A Retrospective Review of Real-life Practice of Intravenous Immunoglobulin Usage in Autoimmune Neurological Disease

Abstract

OBJECTIVES: To review the prescription of Intravenous immunoglobulin (IVIg) in neurological disease regarding its efficacy, prescription pattern, indication and treatment outcome. MATERIALS AND METHODS: We studied IVIg usage and treatment outcomes by reviewing the prescription database and medical records from 2013 to 2019 at Thammasat University Hospital (TUH), which is the university hospital in the lower central region of Thailand, and records at Bangkok International Hospital (BIH), part of the largest private hospital network in Thailand. RESULTS: IVIg was used in 28 patients in TUH and 86 patients in BIH. The diagnoses were Guillain-Barré syndrome (GBS) (50%), myasthenia gravis (MG) crisis (23%) and chronic inflammatory demyelinating polyneuropathy (CIDP) (6%). 39.5% of patients were prescribed IVIg apart from those prescribed in line with the Thailand national list of essential medicine (NLEM) indication. The major cause of NLEM deviation is usage beyond reimbursement guidelines, but the dose of IVIg administered is within standard guidelines. IVIg usage and treatment outcomes were similar in both hospitals in the case of GBS and MG. Both groups show beneficial outcomes from IVIg. BIH used IVIg often as first line treatment for CIDP, but TUH used IVIg as subsequent therapy after failure of corticosteroid administration. TUH preferred plasmapheresis combined with a high dose steroid for neuromyelitis optica spectrum disorder (NMOSD) and autoimmune encephalitis reflecting the cost of therapy and reimbursement guidelines. CONCLUSION: IVIg is still the mainstay treatment of GBS and MG crisis in Thailand. The outcome of GBS and MG crisis is similar in both hospitals. Private hospitals seem to have more off label use and often used IVIg as a first line therapy in CIDP, NMOSD and autoimmune encephalitis. Reimbursement guidelines and NLEM have a major impact on prescription patterns.