primary & secondary antibody deficiency. antibodies & immunoglobulins
TRANSCRIPT
PRIMARY & SECONDARYANTIBODY DEFICIENCY
ANTIBODIES&
IMMUNOGLOBULINS
PRIMARY ANTIBODY DEFICIENCY
The European internet-based patient and research database for primary immunodeficiencies: results 2006-2008.Gathman et al., Clin Exp Immunol (2009); 157 Suppl 1: 3-11.
Brit Med J (1989); 298: 516-7
THERAPEUTIC IMMUNOGLOBULIN
• 1970s - IMIg
• 1980s - IVIg
• 1990s - IVIg, SCIg
• 2000s - product safety- infusion rates / concentration- immunoglobulin retrieval
REPLACEMENT THERAPY
TREATMENT OUTCOMES
Wood et al. Clin Exp Immunol (2007); 149: 410-423
EFFICACY & ADVERSITY
• Immunoglobulin• Excipients• Soluble CD4/ CD8/ HLA• Cytokines
Clin Exp Immunol (2004); 136: 111-3
IVIg & SCIg
ESID Register 2009
HOME THERAPY
2008 and 2011
SAME OLD SAME OLD
• Core of PID management• No alternatives• Lifelong requirement (usually)• Effective
(bacterial infection, antibiotic usage, QoL, hospitalisation, life expectancy)
• Dose requirement in:- frequent breakthrough infections- chronic inflammation / tissue damage- poor prognosis disease variants
WHAT’S NEW?
The three Rs:
• Reorganisation• Reclassification • Aarrrgh
- ongoing uncertainties over dosing / target levels
DOSE?
Impact of trough IgG on pneumonia incidence in primary immunodeficiency: A meta-analysis of clinical studies.Orange JS et al. Clinical Immunology (2010); 137: 21-30
DOSE: INDIVIDUALISATION
‘The goal of replacement therapy should be to improve clinicaloutcome and not to reach a particular IgG trough level.’
J Allergy Clin Immunol (2010);125:1354-60
DOSE: INDIVIDUALISATION
‘….individualizing the dosage….is preferable to using mean pharmacokinetic parameters.’
Clin Immunol (2011);139:133-41
RECLASSIFICATION
• Specific Antibody Deficiency
• Kawasaki Disease ‘Other’ Section
REORGANISATION
PRIMARY ANTIBODY DEFICIENCY DISORDERS
SPECIFIC DISORDERS
Thymoma with immunodeficiency(Good’s Syndrome)
Combined immunodeficiencies requiringhaemopoietic stem cell transplantation
(HSCT)
Specific antibody deficiency(SAD)
Transient hypogammaglobulinaemia of infancy(THI)
SPECIFIC DISORDERS
DISORDER RECOMMENDATION / REQUIREMENT
GOOD’S Profound B cell depletion / significant antibody deficiency
HSCT Duration based on B cell reconstitution post-transplantation
SAD Robust application of selection criteria
THI Define planned duration of therapy prior to initiation
(GRADE C, LEVEL III)
SUMMARY: PID
SECONDARY ANTIBODY DEFICIENCY
ANTIBODYDEFICIENCY
PRIMARY SECONDARY
Malignant diseaseDrugsProtein-losing statesInfection (cause & effect)Systemic diseaseIatrogenic causesChromosomal abnormalities
WHAT’S NEW?
• Secondary Antibody Deficiency
• Revision / collation into a single indication+ review outcomes (infection / hospitalisation)+ dosing (minimum IgG trough 6 g/L)
RECOMMENDATIONS
• Irreversible hypo-• Hypo- associated with CLL/NHL/MM etc.
and
GUIDELINES
‘Systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances’
• Evidence-based use• Consistency of care• Access to safe, high quality products• Security of supply• Utilising scarce resource
OUTCOMES
COMPLICATIONSPROGRESSION OF COMPLICATIONS
QUALITY OF LIFEWORKING CAPACITYLIFE EXPECTANCYOPTIMISED GROWTH / DEVELOPMENT