors weaken the immune system. Expert consensus guidelines recommend immunoglobulin replacement therapy to manage immunoglobulin G (IgG) levels and mitigate severe, recurrent, and persistent infections. Hyaluronidase-facilitated subcutaneous immunoglobulin (fSCIG) 10% is a dual-vial unit of IgG and recombinant human hyaluronidase; the latter enables absorption of higher volumes of IgG than conventional subcutaneous therapies. Methods: For this systematic literature review, Embase, MEDLINE®, and the Cochrane Library were searched on 9 August 2023, with supplemental congress searches. Results: Eight studies fulfilled the inclusion criteria, reporting real-world evidence of the clinical effectiveness, safety, and tolerability of fSCIG 10% in 183 patients with SID in Europe from September 2014 to August 2021. The potential causes of SID were primarily hematological malignancies, most commonly chronic lymphocytic leukemia. Treatment was typically administered at 4-week or 3-week intervals, with doses of approximately 0.4 g/kg/month. Infections were rare during follow-up, with numerical reductions observed after fSCIG 10% treatment initiation compared with the period before initiation. Adverse reactions, including local infusion site reactions, and tolerability events were uncommon. Conclusions: Given the recency of fSCIG 10% use in patients with SID, there are opportunities for future research to better understand survival and patient-reported outcomes after receiving this treatment. Despite SID heterogeneity, this study demonstrates the feasibility of fSCIG 10% treatment for this condition.

Understanding secondary hypogammaglobulinemia and its implications for cancer prognosis in children: A retrospective cohort study

INTRODUCTION

Immunodeficiencies are disturbances in the immune system that can affect cell function, quantity, or both. They can be either primary, associated with genetic defects, or secondary, linked to external factors such as hemato-oncological conditions. Secondary immunodeficiencies can lead to the initiation, reactivation, or acceleration of latent, residual, or active infections, which are the leading cause of mortality.

OBJECTIVE

To elucidate the occurrence and clinical characteristics of hypogammaglobulinemia in pediatric oncology patients in a high-complexity hospital in Colombia between January 2020 and December 2022.

MATERIALS AND METHODS

We conducted an observational study with patients under 18 years old with a cancer diagnosis, serum immunoglobulins measurements at the time of the diagnosis, and later follow-up during treatment.

RESULTS

We included 133 patients with a median age of eight years. Based on local guidelines of immunoglobulin levels for age, all patients had normal values at the time of cancer diagnosis. In the follow-up, the most significant reduction among all ages was for IgA and was related to infections and death.

CONCLUSIONS

Our findings highlight the importance of measuring immunoglobulin levels at the time of the cancer diagnosis, as hypogammaglobulinemia may be linked to a poorer prognosis. Early detection could potentially improve patient outcomes.

Sentiment analysis of subcutaneous and intravenous immunoglobulin therapy: public healthcare perception through social media discourse

Purpose

Immunoglobulin replacement therapy remains a cornerstone of treatment in antibody deficiencies and other inborn errors of immunity. While patient preferences between subcutaneous and intravenous immunoglobulin have been studied through questionnaires, no study has yet explored patient perspectives in a free environment. Therefore, we aimed to conduct a sentiment analysis as well as a temporal and geographical analysis on public opinions obtained from social media to better understand patient satisfaction and public perception on immunoglobulin therapy.

Methods

A dataset of 43,700 tweets spanning from the 1st of January of 2012 to the 31st of December of 2022 was obtained. A Valence Aware Dictionary for Sentiment Reasoning sentiment analysis was performed, followed by statistical, geographical and temporal analyses.

Results

Mean polarity of intravenous immunoglobulin related tweets was 0.1295 (positive), while mean polarity for subcutaneous immunoglobulin was 0.2117 (positive). Temporal analysis through a statistical model demonstrated that the volume of tweets increased over time for both subcutaneous and intravenous treatment. Geographical analysis revealed that the majority of texts originated from the United States. The highest mean polarity was observed in Romania with a mean value of 0.2966, while the lowest polarity was documented in Norway with a mean of -0.0211.

Conclusion

Tweets linked to subcutaneous immunoglobulin treatment had a higher average polarity, indicating a more positive public perception. The amount of tweets relating to both therapies showed a tendency to increase as the years progressed, implying an increase in public discussion on immunoglobulin treatment.

Immunoglobulin Replacement Therapy: Insights into Multiple Myeloma Management

Immunoglobulin (Ig) replacement therapy (IgRT) consists of the administration of low-dose human polyclonal Igs for the treatment of primary and secondary hypogammaglobulinemia that are associated with recurrent infections and immune dysfunction. IgRT restores physiological antibody levels and induces an immunomodulatory effect by strengthening immune effector cells, thus reducing infections. Here, we describe the pharmacology of different Ig formulations with a particular focus on their mechanism of action as low-dose IgRT, including the direct anti-microbial effect and the immunomodulatory function. In addition, we describe the use of therapeutic Igs for the management of multiple myeloma (MM), a hematologic malignancy characterized by severe secondary hypogammaglobulinemia associated with poor patient outcome. In MM settings, IgRT prevents life-threatening and recurrent infections showing promising results regarding patient survival and quality of life. Nevertheless, the clinical benefits of IgRT are still controversial. A deeper understanding of the immune-mediated effects of low-dose IgRT will provide the basis for novel combined therapeutic options and personalized therapy in MM and other conditions characterized by hypogammaglobulinemia.

Insights into Patient Experiences with Facilitated Subcutaneous Immunoglobulin Therapy in Primary Immune Deficiency: A Prospective Observational Cohort

BACKGROUND

Immunoglobulin G replacement therapy (IgRT), intravenous (IV) and subcutaneous (SC) routes, is pivotal in treatment of primary immunodeficiencies (PID). In recent years, facilitated subcutaneous immunoglobulin (fSCIG), a combination of rHuPH20 and 10% IgG has emerged as a delivery method to combine advantages of both IV and SC.

METHOD

In an observational prospective cohort, we investigated patient experience with fSCIG in PID patients from 5 PID centers for up to 12 months. We assessed the efficacy and safety of this treatment with patient/caregiver- and physician-reported indicators. Additionally, we analyzed patient treatment satisfaction (TSQM-9) and quality of life (QoL).

RESULTS

We enrolled 29 patients (22 pediatric and 7 adults; 14 females and 15 males; (median: 15, min-max: 2-40.9 years) who initiated fSCIG as IgRT-naive (n = 1), switched from conventional rapid-push 10% SCIG (n = 6) or IVIG (n = 22). Among the participants, 19 (65%) exhibited antibody deficiencies, 8 (27%) combined immunodeficiencies, and 2 (7%) immune dysregulations. Remarkably, targeted trough immunoglobulin G levels were achieved under all previous IgRTs as well as fSCIG. No severe systemic adverse drug reactions were documented, despite prevalent local (%86.45) and mild systemic (%26.45) adverse reactions were noted with fSCIG. Due to mild systemic symptoms, 2 patients switched from fSCIG to 10% SCIG. The patient satisfaction survey revealed a notable increase at 2-4th (p = 0.102); 5-8th (p = 0.006) and 9-12th (p < 0.001) months compared to the baseline. No significant trends were observed in QoL surveys.

CONCLUSION

fSCIG demonstrates admissable tolerability and efficacy in managing PIDs in addition to notable increase of patients' drug satisfaction with IgRT. The identified benefits support the continuation of this therapy despite the local reactions.

Long-term safety of hyaluronidase-facilitated subcutaneous immunoglobulin 10%: a European post-authorization study

Aim: To assess the long-term safety of hyaluronidase-facilitated subcutaneous immunoglobulin (fSCIG) 10% in European routine clinical practice.Materials & methods: This prospective, noninterventional, open-label, post-authorization safety study (EUPAS5812) sourced data on adverse events, immunogenicity, treatment regimens and product administration for 106 adult patients prescribed fSCIG 10% across 17 sites in six European countries from July 2014 to February 2020.Results: In total, 1171 treatment-emergent adverse events were reported in 94 patients (88.7%); 25.5% of these events were considered related to fSCIG 10%. Positive binding antibody titers developed in three patients; no neutralizing antibodies to recombinant human hyaluronidase were detected.Conclusion: This real-world study of fSCIG 10% is the longest to date and confirms its long-term safety and tolerability in adults with antibody deficiency diseases.

Towards more tolerable subcutaneous administration: Review of contributing factors for improving combination product design

Subcutaneous (SC) injections can be associated with local pain and discomfort that is subjective and may affect treatment adherence and overall patient experience. With innovations increasingly focused on finding ways to deliver higher doses and volumes (≥2 mL), there is a need to better understand the multiple intertwined factors that influence pain upon SC injection. As a priority for the SC Drug Development & Delivery Consortium, this manuscript provides a comprehensive review of known attributes from published literature that contribute to pain/discomfort upon SC injection from three perspectives: (1) device and delivery factors that cause physical pain, (2) formulation factors that trigger pain responses, and (3) human factors impacting pain perception. Leveraging the Consortium's collective expertise, we provide an assessment of the comparative and interdependent factors likely to impact SC injection pain. In addition, we offer expert insights and future perspectives to fill identified gaps in knowledge to help advance the development of patient-centric and well tolerated high-dose/high-volume SC drug delivery solutions.

A Phase 1 Open-Label Study to Assess the Tolerability, Safety, and Immunogenicity of Hyaluronidase-Facilitated Subcutaneous Immunoglobulin 20% in Healthy Adults

PURPOSE

Hyaluronidase-facilitated subcutaneous immunoglobulin (fSCIG) 20% will allow reduced infusion volumes and frequency versus existing subcutaneous therapies such as fSCIG 10% and conventional subcutaneous immunoglobulin 20%, respectively. We assessed the tolerability, safety, and immunogenicity of warmed and unwarmed fSCIG 20%.

METHODS

This phase 1, single-dose, open-label, three-arm study enrolled healthy adults aged 19-50 years (inclusive) at a single US center (NCT05059977). Post-screening, participants received a single fSCIG 20% dose comprising recombinant human hyaluronidase and varying doses of in-line warmed or unwarmed immunoglobulin G (IgG) during a 4-day treatment period in a sentinel and sequential dosing design (treatment arm 1, warmed IgG 20% 0.4 g/kg; treatment arm 2, warmed IgG 20% 1.0 g/kg; treatment arm 3, unwarmed IgG 20% 1.0 g/kg). Participants were followed for 12 (± 1) weeks post-infusion. The primary endpoint was tolerability ("tolerable" infusions were not interrupted, stopped, or reduced in rate owing to fSCIG 20%-related treatment-emergent adverse events (TEAEs)). Secondary endpoints included occurrence of TEAEs.

RESULTS

Overall, 24 participants were included, 8 per treatment arm (mean age 39.0 years, 54.2% men). All participants tolerated the infusions. All TEAEs were mild (107 events, in all participants), and all participants experienced fSCIG 20%-related (105 events) and local (102 events) TEAEs. Infusion site erythema and infusion site swelling were most frequently reported. No serious TEAEs occurred, and no participants discontinued the study owing to TEAEs.

CONCLUSION

fSCIG 20% was well-tolerated with a favorable safety profile in healthy adults. Future studies will evaluate fSCIG 20% in primary immunodeficiency diseases. Trial registration number (ClinicalTrials.gov): NCT05059977 (registered 28 September 2021).

Insights into Facilitated Subcutaneous Immunoglobulin Use in Patients with Secondary Immunodeficiency Diseases: A FIGARO Subgroup Analysis

The Facilitated Immunoglobulin Administration Registry And Outcomes (FIGARO) Study was a European, multicenter, prospective, observational study conducted across Europe designed to provide insights on the clinical use and tolerability of facilitated subcutaneous immunoglobulin (fSCIG). Data herein are reported for the cohort of patients with secondary immunodeficiency (SID), with a subgroup analysis by age. The SID cohort included 31 patients: 1 pediatric, 15 adult, and 15 older adult patients. Over the 36-month observation period, the median monthly dose of fSCIG (30 g) and median monthly infusion volume per patient (300 mL) remained constant in both adult-age cohorts. Serum trough levels tended to increase over time. Most patients required only one infusion site and could receive the full dose every 3-4 weeks. There was a trend toward self-administration at home. In the adult group, infusion site inflammation and headache were reported at the inclusion visit (n = 1 each), with no adverse drug reactions reported at any of the follow-up visits. No acute severe bacterial infections were reported during the study follow-up. These results demonstrate the feasibility and tolerability of fSCIG use in patients with SID and the flexibility of administration settings including self-administration at home in patients aged ≥65 years.