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Conti F, Moratti M, Leonardi L, Catelli A, Bortolamedi E, Filice E, Fetta A, Fabi M, Facchini E, Cantarini ME, Miniaci A, Cordelli DM, Lanari M, Pession A, Zama D. Anti-Inflammatory and Immunomodulatory Effect of High-Dose Immunoglobulins in Children: From Approved Indications to Off-Label Use. Cells 2023; 12:2417. [PMID: 37830631 PMCID: PMC10572613 DOI: 10.3390/cells12192417] [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: 08/07/2023] [Revised: 09/23/2023] [Accepted: 10/05/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND The large-scale utilization of immunoglobulins in patients with inborn errors of immunity (IEIs) since 1952 prompted the discovery of their key role at high doses as immunomodulatory and anti-inflammatory therapy, in the treatment of IEI-related immune dysregulation disorders, according to labelled and off-label indications. Recent years have been dominated by a progressive imbalance between the gradual but constant increase in the use of immunoglobulins and their availability, exacerbated by the SARS-CoV-2 pandemic. OBJECTIVES To provide pragmatic indications for a need-based application of high-dose immunoglobulins in the pediatric context. SOURCES A literature search was performed using PubMed, from inception until 1st August 2023, including the following keywords: anti-inflammatory; children; high dose gammaglobulin; high dose immunoglobulin; immune dysregulation; immunomodulation; immunomodulatory; inflammation; intravenous gammaglobulin; intravenous immunoglobulin; off-label; pediatric; subcutaneous gammaglobulin; subcutaneous immunoglobulin. All article types were considered. IMPLICATIONS In the light of the current imbalance between gammaglobulins' demand and availability, this review advocates the urgency of a more conscious utilization of this medical product, giving indications about benefits, risks, cost-effectiveness, and administration routes of high-dose immunoglobulins in children with hematologic, neurologic, and inflammatory immune dysregulation disorders, prompting further research towards a responsible employment of gammaglobulins and improving the therapeutical decisional process.
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Affiliation(s)
- Francesca Conti
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.C.); (A.M.); (A.P.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
| | - Mattia Moratti
- Specialty School of Paediatrics, University of Bologna, 40138 Bologna, Italy; (A.C.); (E.B.)
| | - Lucia Leonardi
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, 00185 Rome, Italy;
| | - Arianna Catelli
- Specialty School of Paediatrics, University of Bologna, 40138 Bologna, Italy; (A.C.); (E.B.)
| | - Elisa Bortolamedi
- Specialty School of Paediatrics, University of Bologna, 40138 Bologna, Italy; (A.C.); (E.B.)
| | - Emanuele Filice
- Department of Pediatrics, Maggiore Hospital, 40133 Bologna, Italy;
| | - Anna Fetta
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria dell’Età Pediatrica, 40139 Bologna, Italy
| | - Marianna Fabi
- Paediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Elena Facchini
- Pediatric Oncology and Hematology Unit “Lalla Seràgnoli”, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (E.F.); (M.E.C.)
| | - Maria Elena Cantarini
- Pediatric Oncology and Hematology Unit “Lalla Seràgnoli”, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (E.F.); (M.E.C.)
| | - Angela Miniaci
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.C.); (A.M.); (A.P.)
| | - Duccio Maria Cordelli
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria dell’Età Pediatrica, 40139 Bologna, Italy
| | - Marcello Lanari
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- Paediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Andrea Pession
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.C.); (A.M.); (A.P.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
| | - Daniele Zama
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- Paediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
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Doudouliaki T, Papadopoulou C, Deakin CT. Use of Rescue Therapy with IVIG or Cyclophosphamide in Juvenile Myositis. Curr Rheumatol Rep 2021; 23:24. [PMID: 33686540 DOI: 10.1007/s11926-021-00990-3] [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] [Accepted: 01/20/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review aims to present the literature available to date on the use of intravenous immunoglobulin and cyclophosphamide for juvenile patients with inflammatory myopathies, to evaluate the strength of the evidence so far for both these medications, and to reach conclusions about their efficacy. RECENT FINDINGS Juvenile idiopathic inflammatory myopathies, mainly represented by juvenile dermatomyositis (JDM), are rare diseases but quite debilitating for the patients. JDM is an autoimmune condition with predominantly muscle and skin involvement but also systemic features affecting the cardiovascular, respiratory, and gastrointestinal systems. The mainstay therapy is based on corticosteroids and methotrexate, but often other therapeutic alternatives are sought for patients with severe or refractory disease. The rarity of these conditions makes research for new medications even more challenging. Innovative trial designs or statistical methods can be used to emulate a randomized study and investigate drug effectiveness. Despite the lack of Level I evidence on the use and efficacy of intravenous immunoglobulin and cyclophosphamide, their use is advocated by a substantial number of case reports and case series as well as analyses using marginal structural models.
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Affiliation(s)
- Theonymfi Doudouliaki
- Department of Rheumatology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Charalampia Papadopoulou
- Department of Rheumatology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
- Infection, Immunity and Inflammation Research and Teaching Department, UCL, Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Claire T Deakin
- Infection, Immunity and Inflammation Research and Teaching Department, UCL, Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK.
- Centre for Adolescent Rheumatology Versus Arthritis at UCL, UCLH and GOSH, London, UK.
- NIHR Biomedical Research Centre at Great Ormond Street Hospital, London, UK.
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Kul Cinar O, Papadopoulou C, Pilkington CA. Treatment of Calcinosis in Juvenile Dermatomyositis. Curr Rheumatol Rep 2021; 23:13. [PMID: 33555459 DOI: 10.1007/s11926-020-00974-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE OF REVIEW Juvenile dermatomyositis (JDM) is a rare autoimmune disease characterised by muscle and skin involvement. Calcinosis is a debilitating complication of JDM which is difficult to treat and may cause long-term morbidity. The purpose of this review is to provide an update for the treatment of JDM-associated calcinosis based on previously published studies. RECENT FINDINGS Evidence-based studies are lacking for the management of calcinosis, and current treatment modalities have been largely based on case reports, case series, cohort studies, limited controlled studies and anecdotal clinical experience. The use of early aggressive therapy for resistant cases is strongly suggested to halt persistent disease activity which may help in reducing steroid use and their associated complications. Recent insights into disease pathogenesis, myositis-specific antibodies and genetic associations have led to identification of novel therapeutic targets such as Janus kinase (JAK) 1/2. Different treatment regimens with variable outcomes are in use for the treatment of refractory calcinosis; nevertheless, the level of evidence is not sufficient to propose specific guidelines. Recently, JAK 1/2 inhibitors have shown to be effective as an emerging therapeutic option highlighting that translational and clinical research is crucial to develop targeted treatment for JDM-associated calcinosis.
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Affiliation(s)
- Ovgu Kul Cinar
- Paediatric Rheumatology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK. .,Division of Infection and Immunity, University College London, London, WC1E 6BT, UK.
| | - Charalampia Papadopoulou
- Paediatric Rheumatology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.,Infection, Inflammation and Rheumatology Section, University College London Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
| | - Clarissa A Pilkington
- Paediatric Rheumatology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.,NIHR Biomedical Research Centre, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Abstract
INTRODUCTION Juvenile dermatomyositis (JDM) is a rare, chronic autoimmune illness with primary features of symmetric, proximal muscle weakness and involvement of the skin with a number of identifiable rashes. Evidence to support treatment decisions is limited, given the paucity of clinical trials. Consensus based methods, informed by available data, play an important role in treatment recommendations. Areas covered: This review focuses on evidence and consensus opinion regarding therapeutic options in JDM and identifies gaps where future research is needed. Expert commentary: The combination of trial evidence (as limited as it is) and consensus opinion support standard initial management for children with JDM to consist of high-dose corticosteroids, either intravenous or oral, and methotrexate. Several other agents have preliminary support, either through clinical trials or case series for their use in patients who either fail to respond adequately, have severe disease or have contraindications to standard initial therapy. One of the important goals of management in JDM will be to reduce the corticosteroid exposure experienced by patients. To meet this goal, progress in a number of key areas is needed: increased international collaboration, advances in study design and increased translational research.
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Affiliation(s)
- Adam M Huber
- a Division of Pediatric Rheumatology , Dalhousie University , Halifax , Nova Scotia , Canada
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Abstract
The idiopathic inflammatory myopathies of childhood consist of a heterogeneous group of autoimmune diseases characterised by proximal muscle weakness and pathognomonic skin rashes. The overall prognosis of juvenile myositis has improved significantly over recent years, but the long-term outcome differs substantially from patient to patient, suggestive of distinct clinical phenotypes with variable responses to treatment. High doses of corticosteroids remain the cornerstone of therapy along with other immunosuppressant therapies depending on disease severity and response. The advent of biological drugs has revolutionised the management of various paediatric rheumatologic diseases, including inflammatory myopathies. There are few data from randomised controlled trials to guide management decisions; thus, several algorithms for the treatment of juvenile myositis have been developed using international expert opinion. The general treatment goals now include elimination of active disease and normalisation of physical function, so as to preserve normal growth and development, and to prevent long-term damage and deformities. This review summarises the newer and possible future therapies of juvenile inflammatory myopathies, including evidence supporting their efficacy and safety.
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Hara M, Kinoshita M, Saito E, Hashimoto H, Miyasaka N, Yoshida T, Ichikawa Y, Koike T, Ichikawa Y, Okada J, Kashiwazaki S. Prospective study of high-dose intravenous immunoglobulin for the treatment of steroid-resistant polymyositis and dermatomyositis. Mod Rheumatol 2014; 13:319-25. [DOI: 10.3109/s10165-003-0250-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Cutaneous dermatomyositis: an updated review of treatment options and internal associations. Am J Clin Dermatol 2013; 14:291-313. [PMID: 23754636 DOI: 10.1007/s40257-013-0028-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Dermatomyositis is a specific type of inflammatory myopathy with characteristic cutaneous findings. Patients may have skin disease without clinically apparent muscle disease, but this disorder is best thought of as a systemic process. Therefore, all patients with dermatomyositis skin lesions need appropriate evaluation for muscle disease, esophageal dysfunction, cardiopulmonary disease, and potential internal malignancy. There are many therapies that have been used for patients with dermatomyositis, but most are based upon case series or expert opinion rather than meta-analyses or randomized, placebo-controlled trials. Even those therapies that have been subjected to randomized, blinded, placebo-controlled trials include a mixture of patients with idiopathic inflammatory myopathy and do not utilize a validated assessment tool for measuring cutaneous disease responses. In this review, we discuss the therapies available as well as the internal associations with dermatomyositis.
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Affiliation(s)
- Christina Lam
- Department of Dermatology; Brigham and Women's Hospital; Boston; Massachusetts
| | - Ruth Ann Vleugels
- Department of Dermatology; Brigham and Women's Hospital; Boston; Massachusetts
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Walling HW, Gerami P, Sontheimer RD. Juvenile-onset clinically amyopathic dermatomyositis: an overview of recent progress in diagnosis and management. Paediatr Drugs 2010; 12:23-34. [PMID: 20034339 DOI: 10.2165/10899380-000000000-00000] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Juvenile-onset amyopathic dermatomyositis is an uncommon variant of juvenile-onset dermatomyositis (JDM), characterized by the hallmark cutaneous features of dermatomyositis for at least 6 months without clinical or laboratory evidence of muscle disease. Cutaneous calcinosis, vasculopathy, and interstitial lung disease frequently complicate the course of classic JDM (typical JDM with myositis) but are infrequent in amyopathic JDM. Recent literature suggests that approximately 75% of amyopathic JDM patients will remain free from muscle disease after years of follow-up, while approximately 25% of patients will evolve to having classic JDM. No clinical, laboratory, or ancillary parameters have been found to be predictive for this transition to muscle disease. Treatment of the cutaneous disease of amyopathic JDM centers on photoprotection and topical therapies directed against inflammation. Oral antimalarials are effective for cutaneous disease not adequately controlled with topical care. Systemic corticosteroids, while central to the treatment of classic JDM, are controversial in the treatment of amyopathic JDM. Randomized controlled trials are not available to guide the management of this disease. Proponents for early aggressive systemic corticosteroid therapy for amyopathic JDM advocate that this intervention may decrease the likelihood of progression to classic JDM, and/or prevent disease-specific complications of JDM such as calcinosis. Opponents of early intervention with systemic corticosteroids favor expectant management directed toward controlling skin disease, citing the predictable adverse effects of systemic corticosteroids in the face of uncertain benefit. Other therapeutic options for severe and recalcitrant cutaneous disease, including methotrexate, intravenous immunoglobulin, and rituximab, are reviewed, as are treatment options for calcinosis cutis. In weighing the available evidence, the authors conclude that early aggressive treatment of amyopathic JDM with systemic immunosuppressant agents should be avoided in most cases as the risk of these medications will outweigh the measurable benefit. The reported literature suggests a good prognosis for amyopathic JDM. Ongoing clinical follow-up is recommended in all cases to allow early detection of subtle signs of muscle disease.
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Magro CM, Iwenofu OH, Kearns MJ, Nuovo GJ, Dyrsen ME, Segal JP. Fulminant and accelerated presentation of dermatomyositis in two previously healthy young adult males: a potential role for endotheliotropic viral infection. J Cutan Pathol 2009; 36:853-8. [DOI: 10.1111/j.1600-0560.2008.01171.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Dyrsen ME, Iwenofu OH, Nuovo G, Magro CM. Parvovirus B19-associated catastrophic endothelialitis with a Degos-like presentation. J Cutan Pathol 2008; 35 Suppl 1:20-5. [PMID: 18537856 DOI: 10.1111/j.1600-0560.2007.00974.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Parvovirus B19 is a single-stranded DNA virus exhibiting affinity for a variety of cell types including endothelial cells. The basis of the affinity is globoside expression, the receptor for B19. B19 endothelial cell parasitism accelerates endothelial cell apoptosis, potentially critical in inducing neoantigenicity and secondary antibody formation. A 38-year-old previously healthy male developed intestinal and cutaneous infarction, elevated creatinine phosphokinase (CPK) levels and progressive cytopenias. The basis of his clinical presentation was unclear until a skin biopsy suggested a potential role for virally mediated endothelial cell injury. Hematoxylin and eosin, immunohistochemical, immunofluorescent and reverse transcriptase in situ polymerase chain reaction studies were conducted on skin biopsies to assess for viral triggers. B19 viremia and localization of B19 RNA transcripts to vascular endothelium were uncovered. A diagnosis of catastrophic endothelial cell injury attributable to B19 infection was rendered. The patient showed significant improvement with intravenous immunoglobulin (IVIG). Parvovirus B19 is a ubiquitous virus that in the majority of affected patients remains asymptomatic. Nevertheless, because of its ability to infect endothelium it can cause severe multiorgan endothelial cell injury.
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Affiliation(s)
- Molly E Dyrsen
- Dermatopathology Division, Department of Pathology, Weill Medical College Cornell, New York, NY, USA
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Murota H, Muroi E, Yamaoka T, Hamasaki Y, Katayama I. Successful treatment with regimen of intravenous gamma globulin and cyclophosphamide for dermatomyositis accompanied by interstitial pneumonia, opportunistic infection and steroid psychosis. Allergol Int 2006; 55:199-202. [PMID: 17075258 DOI: 10.2332/allergolint.55.199] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2005] [Accepted: 11/08/2005] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND A 47-year-old Japanese woman was suffering from dermatomyositis with progressive interstitial pneumonia, which was resistant to treatment with prednisolone (Pred) and cyclosporine A (CsA). Unfortunately, the opportunistic infection and steroid psychosis made therapeutic intervention using additional immunosuppressive drugs problematic. To overcome these difficulties, we created a regimen of intravenous gammaglobulin (IVIG) and cyclophosphamide (CPM) for the treatment of this patient. METHODS For the simultaneous treatment, IVIG-CPM was added to Pred/CsA by means of infusion of IVIG on five consecutive days per month, followed by CPM infusion on the ninth day after the last IVIG administration. The treatment was repeated for four months. RESULTS This regimen induced almost full remission without exacerbation of the opportunistic infection or mental disturbance. CONCLUSIONS The outcome reported here suggests that the combination therapy of Pred/CsA and IVIG-CPM appears to be useful for the treatment of dermatomyositis with pulmonary, infectious and mental complications.
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Affiliation(s)
- Hiroyuki Murota
- Department of Dermatology, Course of Molecular Medicine, Graduate School of Medicine Osaka University, Suita-shi, Osaka, Japan.
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Michels H, Burmester GR, Buttgereit F. [Intravenous immunoglobulins in chronic idiopathic myositis]. Z Rheumatol 2005; 64:102-10. [PMID: 15793676 DOI: 10.1007/s00393-005-0695-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- H Michels
- Rheumaklinik für Kinder und Jugendliche, Gehfeldstr. 24, 82467 Garmisch-Partenkirchen, Germany.
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Kamali S, Cefle A, Sayarlioglu M, Gul A, Inanc M, Ocal L, Aral O, Konice M. Experience with monthly, high-dose, intravenous immunoglobulin therapy in patients with different connective tissue diseases. Rheumatol Int 2004; 25:211-4. [PMID: 14722731 DOI: 10.1007/s00296-003-0422-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2003] [Accepted: 10/25/2003] [Indexed: 11/27/2022]
Abstract
We aimed to investigate the efficacy and safety profile of high-dose intravenous immunoglobulin (HD-IVIG) therapy in patients with severe systemic lupus erythematosus (SLE), inflammatory muscle disease (IMD), Wegener's granulomatosis (WG), and/or concurrent infection who failed to respond to standard therapies. We evaluated the records of eight patients with SLE, eight with IMD, and four with WG who were treated with HD-IVIG (2 g/kg per month for 1-12 months) for active disease in 19 patients and concurrent infection in three (mycobacterial in two with SLE and cytomegaloviral in one with WG). Systemic lupus erythematosus disease activity index (SLEDAI) scores before and after HD-IVIG were statistically analysed. Remission was achieved in 14 cases (70%). The SLEDAI scores significantly decreased in patients with SLE (P=0.02). No serious side effect was observed. High-dose IVIG may be used as an adjunctive treatment in connective tissue diseases that do not respond to standard therapies or as alternative treatment for patients with concurrent severe infections or for whom immunosuppressives are contraindicated.
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Affiliation(s)
- Sevil Kamali
- Department of Rheumatology, Division of Internal Medicine, Medical Faculty, Istanbul University, Istanbul, Turkey.
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Abstract
Immunoglobulin (Ultravenous, IGIV) is now used in a variety of immune-mediated diseases. Its presumed mechanism of action involves both anti-inflammatory and immunomodulatory activities. A number of dermatologic conditions are believed to be immune mediated and in these disorders, IGIV has shown benefit in reducing symptoms and the need for cortecosteroids or cytotaxic drugs. In many of these diseases, the initial benefits seen in open-labeled trials must be confirmed in controlled clinical trials.
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Affiliation(s)
- Erwin W Gelfand
- Division of Cell Biology, Department of Pediatrics, National Jewish Medical and Research Center, Denver, Colorado 80206, USA.
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Abstract
Juvenile dermatomyositis (JDM) is a multisystem disease characterized by acute and chronic lymphocytic inflammation of the skeletal muscle and skin. The disease is marked early in its course by the presence of a vasculopathy or vasculitis, and later by the development of calcinosis. Research has focused on the epidemiology, etiology, and pathogenesis of the disease with, until more recently, limited therapeutic interventions. This article highlights treatment regimens, both traditional and more recent interventions. Traditional treatment for JDM includes high dose corticosteroid treatment with additional agents used in resistant disease or children with unwarranted adverse effects. Traditional therapy begins with daily oral corticosteroids, with intravenous corticosteroids utilized in severe disease; however, recent data suggests that short-term use of intravenous corticosteroids will allow a short-term improvement in strength, with no long-term change in outcome. More recent investigations suggest that early intervention with additional immunomodulatory agents will allow for a faster recovery, with less medication and disease sequelae. Use of methotrexate as an agent early in the disease course is becoming common place. Methotrexate, in conjunction with oral corticosteroids, allows a rapid improvement in symptoms, and allows for a more rapid reduction in corticosteroid dose. Methotrexate is considered as a steroid sparing agent, whether oral or intravenous corticosteroids are used. Additional immunomodulatory agents include the use of cyclosporine with or without methotrexate. Intravenous immunoglobulin has been reported to have benefit in resistant disease. There are exciting new agents which have great potential in treating JDM. Many of these agents are termed biologics and are being tested in adult myositis and juvenile arthritis. These include tumor necrosis factor (TNF)-alpha inhibitors, such as a chimeric monoclonal antibody to TNF-alpha, and a recombinant soluble human TNF receptor (p75)-Fc fusion protein. Many other new biological agents are also being tested in myositis.
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Affiliation(s)
- Ann M Reed
- Division of Rheumatology, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Gurmin V, Mediwake R, Fernando M, Whittaker S, Rustin MHA, Beynon HLC. Psoriasis: response to high-dose intravenous immunoglobulin in three patients. Br J Dermatol 2002; 147:554-7. [PMID: 12207600 DOI: 10.1046/j.1365-2133.2002.04753.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Treatment of recalcitrant psoriasis and psoriatic arthritis can be challenging, with treatment options limited by drug intolerance or poor efficacy. High-dose intravenous immunoglobulin (hdIVIg) has been used successfully in Kawasaki's disease and idiopathic thrombocytopenic purpura, where it has become the standard treatment. The literature also suggests its positive effect in the treatment of dermatological conditions, such as autoimmune chronic urticaria, atopic dermatitis, scleromyxoedema, dermatomyositis and autoimmune bullous disorders. We report three patients with treatment-resistant psoriasis and psoriatic arthritis who improved with hdIVIg.
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Affiliation(s)
- V Gurmin
- Department of Rheumatology, Royal Free Hospital, Pond Street, London NW3 2QG, U.K
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Rütter A, Luger TA. High-dose intravenous immunoglobulins: An approach to treat severe immune-mediated and autoimmune diseases of the skin. J Am Acad Dermatol 2001; 44:1010-24. [PMID: 11369915 DOI: 10.1067/mjd.2001.112325] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Adjuvant high-dose intravenous immunoglobulins (IVIgs) are being used increasingly in a range of immune-mediated and autoimmune diseases. Although numerous immunomodulatory mechanisms have been suggested, the exact mechanisms of action are poorly understood. The efficacy of IVIg in certain diseases has been proven in clinical trials, insofar as IVIg is approved as the therapy of choice for Kawasaki syndrome or idiopathic thrombocytopenic purpura. IVIg treatment has been shown to be safe, without the many drug-related adverse effects, including systemic immunosuppression, that are related to corticosteroids and other immunosuppressive agents. Current dermatologic uses of IVIg are increasing, which calls for adequately controlled clinical trials. This review focuses on experiences with IVIg therapy for skin diseases and discusses current opinion concerning its potential immunomodulating mechanisms.
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Affiliation(s)
- A Rütter
- Department of Dermatology, University of Münster, Germany
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Colsky AS. Intravenous immunoglobulin in autoimmune and inflammatory dermatoses. A review of proposed mechanisms of action and therapeutic applications. Dermatol Clin 2000; 18:447-57, ix. [PMID: 10943540 DOI: 10.1016/s0733-8635(05)70193-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Off-label use of intravenous immunoglobulin (IVIG) at high doses has resulted in numerous anecdotal reports of its effectiveness in a variety of autoimmune and inflammatory conditions. Despite its growing acceptance as a viable therapeutic option in the management of several such disorders, the poorly defined mechanism of action of IVIG has stifled its rational therapeutic application. The lack of carefully designed prospective randomized clinical trials has further fueled controversy and mitigates against optimal application of this burgeoning therapy. Nevertheless, some standardization of IVIG therapy is slowly advancing that promises to support the use of this treatment for a growing number of autoimmune and inflammatory dermatoses.
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Affiliation(s)
- A S Colsky
- Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Florida, USA
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Sadayama T, Miyagawa S, Shirai T. Low-dose intravenous immunoglobulin therapy for intractable dermatomyositis skin lesions. J Dermatol 1999; 26:457-9. [PMID: 10458087 DOI: 10.1111/j.1346-8138.1999.tb02026.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We report a 45-year-old female patient with dermatomyositis whose corticosteroid-resistant cutaneous manifestations improved with low-dose (0.1 g/kg body weight/day for 5 days weekly for 2 weeks) intravenous immunoglobulin (IVIG) therapy.
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Affiliation(s)
- T Sadayama
- Department of Dermatology, Nara Medical University, Japan
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22
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Rider LG, Miller FW. Classification and treatment of the juvenile idiopathic inflammatory myopathies. Rheum Dis Clin North Am 1997; 23:619-55. [PMID: 9287380 DOI: 10.1016/s0889-857x(05)70350-1] [Citation(s) in RCA: 117] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
This article reviews the current status of the classification and treatment of the juvenile idiopathic inflammatory myopathies. The intent of classification is to define homogeneous groups that share similar clinical features, disease courses, and responses to therapy. The classification scheme proposed includes clinicopathologic subsets, serologic subjects based on the presence of myositis-specific and myositis-associated autoantibodies, and environmental triggers of myositis. Juvenile dermatomyositis is the most common and widely recognized of these disorders. The second part reviews the history of treatment of juvenile dermatomyositis and discusses agents to consider for patients with refractory disease, unacceptable steroid toxicity, or poor prognostic factors.
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Affiliation(s)
- L G Rider
- Laboratory of Molecular and Developmental Immunology, Food and Drug Administration, Bethesda, Maryland, USA
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23
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De Pità O, Bellucci AM, Ruffelli M, Girardelli CR, Puddu P. Intravenous immunoglobulin therapy is not able to efficiently control cutaneous manifestations in patients with lupus erythematosus. Lupus 1997; 6:415-7. [PMID: 9175031 DOI: 10.1177/096120339700600414] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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24
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Kikuchi-Numagami K, Sato M, Tagami H. Successful treatment of a therapy-resistant severely pruritic skin eruption of malignancy-associated dermatomyositis with high-dose intravenous immunoglobulin. J Dermatol 1996; 23:340-3. [PMID: 8675825 DOI: 10.1111/j.1346-8138.1996.tb04027.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Malignancy-associated dermatomyositis developing in a middle-aged Japanese female was successfully treated by removal of her gastric cancer. However, five years later, concomitant with catching a cold, her severely pruritic skin lesions recurred on exposed areas. Six years after the start of corticosteroid therapy for her annoying skin lesion, we started to treat her with high-dose intravenous immunoglobulin (IVIG) infusion therapy because of the difficulty of reducing the dosage of oral prednisone, that had secondarily induced adverse effects. After five courses of the therapy, her recalcitrant, pruritic, erythematous skin lesions improved dramatically, enabling a satisfactory reduction in the dosage of oral prednisone. There were no significant adverse side effects with IVIG.
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Affiliation(s)
- K Kikuchi-Numagami
- Department of Dermatology, Tohoku University School of Medicine, Sendai, Japan
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25
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Abstract
Juvenile dermatomyositis (JDMS) is a chronic inflammatory condition characterized by muscle weakness and a distinctive rash caused by underlying vasculopathy. Long-term complications include subcutaneous and muscular calcification, contractures and in some cases the gradual development of a second connective tissue disease. Early aggressive treatment with systemic immunosuppressants and other agents such as intravenous immunoglobulin (IVIG) reduces mortality and morbidity.
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Affiliation(s)
- A R Halbert
- Department of Dermatology, Princess Margaret Hospital for Children, Subiaco, Western Australia
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26
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Galeazzi M, Bellucci AM, Girardelli CR, Bono R, De Pita O, Puddu P. Efficacy of intravenous immunoglobulin therapy in a case of juvenile dermatomyositis. Clin Rheumatol 1996; 15:215-6. [PMID: 8777863 DOI: 10.1007/bf02230347] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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27
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Cavalieri S, Rotoli M, Cerimele D. Treatment of dermatomyositis with intravenous immunoglobulin. J DERMATOL TREAT 1996. [DOI: 10.3109/09546639609089543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- S Cavalieri
- Department of Dermatology, Catholic University of The Sacred Heart, Rome, Italy
| | - M Rotoli
- Department of Dermatology, Catholic University of The Sacred Heart, Rome, Italy
| | - D Cerimele
- Department of Dermatology, Catholic University of The Sacred Heart, Rome, Italy
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28
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Messer G, Sizmann N, Feucht H, Meurer M. High-dose intravenous immunoglobulins for immediate control of severe pemphigus vulgaris. Br J Dermatol 1995; 133:1014-6. [PMID: 8547028 DOI: 10.1111/j.1365-2133.1995.tb06952.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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29
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Mohr C, Sunderkötter C, Hildebrand A, Biel K, Rütter A, Rütter GH, Luger TA, Kolde G. Successful treatment of epidermolysis bullosa acquisita using intravenous immunoglobulins. Br J Dermatol 1995; 132:824-6. [PMID: 7772494 DOI: 10.1111/j.1365-2133.1995.tb00735.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
We report a 55-year-old man with severe inflammatory epidermolysis bullosa acquisita. The skin lesions did not respond to various immunosuppressive treatments. The combined administration of prednisone, azathioprine, dapsone and colchicine resulted only in a transient and incomplete resolution of the lesions. The bullae and increased skin fragility were successfully controlled by the addition of high-dose intravenous immunoglobulin therapy.
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Affiliation(s)
- C Mohr
- Department of Dermatology, Westfälische-Wilhelms-Universität, Münster, Germany
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30
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31
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Esteve E, Cambie MP, Serpier H, Vanderbroere-Bouquet A, Bellaiche P, Kalis B. Paraneoplastic dermatomyositis: efficacy of intravenous gammaglobulin. Br J Dermatol 1994; 131:917-8. [PMID: 7857856 DOI: 10.1111/j.1365-2133.1994.tb08609.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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