Intravenous Immunoglobulin Therapy in Patients With Painful Idiopathic Small Fiber Neuropathy
Margot Geerts, Bianca T A de Greef, Maurice Sopacua, Sander M J van Kuijk, Janneke G J Hoeijmakers, Catharina G Faber, Ingemar S J Merkies, Margot Geerts, Bianca T A de Greef, Maurice Sopacua, Sander M J van Kuijk, Janneke G J Hoeijmakers, Catharina G Faber, Ingemar S J Merkies
Abstract
Objective: This is the first double-blind randomized controlled trial evaluating the efficacy and safety of IV immunoglobulin (IVIG) vs placebo in patients with idiopathic small fiber neuropathy (I-SFN).
Methods: Between July 2016 and November 2018, 60 Dutch patients with skin biopsy-proven I-SFN randomly received a starting dose of IVIG (2 g/kg body weight) or matching placebo (0.9% saline). Subsequently, 3 additional infusions of IVIG (1 g/kg) or placebo were administered at 3-week intervals. The primary outcome was a 1-point change in Pain Intensity Numerical Rating Scale score at 12 weeks compared to baseline.
Results: Thirty patients received IVIG, and 30 received placebo. In both groups, 29 patients completed the trial. In 40% of patients receiving IVIG, the mean average pain was decreased by at least 1 point compared to 30% of the patients receiving placebo (p = 0.588, odds ratio 1.56, 95% confidence interval 0.53-4.53). No significant differences were found on any of the other prespecified outcomes, including general well-being, autonomic symptoms, and overall functioning and disability.
Conclusions: This randomized controlled trial showed that IVIG treatment had no significant effect on pain in patients with painful I-SFN.
Trial registration information: ClinicalTrials.gov Identifier: NCT02637700, EudraCT 2015-002624-31.
Classification of evidence: This study provides Class I evidence that for patients with painful I-SFN, IVIG did not significantly reduce pain compared to placebo.
Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.
Figures
References
- Hoeijmakers JG, Faber CG, Lauria G, Merkies IS, Waxman SG. Small-fibre neuropathies-advances in diagnosis, pathophysiology and management. Nat Rev Neurol 2012;8:369–379.
- Cazzato D, Lauria G. Small fibre neuropathy. Curr Opin Neurol 2017;30:490–499.
- Hoitsma E, Marziniak M, Faber CG, et al. . Small fibre neuropathy in sarcoidosis. Lancet 2002;359:2085–2086.
- Sumner CJ, Sheth S, Griffin JW, Cornblath DR, Polydefkis M. The spectrum of neuropathy in diabetes and impaired glucose tolerance. Neurology 2003;60:108–111.
- Brannagan TH III, Hays AP, Chin SS, et al. . Small-fiber neuropathy/neuronopathy associated with celiac disease: skin biopsy findings. Arch Neurol 2005;62:1574–1578.
- Gondim FA, Brannagan TH III, Sander HW, Chin RL, Latov N. Peripheral neuropathy in patients with inflammatory bowel disease. Brain 2005;128:867–879.
- Mori K, Iijima M, Koike H, et al. . The wide spectrum of clinical manifestations in Sjogren's syndrome-associated neuropathy. Brain 2005;128:2518–2534.
- Goransson LG, Tjensvoll AB, Herigstad A, Mellgren SI, Omdal R. Small-diameter nerve fiber neuropathy in systemic lupus erythematosus. Arch Neurol 2006;63:401–404.
- Orstavik K, Norheim I, Jorum E. Pain and small-fiber neuropathy in patients with hypothyroidism. Neurology 2006;67:786–791.
- Zhou L, Kitch DW, Evans SR, et al. . Correlates of epidermal nerve fiber densities in HIV-associated distal sensory polyneuropathy. Neurology 2007;68:2113–2119.
- Gorson KC, Herrmann DN, Thiagarajan R, et al. . Non-length dependent small fibre neuropathy/ganglionopathy. J Neurol Neurosurg Psychiatry 2008;79:163–169.
- Stogbauer F, Young P, Kuhlenbaumer G, et al. . Autosomal dominant burning feet syndrome. J Neurol Neurosurg Psychiatry 1999;67:78–81.
- Faber CG, Hoeijmakers JG, Ahn HS, et al. . Gain of function NaV1.7 mutations in idiopathic small fiber neuropathy. Ann Neurol 2012;71:26–39.
- Faber CG, Lauria G, Merkies IS, et al. . Gain-of-function Nav1.8 mutations in painful neuropathy. Proc Natl Acad Sci USA 2012;109:19444–19449.
- de Greef BTA, Hoeijmakers JGJ, Gorissen-Brouwers CML, Geerts M, Faber CG, Merkies ISJ. Associated conditions in small fiber neuropathy: a large cohort study and review of the literature. Eur J Neurol 2018;25:348–355.
- Huang J, Han C, Estacion M, et al. . Gain-of-function mutations in sodium channel Na(v)1.9 in painful neuropathy. Brain 2014;137:1627–1642.
- Bakkers M, Merkies IS, Lauria G, et al. . Intraepidermal nerve fiber density and its application in sarcoidosis. Neurology 2009;73:1142–1148.
- Goransson LG, Herigstad A, Tjensvoll AB, Harboe E, Mellgren SI, Omdal R. Peripheral neuropathy in primary Sjogren syndrome: a population-based study. Arch Neurol 2006;63:1612–1615.
- Goransson LG, Brun JG, Harboe E, Mellgren SI, Omdal R. Intraepidermal nerve fiber densities in chronic inflammatory autoimmune diseases. Arch Neurol 2006;63:1410–1413.
- Chamberlain JL, Pittock SJ, Oprescu AM, et al. . Peripherin-IgG association with neurologic and endocrine autoimmunity. J Autoimmun 2010;34:469–477.
- Ferrari S, Morbin M, Nobile-Orazio E, et al. . Antisulfatide polyneuropathy: antibody-mediated complement attack on peripheral myelin. Acta Neuropathol 1998;96:569–574.
- Dabby R, Weimer LH, Hays AP, Olarte M, Latov N. Antisulfatide antibodies in neuropathy: clinical and electrophysiologic correlates. Neurology 2000;54:1448–1452.
- Levine TD, Kafaie J, Zeidman LA, et al. . Cryptogenic small-fiber neuropathies: serum autoantibody binding to trisulfated heparan disaccharide and fibroblast growth factor receptor-3. Muscle Nerve 2019;61:512–515.
- Zafrir B, Zimmerman M, Fellig Y, Naparstek Y, Reichman N, Flatau E. Small fiber neuropathy due to isolated vasculitis of the peripheral nervous system. Isr Med Assoc J 2004;6:183–184.
- Kelkar P, McDermott WR, Parry GJ. Sensory-predominant, painful, idiopathic neuropathy: inflammatory changes in sural nerves. Muscle Nerve 2002;26:413–416.
- Uceyler N, Kafke W, Riediger N, et al. . Elevated proinflammatory cytokine expression in affected skin in small fiber neuropathy. Neurology 2010;74:1806–1813.
- Goebel A. Immunoglobulin responsive chronic pain. J Clin Immunol 2010;30(suppl 1):S103–S108.
- Hughes RA, Donofrio P, Bril V, et al. . Intravenous immune globulin (10% caprylate-chromatography purified) for the treatment of chronic inflammatory demyelinating polyradiculoneuropathy (ICE study): a randomised placebo-controlled trial. Lancet Neurol 2008;7:136–144.
- van Schaik IN, Bouche P, Illa I, et al. . European Federation of Neurological Societies/Peripheral Nerve Society guideline on management of multifocal motor neuropathy. Eur J Neurol 2006;13:802–808.
- Eftimov F, Winer JB, Vermeulen M, de Haan R, van Schaik IN. Intravenous immunoglobulin for chronic inflammatory demyelinating polyradiculoneuropathy. Cochrane Database Syst Rev 2013:CD001797.
- Parambil JG, Tavee JO, Zhou L, Pearson KS, Culver DA. Efficacy of intravenous immunoglobulin for small fiber neuropathy associated with sarcoidosis. Respir Med 2011;105:101–105.
- Wakasugi D, Kato T, Gono T, et al. . Extreme efficacy of intravenous immunoglobulin therapy for severe burning pain in a patient with small fiber neuropathy associated with primary Sjogren's syndrome. Mod Rheumatol 2009;19:437–440.
- Gaillet A, Champion K, Lefaucheur JP, Trout H, Bergmann JF, Sene D. Intravenous immunoglobulin efficacy for primary Sjogren's Syndrome associated small fiber neuropathy. Autoimmun Rev 2019;18:102387.
- Makonahalli R, Seneviratne J, Seneviratne U. Acute small fiber neuropathy following mycoplasma infection: a rare variant of Guillain-Barre syndrome. J Clin Neuromuscul Dis 2014;15:147–151.
- Tavee JO, Karwa K, Ahmed Z, Thompson N, Parambil J, Culver DA. Sarcoidosis-associated small fiber neuropathy in a large cohort: clinical aspects and response to IVIG and anti-TNF alpha treatment. Respir Med 2017;126:135–138.
- Souayah N, Chin RL, Brannagan TH, et al. . Effect of intravenous immunoglobulin on cerebellar ataxia and neuropathic pain associated with celiac disease. Eur J Neurol 2008;15:1300–1303.
- Schofield JR, Chemali KR. How we treat autoimmune small fiber polyneuropathy with immunoglobulin therapy. Eur Neurol 2018;80:304–310.
- Liu X, Treister R, Lang M, Oaklander AL. IVIG for apparently autoimmune small-fiber polyneuropathy: first analysis of efficacy and safety. Ther Adv Neurol Disord 2018;11:1756285617744484.
- Oaklander AL, Nolano M. Scientific advances in and clinical approaches to small-fiber polyneuropathy: a review. JAMA Neurol Epub 2019 Sep 9.
- de Greef BT, Geerts M, Hoeijmakers JG, Faber CG, Merkies IS. Intravenous immunoglobulin therapy for small fiber neuropathy: study protocol for a randomized controlled trial. Trials 2016;17:330.
- Tesfaye S, Boulton AJ, Dyck PJ, et al. . Diabetic neuropathies: update on definitions, diagnostic criteria, estimation of severity, and treatments. Diabetes Care 2010;33:2285–2293.
- Farrar JT. What is clinically meaningful: outcome measures in pain clinical trials. Clin J Pain 2000;16:S106–S112.
- Dworkin RH, Turk DC, Wyrwich KW, et al. . Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations. J Pain 2008;9:105–121.
- Vernon MK, Brandenburg NA, Alvir JM, Griesing T, Revicki DA. Reliability, validity, and responsiveness of the daily sleep interference scale among diabetic peripheral neuropathy and postherpetic neuralgia patients. J Pain Symptom Manage 2008;36:54–68.
- Brouwer BA, Bakkers M, Hoeijmakers JG, Faber CG, Merkies IS. Improving assessment in small fiber neuropathy. J Peripher Nerv Syst 2015;20:333–340.
- Galer BS, Jensen MP. Development and preliminary validation of a pain measure specific to neuropathic pain: the Neuropathic Pain Scale. Neurology 1997;48:332–338.
- Aaronson NK, Muller M, Cohen PD, et al. . Translation, validation, and norming of the Dutch language version of the SF-36 Health Survey in community and chronic disease populations. J Clin Epidemiol 1998;51:1055–1068.
- Draak THP, de Greef BTA, Faber CG, Merkies ISJ; PeriNomS Study Group. The minimum clinically important difference: which direction to take. Eur J Neurol 2019;26:850–855.
- McQuay H, Carroll D, Moore A. Variation in the placebo effect in randomised controlled trials of analgesics: all is as blind as it seems. Pain 1996;64:331–335.
- Farmacotherapeutisch Kompas—Gamunex—last visit. 2019. Available at: . Accessed May 19, 2015.
Source: PubMed