Does IVIG Offer Promise?
By A. G. Moore 9/16/2013
Diagram of Immunoglobulin Basic Unit
By:Y_Tambe On Wikimedia Commons
Under attribution share alike license
IVIG is an immunoglobulin derived from blood plasma. While infusion with IVIG has helped countless patients–many of them desperately ill–its use as a treatment for lupus continues to be investigated. Some studies have yielded promising results; others have not been so encouraging.
One research paper, Intravenous Immunoglobulin in the Management of Lupus Nephritis, reported that patients with stage IV and V lupus nephritis responded well to IVIG therapy. According to this paper, not only did stage IV and V nephritis patients show improvement on IVIG therapy, but the drug was effective in treating those whose kidneys were less severely compromised. Another article, in Oxford Journals, suggested that IVIG might help women with lupus to have full-term pregnancies. This article described a study in which women, all with lupus and prior histories of spontaneous miscarriage, were treated with IVIG. Every woman in the study was able to have a successful pregnancy.
The positive outcomes described in these articles seem to indicate that IVIG could be a game-changer for some people with lupus; however, a number of issues with this therapy need to be addressed before its true value in lupus care can be determined.
One of the issues is the paucity of controlled studies: many patients who receive IVIG have already been treated with one or more standard immunosuppressive drugs, such as mycophenolate or cyclophosphamide. It’s hard in this context to sort out precisely the influence of IVIG from other medications; these often have a delayed reaction and may kick in after IVIG therapy has begun.
Another issue with IVIG is that there is no agreement as to the ideal dose and how best to administer this dose. Some studies suggest patient response is better with a high dose. Other studies have shown good response to a lower dose administered over a longer period of time. Lower doses are usually associated with better tolerance–that is, fewer side effects.
Side effects of IVIG treatment can be serious. A very important one is anaphylaxis: for a subset of patients–those with an IgA deficiency (estimated at about one in 700 people )–an allergic reaction to IVIG infusion may occur. The reaction isn’t really to the IVIG, it’s to trace elements of IgA that are found in solution. Although every effort is made to “scrub” a solution clean of IgA, this is not yet possible. Until it is, IVIG is contraindicated in people with IgA deficiency.
Other reported side effects are seizure, headache and nausea. A list of possible side effects can be found at the Mayo Clinic website.
Despite the very positive results some studies have shown for IVIG therapy in the treatment of lupus, the medicine is used conservatively; one reason for this is the cost of the drug. IVIG has to be extracted from the blood of thousands of healthy donors. And demand is high because the drug is used in the treatment of so many conditions.
A word about drug formulations: doctors have learned that not all brands of IVIG are the same. One significant difference between them may be the substances used to stabilize the solution. While it has been known that IVIG use can result in renal failure, tissue samples revealed that in an overwhelming number of cases use of sugar as a solution stabilizer caused the damage. When sugar is not used to stabilize, renal failures due to IVIG infusion decreased by about 90%. Two articles that discuss this issue are: Reemergence of Sucrose Nephropathy: Acute Renal Failure Caused by High Dose Intravenous Immune Globulin Therapy and, Acute renal failure and intravenous immune globulin: occurs with sucrose-stabilized, but not with D-sorbitol-stabilized, formulation.
As for an absolute determination about the effectiveness of IVIG therapy in lupus: the research community is divided. But, those patients looking for alternatives to current therapies may be interested in learning more. Below is a list of research articles that describe encouraging and not so encouraging studies about IVIG use in the treatment of lupus.
One thing my reading suggests to me is this: IVIG warrants the kind of focus only large, controlled, well-designed research studies can offer. Once a sufficient reservoir of reliable data is available, lupus treatment providers–and lupus patients–may decide if and how to use IVIG therapy.