1
|
Carrillo de Albornoz S, Chai KL, Higgins AM, Petrie D, Wood EM, McQuilten ZK. A systematic review of the cost and cost-effectiveness of immunoglobulin treatment in patients with hematological malignancies. Int J Technol Assess Health Care 2024; 40:e32. [PMID: 38751245 DOI: 10.1017/s026646232400028x] [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] [Indexed: 05/28/2024]
Abstract
OBJECTIVES Patients with hematological malignancies are likely to develop hypogammaglobulinemia. Immunoglobulin (Ig) is commonly given to prevent infections, but its overall costs and cost-effectiveness are unknown. METHODS A systematic review was conducted following the PRISMA guidelines to assess the evidence on the costs and cost-effectiveness of Ig, administered intravenously (IVIg) or subcutaneously (SCIg), in adults with hematological malignancies. RESULTS Six studies met the inclusion criteria, and only two economic evaluations were identified; one cost-utility analysis (CUA) of IVIg versus no Ig, and another comparing IVIg with SCIg. The quality of the evidence was low. Compared to no treatment, Ig reduced hospitalization rates. One study reported no significant change in hospitalizations following a program to reduce IVIg use, and an observational study comparing IVIg with SCIg suggested that there were more hospitalizations with SCIg but lower overall costs per patient. The CUA comparing IVIg versus no Ig suggested that IVIg treatment was not cost-effective, and the other CUA comparing IVIg to SCIg found that home-based SCIg was more cost-effective than IVIg, but both studies had serious limitations. CONCLUSIONS Our review highlighted key gaps in the literature: the cost-effectiveness of Ig in patients with hematological malignancies is very uncertain. Despite increasing Ig use worldwide, there are limited data regarding the total direct and indirect costs of treatment, and the optimal use of Ig and downstream implications for healthcare resource use and costs remain unclear. Given the paucity of evidence on the costs and cost-effectiveness of Ig treatment in this population, further health economic research is warranted.
Collapse
Affiliation(s)
| | - Khai Li Chai
- School of Public Health and Preventive Medicine, Monash University, Clayton, VIC, Australia
| | - Alisa M Higgins
- School of Public Health and Preventive Medicine, Monash University, Clayton, VIC, Australia
| | - Dennis Petrie
- Centre for Health Economics, Monash Business School, Monash University, Clayton, VIC, Australia
| | - Erica M Wood
- School of Public Health and Preventive Medicine, Monash University, Clayton, VIC, Australia
| | - Zoe K McQuilten
- School of Public Health and Preventive Medicine, Monash University, Clayton, VIC, Australia
| |
Collapse
|
2
|
Nooka AK, Rodriguez C, Mateos MV, Manier S, Chastain K, Banerjee A, Kobos R, Qi K, Verona R, Doyle M, Martin TG, van de Donk NWCJ. Incidence, timing, and management of infections in patients receiving teclistamab for the treatment of relapsed/refractory multiple myeloma in the MajesTEC-1 study. Cancer 2024; 130:886-900. [PMID: 37960969 DOI: 10.1002/cncr.35107] [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: 06/30/2023] [Revised: 09/20/2023] [Accepted: 09/26/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Patients with relapsed/refractory multiple myeloma are at increased risk of infection. Infections during treatment with teclistamab, the first B-cell maturation antigen-directed bispecific antibody approved for triple-class-exposed relapsed/refractory multiple myeloma, was examined in the phase 1/2 MajesTEC-1 study. METHODS Patients (N = 165) received subcutaneous teclistamab 1.5 mg/kg weekly after a step-up dosing schedule (0.06 mg/kg and 0.3 mg/kg, each separated by 2-4 days). Patients were monitored frequently for infections; prophylaxis and management were per institutional guidelines. RESULTS At a median follow-up of 22.8 months (range, 0.3-33.6), infections were reported in 132 patients (80.0%). Grade 3/4 infections occurred in 91 patients (55.2%), including COVID-19 (21.2%), respiratory infections (19.4%), Pneumocystis jirovecii pneumonia (4.2%), viral infections (4.2%), and gastrointestinal infections (1.2%). Twenty-one patients died from infections (18 from COVID-19). Median time to first onset of any-grade and grade 3 to 5 infections was 1.7 and 4.2 months, respectively. Overall, 70.9% of patients had ≥1 postbaseline immunoglobulin G (IgG) level <400 mg/dL; median time to IgG <400 mg/dL was 1.2 months (range, 0.2-19.8) and 46.1% received ≥1 dose of IgG replacement. Grade 3/4 neutropenia occurred in 65.5% of patients (median time to grade ≥3 neutropenia/febrile neutropenia was 2.3 months [range, 0-18.1]). CONCLUSION Based on the infection profile of B-cell maturation antigen-targeted bispecific antibodies such as teclistamab, it is recommended that clinicians and patients remain vigilant for a range of infection types throughout treatment to facilitate prompt intervention. Appropriate screening, prophylaxis, and management of infections, hypogammaglobulinemia, and neutropenia are important. CLINICAL TRIAL REGISTRATION NCT03145181/NCT04557098 (ClinicalTrials.gov) PLAIN LANGUAGE SUMMARY: Before starting teclistamab, patients should be up to date with vaccinations (including COVID-19) and screened for hepatitis B and C and HIV. Teclistamab should not be given to patients with any active infections. Prophylactic antimicrobials should be administered per institutional guidelines. Prophylaxis for Pneumocystis jirovecii pneumonia and herpes simplex/varicella zoster virus is recommended during teclistamab treatment. Close monitoring of infections and immunoglobulin G (IgG) levels should continue throughout teclistamab treatment. IgG replacement (administered every 3-6 weeks) should be used to maintain IgG ≥400 mg/dL. Growth factors should be considered for grade ≥3 neutropenia with infection/fever and grade 4 neutropenia.
Collapse
Affiliation(s)
- Ajay K Nooka
- Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Cesar Rodriguez
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | - Arnob Banerjee
- Janssen Research & Development LLC, Spring House, Pennsylvania, USA
| | - Rachel Kobos
- Janssen Research & Development LLC, Raritan, New Jersey, USA
| | - Keqin Qi
- Janssen Research & Development LLC, Titusville, New Jersey, USA
| | - Raluca Verona
- Janssen Research & Development LLC, Spring House, Pennsylvania, USA
| | | | - Thomas G Martin
- University of California, San Francisco, San Francisco, California, USA
| | - Niels W C J van de Donk
- Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
3
|
Counihan M, Cervenakova L, Misztela D, Van Baelen M, D.Naughton B. Access and use of immunoglobulins in supportive cancer care: A thematic analysis of a systematic review data set. THE JOURNAL OF MEDICINE ACCESS 2024; 8:27550834241236596. [PMID: 38559466 PMCID: PMC10981255 DOI: 10.1177/27550834241236596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 02/15/2024] [Indexed: 04/04/2024]
Abstract
Background Secondary immunodeficiency (SID) disorders are known to occur in patients with haematological malignancies (HM) due to immunosuppressive treatments. Recurring infections causing subsequent morbidity and mortality commonly occur in this patient cohort. Immunoglobulin replacement therapy (IgRT) benefits patients with primary antibody deficiencies. However, evidence supporting their therapeutic role is not as explicit in SID-associated antibody deficiencies, which raises the questions regarding its use in SID and the knock-on effects of this use on its access and availability more generally. Objectives This study aimed to learn about the use of immunoglobulins in SID, identify themes concerning its use and access and suggest methods for improving access. Design This study included a thematic analysis of a published data set of 43 articles concerning immunoglobulin use and access in SID. Data Sources and Methods The data set used to perform the thematic analysis is based on research articles identified from Excerpta Medica Database (EMBASE) and PubMed databases, published as part of a systematic review and part 1 of this two-part publication series. Results A thematic synthesis was conducted to identify recurrent themes. The three primary themes included (1) the context for IgRT prescription, which included patient characteristics and cost burden of IgRT administration, and its use in different countries; (2) factors contributing to inappropriate IgRT use, including health care professionals' awareness of IgRT, disparity between guidelines and actual clinical practice, and the effect of shortages on prescription and chemotherapy-induced hypogammaglobulinemia (HGG); and (3) measures identified to improve IgRT use and access, which included multidisciplinary involvement, improved diagnostic tools and safer withdrawal and stewardship protocols. Conclusions IgRT use is increasing in HM as a supportive therapy but without comprehensive clinical guidelines and appropriate prescribing recommendations, medication wastage may occur with consequences for immunoglobulin access.
Collapse
Affiliation(s)
- Muireann Counihan
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | | | | | | | - Bernard D.Naughton
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, University of Dublin, Dublin, Ireland
- Centre for Pharmaceutical Medicine Research, Institute of Pharmaceutical Science, Kings College London, Franklin-Wilkins Building, London, UK
| |
Collapse
|
4
|
Anderson LD, Dhakal B, Jain T, Oluwole OO, Shah GL, Sidana S, Perales MA, Pasquini MC. Chimeric Antigen Receptor T Cell Therapy for Myeloma: Where Are We Now and What Is Needed to Move Chimeric Antigen Receptor T Cells Forward to Earlier Lines of Therapy? Expert Panel Opinion from the American Society for Transplantation and Cellular Therapy. Transplant Cell Ther 2024; 30:17-37. [PMID: 37913909 PMCID: PMC10873054 DOI: 10.1016/j.jtct.2023.10.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 10/27/2023] [Indexed: 11/03/2023]
Abstract
Since 2021, 2 B cell maturation antigen (BCMA)-directed chimeric antigen receptor T cell (CAR-T) therapies-idecabtagene vicleucel (ide-cel), and ciltacabtagene autoleucel (cilta-cel)-have been approved by the US Food and Drug Administration (FDA) for treating relapsed or refractory multiple myeloma (RRMM) after 4 or more prior lines of therapy, including an immunomodulatory drug, a proteasome inhibitor, and an anti-CD38 antibody. The 2 products have shown unprecedented activity in RRMM, but relapses remain common, and access to and safety of CAR-T therapy in patients with rapidly progressing advanced disease are not ideal. Sequencing CAR-T therapy with other options, including the 2 recently approved BCMA-directed T cell-engaging bispecific antibodies teclistamab and elranatamab, has become increasingly challenging owing to data showing inferior outcomes from CAR-T therapy after prior BCMA-directed therapy. This has led to the consideration of CAR-T therapy earlier in the course of disease for myeloma, when T cells are potentially healthier and the myeloma is less aggressive. To address the question of earlier use of CAR-T therapy, several trials are either ongoing or planned, and results have recently been reported for 2 randomized trials of CAR-T therapy showing improved progression-free survival compared to standard of care therapy in second-line (CARTITUDE-4) or third-line therapy (KarMMA-3). With the anticipation of the FDA possibly expanding approval of CAR-T to earlier lines of myeloma therapy, the American Society for Transplantation and Cellular Therapy convened a group of experts to provide a comprehensive review of the studies that led to the approval of CAR-T therapy in late-line therapy for myeloma, discuss the recently reported and ongoing studies designed to move CAR-T therapy to earlier lines of therapy, and share insights and considerations for sequencing therapy and optimization of patient selection for BCMA-directed therapies in current practice.
Collapse
Affiliation(s)
- Larry D Anderson
- Myeloma, Waldenstrom's, and Amyloidosis Program, Hematologic Malignancies and Cellular Therapy Program, Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas.
| | - Binod Dhakal
- BMT & Cellular Therapy Program, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Tania Jain
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Olalekan O Oluwole
- Division of Hematology/Oncology, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Gunjan L Shah
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Surbhi Sidana
- Stanford University School of Medicine, Stanford, California
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Marcelo C Pasquini
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| |
Collapse
|
5
|
Czapka MT, Riedell PA, Pisano JC. Infectious complications of car T-cell therapy: A longitudinal risk model. Transpl Infect Dis 2023; 25 Suppl 1:e14148. [PMID: 37695203 DOI: 10.1111/tid.14148] [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: 05/22/2023] [Revised: 08/25/2023] [Accepted: 08/31/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND CAR T-cell therapy, where a patient's own T cells are re-engineered to express a receptor to a target of interest, is becoming an increasingly utilized cancer-directed therapy. There are significant toxicities that contribute to a novel state of immunocompromise, leading to new patterns of infectious complications that require further detailed study. METHODS We created a single-center cohort of adult recipients of CD19-directed CAR T-cell therapy and assessed infectious outcomes, supportive care received, toxicities, and markers of immune function up to 2 years following CAR T-cell therapy. Descriptive statistics were used as appropriate for analysis. We additionally conducted time-to-event analysis assessing time-to-first infection with either log-rank testing or Cox regression with univariate analysis, before including significant predictors into a multivariate Cox model of time to infection. RESULTS We identified 73 patients who received CD19-directed CAR T-cell therapy who predominantly had diffuse large B-cell lymphoma. Within 30 days of cell infusion, bacterial and Candida infections were the most common, with 64% of infections due to these organisms. Between 30 days and 2 years postinfusion, respiratory viruses and pneumonia were the most frequent infections, with 68% of infections due to these etiologies. Receipt of tocilizumab, development of immune effector cell-associated neurotoxicity syndrome (ICANS), or lower neutrophil count were associated with quicker onset of infection in a multivariate Cox model. CONCLUSIONS Respiratory viruses remain an important infectious complication of CAR T-cell therapy following the first year. The model may be a useful tool to identify patients at the highest risk of infection.
Collapse
Affiliation(s)
- Michael T Czapka
- Department of Medicine, Section of Infectious Disease, University of Chicago, Chicago, Illinois, USA
| | - Peter A Riedell
- Department of Medicine, Section of Hematology and Oncology, University of Chicago, Chicago, Illinois, USA
| | - Jennifer C Pisano
- Department of Medicine, Section of Infectious Disease, University of Chicago, Chicago, Illinois, USA
| |
Collapse
|
6
|
Counihan M, Cervenakova L, Misztela D, Van Baelen M, Naughton BD. Access and use of immunoglobulins in secondary supportive cancer care: A systematic literature review. THE JOURNAL OF MEDICINE ACCESS 2023; 7:27550834231197315. [PMID: 37846344 PMCID: PMC10576927 DOI: 10.1177/27550834231197315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 08/04/2023] [Indexed: 10/18/2023]
Abstract
Background Immunoglobulin replacement therapy (IgRT) benefits patients with primary immuno deficiency (PID) originating from the innate or polygenic defects in the immune system. However, evidence supporting their therapeutic role is not as explicit in secondary immuno deficiency (SID) resulting from the treatment of haematological malignancies. Objectives This study aimed to (1) create a dataset of relevant research papers, which explore the use of IgRT in SID for analysis, (2) assess the risk of bias within this dataset and (3) study the characteristics of these papers. Design This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. In addition to the risk of bias, the study characteristics explored in this article included study design, study geographical location and year of publication. Data Sources and Methods To identify studies relevant to the research question, EMBASE and PubMed databases were searched. The Population, Intervention, Comparison and Outcome (PICO) framework was used to assess study quality. Risk of bias and quality of studies were assessed in accordance with the study design. As one model was not appropriate to assess bias in all articles, several tools were used. Results A total of 43 studies were identified from the literature search as relevant to the research objective. The most common study design was a retrospective case-control cohort study (n = 16/43), and randomised trials were among the least commonly used approaches (n = 1). Research in this area is occurring around the globe including the United States (n = 7), Italy (n = 7), China, India, Japan and throughout Europe. The annual number of papers in this area has varied from 2012 (n = 1) to 2021 (n = 7). The studies in this article demonstrated a varied risk of bias, with 9 of the 20 cohort studies scoring less than 5 out of 9 stars. Conclusions Randomised controlled trials are less frequently used to assess access and use of immunoglobulins. More commonly, a retrospective case-control cohort study was used which correlates with the higher risk of bias seen in the studies in this article. Most of the research concerning immunoglobulin use and access occurs in higher-income countries.
Collapse
Affiliation(s)
- Muireann Counihan
- The School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | | | | | | | - Bernard D. Naughton
- The School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, The University of Dublin, Dublin, Ireland
- Plasma Protein Therapeutics Association, Brussels, Belgium
| |
Collapse
|
7
|
Langi Sasongko P, van Kraaij M, So‐Osman C. Using a scenario approach to assess for the current and future demand of immunoglobulins: An interview and literature study from The Netherlands. Transfus Med 2022; 32:410-421. [PMID: 35751376 PMCID: PMC9795925 DOI: 10.1111/tme.12889] [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: 01/25/2022] [Revised: 05/02/2022] [Accepted: 05/13/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To explore the current and future demand of immunoglobulins globally and specifically for the Netherlands by assessing: (I) which specialties contribute to current demand, (II) new areas of medical need, (III) which transformational factors may impact demand and to what effect, by using a scenario approach. BACKGROUND As immunoglobulin demand continues to increase globally, there is concern of increasing shortages and questions of whether and how future demand will continue based on medical need. METHODS/MATERIALS In line with scenario principles, a scoping review of Pubmed, Web of Science, Embase and Cochrane and grey literature was conducted. Semi-structured interviews with subject matter experts were held. The results of the review and interviews were analysed for major themes. RESULTS The scoping review resulted in 97 articles, 74 regarding clinical uses, and 23 regarding organisational and other themes. Fifteen clinical and non-clinical experts were interviewed. I) Neurology, immunology, and haematology were specialties that contribute most to current demand. II) Regarding potential new areas of medical need, the literature review resulted in more indications than the interviews, for example, post-renal transplants. III) Four groups of key transformational factors were found: factors that could increase immunoglobulin demand (e.g., EMA revisions), decrease demand (e.g., replacement products, Dutch Transfer Act 2021), factors that remain to be seen how it impacts demand (e.g., further evidence), and miscellaneous factors (e.g., supply-related). CONCLUSION Having identified the specialties and relevant transformational factors that affect immunoglobulin demand, more research is needed on what clinical or organisational strategies would be effective in controlling demand in general for the Netherlands and abroad. Other blood establishments may also use a scenario approach to increase preparedness for future (un)expected developments.
Collapse
Affiliation(s)
- Praiseldy Langi Sasongko
- Department of Donor Medicine ResearchUnits Transfusion Technology Assessment and Donor Studies, Sanquin ResearchAmsterdamThe Netherlands,Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | | | - Cynthia So‐Osman
- Department of Unit Transfusion MedicineSanquin Blood BankAmsterdamThe Netherlands,Department of HaematologyErasmus Medical CenterRotterdamThe Netherlands
| |
Collapse
|
8
|
McBride A, Hudson-DiSalle S, Pilz J, Hamm M, Boring B, Buie LW, DeRemer DL. National Survey on the Effect of Oncology Drug Shortages in Clinical Practice: A Hematology Oncology Pharmacy Association Survey. JCO Oncol Pract 2022; 18:e1289-e1296. [PMID: 35544740 DOI: 10.1200/op.21.00883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Drug shortages are a clear and growing challenge. Prominent shortages included oncology medications and supportive care products essential for the care of patients with cancer. Oncology drug shortages often result in disruptions in the timing of chemotherapy treatments, alterations in the dose or regimen administered, or even missed doses when alternative agents are unavailable. The purpose of this survey was to characterize the impact of oncology drug shortages across the United States, including the experiences of health care organizations, resource implications, and the impact on patient safety, patient care, and clinical trials. METHODS A 36-item online survey was distributed to membership of the Hematology/Oncology Pharmacy Association to gather information on shortages of oncology drugs (ie, all drugs essential in the care of patients with cancer, including supportive care agents). RESULTS Sixty-eight US organizations participated in the survey between December 2019 and July 2020. Sixty-three percent of institutions reported one or more drug shortages per month, with a 34% increase in 2019 from 2018. Treatment delays, reduced doses, or alternative regimens were reported by 75% of respondents. The most difficult agents to obtain were vincristine, vinblastine, intravenous immunoglobulin, leucovorin, and Bacillus Calmette-Guerin. CONCLUSION A survey of US oncology pharmacists indicated that oncology drug shortages occurred frequently in 2020. Shortages led to delays in chemotherapy and changes in treatment or omission, complicated clinical research, and increased risk of medication errors and adverse outcomes.
Collapse
Affiliation(s)
- Ali McBride
- University of Arizona Cancer Center, Tucson, AZ.,Bristol Myers Squibb, WW Health Economics Outcomes Research Markets, Lawrence Township, NJ
| | - Sarah Hudson-DiSalle
- Department of Pharmacy, The James Cancer Hospital and Wexner Medical Center at the Ohio State University, Columbus, OH
| | - Jeff Pilz
- Department of Pharmacy, The James Cancer Hospital and Wexner Medical Center at the Ohio State University, Columbus, OH
| | - Mark Hamm
- Department of Pharmacy, Aurora St Luke's Medical Center, Milwaukee, WI
| | - Brooke Boring
- Executive Director Incorporated (EDI), Milwaukee, WI
| | - Larry W Buie
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David L DeRemer
- University of Florida Health Cancer Center, Gainesville, FL.,Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL
| |
Collapse
|
9
|
Controversies about immunoglobulin replacement therapy in HSCT recipients with hypogammaglobulinemia. Bone Marrow Transplant 2022; 57:874-880. [PMID: 35440805 PMCID: PMC9017083 DOI: 10.1038/s41409-022-01680-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/04/2022] [Accepted: 04/05/2022] [Indexed: 12/20/2022]
Abstract
The efficacy of immunoglobulin replacement therapy (IgRT) has been demonstrated for primary immune deficiency diseases and hematological malignancies such as chronic lymphocytic leukemia (CLL) or multiple myeloma with hypogammaglobulinemia. Clinical development of anti-B cell therapies including a monoclonal antibody, bispecific antibody, or chimeric antigen receptor T-cell therapy which could result in severe hypogammaglobulinemia accelerates the argument of prophylactic use of IgRT. Clinical guidelines for CLL describe immunoglobulin administration in patients with a low IgG who have experienced a severe/repeated bacterial infection. The utility in hematopoietic stem-cell transplantation (HSCT) remains unknown. Although an early randomized trial demonstrated that IgRT decreased infection risk and transplant-related mortality after HSCT, subsequent clinical trials could not validate the benefit. Consequently, a meta-analysis did not show the benefit of IgRT in HSCT. Most of the available data derives from matched-related HSCT using myeloablative regimen, and the impact in haploidentical and cord blood transplantation, or reduced-intensity HSCT remains unknown. One crucial issue is that no studies exist for patients with only hypogammaglobulinemia after HSCT. Other challenges are heterogeneous patient characteristics, or immunoglobulin formulation, dosage, schedule, route and duration of IgRT. Without evidence in HSCT, it would be reasonable to follow the guidelines for other diseases with hypogammaglobulinemia.
Collapse
|
10
|
Kampouri E, Walti CS, Gauthier J, Hill JA. Managing Hypogammaglobulinemia in Patients Treated with CAR-T-cell Therapy: Key Points for Clinicians. Expert Rev Hematol 2022; 15:305-320. [PMID: 35385358 DOI: 10.1080/17474086.2022.2063833] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The unprecedented success of chimeric antigen receptor (CAR)-T-cell therapy in the management of B-cell malignancies comes with a price of specific side effects. Healthy B-cell depletion is an anticipated 'on-target' 'off-tumor' side effect and can contribute to severe and prolonged hypogammaglobulinemia. Evidence-based guidelines for the use of immunoglobulin replacement therapy (IGRT) for infection prevention are lacking in this population. AREAS COVERED This article reviews the mechanisms and epidemiology of hypogammaglobulinemia and antibody deficiency, association with infections, and strategies to address these issues in CD19- and BCMA-CAR-T-cell recipients. EXPERT OPINION CD19 and BCMA CAR-T-cell therapy result in unique immune deficits due to depletion of specific B-lineage cells and may require different infection prevention strategies. Hypogammaglobulinemia before and after CAR-T-cell therapy is frequent, but data on the efficacy and cost-effectiveness of IGRT are lacking. Monthly IGRT should be prioritized for patients with severe or recurrent bacterial infections. IGRT may be more broadly necessary to prevent infections in BCMA-CAR-T-cell recipients and children with severe hypogammaglobulinemia irrespective of infection history. Vaccinations are indicated to augment humoral immunity and can be immunogenic despite cytopenias; re-vaccination(s) may be required. Controlled trials are needed to better understand the role of IGRT and vaccines in this population.
Collapse
Affiliation(s)
- Eleftheria Kampouri
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Carla S Walti
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Infectious Disease and Hospital Epidemiology Division, University Hospital Basel, Basel, Switzerland
| | - Jordan Gauthier
- Department of Medicine, University of Washington, Seattle, Washington, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Joshua A Hill
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| |
Collapse
|
11
|
Kan AKC, Leung GMK, Chiang V, Au EYL, Lau CS, Li PH. Ten-year population trends of immunoglobulin use, burden of adult antibody deficiency and feasibility of subcutaneous immunoglobulin (SCIg) replacement in Hong Kong Chinese. Front Immunol 2022; 13:984110. [PMID: 36591300 PMCID: PMC9795180 DOI: 10.3389/fimmu.2022.984110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 11/29/2022] [Indexed: 12/15/2022] Open
Abstract
Background Adult antibody deficiency remains under-recognised and under-studied - especially among Asian populations. Patterns of immunoglobulin use and the feasibility of subcutaneous immunoglobulin (SCIg) replacement among Chinese patients remains unclear. Objective To investigate the trends of immunoglobulin use, burden of adult antibody deficiency and the outcomes of patients on SCIg compared to intravenous immunoglobulin (IVIg) replacement in Hong Kong through a retrospective observational study. Methods Population-wide data of immunoglobulin recipients in Hong Kong between 2012 and 2021, and longitudinal clinical data of adult immunodeficiency patients at Queen Mary Hospital were collected and analysed. Results Total immunoglobulin consumption and recurrent immunoglobulin recipients increased continuously from 175,512g to 298,514g (ρ=0.99, p<0.001) and 886 to 1,508 (ρ=0.89, p=0.001) between 2012-21 in Hong Kong. Among 469 immunoglobulin recipients at Queen Mary Hospital in 2021, 344 (73.3%) were indicated for replacement. Compared to those on IVIg (n=14), patients on SCIg replacement (n=8) had fewer immunodeficiency-related hospitalisations (IRR=0.11) and shorter duration of hospitalisation stay (IRR=0.10) per year, as well as better quality of life (SF-36v2 Health Survey and Life Quality Index). Estimated annual healthcare cost of SCIg replacement per patient was lower than that of IVIg (HKD196,850 [USD25,096] vs HKD222,136 [USD28,319]). Conclusion There was a significantly increasing burden of adult antibody deficiency and immunoglobulin consumption in Hong Kong. SCIg was feasible and more cost-effective when compared to IVIg, with SCIg patients experiencing better clinical outcomes and quality of life. Future prospective studies to confirm the long-term efficacy and superiority of SCIg are required.
Collapse
Affiliation(s)
- Andy Ka Chun Kan
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Garret Man Kit Leung
- Division of Haematology, Medical Oncology and Haemopoietic Stem Cell Transplantation, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Valerie Chiang
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong, Hong Kong SAR, China
| | - Elaine Yuen Ling Au
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong, Hong Kong SAR, China
| | - Chak Sing Lau
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Philip Hei Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- *Correspondence: Philip Hei Li,
| |
Collapse
|
12
|
Single-Center Experience of Outcomes and Prescribing Patterns of IV Immunoglobulin Use in Critically Ill Patients. Crit Care Explor 2021; 3:e0314. [PMID: 33458682 PMCID: PMC7803672 DOI: 10.1097/cce.0000000000000314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. Previous literature has not compared prescribing practices of IV immunoglobulin in medical ICU survivors and nonsurvivors. The objective of this study was to study IV immunoglobulin use in patients admitted to a medical ICU evaluating differences between hospital survivors and nonsurvivors in regards to level of evidence supporting use, prescribing patterns, and cost.
Collapse
|