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Home sequential high dose intravenous immunoglobulins in systemic autoimmune disease
  1. E Hachulla1,
  2. A Wibaux1,
  3. P-Y Hatron1,
  4. U Michon-Pasturel1,
  5. V Queyrel1,
  6. A-L Fauchais1,
  7. B Devulder1,
  8. M-N Lefebvre2,
  9. M Yilmaz2
  1. 1Internal Medicine Department, Hôpital Claude Huriez, University of Lille, 59037 Lille cedex, France
  2. 2Central Pharmacy, University of Lille
  1. Correspondence to:
    Professor E Hachulla, Internal Medicine Department, Hôpital Claude Huriez, University of Lille, 59037 Lille cedex, France;
    ehachulla{at}chru-lille.fr

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The high cost of IV immunoglobulins is often considered to be a disadvantage of this treatment. However, this does not take into account the benefits gained—for example, the savings achieved in the costs of corticosteroids and immunosuppressive drugs and, above all, the improvement in quality of life achieved through functional improvement, as noticed in inflammatory myopathies and Still's disease.1–3 It is precisely to minimise the costs of IV immunoglobulin treatments and to enable patients to remain at home that we have developed the administration of IV immunoglobulins at home when sequential treatments are necessary.

Between January 1995 and March 2000 30 patients (18 women, 12 men) were enrolled, with a mean (SD) age of 44 (0.9) for the women and 51 (0.9) years for the men (range 21–74). All the patients had received the first two treatments in hospital to ascertain their tolerance. Patients mostly received Tégéline (314 treatments), Endobuline (81 treatments), and Gammagard (three treatments). All the patients had a corticodependent or refractory autoimmune disease (mostly polymyositis, dermatomyositis, and adult onset Still's disease).

The doses prescribed for each treatment were generally 2 g/kg. Treatments were carried out monthly and consisted of two days when performed in hospital and five days when performed at home. The average flow rate of the IV immunoglobulin perfusions performed at home was 10 g/2 h (extreme values: 30 min–4 h). The secondary effects of the treatments at home remained conventional and minor.

The efficacy of the IV immunoglobulin was described by the patients as very good 17%, good 33%, modest 3%, nil 47%. The efficacy of the IV immunoglobulin was described by the senior doctor as very good 53%, good 30%, nil 17%. Evaluation of the efficacy described by the patients themselves was based on purely functional criteria (general condition, pain, muscular deficit, etc), which explains the difference between the two evaluations. Cases where the IV immunoglobulin resulted in a reduced use of corticosteroids, or cases where IV immunoglobulins made it possible to avoid using immunosuppressive drugs were regarded as a success by the senior doctor, whereas patients did not necessarily have the same impression.

The 23 patients (77%) who said they had benefited from the IV immunoglobulin treatments at home gave the following reasons: better comfort (n=12), presence of next of kin (n=10), more occupation (n=6), time gain (n=5), better mood (n=3), maintaining activities (n=3), avoiding repeated trips to the hospital (n=3), better quality of sleep (n=2), better food (n=2). The seven patients (23%) who preferred the treatments at the hospital gave the following reasons: better monitoring, less trouble (IV immunoglobulin collected at the hospital pharmacy, calling the nurse at home, collection of tubes, needles, and perfusion stand at the pharmacy and at home).

The mean cost of a treatment in hospital was $2701 against $2471 for a treatment at home. The difference seems to be modest, yet for the 277 treatments performed at home over five years, the savings for the community amount to $63 691 with $85 377 of budget revenues for the hospital (the 15% increase is in fact invoiced by the hospital administration for management and traceability costs). By this procedure, we have achieved a virtual economy on our drug budget and small equipment of $580 556 in the past five years (table 1).

In the light of our experience and published reports of side effects,4–8 we propose some guidelines for home IV immunoglobulin infusion for patients with autoimmune disease (table 2). This procedure is appreciated by the patients and medical board and contributes to balancing the expenses for the National Health System.

Table 1

Evaluation of the cost of at home IV immunoglobulin treatments (n=277) and comparison with the theoretical cost in hospital

Table 2

Home IV immunoglobulin infusion guidelines for patients with autoimmune disease

Acknowledgments

To Monique Tomczak who typed this document; Thomas Rémy, Bernard Dauvergne, and Mazen Elzaabi (Laboratoire français du fractionnement et des biotechnologies, 3 avenue des Tropiques, BP 305, Les Ulis, 91958 Courtaboeuf cedex) who helped us with the technical aspect of this study.

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