Usage judicieux des immunoglobulines chez les patients adultes atteints d’hypogammaglobulinémie secondaire à un cancer hématologique : une perspective canadienne
Résumé
L’hypogammaglobulinémie est identifiée par la détection de faibles taux d’immunoglobulines (Ig) sériques. L’hypogammaglobulinémie secondaire (HGS) est un état acquis dans lequel les taux d’Ig circulantes sont diminués en raison d’une suppression de la production d’anticorps ou d’une augmentation de la perte d’anticorps. Plus précisément, l’HGS fait le plus souvent référence à de faibles taux d’IgG totales circulantes. En revanche, l’hypogammaglobulinémie primaire (HGP) est due à une anomalie congénitale de l’immunité qui contribue à une production faible ou déficiente d’Ig et à des infections fréquentes et/ou graves.
Chez les patients atteints de cancers hématologiques, il est important d’évaluer les taux d’Ig (IgG, IgM, IgA) de base au moment du diagnostic. Il peut toutefois être difficile de déterminer si les faibles taux d’Ig sont attribuables à une HGP ou à une HGS, car des anomalies des anticorps ont été identifiées dans le contexte d’hémopathies malignes (notamment la leucémie lymphoïde chronique [LLC], le lymphome et le myélome multiple), même avant le début du traitement immunosuppresseur. La HGP doit être envisagée, en particulier chez les patients plus jeunes présentant une hémopathie maligne et ayant des antécédents d’infections.
Le traitement de plusieurs hémopathies malignes comprend une thérapie par anti-CD20 visant à réduire le nombre de lymphocytes B, mais aussi connue pour induire une HGS. Les progrès réalisés dans le traitement des lymphomes et du myélome incluent désormais les thérapies par des anticorps bispécifiques et par lymphocytes T à récepteurs antigéniques chimériques (CAR-T), qui ont révolutionné la prise en charge des patients atteints de maladies réfractaires aux traitements conventionnels. Le risque de développer une HGS est cependant important, avec des taux ≥ 70 % pour les traitements par anticorps bispécifiques et de 20 à 46 % pour les thérapies CAR-T. Ainsi, les patients atteints d’hémopathies malignes ont un taux élevé d’HGS attribuable à la fois à la maladie sous-jacente et au traitement associé.
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