Miscellaneous therapy

Plasmapheresis has been used in patients with severe IgG-induced immune hemolytic anemia but has met with limited success, possibly because more than half of the IgG is extravascular and the plasma contains only small amounts of the specific antibody (most of the antibody being on the red blood cell surface). However, plasmapheresis has been effective in IgM-induced hemolytic anemia. This is only of short-term benefit, but has reduced the level of cold agglutinins by virtue of the fact that IgM is a high molecular weight molecule that remains predominantly within the intravascular space.

Other measures that have been used effectively are vincristine and vinblastine infusions, gamma globulin infusion and hormonal therapy. Gamma globulin infusion is effective in IgG-induced immune hemolytic anemia, probably by primarily inhibiting the clearance of the IgG-coated cells. In hormonal therapy the synthetic androgen danazol has been effective in several patients. Because of the limited side-effects (limited masculinizing effects, mild weight gain), danazol or a similar agent may become an attractive alternative to glucocorticoid therapy in some patients with IgG-induced immune hemolytic anemia. However, danazol does not appear effective in IgM-induced hemolytic anemia. The data suggest that one mechanism of danazol's effect is through modulation (inhibition) of macrophage Fc-y receptor expression. Hormonal influence of macrophage Fey receptor expression probably explains, at least in part, the increased clinical activity of IgG-induced immune hemolytic anemia during pregnancy. During pregnancy, blood estrogen levels increase to an extent where they enhance splenic macrophage Fey receptor expression and thereby accelerate the clearance of IgG-coated cells.

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