Augmentation therapy

Augmentation therapy is administered weekly by intravenous infusion

The specific therapy for the treatment of Alpha-1-related lung disease is augmentation therapy – also called replacement therapy. Augmentation therapy is the use of alpha-1 antitrypsin protein (AAT) from the blood plasma of healthy human donors to augment (increase) the alpha-1 levels circulating in the blood and lungs of Alphas diagnosed with emphysema. The therapy is administered by a weekly intravenous infusion and, until other therapies become available, is considered ongoing and lifelong.

While augmentation therapy is considered the only specific therapy for Alpha-1 lung disease, the treatment plan for lung-affected individuals with Alpha-1 should also include the appropriate use of antibiotics, an immunization program including viral hepatitis and influenza strains, reduction or elimination of environmental risk factors, appropriate inhaled medications, an exercise program, and oxygen, if needed.

What are the goals of therapy?

The basic goal of augmentation therapy is to increase the level of alpha-1 protein in the lungs. Alpha-1 antitrypsin protects the lungs from the destructive effects of neutrophil elastase, an enzyme released by our body’s white blood cells as they respond to inflammation or infection.

The ultimate goal is to slow or stop the progression of lung destruction by replacing the deficient protein. The therapy cannot restore lost lung function — nor is it considered a cure. There is also some evidence that augmentation therapy can reduce the frequency and severity of pulmonary exacerbations (flare-ups of lung disease) and it appears to be an effective treatment for the Alpha-1 related skin disease, Necrotizing Panniculitis.

Currently available therapy

There are four augmentation therapy products approved by the U.S. Food and Drug Administration (FDA) and available in the United States, and more potential therapies are on the horizon. The four approved products are Prolastin-C® from Grifols, Aralast NP™ from Baxter Healthcare, Zemaira® from CSL Behring and Glassia® from Kamada Ltd. A product named Trypsone® from Grifols is available in Spain. Prolastin has been marketed since 1988 and has an excellent safety record. Aralast NP and Zemaira were introduced to the marketplace in mid-2003 and Glassia was introduced in late 2010. Each was approved by demonstrating that they were comparable to Prolastin in their safety and in augmenting blood and lung alpha-1 levels.

Augmentation infusions are typically given by healthcare professionals in the home, at a physician’s office, outpatient infusion center or other medical facility.

Sometimes Alphas choose to self-infuse after receiving appropriate instruction from a healthcare professional and with the approval of their physician. Health insurance payment rules often dictate the place of infusion. A quick reference chart describing the available products is at the end of this article.

Who should receive augmentation therapy and when should they start?

Augmentation therapy should be given to individuals with documented emphysema and severe Alpha-1 (defined as individuals with two abnormal alpha-1 genes). There has been some controversy, however, about giving augmentation therapy to anyone whose lung disease is very mild or very severe.

In some research studies conducted since the introduction of augmentation therapy, the benefits identified were primarily seen in certain groups of people. In these studies, the most dramatic effects were seen in those people whose lung function fell in the mid-range of severity.

Some members of the healthcare community have used these results incorrectly, to suggest that only those with moderate lung disease should receive augmentation therapy. However, because augmentation therapy is considered preventive rather than curative – it puts the brakes on lung destruction rather than reversing it – it seems logical to begin therapy as soon as possible after Alpha-1 lung disease has been detected, especially if the lung disease is progressing in spite of eliminating risk factors such as smoking.

Since we do not know which individuals with Alpha-1 will get lung disease, and because the current methods for detection of early lung disease are poor, it could be argued that everyone with Alpha-1 should receive augmentation therapy to keep their lungs as healthy as possible. If augmentation therapy were perfectly safe, easy to administer, inexpensive, proven effective, and available in unlimited supply, all Alphas probably would be taking it.

Unfortunately, none of these conditions are true.

Things to consider before beginning augmentation therapy

Before beginning augmentation therapy, a patient should be tested for IgA deficiency, a hereditary condition that makes potentially severe allergic reactions to plasma products more likely.

AlphaNet recommends that immunization against both Hepatitis A and B be considered for all Alphas to reduce the risk of liver injury. Vaccination entails a series of three injections, generally administered over six months. Augmentation therapy can be started independent of whether or when hepatitis vaccine will be given.

Are there any side effects from augmentation therapy?

Alphas receiving any of the available augmentation therapies have reported a variety of side effects, although the vast majority never have any significant problems. The most common side effect is a sense of feeling drained or having flu-like symptoms that typically lasts for up to 24 hours after an infusion. These symptoms can often be reduced or eliminated by slowing the rate of infusion. Some Alphas have symptoms that seem like mild allergic reactions: rash or hives, itching, tightness in the chest, dyspnea, and/or wheezing. Many of them can continue receiving augmentation therapy if they take an antihistamine, such as Benadryl, before their infusions. Rarely, side effects are severe enough to cause an Alpha to stop augmentation therapy entirely.

Augmentation therapy should be given to individuals with documented Alpha-1 and emphysema.

The FDA has approved a dose of 60 mg/kg of body weight administered once a week for each of the currently available augmentation products. Therefore, the recommended dose for someone weighing 165 lbs (or 75 kg) would be 4,500 mg per week.

Monitoring AAT levels not recommended

Some physicians feel they should monitor alpha-1 levels in the blood and then adjust the dose of augmentation to achieve some particular level they feel will protect the patient from lung damage. This approach is not recommended at the present time.

The potential fallacy of such an approach lies in the fact that the levels of alpha-1 found in the lungs following prolonged augmentation therapy tend to be much more stable and consistent than the levels found in the blood. Therefore, routine dose adjustments based on blood levels may not produce the desired effect within the lungs. The dosing recommendations approved by the FDA are based on this understanding of the need to achieve a consistent protective level of alpha-1 within the lungs.

No randomized-controlled trial has evaluated the efficacy of augmentation therapy, and no study has determined the optimum dose of augmentation therapy. Therefore, we suggest the recommended dose of 60 mg/kg of body weight weekly should be administered without blood level testing.

Alternative infusion schedules

Many individuals and their physicians have used alternative dosing regimens outside those recommended by the FDA. These include dosing every second week at 120 mg/kg, dosing every third week at 180 mg/kg, and monthly dosing at 250 mg/kg. While these regimens have been used for years, some evidence suggests that weekly dosing at 60 mg/kg is the most effective. Most Alpha-1 aware physicians limit the use of more extended dosing intervals to those with problems that make weekly dosing a hardship. Even in these individuals, if lung function decline seems to remain accelerated or if side effects become a problem, it is wise to consider switching to weekly dosing to determine if this helps.

It is interesting to note that Alphas on augmentation who have their phenotype retested will return a result of PiMZ if they were PiZZ prior to therapy. This is because phenotyping looks at the types of alpha-1 protein in the blood. Augmentation delivers normal PiMM protein to individuals who are PiZZ. Thus phenotype testing will reveal both the Alpha’s own alpha-1 phenotype, as well as the augmentation-delivered normal phenotype. Genotyping, rather than phenotyping, would be required to determine someone’s underlying alpha-1 genes while on augmentation therapy.

IV access for augmentation therapy

The overwhelming majority of Alphas receiving augmentation therapy choose to have a simple IV catheter or needle placed in the hand or arm at the time of each infusion. These catheters are well-tolerated; remain in place for a short time; and the complications are minimal. There are a variety of devices available, all designed to provide for ease of placement and patient comfort.

Some people have veins that are hard to see and hard to access. Devices implanted under the skin – most often a port – can make regular infusions more convenient. See “Veins or a Port” below.

This information is based on AlphaNet’s booklet, Augmentation Therapy, The Specific Therapy for Alpha-1 Lung Disease. The booklet is part of the Skinny Little Reference Guide series, extracted from AlphaNet’s Big Fat Reference Guide to Alpha-1. These resources are available on AlphaNet’s website, www.alphanet.org.  The Alpha-1 Foundation is grateful to AlphaNet for its generous help.

PROLASTIN-C® ARALAST NP™ ZEMAIRA® GLASSIA®
Entered market February 1988 May 2003 July 2003 October 2010
Marketed by Grifols Baxter Healthcare CSL Behring Baxter Healthcare
Recommended dose 60mg/kg IV weekly 60mg/kg IV weekly 60mg/kg IV weekly 60 mg/kg IV weekly
Storage Refrigerated 2-8° C/36–46° F or at temperatures not to exceed 25° C or 77° F. Do not freeze. At temperatures not to exceed 25° C or 77° F. Do not freeze. Up to 25°C or 77°F. Do not freeze. Refrigerated 2-8° C/36–46° F. Do not freeze. Or at room temperature not exceeding 25° C/77° F for up to one month.
Dilutant (sterile water) 20ml for 1000mg vial 25ml 500mg vial50ml 1,000mg vial 20ml 1,000mg vial None (comes as a liquid ready to use). Volume of product 50ml for 1000mg via
Infusion rate 0.08 ml/kg per min 0.2 ml/kg per min 0.08 ml/kg per min 0.2 ml/kg per min
Infusion time (approximate) 15 minutes 15 minutes 15 minutes 15 minutes
Contraindications Individuals with known selective IgA deficiency with antibodies against IgA Individuals with known selective IgA deficiency (< 15mg/dl) with antibodies against IgA Individuals with known selective IgA deficiency with antibodies against IgA Individuals with known selective IgA deficiency with antibodies against IgA
Common side effects Chills, malaise, headache, rash, hot flush, pruritis (itching) Headache, somnolence, chills, fever, vasodilation, pruritus, (itching) rash, abnormal vision, chest pain, increased cough, dyspnea Asthenia (weakness) injection site pain, dizziness, headache, paresthesia (abnormal skin sensations) and pruritis (itching) Headache, dizziness
Viral inactivation processes Solvent detergentNanofiltration Solvent detergentNanofiltration PasteurizationDual ultra-filtration Solvent detergentNanofiltration
Number for reporting adverse events 800-520-2807 888-675-2762 800-504-5434 866-GLASSIA

Your Veins or a Port?

What an Alpha Needs to Know

Some Alphas, often directed by their healthcare providers, choose a device placed under the skin for their infusions. These devices include the Implanted Vascular Access Device (IVAD), usually called a port, and various types of tunneled central catheters or Peripherally Inserted Central Catheters (PICC)

The decision to choose one method of IV access over another should be a well-researched and informed decision. Having such a device in place may make the infusion process easier, but it may pose some additional risk to you.

Be sure that you clearly understand the procedures involved in the insertion of each of these devices when making your decision. It is important to discuss the risks and benefits of any type of IV access thoroughly with your health care provider and then choose the IV device that makes the most sense for your particular situation.

The major points to consider

What to consider when choosing an implanted vascular access device (a port) or a central catheter:

  • What is the general condition of your veins? Are they visible on the back of the hands and forearms?
  • Are they accessible?
  • What is your infusion schedule?
  • Have you had difficulty with peripheral IV insertion?
  • Have you had good experience with IVs given by certain healthcare providers and bad experiences with others?
  • Have you been informed of the risks and benefits of the particular device and do the benefits outweigh the risks?
  • Do you understand the procedures for insertion?
  • Have you talked with others who have had an implanted device?
  • Do you plan to do your own infusions, or have a spouse or significant other do them for you?
  • Do you understand the special care and maintenance required of the device?

 

Port and central catheter infections

Infection of the port or central catheter can pose an important challenge for healthcare providers and Alphas receiving augmentation therapy — because the signs and symptoms of a port infection often mimic the signs and symptoms of a reaction to augmentation therapy.

An infection can be external, located at the site where the port or central catheter is implanted, under the skin in the “pouch,” or along the tunneled area of the catheter. An infection also can occur within the reservoir of a port, or along the walls of the central catheter in the vein. Bacteria can be inadvertently introduced into the device through lapses in sterile technique; inadequate skin preparation; or contaminated equipment. The device may attract bacteria from other infections in the body, which can flourish in the port or central catheter. If an infection is present, when the device is accessed and flushed, a shower of bacteria can be sent into the bloodstream.

Important signs of infection include:

  • Localized site redness, swelling, tenderness, drainage
  • Body aches
  • Weakness
  • Shaking, chills, and/or fever over 101° F
  • Abdominal pain
  • Nausea and vomiting
  • Increased difficulty breathing

Many people mistakenly assume these symptoms are caused by a reaction to their medication. Both situations have similar symptoms, and one can mimic the other. Though some patients do have side effects from their therapy, a patient with an indwelling port or a central catheter must first consider an infection, and this should be ruled out before assuming that a medication reaction has occurred.

What to do if you have symptoms after an infusion and you have a port or central catheter

If you have a port or other implanted device and you experience problems during or shortly after your infusion, report this immediately to your nurse and physician. Check your temperature, especially if you experience shaking or chills. Call your doctor promptly if you have a fever over 101°. If symptoms are severe, seek immediate medical attention.

Your physician will want you to have laboratory tests to check for the presence of an infection. The diagnosis of an infection is based on results from blood cultures, often drawn from a vein in your arm as well as from the port or other device.

If you are due for an infusion while undergoing a work-up for infection, you still may receive your infusion if approved by your physician. It is recommended, however, you DO NOT USE the port for the infusion. The infusion should be administered through an IV catheter placed in your hand or arm.

Watching for symptoms during this peripheral infusion will help to determine if a medication side effect is the source of the problems, or if the symptoms are related to the port or central catheter.

If an infection has been confirmed, depending on the severity or the bacteria involved, IV antibiotics may be required to treat the infection. In some instances, the device will need to be removed. If all blood cultures are negative, further monitoring is required, and investigation into a reaction to the medication should be pursued.

Prevention is the best intervention

The best intervention for a port or other central catheter infection is prevention. Preventing infection should be the priority of everyone who has a port or other central device, as well as a top priority for those healthcare providers who access these devices. Because these devices provide a direct connection from the outside environment into the large blood vessels of the body, excellent hand washing and the maintenance of sterile technique while performing all procedures is essential in the prevention of infection.

It’s a good idea to limit the number of people who handle the port or central line — and never allow anyone who is ill to handle the device. It is generally recommended that anyone caring for these devices wear a mask. A mask is provided in most central device access kits for just this purpose.

Augmentation Questions and Answers

The purpose of augmentation therapy

Q: What is the primary purpose of augmentation therapy? What results can people expect if they are taking augmentation therapy? Do these expectations change depending on the severity of the underlying lung disease?

A: Augmentation therapy is intended to augment (add to) the amount of alpha-1 antitrypsin protein (AAT) floating in the blood and bathing the tissues of the body in people with lung disease related to Alpha-1. Although some people report that they notice improvements in their health when on augmentation therapy, and there is some evidence for a decrease in the number of lung infections in individuals receiving augmentation therapy, the primary aim of this therapy is to reduce the rate of decline of lung function towards normal and, therefore, improve the long-term quality of life and even the lifespan of those with lung disease due to Alpha-1.

Everyone loses lung function during their adult life, whether they have Alpha-1 or not. Alphas with lung disease lose their lung function at a more rapid rate than normal. If augmentation therapy is effective, it will be expected to slow this increased rate of decline, regardless of the severity of the underlying lung disease.

How often should alpha-1 blood levels be checked?

Q: How often should the levels of alpha-1 protein in the blood be checked?
A: It usually is not necessary to have more than one alpha-1 protein level checked during an Alpha’s lifetime, just as it usually is not necessary to have an Alpha’s phenotype or genotype checked more than once in a lifetime. However, there are some exceptions. When the initial diagnosis is made, it is reasonable to recheck and confirm it, preferably at a reference laboratory with experience in testing for Alpha-1.

Some people with unusual phenotypes and evidence of lung disease may have their levels rechecked to evaluate whether their baseline level is low enough to cause concern. It is not recommended that levels be checked after augmentation therapy begins. It is also important to know that phenotype tests will be inaccurate in those receiving augmentation therapy. Physicians should not make changes from the recommended dosing of augmentation therapy based on blood levels of AAT.

Why Alpha docs test for IgA deficiency

Q: What is the deal about augmentation therapy and IgA deficiency?

A: IgA is one of the most common hereditary immune deficiencies. IgA deficiency, like Alpha-1, can be associated with lung and allergic symptoms. People with either of these conditions (IgA deficiency or Alpha-1) can lead normal, healthy lives without ever knowing they have one of these conditions.

Alphas who are about to start augmentation therapy should be tested for IgA deficiency, because giving repeated infusions of a plasma-derived product can lead to severe allergic reactions in people who are IgA-deficient. This is due to the small amount of IgA protein contained in each vial of augmentation therapy. Anyone with hereditary IgA deficiency has circulating antibodies to the IgA molecule and these antibodies can cause an allergic reaction when even small amounts of IgA protein are delivered intravenously.

Since augmentation therapy is only given to patients with lung disease due to Alpha-1, it is hard to know whether those with IgA deficiency have worse lung problems than those without. It is logical to assume they would. Both Alpha-1 and IgA deficiency, when they cause problems, can lead to recurrent lung infections and bronchiectasis, and there may well be some additive effects of having both.

Helpful Links

The American Thoracic Society and European Respiratory Society have established standards for testing and management of Alpha-1 Antitrypsin Deficiency. The American Journal of Respiratory and Critical Care Medicine published the standards in 2003.  View the ATS/ERS Standards Document

The Alpha-1 Association has a web page on Access and Reimbursement for augmentation therapy.

The Alpha-1 Foundation has published a press release in response to a review published by the Cochrane Library recommending against the use of Alpha-1 augmentation therapy.  Read the response