IVIG in CLL – pro

The hypogammaglobinemia and impaired T-cell function associated with chronic lymphocytic leukemia (CLL) predispose patients to potentially serious infections. Patients who demonstrate a pattern of repeated infections, such as pneumonia and septicemia, should be treated monthly with prophylactic parenteral gamma globulin. In the initial study published in 1988, the survival probability of patients with initial levels of gammaglobulin of less than 700 mg/dl was significantly lower (P = 0.03) than in patients with initial levels of 700 mg/dl or more. NCCN recommends IVIG prophylaxis when there are recurrent infections requiring antibiotics or hospitalization and IGG levels are below 500. IVIG is FDA indicated for CLL. Data from six randomized clinical trials in CLL and one with MM patients with hypogammaglobulinemia and history of infections demonstrated that IVIg significantly decreased the rate of bacterial infections and prolonged the time to first infection, with no differences in non-bacterial infections. These trials suggested that the best dosing was 400 mg/kg/3 weeks until steady state is reached, followed by 400 mg/kg/5 weeks (grade A recommendation, level 1b evidence) There is literature support for low grade IvIG for hypoglobulinemia patients with infectiona for lyphomas treated with rituximab, follicular lymphoma and Waldestrom type low grade lymphomas.

Dreyling M , Ghielmini M, Marcus R, Salles G, Vitolo U: ESMO Guidelines Working Group. Newly diagnosed and relapsed follicular lymphoma. ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol Suppl 6:vi59-63, 2011.
NCCN.ORG, CLL, 2018

Dhalla F, Lucas M, Schuh A, Bhole M, Jain R, Patel SY, et al. Antibody deficiency secondary to chronic lymphocytic leukemia: should patients be treated with prophylactic replacement immunoglobulin? J Clin Immunol (2014) 34(3):277–82.

Sánchez-Ramón S, Dhalla F, Chapel H. Challenges in the Role of Gammaglobulin Replacement Therapy and Vaccination Strategies for Hematological Malignancy. Front Immunol. 2016;7:317. Published 2016 Aug 22.

Work Group Report of the American Academy of Allergy, Asthma & Immunology
Update on the use of immunoglobulin in human disease: A review of evidenceJ Allergy Clin Immunol 2017;139:S1-46.

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