Burden of illness in chronic inflammatory demyelinating polyneuropathy: some facts and solutions
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LETTER TO THE EDITORS
Burden of illness in chronic inflammatory demyelinating polyneuropathy: some facts and solutions Yusuf A. Rajabally1,2 Received: 28 June 2020 / Accepted: 20 July 2020 © Springer-Verlag GmbH Germany, part of Springer Nature 2020
Dear Sirs, I read with great interest the paper by Querol et al. entitled “Systematic literature review of burden of illness in chronic inflammatory demyelinating polyneuropathy (CIDP)”, in the current edition of the journal [1]. Disease burden, as considered by the authors, includes the humanistic burden, but also that resulting from treatment side-effects and costs, which, in CIDP, are both necessarily mainly linked to intravenous immunoglobulins (IVIg) usage. It is first perplexing, in a declared systematic literature review, therefore, that Querol et al. should fail to include adequate reference to treatment side-effects. While those of steroids are enumerated, IVIg is stated as being more commonly used in high-income countries as having similar efficacy and “fewer side-effects”, without any further mention or discussion, except briefly, exclusively in the comparison with subcutaneous immunoglobulin administration. The huge burden on those, not so exceptional, unfortunate patients who experience thromboembolic complications from IVIg is, as a result, disregarded, although of considerable morbidity and mortality [2]. Side-effects to IVIg can be very serious with long-term irreversible outcomes [3], and exclusion of this major and well-established fact is unfortunate. The paragraph on supplementing IVIg with concomitant immunosuppression is also inaccurate in the setting of this systematic review. The only randomized-controlled trial (RCT) cited, the RMC Trial, was unambiguously negative about methotrexate as adjunct for IVIg or steroids [4]. However, the authors suggest the contrary, choosing to quote * Yusuf A. Rajabally [email protected] 1
Inflammatory Neuropathy Clinic, Department of Neurology, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, UK
Aston Medical School, Aston University, Birmingham, UK
2
the percentages in both arms of the trial, while omitting the insignificant statistical result. They concomitantly fail to consider the existing global literature on immunosuppressants in CIDP, which to date, considering RCTs, simply provides no evidence whatsoever for their use [5]. Their section on immunosuppressants, however, unfortunately leaves the reader with the impression of the contrary being quite possible, this based on the authors’ opinion rather than systematic review. Regarding plasma exchange, similarly, their views, with selected rather than exhaustive references, produce the statement that “fewer patients achieve a response… compared with IVIg”, an assertion which is equally unsubstantiated [6]. Last but not least, comes the economic burden of CIDP as described in this paper. Our study, which is the latest from the U.K., published in Journal of Neurology in February 2019 [7] was regrettably and inexplic
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