Expert opinion regarding clinical and other outcome considerations in the formulary review of immune globulin

Management of adverse events in the treatment of patients with immunoglobulin therapy: A review of evidence

Immunoglobulin (IG) therapy is actually used for a broad range of diseases including primary and secondary immunodeficiency disorders, and autoimmune diseases. This therapy is available for intravenous (IV) and subcutaneous (SC) administration. The efficacy of the IG therapy has been demonstrated in numerous studies and across different diseases. Generally, IG infusions are well tolerated; however some well-known adverse reactions, ranging from mild to severe, are associated with the therapy. The most common adverse reactions including headache, nausea, myalgia, fever, chills, chest discomfort, skin and anaphylactic reactions, could arise immediately during or after the infusion. Delayed events could be more severe and include migraine headaches, aseptic meningitis, haemolysis renal impairment and thrombotic events. This paper reviews all the potential adverse events related to IG therapy and establishes a comprehensive guideline for the management of these events. Moreover it resumes the opinions and clinical experience of expert endorsers on the utilization of the treatment. Published data were classified into levels of evidence and the strength of the recommendation was given for each intervention according to the GRADE system.

Guidelines for the use of human immunoglobulin therapy in patients with primary immunodeficiencies in Latin America

Antibodies are an essential component of the adaptative immune response and hold long-term memory of the immunological experiences throughout life. Antibody defects represent approximately half of the well-known primary immunodeficiencies requiring immunoglobulin replacement therapy. In this article, the authors review the current indications and therapeutic protocols in the Latin American environment. Immunoglobulin replacement therapy has been a safe procedure that induces dramatic positive changes in the clinical outcome of patients who carry antibody defects.

Dosing and therapy utilization: a discussion of updates on PI treatment guidelines

Treatment decisions made in clinical practice, based on current guidelines, often conflict with decisions by third-party payors that restrict the ability of patients with primary immunodeficiency disease (PI) to adhere to appropriate treatment. This is seen by many physicians as potentially placing the health of patients at risk. Key treatment decisions challenged by third-party payors and discussed here include dosing, product safety, and routes of administration. Data on safety issues emphasize that IgG products are not generic drugs and each of the products currently licensed by the Food and Drug Administration (FDA) must be regarded as an individual therapy, given the products' different manufacturing processes and stabilizing ingredients. The issue of switching patients to a different product needs careful consideration as evidence shows that infusion-related adverse events in many patients are frequently related to this activity. Decisions regarding the route of therapy should also be individualized to the patient, weighing such factors as side effects, adherence with therapy, and lifestyle.

Intravenous immunoglobulins induce potentially synergistic immunomodulations in autoimmune disorders

The increase in platelets in patients with immune thrombocytopenia (ITP) by intravenous administration of human immunoglobulin concentrates (IVIG) reflects a therapeutic immunomodulatory intervention targeted at the disturbed immune response in many inflammatory and autoimmune disorders. These immunoglobulin concentrates contain large numbers of antibodies as well as trace levels of various other immunologically active molecules. Clinical and laboratory studies have documented various mechanisms of action of IVIG. The complex network of immunological reactions resulting from the infusion of IVIG includes changes in several cytokines, interactions with dendritic cells, T- and B- lymphocyte effects, macrophage effects, mediated by distinct Fc-gamma receptors. In addition, effects on complement components and apoptosis have also been observed. Synergism between the different elements of the immune response characterizes the beneficial effects of IVIG in inflammatory and autoimmune disorders. They have immunopathogeneses and clinical manifestations which are difficult to define and therefore IVIG treatment indications remain heterogeneous. Dose finding studies are missing for most of the indications of the drug. In future research, defining the appropriate subgroups of patients should be undertaken. This may be accomplished by prospective registries collecting data on large numbers of patients with long-term follow-up. Controlled clinical and laboratory studies may follow based on new, validated patient selection criteria and focused on mechanisms of action, leading to more evidence-based indications.

History of immunoglobulin replacement

The provision of antibodies to prevent and treat infection began with the application of "curative serum" in the first years of the last century. After the process of large-scale plasma fractionation was developed in the 1940s, the general use of immunoglobulin expanded. Intravenous immunoglobulin products became available in the 1970s, and their only use for the provision of antibodies governed the opinion of experts over the next decade. Modulation of inflammation and immunosuppression were introduced in treatment of inflammatory and autoimmune diseases and became accepted indications. The history of adverse events of treatment and their management are outlined in this article. Consensus indications and evidence-based off-label uses are discussed.

Preparation and use of therapeutic antibodies primarily of human origin

Therapeutic antibodies include polyclonal immunoglobulins isolated from regular or high-titered human plasma, sera from immunized animals, and monoclonal antibodies. This array of therapeutic antibodies is used for the prevention and treatment of many infectious diseases, antibody immunodeficiencies, autoimmune and inflammatory diseases, neurological disorders, and cancers. Polyclonal human immunoglobulins are available for intramuscular injection (IGIM), intravenous infusion (IGIV) and subcutaneous infusion (SCIG). We review these products and detail the therapeutic use of polyclonal human antibodies in the treatment of antibody immunodeficiencies, including their occasional local side effects (tenderness, sterile abscesses), minor systemic side effects (chills, muscle aches, malaise, headaches) and major side effects (aseptic meningitis, nephropathy, thrombosis).