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Article re: IVIG used in comatose HE patient

February 7, 2013 3 comments

Today I added the following article to our database of Case Reports and Research. It was published late in 2010, and had previously escaped my attention.  This may be helpful for those looking for documented evidence for use of IVIG in HE :

Successful response to intravenous immunoglobulin as rescue therapy in a patient with Hashimoto’s encephalopathy.

R. Cornejo, P Venegas, D Goñi, A Salas, and C Romero

BMJ Case Rep. 2010 Dec 29

Full Text:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3027904/

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Treatment Options

October 13, 2012 1 comment

Many patients – particularly those who are newly diagnosed – wonder what the treatment options are.  The following is a summary based on recent scientific articles.

The most frequently used initial treatment for the newly diagnosed is High Pulse IV Steroid Treatment with Solu-Medrol (methylprednisolone sodium succinate).  Patients are generally given between 3 and 7 days of IV treatment.  Treatment usually consists of receiving two infusions per day, for a total of 1000 mg (1 gram) of Solu-Medrol each day.  Thereafter, patients are given oral prednisone and taper down the dosage over time.  Most commonly, patients start with 60 mg per day at the conclusion of the IV treatment, and they taper the dosage slowly down over many months.  In some patients, it will take up to a year to completely wean off steroids.  Other patients, in whom symptoms re-emerge, require  a maintenance dose of between 2 and 10 mg per day of prednisone indefinitely. More recently, physicians have found success in using so-called steroid-sparing agents as a form of ongoing maintenance for HE/SREAT.  There are a number of different medications used for ongoing treatment.  Research indicates that the most commonly used alternatives for maintenance are Imuran, Cellcept, or Methotrexate.  A future post will focus on and discuss these maintenance therapies.

For those who do not respond sufficiently well to steroid therapy, there is the option of Intravenous Immunoglobulin treatment (IVIG).  In this treatment protocol, the patient’s own antibodies are replaced with an infusion of antibodies from donors.  Treatment is usually given as an outpatient, although the first session is often done inpatient to monitor for side effects.  Typically, a patient will begin by receiving twice weekly infusions (intraveonusly), with each infusion taking 3 to 4 hours.  Over time, treatment will go from the initial twice weekly treatments for the first month, to treatments once a week each month, and then ultimately to infusions given once each month.  The goal is for the patient to, over time, go as long as possible between infusions.  It should be noted that many insurance companies balk at this treatment because it is quite expensive.  But research shows (see Case Studies link above) that IVIG can be a very effective way to treat patients who do not respond sufficiently well to steroid treatment.

The other treatment that has been found effective for many patients is Plasmapheresis, sometimes called Plasma Exchange or Plasma Transfer.  In Plasmapheresis, a patient’s blood is filtered through a machine that separates the plasma from actual blood cells.  The patient’s plasma may then be  replaced with saline, albumin, or donor plasma. The reconstituted solution is then returned to the patient. 

These are the most commonly used treatment options as of the date of this posting (October 2012). Future posts will discuss some of the maintenance therapies currently  being used with good results.

What’s the Typical IVIG Dose?

After a discussion with my doctor today as to why others are being treated with higher levels of IVIG than I am, he told me all the literature he could find supports his dosing.  Of course I had to find out for myself.  And it turns out he’s right.

I looked up every pub med study I could (in 4-5 hours) in order to find the typical dosage of IVIG.

The typical “loading dose” is 400mg/kg body weight per day for 5 days.  So that ends up being a TOTAL of 2g/kg.

I only found one study that deviated by administering 1000mg/kg, but it didn’t tell over how many days, so it was useless to determine a typical dose.

The maintenance dose is also 400mg/kg/day for 1 day.  However I found this varied in frequency.  Some never got a maintenance dose, some every 4 weeks, some every 6 weeks…  I think every 4 weeks is more typical.

So there’s the typical dosing, based on pub med studies.  Below is the data.

  • 2004 Review of case report from 1987 woman with HE
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1739535/pdf/v076p00455.pdf
    400mg/kg daily as initial 5 day dose
  • 2005 Review of case report of 2 year old boy with acute encephalopathy
    http://www.ajnr.org/cgi/content/full/26/9/2311
    Prolongation of the infectious encephalopathy condition was suspected, and high-dose (1000 mg/kg) intravenous immunoglobulin therapy was administered in the hope of improving the neurologic symptoms. The patient showed no clinical symptoms during and after infusion, but disturbed consciousness and weakness of limbs appeared later that evening.
    Low-dose (100–200 mg/kg) intravenous immunoglobulin is used as a replacement therapy for antibody deficiencies and high-dose (400–1000 mg/kg) intravenous immunoglobulin is used as an immunomodulatory agent in many immune and inflammatory disorders.
  • Review of 10 case reports on limbic encephalitis
    http://brain.oxfordjournals.org/cgi/reprint/127/3/701
    case 1: IvIg; 2g/kg divided into five daily doses
    Case 4: IvIg; 2g/kg divided into five daily doses (improvement within 1 week, normal within 3 months)
    Case 8: IvIg; 2g/kg divided into five daily doses (worsened, then plasma exchange, no change then improved with steroids)
  • 2001 Review of 10 cases with OMS
    http://brain.oxfordjournals.org/cgi/reprint/124/2/437
    3 cases: 0.4g/kg over 5 days (all recovered in ❤ months)
  • Review of 55 year old woman with Guillain-Barre
    IVIG 0.4g/kg per day was started
  • 10 year review of MS patients receiving IVIG
    http://informahealthcare.com/doi/abs/10.1080/08916930600825867
    initial loading dose of 0.4g/kg body weight/day for 5 days
    booster maintenance dose of 0.4 g/kg every 6 weeks.
Categories: Antibodies, IVIG