Gamma Globulin to Prevent Infections?

Gamma globulin is the component of human blood which
contains antibodies -- certain proteins which are specially made
by the body to fight particular infections. A number of gamma
globulin preparations are available as prescription drugs; when
injected, the antibodies provide temporary protection against
certain infections, for up to several weeks. They provide a
passive immunity (unlike vaccines, which stimulate the body's own
immune system to produce antibodies and/or infection-fighting
cells).

Unfortunately, the more recently available intravenous gamma
globulin preparations are too expensive for widespread use
(except for infants and children with HIV, who probably have a
greater need for this protection than adults do). But
intramuscular gamma globulin, which has been available for
decades, costs very little; it is safe, FDA approved, and is
routinely used to protect against various infections. It has not
been formally tested for persons with HIV, and there might never
be such a trial. But the safety and cost "downside" of this
treatment -- a sterile preparation made from HIV-negative blood
-- is low enough that patients and physicians may want to try it,
despite the lack of formal trials.

This potential treatment was brought to our attention by
Joseph A. Hertell, M. D., an internist in private practice in
Atlanta, who was involved in developing intramuscular gamma
globulin in the 1950s. We asked several other physicians what
they thought about using this treatment for persons with HIV. Our
impression is that while few HIV physicians have used it, most do
not dismiss the possibility; they recognize that it does have a
scientific rationale. (There is more interest among physicians
in the much more expensive intravenous gamma globulin, but little
use of it for adults because of the cost. Physicians can often
get insurance reimbursement, however, by being very familiar with
the FDA-approved non-HIV indications for this treatment; patients
who are candidates can often be fit into one of those.) We
suspect that the low- cost intramuscular gamma globulin may be
underused, since there is no commercial incentive for any company
to promote it.

Dr. Hertell has had little problem getting insurance
companies to pay for the intramuscular gamma globulin -- which is
not surprising, since this treatment costs very little and might
prevent hospitalization or other expensive care. But
reimbursement is not critical, since the cost is so low that most
patients could pay it themselves if necessary.

Interview with Joseph Hertell, M. D.

JJ: How did you decide to try gamma globulin?

JH: "I was medical director of the American National Red
Cross in the early 1950s when we started fractionation of plasma
proteins. At that time we brought out gamma globulin,
fibrinogen, and the other proteins. My interest was in gamma
globulin. We first used it to prevent hepatitis.

"I'm a general internist; for a while, we in Atlanta
depended on the infectious disease physicians to treat HIV
patients. But with the rising number of cases it became
impossible for them to carry the load. So I became more involved
in taking care of AIDS patients as their counts began to drop. I
first tried gamma globulin because I did not see any hazard to
the patient; and on the positive side, it has a number of
antibodies, and might be of value in preventing infections in
immune-deficient persons.

"We started using gamma globulin over two years ago. I
usually began the treatment when patients' T-helper counts fell
below 400. We have followed 14 patients using gamma globulin;
only one of them has discontinued the treatment. Of the 14, three
started with T-helper counts under 100, two between 100 and 200,
three between 200 and 300, five between 300 and 400, and one with
over 400.

"This treatment does not seem to make much difference in the
drop of the T-helper cells. What has impressed me is that none
of these people has had any serious AIDS-related illnesses; in
fact some of them have been able to resume activities. One with
a count of 33 has gone back to work, and one with a count of 52
has taken a long vacation overseas. They're all active, and they
have not had the AIDS-related illnesses I see in other patients.

"We also start patients on vitamin B-12 injections after
they go below 100, because they might not absorb B-12 easily from
the gastrointestinal tract. This is based on studies in the very
elderly, who have a compromised immune system.

"Now I routinely start gamma globulin when patients go below
500 T-helper cells. We give 2 cc of gamma globulin weekly. That
seems to be working well. I have not gone to the IV gamma
globulin; that is very expensive. We do use it in pediatric HIV
cases, especially when they have AIDS-related problems. But for
adults it is expensive, and I see no reason for it, since the
intramuscular form is rapidly taken up in the blood.

"The gamma globulin we use (brand name Gammar) costs about
$30 for a multiple-dose vial. The patient buys it; most of the
insurance companies will pay for it. The patients bring the vial
to us, and we put their name on it. We don't have to charge them
for the drug, and we give them the injections once a week.

"What I notice is the lack of AIDS-related opportunistic
infections. We do use aggressive prophylaxis. We often start
Bactrim three times a week when the T-helper count goes below
500; when it drops below 200, we add fluconazole to avoid
cryptococcal meningitis, clarithromycin to avoid MAC, and
sometimes acyclovir. But the difference seems to be the gamma
globulin."

JJ: What dose do you use (for adults)?

JH: "We give 2 cc of Gammar every week.

"I am pleased with the results, and expect to use it
increasingly for patients with T-helper counts below 500. We
seem to be holding off infections in these patients, by using
other peoples' antibodies, from a pool of people. [Blood is
pooled from a number of people to make each batch of Gammar;
therefore, many different antibodies are likely to be present.]
By repeating the treatment weekly, I believe that we are giving
immunity to a host of perhaps minor infections, which would not
be good for persons with compromised immune systems. While this
treatment is not affecting the basic course of the illness, at
least these people are able to do activities, to work and take
vacations, that otherwise they might not be able to do because of
numerous minor infections. The number of patients treated so far
is small, but we have seen them in good health month after
month."