114 Chapter 3 contamination59 (Figure 3.4). Overcoming shortages, therefore, require attention to these various systemic elements. 3.4 DISCUSSION This study sought to gain insights into the future demand of Ig in the Netherlands by using a scenario approach. This led to the identification of relevant groups of transformational factors that could increase, decrease, or impact (with yet unknown effect) the future demand of Ig for the Netherlands, with global implications as well. Although there is no Dutch centralized monitoring system, current demand lies within the specialties of neurology, immunology, and hematology similar to other countries.8,25,27,54 As the latter two are part of 11 sub-specialties within Internal Medicine, it is conceivable that Internal Medicine and neurology are the main consumers of Ig in the Dutch context. In a study amongst Dutch neurologists treating CIDP, substantial variation in diagnosis and treatment options were found, with authors stating there is potential in decreasing IVIG usage if there was clearer advice in the European Federation of Neurological Societies/Peripheral Nerve Society guidelines.76 Healthcare Institute Netherlands has a database that shows how Nanogam’s users have increased from 2016–2020 and it is the third most expensive drug to reimburse.24 Hence, at the beginning of this study in 2019, the then-upcoming Transfer Act in 2021 was perceived as a major political change to create transparency and oversight into Ig prescription to reduce demand from unnecessary indications90 but it was cancelled indefinitely due to COVID-19.91 What is applicable for both the Netherlands and high-income countries are the following transformational factors, subdivided into specific factors for immune deficiencies and immunomodulation. With regards to PIDs, there could be increased demand as experts highlighted that clinicians are growing in awareness of diagnosing PIDs and using Ig treatment which may lead to increased demand,92 particularly in diagnosing and treating adult patients.93 A study using latent therapeutic demand modelling showed that the potential demand for treating CVID or XLA (two of the most common PIDs using Ig) actually exceed current demand, meaning that more Ig could be used to treat these conditions.94,95 Conversely, gene-correcting therapies could counterbalance this demand, although it is currently suitable for certain monogenetic causes of disease and is not yet applicable for CVID or XLA.65 As SIDs occur as a consequence of disease or therapy,4 SID demand could continue increasing with the rise of immunosuppressive therapies, such as CAR-T cell,56,57 compounded with the effects of socio-demographic factors (increasing age, weight). The effect of
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