Submitted by Nandita Keole, MD
Edited by Francisco Gomez, MD
Combined Intravenous Immunoglobulin and Methylprednisolone as Induction Treatment in Chronic Inflammatory Demyelinating Polyneuropathy (OPTIC protocol): A Prospective Pilot Study
Adrichem ME1, Bus SR1, Wieske L1, Mohammed H2, Verhamme C1, Hadden R2, van Schaik IN1, Eftimov F1. Eur J Neurol. 2020 Mar;27(3):506-513
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an immune‐mediated neuropathy causing appendicular sensorimotor. Treatment of CIDP frequently consists of immunomodulation via IVIg or steroids, however an efficacious and cost-effective treatment regime has proven elusive. In this non-controlled open-label pilot study, which is to precede a randomized control trial, authors sought to test a combined IVIg and IV methylprednisolone (IVMP) regimen.
They included 20 consecutive treatment-naive patients with chronic inflammatory demyelinating polyradiculoneuropathy (diagnosed as per European Federation of Neurological Societies/Peripheral Nerve Society criteria), of which 17 completed the treatment schedule. Remission was defined as improvement at 18 weeks without the need for further immune treatment between end of the treatment schedule and 1 year follow-up and set as the primary outcome.
Participants were then treated with IVIg, 2 g/kg loading dose and 1 g/kg maintenance treatment every 3 weeks, combined with 3 weekly 1g IV methyl prednisolone infusions, for a total of 18 weeks. The cumulative steroid dose was 7g. All patients underwent osteoporosis prophylaxis with alendronate and vitamin D.
Improvement was defined as a minimal clinically important difference on the Inflammatory Rasch-Built Overall Disability Scale and/or an increase of ≥8 kPa in grip strength between baseline and week 18. A total of 13 (76%) of patients showed improvement at 18 weeks of treatment initiation and 10 (59%) exhibited remission at 1 year. Short-term combined induction treatment with IVIg and IVMP induced remission in almost 60% of patients who completed the treatment schedule. Combined induction therapy was generally well tolerated, although 4 patients suffered serious adverse events.
Comments: The investigators found combination treatment of IVIG and IVMP may be effective in the treatment of CDIP and lead to sustained remission at 1 year. A treatment schedule lasting only 18 weeks and providing clinical improvement would be a boon to our patients whom would otherwise suffer a protracted course of CIDP and also reduce total IVIG administered and concurrent costs.
A randomized control trial is currently underway to further test this treatment schedule, which shows promise.