Safety, Efficacy and Pharmacokinetics of a New 10% Liquid Intravenous Immunoglobulin (IVIG) in Patients with Primary Immunodeficiency

Abstract

An investigational 10% liquid intravenous immunoglobulin (IVIG) was studied in 63 patients with primary immunodeficiency (PID) at 15 study sites.
Patients were treated every 3 or 4 weeks with 254-1029 mg/kg/infusion of IVIG.
Overall, Biotest-IVIG infusions were well tolerated. The proportion of infusions that were associated with adverse events during infusion, and up to 72 h after infusion, including those unrelated to study product, was 27.7% with an upper 95% confidence limit ≤30.6%. Two serious bacterial infections (SBIs) were observed resulting in a serious bacterial infection rate of 0.035 per person per year and an upper one-sided 99% confidence limit of ≤0.136 SBI/patient/year. The number of days of work or school missed due to infection were relatively low at 2.28 days/patient/year. Two patients were hospitalized for infection producing a rate of 0.21 hospitalization days/patient/year. The IgG half-life was approximately 30 days with variation among individuals.
Pharmacokinetic parameters of specific antibody activities were essentially the same as those of total IgG. Biotest-IVIG is safe and effective in the treatment of PID.

Full text

Safety, Efficacy and Pharmacokinetics of a New 10% Liquid
Intravenous Immunoglobulin (IVIG) in Patients
with Primary Immunodeficiency
Richard L. Wasserman &Joseph A. Church &
Mark Stein &James Moy &Martha White &
Steven Strausbaugh &Harry Schroeder &Mark Ballow &
James Harris &Isaac Melamed &David Elkayam &
William Lumry &Daniel Suez &Syed M. Rehman
Received: 4 November 2011 / Accepted: 18 January 2012 /Published online: 6 March 2012
#The Author(s) 2012. This article is published with open access at Springerlink.com
Abstract
Introduction An investigational 10% liquid intravenous im-
munoglobulin (IVIG) was studied in 63 patients with pri-
mary immunodeficiency (PID) at 15 study sites.
Methods Patients were treated every 3 or 4 weeks with 254–
1029 mg/kg/infusion of IVIG.
Results Overall, Biotest-IVIG infusions were well tolerated.
The proportion of infusions that were associated with
adverse events during infusion, and up to 72 h after infusion,
including those unrelated to study product, was 27.7% with
an upper 95% confidence limit ≤30.6%. Two serious bacte-
rial infections (SBIs) were observed resulting in a serious
bacterial infection rate of 0.035 per person per year and an
upper one-sided 99% confidence limit of ≤0.136 SBI/pa-
tient/year. The number of days of work or school missed due
to infection were relatively low at 2.28 days/patient/year.
R. L. Wasserman (*)
Pediatric Allergy/Immunology Associates,
777 Forest Lane, Suite B-332,
Dallas, TX 75230, USA
e-mail: drrichwasserman@gmail.com
J. A. Church
Children’s Hospital Los Angeles,
Los Angeles, CA, USA
M. Stein
Allergy Associates of Palm Beaches,
North Palm Beach, FL, USA
J. Moy
Rush Universty Medical Center,
Chicago, IL, USA
M. White
Institute for Allergy and Asthma,
Wheaton, MD, USA
S. Strausbaugh
University Hospital Case Medical Center,
Cleveland, OH, USA
H. Schroeder
University of Alabama at Birmingham,
Birmingham, AL, USA
M. Ballow
Women & Children’s Hospital of Buffalo,
Buffalo, NY, USA
J. Harris
South Bend Clinic LLP,
South Bend, IN, USA
I. Melamed
1st Allergy & Clinical Research Center,
Centennial, CO, USA
D. Elkayam
Bellingham Asthma, Allergy & Immunology Clinic,
Bellingham, WA, USA
W. Lumry
Allergy and Asthma Specialists,
Dallas, TX, USA
D. Suez
Allergy, Asthma & Immunology Clinic, PA,
Dallas, TX, USA
S. M. Rehman
Allergy & Asthma Center,
Toledo, OH, USA
J Clin Immunol (2012) 32:663–669
DOI 10.1007/s10875-012-9656-5

Two patients were hospitalized for infection producing a
rate of 0.21 hospitalization days/patient/year. The IgG
half-life was approximately 30 days with variation among
individuals.
Conclusions Pharmacokinetic parameters of specific anti-
body activities were essentially the same as those of total
IgG. Biotest-IVIG is safe and effective in the treatment of PID.
Keywords Intravenous immunoglobulin (IVIG) .primary
immunodeficiency (PID) .clinical trial .safety .efficacy .
pharmacokinetics
Introduction
Human immunoglobulin G (IgG) has been used to treat
people with inherited antibody deficiencies since 1952
when Bruton demonstrated that monthly subcutaneous
injections of IgG successfully prevented recurrent pneu-
mococcal infections in a child with agammaglobulin-
emia [1]. The first commercial human IgG preparations
were restricted to intramuscular injection at relatively
low doses, usually 25 mg/kg/week. In order to avoid the
pain of intramuscular IgG injections and to administer larger
doses, intravenous immunoglobulin products (IVIG) were
developed. Periodic reports of hepatitis transmission and rec-
ognition that primary immunodeficient (PID) patients must be
treated for a lifetime resulted in development of IVIG manu-
facturing procedures that inactivate or remove blood-borne
pathogens. Manufacturing steps that enhance purity, minimize
damage to IgG molecules, decrease the frequency of adverse
reactions, and result in higher concentration liquid IVIG have
also been introduced. We report here the results of a clinical
trial of a new liquid 10% IVIG (Biotest-IVIG) in patients with
primary immunodeficiency.
Methods
Study Product
The investigational 10% liquid IVIG used in this study
(Biotest-IVIG) was manufactured by Nabi Biopharmaceut-
icals, subsequently acquired by Biotest Pharmaceuticals
Corporation, in Boca Raton, Florida. Biotest-IVIG was
manufactured from source plasma, fully screened for blood
borne pathogens, by Cohn-Oncley fractionation followed by
ion exchange chromatography [2,3]. Three virus removal/
inactivation steps (cold ethanol fractionation, solvent/deter-
gent inactivation and nanofiltration) are incorporated into
the manufacturing process [4–8]. The final product contains
100±10 mg/mL protein, sodium chloride, glycine and
polysorbate 80 at low pH. The IgG monomer plus dimer
content is >95%.
Study Patients
Sixty-three patients with primary immunodeficiency were
enrolled and treated at 15 study sites. Enrollees were male or
female ages≥6 and≤75 years with a confirmed diagnosis of
primary immunodeficiency, a history of hypogammaglobu-
linemia (i.e., IgG<500 mg/dL) or deficient antibody produc-
tion prior to IgG replacement therapy. Prior to enrollment,
patients were required to have received IVIG infusions every
3 or every 4 weeks for ≥3 months at a dose aimed to be
between 300 and 800 mg/kg. Patients were excluded if they
were positive at screening for any markers of infectious blood-
borne viruses, had a history of adverse reactions to other IgG
or blood products, had selective IgA deficiency or antibodies
to IgA, had a history of acute renal failure/or severe renal
impairment, had a history of deep venous thrombosis or were
pregnant or lactating.
Study Design
This was an open-label, phase III safety, efficacy and
pharmacokinetic study of patients with documented pri-
mary immunodeficiency. Each patient was scheduled to
receive a Biotest IVIG infusion of 300 to 800 mg/kg every 3
or 4 weeks for approximately 1 year. Dosing intervals
were determined by the patient’s pre-study dosing schedule.
All patients had safety monitoring studies performed
prior to each infusion, at the final clinical visit and 3 months
after the last infusion. Blood samples were collected
before each infusion for determination of trough IgG
levels. Patients also had blood samples taken prior to several
infusions to test for anti-Streptococcus pneumoniae,anti-Hae-
mophilus influenzae type b and anti-tetanus toxoid antibody
concentrations.
Twenty patients (5 on the 3 week and 15 on the 4 week
dosing schedule) were enrolled in the pharmacokinetic (PK)
portion of the study. Tests for total IgG, IgG subclasses,
Streptococcus pneumoniae antibodies, Haemophilus influ-
enzae type b antibody and tetanus toxoid antibody were
performed for PK analysis.
When necessary, doses of Biotest IVIG were adjusted
during the study to maintain minimum trough IgG concen-
trations >500 mg/dL.
Evaluation of Safety
Patients were monitored for adverse events (AEs) and seri-
ous adverse events (SAEs) during infusion and between
infusions using home diaries. AEs were defined as a
treatment-emergent adverse events associated with the use
664 J Clin Immunol (2012) 32:663–669

of IVIG, whether or not the AE was determined to be
product related. The patients recorded all AEs, complaints
or problems including start and stop dates, start and stop
times and severity in their diaries.
AEs occurring during and within 72 h of infusion regard-
less of causality were considered temporally associated ad-
verse events (TAAE). The primary safety endpoint was
defined as the proportion of infusions with ≥1 temporally
associated AEs including those that were determined to be
unrelated to the investigational product. The target for this
endpoint was an upper one-sided 95% confidence limit of
less than 0.40 [9].
Evaluation of Efficacy
The primary efficacy endpoint was demonstration that the
rate of acute serious bacterial infections (SBIs) was less than
1.0 per person-year during regular administration of inves-
tigational IVIG for 12 months. Diagnostic criteria for SBIs
were defined prospectively [9].
Secondary efficacy parameters included all infections of
any kind or severity, time to the first infection of any kind,
time to first SBI, days missed from school or work due to
infection, days on antibiotics, hospitalizations and days of
hospitalization due to infection.
Evaluation of Pharmacokinetics (PK)
PK assessments were performed at the 4
th
or 5
th
infusion of
study IVIG in order to wash out previous IVIG products. At
certain study sites, PK parameters were assessed at infusion
13 or infusion 17 for patients who did not participate in the
earlier PK study. Blood samples for PK assessment were
taken before the infusion and at the following times after the
infusion: 15 min, 1 h, 24 h, 3 days, 7 days, 14 days, 21 days
and 28 days (if applicable.) The samples were tested for
concentrations of total IgG, IgG subclasses and specific
antibodies against several S. pneumoniae capsular polysac-
charide serotypes, H. influenzae type b and tetanus toxoid.
The calculated pharmacokinetic parameters were Cmax, the
maximum serum concentration, Tmax, the time to reach the
maximum serum concentration, AUC 0-t, the area under the
concentration-time curve over 1 dosing interval, t
1/2
or the
elimination half-life, CL the total body clearance and Vz,
the volume of distribution.
Statistical Analysis
Descriptive summaries are provided where appropriate for
each of the primary and secondary endpoints. In general,
summaries are provided for the entire Safety, Intent to Treat
(ITT), Per Protocol (PP) or PK populations and by IVIG
infusion schedule (i.e., 3-week or 4-week dosing schedule).
Continuous, quantitative, variable summaries include the
number of patients (N), mean, standard deviation (SD),
median, and range (minimum and maximum). Categorical,
qualitative, variable summaries include the frequency and
percentage of patients who are in the particular category. In
general the denominator for percentage calculations was
based upon the number of patients by infusion schedule
(i.e., 3-week or 4-week-cycle) or overall, unless otherwise
specified.
All efficacy and safety analyses were performed using
SAS® Software version 8.2 or later. All pharmacokinetic
parameter calculations were performed using WinNonlin
Professional® version 5.2 or later but summary statistics
were supported by SAS® Software version 8.2 or later.
Results
Sixty-three patients were enrolled in this study, were treated
with Biotest-IVIG and were included in the population
evaluated for safety. Seventeen patients were infused with
investigational product every 3 weeks and 46 were infused
every 4 weeks. Of the 63 enrollees, 5 lost to follow-up when
a study site was discontinued. This resulted in 58 patients in
the ITT population. Seven patients with major protocol
violations were excluded from the ITT population resulting
in a per-protocol (PP) population of 51 patients. The ITT
and PP populations were analyzed for efficacy.
As shown in Table I, 98% of patients were Caucasian and
the most common immunodeficiency diagnosis was com-
mon variable immunodeficiency (CVID) (81% of patients).
The average age was 41.2 years (range 6–75). Eight patients
had a history of acute serious bacterial infection (SBI)
prior to entry into this study. The most common was bacte-
rial pneumonia in 7 patients.
Safety
During the study a total of 746 infusions of Biotest-
IVIG were administered to the 63 patients in the safety
population with a mean of 13 infusions per patient and a
range of 1 to 17 infusions. The mean dose per patient per
infusion was 500 mg/kg with a range of 254 to 1029 mg/kg.
Fifty-two patients were treated with study product for
12 months. More than 80% of patients were infused at a
rate≥3.0 mL/kg/h (300 mg/kg/h) and 49.6% were infused at
arate≥3.5 mL/kg/h (350 mg/kg/h).
A total of 937 AEs were recorded in the 63 patients in the
safety population (Table II). Of the 937 AEs, the most
frequent (>20%) were headache (50.8%), sinusitis (38.1%)
fatigue (28.6%), upper respiratory tract infection (25.4%),
cough (22.2%), pharyngolaryngeal pain and diarrhea (each
J Clin Immunol (2012) 32:663–669 665

20.6%), Six patients (9.5%) reported 339 (36.2%) of the 937
AEs.
Fifty-nine patients (93.7%) reported at least one adverse
event. Of these, 40 patients (63.5%) were judged to have
experienced an AE that was related to study product. Mild
AEs occurred in 11 (17.5%) patients, moderate AEs oc-
curred in 21 (33.3%) patients and severe AEs were reported
in 8 (12.7%) patients. The most frequent severe, drug-
related AEs were headache (3 patients, 4.8%), migraine
and fatigue (2 patients, 3.2% each).
Eleven serious adverse events (SAEs) were reported in 7
(11.1%) patients. Two of the SAEs (vomiting, mild in severity
and dehydration, moderate in severity) leading to hospitaliza-
tion in 1 patient were considered as related to study product.
None of the SAEs resulted in a dose change, dose interruption
or discontinuation from the study and all the SAEs resolved.
There were no deaths.
There were 431 temporally associated AEs (TAAEs)
in 47 (74.6%) patients. Most TAAEs (335, 78%) oc-
curred during and within the first 24 h after infusion in
36 (57.1%) patients. The proportion of infusions with ≥1
temporally associated AEs, regardless of relationship to
study product, was 27.7% with an upper one-sided 95%
confidence limit of ≤30.6%. This is significantly below
the upper one-sided 95% confidence limit of 40% for
TAAEs recommended by FDA [9]. The most frequent
TAAE reported was headache (occurred with 115 infusions
in 27 patients) followed by fatigue (59 infusions in 15
patients) (Table III).
There was no clinically relevant effect of study treatment
on systolic blood pressure or diastolic blood pressure mea-
sured before or after study infusions. Although several
patients had AEs related to vital signs, no safety concerns
were identified by the investigators.
There were no hematology or clinical chemistry abnor-
malities determined by an investigator to be clinically rele-
vant. None of the patients exhibited signs of hemolysis at
any time during the study as demonstrated by stable values
of hematocrit, hemoglobin and LDH.
Tab l e I Demographics and baseline characteristics of the safety
population
Parameter Total (N063)
Gender
Female 32 (50.8%)
Male 31 (49.2%)
Age (yr)
Mean (SD) 41.2 (19.68)
Median 44.0
Minimum, Maximum 6, 75
Age group
6–11 Years 4 (6.3%)
12–17 Years 6 (9.5%)
18–64 Years 44 (69.8%)
65 Years and Older 9 (14.3%)
Race
Caucasian 62 (98.4%)
Asian 1 (1.6%)
Primary diagnosis
X-linked agammaglobulinemia 6 (9.5%)
Common variable immunodeficiency 51 (81.0%)
Other hypogammaglobulinemia 6 (9.5%)
SBI history 8 (12.7%)
Bacterial pneumonia 7 (11.1%)
Other 1 (1.6%)
Table II Summary of adverse events in the safety population (N063)
Metric Total (%)
Adverse events 937
Total number of infusions 746
Patients with ≥1AE 59 (93.7%)
Drug-related AEs 300 (32.0%)
Patients with ≥1 drug-related AE 40 (63.5%)
Infusions with ≥1 TAAE 209 (28.0%)
Infusions with ≥1 drug-related TAAE 152 (20.4%)
Patients with ≥1 SAE 7 (11.1%)
Number of SAEs 11
Patients with ≥1 drug-related SAE 1 (1.6%)
Patients with ≥1 AE leading to withdrawal 2 (3.2%)
Severity of drug-related AEs
Mild (No. of patients) 11 (17.5%)
Moderate (No. of patients) 21 (33.3%)
Severe (No. of patients) 8 (12.7%)
TAAE temporally associated adverse event, i.e. occurs within 72 h of an
infusion
SAE serious adverse event
Table III Temporally associated adverse events (TAAEs) in more
than 5% patients in the safety population (N063)
AE By Patient (n,%)
(47 patients)
By Infusion (n,%)
(431 infusions)
Headache 27 (42.9%) 115 (15.4%)
Fatigue 15 (23.8%) 59 (7.9%)
Infusion site reaction 5 (7.9%) 5 (0.7%)
Nausea 5 (7.9%) 8 (1.1%)
Blood Pressure increased 4 (6.3%) 5 (0.7%)
Diarrhea 4 (6.3%) 4 (0.5%)
Dizziness 4 (6.3%) 4 (0.5%)
Lethargy 4 (6.3%) 4 (0.5%)
666 J Clin Immunol (2012) 32:663–669

Tests for parvovirus B19, HIV, HCV and HBV were
performed at screening, prior to infusions 8 and 12 and at
the final safety follow-up visit. There was no evidence of
viral transmission by study product. There was a single
positive finding for parvovirus B19 during the study that
was attributed to exposure to a child with symptomatic
Fifth’s disease.
Efficacy
Two serious bacterial infections occurred during the
study. A 20 year old man treated every 4 weeks with
study IVIG developed pneumonia 16 days after his last
study infusion. He was hospitalized and the diagnosis of
pneumonia was confirmed by computed axial tomogra-
phy. The pneumonia resolved 5 days after diagnosis. A
48 year old woman treated every 4 weeks with study
IVIG was hospitalized for apparent acute exacerbation
of chronic obstructive bronchitis that was later classified
by the FDA as bacterial pneumonia. These two episodes
resulted in a serious bacterial infection rate of 0.035
SBI/patient/year with an upper 99% confidence limit
of ≤0.136 SBI/patient/year. This result is substantially
below the target SBI rate of ≤1.0 SBI/patient/year de-
fined by the FDA as an appropriate endpoint for PID
patients receiving regular doses of IVIG [9].
Infections of any kind or seriousness are listed in
Table IV. Since the incidence of infections was essentially
the same in the PP population as in the ITT population, the
most frequent infections (other than SBI) were reported
for the ITT population (Table V) and included acute
sinusitis, other respiratory tract infections, unclassified infec-
tions designated as “other,”otitis media, and bronchitis.
Table VI lists the secondary efficacy endpoints observed
in the ITT population. Means, standard deviations and rates
are summarized. Twenty-one patients (33.3%) missed work
or school because of infection at a rate of 2.28 days/patient/
year (Table VI). Thirty-eight patients (60.3%) were treated
with therapeutic antibiotics at a rate of 39.1 days of thera-
peutic antibiotics/patient/year. The rate of hospitalizations
was 0.21 days per patient per year.
Pharmacokinetics
The PK population was composed of 5 patients in the 3-week
infusion group and 16 in the 4-week group. PK parameters for
total IgG are shown in Table VII. Cmax and Tmax were
similar for the 2 treatment groups. The area under the
concentration-time curve AUC
0-t
was higher in 4-week
patients than 3-week patients because of the longer time
Table IV Infections of any kind or seriousness in the ITT and PP
populations
Parameter ITT (N058) PP (N051)
Total Infections 139 132
Mean ± SD per subject 2.4±2.7 2.6± 2.7
Infections per subject per
year (90% CI)
2.6 [2.3–2.7] 2.6 [2.2–3.0]
Table V Infections observed in the ITT population (N058)
Infections No. of Patients
(% of infections)
Acute sinusitis 36 (25.9%)
Other respiratory tract infection 30 (21.6%)
Other 23 (16.5%)
Otitis Media/ear infection 15 (10.8%)
Bronchitis 14 (10.1%)
Acute exacerbation of chronic sinusitis 7 (5.0%)
GI Infection 7 (5.0%)
Urinary tract infection 4 (2.9%)
Pneumonia 2 (1.4%)
Conjunctivitis 1 (0.7%)
Table VI Secondary efficacy endpoints in the ITT population
Parameter Total (N058)
Infections of any kind (total) 139
Mean ± SD 2.4 ±2.7
Min–Max 0–14
Patients with any infection (n) 40
Infection rate/patient/year 2.6
Days off work/school due to infection (n)
Mean ± SD 2.1 ±4.84
Min - Max 0–24
Patients with any days off work or school (n) 21
Days off work or school/patient/year 2.28
Days on antibiotics
Mean ± SD 76.4 ±118.3
Min - Max 0–372
Patients with any days on antibiotics (n) 46
Days of antibiotics/patient/year 82
Days on therapeutic antibiotics
Mean ± SD 36.2 ±52.7
Min - Max 0–306
Patients on therapeutic antibiotics (n) 38
Days of therapeutic antibiotics/patient/year 39.1
Days of hospitalization due to infection (n) 11
Patients hospitalized (n) 2
Hospitalization days/patient/year 0.21
SD standard deviation
J Clin Immunol (2012) 32:663–669 667

interval between infusions. The IgG half-life in 3-week sub-
jects was 19.6 days compared to 33.5 days in 4-week subjects;
however these differences were not significant.
Pharmacokinetic parameters of specific antibodies were
comparable to values for total IgG. Data from 28-day patients
are shown in Table VIII. Similar results were observed in the
five 21 day patients (data not shown). The antibody half-lives
are the same order of magnitude as total IgG with values
ranging from 25 to 84 days.
The doses administered in this study produced mean
trough IgG levels of 1076±254 mg/dL (range 606 to
1780 mg/dL) in 21-day patients and 943 ± 215 (range 487
to 2250 mg/dL) in 28-day patients. The 487 mg/dL value
was a single test result that was reported at the 6
th
infusion
in one patient; however, trough IgG levels above 500 mg/dL
were observed at all other infusions in this patient.
Discussion
Biotest-IVIG incorporates the best practices in IVIG manu-
facturing by combining Cohn-Oncley cold ethanol fraction-
ation, purification by ion-exchange chromatography, solvent-
detergent virus inactivation, virus removal by nanofiltration
and formulation at 10% protein [2–8].
The purpose of this clinical trial was to evaluate the safety,
efficacy, tolerability and pharmacokinetics of Biotest-IVIG in
patients with primary immunodeficiency. The study trial fol-
lowed the FDA guidelines published in 2008 that has lead to
the standardization of many safety, efficacy and pharmacoki-
netic endpoints [9].
The observed types, severity and frequency of AEs assessed
as medically related to Biotest-IVIG are commonly reported as
associated with infusions of any IVIG. Eighty percent of the
adverse events related to study IVIG were judged to be mild or
moderate. As reported in other IVIG clinical trials [10–15], the
most common adverse eventwas headache. A large proportion
of adverse events (339, 36.2%) occurred in a small number of
patients (6 patients, 9.5%). Although sporadic fluctuations in
blood pressure and pulse were noted throughout the study,
none were considered to be clinically significant. Analyses of
serum chemistries, urinalysis, and viral safety tests showed no
clinically significant or unexpected results for a population of
PID patients receiving IVIG.
The primary efficacy endpoint, 0.035 SBI/person/year,
compares favorably to SBI rates observed in studies of other
IVIGs in patients with primary immunodeficiency who re-
ceived IVIG doses that were similar to those administered in
this study [10–15].
Infections other than serious infections occurred at a rate
of 2.6 infections/patient/year. The most frequent infections
were acute sinusitis and other respiratory tract infections.
Among other efficacy parameters, the rate of days away
from work or school because of infection (2.28 days/patient/
year) was relatively low compared to literature reports.
[10–14]. Analysis of days on antibiotics revealed that inves-
tigators were more likely to treat patients on 21-day infusion
schedules with prophylactic antibiotics than patients treated
with IVIG every 28 days. This correlation between three
week IVIG dosing and prophylactic antibiotic treatment
may reflect difficulty in controlling infection in this patient
population.
All patients maintained average trough IgG concentra-
tions above the target level of >500 mg/kg with higher mean
trough levels observed in recipients of infusions every 21 days
Table VII IgG pharmacokinetic parameters
Parameter 3-week cycle (N05)
Mean ± SD)
4-week cycle (N016)
Mean ± SD)
C
max
(mg/dL) 2184± 293 2122 ± 425
T
max
median
(range) (h)
4.05 (2.67–26.1) 3.48 (2.6–78.6)
AUC 0-t
(h*mg/dL)
668,173± 118,198 852,213 ±155,334
T
1/2
(days)
(min-max)
19.6 (4.1) 33.5 (10.7)
(16.2–26.7) (18.3–51.6)
CL (mL/kg/day) 1.97± 0.22 1.41 ± 0.46
Vz (L/kg) 0.056± 0.014 0.064 ± 0.015
Table VIII Pharmacokinetic parameters of specific antibodies in patients infused every 4 weeks
Tetanus (N016)
(IU/mL)
H. influenzae b(N015)
(mg/L)
S. pneumoniae serotypes (μg/mL) (N016)
14 19A 23F
Elimination half-life (days) 83.76 (n014) 25.16
a
(n014) 40.77 (n015) 60.04 (n015) 29.98 (n014)
Cmax (units) 6.96 6.62 14.62 46.14 36.38
Tmax (days) 0.131 0.644 1.821 1.861 1.682
AUC
0-t
(units*days) 142.48 (n014) 96.09 (n014) 253.99 (n015) 1026.63 (n015) 563.89 (n015)
a
Outlying value of patient 6003 was excluded from calculation.
668 J Clin Immunol (2012) 32:663–669

compared to patients who received infusions every 28 days. In
general, concentration-time profiles were similar for IgG, IgG
subclasses and specific antibodies with initial increases on the
day of the infusion followed by slow return to baseline at
around 14 to 21 days (data not shown).
Half-life results for total IgG and specific antibodies
demonstrated significant interpatient variability. The IgG
half-life for all patients was approximately 30 days with a
37.5% coefficient of variation. Variation in half-life deter-
minations may reflect shortcomings associated with mea-
suring the decline in concentration of IgG [16]. If the rate of
elimination depends on serum concentration, it is possible
that half-lives are altered by different doses.
The differences in pharmacokinetic parameters resulted
from differences in individual dosing since doses were titrated
for each subject. AUC0-t is always larger for the 4-week
period compared to the 3-week period unless the dose is
reduced, otherwise the patient is receiving more IgG.
Differences in AUC0-t result in differences calculated for
CL and Vz. Total body clearance is dose divided by AUC0-t
so the difference in AUC0-t produced a difference in total
body clearance. Volume of distribution is CL divided by the
elimination rate constant. Individual doses were used for
calculation of CL. Therefore dose differences also contrib-
ute to CL and Vz variation.
Half-life variability may also result from differences in
each patient’s ability to synthesize endogenous IgG. If a
patient produces IgG, the serum concentration is increased
and the half-life appears to be prolonged [16].
Measurement of passively acquired antibodies to specific
organisms may provide more meaningful clinical informa-
tion about IgG metabolism than determination of IgG con-
centrations by immunochemical tests if the antibodies are
not consumed by an infection. Unfortunately antibody lev-
els are extremely low (micrograms or nanograms per mL)
compared to IgG (mg/mL) and it is often difficult to accurately
measure levels above baseline especially 2–4 weeks after
infusion. In this study, determination of the pharmacokinetic
parameters for several representative antibodies indicated that
antibody activities that are present in the starting plasma are
preserved during the manufacture of Biotest-IVIG.
Acknowledgements Financial support was provided by Biotest
Pharmaceuticals Corporation, Boca Raton, Florida. The authors wish
to thank the following persons from Biotest Pharmaceuticals Corpora-
tion for their support and successful completion of the study through
study management and review of the manuscript: Shailesh Chavan and
Debbie L. Mirjah. We also wish to thank the following persons from
Biotest AG, Dreieich, Germany for their support in review of the
manuscript: Andrea Wartenberg-Demand and Rainer Schmeidl. The
statistical support provided by Premier Research Group and Mathias
Broz (StatConsult, Magdeburg, Germany) and the technical support
provided by John Hooper (BioCatalyst Research LLC, Liberty, Missouri,
USA) is gratefully appreciated.
Open Access This article is distributed under the terms of the Crea-
tive Commons Attribution License which permits any use, distribution,
and reproduction in any medium, provided the original author(s) and
the source are credited.
References
1. Bruton OC. Agammaglobulinema. Pediatrics. 1952;9:722–7.
2. Cohn EJ, Strong LE, Hughes Jr WL, et al. Preparation and prop-
erties of serum and plasma proteins III: A system for the separation
into fractions of the protein and lipoprotein components of biolog-
ical tissues and fluids. J Am Chem Soc. 1946;68:459–75.
3. Melin JL, Oncley M, Richert DA, et al. The separation of the
antibodies, isoagglutinins, prothrombin, plasminogen and beta-
lipoprotein into subfractions of human plasma. J Am Chem Soc.
1949;71:541–50.
4. Wells MA, Wittek AE, Epstein JS, Marcus-Sekura C, Daniel S,
Tankersley DL, et al. Inactivation and partition of human T-cell
lymphotrophic virus, type III, during ethanol fractionation of plas-
ma. Transfusion. 1986;6:210–3.
5. Mitra G, Wong MF, Mozen MM, McDougal JS, Levy JA. Elimi-
nation of infectious retroviruses during preparation of immunoglo-
bulins. Transfusion. 1986;26:394–7.
6. Yei S, Yu MW, Tankersley DL. Partitioning of hepatitis C
virus during Cohn-Oncley fractionation of plasma. Transfusion.
1992;32:824–8.
7. Horowitz B, Wiebe ME, Lippin A, Stryker MH. Inactivation of
viruses in labile blood derivatives I: Disruption of lipid-enveloped
viruses by tri (n-butyl) phosphate detergent combinations. Transfu-
sion. 1985;25:516–22.
8. Omar A, Kempf C. Removal of neutralized model parvoviruses
and enteroviruses in human IgG solutions by nanofiltration. Trans-
fusion. 2002;42:1005–10.
9. FDA/CBER. Guidance for industry: Safety, efficacy, and pharma-
cokinetic studies to support marketing of immune globulin intra-
venous (Human) as replacement therapy for primary humoral
immunodeficiency, http://www.fda.gov.cber/gdlns/igivimmuno.
htm, June 2008.
10. Ochs HD, Pinciaro PJ, et al. Octagam® 5%, an Intravenous IgG
Product, is efficacious and well tolerated in patients with primary
immunodeficiency diseases. J Clin Immunol. 2004;24(3):309–14.
11. Berger M, Pinciaro PJ, et al. Safety, efficacy and pharmacokinetics
of flebogamma® 5% [Immune Globulin Intravenous (Human)] for
replacement therapy in primary immunodeficiency diseases. J Clin
Immunol. 2004;24(4):389–96.
12. Berger M, et al. A multicenter, prospective, open label, historically
controlled clinical trial to evaluate efficacy and safety in primary
immunodeficiency diseases (PID) patients of Flebogamma® 5% DIF,
the next generation of Flebogamma. J Clin Immunol. 2007;27:628–33.
13. Church JA, Leibl H, Stein MR, Melamed IR, Rubinstein A,
Schneider LC, et al. Efficacy, safety and tolerability of a new 10%
liquid intravenous immune globulin (IGIV 10%) in patients with
primary immunodeficiency. J Clin Immunol. 2006;26:388–95.
14. Stein MR, Nelson RP, Church JA, Wasserman RL, Church JA,
Wasserman RL, et al. Safety and efficacy of Privigen®, a novel 10%
liquid immunoglobulin preparation for intravenous use, in patients with
primary immunodeficiencies. J Clin Immunol. 2009;29:137–44.
15. Berger M, Pinciaro PJ, Althaus A, Ballow M, Chouksey A, Moy J,
et al. Efficacy, pharmacokinetics, safety, and tolerability of flebo-
gamma® 10% DIF, a high-purity human intravenous immunoglobu-
lin, in primary immunodeficiency. J Clin Immunol. 2010;30:321–9.
16. Schiff RI. Intravenous gammaglobulin: pharmacology, clinical
uses and mechanisms of action. Pediatr Allergy Immunol.
1994;5:63–87.
J Clin Immunol (2012) 32:663–669 669