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Hewett K, Sanders DB, Grove RA, Broderick CL, Rudo TJ, Bassiri A, Zvartau-Hind M, Bril V. Randomized study of adjunctive belimumab in participants with generalized myasthenia gravis. Neurology 2018; 90:e1425-e1434. [PMID: 29661905 PMCID: PMC5902787 DOI: 10.1212/wnl.0000000000005323] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 01/17/2018] [Indexed: 01/28/2023] Open
Abstract
Objective To investigate the efficacy and safety of belimumab, a fully human immunoglobulin G1λ monoclonal antibody against B-lymphocyte stimulator, in participants with generalized myasthenia gravis (MG) who remained symptomatic despite standard of care (SoC) therapy. Methods Eligible participants with MG were randomized 1:1 to receive IV belimumab 10 mg/kg or placebo in this phase II, placebo-controlled, multicenter, double-blind study (NCT01480596; BEL115123). Participants received SoC therapies throughout the 24-week treatment phase and 12-week follow-up period. The primary efficacy endpoint was mean change from baseline in the Quantitative Myasthenia Gravis (QMG) scale at week 24; safety assessments included the frequency and severity of adverse events (AEs) and serious AEs. Results Forty participants were randomized (placebo n = 22; belimumab n = 18). The mean change in QMG score from baseline at week 24 was not significantly different for belimumab vs placebo (p = 0.256). There were no statistically significant differences between treatment groups for secondary endpoints, including the MG Composite and MG–Activity of Daily Living scores. Acetylcholine receptor antibody levels decreased over time in both treatment groups. No unexpected AEs were identified and occurrence was similar in the belimumab (78%) and placebo (91%) groups. One participant receiving placebo died (severe sepsis) during the treatment phase. Conclusions The primary endpoint was not met for belimumab in participants with generalized MG receiving SoC. There was no significant difference in mean change in the QMG score at week 24 for belimumab vs placebo. The safety profile of belimumab was consistent with previous systemic lupus erythematosus studies. Classification of evidence This study provides Class I evidence that for participants with generalized MG, belimumab did not significantly improve QMG score compared with placebo.
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Affiliation(s)
- Karen Hewett
- From GSK (K.H.), Stevenage, Herts, UK; Department of Neurology (D.B.S.), Duke University School of Medicine, Durham, NC; GSK (R.A.G.), Uxbridge, Middlesex, UK; GSK (C.L.B., T.J.R., A.B.), Philadelphia, PA; GSK (M.Z.-H.), Brentford, London, UK; and University Health Network (V.B.), University of Toronto, Canada
| | - Donald B Sanders
- From GSK (K.H.), Stevenage, Herts, UK; Department of Neurology (D.B.S.), Duke University School of Medicine, Durham, NC; GSK (R.A.G.), Uxbridge, Middlesex, UK; GSK (C.L.B., T.J.R., A.B.), Philadelphia, PA; GSK (M.Z.-H.), Brentford, London, UK; and University Health Network (V.B.), University of Toronto, Canada
| | - Richard A Grove
- From GSK (K.H.), Stevenage, Herts, UK; Department of Neurology (D.B.S.), Duke University School of Medicine, Durham, NC; GSK (R.A.G.), Uxbridge, Middlesex, UK; GSK (C.L.B., T.J.R., A.B.), Philadelphia, PA; GSK (M.Z.-H.), Brentford, London, UK; and University Health Network (V.B.), University of Toronto, Canada
| | - Christine L Broderick
- From GSK (K.H.), Stevenage, Herts, UK; Department of Neurology (D.B.S.), Duke University School of Medicine, Durham, NC; GSK (R.A.G.), Uxbridge, Middlesex, UK; GSK (C.L.B., T.J.R., A.B.), Philadelphia, PA; GSK (M.Z.-H.), Brentford, London, UK; and University Health Network (V.B.), University of Toronto, Canada
| | - Todd J Rudo
- From GSK (K.H.), Stevenage, Herts, UK; Department of Neurology (D.B.S.), Duke University School of Medicine, Durham, NC; GSK (R.A.G.), Uxbridge, Middlesex, UK; GSK (C.L.B., T.J.R., A.B.), Philadelphia, PA; GSK (M.Z.-H.), Brentford, London, UK; and University Health Network (V.B.), University of Toronto, Canada
| | - Ashlyn Bassiri
- From GSK (K.H.), Stevenage, Herts, UK; Department of Neurology (D.B.S.), Duke University School of Medicine, Durham, NC; GSK (R.A.G.), Uxbridge, Middlesex, UK; GSK (C.L.B., T.J.R., A.B.), Philadelphia, PA; GSK (M.Z.-H.), Brentford, London, UK; and University Health Network (V.B.), University of Toronto, Canada
| | - Marina Zvartau-Hind
- From GSK (K.H.), Stevenage, Herts, UK; Department of Neurology (D.B.S.), Duke University School of Medicine, Durham, NC; GSK (R.A.G.), Uxbridge, Middlesex, UK; GSK (C.L.B., T.J.R., A.B.), Philadelphia, PA; GSK (M.Z.-H.), Brentford, London, UK; and University Health Network (V.B.), University of Toronto, Canada
| | - Vera Bril
- From GSK (K.H.), Stevenage, Herts, UK; Department of Neurology (D.B.S.), Duke University School of Medicine, Durham, NC; GSK (R.A.G.), Uxbridge, Middlesex, UK; GSK (C.L.B., T.J.R., A.B.), Philadelphia, PA; GSK (M.Z.-H.), Brentford, London, UK; and University Health Network (V.B.), University of Toronto, Canada.
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Marino M, Bartoccioni E, Alboini PE, Evoli A. Rituximab in myasthenia gravis: a “to be or not to be” inhibitor of T cell function. Ann N Y Acad Sci 2018; 1413:41-48. [DOI: 10.1111/nyas.13562] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/26/2017] [Accepted: 10/30/2017] [Indexed: 12/24/2022]
Affiliation(s)
- Mariapaola Marino
- Istituto di Patologia Generale; Università Cattolica del Sacro Cuore; Rome Italy
| | - Emanuela Bartoccioni
- Istituto di Patologia Generale; Università Cattolica del Sacro Cuore; Rome Italy
| | | | - Amelia Evoli
- Istituto di Neurologia; Università Cattolica del Sacro Cuore; Rome Italy
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Evoli A, Alboini PE, Damato V, Iorio R, Provenzano C, Bartoccioni E, Marino M. Myasthenia gravis with antibodies to MuSK: an update. Ann N Y Acad Sci 2017; 1412:82-89. [PMID: 29266255 DOI: 10.1111/nyas.13518] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 09/06/2017] [Accepted: 09/12/2017] [Indexed: 02/06/2023]
Abstract
Myasthenia gravis with antibodies to the muscle-specific tyrosine kinase (MuSK+ MG) is a rare disease with distinctive pathogenic mechanisms and clinical features. An acute onset and predominant bulbar muscle weakness are very common and highly suggestive of the disease. On the other hand, a more indolent course, atypical ocular presentation, and signs of cholinergic hyperactivity may complicate the diagnosis. Though MuSK+ MG is still a severe disease, over the years we have observed a steady reduction in the rate of respiratory crisis and a significant improvement in the clinical outcome, both likely related to earlier diagnosis and timely treatment. Despite the improved management, MuSK+ MG patients tend to remain dependent on long-term immunosuppressive treatment and may develop permanent disabling weakness. In uncontrolled studies, B cell depletion with rituximab proved effective in most patients with refractory disease, inducing prolonged clinical responses associated with a sustained reduction of serum antibody levels. Promising results from experimental studies and case reports suggest that both 3,4-diaminopyridine and albuterol may be effective as symptomatic agents.
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Affiliation(s)
- Amelia Evoli
- Institute of Neurology, Catholic University, Fondazione Policlinico Gemelli, Rome, Italy
| | - Paolo E Alboini
- Institute of Neurology, Catholic University, Fondazione Policlinico Gemelli, Rome, Italy
| | - Valentina Damato
- Institute of Neurology, Catholic University, Fondazione Policlinico Gemelli, Rome, Italy
| | - Raffaele Iorio
- Institute of Neurology, Catholic University, Fondazione Policlinico Gemelli, Rome, Italy
| | - Carlo Provenzano
- Institute of General Pathology, Catholic University, Fondazione Policlinico Gemelli, Rome, Italy
| | - Emanuela Bartoccioni
- Institute of General Pathology, Catholic University, Fondazione Policlinico Gemelli, Rome, Italy
| | - Mariapaola Marino
- Institute of General Pathology, Catholic University, Fondazione Policlinico Gemelli, Rome, Italy
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Analysis of peripheral B cells and autoantibodies against the anti-nicotinic acetylcholine receptor derived from patients with myasthenia gravis using single-cell manipulation tools. PLoS One 2017; 12:e0185976. [PMID: 29040265 PMCID: PMC5645109 DOI: 10.1371/journal.pone.0185976] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 09/23/2017] [Indexed: 11/23/2022] Open
Abstract
The majority of patients with myasthenia gravis (MG), an organ-specific autoimmune disease, harbor autoantibodies that attack the nicotinic acetylcholine receptor (nAChR-Abs) at the neuromuscular junction of skeletal muscles, resulting in muscle weakness. Single cell manipulation technologies coupled with genetic engineering are very powerful tools to examine T cell and B cell repertoires and the dynamics of adaptive immunity. These tools have been utilized to develop mAbs in parallel with hybridomas, phage display technologies and B-cell immortalization. By applying a single cell technology and novel high-throughput cell-based binding assays, we identified peripheral B cells that produce pathogenic nAChR-Abs in patients with MG. Although anti-nAChR antibodies produced by individual peripheral B cells generally exhibited low binding affinity for the α-subunit of the nAChR and great sequence diversity, a small fraction of these antibodies bound with high affinity to native-structured nAChRs on cell surfaces. B12L, one such Ab isolated here, competed with a rat Ab (mAb35) for binding to the human nAChR and thus considered to recognize the main immunogenic region (MIR). By evaluating the Ab in in vitro cell-based assays and an in vivo rat passive transfer model, B12L was found to act as a pathogenic Ab in rodents and presumably in humans.These findings suggest that B cells in peripheral blood may impact MG pathogenicity. Our methodology can be applied not only to validate pathogenic Abs as molecular target of MG treatment, but also to discover and analyze Ab production systems in other human diseases.
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Jing S, Song Y, Song J, Pang S, Quan C, Zhou L, Huang Y, Lu J, Xi J, Zhao C. Responsiveness to low-dose rituximab in refractory generalized myasthenia gravis. J Neuroimmunol 2017; 311:14-21. [DOI: 10.1016/j.jneuroim.2017.05.021] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 05/13/2017] [Accepted: 05/26/2017] [Indexed: 11/30/2022]
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Russell A, Yaraskavitch M, Fok D, Chhibber S, Street L, Korngut L. Obinutuzumab Plus Chlorambucil in a Patient with Severe Myasthenia Gravis and Chronic Lymphocytic Leukemia. J Neuromuscul Dis 2017; 4:251-257. [DOI: 10.3233/jnd-170211] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Angela Russell
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Megan Yaraskavitch
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Daniel Fok
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Sameer Chhibber
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Lesley Street
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lawrence Korngut
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
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Dalakas MC, Rakocevic G, Dambrosia JM, Alexopoulos H, McElroy B. A double-blind, placebo-controlled study of rituximab in patients with stiff person syndrome. Ann Neurol 2017; 82:271-277. [PMID: 28749549 DOI: 10.1002/ana.25002] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 07/18/2017] [Accepted: 07/21/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE In stiff person syndrome (SPS), an antibody-mediated impaired γ-aminobutyric acidergic (GABAergic) neurotransmission is believed to cause muscle stiffness and spasms. Most patients improve with GABA-enhancing drugs and intravenous immunoglobulin, but some respond poorly and remain disabled. The need for more effective therapy prompted a trial with the anti-CD20 monoclonal antibody rituximab. METHODS This was a placebo-controlled randomized trial of rituximab (2 biweekly infusions of 1g each). The primary outcome was a change in stiffness scores at 6 months. Secondary outcomes were changes in heightened-sensitivity and quality of life scores. Enrolling 24 patients was calculated to detect 50% change in stiffness scores. RESULTS Randomization was balanced for age, sex, disease duration, and glutamic acid decarboxylase autoantibody titers. No significant changes were noted at 6 months after treatment in all outcomes. Specifically, no differences were noted in the stiffness index, the primary outcome, or sensitivity scores, the secondary outcome, at 3 or 6 months. Quality of life scores improved significantly (p < 0.01) at 3 months in both groups, but not at 6 months, denoting an early placebo effect. Blinded self-assessment rating of the overall stiffness for individual patients revealed improvement in 4 patients in each group. At 6 months, improvement persisted in 1 patient in the placebo group versus 3 of 4 in the rituximab group, where these meaningful improvements were also captured by video recordings. INTERPRETATION This is the largest controlled trial conducted in SPS patients and demonstrates no statistically significant difference in the efficacy measures between rituximab and placebo. Rituximab's lack of efficacy could be due to a considerable placebo effect; insensitivity of scales to quantify stiffness, especially in the less severely affected patients; or drug effectiveness in only a small patient subset. Ann Neurol 2017;82:271-277.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA.,Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Goran Rakocevic
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA
| | - James M Dambrosia
- National Institute of Neurological Disorders and Stroke, Bethesda, MD (retired)
| | - Harry Alexopoulos
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Beverly McElroy
- National Institute of Neurological Disorders and Stroke, Bethesda, MD (retired)
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Gungor-Tuncer O, Yilmaz V, Toker A, Saruhan-Direskeneli G, Gulsen-Parman Y, Oflazer-Serdaroglu P, Deymeer F. Prompt Response to Prednisone Predicts Benign Course in MuSK-MG. Eur Neurol 2017; 78:137-142. [DOI: 10.1159/000479228] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 07/04/2017] [Indexed: 11/19/2022]
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Fukatsu M, Murakami T, Ohkawara H, Saito S, Ikeda K, Kadowaki S, Sasaki I, Segawa M, Soeda T, Hoshi A, Takahashi H, Shichishima-Nakamura A, Ogawa K, Sugiura Y, Ohto H, Takeishi Y, Ikezoe T, Ugawa Y. A possible role of low regulatory T cells in anti-acetylcholine receptor antibody positive myasthenia gravis after bone marrow transplantation. BMC Neurol 2017; 17:93. [PMID: 28506261 PMCID: PMC5433011 DOI: 10.1186/s12883-017-0881-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 05/09/2017] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Chronic graft-versus-host disease (GVHD) appears several months following allogenic hematopoietic stem cell transplantation (HSCT) and is clinically analogous to autoimmune disorder. Polymyositis is a common neuromuscular disorder in chronic GVHD, but myasthenia gravis (MG) is extremely rare. Hence, its pathophysiology and treatment have not been elucidated. CASE PRESENTATION A 63-year-old man with a history of chronic GVHD presented with ptosis, dropped head, and dyspnea on exertion, which had worsened over the previous several months. He showed progressive decrement of compound muscle action potential in the deltoid muscle evoked by 3-Hz repetitive nerve stimulation, a positive edrophonium test, and elevated levels of serum anti-acetylcholine receptor antibodies, which suggested a diagnosis of generalized MG. No thymoma was found. Flow cytometric analysis revealed a remarkable depletion of peripheral Tregs (CD4+CD25highFOXP3+ cells, 0.24% of the total lymphocytes). Administration of prednisolone and tacrolimus was insufficient to alleviate his symptoms; however, the use of rituximab successfully improved his condition. CONCLUSIONS Myasthenic symptoms appeared in the process of tapering prednisolone for the treatment of chronic GVHD, supporting the diagnosis of MG associated with chronic GVHD. The present case proposes a possibility that reduction of Tregs might contribute to the pathogenesis of MG underlying chronic GVHD. Immunotherapy with rituximab is beneficial for treatment of refractory MG and GVHD.
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Affiliation(s)
- Masahiko Fukatsu
- Department of Neurology, Fukushima Medical University, 1 Hikariga-oka, Fukushima, Fukushima, 960-1295, Japan
| | - Takenobu Murakami
- Department of Neurology, Fukushima Medical University, 1 Hikariga-oka, Fukushima, Fukushima, 960-1295, Japan.
| | - Hiroshi Ohkawara
- Department of Hematology, Fukushima Medical University, Fukushima, Japan
| | - Shunichi Saito
- Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University, Fukushima, Japan
| | - Kazuhiko Ikeda
- Department of Hematology, Fukushima Medical University, Fukushima, Japan.,Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University, Fukushima, Japan
| | - Suguru Kadowaki
- Department of Neurology, Fukushima Medical University, 1 Hikariga-oka, Fukushima, Fukushima, 960-1295, Japan
| | - Itaru Sasaki
- Department of Neurology, Fukushima Medical University, 1 Hikariga-oka, Fukushima, Fukushima, 960-1295, Japan
| | - Mari Segawa
- Department of Neurology, Fukushima Medical University, 1 Hikariga-oka, Fukushima, Fukushima, 960-1295, Japan
| | - Tomoko Soeda
- Department of Neurology, Fukushima Medical University, 1 Hikariga-oka, Fukushima, Fukushima, 960-1295, Japan
| | - Akihiko Hoshi
- Department of Neurology, Fukushima Medical University, 1 Hikariga-oka, Fukushima, Fukushima, 960-1295, Japan
| | - Hiroshi Takahashi
- Department of Hematology, Fukushima Medical University, Fukushima, Japan
| | | | - Kazuei Ogawa
- Department of Hematology, Fukushima Medical University, Fukushima, Japan
| | - Yoshihiro Sugiura
- Department of Neurology, Fukushima Medical University, 1 Hikariga-oka, Fukushima, Fukushima, 960-1295, Japan
| | - Hitoshi Ohto
- Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University, Fukushima, Japan
| | - Yasuchika Takeishi
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Takayuki Ikezoe
- Department of Hematology, Fukushima Medical University, Fukushima, Japan
| | - Yoshikazu Ugawa
- Department of Neurology, Fukushima Medical University, 1 Hikariga-oka, Fukushima, Fukushima, 960-1295, Japan.,Fukushima Global Medical Science Center, Advanced Clinical Research Center, Fukushima Medical University, Fukushima, Japan
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