Hypogammaglobulinemia Treatment & Management

Updated: Apr 11, 2017
  • Author: Amit J Shah, MD; Chief Editor: Michael A Kaliner, MD  more...
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Treatment

Medical Care

See the list below:

  • IgG replacement therapy is the treatment of choice for most primary immunodeficiency syndromes, including X-linked agammaglobulinemia (Bruton disease; XLA), common variable immunodeficiency (CVID), severe combined immunodeficiency (SCID), hyper-IgM, adenosine deaminase (ADA) deficiency, and Wiskott-Aldrich syndrome (WAS). IgG is usually routinely administered intravenously (IVIG) or subcutaneously (SCIG). IgG replacement is usually needed for at least 1 year after hematopoietic stem cell transplantation (HSCT) in patients with SCID.

  • Patients with IgG subclass deficiency should not be given IVIG unless they fail to produce antibodies to protein and polysaccharide antigens and they have significant morbidity due to infection that cannot be managed with antibiotics alone. In selective IgA deficiency, IVIG therapy is not indicated.

  • Effort should be focused on the treatment of infections, allergic reactions, autoimmune diseases, and gastrointestinal diseases. Aggressive and prolonged antibiotic therapy covering S pneumoniae and H influenza is indicated. Because of the high frequency of G lamblia infection in these patients, an empiric course of metronidazole may result in dramatic improvement of the diarrhea and, to a certain extent, of malabsorption syndrome.

  • The treatment of secondary hypogammaglobulinemia is directed at the underlying cause. Successful treatment of nephrotic syndrome and protein-losing enteropathy may result in improvement of Ig levels.

  • IVIG is not indicated for the treatment of lymphoproliferative disorders, unless Ig levels are low in association with recurrent infections or if IVIG is being used for autoimmune conditions such as immune thrombocytopenic purpura (ITP) or immune hemolytic anemia, which may accompany these disorders.

  • Live vaccines (eg, bacille Calmette-Guérin, polio, measles, rubella, mumps) should not be given to patients with T-cell disorders, XLA, or other severe B-cell disorders or to the family members of such patients. In patients with IgA deficiency, live vaccines are not an absolute contraindication if given intramuscularly.

  • High doses of IVIG or intrathecal Ig may be beneficial in patients with XLA who have enteroviral meningoencephalitis.

  • HSCT is the treatment of choice for patients with SCID and, if a matched donor is available, for a patient with ADA deficiency. [1]

  • In patients with ADA deficiency who lack an HLA-identical sibling, enzyme replacement with polyethylene glycol-ADA (PEG-ADA) may be an effective alternative therapeutic agent.

  • Tumor necrosis factor (TNF) inhibitors have been used to treat granulomatous diseases in patients with CVID.

  • Gene therapy has been shown to be successful in reconstituting immune function in infants with X-linked SCID, but efficacy is less proven in older children and young adults. [2] Gene therapy for ADA deficiency is most effective when patients receive myeloablative chemotherapy and are withdrawn from PEG-ADA beforehand. Case series of ADA-deficient patients receiving gene therapy have shown excellent results at 4-year follow-up. [19]

  • Timely vaccination with the 13-valent pneumococcal conjugate vaccine (PCV13) and the 23-valent pneumococcal polysaccharide vaccine (PPSV23) is a key component to prevention of B-cell disorders, with changes implemented in the order and interval period of PCV13 and PPSV23 administration. The Advisory Committee on Immunization Practices (ACIP) has recommended routine administration of a dose of PCV13 followed at least 12 months later by a dose of PPSV23 for immunocompetent adults aged 65 years or older. For adults aged 65 years or older with immuncompromising conditions, functional or anatomic asplenia, cerebrospinal fluid leaks, or cochlear implants, ACIP has recommended an interval of at least 8 weeks between PCV13 and PPSV23 adminisration. ACIP also has recommended that all adults aged 65 years or older who already received PPSV23 should receive a dose of PCV13 at least 1 year after receiving PPSV23. [20]

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