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Sabre L, Punga T, Punga AR. Circulating miRNAs as Potential Biomarkers in Myasthenia Gravis: Tools for Personalized Medicine. Front Immunol 2020; 11:213. [PMID: 32194544 PMCID: PMC7065262 DOI: 10.3389/fimmu.2020.00213] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 01/27/2020] [Indexed: 12/11/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disease caused by antibodies which attack receptors at the neuromuscular junction. One of the main difficulties in predicting the clinical course of MG is the heterogeneity of the disease, where disease progression differs greatly depending on the subgroup that the patient is classified into. MG subgroups are classified according to: age of onset [early-onset MG (EOMG; onset ≤ 50 years) versus late-onset MG (LOMG; onset > 50 years]; the presence of a thymoma (thymoma-associated MG); antibody subtype [acetylcholine receptor antibody seropositive (AChR+) and muscle-specific tyrosine kinase antibody seropositive (MuSK+)]; as well as clinical subtypes (ocular versus generalized MG). The diagnostic tests for MG, such as antibody titers, neurophysiological tests, and objective clinical fatigue score, do not necessarily reflect disease progression. Hence, there is a great need for reliable objective biomarkers in MG to follow the disease course as well as the individualized response to therapy toward personalized medicine. In this regard, circulating microRNAs (miRNAs) have emerged as promising potential biomarkers due to their accessibility in body fluids and unique profiles in different diseases, including autoimmune disorders. Several studies on circulating miRNAs in MG subtypes have revealed specific miRNA profiles in patients’ sera. In generalized AChR+ EOMG, miR-150-5p and miR-21-5p are the most elevated miRNAs, with lower levels observed upon treatment with immunosuppression and thymectomy. In AChR+ generalized LOMG, the miR-150-5p, miR-21-5p, and miR-30e-5p levels are elevated and decrease in accordance with the clinical response after immunosuppression. In ocular MG, higher levels of miR-30e-5p discriminate patients who will later generalize from those remaining ocular. In contrast, in MuSK+ MG, the levels of the let-7 miRNA family members are elevated. Studies of circulating miRNA profiles in Lrp4 or agrin antibody-seropositive MG are still lacking. This review summarizes the present knowledge of circulating miRNAs in different subgroups of MG.
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Affiliation(s)
- Liis Sabre
- Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia.,Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Uppsala, Sweden
| | - Tanel Punga
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | - Anna Rostedt Punga
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Uppsala, Sweden
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242nd ENMC International Workshop: Diagnosis and management of juvenile myasthenia gravis Hoofddorp, the Netherlands, 1-3 March 2019. Neuromuscul Disord 2020; 30:254-264. [PMID: 32173249 DOI: 10.1016/j.nmd.2020.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 02/03/2020] [Indexed: 12/13/2022]
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Gable KL, Guptill JT. Antagonism of the Neonatal Fc Receptor as an Emerging Treatment for Myasthenia Gravis. Front Immunol 2020; 10:3052. [PMID: 31998320 PMCID: PMC6965493 DOI: 10.3389/fimmu.2019.03052] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/12/2019] [Indexed: 12/30/2022] Open
Abstract
Myasthenia gravis is an autoimmune disease in which immunoglobulin G (IgG) autoantibodies are formed against the nicotinic acetylcholine receptor (AChR) or other components of the neuromuscular junction. Though effective treatments are currently available, many commonly used therapies have important limitations and alternative therapeutic options are needed for patients. A novel treatment approach currently in clinical trials for myasthenia gravis targets the neonatal Fc receptor (FcRn). This receptor plays a central role in prolonging the half–life of IgG molecules. The primary function of FcRn is salvage of IgG and albumin from lysosomal degradation through the recycling and transcytosis of IgG within cells. Antagonism of this receptor causes IgG catabolism, resulting in reduced overall IgG and pathogenic autoantibody levels. This treatment approach is particularly intriguing as it does not result in widespread immune suppression, in contrast to many therapies in routine clinical use. Experience with plasma exchange and emerging phase 2 clinical trial data of FcRn antagonists provide proof of concept for IgG lowering in myasthenia gravis. Here we review the IgG lifecycle and the relevance of IgG lowering to myasthenia gravis treatment and summarize the available data on FcRn targeted therapeutics in clinical trials for myasthenia gravis.
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Affiliation(s)
- Karissa L Gable
- Department of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - Jeffrey T Guptill
- Department of Neurology, Duke University School of Medicine, Durham, NC, United States.,Duke Clinical Research Institute, Durham, NC, United States
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Rath J, Brunner I, Tomschik M, Zulehner G, Hilger E, Krenn M, Paul A, Cetin H, Zimprich F. Frequency and clinical features of treatment-refractory myasthenia gravis. J Neurol 2019; 267:1004-1011. [PMID: 31828474 PMCID: PMC7109164 DOI: 10.1007/s00415-019-09667-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 12/04/2019] [Indexed: 02/04/2023]
Abstract
Background To investigate the frequency and characterize the clinical features of treatment-refractory myasthenia gravis in an Austrian cohort. Methods Patient charts of 126 patients with generalized myasthenia gravis and onset between 2000 and 2016 were analyzed retrospectively. Patients were classified as treatment-refractory according to strict, predefined criteria. These mandated patients being at least moderately symptomatic (i.e., MGFA class III) or needing either maintenance immunoglobulins or plasma exchange therapy for at least 1 year in spite of two adequately dosed immunosuppressive drugs. Clinical features and outcome at last follow-up were compared to treatment-responsive patients. Results 14 out of 126 patients (11.1%) met these criteria of treatment-refractory myasthenia gravis. Treatment-refractory patients had more frequent clinical exacerbations and more often received rescue treatments or a further escalation of immunosuppressive therapies. They also remained more severely affected at last follow-up. An early onset of myasthenia gravis was associated with a higher risk for a refractory course. Conclusion A small subgroup of patients with generalized myasthenia gravis do not respond sufficiently to standard therapies. Refractory disease has considerable implications for both patients and health care providers and highlights an unmet need for new treatment options.
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Affiliation(s)
- Jakob Rath
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Ines Brunner
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Matthias Tomschik
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Gudrun Zulehner
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Eva Hilger
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Martin Krenn
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Anna Paul
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Hakan Cetin
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Fritz Zimprich
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
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Subramanian MP. Commentary: Thoughts on Thymectomy-When Myasthenia Is Made Worse. Semin Thorac Cardiovasc Surg 2019; 32:386-387. [PMID: 31783121 DOI: 10.1053/j.semtcvs.2019.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 11/15/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Melanie P Subramanian
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri.
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Shi S, Ji X, Wang Y, Liu B, Zhang H, Lu C. Acupuncture for patients with myasthenia gravis: A systematic review protocol. Medicine (Baltimore) 2019; 98:e17563. [PMID: 31626122 PMCID: PMC6824655 DOI: 10.1097/md.0000000000017563] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 09/19/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The objective of this systematic review protocol is to provide the methods for evaluating the effectiveness and safety of acupuncture on the treatment of myasthenia gravis (MG). METHODS AND ANALYSIS We will search randomized controlled trials (RCTs) on this subject in 8 electronic databases and they are Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PubMed, Chinese Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), the Wan-Fang Database, and Chinese Scientific Journal Database (VIP database). Other relevant literatures will be manually searched as a complement. Only RCTs related to acupuncture for MG will be included, without Language restrictions and limitation of publication types. The risk of bias and trial quality will be assessed by the Cochrane collaboration tool. The study inclusion, data extraction and quality assessment will be conducted independently by 2 reviewers. All data from the studies included will be analyzed by RevMan V.5.3 statistical software. RESULTS This study will provide a high-quality synthesis of RCTs on the efficacy and safety of acupuncture as an adjuvant therapy in the treatment of MG. CONCLUSION This systemic review will provide high quality evidence to evaluate acupuncture as adjuvant therapy in patients with MG. PROSPERO REGISTRATION NUMBER PROSPERO CRD42019133577.
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Affiliation(s)
| | - Xinyu Ji
- Institute of Basic Research in Clinical Medicine
| | - Yanping Wang
- Institute of Basic Research in Clinical Medicine
| | - Bin Liu
- Institute of Basic Research in Clinical Medicine
| | - Huamin Zhang
- Institute of Information on Traditional Chinese Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Cheng Lu
- Institute of Basic Research in Clinical Medicine
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Barnett C, Herbelin L, Dimachkie MM, Barohn RJ. Measuring Clinical Treatment Response in Myasthenia Gravis. Neurol Clin 2019; 36:339-353. [PMID: 29655453 DOI: 10.1016/j.ncl.2018.01.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
In this article we provide an overview of health-related outcome measurement-to better understand what different outcomes used in myasthenia actually measure-and to provide some guidance when choosing measures based on the clinical context and question. In myasthenia, the most commonly used outcome measures are aimed at assessing the signs and symptoms. In this review, we provide a summary of the most commonly used outcome measures. We discuss instruments that gauge disease overall health impact, such as on disability and quality of life. Finally, we discuss other relevant outcomes such as steroid-sparing effects and the role of surrogate markers.
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Affiliation(s)
- Carolina Barnett
- Neurology (Medicine), University of Toronto, University Health Network, Toronto, Ontario, Canada.
| | - Laura Herbelin
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Mazen M Dimachkie
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Richard J Barohn
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
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Cavalcante P, Mizrachi T, Barzago C, Scandiffio L, Bortone F, Bonanno S, Frangiamore R, Mantegazza R, Bernasconi P, Brenner T, Vaknin-Dembinsky A, Antozzi C. MicroRNA signature associated with treatment response in myasthenia gravis: A further step towards precision medicine. Pharmacol Res 2019; 148:104388. [PMID: 31401213 DOI: 10.1016/j.phrs.2019.104388] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/26/2019] [Accepted: 08/02/2019] [Indexed: 01/01/2023]
Abstract
Myasthenia gravis (MG) is an autoimmune disorder affecting neuromuscular transmission currently treated with chronic immunosuppression. Inter-subject variation in treatment response and side effects highlight the need for personalized therapies by identification of biomarkers predictive of drug efficacy in individual patients, still lacking in MG. MicroRNAs (miRNAs) play a key role in immune response and drug metabolism modulation. This study, part of an Italian-Israeli collaborative project, aimed to identify specific miRNAs as biomarkers associated with immunosuppressive treatment response in MG patients. Whole miRNome sequencing, followed by miRNA validation by real-time PCR, was performed in peripheral blood from Italian MG patients (n = 40) classified as responder and non-responder to immunosuppressive therapies. MiRNA sequencing identified 41 miRNAs differentially expressed in non-responder compared to responder Italian MG patients. Validation phase pointed out three miRNAs, miR-323b-3p, -409-3p, and -485-3p, clustered on chromosome 14q32.31, the levels of which were significantly decreased in non-responder versus responder patients, whereas miR-181d-5p and -340-3p showed an opposite trend. ROC curve analysis showed sensitivity and specificity performance results indicative of miR-323b-3p, -409-3p, and -485-3p predictive value for responsiveness to immunosuppressive drugs in MG. Validated miRNAs were further analyzed in blood from responder and non-responder MG patients of the Israeli population (n = 33), confirming a role for miR-323b-3p, -409-3p, -485-3p, -181d-5p and -340-3p as biomarkers of drug efficacy. Gene Ontology enrichment analysis, mRNA target prediction, and in silico modeling for function of the identified miRNAs disclosed functional involvement of the five miRNAs, and their putative target genes, in both immune (i.e. neurotrophin TRK and Fc-epsilon receptor signaling pathways) and drug metabolism processes. Our overall findings thus revealed a blood "miR-323b-3p, -409-3p, -485-3p, -181d-5p, and -340-3p" signature associated with drug responsiveness in MG patients. Its identification sets the basis for precision medicine approaches based on "pharmacomiRs" as biomarkers of drug responsiveness in MG, promising to improve therapeutic success in a cost/effective manner.
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Affiliation(s)
- Paola Cavalcante
- Neurology IV - Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy.
| | - Tehila Mizrachi
- Laboratory of Neuroimmunology, Department of Neurology, The Agnes Ginges Center for Human Neurogenetics, Hadassah-Hebrew University Medical Center, PO Box 12000, Jerusalem, Israel.
| | - Claudia Barzago
- Neurology IV - Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy.
| | - Letizia Scandiffio
- Neurology IV - Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy.
| | - Federica Bortone
- Neurology IV - Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy.
| | - Silvia Bonanno
- Neurology IV - Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy.
| | - Rita Frangiamore
- Neurology IV - Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy.
| | - Renato Mantegazza
- Neurology IV - Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy.
| | - Pia Bernasconi
- Neurology IV - Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy.
| | - Talma Brenner
- Laboratory of Neuroimmunology, Department of Neurology, The Agnes Ginges Center for Human Neurogenetics, Hadassah-Hebrew University Medical Center, PO Box 12000, Jerusalem, Israel.
| | - Adi Vaknin-Dembinsky
- Laboratory of Neuroimmunology, Department of Neurology, The Agnes Ginges Center for Human Neurogenetics, Hadassah-Hebrew University Medical Center, PO Box 12000, Jerusalem, Israel.
| | - Carlo Antozzi
- Neurology IV - Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy.
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Blackmore D, Siddiqi Z, Li L, Wang N, Maksymowych W. Beyond the antibodies: serum metabolomic profiling of myasthenia gravis. Metabolomics 2019; 15:109. [PMID: 31372762 DOI: 10.1007/s11306-019-1571-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 07/23/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Myasthenia gravis (MG) is a chronic, potentially debilitating autoimmune disease characterized by weakness and rapid fatigue of the voluntary muscles that worsens on exertion. Left untreated, MG symptoms may cause significant morbidity or even death. To date, no robust biological marker is available to follow the course of the disease. Therefore, new diagnostic approaches and biological markers are essential not only for improved diagnosis of the disease but for improved outcomes. OBJECTIVES The present study applied a two-control, multi-label metabolomics profiling approach as a potential strategy for the identification of biomarkers unique to myasthenia gravis (MG). METHODS Metabolic analyses using acid- and dansyl-labelled serum from seropositive MG (n = 46), rheumatoid arthritis (RA) (n = 23) and healthy controls (HC) (n = 49) were performed on samples from adult patients presenting to the University of Alberta Hospital neuromuscular and rheumatology clinics. Comparisons between patients with MG vs. HC, and RA vs. HC were made using univariate and multivariate statistics. RESULTS Serum biomarker patterns were statistically significantly different between groups. Principal component analysis (PCA) and partial least squares discriminant analysis (PLS-DA) models exhibited considerable distinction between all groups. Metabolites were then filtered to remove peak pairs common to both disease cohorts. Combined metabolite panels revealed clear separation between MG and HC for both library-matched (AUROC: 0.92 ± 0.03) and highest AUC patients (AUROC: 0.94 ± 0.05). CONCLUSION In patients presenting to the clinic with seropositive MG, metabolomic profiling is capable of distinguishing patients with disease from those without. These results provide an important first step towards a potential biomarker for improving MG identification.
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Affiliation(s)
- Derrick Blackmore
- Division of Neurology, University of Alberta, 7th floor, Clinical Sciences Building, 11350 - 83 Ave NW, Edmonton, AB, T6G 2G, Canada.
| | - Zaeem Siddiqi
- Division of Neurology, University of Alberta, 7th floor, Clinical Sciences Building, 11350 - 83 Ave NW, Edmonton, AB, T6G 2G, Canada
| | - Liang Li
- Department of Chemistry, University of Alberta, Chemistry Centre Room W3-39C, Edmonton, AB, T6G 2G2, Canada
| | - Nan Wang
- Department of Chemistry, University of Alberta, Chemistry Centre Room W3-39C, Edmonton, AB, T6G 2G2, Canada
| | - Walter Maksymowych
- 568A Heritage Medical Research Centre, University of Alberta, Edmonton, AB, T6G 2S2, Canada
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Chen S, Xu MB, Zhou XL, Rong PQ, Jin TY, Zheng GQ. Chinese Herbal Medicine for Myasthenia Gravis: A Systematic Review and Meta-Analysis. Front Pharmacol 2018; 9:969. [PMID: 30214409 PMCID: PMC6125412 DOI: 10.3389/fphar.2018.00969] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 08/06/2018] [Indexed: 11/13/2022] Open
Abstract
Myasthenia gravis (MG) is an acquired autoimmune disease with the disorder of the neuromuscular junction transmission caused by autoantibodies. Currently, various Chinese herbal medicines (CHMs) are widely used for MG. This meta-analysis was conducted to assess the effectiveness and safety of CHMs for MG and its possible mechanisms. Fourteen studies with 1039 individuals were identified by searching seven databases from inception to March 2017. The methodological quality was assessed by using 7-item criteria from the Cochrane's Collaboration tool, and which assessed ≥4 "yes" in the domains were selected for detailed assessment and meta-analysis. All the data were analyzed using Rev-Man 5.3 software. Meta-analysis showed a significant effect of CHM as adjuvant therapy for improving the effectiveness compared with WCM alone or placebo in treating MG (p < 0.01). Moreover, there were fewer adverse effects and relapse rate in total when compared with the control group. The possible mechanisms of CHM for MG are associated with immunoregulation by reconstituting the functional ability of Tregs. In conclusion, despite the apparent positive results, the present evidence supports, to an extent, that CHM can be used for MG patients because of the methodological flaws and CHM heterogeneity. Further rigorous RCT for MG is needed.
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Affiliation(s)
- Shuang Chen
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Meng-Bei Xu
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiao-Li Zhou
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Pei-Qing Rong
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ting-Yu Jin
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Guo-Qing Zheng
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
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Circulating microRNA miR-21-5p, miR-150-5p and miR-30e-5p correlate with clinical status in late onset myasthenia gravis. J Neuroimmunol 2018; 321:164-170. [DOI: 10.1016/j.jneuroim.2018.05.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 05/03/2018] [Accepted: 05/04/2018] [Indexed: 12/16/2022]
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Wang S, Breskovska I, Gandhy S, Punga AR, Guptill JT, Kaminski HJ. Advances in autoimmune myasthenia gravis management. Expert Rev Neurother 2018; 18:573-588. [PMID: 29932785 PMCID: PMC6289049 DOI: 10.1080/14737175.2018.1491310] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Myasthenia gravis (MG) is an autoimmune neuromuscular disorder with no cure and conventional treatments limited by significant adverse effects and variable benefit. In the last decade, therapeutic development has expanded based on improved understanding of autoimmunity and financial incentives for drug development in rare disease. Clinical subtypes exist based on age, gender, thymic pathology, autoantibody profile, and other poorly defined factors, such as genetics, complicate development of specific therapies. Areas covered: Clinical presentation and pathology vary considerably among patients with some having weakness limited to the ocular muscles and others having profound generalized weakness leading to respiratory insufficiency. MG is an antibody-mediated disorder dependent on autoreactive B cells which require T-cell support. Treatments focus on elimination of circulating autoantibodies or inhibition of effector mechanisms by a broad spectrum of approaches from plasmapheresis to B-cell elimination to complement inhibition. Expert commentary: Standard therapies and those under development are disease modifying and not curative. As a rare disease, clinical trials are challenged in patient recruitment. The great interest in development of treatments specific for MG is welcome, but decisions will need to be made to focus on those that offer significant benefits to patients.
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Affiliation(s)
- Shuhui Wang
- Department of Neurology, George Washington University, Washington DC 20008
| | - Iva Breskovska
- Department of Neurology, George Washington University, Washington DC 20008
| | - Shreya Gandhy
- Department of Neurology, George Washington University, Washington DC 20008
| | - Anna Rostedt Punga
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Uppsala, Sweden
| | - Jeffery T. Guptill
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Henry J. Kaminski
- Department of Neurology, George Washington University, Washington DC 20008
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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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Molin CJ, Sabre L, Weis CA, Punga T, Punga AR. Thymectomy lowers the myasthenia gravis biomarker miR-150-5p. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2018; 5:e450. [PMID: 29511707 PMCID: PMC5833334 DOI: 10.1212/nxi.0000000000000450] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 01/30/2018] [Indexed: 12/31/2022]
Abstract
Objective The aim of the study was to analyze the effect of thymectomy on the proposed disease-specific microRNA (miRNA) biomarkers miR-150-5p and miR-21-5p in patients from the prospective randomized trial of thymectomy in myasthenia gravis (MGTX trial) and to evaluate the longitudinal changes in clinical patterns compared with these miRNA levels. Methods Serum samples were obtained from 80 patients with MG who were included in the MGTX trial. Thirty-eight patients were randomized to thymectomy plus prednisone treatment, and 42 patients were randomized to prednisone treatment. Serum samples were analyzed for the expression of miR-150-5p and miR-21-5p, with quantitative reverse transcriptase PCR at baseline and at 12, 24, and 36 months after randomization. The inclusion criteria for participation in the MGTX trial were age 18-65 years, generalized myasthenia gravis (Myasthenia Gravis Foundation of America Class II-IV), disease duration of less than 5 years, and seropositivity for acetylcholine receptor antibodies (AChR+). Results Patients treated with thymectomy had lower levels of miR-150-5p at 24 months, both compared with baseline values (p = 0.0011) and the prednisone group (p = 0.04). No change in miRNA levels was found in the prednisone group. Levels of miR-21-5p displayed a negative correlation with the prednisone dose within the prednisone-only group (p ≤ 0.001). Conclusions Thymectomy lowers the levels of the proposed biomarker miR-150-5p, which strengthens its position as a potential disease-specific biomarker for AChR+ MG.
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Affiliation(s)
- Carl Johan Molin
- Department of Neuroscience, Clinical Neurophysiology (C.J.M., L.S., A.R.P.), Uppsala University, Sweden; Institute of Pathology (C.-A.W.), University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany; and Department of Medical Biochemistry and Microbiology (T.P.), Uppsala University, Sweden
| | - Liis Sabre
- Department of Neuroscience, Clinical Neurophysiology (C.J.M., L.S., A.R.P.), Uppsala University, Sweden; Institute of Pathology (C.-A.W.), University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany; and Department of Medical Biochemistry and Microbiology (T.P.), Uppsala University, Sweden
| | - Cleo-Aron Weis
- Department of Neuroscience, Clinical Neurophysiology (C.J.M., L.S., A.R.P.), Uppsala University, Sweden; Institute of Pathology (C.-A.W.), University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany; and Department of Medical Biochemistry and Microbiology (T.P.), Uppsala University, Sweden
| | - Tanel Punga
- Department of Neuroscience, Clinical Neurophysiology (C.J.M., L.S., A.R.P.), Uppsala University, Sweden; Institute of Pathology (C.-A.W.), University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany; and Department of Medical Biochemistry and Microbiology (T.P.), Uppsala University, Sweden
| | - Anna Rostedt Punga
- Department of Neuroscience, Clinical Neurophysiology (C.J.M., L.S., A.R.P.), Uppsala University, Sweden; Institute of Pathology (C.-A.W.), University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany; and Department of Medical Biochemistry and Microbiology (T.P.), Uppsala University, Sweden
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Guptill JT, Raja S, Sanders DB, Narayanaswami P. Comparative effectiveness clinical trials to advance treatment of myasthenia gravis. Ann N Y Acad Sci 2018; 1413:69-75. [PMID: 29377158 DOI: 10.1111/nyas.13582] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 11/20/2017] [Accepted: 11/27/2017] [Indexed: 12/15/2022]
Abstract
Myasthenia gravis (MG) presents many challenges for establishing treatment efficacy through clinical trials. Among these are the rarity and heterogeneity of the disease, spontaneous fluctuations, prolonged latency to effect for many immunosuppressive drugs, and the uncertain generalizability of results from randomized controlled trials (RCTs). Prospective observational study designs may overcome some of these limitations, but attention is required to ensure that internal validity is not compromised. Observational comparative effectiveness research (CER) utilizes data obtained during routine clinical care to evaluate the effectiveness of interventions in real-life practice conditions, thereby improving generalizability to the clinic. Compared with RCTs, observational CER studies may be less resource intensive and costly. Recent advances that have improved the feasibility of CER studies for MG are (1) the development of MG common data elements, (2) the publication of international consensus guidance for MG treatment, and (3) the development of a web-based REDCap database that can be shared and adapted to standardize data collection. This infrastructure could be used for multisite comparisons of commonly used therapies and provides longitudinal information on patient- and clinician-centered MG outcome measures. A challenge is to design studies that address the potential limitations of observational trials, such as confounding and selection and information bias.
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Affiliation(s)
- Jeffrey T Guptill
- Department of Neurology, Duke University, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina
| | - Shruti Raja
- Department of Neurology, Duke University, Durham, North Carolina
| | - Donald B Sanders
- Department of Neurology, Duke University, Durham, North Carolina
| | - Pushpa Narayanaswami
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Liu C, Gui M, Cao Y, Lin J, Li Y, Ji S, Bu B. Tacrolimus Improves Symptoms of Children With Myasthenia Gravis Refractory to Prednisone. Pediatr Neurol 2017; 77:42-47. [PMID: 29074055 DOI: 10.1016/j.pediatrneurol.2017.08.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 08/07/2017] [Accepted: 08/23/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Myasthenia gravis tends to affect children in China. Oral pyridostigmine and prednisone could effectively improve the symptoms, but multiple side effects become a major concern after long-term oral prednisone. To avoid the long-term complications of prednisone therapy and to obtain more satisfactory improvement, we tested the efficacy and safety of tacrolimus in children with myasthenia gravis. METHODS Children with myasthenia gravis who had not achieved satisfactory improvement or who experienced severe side effects after prednisone therapy were recruited between January 2015 and December 2016 at Tongji Hospital. All the children were treated with tacrolimus 1 mg to 2 mg daily and the dose was adjusted on the basis of the clinical response and the serum concentration. The dosage of prednisone, the severity of symptoms, blood samples, the serum concentration of tacrolimus, and titers of antiacetylcholine receptor antibodies were evaluated every four weeks. RESULTS Fourteen children were enrolled. One child withdrew two weeks after the enrollment. Thirteen children have completed the therapy for one year. At the end point, the dosage of prednisone was significantly decreased (P < 0.05), the symptoms were evaluated by the quantitative myasthenia gravis score, and myasthenia gravis-specific manual muscle testing and myasthenia gravis-activities of daily living scores were significantly improved (P < 0.05, P < 0.05, and P < 0.01, respectively). More importantly, ten (76.9%) patients had completely discontinued prednisone, and the major side effects were nearly reversed. The mean titer of antiacetylcholine receptor antibodies significantly dropped from 1.96±2.62 nmol/L to 0.70±1.04 nmol/L (P < 0.05). No severe adverse events were reported. CONCLUSIONS Our results suggest that tacrolimus is a promising agent for children with refractory myasthenia gravis. Randomized clinical trials are needed to confirm the observation.
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Affiliation(s)
- Chanchan Liu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Mengcui Gui
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yayun Cao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jing Lin
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yue Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Suqiong Ji
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bitao Bu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Punga AR, Punga T. Circulating microRNAs as potential biomarkers in myasthenia gravis patients. Ann N Y Acad Sci 2017; 1412:33-40. [PMID: 29125182 DOI: 10.1111/nyas.13510] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 09/05/2017] [Accepted: 09/09/2017] [Indexed: 12/16/2022]
Abstract
MicroRNAs (miRNAs) are small noncoding RNA molecules that bind to specific mRNA targets and regulate a wide range of important biological processes within cells. Circulating miRNAs are released into the extracellular space and can be measured in most biofluids, including blood serum and plasma. Recently, circulating miRNAs have emerged as easily accessible markers in various body fluids with different profiles and quantities specific for different human disorders, including autoimmune diseases. In myasthenia gravis (MG), diagnostic tests such as titers of serum autoantibodies specific for either the acetylcholine receptor (AChR+ ) or muscle-specific tyrosine kinase (MuSK+ ) do not necessarily reflect disease progression, and there is a great need for reliable objective biomarkers to monitor the disease course and therapeutic response. Recent studies in AChR+ MG revealed elevated levels of the immuno-miRNAs miR-150-5p and miR-21-5p. Of particular importance, levels of miR-150-5p were lower in immunosuppressed patients and in patients with clinical improvement following thymectomy. In MuSK+ MG, another profile of circulating miRNAs was found, including upregulation of the let-7 family of miRNAs. Here, we summarize the potential role of circulating miRNAs as biomarkers in general and in MG, and highlight important considerations for the analysis of circulating miRNA.
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Affiliation(s)
- Anna Rostedt Punga
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Uppsala, Sweden
| | - Tanel Punga
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
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A novel ABCC6 haplotype is associated with azathioprine drug response in myasthenia gravis. Pharmacogenet Genomics 2017; 27:51-56. [PMID: 27922550 DOI: 10.1097/fpc.0000000000000257] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE We investigated the association of single nucleotide polymorphisms (SNPs) in drug-metabolizing enzymes and transporters (DMETs) with the response to azathioprine (AZA) in patients affected by myasthenia gravis (MG) to determine possible genotype-phenotype correlations. PATIENTS AND METHODS Genomic DNA from 180 AZA-treated MG patients was screened through the Affymetrix DMET platform, which characterizes 1931 SNPs in 225 genes. The significant SNPs, identified to be involved in AZA response, were subsequently validated by allelic discrimination and direct sequencing. SNP analysis was carried out using the SNPassoc R package and the haploblocks were determined using haploview software. RESULTS We studied 127 patients in the discovery phase and 53 patients in the validation phase. We showed that two SNPs (rs8058694 and rs8058696) found in ATP-binding cassette subfamily C member 6, a subfamily member of ATP-binding cassette genes, constituted a new haplotype associated with AZA response in MG patients in the discovery cohort (P=0.011; odds ratio: 0.40; 95% confidence interval: 0.20-0.83) and in the combined cohort (P=0.04; odds ratio: 1.58). CONCLUSION These findings highlight the role that the ATP-binding cassette subfamily C member 6 haplotype may play in AZA drug response. In view of the significant effects and AZA intolerance, these novel SNPs should be taken into consideration in pharmacogenetic profiling for AZA.
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Diagnostic Utility of Repetitive Nerve Stimulation in a Large Cohort of Patients With Myasthenia Gravis. J Clin Neurophysiol 2017; 34:400-407. [DOI: 10.1097/wnp.0000000000000398] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Hehir MK, Hobson-Webb LD, Benatar M, Barnett C, Silvestri NJ, Howard JF, Howard D, Visser A, Crum BA, Nowak R, Beekman R, Kumar A, Ruzhansky K, Chen IHA, Pulley MT, LaBoy SM, Fellman MA, Greene SM, Pasnoor M, Burns TM. Rituximab as treatment for anti-MuSK myasthenia gravis: Multicenter blinded prospective review. Neurology 2017; 89:1069-1077. [PMID: 28801338 DOI: 10.1212/wnl.0000000000004341] [Citation(s) in RCA: 154] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 05/22/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy of rituximab in treatment of anti-muscle-specific kinase (MuSK) myasthenia gravis (MG). METHODS This was a multicenter, blinded, prospective review, comparing anti-MuSK-positive patients with MG treated with rituximab to those not treated with rituximab. The primary clinical endpoint was the Myasthenia Gravis Status and Treatment Intensity (MGSTI), a novel outcome that combines the Myasthenia Gravis Foundation of America (MGFA) postintervention status (PIS) and the number and dosages of other immunosuppressant therapies used. A priori, an MGSTI of level ≤2 was used to define a favorable outcome. Secondary outcomes included modified MGFA PIS of minimal manifestations or better, mean/median prednisone dose, and mean/median doses of other immunosuppressant drugs. RESULTS Seventy-seven of 119 patients with anti-MuSK MG evaluated between January 1, 2005, and January 1, 2015, at 10 neuromuscular centers were selected for analysis after review of limited clinical data by a blinded expert panel. An additional 22 patients were excluded due to insufficient follow-up. Baseline characteristics were similar between the rituximab-treated patients (n = 24) and the controls (n = 31). Median follow-up duration was >3.5 years. At last visit, 58% (14/24) of rituximab-treated patients reached the primary outcome compared to 16% (5/31) of controls (p = 0.002). Number needed to treat for the primary outcome is 2.4. At last visit, 29% of rituximab-treated patients were taking prednisone (mean dose 4.5 mg/day) compared to 74% of controls (mean dose 13 mg/day) (p = 0.001 and p = 0.005). CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that for patients with anti-MuSK MG, rituximab increased the probability of a favorable outcome.
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Affiliation(s)
- Michael K Hehir
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville.
| | - Lisa D Hobson-Webb
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Michael Benatar
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Carolina Barnett
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Nicholas J Silvestri
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - James F Howard
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Diantha Howard
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Amy Visser
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Brian A Crum
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Richard Nowak
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Rachel Beekman
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Aditya Kumar
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Katherine Ruzhansky
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - I-Hweii Amy Chen
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Michael T Pulley
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Shannon M LaBoy
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Melissa A Fellman
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Shane M Greene
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Mamatha Pasnoor
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Ted M Burns
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
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Oliveira EF, Valério BCO, Cavalcante V, Urbano JJ, Silva AS, Polaro MN, Nacif SR, Oliveira CS, Resende MBD, Oliveira ASB, Oliveira LVF. Quantitative Myasthenia Gravis Score: a Brazilian multicenter study for translation, cultural adaptation and validation. ARQUIVOS DE NEURO-PSIQUIATRIA 2017; 75:457-463. [PMID: 28746433 DOI: 10.1590/0004-282x20170075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 03/30/2017] [Indexed: 11/22/2022]
Abstract
Objective To perform the translation, cross-cultural adaptation and validation of the Quantitative Myasthenia Gravis Score (QMGS) to Brazilian Portuguese in accordance with international ethical standards. Methods The following steps were taken: (1) implementation of the translation protocol and transcultural adaptation, (2) validation of the adapted content, and (3) assessment of reliability. To check intra- and inter-observer reproducibility, each patient underwent two interviews with interviewer-A and one with B. The QMGS was compared to the Myasthenia Gravis Composite Scale and Myasthenia-specific Quality of Life Questionnaire. Results Our study group consisted of 30 patients, with a mean age of 47.6±11.4 years and a mean duration of illness of 11.33±8.49 years. Correlation between the QMGS and MGC was very strong (r = 0.928; p < 0.001) and substantial between the QMGS and MG-QOL 15 (r = 0.737; p < 0.001). Conclusion The Brazilian Portuguese translation, and validation of the QMGS was successfully performed.
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Affiliation(s)
- Ezequiel Fernandes Oliveira
- Universidade Nove de Julho, Programa de Pós-Graduação Doutorado em Ciências da Reabilitação, São Paulo SP, Brasil
| | - Berenice Cataldo Oliveira Valério
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Clínica Médica, Disciplina de Neurologia, São Paulo SP, Brasil
| | - Valéria Cavalcante
- Universidade Federal de São Paulo, Departamento de Neurologia e Neurocirurgia, Divisão de Distúrbios Neuromusculares, São Paulo SP, Brasil
| | - Jessica Julioti Urbano
- Universidade Nove de Julho, Programa de Pós-Graduação Doutorado em Ciências da Reabilitação, São Paulo SP, Brasil
| | - Anderson Soares Silva
- Universidade Nove de Julho, Programa de Pós-Graduação Doutorado em Ciências da Reabilitação, São Paulo SP, Brasil
| | - Melissa Nunes Polaro
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Clínica Médica, Disciplina de Neurologia, São Paulo SP, Brasil
| | - Sergio Roberto Nacif
- Hospital Servidor Publico Estadual, Programa de Pós-Graduação Doutorado em Ciências da Saúde, São Paulo SP, Brasil
| | - Claudia Santos Oliveira
- Universidade Nove de Julho, Programa de Pós-Graduação Doutorado em Ciências da Reabilitação, São Paulo SP, Brasil
| | - Maria Bernadete Dutra Resende
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia Clínica, São Paulo SP, Brasil
| | - Acary Souza Bulle Oliveira
- Universidade Federal de São Paulo, Departamento de Neurologia e Neurocirurgia, Divisão de Distúrbios Neuromusculares, São Paulo SP, Brasil
| | - Luis Vicente Franco Oliveira
- Universidade Nove de Julho, Programa de Pós-Graduação Doutorado em Ciências da Reabilitação, São Paulo SP, Brasil
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73
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Zhou L, Liu W, Li W, Li H, Zhang X, Shang H, Zhang X, Bu B, Deng H, Fang Q, Li J, Zhang H, Song Z, Ou C, Yan C, Liu T, Zhou H, Bao J, Lu J, Shi H, Zhao C. Tacrolimus in the treatment of myasthenia gravis in patients with an inadequate response to glucocorticoid therapy: randomized, double-blind, placebo-controlled study conducted in China. Ther Adv Neurol Disord 2017; 10:315-325. [PMID: 28861121 PMCID: PMC5557184 DOI: 10.1177/1756285617721092] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 05/19/2017] [Indexed: 02/05/2023] Open
Abstract
Background To determine the efficacy of low-dose, immediate-release tacrolimus in patients with myasthenia gravis (MG) with inadequate response to glucocorticoid therapy in a randomized, double-blind, placebo-controlled study. Methods Eligible patients had inadequate response to glucocorticoids (GCs) after ⩾6 weeks of treatment with prednisone ⩾0.75 mg/kg/day or 60–100 mg/day. Patients were randomized to receive 3 mg tacrolimus or placebo daily (orally) for 24 weeks. Concomitant glucocorticoids and pyridostigmine were allowed. Patients continued GC therapy from weeks 1–4; from week 5, the dose was decreased at the discretion of the investigator. The primary efficacy outcome measure was a reduction, relative to baseline, in quantitative myasthenia gravis (QMG) score assessed using a generalized linear model; supportive analyses used alternative models. Results Of 138 patients screened, 83 [tacrolimus (n = 45); placebo (n = 38)] were enrolled and treated. The change in adjusted mean QMG score from baseline to week 24 was −4.9 for tacrolimus and −3.3 for placebo (least squares mean difference: –1.7, 95% confidence interval: −3.5, −0.1; p = 0.067). A post-hoc analysis demonstrated a statistically significant difference for QMG score reduction of ⩾4 points in the tacrolimus group (68.2%) versus the placebo group (44.7%; p = 0.044). Adverse event profiles were similar between treatment groups. Conclusions Tacrolimus 3 mg treatment for patients with MG and inadequate response to GCs did not demonstrate a statistically significant improvement in the primary endpoint versus placebo over 24 weeks; however, a post-hoc analysis demonstrated a statistically significant difference for QMG score reduction of ⩾4 points in the tacrolimus group versus the placebo group. This study was limited by the low number of patients, the absence of testing for acetylcholine receptor antibody and the absence of stratification by disease duration (which led to a disparity between the two groups). ClinicalTrials.gov identifier: NCT01325571
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Affiliation(s)
- Lei Zhou
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Weibin Liu
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wei Li
- Department of Neurology, Qilu Hospital of Shandong University, Shandong, China
| | - Haifeng Li
- Department of Neurology, Qilu Hospital of Shandong University, Shandong, China
| | - Xu Zhang
- Department of Neurology, The Affiliated Hospital of Medical College Qingdao University, Qingdao, China
| | - Huifang Shang
- Department of Neurology, West China Hospital, Sichuan University, Sichuan, China
| | - Xu Zhang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Zhejiang, China
| | - Bitao Bu
- Department of Neurology, Tongji Hospital, Tongji Medical College of Huazhong University of Science & Technology, Wuhan, China
| | - Hui Deng
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Qi Fang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Jiangsu, China
| | - Jimei Li
- Department of Neurology, Beijing Friendship Hospital Affiliated to Capital University of Medical Sciences, Beijing, China
| | - Hua Zhang
- Department of Neurology, Beijing Hospital, Beijing, China
| | - Zhi Song
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Changyi Ou
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chuanzhu Yan
- Department of Neurology, Qilu Hospital of Shandong University, Shandong, China
| | - Tao Liu
- Department of Neurology, The Affiliated Hospital of Medical College Qingdao University, Qingdao, China
| | - Hongyu Zhou
- Department of Neurology, West China Hospital, Sichuan University, Sichuan, China
| | - Jianhong Bao
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Zhejiang, China
| | - Jiahong Lu
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Huawei Shi
- Astellas Pharma China, Inc., Beijing, China
| | - Chongbo Zhao
- Department of Neurology, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Rd, Shanghai, 200040, China
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74
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Peritoneal recurrence of thymoma treated by surgery and hyperthermic intraperitoneal chemotherapy. Lung Cancer 2017; 111:59-60. [PMID: 28838398 DOI: 10.1016/j.lungcan.2017.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 06/14/2017] [Accepted: 06/18/2017] [Indexed: 11/23/2022]
Abstract
Thymomas are rare (1,5 cases/million) and typically occur in adults with a median age of 50 years old. Thymomas are indolent with a 10-year overall survival for resected stage II thymomas of 70%. Late relapses occur in 20% of the cases, and distant metastasis from thymoma is rare. Peritoneal recurrence of thymoma treated with surgery associated with hyperthermic intraperitoneal chemotherapy (HIPEC) has not been described in the literature. This report manages peritoneal recurrence of thymoma with HIPEC, suggesting that aggressive therapies may decrease the risk of recurrence.
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75
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Xie Y, Li HF, Sun L, Kusner LL, Wang S, Meng Y, Zhang X, Hong Y, Gao X, Li Y, Kaminski HJ. The Role of Osteopontin and Its Gene on Glucocorticoid Response in Myasthenia Gravis. Front Neurol 2017; 8:230. [PMID: 28620344 PMCID: PMC5450020 DOI: 10.3389/fneur.2017.00230] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 05/11/2017] [Indexed: 12/12/2022] Open
Abstract
Biomarkers that assess treatment response for patients with the autoimmune disorder, myasthenia gravis (MG), have not been evaluated to a significant extent. We hypothesized the pro-inflammatory cytokine, osteopontin (OPN), may be associated with variability of response to glucocorticoids (GCs) in patients with MG. A cohort of 250 MG patients treated with standardized protocol of GCs was recruited, and plasma OPN and polymorphisms of its gene, secreted phosphoprotein 1 (SPP1), were evaluated. Mean OPN levels were higher in patients compared to healthy controls. Carriers of rs11728697*T allele (allele definition: one of two or more alternative forms of a gene) were more frequent in the poorly GC responsive group compared to the GC responsive group indicating an association of rs11728697*T allele with GC non-responsiveness. One risk haplotype (AGTACT) was identified associated with GC non-responsiveness compared with GC responsive MG group. Genetic variations of SPP1 were found associated with the response to GC among MG patients.
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Affiliation(s)
- Yanchen Xie
- Department of Neurology, The George Washington University, Washington, DC, United States.,Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hai-Feng Li
- Department of Neurology, Qilu Hospital of Shandong University, Jinan, China
| | - Liang Sun
- The Key Laboratory of Geriatrics, Beijing Hospital, Beijing Institute of Geriatrics, Ministry of Health, Beijing, China
| | - Linda L Kusner
- Department of Pharmacology, The George Washington University, Washington, DC, United States.,Department of Physiology, The George Washington University, Washington, DC, United States
| | - Shuhui Wang
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yunxiao Meng
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Xu Zhang
- Department of Neurology, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yu Hong
- Department of Neurology, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xiang Gao
- Department of Neurology, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yao Li
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Henry J Kaminski
- Department of Neurology, The George Washington University, Washington, DC, United States.,Department of Pharmacology, The George Washington University, Washington, DC, United States.,Department of Physiology, The George Washington University, Washington, DC, United States
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76
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Raggi A, Leonardi M, Ayadi R, Antozzi C, Maggi L, Baggi F, Mantegazza R. Validation of the italian version of the 15‐item Myasthenia Gravis Quality‐of‐Life questionnaire. Muscle Nerve 2017; 56:716-720. [DOI: 10.1002/mus.25545] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2016] [Indexed: 01/22/2023]
Affiliation(s)
- Alberto Raggi
- Neurology, Public Health and Disability Unit, Neurological Institute C. Besta IRCCS FoundationVia Celoria 11, 20133Milan Italy
| | - Matilde Leonardi
- Neurology, Public Health and Disability Unit, Neurological Institute C. Besta IRCCS FoundationVia Celoria 11, 20133Milan Italy
| | - Roberta Ayadi
- Neurology, Public Health and Disability Unit, Neurological Institute C. Besta IRCCS FoundationVia Celoria 11, 20133Milan Italy
| | - Carlo Antozzi
- Department of Neuroimmunology and Neuromuscular DisordersNeurological Institute C. Besta IRCCS FoundationMilan Italy
| | - Lorenzo Maggi
- Department of Neuroimmunology and Neuromuscular DisordersNeurological Institute C. Besta IRCCS FoundationMilan Italy
| | - Fulvio Baggi
- Department of Neuroimmunology and Neuromuscular DisordersNeurological Institute C. Besta IRCCS FoundationMilan Italy
| | - Renato Mantegazza
- Department of Neuroimmunology and Neuromuscular DisordersNeurological Institute C. Besta IRCCS FoundationMilan Italy
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77
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Lipka AF, Vrinten C, van Zwet EW, Schimmel KJ, Cornel MC, Kuijpers MR, Hekster YA, Weinreich SS, Verschuuren JJ. Ephedrine treatment for autoimmune myasthenia gravis. Neuromuscul Disord 2017; 27:259-265. [DOI: 10.1016/j.nmd.2016.11.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 11/09/2016] [Accepted: 11/14/2016] [Indexed: 11/27/2022]
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Abstract
The development of validated assessment tools for evaluating disease status and response to interventions in patients with myasthenia gravis (MG) has been driven by clinical studies of emerging MG therapies. However, only a small proportion of MG-focused neurology practices have adopted these assessment tools for routine clinical use. This article reviews the suitability of 5 assessment instruments for incorporation into clinical practice, which should be driven by their ability to contribute to improved patient outcomes, and to be implemented within practice personnel and resource constraints. It is recommended that assessments based on both physician-evaluated and patient-reported outcomes be selected, to adequately evaluate both point-in-time symptom load and functional impact of MG symptoms over time. Provider resource allocation and reimbursement issues may be the most significant roadblocks to successful ongoing use of these tools; to that end, the addition of regular assessments to MG standards of care is recommended.
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Affiliation(s)
- Srikanth Muppidi
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA
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79
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Sanders DB, Massey JM. Does change in neuromuscular jitter predict or correlate with clinical change in MG? Muscle Nerve 2017; 56:45-50. [DOI: 10.1002/mus.25440] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 09/28/2016] [Accepted: 10/18/2016] [Indexed: 11/05/2022]
Affiliation(s)
- Donald B. Sanders
- Neuromuscular Section; Department of Neurology, Box 3403, Duke University Medical Center; Durham North Carolina 27710 USA
| | - Janice M. Massey
- Neuromuscular Section; Department of Neurology, Box 3403, Duke University Medical Center; Durham North Carolina 27710 USA
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80
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Verschuuren J, Strijbos E, Vincent A. Neuromuscular junction disorders. HANDBOOK OF CLINICAL NEUROLOGY 2017; 133:447-66. [PMID: 27112691 DOI: 10.1016/b978-0-444-63432-0.00024-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Diseases of the neuromuscular junction comprise a wide range of disorders. Antibodies, genetic mutations, specific drugs or toxins interfere with the number or function of one of the essential proteins that control signaling between the presynaptic nerve ending and the postsynaptic muscle membrane. Acquired autoimmune disorders of the neuromuscular junction are the most common and are described here. In myasthenia gravis, antibodies to acetylcholine receptors or to proteins involved in receptor clustering, particularly muscle-specific kinase, cause direct loss of acetylcholine receptors or interfere with the agrin-induced acetylcholine receptor clustering necessary for efficient neurotransmission. In the Lambert-Eaton myasthenic syndrome (LEMS), loss of the presynaptic voltage-gated calcium channels results in reduced release of the acetylcholine transmitter. The conditions are generally recognizable clinically and the diagnosis confirmed by serologic testing and electromyography. Screening for thymomas in myasthenia or small cell cancer in LEMS is important. Fortunately, a wide range of symptomatic treatments, immunosuppressive drugs, or other immunomodulating therapies is available. Future research is directed to understanding the pathogenesis, discovering new antigens, and trying to develop disease-specific treatments.
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Affiliation(s)
- Jan Verschuuren
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands.
| | - Ellen Strijbos
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
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81
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Oliveira EF, Lima VC, Perez EA, Polaro MN, Valério BCO, Pereiro JR, Nacif SR, Oliveira CS, Oliveira ASB, Oliveira LVF. Brazilian-Portuguese translation, cross-cultural adaptation and validation of the Myasthenia Gravis Composite scale. A multicentric study. ARQUIVOS DE NEURO-PSIQUIATRIA 2016; 74:914-920. [PMID: 27901257 DOI: 10.1590/0004-282x20160129] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 06/20/2016] [Indexed: 11/22/2022]
Abstract
Objective To perform the translation, cultural adaptation and validation of the Myasthenia Gravis Composite (MGC) scale in Brazil. Methods The study was conducted at three neuromuscular disease research centers in accordance with the international ethical standards, following a multi-modal approach and was conducted in three steps consisting of translation, cultural adaptation, and validation according to international guidelines. The final version of the MGC was applied in a sample of 27 MG patients and the total score was compared to a Portuguese version of the MG-QOL-15. Results The internal consistency verified by Cohen's Kappa test was excellent (0.766). The correlation between the MGC and MG-QOL-15 was strong (R = 0.777; p = 0.000). No significant differences were found between the responses of patients in the first and second applications of the MGC. Conclusion The MGC scale, validated into Brazilian Portuguese, has proven to be a reliable instrument that is easy to use, and is highly reproducible.
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Affiliation(s)
- Ezequiel Fernandes Oliveira
- Universidade Nove de Julho, Programa de Pós Graduação Mestrado e Doutorado em Ciências da Reabilitação, São Paulo SP, Brasil
| | - Valéria Cavalcante Lima
- Universidade Federal de São Paulo, Departamento de Neurologia e Neurocirurgia, Divisão de Doença Neuromuscular, São Paulo SP, Brasill
| | - Eduardo Araujo Perez
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Programa de Mestrado e Doutorado em Pesquisa em Cirurgia, São Paulo SP, Brasil
| | - Melissa Nunes Polaro
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Clínica Médica, Disciplina de Neurologia, São Paulo SP, Brasil
| | - Berenice Cataldo Oliveira Valério
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Clínica Médica, Disciplina de Neurologia, São Paulo SP, Brasil
| | - João R Pereiro
- Hospital do Servidor Público Estadual, Programa de Pós Graduação em Ciências da Saúde, São Paulo SP, Brasil
| | - Sergio Roberto Nacif
- Hospital do Servidor Público Estadual, Programa de Pós Graduação em Ciências da Saúde, São Paulo SP, Brasil
| | - Claudia Santos Oliveira
- Universidade Nove de Julho, Programa de Pós Graduação Mestrado e Doutorado em Ciências da Reabilitação, São Paulo SP, Brasil
| | - Acary Souza Bulle Oliveira
- Universidade Federal de São Paulo, Departamento de Neurologia e Neurocirurgia, Divisão de Doença Neuromuscular, São Paulo SP, Brasill
| | - Luis Vicente Franco Oliveira
- Universidade Nove de Julho, Programa de Pós Graduação Mestrado e Doutorado em Ciências da Reabilitação, São Paulo SP, Brasil
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De Meel RHP, Lipka AF, Van Der Lende M, Van Zwet EW, Tannemaat MR, Verschuuren JJGM. Activity limitations in myasthenia gravis and relation to clinical variables. Muscle Nerve 2016; 56:64-70. [PMID: 27859371 DOI: 10.1002/mus.25463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 11/03/2016] [Accepted: 11/07/2016] [Indexed: 11/09/2022]
Abstract
INTRODUCTION It is unknown how fluctuations in muscle weakness affect activity limitations in myasthenia gravis patients and how the severity of these limitations compares with published data on other neuromuscular disorders (NMD). METHODS In this study we analyzed ACTIVLIM (acronym of "ACTIVity LIMitations") and quantitative myasthenia gravis (QMG) scores. We assessed the impact of QMG and other clinical variables on ACTIVLIM, using B coefficients. RESULTS The mean ACTIVLIM score in 118 MG patients was 3.3. There was a correlation between QMG and ACTIVLIM (B coefficient = -0.206, P < 0.001) and between changes in both scores (B coefficient = -0.175, P = 0.002). Men and patients without another autoimmune disease had a better ACTIVLIM score (B coefficient = 0.785, P = 0.015 and B coefficient = 0.998, P = 0.008, respectively). CONCLUSIONS The ACTIVLIM score in MG is higher than in other NMD. Fluctuations in QMG correlated significantly with changes in ACTIVLIM. Muscle Nerve 56: 64-70, 2017.
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Affiliation(s)
- Robert H P De Meel
- Department of Neurology, Leiden University Medical Center, J3-166, P.O. Box 9600, 2300, RC Leiden, The Netherlands
| | - Alexander F Lipka
- Department of Neurology, Leiden University Medical Center, J3-166, P.O. Box 9600, 2300, RC Leiden, The Netherlands
| | - Marije Van Der Lende
- Department of Neurology, Leiden University Medical Center, J3-166, P.O. Box 9600, 2300, RC Leiden, The Netherlands
| | - Erik W Van Zwet
- Department of Biostatistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Martijn R Tannemaat
- Department of Neurology, Leiden University Medical Center, J3-166, P.O. Box 9600, 2300, RC Leiden, The Netherlands
| | - Jan J G M Verschuuren
- Department of Neurology, Leiden University Medical Center, J3-166, P.O. Box 9600, 2300, RC Leiden, The Netherlands
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Liik M, Punga AR. Repetitive nerve stimulation often fails to detect abnormal decrement in acute severe generalized Myasthenia Gravis. Clin Neurophysiol 2016; 127:3480-3484. [DOI: 10.1016/j.clinph.2016.09.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 09/07/2016] [Accepted: 09/08/2016] [Indexed: 11/30/2022]
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Mourão AM, Gomez RS, Barbosa LSM, da Silva Freitas D, Comini-Frota ER, Kummer A, Lemos SMA, Teixeira AL. Determinants of quality of life in Brazilian patients with myasthenia gravis. Clinics (Sao Paulo) 2016; 71:370-4. [PMID: 27464292 PMCID: PMC4946526 DOI: 10.6061/clinics/2016(07)03] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 04/07/2016] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES The aims of the current study were 1) to evaluate the reliability and validity of the Brazilian version of the 15-item Myasthenia Gravis Quality of Life Scale and 2) to investigate the quality of life of Brazilian patients with myasthenia gravis and its determinants. METHODS This cross-sectional study included 69 patients with myasthenia gravis who underwent neurological evaluation and completed questionnaires regarding quality of life (the 36-item Short Form of the Medical Outcomes Study and the 15-item Myasthenia Gravis Quality of Life Scale), anxiety and depressive symptoms. RESULTS The Brazilian version of the 15-item Myasthenia Gravis Quality of Life Scale showed high internal consistency and good concurrent validity with the 36-item Short Form of the Medical Outcomes Study and its subscales. Determinants of quality of life in Brazilian patients with myasthenia gravis included the current status of myasthenia gravis as assessed by the Myasthenia Gravis Composite, the current prednisone dose and the levels of anxiety and depression. CONCLUSION The Brazilian version of the 15-item Myasthenia Gravis Quality of Life Scale is a valid instrument. Symptom severity, prednisone dosage and anxiety and depression levels impact the quality of life of patients with myasthenia gravis.
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Affiliation(s)
- Aline Mansueto Mourão
- Universidade Federal de Minas Gerais (UFMG), Hospital Universitário, Unidade de Neurologia, Clinica Neuromuscular
- Laboratório Interdisciplinar de Investigação Médica, Belo Horizonte/MG, Brazil
| | - Rodrigo Santiago Gomez
- Universidade Federal de Minas Gerais (UFMG), Hospital Universitário, Unidade de Neurologia, Clinica Neuromuscular
| | - Luiz Sergio Mageste Barbosa
- Universidade Federal de Minas Gerais (UFMG), Hospital Universitário, Unidade de Neurologia, Clinica Neuromuscular
| | - Denise da Silva Freitas
- Universidade Federal de Minas Gerais (UFMG), Hospital Universitário, Unidade de Neurologia, Clinica Neuromuscular
| | | | - Arthur Kummer
- Laboratório Interdisciplinar de Investigação Médica, Belo Horizonte/MG, Brazil
| | | | - Antonio Lucio Teixeira
- Universidade Federal de Minas Gerais (UFMG), Hospital Universitário, Unidade de Neurologia, Clinica Neuromuscular
- Laboratório Interdisciplinar de Investigação Médica, Belo Horizonte/MG, Brazil
- E-mail:
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85
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Pasnoor M, He J, Herbelin L, Burns TM, Nations S, Bril V, Wang AK, Elsheikh BH, Kissel JT, Saperstein D, Shaibani JA, Jackson C, Swenson A, Howard JF, Goyal N, David W, Wicklund M, Pulley M, Becker M, Mozaffar T, Benatar M, Pazcuzzi R, Simpson E, Rosenfeld J, Dimachkie MM, Statland JM, Barohn RJ. A randomized controlled trial of methotrexate for patients with generalized myasthenia gravis. Neurology 2016; 87:57-64. [PMID: 27306628 DOI: 10.1212/wnl.0000000000002795] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 03/17/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the steroid-sparing effect of methotrexate (MTX) in patients with symptomatic generalized myasthenia gravis (MG). METHODS We performed a 12-month multicenter, randomized, double-blind, placebo-controlled trial of MTX 20 mg orally every week vs placebo in 50 acetylcholine receptor antibody-positive patients with MG between April 2009 and August 2014. The primary outcome measure was the prednisone area under the dose-time curve (AUDTC) from months 4 to 12. Secondary outcome measures included 12-month changes of the Quantitative Myasthenia Gravis Score, the Myasthenia Gravis Composite Score, Manual Muscle Testing, the Myasthenia Gravis Quality of Life, and the Myasthenia Gravis Activities of Daily Living. RESULTS Fifty-eight patients were screened and 50 enrolled. MTX did not reduce the month 4-12 prednisone AUDTC when compared to placebo (difference MTX - placebo: -488.0 mg, 95% confidence interval -2,443.4 to 1,467.3, p = 0.26); however, the average daily prednisone dose decreased in both groups. MTX did not improve secondary measures of MG compared to placebo over 12 months. Eight participants withdrew during the course of the study (1 MTX, 7 placebo). There were no serious MTX-related adverse events. The most common adverse event was nonspecific pain (19%). CONCLUSIONS We found no steroid-sparing benefit of MTX in MG over 12 months of treatment, despite being well-tolerated. This study demonstrates the challenges of conducting clinical trials in MG, including difficulties with recruitment, participants improving on prednisone alone, and the need for a better understanding of outcome measure variability for future clinical trials. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that for patients with generalized MG MTX does not significantly reduce the prednisone AUDTC over 12 months of therapy.
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Affiliation(s)
- Mamatha Pasnoor
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA.
| | - Jianghua He
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Laura Herbelin
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Ted M Burns
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Sharon Nations
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Vera Bril
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Annabel K Wang
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Bakri H Elsheikh
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - John T Kissel
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - David Saperstein
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - J Aziz Shaibani
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Carlayne Jackson
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Andrea Swenson
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - James F Howard
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Namita Goyal
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - William David
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Matthew Wicklund
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Michael Pulley
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Mara Becker
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Tahseen Mozaffar
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Michael Benatar
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Robert Pazcuzzi
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Ericka Simpson
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Jeffrey Rosenfeld
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Mazen M Dimachkie
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Jeffrey M Statland
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Richard J Barohn
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
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Benatar M, Mcdermott MP, Sanders DB, Wolfe GI, Barohn RJ, Nowak RJ, Hehir M, Juel V, Katzberg H, Tawil R. Efficacy of prednisone for the treatment of ocular myasthenia (EPITOME): A randomized, controlled trial. Muscle Nerve 2016; 53:363-9. [PMID: 26179124 PMCID: PMC6038933 DOI: 10.1002/mus.24769] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 07/07/2015] [Accepted: 07/08/2015] [Indexed: 11/12/2022]
Abstract
INTRODUCTION In this study we evaluated the safety, tolerability, and efficacy of prednisone in patients with ocular myasthenia gravis (OMG) concurrently treated with pyridostigmine. METHODS This investigation was a randomized, double-blind, placebo-controlled trial. Participants whose symptoms failed to remit on pyridostigmine were randomized to receive placebo or prednisone, initiated at 10 mg every other day, and titrated to a maximum of 40 mg/day over 16 weeks. The primary outcome measure was treatment failure. RESULTS Fewer subjects were randomized than the 88 planned. Of the 11 randomized, 9 completed 16 weeks of double-blind therapy. Treatment failure incidence was 100% (95% CI 48%-100%) in the placebo group (n = 5) vs. 17% (95% CI 0%-64%) in the prednisone group, P = 0.02 (n = 6). Median time to sustained minimal manifestation status (MMS) was 14 weeks, requiring an average prednisone dose of 15 mg/day. Adverse events were infrequent and generally mild in both groups. CONCLUSIONS A strategy of low-dose prednisone with gradual escalation appears to be safe, well-tolerated, and effective in treating OMG.
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Affiliation(s)
- Michael Benatar
- Department of Neurology, Miller School of Medicine, University of Miami, 1120 NW 14th Street, CRB 1318, Miami, Florida, 33136, USA
| | - Michael P Mcdermott
- Department of Neurology, Miller School of Medicine, University of Miami, 1120 NW 14th Street, CRB 1318, Miami, Florida, 33136, USA
| | - Donald B Sanders
- Department of Neurology, Miller School of Medicine, University of Miami, 1120 NW 14th Street, CRB 1318, Miami, Florida, 33136, USA
| | - Gil I Wolfe
- Department of Neurology, Miller School of Medicine, University of Miami, 1120 NW 14th Street, CRB 1318, Miami, Florida, 33136, USA
| | - Richard J Barohn
- Department of Neurology, Miller School of Medicine, University of Miami, 1120 NW 14th Street, CRB 1318, Miami, Florida, 33136, USA
| | - Richard J Nowak
- Department of Neurology, Miller School of Medicine, University of Miami, 1120 NW 14th Street, CRB 1318, Miami, Florida, 33136, USA
| | - Michael Hehir
- Department of Neurology, Miller School of Medicine, University of Miami, 1120 NW 14th Street, CRB 1318, Miami, Florida, 33136, USA
| | - Vern Juel
- Department of Neurology, Miller School of Medicine, University of Miami, 1120 NW 14th Street, CRB 1318, Miami, Florida, 33136, USA
| | - Hans Katzberg
- Department of Neurology, Miller School of Medicine, University of Miami, 1120 NW 14th Street, CRB 1318, Miami, Florida, 33136, USA
| | - Rabi Tawil
- Department of Neurology, Miller School of Medicine, University of Miami, 1120 NW 14th Street, CRB 1318, Miami, Florida, 33136, USA
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87
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Raggi A, Leonardi M, Schiavolin S, Antozzi C, Brenna G, Maggi L, Mantegazza R. Validation of the MG-DIS: a disability assessment for myasthenia gravis. J Neurol 2016; 263:871-882. [DOI: 10.1007/s00415-016-8072-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 02/12/2016] [Accepted: 02/15/2016] [Indexed: 01/22/2023]
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Binks S, Vincent A, Palace J. Myasthenia gravis: a clinical-immunological update. J Neurol 2015; 263:826-34. [PMID: 26705120 PMCID: PMC4826656 DOI: 10.1007/s00415-015-7963-5] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 10/06/2015] [Indexed: 12/13/2022]
Abstract
Myasthenia gravis (MG) is the archetypic disorder of both the neuromuscular junction and autoantibody-mediated disease. In most patients, IgG1-dominant antibodies to acetylcholine receptors cause fatigable weakness of skeletal muscles. In the rest, a variable proportion possesses antibodies to muscle-specific tyrosine kinase while the remainder of seronegative MG is being explained through cell-based assays using a receptor-clustering technique and, to a lesser extent, proposed new antigenic targets. The incidence and prevalence of MG are increasing, particularly in the elderly. New treatments are being developed, and results from the randomised controlled trial of thymectomy in non-thymomatous MG, due for release in early 2016, will be of particular clinical value. To help navigate an evidence base of varying quality, practising clinicians may consult new MG guidelines in the fields of pregnancy, ocular and generalised MG (GMG). This review focuses on updates in epidemiology, immunology, therapeutic and clinical aspects of GMG in adults.
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Affiliation(s)
- Sophie Binks
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Jacqueline Palace
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK.
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Antozzi C, Brenna G, Baggi F, Camera G, Maggi L, Rezzani C, Montomoli C, Mantegazza R. Validation of the Besta Neurological Institute rating scale for myasthenia gravis. Muscle Nerve 2015; 53:32-7. [PMID: 26372817 DOI: 10.1002/mus.24911] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 09/02/2015] [Accepted: 09/11/2015] [Indexed: 11/09/2022]
Abstract
INTRODUCTION We validated the scale for myasthenia gravis (MG) developed at the Neurological Institute Foundation of Milan (INCB-MG scale). METHODS A total of 174 patients were evaluated with the INCB-MG and compared with the MG Composite (MGC) as the gold standard. Dimensionality, reliability, and validity of the INCB-MG scale were studied by principal component factor analysis, Cronbach alpha, and Pearson correlation coefficients; interobserver reliability was calculated by the weighted Cohen K coefficient. RESULTS Generalized and bulbar INCB-MG subscales were unidimensional with excellent consistency; the INCB-MG and MGC scales were strongly correlated. Fatigability assessment was correlated with the INCB-MG generalized, bulbar, and respiratory subscales. CONCLUSIONS The INCB-MG scale is a reliable tool to assess MG and is strongly correlated with the MGC. The INCB-MG scale is a valid tool for every day practice and should be further investigated for its application in clinical trials.
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Affiliation(s)
- Carlo Antozzi
- U.O. Neurologia IV - Neuroimmunologia e Malattie Neuromuscolari, Fondazione IRCCS Istituto Nazionale Neurologico C. Besta, Via Celoria 11, 20133, Milano
| | - Greta Brenna
- U.O. Neurologia IV - Neuroimmunologia e Malattie Neuromuscolari, Fondazione IRCCS Istituto Nazionale Neurologico C. Besta, Via Celoria 11, 20133, Milano
| | - Fulvio Baggi
- U.O. Neurologia IV - Neuroimmunologia e Malattie Neuromuscolari, Fondazione IRCCS Istituto Nazionale Neurologico C. Besta, Via Celoria 11, 20133, Milano
| | - Giorgia Camera
- U.O. Neurologia IV - Neuroimmunologia e Malattie Neuromuscolari, Fondazione IRCCS Istituto Nazionale Neurologico C. Besta, Via Celoria 11, 20133, Milano
| | - Lorenzo Maggi
- U.O. Neurologia IV - Neuroimmunologia e Malattie Neuromuscolari, Fondazione IRCCS Istituto Nazionale Neurologico C. Besta, Via Celoria 11, 20133, Milano
| | - Cristiana Rezzani
- Unità di Biostatistica ed Epidemiologia Clinica, Dipartimento Sanità Pubblica, Medicina Sperimentale e Forense, Università di Pavia, Pavia, Italy
| | - Cristina Montomoli
- Unità di Biostatistica ed Epidemiologia Clinica, Dipartimento Sanità Pubblica, Medicina Sperimentale e Forense, Università di Pavia, Pavia, Italy
| | - Renato Mantegazza
- U.O. Neurologia IV - Neuroimmunologia e Malattie Neuromuscolari, Fondazione IRCCS Istituto Nazionale Neurologico C. Besta, Via Celoria 11, 20133, Milano
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Vrinten C, Lipka AF, van Zwet EW, Schimmel KJM, Cornel MC, Kuijpers MR, Hekster YA, Weinreich SS, Verschuuren JJGM. Ephedrine as add-on therapy for patients with myasthenia gravis: protocol for a series of randomised, placebo-controlled n-of-1 trials. BMJ Open 2015; 5:e007863. [PMID: 26185179 PMCID: PMC4513481 DOI: 10.1136/bmjopen-2015-007863] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Myasthenia gravis (MG), a rare neuromuscular disease, is often initially treated using acetylcholinesterase inhibitors. Patients who do not respond adequately depend on the use of corticosteroids or other immunosuppressive medication, but these may have serious side effects. Clinical observations suggest that ephedrine can diminish, postpone or even prevent the need for immunosuppressive therapy when added to acetylcholinesterase inhibitors or low-dose prednisone. In the Netherlands, ephedrine is not licensed for MG nor is reimbursement guaranteed. MG is a rare condition, and ephedrine might be indicated only in a subset of patients. Thus, randomised controlled trials comparing large groups are difficult to conduct. We, therefore, aim to aggregate data from a small series of n-of-1 trials (also known as single patient trials) to assess the effect of ephedrine as add-on treatment for MG. METHODS AND ANALYSIS Single-centre, placebo-controlled, double-blind, randomised, multiple crossover n-of-1 studies in 4 adult patients with generalised MG who show inadequate improvement on pyridostigmine and/or immunosuppressive drugs. Each n-of-1 trial has 3 cycles of two 5-day intervention periods. TREATMENT 25 mg ephedrine or placebo, twice daily. MAIN OUTCOME MEASURE Quantitative Myasthenia Gravis (QMG) test. STATISTICAL ANALYSIS fixed effects linear model for QMG for all patients combined. SECONDARY OUTCOME MEASURES Clinical: effects on MG-Composite and MG-Activities of Daily Living (MG-ADL) scales; QMG at individual level; adverse events. Acceptability of trial design: number of patients eligible and enrolled; number of treatment cycles completed; patients' and caregivers' experiences. ETHICS AND DISSEMINATION This study was approved by the Medical Ethics Committee of Leiden University Medical Center, No. P14.108. Results of the trial will be reported in a peer-reviewed publication. Regulatory stakeholders will comment on the suitability of the trial for market authorisation and reimbursement purposes. TRIAL REGISTRATION NUMBER This study is registered under EudraCT number 2014-001355-23, protocol no. 40960, V.1.0, registration date 27 March 2014.
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Affiliation(s)
- Charlotte Vrinten
- Department of Epidemiology and Public Health, University College London, London, UK
- Department of Clinical Genetics, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Alexander F Lipka
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik W van Zwet
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Kirsten J M Schimmel
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Martina C Cornel
- Department of Clinical Genetics, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Marja R Kuijpers
- Department of Care, Section Pharmaceutical Care, National Health Care Institute, Diemen, The Netherlands
| | - Yechiel A Hekster
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stephanie S Weinreich
- Department of Clinical Genetics, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
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Punga AR, Andersson M, Alimohammadi M, Punga T. Disease specific signature of circulating miR-150-5p and miR-21-5p in myasthenia gravis patients. J Neurol Sci 2015; 356:90-6. [PMID: 26095457 DOI: 10.1016/j.jns.2015.06.019] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 05/06/2015] [Accepted: 06/10/2015] [Indexed: 01/08/2023]
Abstract
PURPOSE Reliable biological markers for patients with the autoimmune neuromuscular disorder myasthenia gravis (MG) are lacking. We determined whether levels of the circulating immuno-microRNAs miR-150-5p and miR-21-5p were elevated in sera from clinically heterogeneous MG patients, with and without immunosuppression, as compared to healthy controls and patients with other autoimmune disorders. METHODS Sera from 71 MG patients and 55 healthy controls (HC) were analyzed for the expression levels of miR-150-5p and miR-21-5p with qRT-PCR. Sera were also assayed from 23 patients with other autoimmune disorders (AID; psoriasis, Addison's and Crohn's diseases). RESULTS 34 MG patients had no immunosuppressive drug treatment (MG-0) and 37 patients were under stable immunosuppressive drug treatment since ≥ 6 months (MG+IMM). Serum levels of miR-150-5p and miR-21-5p were higher in the MG-0 patients compared to HC (p<0.0001). Further, miR-150-5p levels were 41% lower and miR-21-5p levels were 25% lower in the MG+IMM compared to MG-0 (p=0.0051 and 0.0419). In the AID patients, mean miR-150-5p and miR-21-5p were comparable with healthy controls (p=0.66). CONCLUSIONS The immuno-microRNAs miR-150-5p and miR-21-5p show a disease specific signature, which suggests these microRNAs as possible biological autoimmune markers of MG.
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Affiliation(s)
- Anna Rostedt Punga
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Uppsala, Sweden.
| | | | | | - Tanel Punga
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
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Rostedt Punga A, Kaminski HJ, Richman DP, Benatar M. How clinical trials of myasthenia gravis can inform pre-clinical drug development. Exp Neurol 2015; 270:78-81. [PMID: 25592627 DOI: 10.1016/j.expneurol.2014.12.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 12/21/2014] [Accepted: 12/25/2014] [Indexed: 11/30/2022]
Abstract
Pre-clinical evaluations often provide the rationale for therapeutic assessments in humans; however, in many diseases an agent found successful in animal models does not show efficacy in human subjects. Our contention is that the approach of rigorous, clinical trials can be used to inform how preclinical assessments should be performed. Clinical trials in humans are carefully designed investigations executed with consideration of critical methodological issues, such as pre-specified entrance criteria and validated, outcome measures coupled with power analysis to identify sample size. Blinding of evaluators of subjective measures and randomization of subjects are also critical aspects of trial performance. Investigative agents are also tested in subjects with active disease, rather than prior to disease induction as in some pre-clinical assessments. Application of standard procedures, including uniform reporting standards, would likely assist in reproducibility of pre-clinical experiments. Adapting methods of clinical trial performance will likely improve the success rate of therapeutics to ultimately achieve human use.
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Affiliation(s)
- Anna Rostedt Punga
- Institute of Neuroscience, Department of Clinical Neurophysiology, Uppsala University, Uppsala, Sweden
| | - Henry J Kaminski
- Department of Neurology, George Washington University, Washington DC, USA.
| | - David P Richman
- Department of Neurology, University of California Davis School of Medicine, Davis, CA, USA
| | - Michael Benatar
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
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Barnett C, Katzberg HD, Keshavjee S, Bril V. Thymectomy for non-thymomatous myasthenia gravis: a propensity score matched study. Orphanet J Rare Dis 2014; 9:214. [PMID: 25539860 PMCID: PMC4296689 DOI: 10.1186/s13023-014-0214-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 12/12/2014] [Indexed: 11/10/2022] Open
Abstract
Background The efficacy of thymectomy in patients with non-thymomatous Myasthenia Gravis (MG) is still unclear. Main limitations have been variable outcome definitions, lack of a control group and adjustment for confounding. Objective To study the efficacy of thymectomy in achieving remission or minimal manifestation (R/MM) status in patients with non-thymomatous MG. Methods Patients with generalized MG and minimum follow-up of 6 months were included. Demographic data and treatments were recorded, as well as the MGFA post-intervention status at the last visit. Propensity scores were used to create a matched cohort of treated and untreated patients. Standard and Bayesian Cox models were used to study treatment effects. Results Of 395 patients included, 183(46%) had a thymectomy. Thymectomy patients were younger (p < 0.001), with more females (p < 0.001) and more patients in MGFA classes 4–5 at diagnosis (p = 0.01). A matched cohort of thymectomized patients and controls (n = 98) was created. The hazard ratio (HR) for the matched cohort was 1.9 (CI:1.6-2.3), favoring thymectomy. The predicted R/MM rate was 21% in treated and 6% in controls at 5 years (Absolute difference:15%). A Bayesian Cox model for the matched cohort had an estimated probability of thymectomy efficacy (HR > 1) of 96% using a non-informative prior, and 79% using a skeptical prior. Discussion When controlling for potential confounders, thymectomized patients had a higher probability of achieving R/MM status through time compared to controls. This study provides class III evidence of the efficacy of thymectomy in non-thymomatous myasthenia gravis.
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Affiliation(s)
- Carolina Barnett
- Division of Neurology - Department of Medicine, University of Toronto and University Health Network, Toronto, Canada. .,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
| | - Hans D Katzberg
- Division of Neurology - Department of Medicine, University of Toronto and University Health Network, Toronto, Canada.
| | - Shaf Keshavjee
- Division of Thoracic Surgery, Department of Surgery, University Health Network, Toronto, Canada.
| | - Vera Bril
- Division of Neurology - Department of Medicine, University of Toronto and University Health Network, Toronto, Canada.
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94
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Liu GC, Gao BL, Yang HQ, Qi GY, Liu P. The clinical absolute and relative scoring system-a quantitative scale measuring myasthenia gravis severity and outcome used in the traditional Chinese medicine. Complement Ther Med 2014; 22:877-86. [PMID: 25440379 DOI: 10.1016/j.ctim.2014.08.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 06/30/2014] [Accepted: 08/05/2014] [Indexed: 12/24/2022] Open
Abstract
Myasthenia gravis (MG) is a chronic autoimmune disease caused by autoantigen against the nicotine acetylcholine receptor at the neuromuscular junction. With modern treatment facilities, the treatment effect and outcome for MG has been greatly improved with MG and non-MG patients enjoying the same life expectancy. Many classifications of disease distribution and severity have been set up and tested all over the world, mainly in the western world. However, the absolute and relative scoring system for evaluating the severity and treatment effect of MG in China where traditional Chinese medicine (TCM) has been practiced for thousands of years has not been introduced worldwide. The TCM has achieved a great success in the treatment of MG in the country with a huge population. This article serves to introduce this scoring system to the world.
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Affiliation(s)
- Guo-Chao Liu
- Shijiazhuang First Hospital, Hebei Medical University, China
| | - Bu-Lang Gao
- Shijiazhuang First Hospital, Hebei Medical University, China.
| | - Hong-Qi Yang
- Department of Neurology, Henan Provincial People's Hospital, Zhengzhou University, China
| | - Guo-Yan Qi
- Shijiazhuang First Hospital, Hebei Medical University, China
| | - Peng Liu
- Shijiazhuang First Hospital, Hebei Medical University, China
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95
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Zhang Z, Guo J, Su G, Li J, Wu H, Xie X. Evaluation of the quality of guidelines for myasthenia gravis with the AGREE II instrument. PLoS One 2014; 9:e111796. [PMID: 25402504 PMCID: PMC4234220 DOI: 10.1371/journal.pone.0111796] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 10/07/2014] [Indexed: 12/21/2022] Open
Abstract
Background Clinical practice guidelines (CPGs) are systematically developed statements to assist practitioners in making decisions about appropriate healthcare in specific clinical circumstances. The methodological quality of CPGs for myasthenia gravis (MG) are unclear. Objective To critically evaluate the methodological quality of CPGs for MG using AGREE II instrument. Method A systematical search strategy on PubMed, EMBASE, DynaMed, the National Guideline Clearinghouse (NGC) and the Chinese Biomedical Literature database (CBM) was performed on September 20th 2013. All guidelines related to MG were evaluated with AGREE II. The software used for analysis was SPSS 17.0. Results A total of 15 CPGs for MG met the inclusion criteria (12 CPGs in English, 3 CPGs in Chinese). The overall agreement among reviews was moderate or high (ICC >0.70). The mean scores (mean ± SD) for al six domains were presented as follows: scope and purpose (60.93% ±16.62%), stakeholder involvement (40.93% ±20.04%), rigor of development (37.22% ±30.46%), clarity of presentation (64.26% ±16.36%), applicability (28.19% ±20.56%) and editorial independence (27.78% ±28.28%). Compared with non-evidence-based CPGs, evidence-based CPGs had statistically significant higher quality scores for all AGREE II domains (P<0.05). All domain scores appear slightly higher for CPGs published after AGREE II instrument development and validation (P>0.05). The quality scores of CPGs developed by NGC/AAN were higher than the quality scores of CPGs developed by other organizations for all domains. The difference was statistically significant for all domains with the exception of clarity of presentation (P = 0.07). Conclusions The qualities of CPGs on MG were generally acceptable with several flaws. The AGREE II instrument should be adopted by guideline developers, particularly in China.
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Affiliation(s)
- Zhenchang Zhang
- School of Basic Medical Sciences, Lanzhou University, Lanzhou, P. R. China
- Department of Neurology, The Second Hospital of Lanzhou University, Lanzhou, P. R. China
| | - Jia Guo
- Department of Neurology, The Second Hospital of Lanzhou University, Lanzhou, P. R. China
| | - Gang Su
- School of Basic Medical Sciences, Lanzhou University, Lanzhou, P. R. China
| | - Jiong Li
- School of Basic Medical Sciences, Lanzhou University, Lanzhou, P. R. China
| | - Hua Wu
- Department of Neurology, The Second Hospital of Lanzhou University, Lanzhou, P. R. China
| | - Xiaodong Xie
- School of Basic Medical Sciences, Lanzhou University, Lanzhou, P. R. China
- * E-mail:
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96
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Alabdali M, Barnett C, Katzberg H, Breiner A, Bril V. Intravenous immunoglobulin as treatment for myasthenia gravis: current evidence and outcomes. Expert Rev Clin Immunol 2014; 10:1659-65. [PMID: 25331319 DOI: 10.1586/1744666x.2014.971757] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
We examined the current evidence for the efficacy of IV immunoglobulin (IVIG) in myasthenia gravis (MG) and the outcomes used to demonstrate this efficacy. There is class 1 evidence for the use of short-term IVIG in MG patients worsening MG and also good evidence for IVIG use in myasthenic crisis. For long-term maintenance therapy, controlled studies are lacking and the evidence is limited to class III retrospective studies. The clinical scales, serological, electrophysiological, and patient-reported quality of life outcomes with IVIG have been assessed. At this time, the quantitative myasthenia gravis score, a functional scale, remains the preferable outcome measure as it has demonstrated responsiveness in the clinical trial setting, but a scale incorporating patient-reported outcomes and the patients complaint of fatigue is likely to be preferable. The MG-composite is such a scale, but has measurement limitations that may reduce its sensitivity. Across trials, IVIG has generally been well tolerated.
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Affiliation(s)
- Majed Alabdali
- Division of Neurology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth St, Toronto, Ontario, M5A 4H9, Canada
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97
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Kusner LL, Ciesielski MJ, Marx A, Kaminski HJ, Fenstermaker RA. Survivin as a potential mediator to support autoreactive cell survival in myasthenia gravis: a human and animal model study. PLoS One 2014; 9:e102231. [PMID: 25050620 PMCID: PMC4106794 DOI: 10.1371/journal.pone.0102231] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 06/16/2014] [Indexed: 12/30/2022] Open
Abstract
The mechanisms that underlie the development and maintenance of autoimmunity in myasthenia gravis are poorly understood. In this investigation, we evaluate the role of survivin, a member of the inhibitor of apoptosis protein family, in humans and in two animal models. We identified survivin expression in cells with B lymphocyte and plasma cells markers, and in the thymuses of patients with myasthenia gravis. A portion of survivin-expressing cells specifically bound a peptide derived from the alpha subunit of acetylcholine receptor indicating that they recognize the peptide. Thymuses of patients with myasthenia gravis had large numbers of survivin-positive cells with fewer cells in the thymuses of corticosteroid-treated patients. Application of a survivin vaccination strategy in mouse and rat models of myasthenia gravis demonstrated improved motor assessment, a reduction in acetylcholine receptor specific autoantibodies, and a retention of acetylcholine receptor at the neuromuscular junction, associated with marked reduction of survivin-expressing circulating CD20+ cells. These data strongly suggest that survivin expression in cells with lymphocyte and plasma cell markers occurs in patients with myasthenia gravis and in two animal models of myasthenia gravis. Survivin expression may be part of a mechanism that inhibits the apoptosis of autoreactive B cells in myasthenia gravis and other autoimmune disorders.
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Affiliation(s)
- Linda L. Kusner
- Department of Pharmacology and Physiology, George Washington University, Washington, District of Columbia, United States of America
- * E-mail:
| | - Michael J. Ciesielski
- Department of Neurosurgery, Roswell Park Cancer Institute, Buffalo, New York, United States of America
- Center for Immunotherapy, Roswell Park Cancer Institute, Buffalo, New York, United States of America
| | - Alexander Marx
- Institute of Pathology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Henry J. Kaminski
- Department of Neurology, George Washington University, Washington, District of Columbia, United States of America
| | - Robert A. Fenstermaker
- Department of Neurosurgery, Roswell Park Cancer Institute, Buffalo, New York, United States of America
- Center for Immunotherapy, Roswell Park Cancer Institute, Buffalo, New York, United States of America
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98
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George S, Paulick S, Knütter I, Röber N, Hiemann R, Roggenbuck D, Conrad K, Küpper JH. Stable expression of human muscle-specific kinase in HEp-2 M4 cells for automatic immunofluorescence diagnostics of myasthenia gravis. PLoS One 2014; 9:e83924. [PMID: 24416182 PMCID: PMC3886972 DOI: 10.1371/journal.pone.0083924] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 11/11/2013] [Indexed: 12/22/2022] Open
Abstract
Muscle-specific kinase (MuSK) belongs to the nicotinic acetylcholine receptor complex which is targeted by pathogenic autoantibodies causing Myasthenia gravis. While up to 95% of patients with generalized Myasthenia gravis were shown to be positive for acetylcholine receptor-specific autoantibodies, up to 70% of the remaining patients develop autoantibodies against MuSK. Discrimination of the autoantibody specificity is important for therapy of Myasthenia gravis. Recently, the new automatic fluorescence assessment platform AKLIDES has been developed for immunofluorescence-based diagnostics of autoimmune diseases. In order to establish an AKLIDES procedure for the detection of MuSK-specific autoantibodies (anti-MuSK), we developed a recombinant HEp-2 cell clone expressing the human MuSK cDNA. Here we show at the mRNA and protein level that the cell clone HEp-2 M4 stably expresses human MuSK. We provide evidence for a localization of MuSK at the cell membrane. Using cell clone HEp-2 M4 on the AKLIDES system, we investigated 34 patient sera that were previously tested anti-MuSK positive by radioimmunoassay as positive controls. As negative controls, we tested 29 acetylcholine receptor-positive but MuSK-negative patient sera, 30 amytrophic lateral sclerosis (ALS) patient sera and 45 blood donors. HEp-2 M4 cells revealed a high specificity for the detection of MuSK autoantibodies from 25 patient sera assessed by a specific pattern on HEp-2 M4 cells. By using appropriate cell culture additives, the fraction of cells stained positive with anti-MuSK containing sera can be increased from 2-16% to 10-48%, depending on the serum. In conclusion, we provide data showing that the novel recombinant cell line HEp-2 M4 can be used to screen for anti-MuSK with the automatic AKLIDES system.
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Affiliation(s)
- Sandra George
- Faculty of Science, Brandenburg University of Technology Cottbus-Senftenberg, Senftenberg, Germany
- Institute of Immunology, Technical University Dresden, Dresden, Germany
| | - Silvia Paulick
- Faculty of Science, Brandenburg University of Technology Cottbus-Senftenberg, Senftenberg, Germany
| | - Ilka Knütter
- GA Generic Assays GmbH, Dahlewitz/Berlin, Germany
| | - Nadja Röber
- Institute of Immunology, Technical University Dresden, Dresden, Germany
| | - Rico Hiemann
- GA Generic Assays GmbH, Dahlewitz/Berlin, Germany
| | - Dirk Roggenbuck
- Faculty of Science, Brandenburg University of Technology Cottbus-Senftenberg, Senftenberg, Germany
- GA Generic Assays GmbH, Dahlewitz/Berlin, Germany
| | - Karsten Conrad
- Institute of Immunology, Technical University Dresden, Dresden, Germany
| | - Jan-Heiner Küpper
- Faculty of Science, Brandenburg University of Technology Cottbus-Senftenberg, Senftenberg, Germany
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99
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Wong SH, Huda S, Vincent A, Plant GT. Ocular Myasthenia Gravis: Controversies and Updates. Curr Neurol Neurosci Rep 2013; 14:421. [DOI: 10.1007/s11910-013-0421-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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100
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