HIGH-DOSE INTRAVENOUS IMMUNOGLOBULIN IN AUTOIMMUNE RHEUMATIC DISORDERS

Since the effectiveness of high dose intravenous immunoglobulin (IVIg) was first demonstrated in autoimmune thrombocytopenia, IVIg has been investigated in the treatment of various autoimmune rheumatic disorder s. Controlled randomised studies have established the efficacy of IVIg in Kawasaki's syndrome, for which combined IVIg and aspirin (acetylsa licylic acid) now constitutes the standard treatment. Another controll ed study has demonstrated the benefit of IVIg in dermatomyositis. IVIg treatment in juvenile rheumatoid arthritis has produced contradictory results. Uncontrolled studies and case reports on the application of IVIg in systemic lupus erythematosus, ANCA-associated vasculitides and adult rheumatoid arthritis generally describe short term positive eff ects. Various mechanisms are thought to underlie the effect of IVIg on autoimmune rheumatic diseases, such as: (i) blockade of Fc receptorsr (ii) immunomodulation via anti-idiotypic interactions: (iii) inhibiti on of complement-mediated tissue damage; (iv) modulation of cytokine e xpression by leucocytes and endothelial cells; and (v) inhibition of s uperantigen-mediated T cell activation. IVIg is considered to be a low -risk form of treatment. Reported adverse effects include headache, as eptic meningitis and transient impairment of renal function. Haemolysi s and anaphylactic reactions are rare. The effect profile of IVIg make s it a relevant, although still experimental, form of treatment in aut oimmune rheumatic disorders, but its high cost renders it unsuitable a s a first-line treatment. Because IVIg does not weaken patients' resis tance to infection, it might serve as a therapeutic option in bridging clinical situations where immunosuppressive or cytotoxic approaches a re contraindicated in patients with autoimmune disorders, such as inte rcurrent infection or in the period immediately before and after surge ry.