Tuesday, October 15, 2013

Intravenous IVIG in CRPS

From Lost and Tired

Of course, the banner at the top of the PubMed page reads:

PubMed is open, however it is being maintained with minimal staffing due to the lapse in government funding. Information will be updated to the extent possible, and the agency will attempt to respond to urgent operational inquiries.
Part of the reason I've not yet posted Part Two of the latest Clinical Trials updates for CRPS is precisely because they are shut down, though the staff there is also operating on a "compassionate" basis, helping people with end stage cancers find trials to try.  There are angels everywhere.  Yes, yes, I am sure there are even some GOP members who sport halos.


Anyway, I'm posting the abstract for this case study about immunoglobulin infusions in treating CRPS because some wider (and much older) research studies have claimed success in reducing pain -- significantly -- with as high a success rate as 30-40%.  The usual caveat seems to hold true -- that the likelihood of IVIG being effective is greatest in that magic initial 3 to 6 month period after onset.  So many people face huge battles in getting a correct diagnosis, often for years, so hearing that "3-6 month" mantra again is a bit of a downer. But as groups like RSDSA.org continue the battle for awareness and research, maybe these promising treatments will start reaching that target demographic and there will be fewer and fewer "intractable" cases of CRPS.

I took my optimism pill this morning.  That said, please do remember that this is a case study.  But heck, it was a case study that caught someone's attention about ketamine.  And from ketamine has been extrapolated experimental uses of other drugs blocking NMDA receptors -- she said, hopefully, taking her Namenda (memantine)!


 2013 Nov;29(11):e33-e34.
Favorable Outcome of an Acute Complex Regional Pain Syndrome With Immunoglobulin Infusions.

Medlin FZekeridou ARenaud SKuntzer T.

Nerve-Muscle Unit, Department of Clinical Neurosciences, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland.


To emphasize that complex regional pain syndrome (CRPS), a disabling disorder with the implication of aberrant inflammation, vasomotor dysfunction, and maladaptive neuroplasticity, might be treated with a high dose of intravenous immunoglobulin infusions (IVIG).

We describe a patient who presented with CRPS in the acute phase of the disease.

The CRPS developed secondary to sciatic compression in a young patient and was treated within 10 days by high-dose IVIG (2 g/kg). It resolved completely within days after infusions.

This observational study emphasizes that high-dose IVIG may be a treatment option in the acute phase of CRPS.

Here is a slightly older study with a resounding cohort of participants -- all TWELVE of them -- who were past the "acute phase" of CRPS onset.  There was evidence of some pain reduction, but again, there were also methodological problems with the research.  I don't know that researchers will ever be able to establish "statistical relevancy" given the unlikelihood of ever achieving a decent number of subjects.  That's why we must sometimes give the hairy eyeball to those who mock CRPSers for our excitement over a case study of one patient -- we deal with what we have and try our darnedest to establish good science behind it.

Please excuse the funky layout below.  Blogger is punking me.

 2010 Feb 2;152(3):152-8. doi: 10.7326/0003-4819-152-3-201002020-00006.

Intravenous immunoglobulin treatment of the complex regional pain syndrome: a randomized trial.


University of Liverpool, Clinical Sciences Building, University Hospital Aintree, Liverpool L9 7AL, United Kingdom.



Treatment of long-standing complex regional pain syndrome (CRPS) is empirical and often of limited efficacy. Preliminary data suggest that the immune system is involved in sustaining this condition and that treatment with low-dose intravenous immunoglobulin (IVIG) may substantially reduce pain in some patients.


To evaluate the efficacy of IVIG in patients with longstanding CRPS under randomized, controlled conditions.


A randomized, double-blind, placebo-controlled crossover trial. (National Research Registry number: N0263177713; International Standard Randomised Controlled Trial Number Registry: 63918259)


University College London Hospitals Pain Management Centre.


Persons who had pain intensity greater than 4 on an 11-point (0 to 10) numerical rating scale and had CRPS for 6 to 30 months that was refractory to standard treatment.


IVIG, 0.5 g/kg, and normal saline in separate treatments, divided by a washout period of at least 28 days.


The primary outcome was pain intensity 6 to 19 days after the initial treatment and the crossover treatment.


13 eligible participants were randomly assigned between November 2005 and May 2008; 12 completed the trial. The average pain intensity was 1.55 units lower after IVIG treatment than after saline (95% CI, 1.29 to 1.82; P < 0.001). In 3 patients, pain intensity after IVIG was less than after saline by 50% or more. No serious adverse reactions were reported.


The trial was small, and recruitment bias and chance variation could have influenced results and their interpretation.


IVIG, 0.5 g/kg, can reduce pain in refractory CRPS. Studies are required to determine the best immunoglobulin dose, the duration of effect, and when repeated treatments are needed.


Association of Anaesthetists of Great Britain and Ireland, University College London Hospitals Charity, and CSL-Behring.

Summary for patients in

Potential Conflicts of Interest: Disclosures can be viewed atwww.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M09-1292.
Requests for Single Reprints: Andreas Goebel, MD, PhD, Pain Research Institute, University of Liverpool, Clinical Sciences Building, University Hospital Aintree, Liverpool L9 7AL, United Kingdom; e-mail,andreasgoebel@rocketmail.com.
Current Author Addresses: Dr. Goebel: Pain Research Institute, University of Liverpool, Clinical Sciences Building, University Hospital Aintree, Liverpool L9 7AL, United Kingdom.
Dr. Baranowski and Mrs. Ghiai: Pain Management Centre, The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, United Kingdom.
Dr. Maurer: Institute of Anesthesiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland.
Dr. McCabe: The National Hospital for Rheumatic Diseases, Upper Borough Walls, Bath BA1 1RL, United Kingdom.
Dr. Ambler: Joint University College London Hospitals/University College London Biomedical Research Unit, Ground Floor, Rosenheim Wing, 25 Grafton Way, London WC1E 6DB, United Kingdom.


But what would a post be without a measure of balancing skepticism?  Here is a taste of some of the immediate reaction to this 2010 study in the form of an editorial, even -- you'll have to use your "zoom" function to enlarge it, sorry!

© 2013 L. Ryan

No comments:

Post a Comment

The Haddock Corporation's newest dictate: Anonymous comments are no longer allowed. It is easy enough to register and just takes a moment. We look forward to hearing from you non-bots and non-spammers!