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B-Cell and T-Cell Combined Disorders Medication

  • Author: Terry W Chin, MD, PhD; Chief Editor: Harumi Jyonouchi, MD  more...
 
Updated: Aug 26, 2014
 

Medication Summary

Unlike in other combined immunodeficiency syndromes, gamma-globulin replacement therapy does not appear to be beneficial in patients with ataxia-telangiectasia (AT) because of marked variation of humoral immunodeficiency with concomitant variable susceptibility to infections; however, individual patients may benefit. A study by Claret Teruel et al indicated that 7 out of 12 patients with AT received gamma-globulin due to immunoglobulin G (IgG) deficiency. Similarly, Kalfa et al described 9 patients with chronic mucocutaneous candidiasis (CMC) with selective antibody deficiency.[16] All 9 had IgG2 deficiency with IgG4 deficiency in 8 patients and immunoglobulin A (IgA) deficiency in 3 patients. All 9 had recurrent severe lung infections and may have benefited from intravenous immunoglobulin (IVIG) therapy.

Replacement therapy using IVIG in patients with primary immunodeficiencies

Overall consensus among clinical immunologists is that an IVIG dose of 400-600 mg/kg/mo or a dose that maintains trough serum IgG levels at greater than 500 mg/dL is desirable. Patients (X-linked agammaglobulinemia) with meningoencephalitis require much higher doses (1 g/kg) and, perhaps, intrathecal therapy. Measurements of preinfusion (trough) serum IgG levels every 3 months until a steady state is achieved and then every 6 months if the patient is stable may be helpful in adjusting the dose of IVIG to achieve adequate serum levels. For persons who have a high catabolism of infused IgG, more frequent infusions (eg, q2-3wk) of smaller doses may maintain the serum level in the reference range. The rate of elimination of IgG may be higher during a period of active infection; measuring serum IgG levels and adjusting to higher dosages or shorter intervals may be required.

For replacement therapy in patients with primary immunodeficiency, all brands of IVIG are probably equivalent, although differences in the viral inactivation processes (eg, solvent-detergent treatment versus pasteurization, liquid versus lyophilized powder) may be noted. The choice of brands may depend on the hospital or home care formulary and local availability and cost. The dose, manufacturer, and lot number should be recorded for each infusion to review for adverse events or other consequences. Recording all side effects that occur during the infusion is crucial.

Monitoring liver and renal function test results periodically, approximately 3-4 times yearly, also is recommended. The Food and Drug Administration (FDA) recommends that for patients at risk for renal failure (eg, patients with preexisting renal insufficiency, diabetes, volume depletion, sepsis, or paraproteinemia; patients aged >65 y; and patients who use nephrotoxic drugs), recommended doses should not be exceeded and infusion rates and concentrations should be the minimum levels that are practicable.

Initial treatment should be administered under close supervision by experienced personnel. The risk of adverse reactions during initial treatments is high, especially in patients with infections and patients who form immune complexes. In patients with active infection, infusion rates may need to be slower and the dose halved (ie, 200-300 mg/kg), with the remaining dose administered the next day to achieve a full dose. Treatment should not be discontinued. After achieving reference range serum IgG levels, adverse reactions are uncommon unless patients have active infections.

With the new generation of IVIG products, adverse effects are much reduced. Adverse effects include tachycardia, chest tightness, back pain, arthralgia, myalgia, hypertension or hypotension, headache, pruritus, rash, and low-grade fever. More serious reactions include dyspnea, nausea, vomiting, circulatory collapse, and loss of consciousness. Patients with more profound immunodeficiency or patients with active infections have more severe reactions.

Anticomplementary activity of IgG aggregates in the IVIG and the formation of immune complexes are thought to be related to adverse reactions. The formation of oligomeric or polymeric IgG complexes that interact with Fc receptors and trigger the release of inflammatory mediators is another cause. Most adverse reactions are rate related. Slowing the infusion rate or discontinuing therapy until symptoms subside may diminish the reaction. Pretreatment with ibuprofen (5-10 mg/kg every 6-8 h), acetaminophen (15 mg/kg/dose), diphenhydramine (1 mg/kg/dose), and/or hydrocortisone (6 mg/kg/dose, maximum 100 mg) 1 hour before infusion may prevent adverse reactions. In some patients with a history of severe adverse effects, analgesics and antihistamines may be repeated.

Acute renal failure is a rare but significant complication of IVIG treatment. Reports suggest that IVIG products using sucrose as a stabilizer may be associated with a greater risk for acute renal failure. Acute tubular necrosis, vacuolar degeneration, and osmotic nephrosis are suggestive of osmotic injury to the proximal renal tubules. The infusion rate for sucrose-containing IVIG should not exceed 3 mg sucrose/kg/min. Risk factors for this adverse reaction include preexisting renal insufficiency, diabetes mellitus, dehydration, age older than 65 years, sepsis, paraproteinemia, and concomitant use of nephrotoxic agents. For patients at increased risk, monitoring blood urea nitrogen and creatinine levels before starting treatment and prior to each infusion is necessary. If renal function deteriorates, discontinue the product.

IgE antibodies to IgA have been reported to cause severe transfusion reactions in patients with IgA deficiency. A few reports exist of true anaphylaxis in patients with selective IgA deficiency and common variable immunodeficiency who developed IgE antibodies to IgA after IVIG treatment. However, in actual experience, this reaction is very rare. In addition, anaphylaxis is not a problem in patients with X-linked agammaglobulinemia (Bruton disease) or severe combined immunodeficiency (SCID). Exercise caution in patients with IgA deficiency (< 7 mg/dL) who need IVIG because of IgG-subclass deficiencies. IVIG preparations with very low concentrations of contaminating IgA are advised.

Table. Intravenous Immunoglobulin Therapy[17, 18, 19, 20] (Open Table in a new window)

Brand(Manufacturer) Manufacturing Process pH Additives (IVIG products containing sucrose are more often associated with renal dysfunction, acute renal failure, and osmotic nephrosis, particularly with preexisting risk factors [eg, history of renal insufficiency, diabetes mellitus, age >65 y, dehydration, sepsis, paraproteinemia, nephrotoxic drugs].) Parenteral Form and Final Concentrations IgA Content mcg/mL
Carimune NF



(ZLB Behring)



Kistler-Nitschmann fractionation, pH 4, nanofiltration 6.4-6.8 6% solution: 10% sucrose, < 20 mg NaCl/g protein Lyophilized powder 3%, 6%, 9%, 12% Trace
Flebogamma



(Grifols USA)



Cohn-Oncley fractionation, PEG precipitation, ion-exchange chromatography, pasteurization 5.1-6 Sucrose free, contains 5% D-sorbitol Liquid 5% < 50
Gammagard Liquid 10%



(Baxter Bioscience)



Cohn-Oncley cold ethanol fractionation, cation and anion exchange chromatography, solvent detergent treated, nanofiltration, low pH incubation 4.6-5.1 0.25 M glycine Ready-for-use liquid 10% 37
Gammar-P IV



(ZLB Behring)



Cohn-Oncley fraction II/III, ultrafiltration, pasteurization 6.4-7.2 5% solution: 5% sucrose, 3% albumin, 0.5% NaCl Lyophilized powder 5% < 20
Gamunex



(Talecris Biotherapeutics)



Cohn-Oncley fractionation, caprylate-chromatography purification, cloth and depth filtration, low pH incubation 4-4.5 Contains no sugar, contains glycine Liquid 10% 46
Gammaplex



(Bio Products)



Solvent/detergent treatment targeted to enveloped viruses; virus filtration using Pall Ultipor to remove small viruses including nonenveloped viruses; low pH incubation 4.8-5.1 Contains sorbitol (40 mg/mL); do not administer if fructose intolerant Ready-for-use solution 5% < 10
Iveegam EN



(Baxter Bioscience)



Cohn-Oncley fraction II/III, ultrafiltration, pasteurization 6.4-7.2 5% solution: 5% glucose, 0.3% NaCl Lyophilized powder 5% < 10
Polygam S/D



Gammagard S/D



(Baxter Bioscience for the American Red Cross)



Cohn-Oncley cold ethanol fractionation, followed by ultra centrafiltration and ion exchange chromatography, solvent detergent treated 6.4-7.2 5% solution: 0.3% albumin, 2.25% glycine, 2% glucose Lyophilized powder 5%, 10% < 1.6 (5% solution)
Octagam



(Octapharma USA)



9/24/10: Withdrawn from market because of unexplained reports of thromboembolic events



Cohn-Oncley fraction II/III, ultrafiltration, low pH incubation, S/D treatment pasteurization 5.1-6 10% maltose Liquid 5% 200
Panglobulin



(Swiss Red Cross for the American Red Cross)



Kistler-Nitschmann fractionation, pH 4, trace pepsin, nanofiltration 6.6 Per gram of IgG: 1.67 g sucrose, < 20 mg NaCl Lyophilized powder 3%, 6%, 9%, 12% 720

Although IVIG may improve the ability of some patients to handle infections, aggressive treatment of acute bacterial infections with specific antibiotics remains necessary. In patients with clinically significant T-cell deficiency, prophylaxis may be warranted against Pneumocystis carinii pneumonia, either in the form of oral trimethoprim-sulfamethoxazole (Bactrim or Septra) or pentamidine.

IVIG replacement therapy has not been effective in treating patients with AT and CMC. However, a trial of IVIG may be warranted in other patients with combined B-cell and T-cell deficiency who lack antibody production to specific antigens (eg, tetanus, diphtheria, or polysaccharide antigens to pathogens such as Haemophilus influenzae or Streptococcus pneumoniae).

Several reports describe subcutaneous infusion in children in whom IV access is difficult. Stiehm et al administered dosages of 100 mg/kg/wk (ie, 1 mL/kg of a 10% IV solution) or 250 mg/kg (ie, 2.5 mL/kg) every 3 weeks.[21] Recently, the FDA approved a form of immunoglobulin for subcutaneous use. Exercise caution when treating patients with absent IgA serum levels because of the possibility of anaphylaxis. Some researchers urge screening these patients for serum anti-IgA antibody levels; others use Gammagard.

In patients younger than 2 years, use of passive immunization against respiratory syncytial virus (RSV) should be considered. Severe RSV bronchiolitis and pneumonitis may contribute to the development of chronic lung disease.

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Antibodies

Class Summary

Prevention of RSV in immunodeficient patients is possible with passive immunization with RSV-specific polyclonal IVIG or humanized mouse monoclonal IgG.

RSV-IVIG (RespiGam)

 

Polyclonal human immunoglobulin made by selecting donors with high titers of anti-RSV antibody. With monthly infusion, protects high-risk infants against severe RSV disease. In clinical trials, RSV-IVIG reduced hospitalization for non-RSV infections lower respiratory tract and rates of otitis media compared with placebo.

Palivizumab (Synagis)

 

Humanized mouse monoclonal IgG preparation specifically directed toward RSV.

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Anti-infective Agents

Class Summary

In patients with clinically significant T-cell deficiency, prophylaxis against P carinii pneumonia may be warranted. Prophylaxis may be in the form of oral trimethoprim-sulfamethoxazole (Bactrim or Septra) or pentamidine.

In patients with CMC, topical antifungal therapies are usually not effective. Oral candidiasis can be treated with clotrimazole troches instead of oral nystatin solution. Systemic oral antifungal drugs are occasionally effective and can improve the quality of life for affected patients. However, relapse after cessation of the antifungal therapy is common. Reports described successful treatment with cimetidine and zinc sulphate in patients with CMC.

Trimethoprim-sulfamethoxazole (Bactrim, Septra, Cotrim)

 

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.

Administration on Mondays, Wednesdays, and Fridays instead of 3 consecutive days also effective. This regimen may be especially necessary if physician must desensitize patient because of drug allergy; spreading dose throughout the week allows for continued attachment of drug to IgE on mast cells without degranulation.

Pentamidine (Pentam-300, Pentacarinat, NebuPent)

 

Antiprotozoal agent used for prophylaxis and treatment of P carinii infection. Inhibits growth of protozoa by blocking oxidative phosphorylation and inhibiting incorporation of nucleic acids into RNA and DNA, inhibiting protein and phospholipid synthesis.

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Contributor Information and Disclosures
Author

Terry W Chin, MD, PhD Associate Clinical Professor, Department of Pediatrics, University of California, Irvine, School of Medicine; Associate Director, Cystic Fibrosis Center, Attending Staff Physician, Department of Pediatric Pulmonology, Allergy, and Immunology, Memorial Miller Children's Hospital

Terry W Chin, MD, PhD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Allergy, Asthma and Immunology, American College of Chest Physicians, American Federation for Clinical Research, American Thoracic Society, California Society of Allergy, Asthma and Immunology, California Thoracic Society, Clinical Immunology Society, Los Angeles Pediatric Society, Western Society for Pediatric Research

Disclosure: Nothing to disclose.

Coauthor(s)

Noufa Alonazi, MD, MBBS Allergy and Immunology Postdoctoral Fellow, Department of Pediatrics, Loma Linda University and Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Harumi Jyonouchi, MD Faculty, Division of Allergy/Immunology and Infectious Diseases, Department of Pediatrics, Saint Peter's University Hospital

Harumi Jyonouchi, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Academy of Pediatrics, American Association of Immunologists, American Medical Association, Clinical Immunology Society, New York Academy of Sciences, Society for Experimental Biology and Medicine, Society for Pediatric Research, Society for Mucosal Immunology

Disclosure: Nothing to disclose.

Acknowledgements

John Wilson Georgitis, MD Consulting Staff, Lafayette Allergy Services

John Wilson Georgitis, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Academy of Pediatrics, American Association for the Advancement of Science, American College of Chest Physicians, American Lung Association, American Medical Writers Association, and American Thoracic Society

Disclosure: Nothing to disclose.

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Telangiectasia.
Radiograph shows an 8-month-old boy who required ventilatory support for bilateral pneumonia and who received intravenous antibiotics. The patient recovered and returned home.
Chest radiograph in an 8-month-old boy 2 weeks after he was treated for bilateral pneumonia. The patient returned to the emergency department with a fever and breathing problems.
Chest radiograph in a 9-month-old boy. The patient developed breathing problems 1 month after recovering from a second hospitalization for pneumonia. By this time, serum immunoglobulin levels from the second hospitalization were in the patient's record and showed an immunoglobulin G level of 156 mg/dL and undetectable immunoglobulin A and immunoglobulin M levels. Subsequent bronchoscopy showed the presence of Pneumocystis carinii and cytomegalovirus.
Telangiectasia of conjunctivae.
A 5-year-old boy with thrush.
Table. Intravenous Immunoglobulin Therapy [17, 18, 19, 20]
Brand(Manufacturer) Manufacturing Process pH Additives (IVIG products containing sucrose are more often associated with renal dysfunction, acute renal failure, and osmotic nephrosis, particularly with preexisting risk factors [eg, history of renal insufficiency, diabetes mellitus, age >65 y, dehydration, sepsis, paraproteinemia, nephrotoxic drugs].) Parenteral Form and Final Concentrations IgA Content mcg/mL
Carimune NF



(ZLB Behring)



Kistler-Nitschmann fractionation, pH 4, nanofiltration 6.4-6.8 6% solution: 10% sucrose, < 20 mg NaCl/g protein Lyophilized powder 3%, 6%, 9%, 12% Trace
Flebogamma



(Grifols USA)



Cohn-Oncley fractionation, PEG precipitation, ion-exchange chromatography, pasteurization 5.1-6 Sucrose free, contains 5% D-sorbitol Liquid 5% < 50
Gammagard Liquid 10%



(Baxter Bioscience)



Cohn-Oncley cold ethanol fractionation, cation and anion exchange chromatography, solvent detergent treated, nanofiltration, low pH incubation 4.6-5.1 0.25 M glycine Ready-for-use liquid 10% 37
Gammar-P IV



(ZLB Behring)



Cohn-Oncley fraction II/III, ultrafiltration, pasteurization 6.4-7.2 5% solution: 5% sucrose, 3% albumin, 0.5% NaCl Lyophilized powder 5% < 20
Gamunex



(Talecris Biotherapeutics)



Cohn-Oncley fractionation, caprylate-chromatography purification, cloth and depth filtration, low pH incubation 4-4.5 Contains no sugar, contains glycine Liquid 10% 46
Gammaplex



(Bio Products)



Solvent/detergent treatment targeted to enveloped viruses; virus filtration using Pall Ultipor to remove small viruses including nonenveloped viruses; low pH incubation 4.8-5.1 Contains sorbitol (40 mg/mL); do not administer if fructose intolerant Ready-for-use solution 5% < 10
Iveegam EN



(Baxter Bioscience)



Cohn-Oncley fraction II/III, ultrafiltration, pasteurization 6.4-7.2 5% solution: 5% glucose, 0.3% NaCl Lyophilized powder 5% < 10
Polygam S/D



Gammagard S/D



(Baxter Bioscience for the American Red Cross)



Cohn-Oncley cold ethanol fractionation, followed by ultra centrafiltration and ion exchange chromatography, solvent detergent treated 6.4-7.2 5% solution: 0.3% albumin, 2.25% glycine, 2% glucose Lyophilized powder 5%, 10% < 1.6 (5% solution)
Octagam



(Octapharma USA)



9/24/10: Withdrawn from market because of unexplained reports of thromboembolic events



Cohn-Oncley fraction II/III, ultrafiltration, low pH incubation, S/D treatment pasteurization 5.1-6 10% maltose Liquid 5% 200
Panglobulin



(Swiss Red Cross for the American Red Cross)



Kistler-Nitschmann fractionation, pH 4, trace pepsin, nanofiltration 6.6 Per gram of IgG: 1.67 g sucrose, < 20 mg NaCl Lyophilized powder 3%, 6%, 9%, 12% 720
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