A Canadian perspective on the use of immunoglobulin therapy to reduce infectious complications in chronic lymphocytic leukemia

Abstract

Infections are a major cause of morbidity and mortality in patients with chronic lymphocytic leukemia (cll), who typically have increased susceptibility because of hypogammaglobulinemia (hgg) related to their disease and its treatment. Immunoglobulin replacement therapy (igrt) has been shown to reduce the frequency of bacterial infections and associated hospitalizations in patients with hgg or a history of infection, or both. However, use of igrt in cll is contentious. Studies examining such treatment were conducted largely before the use of newer chemoimmunotherapies, which can extend lifespan, but do not correct the hgg inherent to the disease. Thus, the utility of igrt has to be re-evaluated in the current setting. Here, we discuss the evidence for the use of igrt in cll and provide a practical approach to its use in the prevention and management of infections.

Keywords: Chronic lymphocytic leukemia; hypogammaglobulinemia; immunodeficiency; immunoglobulin replacement therapy; immunoglobulins; infection; ivig; scig.

FIGURE 1

Treatment algorithm for the use of immunoglobulin replacement therapy in chronic lymphocytic leukemia (CLL). ^a Where a patient has “normal” levels of immunoglobulin G (IgG), but a phenotype consistent with humoural immunodeficiency, the patient should be evaluated for monoclonal gammopathy. ^b Response to vaccination before and after boost. For example, for tetanus, obtain serum for a pre-vaccine titer, then administer the vaccine (same day), and 4 weeks later, measure the response to boost. IgA/M = immunoglobulin A/M; IGRT = immunoglobulin replacement therapy; SC = subcutaneous; IV = intravenous; IgR = immunoglobulin replacement.