Revisão Acesso aberto Revisado por pares

Practical aspects of immunoglobulin replacement

2017; Elsevier BV; Volume: 119; Issue: 4 Linguagem: Inglês

10.1016/j.anai.2017.07.020

ISSN

1534-4436

Autores

Mark Ballow,

Tópico(s)

Blood groups and transfusion

Resumo

InstructionsCredit can now be obtained, free for a limited time, by reading the review article in this issue and completing all activity components. Please note the instructions listed below:•Review the target audience, learning objectives and all disclosures.•Complete the pre-test.•Read the article and reflect on all content as to how it may be applicable to your practice.•Complete the post-test/evaluation and claim credit earned. At this time, physicians will have earned up to 1.0 AMA PRA Category 1 CreditTM. Minimum passing score on the post-test is 70%.•Approximately 4-6 weeks later you will receive an online outcomes assessment regarding your application of this article to your practice. Once you have completed this assessment, you will be eligible to receive MOC Part II credit from the American Board of Allergy and Immunology.Overall PurposeParticipants will be able to demonstrate increased knowledge of the clinical treatment of allergy/asthma/immunology and how new information can be applied to their own practices.Learning ObjectivesAt the conclusion of this activity, participants should be able to:•Differentiate the advantages and disadvantages of IVIG and SCIg•Discuss the approach to optimizing dosing of immunoglobulin replacement therapy in patients with antibody immune deficiency•Describe the guiding principles for the effective use of immunoglobulin replacement therapy in patients with antibody immune deficiencyRelease Date: October 1, 2017Expiration Date: September 30, 2019Target AudiencePhysicians involved in providing patient care in the field of allergy/asthma/immunologyAccreditationThe American College of Allergy, Asthma & Immunology (ACAAI) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.DesignationThe American College of Allergy, Asthma & Immunology (ACAAI) designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.Planning Committee MembersMark Ballow, MD (Author)Jonathan A. Bernstein, MD (Annals CME Subcommittee)Guha Krishnaswamy, MD (Annals CME Subcommittee)John J. Oppenheimer, MD (Annals CME Subcommittee, Associate Editor)Mitchell H. Grayson, MD (CME Series Editor, Deputy Editor)Gailen D. Marshall, Jr, MD, PhD (Editor-in-Chief)Disclosure PolicyAs required by the Accreditation Council for Continuing Medical Education (ACCME) and in accordance with the American College of Allergy, Asthma and Immunology (ACAAI) policy, all educational planners, presenters, instructors, moderators, authors, reviewers, and other individuals in a position to control or influence the content of an activity must disclose all relevant financial relationships with any commercial interest that have occurred within the past 12 months. All identified conflicts of interest must be resolved and the educational content thoroughly vetted for fair balance, scientific objectivity, and appropriateness of patient care recommendations. It is required that disclosure be provided to the learners prior to the start of the activity. Individuals with no relevant financial relationships must also inform the learners that no relevant financial relationships exist. Learners must also be informed when off-label, experimental/investigational uses of drugs or devices are discussed in an educational activity or included in related materials. Disclosure in no way implies that the information presented is biased or of lesser quality. It is incumbent upon course participants to be aware of these factors in interpreting the program contents and evaluating recommendations. Moreover, expressed views do not necessarily reflect the opinions of ACAAI.All identified conflicts of interest have been resolved.Disclosure of Relevant Financial RelationshipsAny unapproved/investigative uses of therapeutic agents/devices discussed are appropriately noted.M. Ballow – Advisory Board member for Shire, and Grifols and Speaker for Shire, he received fees; he has received research grants from CSL Behring and Grifols. J.A. Bernstein – PI, Consultant, Speaker for AstraZeneca, CSL Behring, Novartis/Genentech, and Shire, he received research grants and fees; Speaker for Baxalta, he received fees; Consultant for Imedics, he received fees; PI and Consultant for Boehringer Ingelheim and GlaxoSmithKline, he received research grants and fees. G. Krishnaswamy – Clinical Research for CSL Behring, he received a research grant; J. Oppenheimer – Consultant for DBV Technologies, GlaxoSmithKline, and Kaleo, he received other financial gains; Clinical research for AstraZeneca, Boehringer Ingelheim, and Novartis, he received research grants. M.H. Grayson – Clinical research for Polyphor, Ltd., he received a research grant. G.D. Marshall – Clinical Research for Stallergens and Sanofi, he received research grantsRecognition of Commercial Support: This activity has not received external commercial support.Copyright Statement: ©2015-2017 ACAAI. All rights reserved.CME Inquiries: Contact the American College of Allergy, Asthma & Immunology at [email protected] or 847-427-1200. Credit can now be obtained, free for a limited time, by reading the review article in this issue and completing all activity components. Please note the instructions listed below:•Review the target audience, learning objectives and all disclosures.•Complete the pre-test.•Read the article and reflect on all content as to how it may be applicable to your practice.•Complete the post-test/evaluation and claim credit earned. At this time, physicians will have earned up to 1.0 AMA PRA Category 1 CreditTM. Minimum passing score on the post-test is 70%.•Approximately 4-6 weeks later you will receive an online outcomes assessment regarding your application of this article to your practice. Once you have completed this assessment, you will be eligible to receive MOC Part II credit from the American Board of Allergy and Immunology. Overall Purpose Participants will be able to demonstrate increased knowledge of the clinical treatment of allergy/asthma/immunology and how new information can be applied to their own practices. Learning Objectives At the conclusion of this activity, participants should be able to:•Differentiate the advantages and disadvantages of IVIG and SCIg•Discuss the approach to optimizing dosing of immunoglobulin replacement therapy in patients with antibody immune deficiency•Describe the guiding principles for the effective use of immunoglobulin replacement therapy in patients with antibody immune deficiency Release Date: October 1, 2017 Expiration Date: September 30, 2019 Target Audience Physicians involved in providing patient care in the field of allergy/asthma/immunology Accreditation The American College of Allergy, Asthma & Immunology (ACAAI) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Designation The American College of Allergy, Asthma & Immunology (ACAAI) designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Planning Committee Members Mark Ballow, MD (Author) Jonathan A. Bernstein, MD (Annals CME Subcommittee) Guha Krishnaswamy, MD (Annals CME Subcommittee) John J. Oppenheimer, MD (Annals CME Subcommittee, Associate Editor) Mitchell H. Grayson, MD (CME Series Editor, Deputy Editor) Gailen D. Marshall, Jr, MD, PhD (Editor-in-Chief) Disclosure Policy As required by the Accreditation Council for Continuing Medical Education (ACCME) and in accordance with the American College of Allergy, Asthma and Immunology (ACAAI) policy, all educational planners, presenters, instructors, moderators, authors, reviewers, and other individuals in a position to control or influence the content of an activity must disclose all relevant financial relationships with any commercial interest that have occurred within the past 12 months. All identified conflicts of interest must be resolved and the educational content thoroughly vetted for fair balance, scientific objectivity, and appropriateness of patient care recommendations. It is required that disclosure be provided to the learners prior to the start of the activity. Individuals with no relevant financial relationships must also inform the learners that no relevant financial relationships exist. Learners must also be informed when off-label, experimental/investigational uses of drugs or devices are discussed in an educational activity or included in related materials. Disclosure in no way implies that the information presented is biased or of lesser quality. It is incumbent upon course participants to be aware of these factors in interpreting the program contents and evaluating recommendations. Moreover, expressed views do not necessarily reflect the opinions of ACAAI. All identified conflicts of interest have been resolved. Disclosure of Relevant Financial Relationships Any unapproved/investigative uses of therapeutic agents/devices discussed are appropriately noted. M. Ballow – Advisory Board member for Shire, and Grifols and Speaker for Shire, he received fees; he has received research grants from CSL Behring and Grifols. J.A. Bernstein – PI, Consultant, Speaker for AstraZeneca, CSL Behring, Novartis/Genentech, and Shire, he received research grants and fees; Speaker for Baxalta, he received fees; Consultant for Imedics, he received fees; PI and Consultant for Boehringer Ingelheim and GlaxoSmithKline, he received research grants and fees. G. Krishnaswamy – Clinical Research for CSL Behring, he received a research grant; J. Oppenheimer – Consultant for DBV Technologies, GlaxoSmithKline, and Kaleo, he received other financial gains; Clinical research for AstraZeneca, Boehringer Ingelheim, and Novartis, he received research grants. M.H. Grayson – Clinical research for Polyphor, Ltd., he received a research grant. G.D. Marshall – Clinical Research for Stallergens and Sanofi, he received research grants Recognition of Commercial Support: This activity has not received external commercial support. Copyright Statement: ©2015-2017 ACAAI. All rights reserved. CME Inquiries: Contact the American College of Allergy, Asthma & Immunology at [email protected] or 847-427-1200. A woman was diagnosed with common variable immunodeficiency (CVID) at the age of 42 years. She began having infections when she was 24 years of age. Her history included chronic sinusitis and 3 bacterial pneumonias at different times in both lungs. Her infections necessitated antibiotic therapy almost every other month. A specialist in allergy and immunology finally made the diagnosis of immune deficiency and, specifically, CVID on testing. Her immunoglobulin levels were extremely low: serum IgG, 250 mg/dL; IgA, less than 7 mg/dL; and IgM, 40 mg/dL. She had very low specific antibodies to tetanus toxoid and pneumococcal polysaccharides and responded poorly to booster immunizations with these vaccines. T- and B-cell subsets were in the normal range as were her response to mitogens. High-resolution chest computed tomography revealed bronchiectasis in both the right and left lung fields. Because of the extremely low serum IgG level and the presence of bronchiectasis, she was prescribed replacement intravenous immunoglobulin (IVIG) at 600 mg/kg per month. Her allergist/immunologist initiated her treatment in the local hospital infusion center, giving her half the first dose (20 g) and then repeating this dose 2 weeks later. Despite encouragement by her physician to switch to subcutaneous immunoglobulin (SCIG), the patient elected to continue receiving immunoglobulin therapy in the hospital infusion suite because she had made friends with the nursing staff. Unbeknown to the patient, the hospital switched their immunoglobulin formulary to a different product. The patient began to have headaches and myalgias with her infusions that lasted 48 to 72 hours. After conferring with her allergist/immunologist, she decided to go on home therapy with IVIG because she liked the idea of monthly treatments and her physician could choose an IVIG product with the home care company that he had previous experience with in other patients with primary immunodeficiency diseases who had a previous history of headaches. The patient did well for 6 months, with a marked decrease in infections, but thereafter noticed that at approximately the third week of a 4-week treatment cycle she felt fatigued, had increased nasal symptoms, and started to have episodes of sinusitis. Her allergist/immunologist changed her treatment regimen to every 3 weeks, which helped for a short period. With the recurrence of this wear-off effect even after reducing the treatment cycle to 3 weeks, her allergist/immunologist convinced her to switch to SCIG therapy. He explained all the options, including a 10%, 20%, and a facilitated SCIG product. The 10% SCIG product would have to be given every week into multiple sites (eg, 25 mL per site at 4 sites every week for a total of 40 g per month), whereas the 20% immunoglobulin product could be given every other week at 3 sites (eg, 35 mL per site at 3 sites twice monthly for 42 g per month) and the facilitated SCIG product once a month (eg, 200 mL at 2 sites monthly for 40 g). The patient elected to use the 20% SCIG product infusing every other week. Because the patient was infection free with IVIG, her allergist/immunologist switched her to the 20% SCIG product at the same dose as the monthly IVIG dose.

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