[CIS-PAGID] Anti-TNF in pt with selective antibody deficiency

[Terri Tarrant]

In patient 1, if IgA/IgM/IgG and HIB normal and the patient has had no
serious sinopulmonary infections since starting MTX, I question whether or
not there is a clinically significant specific antibody deficiency,
particularly since vaccination responses were measured on
immunosuppression.  I'd immunize to Prevnar, check post vaccination titers,
and if adequate boost demonstrated, would add a biologic to the MTX without
adding IVIG and follow clinically.

In patient 2, a very few of my absolute IgA deficients (with and without
selective antibody deficiency) don't do well with immunosuppression if they
have autoimmunity requiring DMARDs (IBD and RA specifically).  Sinus
infections tend to be a problem.  That being said, I've not seen IVIG help
much with chronic sinusitis, so I tend to treat with antibiotics and
occasionally chronic suppressive/rotating antibiotic therapy.  I also like
to vaccinate them with Prevnar prior to immunosuppression if pneumococcal
titers were not protective.  I tend to pull the trigger for IVIG if they get
pneumonia.

Terri Tarrant, MD
Rheumatology, Allergy, and Immunology
University of North Carolina



On Mon, May 23, 2011 at 9:00 AM, Hare, Nathaniel D
<NHare at cheshire-med.com>wrote:


>  Colleagues,

>

>

> To follow up on Joe Church’s question, I basically have the same question

> about using IVIG in patients either on a TNF-inhibitor or in whom one will

> possibly be started.  In both patients, I am wondering if I need to add

> IVIG.  Like Joe, I am wondering if I am being too cautious.

>

>

>

> Patient 1

>

> 30 yo male with psoriatic arthritis

>

> Treated with methotrexate

>

> Rheumatology wants to add etanercept

>

> Specific Antibody Deficiency (response to 5/23 pneumococcal serotypes after

> Pneumovax vaccination, tested while on methotrexate)

>

> Tested b/c of history of recurrent pneumonia that predated the methotrexate

> therapy

>

>

>

>

>

> Patient 2

>

> 47 yo female with symmetric polyarticular inflammation B27 positive CCP

> positive, treated with methotrexate and etanercept

>

> Selective IgA deficiency, IgG4 subclass deficiency (for what it’s worth)

> and specific antibody deficiency (response to 2/23 pneumococcal serotypes

> after Pneumovax vaccination, tested while on methotrexate and etanercept)

>

> Tested b/c history of chronic sinusitis, CT documented.

>

>

>

>

>

> Thanks,

>

>

>

> Nathan Hare

>

>

>

>

>

> Nathaniel D. Hare MD

>

> Allergy & Immunology

>

> CMC - Dartmouth Hitchcock Keene

>

> Keene, NH  03431

>

>

>

> ph  (603) 354-5496

>

> fax (603) 354-5498

>  ------------------------------

>

> *From:* pagid-bounces at list.clinimmsoc.org [mailto:

> pagid-bounces at list.clinimmsoc.org] *On Behalf Of *Church, Joseph

> *Sent:* Friday, May 20, 2011 9:11 PM

> *To:* pagid at list.clinimmsoc.org

> *Subject:* [CIS-PAGID] Anti-TNF in pt with selective antibody deficiency

>

>

>

> Colleagues:

>

>

>

> I am following a 12yo girl who has rheumatoid arthritis per our

> Rheumatology service.  They are recommending anti-TNF therapy.

>

>

>

> However, she also has IgA deficiency and selective antibody deficiency (+

> response to 2 of 23 pneumococcal serotypes tested after Pneumovax

> immunization.  These were evaluated because of recurrent sinusitis.

>

>

>

> My bias would be to put her on IVIG or SCID while she is receiving

> anti-TNF.  Am I being overly cautious?

>

>

>

> Thank you for your time.

>

>

>

> Joe Church

>

> Children’s Hospital Los Angeles

>

>

>

>

>

>

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