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Intravenous immunoglobulins in multiple sclerosis
Originally, intravenous immunoglobulins (IVIg) were designed to provide replacement therapy for patients with hypogammaglobulinaemia. Fortuitously, Imbach et al discovered in the early 1980s that these preparations were beneficial in idiopathic thrombocytopenic purpura.1 Since then, IVIg has been tried, at least experimentally, in almost every disease of a presumed autoimmune nature,2,3 and several uncontrolled studies evaluating potential therapeutic benefits of IVIg in multiple sclerosis were published,4–6 but it was not until 1997 that the results of controlled trials became available.7 Besides its iridescent immunomodulatory actions, work in experimental animal models suggested that IVIg could have the potential to remyelinate demyelinated lesions. In the past year several studies, both experimental and clinical, have shed some light on the capacity and mechanism of IVIg to support remyelination.
Controlled studies of IVIg in multiple sclerosis
Three double blind, randomised, and placebo controlled trials of IVIg in multiple sclerosis have been performed, all in patients with a relapsing-remitting course.7–9 The design and main results are summarised in table 1. There was agreement between the studies that IVIg can reduce the relapse rate. In two of the studies a favourable impact of IVIg on disability assessed by the Kurtzke expanded disability status scale (EDSS) was noted.7,8 Finally, in the two smaller trials that included MRI outcome criteria the number of new and total gadolinium enhancing lesions in the brain was reduced by IVIg, but there was no change in the total number of T2 weighted lesions.8,9 Although each of the trials was positive for its main outcome parameter, assessment and interpretation of the results pose difficulties. Only one of these studies7 included a sufficient number of patients but concern has been expressed about the blinding in this trial as there was overall no decrease in …