Banerjee Rahul, Mohan Meera, Rejeski Kai, Puliafito Benjamin R, Cirstea Diana D, Kaur Gurbakhash, Midha Shonali, McCaughan Georgia J, Kumar Nikhil M, Mehra Nikita, Bagal Bhausaheb, Raje Noopur S
Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA.
Department of Medicine, Medical College of Wisconsin, Milwaukee, WI.
Blood Adv. 2025 Sep 23;9(18):4720-4726. doi: 10.1182/bloodadvances.2025016490.
Bispecific antibodies (bsAbs), such as teclistamab, elranatamab, linvoseltamab, and talquetamab, have impressive efficacy in multiple myeloma (MM) but come with substantial infectious risks that do not dissipate over time. Immunoglobulin replacement therapy (IgRT), which includes IV and subcutaneous (SC) immunoglobulins, may lower these risks. In this viewpoint, we contrast primary IgRT prophylaxis (initiation regardless of IgG levels) with preemptive IgRT treatment (initiation only once IgG levels fall below a certain threshold) in this setting. We make evidence-based arguments for primary prophylaxis as a safer and simpler approach than preemptive IgG-guided IgRT. We also discuss strategies to improve the cost-effectiveness of IV and SC immunoglobulins across the world. Given the overwhelmingly favorable benefit-risk profile of IgRT, coupled with the limitations inherent to IgG measurements in MM, withholding IgRT access based on arbitrary IgG thresholds is neither scientifically sound nor clinically appropriate for patients with MM who are receiving bsAb therapy.
双特异性抗体（bsAbs），如替雷利珠单抗、埃洛妥珠单抗、利妥昔单抗和talquetamab，在多发性骨髓瘤（MM）中具有显著疗效，但伴随着持续存在的重大感染风险。免疫球蛋白替代疗法（IgRT），包括静脉注射和皮下注射免疫球蛋白，可能会降低这些风险。在本文观点中，我们对比了在这种情况下原发性IgRT预防（无论IgG水平如何均开始治疗）与抢先性IgRT治疗（仅在IgG水平降至特定阈值以下时开始治疗）。我们提出基于证据的观点，认为原发性预防是一种比基于IgG水平指导的抢先性IgRT更安全、更简单的方法。我们还讨论了提高全球静脉注射和皮下注射免疫球蛋白成本效益的策略。鉴于IgRT的益处风险比极为有利，再加上MM中IgG测量固有的局限性，基于任意IgG阈值拒绝为接受bsAb治疗的MM患者提供IgRT既不符合科学依据，在临床上也不合适。
