Intravenous immunoglobulins for relapses of systemic vasculitides associated with antineutrophil cytoplasmic autoantibodies: results of a multicenter, prospective, open-label study of twenty-two patients
Vol. 58, No. 1, January 2008, pp 308–317
2008, American College of Rheumatology
Intravenous Immunoglobulins for Relapses of Systemic
Vasculitides Associated With Antineutrophil
Results of a Multicenter, Prospective, Open-Label Study of Twenty-Two Patients
´rie Martinez,1 Pascal Cohen,1 Christian Pagnoux,1 Ste
Luc Mouthon,1 Laurent Sailler,1 Claire Delaunay,1 Alain Sadoun,2 and Loı¨c Guillevin,1
Objective. To evaluate at 9 months and 24 months
the time of relapse; immunosuppressants could be con-
the safety and efficacy of intravenous immunoglobulins
tinued but could not be reintroduced. At months 9 (end
(IVIGs) administered for 6 months to treat relapses of
point) and 24 (followup), the following information was
Wegener’s granulomatosis (WG) or microscopic polyan-
collected: complete or partial remission, relapse as
giitis (MPA) occurring either under treatment or during
assessed with the Birmingham Vasculitis Activity Score
the year following discontinuation of corticosteroids
(BVAS) 2005, and tolerance and safety of IVIG therapy.
Results. Twenty-two Caucasian patients (7 men
Methods. Patients received IVIGs (0.5 gm/kg/day
and 15 women) were studied: 19 had WG, and 3 had
for 4 days) as additional therapy administered monthly
MPA. Their median age was 53 years (range 19–75
for 6 months and were assessed every 3–6 months.
years), and their median duration of systemic vasculitis
Corticosteroids could be maintained or reintroduced at
was 27 months (range 7–109 months). Their median
BVAS 2005 score was 11 (range 3–25). At study entry, 21
ClinicalTrials.gov identifier: NCT00307658.
patients were ANCA positive, and 21 patients were
Presented in part at the 69th Annual Scientific Meeting of the
American College of Rheumatology, San Diego, CA, November 2005.
taking steroids and/or immunosuppressants. All pa-
tients experiencing relapse were treated with the same
Laboratoire Franc¸ais du Fractionnement et des Biotechnologies,
drug(s) plus IVIGs. All patients initially responded to
Courtaboeuf, France, provided the intravenous immunoglobulins(Tegeline) used in the study.
IVIG therapy. By month 9, 13 patients had complete
1Vale´rie Martinez, MD, PhD, Pascal Cohen, MD, Christian
remission, 1 had partial remission, 7 had relapse, and 1
´phane Vinzio, MD, Alfred Mahr, MD, Luc Mou-
thon, MD, PhD, Laurent Sailler, MD, Claire Delaunay, MD, Loı¨c
had treatment failure. In 8 of the 14 patients who had
remission, the response persisted at month 24. Seven
´ Paris Descartes, Paris, France; 2Alain Sadoun, MD:
patients experienced minor side effects.
Laboratoire Franc¸ais du Fractionnement et des Biotechnologies,Courtaboeuf, France. See Appendix A for members of the French
Conclusion. IVIGs induced complete remissions
of relapsed ANCA-associated vasculitides in 13 of 22
Dr. Mouthon has received consulting fees (less than $10,000)
from Laboratoire Franc¸ais du Fractionnement et des Biotechnologies.
patients at month 9. Because of the good safety and
Dr. Guillevin has received honoraria (less than $10,000 each) from
tolerance profiles of IVIGs, these agents can be included
Actelion (Advisory Board), Wyeth, Roche, and Schering-Plough.
in a therapeutic strategy with other drugs used to treat
Address correspondence and reprint requests to Loı¨c Guil-
levin, MD, Department of Internal Medicine, Ho
relapses of WG or MPA.
ence Center for Rare Diseases (Vasculitis and Scleroderma), Assis-tance Publique Ho
EA 4058, 27 Rue du Faubourg St. Jacques, 75679 Paris Cedex 14,
Wegener’s granulomatosis (WG), microscopic
France. E-mail: email@example.com.
polyangiitis (MPA), and Churg-Strauss syndrome (CSS)
Submitted for publication October 22, 2006; accepted in
are small-vessel vasculitides that are frequently associ-
INTRAVENOUS IMMUNOGLOBULINS FOR VASCULITIS RELAPSE
ated with antineutrophil cytoplasmic autoantibodies
PATIENTS AND METHODS
(ANCAs) (1). Corticosteroids in combination with im-
Study design and patient population.
munosuppressants, such as oral or pulse cyclo-
prospective, open-label study recruited patients from 20
phosphamide, are universally accepted as the standard
French hospitals. The protocol was approved by the Institu-
treatment for inducing remission, preventing relapses,
and sometimes curing these diseases (2–4). However,
Programme Hospitalier de Recherche Clinique. Study moni-toring was sponsored and funded by the Assistance Publique
when therapy is reduced gradually and/or discontinued,
ˆpitaux de Paris. Each patient gave written informed consent
relapses are common and are responsible for substan-
tially more drug-related morbidity and mortality. Al-
Inclusion criteria were a previous diagnosis of WG,
though cyclophosphamide can effectively manage re-
MPA, or CSS based on disease manifestations that met thecriteria of the Chapel Hill Consensus Conference (14) and/or
lapses, repeated cycles of cyclophosphamide are
the American College of Rheumatology classification criteria
associated with bone marrow suppression, myelodyspla-
for WG (15) or CSS (16); factor(s) of poor prognosis at the
sia, infection, infertility, and transitional-cell carcinoma
time of first diagnosis of MPA or CSS (17); vasculitis relapse
of the bladder, which may occur years after its initial use.
occurring during treatment or during the year following treat-ment discontinuation; and age Ͼ18 years.
Therefore, alternative therapies are needed to limit
Patients were excluded for the following reasons: no
treatment for Ͼ12 months; diagnosis of polyarteritis nodosa;
Results of the European Vasculitis Study (EU-
MPA or CSS without factor(s) of poor prognosis at baseline, as
VAS) Trial showed that azathioprine maintenance ther-
defined by the Five-Factors Score (17); recent extracapillaryglomerulonephritis or recent and active glomerulonephritis
apy enabled the reduction of cyclophosphamide expo-
with renal insufficiency (serum creatinine Ͼ300 moles/liter,
sure without increasing the relapse rate over 18 months
or 34 mg/dl); cancer, lymphoma, leukemia, or psychiatric
(2). In addition, the safety and efficacy of agents in-
disorders; age Ͻ18 years; or cutaneous vasculitis or vasculitis
volved in the immune response, such as intravenous
Patients with renal involvement resulting from chronic
immunoglobulins (IVIGs), are being increasingly inves-
extracapillary glomerulonephritis were eligible to participate.
tigated in vasculitis patients. For decades, IVIGs have
However, at the time of relapse, we excluded renal flares with
shown potent therapeutic efficacy in patients with
rapid rises in serum creatinine levels for 2 reasons: immuno-
ANCA-positive vasculitides (5–9). The effectiveness of
globulins seemed unable to control severe renal failure andprevent renal deterioration, and immunoglobulins were inap-
IVIGs alone (8,9) or as concomitant therapy has been
propriate in this context because one of the side effects of high
evaluated in several types of ANCA-associated vasculit-
dose IVIG is impaired renal function.
ides, even though its mechanism(s) of action remains
All patients received IVIGs (Tegeline; Laboratoire
poorly understood (6,7,10,11). In small prospective stud-
Franc¸ais du Fractionnement et des Biotechnologies, Courta-boeuf, France), which were infused at a dosage of 0.5 gm/kg/
ies on persistent ANCA-associated vasculitides, com-
day for 4 consecutive days each month for 6 months. When
plete or partial responses were obtained in 45–75% of
relapse occurred during corticosteroid therapy, clinicians were
the patients given IVIG alone or in combination with
allowed to increase the oral or pulse prednisone dosage for
other drugs (8,9,11–13). Moreover, IVIGs have an ex-
8–21 days provided that the dosage was tapered within 3 weeksto the dosage the patient was taking before relapse occurred.
cellent therapeutic/side-effects index. However, the
Like other brands of IVIGs, Tegeline is derived from the blood
place of IVIG in the treatment regimen of ANCA-
of multiple donors. To prevent transmission of viral and prion
associated vasculitides remains unclear because few
infections, the product is prepared exclusively from selected
trials have evaluated its indication as first- or second-line
donors who have no family history of transmissible spongiformencephalopathy (TSE) and no potential exposure to the risk of
treatment. The only placebo-controlled trial in patients
contracting iatrogenic TSE through neurosurgery, transfusion,
with persistent ANCA-associated vasculitides published
or exposure to bovine spongiform encephalopathy–
to date demonstrated regression of vasculitis at 3 months
contaminated food in the UK. The isolation, purification, and
preparation process consists of several steps that are able toinactivate/remove TSE infectivity, including ethanol precipita-
The present study was designed to evaluate at 9
tion, filtration, 35-nm nanofiltration, and sterilizing filtration.
and 24 months of followup the efficacy and safety of
Immunosuppressants being taken at the time of re-
concomitant administration of IVIGs given monthly for
lapse had to be maintained at the same dosage during IVIG
6 months to patients with relapses of ANCA-associated
therapy and were then reduced, discontinued, or switched to amaintenance treatment if cyclophosphamide had been given.
vasculitides (WG, MPA, or CSS) occurring during ther-
For patients who were off treatment at the time of relapse and
apy with corticosteroids and/or immunosuppressants or
study inclusion, short-term steroids were prescribed as de-
during the year following their termination.
scribed above, but no immunosuppressants were prescribed.
The steroid dosage was freely decided by the treating physician
Our working hypothesis was that
according to the disease severity, with the objective of return-
monthly administration of concomitant high-dose IVIG as an
ing the dosage to the pre-relapse levels within 3 weeks or to the
immunomodulatory agent would attenuate disease activity
minimal effective dosage. In addition, cotrimoxazole as pro-
during relapses of ANCA-associated vasculitides. Given the
phylaxis against Pneumocystis jiroveci
pneumonia was manda-
exploratory nature of this study, we aimed at including 40
tory in patients with CD4 cell counts Ͻ200/mm3, as well as in
patients, with an intermediate analysis based on 20. End points
patients with WG to prevent relapse (18).
were the numbers of complete remissions and partial remis-
Patients’ medical records were
sions and the safety and efficacy of IVIGs. The objective was to
reviewed at study entry (maximum of 5 days before the first
have at least 20% of patients with complete remission or 50%
IVIG infusion), at the time of infusion, monthly during the
of patients with partial remission at month 9 of followup. If this
6-month IVIG treatment period, and at months 9, 12, 15, 18,
goal was reached at the time of the intermediate analysis
and 24 of followup. The following items were recorded on a
corresponding to 20 patients included in the study, the inclu-
preestablished report form: clinical symptoms; current ther-
sion of additional patients would be stopped.
apy; C-reactive protein (CRP) level; serum creatinine level;
Quantitative values are expressed as the mean Ϯ SD or
glomerular filtration rate; Karnofsky Index of performance/
as the median and range. Qualitative values are given as the
function; liver function test results; hemoglobin value; white
number and percentage. Data were collected at the time of
blood cell, neutrophil, lymphocyte, and platelet counts; hema-
infusion, then monthly for 6 months, at month 9 (time of the
turia, proteinuria; results of ANCA testing; and adverse effects
intermediate statistical analysis), and at each followup visit
secondary to IVIG infusion. All patients were tested for
thereafter (at months 12, 15, 18 and 24). Data were analyzed with
human immunodeficiency virus and hepatitis B and C viruses.
the StatView program (1992–1998; SAS Institute, Cary, NC).
The Birmingham Vasculitis Activity Score (BVAS)
2005, which was adapted from BVAS 2 (19,20), was used tospecifically evaluate vasculitis activity. This clinical index is
Characteristics of the patients at study entry.
based on symptoms and signs in 10 categories (systemic signs;
Twenty-four Caucasian patients were screened, and 22
skin; mucous membranes and eyes; ear, nose, and throat;chest; heart and vessels; gastrointestinal tract; kidney; nervous
of them (7 men and 15 women) fulfilled the inclusion
system; and others) divided into 60 predefined items. Each
criteria: 19 had WG and 3 had MPA. Table 1 shows the
item is weighted (range 1–9), and an item is scored if the
patients’ characteristics at study inclusion, by type of
investigator thinks it is present and caused by active vasculitis.
vasculitis. The median age of the 22 patients was 53
Higher scores indicate more active disease. For low-grade
years (range 19–75 years), and the median duration of
grumbling disease, but not new/worse signs, the BVAS 2005
their vasculitis symptoms before study inclusion was 27
Complete remission was defined as the disappearance
months (range 7–109 months). Thirteen patients had
of clinical and biologic signs of vasculitis, as reflected by a
been smokers, and 6 had various allergies. The median
BVAS 2005 score of zero. Partial remission was defined as
BVAS 2005 score at study entry was 11 (range 3–25).
attenuation of clinical and biologic symptoms that were
Before relapse of the vasculitis (prior to study
present at the time of relapse, as reflected by Ն50% decrease
inclusion), the median prednisone dosage was 4 mg/day
in the BVAS 2005 score obtained at study entry. Vasculitis
(range 0–10). At study inclusion, corresponding to the
sequelae (lasting Ͼ3 months) could be present at the time ofevaluation and were not recorded as symptoms of disease
first infusion of IVIG as concomitant therapy, 21 of the
activity, but as persistent damage (e.g., persistent proteinuria
22 patients were taking corticosteroids (dosage range
associated with the disappearance of hematuria, a stable serum
5–60 mg/day of prednisone in 19 patients and/or 1.2
creatinine level above the normal range, or persistent sinus-
mg/kg/day to a maximum dosage of 1 gm/day of pulse
itis). Worsening of symptoms was considered to represent
methylprednisolone in 6 patients) and/or immunosup-
relapse when new symptoms appeared after an initial complete
pressants. One patient received a single pulse of cortico-
remission or partial remission. Treatment failure was recordedwhen there were new symptoms or further deterioration of
steroids at the time of the first IVIG infusion and then
vasculitis symptoms that were present at trial entry.
received IVIGs alone. Patients were taking the following
The Medical Outcomes Study Short Form 36 (SF-36)
immunosuppressants: cyclophosphamide in 7 (intrave-
health survey was completed at each assessment (21,22). The
nous in 5 and oral in 2), azathioprine in 7, methotrexate
SF-36 evaluates 8 dimensions of health status (general andmental health, physical and social functioning, physical and
in 3, and mycophenolate mofetil in 1. Cotrimoxazole had
emotional role, pain, and vitality), and it can be condensed into
been prescribed for 12 WG patients to prevent relapse
2 scores, a physical component summary and a mental com-
(800/160 mg of trimethoprim/sulfamethoxazole) (18)
ponent summary. Scores for each dimension/summary range
and for 1 MPA patient with severe lymphopenia to
from 0 (worst) to 100 (best). A 5-point difference in the SF-36
prevent Pneumocystis jiroveci
pneumonia (400/80 mg of
score is considered clinically and socially relevant (23). Ad-verse events were graded according to predefined World
trimethoprim/sulfamethoxazole). Cotrimoxazole was
Health Organization criteria as mild, moderate, severe, or
started before relapse occurred and before study inclu-
INTRAVENOUS IMMUNOGLOBULINS FOR VASCULITIS RELAPSE
Subsequent course (6–24 months).
At the study
end point at month 9, complete remission persisted in 13of the 16 patients who were in complete remission atmonth 6. Seventeen of the 22 study patients (77.3%)were in complete remission at month 24, and 2 patientswere still in partial remission. Between months 5 and 9of followup, 7 patients experienced a relapse despitetheir initial responses to IVIGs (5 had complete remis-sion and 2 had partial remission initially). Their therapywas modified at the discretion of the treating physician,and 5 achieved complete remission and 2 achievedpartial remission by the end of the study.
For the 13 patients in complete remission at
month 9, the steroid dosage could be reduced in 9 ofthem and stopped in 4 of them. Moreover, dosages ofimmunosuppressants were lowered in 4 other patients.
Outcomes throughout 24 months of followup in patients
One patient received a corticosteroid pulse only with the
with antineutrophil cytoplasmic antibody (ANCA)–associated vascu-litides treated with intravenous immunoglobulins (IVIG) as additional
first IVIG infusion (at the time of relapse and therefore
therapy. Twenty-two patients with ANCA-associated vasculitis, con-
entry into the study); thereafter, no oral drugs were
sisting of either Wegener’s granulomatosis (WG) or microscopic
combined with IVIGs in this patient. His complete
polyangiitis (MPA), were treated for 6 months with monthly infusions
remission was maintained until month 18 of followup,
of IVIGs. Assessments were performed at 6 months, 9 months (study
end point; 3 months after cessation of IVIG infusions), and 24 months,and determinations of complete remission (CR) or partial remission
Monthly IVIG therapy was reintroduced in 3 WG
patients who were in complete remission at month 9.
The first patient relapsed at 10 months, and the treat-ment regimen was intensified with the use of cortico-
All but 1 of the patients were ANCA-positive by
steroids and various immunosuppressants, but there was
indirect immunofluorescence analysis at the time of
no clinical benefit. The second patient had vasculitis that
vasculitis diagnosis and relapse: 2 had perinuclear
was refractory to conventional therapy. Monthly IVIG
ANCAs, 18 had cytoplasmic ANCAs, and 1 had ANCAs
infusions were reintroduced in this patient, and a new
of undetermined pattern. Enzyme-linked immunosor-
complete remission was obtained until the end of fol-
lowup. The third patient was in sustained complete
myeloperoxidase-specific in 3 patients, proteinase
remission as of the fourth IVIG infusion; IVIGs were
3–specific in 16 patients, and of undetermined specificity
continued after the 6 planned cycles because of severe
in 2 patients. All patients were seronegative for human
hypogammaglobulinemia, but the dosage was lowered to
immunodeficiency virus (HIV) and hepatitis B and C
1 gm/kg/day administered for 2 days each month.
viruses. Five patients had antibodies to hepatitis B
In the entire group of
surface antigen as a consequence of vaccination. All
study patients, the median oral prednisone dosage pre-
patients with granulomatous ear/nose/throat lesions also
scribed at study inclusion was 20 mg/day (range 5–1,000),
corresponding to the highest dosage during followup,
Clinical outcomes in the 22 study
and was given in combination with pulse methylpred-
patients at months 6, 9, and 24 of followup are shown in
nisolone (n ϭ 6 patients) at that time. During followup,
the median oral prednisone dosage was decreased to 15
Initial responses (0–6 months).
One WG patient
mg/day (range 0–60) by the second IVIG infusion (4
developed renal insufficiency after the first IVIG infu-
weeks), 10 mg/day (range 0–70) by month 9, and 10
sion and was considered to have failed therapy. Twenty-
one patients achieved remission between month 1 and
In patients who achieved complete or partial
month 5. After 6 months of IVIG therapy, complete
remission, the median oral prednisone dosage at study
remission occurred in 16 of the 22 patients (72.7%; 15
inclusion was 20 mg/day (range 5–500), corresponding to
with WG and 1 with MPA), partial remission occurred in
the highest dosage during followup. This dosage was
2 patients, and relapse occurred in 3.
gradually lowered during followup, to a median of 15
Characteristics of patients with Wegener’s granulomatosis (WG) or microscopic polyangiitis
Duration of vasculitis since first symptoms, months
Ear, nose, and throat involvement, no. (%)
Birmingham Vasculitis Activity Score 2005
mg/day (range 0–30) by the second IVIG infusion, 8
3–25) at study inclusion to 0 (range 0–13) at month 9 and
mg/day (range 0–12) by month 9, and 3.25 mg/day (range
The mean physical component summary score on
No difference in response rates according to the
the SF-36 remained unchanged during followup, with a
different organ manifestations was observed. Because
mean Ϯ SD of 39.11 Ϯ 8.51 at study inclusion, 42.02 Ϯ
IVIGs were able to induce complete remission in 13 of
11.74 at month 9, and 39.94 Ϯ 8.45 at month 24. The
the 22 patients (59.1% [95% confidence interval 0.39–
mental component summary score on the SF-36 im-
0.79]) and partial remission in 1 patient (4.5%) by month
proved from study entry to month 9 and then remained
9, the objective of the study had been reached at the
stable until month 24, with mean Ϯ SD values of 37.12
intermediate analysis, and study inclusions were there-
Ϯ11.67, 43.27 Ϯ 10.00, and 43.82 Ϯ 9.91, respectively.
fore stopped according to the study protocol.
Compared with the values at study inclusion, some
BVAS 2005 and SF-36 scores.
As shown in Figure
scores were markedly improved at month 9: physical role
2, the median BVAS 2005 score dropped from 11 (range
improved from a mean score of 26.25 to a score of 61.36,
INTRAVENOUS IMMUNOGLOBULINS FOR VASCULITIS RELAPSE
Changes in the Birmingham Vasculitis Activity Score (BVAS) 2003 (A
) and the
C-reactive protein level (B
) in patients with Wegener’s granulomatosis and microscopic
polyangiitis in whom complete remission (CA) or partial remission (PR) (A
) or relapse (C
) occurred after or during 6 months of intravenous immunoglobulin infusions added to their
existing therapy. Data are presented as box plots. Boxes represent the 25th and 75th percentiles,
lines within the boxes represent the median, and lines outside the boxes represent the range.
pain improved from 47.05 to 63.50, emotional role
IVIG therapy was maintained in all patients who expe-
improved from 35.00 to 63.64, social functioning im-
rienced an adverse event, and the infusion flow rate was
proved from 51.88 to 62.50, vitality improved from 38.00
adapted to the individual patient’s tolerance level.
to 53.75, and health transition improved from 51.25 to
Three infections developed in 2 patients during
58.33. No relationship was found between the BVAS
followup. One patient developed a staphylococcal infec-
2005 scores at study inclusion and the scores for the
tion in the arteriovenous fistula without septicemia. The
other patient developed Kaposi’s sarcoma, which was
Safety and adverse events.
One patient devel-
related to prior immunosuppressive therapy, and a uri-
oped renal insufficiency after the first IVIG infusion
nary tract infection identified as Escherichia coli
(considered to have failed therapy). This was recorded
Evolution of ANCAs.
Among the 13 patients who
as a serious adverse event. Moderate and transient
were in complete remission at month 9 of study, 5 were
adverse effects of IVIG treatment were reported in 7 of
negative for ANCAs during followup (months 9–18), 6
the 22 patients (31.8%): 1 patient experienced nausea
were positive for ANCAs, and data were missing for the
and/or vomiting at each infusion, 1 patient experienced
other 2 patients. After 24 months of followup, 4 of the 9
nausea only during the first infusion, and 5 patients had
patients who were in complete or partial remission and
headaches after the first infusion, which was associated
underwent ANCA determinations at this time were
with fever at only the first infusion in 1 of them, with
ANCA-positive. The patient who was in partial remis-
arthralgias at only infusion 4 in 1 of them, and with
sion at month 9 remained ANCA-positive during fol-
influenza-like symptoms at only infusion 2 in 1 of them.
lowup. Among the 7 patients who were experiencing a
No severe or life-threatening events were reported.
relapse at month 9 of study, 2 remained ANCA-positive,
3 were ANCA-negative since month 2, and 1 was
lished results, with 59.1% of the patients experiencing
ANCA-negative at month 2 but became ANCA-positive
complete remission, 4.5% experiencing treatment fail-
ure, and 31.8% experiencing relapse at month 9 offollowup. Therapy with IVIGs added to conventionaltreatments was able to induce remission in patients who
were already being treated and to facilitate a reduction
Conventional treatment of ANCA-associated
in the dosages of steroids and/or immunosuppressants.
vasculitides consists of corticosteroids, usually in combi-
An increased steroid dosage was permitted for 3 weeks
nation with immunosuppressants. Maintenance therapy
to “kick-start” a response in our patients, all of whom
typically consists of azathioprine or methotrexate, which
were experiencing relapse of their vasculitis at study
is prescribed for at least 12–18 months (2,24,25). Despite
entry. The strategy of briefly increasing the steroid
optimal treatment regimens, relapses occur in ϳ50% of
dosage was to obtain rapid control of the disease while
WG patients and in Ͻ50% of MPA patients after 5 years
waiting for the effects of the IVIGs to begin, with the
of followup (2–4,25–29). Depending on the maintenance
requirement that the steroid dosages be returned to the
agent prescribed, relapses have been reported in 33–
pre-relapse or minimal effective dosage within 3 weeks.
52% of patients given azathioprine, methotrexate, le-
We believe that the long-term results of IVIG treatment
flunomide, or mycophenolate mofetil (30–34); hence, no
were not attributable to the limited and temporary
single drug seems to be better than the others.
increase in the steroid dosage. Followup of our study
patients continued for 24 months, whereas in the
obtained from pooled blood samples from Ͼ1,000
placebo-controlled study (11), followup continued for 12
healthy blood donors, and they exert their immuno-
months. Although in several open-label studies, fol-
modulatory effects on a wide range of autoimmune
lowup continued for 4 weeks to 5 years, too few patients
and/or systemic inflammatory diseases. IVIGs have been
were included to draw definitive conclusions about the
shown to be effective in the treatment of Kawasaki
disease (35) and to prevent the development of coronary
Our study is the first multicenter, prospective,
aneurysms. They appear to be effective against ANCA-
open-label trial designed to evaluate the long-term
associated vasculitides (6–8). The efficacy of IVIGs
effects of 6 courses of IVIG therapy in patients with
prescribed alone (8,9) or as concomitant therapy has
ANCA-associated vasculitides. IVIGs have a place in
been evaluated in several types of ANCA-associated
the therapeutic approach to relapsing or refractory
vasculitides (2,10,36,37). Treatment with IVIGs alone or
ANCA-associated vasculitides, but there were no previ-
in combination with other drugs achieved responses in
ously published data concerning the persistence of the
45–75% of patients with persistent ANCA-associated
positive effect of IVIGs as additional therapy. Our study
vasculitides included in small prospective studies (8,11–
excluded patients with active crescentic glomerulone-
phritis, which requires other treatments, such as high-
The results of a placebo-controlled trial of IVIGs
dose steroids, cyclophosphamide, and sometimes plasma
in patients with relapsing ANCA-positive vasculitides
exchanges. However, patients with preexisting glomeru-
demonstrated better control of the vasculitis with IVIGs
lonephritis that was controlled at the time of study entry
after standard therapy (11). That study was designed
to investigate the efficacy of a single course of IVIGs
The safety profile of IVIGs was good, with only
(2 gm/kg) administered to previously treated patients
moderate and transient adverse reactions and a positive
with persistent disease activity in whom intensification
impact on the quality-of-life scores, as assessed with the
of therapy was needed. Seventeen patients were ran-
SF-36 health survey. Side effects of IVIG therapy in
domized to receive IVIGs and 17 to receive placebo and
patients with various autoimmune diseases as well as
were followed up for 12 months: 14 of the 17 patients
vasculitides have been reported to occur in 0–36% of
given IVIGs and 6 of the 17 given placebo responded to
patients; most were mild, transient, and completely
treatment (11). That study opened the way for the use of
reversible (5,8,36,38–40). These values are consistent
IVIGs according to a single course of infusions protocol
with the 31.8% rate of moderate side effects observed in
(2 gm/day for 4 days) and showed reduced disease
our patients. Our patients were tested serologically for
activity for 3 months (11), which is consistent with the
antibodies to HIV, hepatitis C virus, and hepatitis B
surface antigen, none of which were detected. One
The results of our study confirm previously pub-
patient developed renal insufficiency after the first IVIG
INTRAVENOUS IMMUNOGLOBULINS FOR VASCULITIS RELAPSE
infusion, with rapid deterioration. Because of the pres-
vasculitic lesions. It is pertinent that the ability of IVIGs
ence of microscopic hematuria and proteinuria, we
to produce lasting disease remissions has been associ-
believe this was probably glomerulonephritis and was
ated with decreased ANCA levels (6). Such mechanisms
not caused by IVIG; however, it was recorded as a
could be at work in the positive effects observed in our
serious adverse event of IVIG therapy, since the treat-
patients; however, antiidiotype antibodies to ANCA
ment was considered to have played a partial role in the
were not monitored. The evolution of ANCAs in our
patients showed that the clinical response was not
To date, no cases of variant Creutzfeldt-Jakob
associated with the appearance or disappearance of
disease related to a plasma-derived product have been
ANCAs. Some patients who were in complete or partial
reported, and the risk of transmission by these products
remission became ANCA-negative, but some remained
is considered to be very low. Indeed, specific precaution-
ary measures in the preparation of plasma-derived prod-
Our findings confirm that IVIGs are a safe,
ucts have been adopted in France to prevent this risk.
well-tolerated, and effective concomitant treatment for
The IVIG preparation used in the present study was
relapses of WG and MPA. We believe that because of
subjected to these precautionary measures in order to
these qualities, IVIGs should be included in the thera-
prevent the transmission of viral and prion infections,
peutic approach to ANCA-associated systemic vasculit-
and the donors had no family history of TSE and no
ides. Our observations also indicate that relapses were
potential exposure to the risk of contracting iatrogenic
frequent after stopping IVIG infusions, suggesting that
TSE through neurosurgery, transfusion, or exposure to
they can temporarily hold the disease at bay, but main-
bovine spongiform encephalopathy–contaminated food
tenance therapy remains necessary after IVIGs are
discontinued or IVIGs should be continued over the
The good safety and tolerance profiles of IVIG
long-term. Prospective studies are needed to evaluate
could place them in the potential key role as the
the indication(s) of IVIGs for use as steroid-sparing and
treatment of choice for ANCA-associated vasculitides.
immunosuppressant-sparing therapy, which was only
Unlike in other studies, we chose 9 months as the study
partially demonstrated in our studies. Because relapses
end point because we wanted to evaluate responses to
frequently occur in patients with WG and MPA, other
IVIGs not only immediately postinfusion, but also at 3
prospective trials are warranted to determine the opti-
months after treatment cessation (i.e., 9 months after
mal duration of IVIG administration and their use in
initial infusion) as well as later (at 12 and 24 months) in
place of, or in addition to, steroids and immunosuppres-
order to assess their long-term impact, if any. Because
IVIGs are an uncommon and expensive treatment, theirwidespread use is a concern. For this reason, we recom-mend treatment with IVIG infusions only in patients
with refractory and/or relapsed ANCA-associated sys-
Dr. Guillevin had full access to all of the data in the study and
temic vasculitides, which represents only a limited num-
takes responsibility for the integrity of the data and the accuracy of thedata analysis.
Pagnoux, Mouthon, Guillevin.
Different mechanisms of action have been pro-
Acquisition of data.
Martinez, Cohen, Pagnoux, Mahr, Mouthon,
posed to explain the beneficial effects of IVIGs on
Delaunay, Sadoun, Guillevin.Analysis and interpretation of data.
Martinez, Vinzio, Sadoun, Guil-
autoimmune diseases, including modulation of Fc␥ re-
ceptor expression on leukocytes and endothelial cells,
Martinez, Mouthon, Sailler, Guillevin.
interaction with complement proteins, modulation of
Martinez, Vinzio, Mahr, Guillevin.
the synthesis and release of cytokines and chemokines,modulation of cell proliferation and apoptosis, remyelin-
ization, neutralization of circulating antibodies, selection
1. Van der Woude FJ, Rasmussen N, Lobatto S, Wiik A, Permin H,
of immune repertoires, and interaction with other cell
van Es LA, et al. Autoantibodies against neutrophils and mono-
surface molecules expressed on lymphocytes and mono-
cytes: tool for diagnosis and marker of disease activity in Wegen-er’s granulomatosis. Lancet 1985;1:425–9.
cytes (41). However, the pathogenesis of ANCA-positive
2. Jayne D, Rasmussen N, Andrassy K, Bacon P, Cohen Tervaert JW,
systemic vasculitides is not completely understood. In
Dadoniene J, et al, for the European Vasculitis Study Group. A
vitro, anti–proteinase 3–specific ANCAs are able to
randomized trial of maintenance therapy for vasculitis associatedwith antineutrophil cytoplasmic autoantibodies. N Engl J Med
activate murine and human neutrophils primed by tumor
necrosis factor ␣ and contribute to the formation of
3. Guillevin L, Cordier JF, Lhote F, Cohen P, Jarrousse B, Royer I,
et al. A prospective, multicenter, randomized trial comparing
21. McHorney CA, Ware JE Jr, Lu JF, Sherbourne CD. The MOS
steroids and pulse cyclophosphamide versus steroids and oral
36-item Short-Form Health Survey (SF-36). III. Tests of data
cyclophosphamide in the treatment of generalized Wegener’s
quality, scaling assumptions, and reliability across diverse patient
granulomatosis. Arthritis Rheum 1997;40:2187–98.
4. Reinhold-Keller E, Beuge N, Latza U, de Groot K, Rudert H,
22. Ware JE Jr, Sherbourne CD. The MOS 36-item Short-Form
Nolle B, et al. An interdisciplinary approach to the care of patients
health survey (SF-36). I. Conceptual framework and item selec-
with Wegener’s granulomatosis: long-term outcome in 155 pa-
tients. Arthritis Rheum 2000;43:1021–32.
23. Ware JE Jr, Snow KK, Kosinski M, Gandek B. SF-36 health
5. Jayne DR, Davies MJ, Fox CJ, Black CM, Lockwood CM.
survey: manual and interpretation guide. 2nd ed. Lincoln (RI):
Treatment of systemic vasculitis with pooled intravenous immu-
noglobulin. Lancet 1991;337:1137–9.
24. De Groot K, Rasmussen N, Bacon PA, Cohen Tervaert JW,
6. Jayne DR, Esnault VL, Lockwood CM. ANCA anti-idiotype
Feighery C, Gregorini G, et al, for the European Vasculitis Study
antibodies and the treatment of systemic vasculitis with intrave-
Group. Randomized trial of cyclophosphamide versus methotrex-
nous immunoglobulin. J Autoimmun 1993;6:207–19.
ate for induction of remission in early systemic antineutrophil
7. Jayne DR, Lockwood CM. Pooled intravenous immunoglobulin in
cytoplasmic antibody–associated vasculitis. Arthritis Rheum 2005;
the management of systemic vasculitis. Adv Exp Med Biol 1993;
25. The Wegener’s Granulomatosis Etanercept Trial (WGET) Re-
8. Jayne DR, Lockwood CM. Intravenous immunoglobulin as sole
search Group. Etanercept plus standard therapy for Wegener’s
therapy for systemic vasculitis. Br J Rheumatol 1996;35:1150–3.
granulomatosis. N Engl J Med 2005;352:351–61.
9. Ito-Ihara T, Ono T, Nogaki F, Suyama K, Tanaka M, Yonemoto S,
26. Hogan SL, Falk RJ, Chin H, Cai J, Jennette CE, Jennette JC, et al.
et al. Clinical efficacy of intravenous immunoglobulin for patients
Predictors of relapse and treatment resistance in antineutrophil
with MPO-ANCA-associated rapidly progressive glomerulone-
cytoplasmic antibody-associated small-vessel vasculitis. Ann Intern
phritis. Nephron Clin Pract 2006;102:c35–42.
10. Richter C, Schnabel A, Csernok E, de Groot K, Reinhold-Keller
27. De Groot K, Adu D, Savage CO. The value of pulse cyclo-
E, Gross WL. Treatment of anti-neutrophil cytoplasmic antibody
phosphamide in ANCA-associated vasculitis: meta-analysis and
(ANCA)-associated systemic vasculitis with high-dose intravenous
critical review. Nephrol Dial Transplant 2001;16:2018–27.
immunoglobulin. Clin Exp Immunol 1995;101:2–7.
28. Guillevin L, Cohen P, Mahr A, Arene JP, Mouthon L, Puechal X,
11. Jayne DR, Chapel H, Adu D, Misbah S, O’Donoghue D, Scott D,
et al, and the French Vasculitis Study Group. Treatment of
et al. Intravenous immunoglobulin for ANCA-associated systemic
polyarteritis nodosa and microscopic polyangiitis with poor prog-
vasculitis with persistent disease activity. QJM 2000;93:433–9.
nosis factors: a prospective trial comparing glucocorticoids and six
12. Levy Y, Uziel Y, Zandman GG, Amital H, Sherer Y, Langevitz P,
or twelve cyclophosphamide pulses in sixty-five patients. Arthritis
et al. Intravenous immunoglobulins in peripheral neuropathy
associated with vasculitis. Ann Rheum Dis 2003;62:1221–3.
29. Hoffman GS, Leavitt RY, Kerr GS, Fauci AS. The treatment of
13. Levy Y, Sherer Y, George J, Langevitz P, Ahmed A, Bar-Dayan Y,
Wegener’s granulomatosis with glucocorticoids and methotrexate.
et al. Serologic and clinical response to treatment of systemic
vasculitis and associated autoimmune disease with intravenous
30. Langford CA, Talar-Williams C, Barron KS, Sneller MC. Use of a
immunoglobulin. Int Arch Allergy Immunol 1999;119:231–8.
cyclophosphamide-induction methotrexate-maintenance regimen
14. Jennette JC, Falk RJ, Andrassy K, Bacon PA, Churg J, Gross WL,
for the treatment of Wegener’s granulomatosis: extended followup
et al. Nomenclature of systemic vasculitides: proposal of an
and rate of relapse. Am J Med 2003;114:463–9.
international consensus conference. Arthritis Rheum 1994;37:187–92.
31. Langford CA, Talar-Williams C, Sneller MC. Use of methotrexate
15. Leavitt RY, Fauci AS, Bloch DA, Michel BA, Hunder GG, Arend
and glucocorticoids in the treatment of Wegener’s granulomatosis:
WP, et al. The American College of Rheumatology 1990 criteria
long-term renal outcome in patients with glomerulonephritis.
for the classification of Wegener’s granulomatosis. Arthritis
32. Metzler C, Fink C, Lamprecht P, Gross WL, Reinhold-Keller E.
16. Masi AT, Hunder GG, Lie JT, Michel BA, Bloch DA, Arend WP,
Maintenance of remission with leflunomide in Wegener’s granu-
et al. The American College of Rheumatology 1990 criteria for the
lomatosis. Rheumatology (Oxford) 2004;43:315–20.
classification of Churg-Strauss syndrome (allergic granulomatosis
33. Reinhold-Keller E, Fink CO, Herlyn K, Gross WL, de Groot K.
and angiitis). Arthritis Rheum 1990;33:1094–100.
High rate of renal relapse in 71 patients with Wegener’s granulo-
17. Guillevin L, Lhote F, Gayraud M, Cohen P, Jarrousse B, Lortho-
matosis under maintenance of remission with low-dose methotrex-
lary O, et al. Prognostic factors in polyarteritis nodosa and
ate. Arthritis Rheum 2002;47:326–32.
Churg-Strauss syndrome: a prospective study in 342 patients.
34. Nowack R, Gobel U, Klooker P, Hergesell O, Andrassy K, van der
Medicine (Baltimore) 1996;75:17–28.
Woude FJ. Mycophenolate mofetil for maintenance therapy of
18. Stegeman CA, Cohen Tervaert JW, de Jong PE, Kallenberg CG,
Wegener’s granulomatosis and microscopic polyangiitis: a pilot
study in 11 patients with renal involvement. J Am Soc Nephrol
Trimethoprim–sulfamethoxazole (co-trimoxazole) for the preven-
tion of relapses of Wegener’s granulomatosis. N Engl J Med
35. Sato N, Sugimura T, Akagi T, Yamakawa R, Hashino K, Eto G, et
al. Selective high dose gamma-globulin treatment in Kawasaki
19. Luqmani RA, Bacon PA, Moots RJ, Janssen BA, Pall A, Emery P,
disease: assessment of clinical aspects and cost effectiveness.
et al. Birmingham Vasculitis Activity Score (BVAS) in systemic
necrotizing vasculitis. QJM 1994;87:671–8.
36. Danieli MG, Cappelli M, Malcangi G, Logullo F, Salvi A, Danieli
20. Merkel PA, Seo P, Aries P, Neogi T, Villa-Forte A, Boers M, et al,
G. Long-term effectiveness of intravenous immunoglobulin in
for the Vasculitis Clinical Research Consortium. Current status of
Churg-Strauss syndrome. Ann Rheum Dis 2004;63:1649–54.
outcome measures in vasculitis: focus on Wegener’s granulomato-
37. Aries PM, Hellmich B, Gross WL. Intravenous immunoglobulin
sis and microscopic polyangiitis. Report from OMERACT 7.
therapy in vasculitis: speculation or evidence? Clin Rev Allergy
INTRAVENOUS IMMUNOGLOBULINS FOR VASCULITIS RELAPSE
38. Boschetti N, Stucki M, Spath PJ, Kempf C. Virus safety of
APPENDIX A: THE FRENCH VASCULITIS STUDY GROUP
intravenous immunoglobulin: future challenges. Clin Rev AllergyImmunol 2005;29:333–44.
Members of the French Vasculitis Study Group who partici-
39. Orbach H, Katz U, Sherer Y, Shoenfeld Y. Intravenous immuno-
pated in the present study are as follows: Drs. L. Astudillo (Toulouse),
globulin: adverse effects and safe administration. Clin Rev Allergy
M. Ballard (Paris), G. Blaison (Colmar), A. K. Bouchou (Saint-
Etienne), J. Cabane (Paris), J. Cadranel (Paris), B. Colombe
40. Sherer Y, Levy Y, Langevitz P, Rauova L, Fabrizzi F, Shoenfeld Y.
(Grenoble), P. de Faucal (Nantes), C. Delaunay (Niort), O. Fain
Adverse effects of intravenous immunoglobulin therapy in 56
patients with autoimmune diseases. Pharmacology 2001;62:133–7.
(Paris), Y. Imbert (Agen), P. Kieffer (Altkirch), D. Launay (Lille), X.
41. Kazatchkine M. Immunomodulation of autoimmune and inflam-
ˆtre), J. Ninet (Lyon), L. Sailler (Toulouse), P.
matory diseases with intravenous immune globulin. N Engl J Med
`gne), B. Wechsler (Paris), and J.-M. Woehl (Col-
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