Immunoglobulin replacement for secondary immunodeficiency after B-cell targeted therapies in autoimmune rheumatic disease: Systematic literature review

Sonali Wijetilleka, Chetan Mukhtyar, David Jayne, Aftab Ala, Philip Bright, Hector Chinoy, Lorraine Harper, Majid Kazmi, Sorena Kiani-Alikhan, Charles Li, Siraj Misbah, Louise Oni, Fiona Price-Kuehne, Alan Salama, Sarita Workman, David Wrench, Mohammed Yousuf Karim

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26 Citations (Scopus)


BACKGROUND: Consensus guidelines are not available for the use of immunoglobulin replacement therapy (IGRT) in patients developing iatrogenic secondary antibody deficiency following B-cell targeted therapy (BCTT) in autoimmune rheumatic disease.  

OBJECTIVES: To evaluate the role of IGRT to manage hypogammaglobulinemia following BCTT in autoimmune rheumatic disease (AIRD).  

METHODS: Using an agreed search string we performed a systematic literature search on Medline with Pubmed as vendor. We limited the search to English language papers with abstracts published over the last 10 years. Abstracts were screened for original data regarding hypogammaglobulinemia following BCTT and the use of IGRT for hypogammaglobulinemia following BCTT. We also searched current recommendations from national/international organisations including British Society for Rheumatology, UK Department of Health, American College of Rheumatology, and American Academy of Asthma, Allergy and Immunology.  

RESULTS: 222 abstracts were identified. Eight papers had original relevant data that met our search criteria. These studies were largely retrospective cohort studies with small patient numbers receiving IGRT. The literature highlights the induction of a sustained antibody deficiency, risk factors for hypogammaglobulinemia after BCTT including low baseline serum IgG levels, how to monitor patients for the development of hypogammaglobulinemia and the limited evidence available on intervention thresholds for commencing IGRT.  

CONCLUSION: The benefit of BCTT needs to be balanced against the risk of inducing a sustained secondary antibody deficiency. Consensus guidelines would be useful to enable appropriate assessment prior to and following BCTT in preventing and diagnosing hypogammaglobulinemia. Definitions for symptomatic hypogammaglobulinemia, intervention thresholds and treatment targets for IGRT, and its cost-effectiveness are required.

Original languageEnglish
Pages (from-to)535-541
Number of pages7
JournalAutoimmunity Reviews
Issue number5
Early online date4 Mar 2019
Publication statusPublished - May 2019


  • Agammaglobulinemia/chemically induced
  • Antirheumatic Agents/adverse effects
  • Autoimmune Diseases/drug therapy
  • B-Lymphocytes/immunology
  • Humans
  • Immunization, Passive/methods
  • Immunoglobulins/therapeutic use
  • Immunologic Deficiency Syndromes/chemically induced
  • Retrospective Studies
  • Rheumatic Diseases/drug therapy
  • Rituximab/adverse effects

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