Use of intravenous immunoglobulin for patients with inflammatory bowel disease with contraindications or who are unresponsive to conventional treatments

Abstract

Background: Managing patients with IBD who are refractory or have contraindications to standard therapies is challenging. Many will lose response, become intolerant to treatment, or develop infections with contraindication for immunosuppression. Therefore, alternative therapies, such as the use of intravenous immunoglobulin (IVIg), could be used to manage patients in these difficult cases. Methods: Data were extracted retrospectively from the electronic medical records at Vanderbilt University on patients with IBD who received IVIg (February 2011-June 2013). Patients were treated with IVIg 0.4 g·kg-1·d-1 for 3 consecutive days and then 0.4 g/kg once monthly. The dose was increased to 0.4 g/kg biweekly for loss of response or partial response. Clinical response was defined as decreasing the Harvey-Bradshaw Index ≥3 points or improvement in C-reactive protein >25%. Clinical remission was defined as Harvey-Bradshaw Index score <5, no hospitalizations or surgeries after IVIg, or symptom resolution. Statistical analysis was performed using Wilcoxon signed-rank test. Results: Twenty-four patients with IBD received IVIg. Seventeen patients received IVIg for failure of standard treatment. Six patients received IVIg during active infection. Two patients had histoplasmosis, 1 patient had tuberculosis, and 2 patients had pulmonary fungal infections. One patient with ulcerative colitis was given IVIg for recurrent Clostridium difficile. Nine patients required dose escalation after median 153 days (30-360). Ninteen patients (79%) had a response or remission. Sixteen (67%) had a response and 3 (12.5%) obtained remission with IVIg. C-reactive protein decreased significantly after treatment (19 mg/dL [0.1-77] to 7.5 [0.2-20]), P < 0.05. Harvey-Bradshaw Index scores improved (8 [0-19] to 6 [0-17]), P = not significant. Of note, 62.5% had endoscopic improvement after treatment. Conclusions: IVIg is safe and effective in the short-term management of patients with IBD when standard therapies are contraindicated.