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IVIG in the treatment of chronic pain syndromes.

Goebel A, Netal S, Schedel R, Sprotte G.

Klinik fur Anaesthesiologie, University Wurzburg, Wurzburg, Germany.

Objective. To examine the use of intravenous immunoglobulin (IVIG) in chronic pain. Design. A prospective multiple-dose, open-label cohort study in 130 consecutive patients who suffered from 12 chronic pain syndromes. The largest symptom groups were (number of patients): Fibromyalgia (48); Spinal pain (20); Complex regional pain syndrome (CRPS, 11); Peripheral neuropathic pain (12); and atypical facial pain (11).

. Results. Overall, 20% of patients had>70% pain relief and 27.7% of patients reported relief between 25% and 70%. Six patients (4.6%) had moderately increased pain levels for a duration of up to 9 weeks. Good relief, of more than 70%, was found in all major symptom groups. Patients with pain of short duration (<2 years) reported high relief rates (33.8% of patients in this group reported relief openface>70%). No serious adverse events were reported. Conclusions. IVIG may be effective in patients suffering from chronic pain.

PMID: 15102158 [PubMed - in process]

: Drugs. 2003;63(3):275-87.

Management of chronic inflammatory demyelinating polyradiculoneuropathy.

Hughes RA.

Department of Clinical Neurosciences, Guy's, King's and St Thomas' School of Medicine, London, UK.

This review briefly describes current concepts concerning the nosological status, pathogenesis and management of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). CIDP is an uncommon variable disorder of unknown but probably autoimmune aetiology. The commonest form of CIDP causes more or less symmetrical progressive or relapsing weakness affecting proximal and distal muscles. Against this background the review describes the short-term responses to corticosteroids, intravenous immunoglobulin (IVIg) and plasma exchange that have been confirmed in randomised trials. In the absence of better evidence about long-term efficacy, corticosteroids or IVIg are usually favoured because of convenience. Benefit following introduction of azathioprine, cyclophosphamide, cyclosporin, other immunosuppressive agents, and interferon-beta and -alpha has been reported but randomised trials are needed to confirm these benefits. In patients with pure motor CIDP and multifocal motor neuropathy, corticosteroids may cause worsening and IVIg is more likely to be effective. General measures to rehabilitate patients and manage symptoms, including foot drop, weak hands, fatigue and pain, are important.

PMID: 12534332 [PubMed - indexed for MEDLINE]

Neurology. 1997 Feb;48(2):321-8.

Chronic inflammatory demyelinating polyneuropathy: clinical features and response to treatment in 67 consecutive patients with and without a monoclonal gammopathy.

Gorson KC, Allam G, Ropper AH.

Neurology Service, St. Elizabeth's Medical Center, Boston, MA 02135, USA.

We report the clinical and EMG details of 67 consecutive patients with strictly defined chronic inflammatory demyelinating polyneuropathy (CIDP) during a 4-year period and compare responses to treatment in patients with idiopathic CIDP (CIDP-I) and CIDP with monoclonal gammopathy of uncertain significance (CIDP-MGUS). Patients were examined an average of 28 months after first symptoms. There were several variant presentations that still conformed to the clinical and electrophysiologic definitions of CIDP, including a pure motor syndrome (10%), sensory ataxic variant (12%), mononeuritis multiplex pattern (9%), paraparetic pattern (4%), and relapsing acute Guillain-Barre syndrome (16%). Pain was more frequent than in previous studies (42%). Conduction block was the commonest EMG abnormality (detected in at least one nerve in 73% of patients), but only 31% had a pure demyelinating neuropathy and the majority had some degree of axonal change. Patients with CIDP-MGUS had less severe weakness, greater imbalance, leg ataxia, vibration loss in the hands, and absent median and ulnar sensory potentials, but were as likely as CIDP-I patients to respond to plasma exchange. Seventeen of 44 patients (39%) with idiopathic CIDP improved for at least 2 months with an initial therapy. Although the response rates among plasma exchange, IVIG, and steroids were similar, functional improvement (Rankin score) was greatest with plasma exchange. Of 26 patients who failed to respond to an initial therapy, 9 (35%) benefited from an alternative treatment, and of the 11 who required a third modality 3 (27%) improved. Overall, 66% responded to one of the three main therapies for CIDP.

PMID: 9040714 [PubMed - indexed for MEDLINE]

Diabetes Metab. 2001 Apr;27(2 Pt 1):155-8.

An unusual neuropathy in a diabetic patient: evidence for intravenous immunoglobin-induced effective therapy.

Romedenne P,.

-St Joseph Medical Center, Mons, Belgium.

We report the case of a 68-year old type-2 diabetic male patient who was admitted to hospital for progressive weakness in the right lower limb. Although his metabolic control was good, he lost more than 20 kg of weight. Despite intensive physio- and vitaminotherapy, his neurological condition kept on degrading with a severe amyotrophy and pain of the right thigh. He was unable to walk and to stand alone. Besides a yet known sensitive polyneuropathy, the electrophysiological study signs of demyelination and axonal degeneration. Combined with the albuminocytologic dissociation observed in the cerebrospinal fluid, a diagnosis of inflammatory neuropathy was diagnosed. The patient underwent a treatment by methylprednisolone andwith immunoglobins a striking improvement of his neurological condition. This case report illustrates that rare forms of neuropathy such as inflammatory neuropathies close to chronic inflammatory demyelinating polyneuropathy (CIDP) can occur in diabetic patients and superimpose on the more commonly described forms of neuropathies. It recalls the importance of inflammatory neuropathies are perfectly curable.

Neurol Sci. 2000 Feb 15;173(2):129-39.

(the following study shows that AAN guidelines for CIDP fail to help in diagnosing patients)

The spectrum of chronic inflammatory demyelinating polyneuropathy.

Rotta FT, Sussman AT, Bradley

Department of Neurology, University of Miami School of Medicine,

Research criteria for the diagnosis of chronic inflammatory demyelinating polyneuropathy (CIDP) were proposed by committee of the American Academy of Neurology (AAN) in 1991, and since then these criteria have been widely used in clinical studies. We have been impressed by the frequent finding of electrophysiological changes of a demyelinating neuropathy in patients whose clinical presentation does not conform to the usually accepted clinical phenotype of CIDP.

In our study the clinical spectrum

of CIDP, Forty-seven patients (54%) had distinct features outside the usual clinical presentation of CIDP. Of these,

15 (17%) had predominantly distal features, 13 (15%) had exclusively sensory polyneuropathy; seven (8%) had markedly

asymmetric disease, seven (8%) had associated CNS demyelination, four (5%) had predominant cranial nerve involvement,

and one (1%) had only the restless legs syndrome. An associated medical condition that may have been responsible for the

acquired demyelinating neuropathy was present in 60% of the patients. We conclude that spectrum of CIDP is broader than

would be indicated by the strict application of the AAN research criteria, and that many of the cases meeting more liberal criteria frequently respond to immunosuppressive therapy.

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