Progress in gammaglobulin therapy for immunodeficiency: from subcutaneous to intravenous infusions and back again

The year 1952 marked the first use of subcutaneous immunoglobulin therapy to treat primary immunodeficiency disease. Subsequently, intramuscular and then intravenous administration became the norm in the United States and most of Europe. Intravenous immunoglobulin therapy, however, can be burdensome and often causes systemic side effects. To overcome obstacles presented by the intravenous route of administration, subcutaneous preparations were developed. To further enhance patient satisfaction, adherence, and quality of life, enzyme-enhanced subcutaneous immunoglobulin administration using hyaluronidase, an enzyme spreading agent, was studied. The dose and flow rate of traditional subcutaneous immunoglobulin infusion is limited by the inhibition of bulk fluid flow by the extracellular matrix. Recombinant human hyaluronidase, administered with or immediately prior to infusate, increases the absorption and dispersion of infused fluids and drugs. Results from a phase III clinical trial indicate that subcutaneous immunoglobulin infusion, facilitated by recombinant human hyaluronidase, is well tolerated, and delivers infusion volumes at treatment intervals and rates equivalent to intravenous administration. This review surveys the state of the art of immunoglobulin replacement therapy.