Recommendations for the use of immunoglobulin therapy for immunomodulation and antibody replacement.

Abstract

Polyvalent immunoglobin, derived from pooled human plasma, can be administered via the intravenous, subcutaneous or intramuscularroute. Therapy is standard of care in the treatment of a number of immune-mediated pathologies across disciplines. By volume, the majorityis used in neurology (~40%). In primary immunodeficiencies, therapy reconstitutes humoral immunity at replacement doses (0.4 - 0.6 g/kg/month), decreasing infections, and is usually lifelong. However, high doses, usually 2 g/kg total dose over five days, are required forimmunomodulation in autoimmune and inflammatory indications. A high-quality evidence base supports use in primary antibody failure,Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, acute idiopathic thrombocytopenia, Kawasaki disease andimmunobullous diseases. Low-quality evidence shows benefit in many other uncommon autoimmune and immunodeficient conditions.In South Africa, use of immunoglobulin therapy is restricted and, given the cost involved, will likely remain so. Therefore, the incrementalbenefit over other forms of immunosuppression, particularly corticosteroids, must be assessed carefully on a case-by-case basis. In mostcases, therapy will be second-line or 'rescue' and motivation will be required. This short review aims to provide clinicians with the necessaryunderstanding of the therapy, general considerations for use, and evidence base and quality thereof for well-established indications.