Treating Neuropathy with IVIG: A Physician’s Perspective

TODD LEVINE, MD, is a board-certified neurologist with a subspecialty in neuromuscular diseases. He practices in Phoenix, Ariz., at Phoenix Neurological Associates (PNA). He is also the founder and director of the PNA ALS (amyotrophic lateral sclerosis) clinic and an adjunct professor of neurology at University of Kansas. In addition, Dr. Levine serves as the chairman of the neuromuscular section of the American Academy of Neurology.

BSTQ: What treatment options do you initially consider after diagnosing a neuropathy?

Dr. Levine: Treatments depend on the cause of the neuropathy. So, if it’s diabetic neuropathy, we control the diabetes; if it’s a toxic substance, we remove the substance; [or] if it’s infectious, we treat the infection. On the other hand, if the neuropathy is caused by the immune system, we use medications to change the immune system. So, the first step is to understand the root cause before we can proceed with a treatment plan.

BSTQ: What are immune-mediated neuropathies?

Dr. Levine: Immune-mediated neuropathies can be subdivided into different groups based on the type of nerve that is damaged: motor, sensory, motor and sensory, or autonomic. They are diagnosed based on characteristic changes on nerve conduction studies, or abnormalities in blood tests, spinal taps or nerve biopsies. At times, it can be difficult to be certain a neuropathy is caused by the immune system. In these cases, doctors may opt for a short trial of a therapy designed to treat immune neuropathies. If patients respond, then it is likely their neuropathy is immune-mediated. Should patients fail to respond to the first trial of therapy, it is still possible they have an immunemediated neuropathy.

BSTQ: Can you give us an overview of the use of intravenous immune globulin (IVIG) to treat various neuropathies?

Dr. Levine: According to a guideline issued by the American Academy of Neurology, IVIG has been identified as an effective treatment for certain disorders of the nerves and muscles, including Guillain-Barré syndrome (GBS) and a form of neuropathy called chronic inflammatory demyelinating polyneuropathy (CIDP). IVIG is a type of immunotherapy that fights the misdirected immune system. Immune globulins are proteins in human blood that likely link themselves with antibodies or other substances directed at the nerves. According to the guideline, strong evidence shows IVIG effectively treats GBS, a rare disorder in which the body’s immune system attacks the peripheral nervous system, causing tingling and weakness in the arms and legs. Strong evidence also shows that long-term use of IVIG can help treat CIDP, which is the chronic counterpart of GBS and can affect nerves in the arms and legs and other parts of the body.

BSTQ: When is IVIG therapy a better alternative than other treatment options for neuropathy?

Dr. Levine: That’s difficult to answer. Even in the best clinical trials of CIDP, only 50 percent improve with IVIG. Other options like steroids, plasmapheresis or immunosuppressive agents can be helpful. I like to say that everyone’s immune system is different, so the path to an effective treatment plan is often filled with trial and error.

BSTQ: How exactly does IG work to alleviate symptoms of neuropathy?

Dr. Levine: There are many different theories. I explain it to patients in a way that makes sense to me. IGs are antibodies from other people that block the bad antibodies in a patient’s system from damaging the nerves. But, it is important to understand we have nothing to help nerves grow. We can lessen the disease, but the patient’s own body has to grow the nerves on its own. So being healthy, eating well and exercise are all also very important aspects of any effective treatment plan.

BSTQ: One subcutaneous IG (SCIG) product was recently approved to treat CIDP, and another is being considered. What benefits do you believe these offer?

Dr. Levine: SCIG generally lessens the side effects patients experience from IVIG treatments and can be easier to manage. Overall, patients will experience fewer headaches, fevers, rashes, etc. The effectiveness of IVIG and SCIG seems to be the same, but for most patients, SCIG can result in more needle sticks per month (depending on the dose of IG they are receiving and the brand). Another advantage of SCIG is that it gives patients more freedom so they are not tied to an infusion center or a nurse. In addition, many patients enjoy the sense of independence they gain from being able to manage their treatment on their own.