Indian Journal of Dermatology
CORRESPONDENCE
Year
: 2011  |  Volume : 56  |  Issue : 1  |  Page : 122--123

Practical issues for clinicians using high-dose intravenous immunoglobulin


S Khan1, S Singh2,  
1 Department of Immunology, Frimley Park Hospital NHS Foundation Trust, Frimley, Camberley, Surrey, GU16 7UJ, United Kingdom
2 Department of Paediatrics, Advanced Paediatric Centre, Post Graduate Institute of Medical Education and Research, Chandigarh-160012, India

Correspondence Address:
S Khan
Department of Immunology, Frimley Park Hospital NHS Foundation Trust, Frimley, Camberley, Surrey, GU16 7UJ
United Kingdom




How to cite this article:
Khan S, Singh S. Practical issues for clinicians using high-dose intravenous immunoglobulin.Indian J Dermatol 2011;56:122-123


How to cite this URL:
Khan S, Singh S. Practical issues for clinicians using high-dose intravenous immunoglobulin. Indian J Dermatol [serial online] 2011 [cited 2019 Aug 23 ];56:122-123
Available from: http://www.e-ijd.org/text.asp?2011/56/1/122/77580


Full Text

Sir,

We read with interest Dr Dhar's perspective on use of high-dose intravenous immunoglobulin (hd-IVIG) in dermatological conditions [1] and wish to comment on some of the important issues raised by the author. In our opinion, hd-IVIG has a rather limited role in the treatment of hypersensitive dermatoses.

The author has further suggested saving of IVIG samples prior to every infusion. This is neither necessary nor recommended as per international guidelines. [2],[3] It has been recommended and is considered a good clinical practice to save serum samples for one-off infusions and annually for those on long-term therapy so as to enable "look-back" studies in case of viral outbreaks. [2],[3] Records of batch numbers of immunoglobulin products should be maintained so that product recall can be facilitated, if required in the future. Although manufacturers of all IVIG preparations routinely employ viral inactivation techniques (solvent/detergent process that destroys lipid-coated viruses) as well as polymerase chain reaction screening tests to detect known viruses (HIV-1, HIV-2, hepatitis B surface antigen, and hepatitis C viruses), any new positive serology (post-IVIG infusion) should be properly investigated and notified to the relevant authorities.

Of the several IVIG preparations currently available in India, only one product ImmunoRel (5% preparation) from Reliance Life Sciences, has the manufacturing plant based in India, while the rest of the products are sourced from abroad. [4] So far, to the best of our knowledge, there has been no case of HIV transmission via immunoglobulin therapy, and therefore, monitoring of hepatitis B and C [yearly monitoring with hepatitis B surface antigen (HbsAg) and hepatitis C PCR for patients with antibody deficiency on long-term IVIG] is considered to be sufficient.

Even though hd-IVIG works in many dermatological conditions, clinicians must consider use of adjunctive therapy than just hd-IVIG, as concurrent immunosuppression (such as using anti-CD20 monoclonal antibody, Rituximab) has a synergistic effect with hd-IVIG [5] and can lead to long-term tolerance which is the proposed "vaccinal effect" of Rituximab. [5] Data from uncontrolled studies and case reports should be interpreted with caution, as often only favorable outcomes end up being published. Several confounding factors like differences in IVIG preparations, dosing schedules, use of concurrent immunosuppression and disease severity may affect the outcome of a given disease in an individual patient, and not just hd-IVIG on its own.

References

1Dhar S. Use of intravenous immunoglobulin in dermatology. Indian J Dermatol 2009;54:77-9.
2Provan D, Chapel HM, Sewell WA, O'Shaughnessy D. Prescribing intravenous immunoglobulin: summary of Department of Health Guidelines. BMJ 2008;337:990-2.
3Orange JS, Hossny EM, Weiler CR, Ballow M, Berger M, Bonilla FA, et al. Use of intravenous immunoglobulin in human disease: a review of evidence by members of the Primary Immunodeficiency Committee of the American Academy of Allergy, Asthma and Immunology. J Allergy Clin Immunol 2006;117:S525-53.
4Singh S. Primary immunodeficiency disorders in India: The physician perspective. Pharmaceuticals Policy Law 2008;10:121-30.
5Ahmed AR, Spigelman Z, Cavacini LA, Posner MR. Treatment of pemphigus vulgaris with rituximab and intravenous immune globulin. N Engl J Med 2006;355:1772-9.