51
|
Kim SW, Kim EH, Lee J, Choi YC, Kim SM, Shin HY. Risk of osteoporosis in patients with chronic inflammatory neuropathy- a population-based cohort study. Sci Rep 2019; 9:9131. [PMID: 31235735 PMCID: PMC6591220 DOI: 10.1038/s41598-019-45591-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 05/30/2019] [Indexed: 12/16/2022] Open
Abstract
The risk of osteoporosis in patients with chronic inflammatory neuropathy (CIN) has not been evaluated in detail. We conducted a population-based case-control study nested in a retrospective cohort to analyze osteoporosis risk among patients with CIN using a nationwide database. Patients with CIN based on the Korean Classification of Disease diagnostic code were included and were matched to controls. A Cox proportional hazards regression model was used to evaluate the effect of CIN on osteoporosis. After propensity score matching, 585 CIN patients and 585 controls were selected. Patients with CIN had an increased osteoporosis risk (hazard ratio [HR] = 2.293, 95% confidence interval [CI] 1.460-3.601) compared with controls. The osteoporosis risk was higher among male patients with CIN than among male controls (HR = 5.404, 95% CI 2.252-12.969), while there were no significant differences among women. Among the CIN patients, the average daily dose of corticosteroids was higher in those who developed osteoporosis (19.6 mg [10.8-49.3]) than those who did not (16.2 mg [7.2-29.1], p = 0.001). The osteoporosis risk among CIN patients is higher than among controls. High risk of osteoporosis in male patients may indicate that osteoporosis in CIN patients results from the disease itself or related treatments.
Collapse
Affiliation(s)
- Seung Woo Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Eun Hwa Kim
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, South Korea
| | - Jinae Lee
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, South Korea
| | - Young-Chul Choi
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Seung Min Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Ha Young Shin
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea.
| |
Collapse
|
52
|
|
53
|
Lucke IM, Wieske L, van der Kooi AJ, van Schaik IN, Eftimov F, Verhamme C. Diagnosis and treatment response in the asymmetric variant of chronic inflammatory demyelinating polyneuropathy. J Peripher Nerv Syst 2019; 24:174-179. [DOI: 10.1111/jns.12325] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 05/07/2019] [Accepted: 05/08/2019] [Indexed: 01/20/2023]
Affiliation(s)
- Ilse M. Lucke
- Department of Neurology and NeurophysiologyAmsterdam UMC ‐ University of Amsterdam Amsterdam The Netherlands
| | - Luuk Wieske
- Department of Neurology and NeurophysiologyAmsterdam UMC ‐ University of Amsterdam Amsterdam The Netherlands
| | - Anneke J. van der Kooi
- Department of Neurology and NeurophysiologyAmsterdam UMC ‐ University of Amsterdam Amsterdam The Netherlands
| | - Ivo N. van Schaik
- Department of Neurology and NeurophysiologyAmsterdam UMC ‐ University of Amsterdam Amsterdam The Netherlands
| | - Filip Eftimov
- Department of Neurology and NeurophysiologyAmsterdam UMC ‐ University of Amsterdam Amsterdam The Netherlands
| | - Camiel Verhamme
- Department of Neurology and NeurophysiologyAmsterdam UMC ‐ University of Amsterdam Amsterdam The Netherlands
| |
Collapse
|
54
|
Cho ME, Branton MH, Smith DA, Bartlett L, Howard L, Reynolds JC, Rosenstein D, Sethi S, Nava MB, Barisoni L, Fervenza FC, Kopp JB. Open-Label Clinical Trials of Oral Pulse Dexamethasone for Adults with Idiopathic Nephrotic Syndrome. Am J Nephrol 2019; 49:377-385. [PMID: 30965344 DOI: 10.1159/000497064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 12/11/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND In adults with primary focal segmental glomerulosclerosis (FSGS), daily prednisone may induce complete remissions (CR) and partial remissions (PR), but relapses are frequent and adverse events are common. METHODS We carried out 2 open-label, uncontrolled trials to explore the efficacy and tolerability of pulse oral dexamethasone as an alternative to daily prednisone. We enrolled adult patients with proteinuria > 3.5 g/day despite the use of renin-angiotensin-aldosterone blockade. In the first trial, we enrolled 14 subjects with FSGS and administered 4 dexamethasone doses (25 mg/m2) daily for 4 days, repeated every 28 days over 32 weeks. The second trial involved a more intensive regimen. Eight subjects received 4 dexamethasone doses of 50 mg/m2 every 4 weeks for 12 weeks, followed by 4 doses of 25 mg/m2 every 4 weeks for 36 weeks; subjects were randomized to 2 doses every 2 weeks or 4 doses every 4 weeks. RESULTS In the first trial, we enrolled 13 subjects with FSGS and 1 with minimal change disease and found a combined CR and PR rate of 36%. In the second trial, we enrolled 8 subjects. The combined CR and PR rate was 29%. Analysis combining both trials showed a combined CR and PR rate of 33%. Adverse events were observed in 32% of subjects, with mood symptoms being most common. There were no serious adverse events related to the study. CONCLUSION We conclude that high dose oral dexamethasone is well tolerated by adults with idiopathic nephrotic syndrome and may have some efficacy.
Collapse
Affiliation(s)
- Monique E Cho
- Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Disease, Bethesda, Maryland, USA
| | - Mary H Branton
- Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Disease, Bethesda, Maryland, USA
| | - David A Smith
- Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Disease, Bethesda, Maryland, USA
| | - Linda Bartlett
- Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Disease, Bethesda, Maryland, USA
| | - Lilian Howard
- Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Disease, Bethesda, Maryland, USA
| | - James C Reynolds
- Radiology and Imaging Services, Mark O. Hatfield Clinical Research Center, Bethesda, Maryland, USA
| | - Donald Rosenstein
- Department of Psychiatry, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Sanjeev Sethi
- Department of Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - M Berenice Nava
- Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Disease, Bethesda, Maryland, USA
- Kaiser Permanente, San Diego, California, USA
| | - Laura Barisoni
- Department of Pathology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Fernando C Fervenza
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeffrey B Kopp
- Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Disease, Bethesda, Maryland, USA,
| |
Collapse
|
55
|
Roux T, Debs R, Maisonobe T, Lenglet T, Delorme C, Louapre C, Leblond V, Viala K. Rituximab in chronic inflammatory demyelinating polyradiculoneuropathy with associated diseases. J Peripher Nerv Syst 2018; 23:235-240. [PMID: 30203907 DOI: 10.1111/jns.12287] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 09/03/2018] [Accepted: 09/06/2018] [Indexed: 11/29/2022]
Abstract
We aimed to analyse the response to rituximab in a cohort of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) patients with associated disorders. We conducted a clinical and electrophysiological retrospective monocentric study in 28 CIDP patients. Response to rituximab was defined as (a) a five-point increase in the Medical Research Council sum score or a one-point decrease in the Overall Neuropathy Limitations Scale score, compared to the score at the first rituximab infusion, or (b) the discontinuation of, or reduced need for, the last treatments before rituximab initiation. Twenty-one patients (75%) were responders to rituximab. The median time before response was 6 months (1-10 months). Only two patients needed to be treated again during a median follow-up of 2.0 years (0.75-9 years). Interestingly, the response rate was good in patients with associated autoimmune disease (5/8) and similar to the response rate observed in patients with a haematological disease (16/20) (P = 0.63). A shorter disease duration was associated with a better clinical response to rituximab (odds ratio 0.81, P = 0.025) and the response rate was better (P = 0.05) in common forms (83.3%) than in sensory forms (42.9%). No major adverse events were recorded. Rituximab is efficacious in CIDP patients with haematological or autoimmune disease. It improves clinical response and decreases dependence on first-line treatments.
Collapse
Affiliation(s)
- Thomas Roux
- Department of Clinical Neurophysiology, APHP, Pitié-Salpêtrière Hospital, Paris, France
| | - Rabab Debs
- Department of Clinical Neurophysiology, APHP, Pitié-Salpêtrière Hospital, Paris, France.,Medical School, Pierre et Marie Curie University-Paris VI, Paris, France
| | - Thierry Maisonobe
- Department of Clinical Neurophysiology, APHP, Pitié-Salpêtrière Hospital, Paris, France.,Medical School, Pierre et Marie Curie University-Paris VI, Paris, France
| | - Timothée Lenglet
- Department of Clinical Neurophysiology, APHP, Pitié-Salpêtrière Hospital, Paris, France.,Medical School, Pierre et Marie Curie University-Paris VI, Paris, France
| | - Cécile Delorme
- Department of Clinical Neurophysiology, APHP, Pitié-Salpêtrière Hospital, Paris, France.,Medical School, Pierre et Marie Curie University-Paris VI, Paris, France
| | - Céline Louapre
- Department of Neurology, APHP, Pitié-Salpêtrière Hospital, Paris, France
| | - Véronique Leblond
- Department of Haematology, APHP, Pitié-Salpêtrière Hospital, Paris, France
| | - Karine Viala
- Department of Clinical Neurophysiology, APHP, Pitié-Salpêtrière Hospital, Paris, France.,Medical School, Pierre et Marie Curie University-Paris VI, Paris, France
| |
Collapse
|
56
|
|
57
|
Hung SKY, Hiew FL, Viswanathan S, Puvanarajah S. Conventional and unconventional therapies in typical and atypical chronic inflammatory demyelinating polyneuropathy with different clinical course of progression. J Peripher Nerv Syst 2018; 23:183-189. [PMID: 30027593 DOI: 10.1111/jns.12282] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/14/2018] [Accepted: 07/16/2018] [Indexed: 11/30/2022]
Abstract
Intravenous immunoglobulin (IVIG), corticosteroids and therapeutic plasma exchange (TPE) are evidence-based conventional treatments for chronic inflammatory demyelinating polyneuropathy (CIDP). In many centres, unconventional treatments are frequently used as alternatives. We evaluated the outcome of conventional and unconventional therapies in 31 CIDP patients. Overall response rate with conventional first-line immunotherapies was 77% (20/26), comparable between IVIG and corticosteroids (80% vs 70%). Use of TPE was limited. Treatment response among typical and atypical CIDP were comparable (76 vs 80%). Non-responders were patients with progressive form of typical CIDP and DADS. Majority (21/26, 81%) of patients with persistent neurological deficits received maintenance therapy. Two subgroups of patients frequently treated with maintenance immunosuppressants were those with improving or stable disease following first-line treatment (12, 57%) and those with progressive form of CIDP (2, 10%). Primary indications for immunosuppressant use were corticosteroids-sparing and additional immunosuppression effects. Nine (64%) patients with improving or stable disease given azathioprine were taken off corticosteroids after a median duration of 14 months (range 12-108). Two (14%) eventually achieved cure or clinical remission without treatment. Maintenance IVIg was given to 6 (29%) relapsing CIDP patients; none of achieved cure or remission after similar median duration of treatment. Less potent immunosuppressant drugs (azathioprine, mycophenolate mofetil, and methotrexate) were frequently used, with moderate adverse effect profiles. In resource limited setting, unconventional treatments were commonly used among CIDP patients with different clinical course of progression. In most cases, careful risk-benefit re-assessment is required to justify its further use.
Collapse
Affiliation(s)
- Stefanie K Y Hung
- Department of Neurology, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
| | - Fu L Hiew
- Department of Neurology, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
| | | | | |
Collapse
|
58
|
Abstract
OBJECTIVES Childhood chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) responds favorably to immunomodulatory treatment. However, the optimal sequencing and selection of immunotherapy is uncertain. METHODS Using accepted diagnostic criteria, pediatric patients with CIDP seen at our center from 1999 to 2015 were identified retrospectively through medical record review. Clinical details and treatment responses were tabulated. RESULTS Ten patients (age 4-16, 6 women) with definite (N = 8) or possible (N = 2) CIDP met criteria. All were initially treated with IVIg; 6 responded but 4 did not. All 4 IVIG nonresponders improved with twice-weekly high-dose oral prednisone, as did 1 IVIg responder who was also treated with twice-weekly oral prednisone when IVIg was discontinued. Pulse steroids were well tolerated. CONCLUSIONS Pulse oral corticosteroid therapy holds promise as an alternative treatment to IVIG in pediatric CIDP. Future multicenter studies are warranted to determine the comparative efficacy and safety of weekly pulse oral corticosteroids versus IVIg in pediatric CIDP.
Collapse
|
59
|
Kim SW, Choi YC, Kim SM, Shin HY. Risk factors for osteoporosis in chronic inflammatory demyelinating polyradiculoneuropathy. Muscle Nerve 2018; 58:407-412. [PMID: 29896772 DOI: 10.1002/mus.26175] [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: 11/20/2017] [Revised: 05/15/2018] [Accepted: 05/20/2018] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) patients possess multiple risk factors for osteoporosis, but few studies have evaluated bone mineral density (BMD) in CIDP patients. METHODS We retrospectively compared the BMD of CIDP patients with that of normal controls, and evaluated the clinical factors associated with osteoporosis. RESULTS Total BMD was lower in CIDP patients than in normal controls (P = 0.017). In a comparison of 16 osteoporotic CIDP patients with 25 non-osteoporotic patients, the cumulative prednisolone dose was lower (P = 0.022) and the duration from disease onset to BMD measurement was shorter (P = 0.014) in osteoporotic patients than in non-osteoporotic patients. Function, as measured by modified Rankin scale score within 3 years of the BMD measurement, was worse in osteoporotic than in non-osteoporotic patients (P = 0.008). DISCUSSION BMD in CIDP patients was significantly lower than in normal controls. Functional status rather than cumulative steroid dose was associated with osteoporosis. Muscle Nerve 58: 407-412, 2018.
Collapse
Affiliation(s)
- Seung Woo Kim
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, South Korea
| | - Young-Chul Choi
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, South Korea
| | - Seung Min Kim
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, South Korea
| | - Ha Young Shin
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, South Korea
| |
Collapse
|
60
|
Na SJ. Corticosteroids Treatment in Spinal Cord and Neuromuscular Disorders. JOURNAL OF NEUROCRITICAL CARE 2017. [DOI: 10.18700/jnc.170032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
|
61
|
Hughes RAC, Mehndiratta MM, Rajabally YA. Corticosteroids for chronic inflammatory demyelinating polyradiculoneuropathy. Cochrane Database Syst Rev 2017; 11:CD002062. [PMID: 29185258 PMCID: PMC6747552 DOI: 10.1002/14651858.cd002062.pub4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a progressive or relapsing and remitting paralysing illness, probably due to an autoimmune response, which should benefit from corticosteroid treatment. Non-randomised studies suggest that corticosteroids are beneficial. Two commonly used corticosteroids are prednisone and prednisolone. Both are usually given as oral tablets. Prednisone is converted into prednisolone in the liver so that the effect of the two drugs is usually the same. Another corticosteroid, dexamethasone, is more potent and is used in smaller doses. The review was first published in 2001 and last updated in 2015; we undertook this update to identify any new evidence. OBJECTIVES To assess the effects of corticosteroid treatment for CIDP compared to placebo or no treatment, and to compare the effects of different corticosteroid regimens. SEARCH METHODS On 8 November 2016, we searched the Cochrane Neuromuscular Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE, and Embase for randomised trials of corticosteroids for CIDP. We searched clinical trials registries for ongoing trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) or quasi-RCTs of treatment with any corticosteroid or adrenocorticotrophic hormone for CIDP, diagnosed by an internationally accepted definition. DATA COLLECTION AND ANALYSIS Two authors extracted data from included studies and assessed the risk of bias independently. The intended primary outcome was change in disability, with change in impairment after 12 weeks and side effects as secondary outcomes. We assessed strength of evidence using the GRADE approach. MAIN RESULTS One non-blinded RCT comparing prednisone with no treatment in 35 eligible participants did not measure the primary outcome for this systematic review. The trial had a high risk of bias. Neuropathy Impairment Scale scores after 12 weeks improved in 12 of 19 participants randomised to prednisone, compared with five of 16 participants randomised to no treatment (risk ratio (RR) for improvement 2.02 (95% confidence interval (CI) 0.90 to 4.52; very low-quality evidence). The trial did not report side effects in detail, but one prednisone-treated participant died.A double-blind RCT comparing daily standard-dose oral prednisolone with monthly high-dose oral dexamethasone in 40 participants reported none of the prespecified outcomes for this review. The trial had a low risk of bias, but the quality of evidence was limited as it came from a single small study. There was little or no difference in number of participants who achieved remission (RR 1.11; 95% CI 0.50 to 2.45 in favour of monthly dexamethasone; moderate-quality evidence), or change in disability or impairment after one year (low-quality evidence). Change of grip strength or Medical Research Council (MRC) scores demonstrated little or no difference between groups (moderate-quality to low-quality evidence). Eight of 16 people in the prednisolone group and seven of 24 people in the dexamethasone group deteriorated. Side effects were similar with each regimen, except that sleeplessness was less common with monthly dexamethasone (low-quality evidence) as was moon facies (moon-shaped appearance of the face) (moderate-quality evidence).Experience from large non-randomised studies suggests that corticosteroids are beneficial, but long-term use causes serious side effects. AUTHORS' CONCLUSIONS We are very uncertain about the effects of oral prednisone compared with no treatment, because the quality of evidence from the only RCT that exists is very low. Nevertheless, corticosteroids are commonly used in practice, supported by very low-quality evidence from observational studies. We also know from observational studies that corticosteroids carry the long-term risk of serious side effects. The efficacy of high-dose monthly oral dexamethasone is probably little different from that of daily standard-dose oral prednisolone. Most side effects occurred with similar frequencies in both groups, but with high-dose monthly oral dexamethasone moon facies is probably less common and sleeplessness may be less common than with oral prednisolone. We need further research to identify factors that predict response.
Collapse
Affiliation(s)
- Richard AC Hughes
- National Hospital for Neurology and NeurosurgeryMRC Centre for Neuromuscular DiseasesPO Box 114Queen SquareLondonUKWC1N 3BG
| | - Man Mohan Mehndiratta
- Janakpuri Superspecialty HospitalDepartment of NeurologyC‐2/B, JanakpuriNew DelhiDelhiIndia110058
| | | | | |
Collapse
|
62
|
|
63
|
Parissis D, Syntila SA, Ioannidis P. Corticosteroids in neurological disorders: The dark side. J Clin Neurosci 2017. [DOI: 10.1016/j.jocn.2017.05.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
64
|
Rajabally YA, Stettner M, Kieseier BC, Hartung HP, Malik RA. CIDP and other inflammatory neuropathies in diabetes — diagnosis and management. Nat Rev Neurol 2017; 13:599-611. [DOI: 10.1038/nrneurol.2017.123] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
65
|
Pitarokoili K, Yoon MS, Kröger I, Reinacher-Schick A, Gold R, Schneider-Gold C. Severe refractory CIDP: a case series of 10 patients treated with bortezomib. J Neurol 2017; 264:2010-2020. [DOI: 10.1007/s00415-017-8599-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 08/17/2017] [Accepted: 08/18/2017] [Indexed: 11/29/2022]
|
66
|
Morise J, Takematsu H, Oka S. The role of human natural killer-1 (HNK-1) carbohydrate in neuronal plasticity and disease. Biochim Biophys Acta Gen Subj 2017; 1861:2455-2461. [PMID: 28709864 DOI: 10.1016/j.bbagen.2017.06.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 06/01/2017] [Accepted: 06/17/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND The human natural killer-1 (HNK-1) carbohydrate, a unique trisaccharide possessing sulfated glucuronic acid in a non-reducing terminus (HSO3-3GlcAß1-3Galß1-4GlcNAc-), is highly expressed in the nervous system and its spatiotemporal expression is strictly regulated. Mice deficient in the gene encoding a key enzyme, GlcAT-P, of the HNK-1 biosynthetic pathway exhibit almost complete disappearance of the HNK-1 epitope in the brain, significant reduction of long-term potentiation, and aberration of spatial learning and memory formation. In addition to its physiological roles in higher brain function, the HNK-1 carbohydrate has attracted considerable attention as an autoantigen associated with peripheral demyelinative neuropathy, which relates to IgM paraproteinemia, because of high immunogenicity. It has been suggested, however, that serum autoantibodies in IgM anti-myelin-associated glycoprotein (MAG) antibody-associated neuropathy patients show heterogeneous reactivity to the HNK-1 epitope. SCOPE OF REVIEW We have found that structurally distinct HNK-1 epitopes are expressed in specific proteins in the nervous system. Here, we overview the current knowledge of the involvement of these HNK-1 epitopes in the regulation of neural plasticity and discuss the impact of different HNK-1 antigens of anti-MAG neuropathy patients. MAJOR CONCLUSIONS We identified the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid-type glutamate receptor subunit GluA2 and aggrecan as HNK-1 carrier proteins. The HNK-1 epitope on GluA2 and aggrecan regulates neural plasticity in different ways. Furthermore, we found the clinical relationship between reactivity of autoantibodies to the different HNK-1 epitopes and progression of anti-MAG neuropathy. GENERAL SIGNIFICANCE The HNK-1 epitope is indispensable for the acquisition of normal neuronal function and can be a good target for the establishment of diagnostic criteria for anti-MAG neuropathy.
Collapse
Affiliation(s)
- Jyoji Morise
- Department of Biological Chemistry, Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Hiromu Takematsu
- Department of Biological Chemistry, Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Shogo Oka
- Department of Biological Chemistry, Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan.
| |
Collapse
|
67
|
Nobile-Orazio E, Gallia F, Terenghi F, Bianco M. Comparing treatment options for chronic inflammatory neuropathies and choosing the right treatment plan. Expert Rev Neurother 2017; 17:755-765. [DOI: 10.1080/14737175.2017.1340832] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Eduardo Nobile-Orazio
- Department of Medical Biotechnology and Translational Medicine (BIOMETRA), University of Milan, Milan, Italy
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical Institute, Milan, Italy
| | - Francesca Gallia
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical Institute, Milan, Italy
| | - Fabrizia Terenghi
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical Institute, Milan, Italy
| | - Mariangela Bianco
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical Institute, Milan, Italy
| |
Collapse
|
68
|
Mahdi‐Rogers M, Brassington R, Gunn AA, van Doorn PA, Hughes RAC. Immunomodulatory treatment other than corticosteroids, immunoglobulin and plasma exchange for chronic inflammatory demyelinating polyradiculoneuropathy. Cochrane Database Syst Rev 2017; 5:CD003280. [PMID: 28481421 PMCID: PMC6481566 DOI: 10.1002/14651858.cd003280.pub5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a disease that causes progressive or relapsing and remitting weakness and numbness. It is probably caused by an autoimmune process. Immunosuppressive or immunomodulatory drugs would be expected to be beneficial. This review was first published in 2003 and has been updated most recently in 2016. OBJECTIVES To assess the effects of immunomodulatory and immunosuppressive agents other than corticosteroids, immunoglobulin, and plasma exchange in CIDP. SEARCH METHODS On 24 May 2016, we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 4) in the Cochrane Library, MEDLINE, Embase, CINAHL, and LILACS for completed trials, and clinical trial registers for ongoing trials. We contacted the authors of the trials identified and other disease experts seeking other published and unpublished trials. SELECTION CRITERIA We sought randomised and quasi-randomised trials of all immunosuppressive agents, such as azathioprine, cyclophosphamide, methotrexate, ciclosporin, mycophenolate mofetil, and rituximab, and all immunomodulatory agents, such as interferon (IFN) alfa and IFN beta, in participants fulfilling standard diagnostic criteria for CIDP. We included all comparisons of these agents with placebo, another treatment, or no treatment. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We wanted to measure the change in disability after one year as our primary outcome. Our secondary outcomes were change in disability after four or more weeks (from randomisation); change in impairment after at least one year; change in maximum motor nerve conduction velocity and compound muscle action potential amplitude after one year; and for participants who were receiving corticosteroids or intravenous immunoglobulin (IVIg), the amount of this medication given during at least one year after randomisation. Participants with one or more serious adverse events during the first year was also a secondary outcome. MAIN RESULTS Four trials fulfilled the selection criteria: one of azathioprine (27 participants), two of IFN beta-1a (77 participants in total) and one of methotrexate (60 participants). The risk of bias was considered low in the trials of IFN beta-1a and methotrexate but high in the trial of azathioprine. None of the trials showed significant benefit in any of the outcomes selected by their authors. The results of the outcomes which approximated most closely to the primary outcome for this review were as follows.In the azathioprine trial there was a median improvement in the Neuropathy Impairment Scale (scale range 0 to 280) after nine months of 29 points (range 49 points worse to 84 points better) in the azathioprine and prednisone treated participants compared with 30 points worse (range 20 points worse to 104 points better) in the prednisone alone group. There were no reports of adverse events.In a cross-over trial of IFN beta-1a with 20 participants, the treatment periods were 12 weeks. The median improvement in the Guy's Neurological Disability Scale (range 1 to 10) was 0.5 grades (interquartile range (IQR) 1.8 grades better to zero grade change) in the IFN beta-1a treatment period and 0.5 grades (IQR 1.8 grades better to 1.0 grade worse) in the placebo treatment period. There were no serious adverse events in either treatment period.In a parallel group trial of IFN beta-1a with 67 participants, none of the outcomes for this review was available. The trial design involved withdrawal from ongoing IVIg treatment. The primary outcome used by the trial authors was total IVIg dose administered from week 16 to week 32 in the placebo group compared with the IFN beta-1a groups. This was slightly but not significantly lower in the combined IFN beta-1a groups (1.20 g/kg) compared with the placebo group (1.34 g/kg, P = 0.75). There were four participants in the IFN beta-1a group and none in the placebo group with one or more serious adverse events, risk ratio (RR) 4.50 (95% confidence interval (CI) 0.25 to 80.05).The methotrexate trial had a similar design involving withdrawal from ongoing corticosteroid or IVIg treatment. At the end of the trial (approximately 40 weeks) there was no significant difference in the change in the Overall Neuropathy Limitations Scale, a disability scale (scale range 0 to 12), the median change being 0 (IQR -1 to 0) in the methotrexate group and 0 (IQR -0.75 to 0) in the placebo group. These changes in disability might have been confounded by the reduction in corticosteroid or IVIg dose required by the protocol. There were three participants in the methotrexate group and one in the placebo with one or more serious adverse events, RR 3.56 (95% CI 0.39 to 32.23). AUTHORS' CONCLUSIONS Low-quality evidence from randomised trials does not show significant benefit from azathioprine or interferon beta-1a and moderate-quality evidence from one randomised trial does not show significant benefit from a relatively low dose of methotrexate for the treatment of CIDP. None of the trials was large enough to rule out small or moderate benefit. The evidence from observational studies is insufficient to avoid the need for randomised controlled trials to discover whether these drugs are beneficial. Future trials should have improved designs, more sensitive outcome measures relevant to people with CIDP, and longer treatment durations.
Collapse
Affiliation(s)
| | - Ruth Brassington
- National Hospital for Neurology and NeurosurgeryQueen Square Centre for Neuromuscular DiseasesPO Box 114LondonUKWC1N 3BG
| | - Angela A Gunn
- National Hospital for Neurology and NeurosurgeryMRC Centre for Neuromuscular DiseasesPO Box 114LondonUKWC1N 3BG
| | - Pieter A van Doorn
- Erasmus University Medical CenterDepartment of NeurologyPO Box 2040RotterdamNetherlands3000 CA
| | - Richard AC Hughes
- National Hospital for Neurology and NeurosurgeryMRC Centre for Neuromuscular DiseasesPO Box 114LondonUKWC1N 3BG
| | | |
Collapse
|
69
|
Léger JM, Haghi Ashtiani B, Guimaraes-Costa R. Investigated and emerging treatments for chronic inflammatory demyelinating polyradiculoneuropathy. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1285225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
70
|
Oaklander AL, Lunn MPT, Hughes RAC, van Schaik IN, Frost C, Chalk CH. Treatments for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP): an overview of systematic reviews. Cochrane Database Syst Rev 2017; 1:CD010369. [PMID: 28084646 PMCID: PMC5468847 DOI: 10.1002/14651858.cd010369.pub2] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a chronic progressive or relapsing and remitting disease that usually causes weakness and sensory loss. The symptoms are due to autoimmune inflammation of peripheral nerves. CIPD affects about 2 to 3 per 100,000 of the population. More than half of affected people cannot walk unaided when symptoms are at their worst. CIDP usually responds to treatments that reduce inflammation, but there is disagreement about which treatment is most effective. OBJECTIVES To summarise the evidence from Cochrane systematic reviews (CSRs) and non-Cochrane systematic reviews of any treatment for CIDP and to compare the effects of treatments. METHODS We considered all systematic reviews of randomised controlled trials (RCTs) of any treatment for any form of CIDP. We reported their primary outcomes, giving priority to change in disability after 12 months.Two overview authors independently identified published systematic reviews for inclusion and collected data. We reported the quality of evidence using GRADE criteria. Two other review authors independently checked review selection, data extraction and quality assessments.On 31 October 2016, we searched the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects (in theCochrane Library), MEDLINE, Embase, and CINAHL Plus for systematic reviews of CIDP. We supplemented the RCTs in the existing CSRs by searching on the same date for RCTs of any treatment of CIDP (including treatment of fatigue or pain in CIDP), in the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL Plus. MAIN RESULTS Five CSRs met our inclusion criteria. We identified 23 randomised trials, of which 15 had been included in these CSRs. We were unable to compare treatments as originally planned, because outcomes and outcome intervals differed. CorticosteroidsIt is uncertain whether daily oral prednisone improved impairment compared to no treatment because the quality of the evidence was very low (1 trial, 28 participants). According to moderate-quality evidence (1 trial, 41 participants), six months' treatment with high-dose monthly oral dexamethasone did not improve disability more than daily oral prednisolone. Observational studies tell us that prolonged use of corticosteroids sometimes causes serious side-effects. Plasma exchangeAccording to moderate-quality evidence (2 trials, 59 participants), twice-weekly plasma exchange produced more short-term improvement in disability than sham exchange. In the largest observational study, 3.9% of plasma exchange procedures had complications. Intravenous immunoglobulinAccording to high-quality evidence (5 trials, 269 participants), intravenous immunoglobulin (IVIg) produced more short-term improvement than placebo. Adverse events were more common with IVIg than placebo (high-quality evidence), but serious adverse events were not (moderate-quality evidence, 3 trials, 315 participants). One trial with 19 participants provided moderate-quality evidence of little or no difference in short-term improvement of impairment with plasma exchange in comparison to IVIg. There was little or no difference in short-term improvement of disability with IVIg in comparison to oral prednisolone (moderate-quality evidence; 1 trial, 29 participants) or intravenous methylprednisolone (high-quality evidence; 1 trial, 45 participants). One unpublished randomised open trial with 35 participants found little or no difference in disability after three months of IVIg compared to oral prednisone; this trial has not yet been included in a CSR. We know from observational studies that serious adverse events related to IVIg do occur. Other immunomodulatory treatmentsIt is uncertain whether the addition of azathioprine (2 mg/kg) to prednisone improved impairment in comparison to prednisone alone, as the quality of the evidence is very low (1 trial, 27 participants). Observational studies show that adverse effects truncate treatment in 10% of people.According to low-quality evidence (1 trial, 60 participants), compared to placebo, methotrexate 15 mg/kg did not allow more participants to reduce corticosteroid or IVIg doses by 20%. Serious adverse events were no more common with methotrexate than with placebo, but observational studies show that methotrexate can cause teratogenicity, abnormal liver function, and pulmonary fibrosis.According to moderate-quality evidence (2 trials, 77 participants), interferon beta-1a (IFN beta-1a) in comparison to placebo, did not allow more people to withdraw from IVIg. According to moderate-quality evidence, serious adverse events were no more common with IFN beta-1a than with placebo.We know of no other completed trials of immunosuppressant or immunomodulatory agents for CIDP. Other treatmentsWe identified no trials of treatments for fatigue or pain in CIDP. Adverse effectsNot all trials routinely collected adverse event data; when they did, the quality of evidence was variable. Adverse effects in the short, medium, and long term occur with all interventions. We are not able to make reliable comparisons of adverse events between the interventions included in CSRs. AUTHORS' CONCLUSIONS We cannot be certain based on available evidence whether daily oral prednisone improves impairment compared to no treatment. However, corticosteroids are commonly used, based on widespread availability, low cost, very low-quality evidence from observational studies, and clinical experience. The weakness of the evidence does not necessarily mean that corticosteroids are ineffective. High-dose monthly oral dexamethasone for six months is probably no more or less effective than daily oral prednisolone. Plasma exchange produces short-term improvement in impairment as determined by neurological examination, and probably produces short-term improvement in disability. IVIg produces more short-term improvement in disability than placebo and more adverse events, although serious side effects are probably no more common than with placebo. There is no clear difference in short-term improvement in impairment with IVIg when compared with intravenous methylprednisolone and probably no improvement when compared with either oral prednisolone or plasma exchange. According to observational studies, adverse events related to difficult venous access, use of citrate, and haemodynamic changes occur in 3% to17% of plasma exchange procedures.It is uncertain whether azathioprine is of benefit as the quality of evidence is very low. Methotrexate may not be of benefit and IFN beta-1a is probably not of benefit.We need further research to identify predictors of response to different treatments and to compare their long-term benefits, safety and cost-effectiveness. There is a need for more randomised trials of immunosuppressive and immunomodulatory agents, routes of administration, and treatments for symptoms of CIDP.
Collapse
Affiliation(s)
| | - Michael PT Lunn
- National Hospital for Neurology and NeurosurgeryDepartment of Neurology and MRC Centre for Neuromuscular DiseasesQueen SquareLondonUKWC1N 3BG
| | - Richard AC Hughes
- National Hospital for Neurology and NeurosurgeryMRC Centre for Neuromuscular DiseasesPO Box 114Queen SquareLondonUKWC1N 3BG
| | - Ivo N van Schaik
- Academic Medical Centre, University of AmsterdamDepartment of NeurologyMeibergdreef 9PO Box 22700AmsterdamNetherlands1100 DE
| | - Chris Frost
- London School of Hygiene & Tropical MedicineDepartment of Medical StatisticsKeppel StreetLondonUKWC1E 7HT
| | - Colin H Chalk
- McGill UniversityDepartment of Neurology & NeurosurgeryMontreal General Hospital ‐ Room L7‐3131650 Cedar AvenueMontrealQCCanadaH3G 1A4
| | | |
Collapse
|
71
|
[Immune-mediated neuropathies]. DER NERVENARZT 2016; 87:887-98. [PMID: 27474733 DOI: 10.1007/s00115-016-0164-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The Guillain-Barré syndrome (GBS) and chronic inflammatory demyelinating polyneuropathy (CIDP) are the most common immune-mediated polyneuropathies, which can show variable clinical and electrophysiological manifestations. Rarer immune-mediated neuropathies encompass paraproteinemic neuropathies (PPN), multifocal motor neuropathy (MMN) and vasculitic neuropathies. The diagnosis usually relies on the history of symptom evolution, distribution of nerve dysfunction and particularly on characteristic features in nerve conduction studies, aided by cerebrospinal fluid (CSF) examination and nerve biopsy findings. The therapeutic toolbox encompasses corticosteroids, immunoglobulins and plasmapheresis often accompanied by long-term immunosuppression. It is important to note that immune-mediated neuropathies selectively respond to treatment and contraindications need to be considered. Despite treatment a considerable number of patients suffer from permanent neurological deficits.
Collapse
|
72
|
Abstract
Primary Sjögren syndrome (pSS) is a progressive autoimmune disease characterized by sicca and systemic manifestations. In this Review, we summarize the available data on topical and systemic medications, according to clinical signs and disease activity, and we describe the ongoing studies using biologic drugs in the treatment of pSS. Expanding knowledge about the epidemiology, classification criteria, systemic activity scoring (ESSDAI) and patient-reported outcomes (ESSPRI) is driving active research. Treatment decisions are based on the evaluation of symptoms and extraglandular manifestations. Symptomatic treatment is usually appropriate, whereas systemic treatment is reserved for systemic manifestations. Sicca is managed by education, environment modification, elimination of contingent offending drugs, artificial tears, secretagogues and treatments for complications. Mild systemic signs such as fatigue are treated by exercise. Pain can require short-term moderate-dose glucocorticoid therapy and, in some cases, disease-modifying drugs. Severe and acute systemic manifestations indicate treatment with glucocorticoids and/or immunosuppressant drugs. The role for biologic agents is promising, but no double-blind randomized controlled trials (RCTs) proving the efficacy of these drugs are available. Targets for new treatments directed against the immunopathological mechanisms of pSS include epithelial cells, T cells, B-cell overactivity, the interferon signature, proinflammatory cytokines, ectopic germinal centre formation, chemokines involved in lymphoid cell homing, and epigenetic modifications.
Collapse
Affiliation(s)
- Alain Saraux
- EA2216, INSERM ESPRI ERI29, Laboratoire d'Immunothérapie et Pathologies lymphocytaires B, Université de Brest, Labex 'Immunotherapy, Graft, Oncology', 29609 Brest Cedex, France.,Department of Rheumatology, Centre Hospitalier Universitaire de la Cavale Blanche, 29609 Brest, France
| | - Jacques-Olivier Pers
- Department of Rheumatology, Centre Hospitalier Universitaire de la Cavale Blanche, 29609 Brest, France
| | - Valérie Devauchelle-Pensec
- EA2216, INSERM ESPRI ERI29, Laboratoire d'Immunothérapie et Pathologies lymphocytaires B, Université de Brest, Labex 'Immunotherapy, Graft, Oncology', 29609 Brest Cedex, France.,Department of Rheumatology, Centre Hospitalier Universitaire de la Cavale Blanche, 29609 Brest, France
| |
Collapse
|
73
|
Vanhoutte EK, Draak THP, Gorson KC, van Nes SI, Hoeijmakers JGJ, Van der Pol WL, Notermans NC, Lewis RA, Nobile-Orazio E, Léger JM, Van den Bergh PYK, Lauria G, Bril V, Katzberg H, Lunn MPT, Pouget J, van der Kooi AJ, Hahn AF, van Doorn PA, Cornblath DR, van den Berg LH, Faber CG, Merkies ISJ. Impairment measures versus inflammatory RODS in GBS and CIDP: a responsiveness comparison. J Peripher Nerv Syst 2016; 20:289-95. [PMID: 26114893 DOI: 10.1111/jns.12118] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 05/10/2015] [Accepted: 06/10/2015] [Indexed: 01/02/2023]
Abstract
This study aimed to 'define responder' through the concept of minimum clinically important differences using the individually obtained standard errors (MCID-SE) and a heuristic 'external criterion' responsiveness method in patients with Guillain-Barré syndrome (GBS) and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). One hundred and fourteen newly diagnosed or relapsing patients (GBS: 55, CIDP: 59) were serially examined (1-year follow-up). The inflammatory Rasch-built overall disability scale (I-RODS), Rasch-transformed MRC sum score (RT-MRC), and Rasch-transformed modified-INCAT-sensory scale (RT-mISS) were assessed. Being-a-responder was defined as having a MCID-SE cut-off ≥1.96. Also, the correlations between patients' scores on each scale and the EuroQoL health-status 'thermometer' (external criterion) were determined (higher correlation indicated better responsiveness). In both diseases, the SEs showed a characteristic 'U'-shaped dynamic pattern across each scales' continuum. The number of patients showing a meaningful change were higher for the I-RODS > RT-MRC > RT-mISS and were in GBS higher than CIDP patients. The MCID-SE concept using Rasch-transformed data demonstrated an individual pattern of 'being-a-responder' in patients with immune-mediated neuropathies, and the findings were validated by the external criterion responsiveness method. The I-RODS showed greater responsiveness compared with the MRC and INCAT-sensory scales, and its use is therefore recommended in future trials in GBS and CIDP.
Collapse
Affiliation(s)
- Els K Vanhoutte
- Department of Clinical Genetics, University Medical Centre Maastricht, Maastricht, The Netherlands
| | - Thomas H P Draak
- Department of Neurology, University Medical Centre Maastricht, Maastricht, The Netherlands
| | - Kenneth C Gorson
- Department of Neurology, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Sonja I van Nes
- Department of Neurology, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
| | | | - W-Ludo Van der Pol
- Department of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Nicolette C Notermans
- Department of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Richard A Lewis
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Eduardo Nobile-Orazio
- Department of Neurological Sciences, Humanitas Clinical Institute, Milan University, Milan, Italy
| | - Jean-Marc Léger
- Department of Neurology, Hôpital de la Salpêtrière, Paris, France
| | | | - Giuseppe Lauria
- Neuromuscular Diseases Unit, National Neurological Institute "Carlo Besta", Milan, Italy
| | - Vera Bril
- Department of Neurology, Toronto General Hospital, Toronto, Canada
| | - Hans Katzberg
- Department of Neurology, Toronto General Hospital, Toronto, Canada
| | - Michael P T Lunn
- Department of Neurology, Centre for Neuromuscular Disease, National Hospital for Neurology and Neurosurgery, London, UK
| | - Jean Pouget
- Department of Neurology, Centre de Référence des Maladies Neuromusculaires et de la SLA, Hôpital de La Timone, Marseille, France
| | | | - Angelika F Hahn
- Department of Neurology, London Health Science Center, London, Canada
| | - Pieter A van Doorn
- Department of Neurology, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - David R Cornblath
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Leonard H van den Berg
- Department of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Catharina G Faber
- Department of Neurology, University Medical Centre Maastricht, Maastricht, The Netherlands
| | - Ingemar S J Merkies
- Department of Neurology, University Medical Centre Maastricht, Maastricht, The Netherlands.,Department of Neurology, Spaarne Hospital, Hoofddorp, The Netherlands
| | | |
Collapse
|
74
|
Press R, Hiew FL, Rajabally YA. Steroids for chronic inflammatory demyelinating polyradiculoneuropathy: evidence base and clinical practice. Acta Neurol Scand 2016; 133:228-38. [PMID: 26437234 DOI: 10.1111/ane.12519] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2015] [Indexed: 12/26/2022]
Abstract
Evidence-based therapies for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) consist of corticosteroids, intravenous immunglobulins (IVIg), and plasma exchange. Steroids represent the oldest treatment used historically. In countries where readily available and affordable, IVIg tends to be favored as first-line treatment. The reason for this preference, despite substantially higher costs, is the perception that IVIg is more efficacious and safer than corticosteroids. However, the unselected use of IVIg as a first-line treatment option in all cases of CIDP raises issues of cost-effectiveness in the long-term. Furthermore, serious although rare, particularly thromboembolic side effects may result from their use. Recent data from randomized trials suggest pulsed corticosteroids to have a higher potential in achieving therapy-free remission or longer remission-free periods compared with IVIg, as well as relatively low rates of serious side effects when given as pulsed intravenous infusions during short periods of time. These specific advantages suggest that pulsed steroids could in many cases be used, as the first, rather than second choice of treatment when initiating immunomodulation in CIDP, primarily in hopes of achieving a remission after the short-term use. This article reviews the evidence base for the use of corticosteroids in its various forms in CIDP and factors that may influence clinicians' choice between IVIg and pulsed steroid treatment. The issue of efficacy, relapse rate and time, and side effect profile are analyzed, and some aspects from the authors' experience are discussed in relation to the possibility of using the steroid option as first-line therapy in a large proportion of patients with CIDP.
Collapse
Affiliation(s)
- R. Press
- Department of Neurology; Clinical Neuroscience; Karolinska Institute; Karolinska University Hospital Huddinge; Stockholm Sweden
| | - F. L. Hiew
- Regional Neuromuscular Clinic; Queen Elizabeth Hospital; University Hospitals of Birmingham; Birmingham UK
| | - Y. A. Rajabally
- Regional Neuromuscular Clinic; Queen Elizabeth Hospital; University Hospitals of Birmingham; Birmingham UK
| |
Collapse
|
75
|
Kleyman I, Brannagan TH. Treatment of chronic inflammatory demyelinating polyneuropathy. Curr Neurol Neurosci Rep 2016; 15:47. [PMID: 26008811 DOI: 10.1007/s11910-015-0563-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is one of the acquired demyelinating neuropathies and is considered to be immune mediated. Diagnosis is typically based on clinical history, neurologic examination, electrophysiologic studies, CSF studies, and pathologic examination. Early diagnosis and treatment is important to prevent irreversible axonal loss and optimize improvement in function. The first-line agents for treatment are intravenous immunoglobulin (IVIg), corticosteroids, and plasmapheresis, which have all been demonstrated to be effective in controlled studies. Studies have not shown a significant difference between these three treatments, and the initial choice of therapy is often based on availability, cost, ease of administration, and side effect profile. If patients do not respond to one of these agents, they may respond to one of the others and sometimes in combination. If the first-line agents are not effective, chemotherapeutic or immunosuppressive agents may be considered. There are limited controlled studies of these modalities, and they are often used in conjunction with a first-line treatment. The majority of patients require long-term therapy to maintain a response and to prevent relapse.
Collapse
Affiliation(s)
- Inna Kleyman
- Peripheral Neuropathy Center, Neurological Institute, Columbia University, College of Physicians and Surgeons, 710 W 168th St, box 163, New York, NY, 10032, USA,
| | | |
Collapse
|
76
|
Mathis S, Vallat JM, Magy L. Novel immunotherapeutic strategies in chronic inflammatory demyelinating polyneuropathy. Immunotherapy 2016; 8:165-78. [PMID: 26809024 DOI: 10.2217/imt.15.107] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a chronic immune-mediated neuropathy: it is clinically heterogeneous (relapsing-remitting form, chronic progressive form, monophasic form or CIDP having a Guillain-Barré syndrome-like onset), but potentially treatable. Although its pathophysiology remains largely unknown, CIDP is considered an immune-mediated neuropathy. Therefore, many immunotherapies have been proposed in this peripheral nervous system disorder, the most known efficient treatments being intravenous immunoglobulin, corticosteroids and plasma exchange. However, these therapies remain unsatisfactory for many patients, so numerous other immunotherapeutic strategies have been evaluated, based on their immunosuppressant or immunomodulatory potency. We have performed a large review of the literature about treatment in CIDP, with a special emphasis on novel and alternative immunotherapeutic strategies.
Collapse
Affiliation(s)
- Stéphane Mathis
- Department of Neurology, University Hospital of Poitiers, 2 Rue de la Milétrie, 86021 Poitiers, France
| | - Jean-Michel Vallat
- Department of Neurology, Centre de Référence "Neuropathies Périphériques Rares", University Hospital of Limoges, 2 Avenue Martin Luther King, 87042 Limoges, France
| | - Laurent Magy
- Department of Neurology, Centre de Référence "Neuropathies Périphériques Rares", University Hospital of Limoges, 2 Avenue Martin Luther King, 87042 Limoges, France
| |
Collapse
|
77
|
Berthon BS, Gibson PG, McElduff P, MacDonald-Wicks LK, Wood LG. Effects of short-term oral corticosteroid intake on dietary intake, body weight and body composition in adults with asthma - a randomized controlled trial. Clin Exp Allergy 2016; 45:908-919. [PMID: 25640664 DOI: 10.1111/cea.12505] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 11/02/2014] [Accepted: 11/12/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND Oral corticosteroids (OCS) are an efficacious treatment for asthma exacerbations, yet risk of adverse effects may decrease patient adherence to therapy. In particular, changes in appetite and dietary intake, which lead to weight gain and changes in body composition, are considered undesirable. OBJECTIVE To determine whether 10-day OCS therapy in adults with asthma causes changes in leptin, appetite, dietary intake, body weight and body composition. METHODS Double-blinded, placebo-controlled randomized cross-over trial of 10 days prednisolone (50 mg) in adults with stable asthma (n = 55) (ACTRN12611000562976). Pre- and post-assessment included spirometry, body weight, body composition measured by dual-energy X-ray absorptiometry and bioelectrical impedance analysis, appetite measured using a validated visual analogue scale (VAS) and dietary intake assessed using 4-day food records. Leptin was measured as a biomarker of appetite and eosinophils as an adherence biomarker. Outcomes were analysed by generalized linear mixed models. RESULTS Subject adherence was confirmed by a significant decrease in blood eosinophils (× 10(9) /L) following prednisolone compared to placebo [Coef. -0.29, 95% CI: (-0.39, -0.19) P < 0.001]. There was no difference in serum leptin (ng/mL) [Coef. 0.13, 95% CI: (-3.47, 3.72) P = 0.945] or appetite measured by VAS (mm) [Coef. -4.93, 95% CI: (-13.64, 3.79) P = 0.267] following prednisolone vs. placebo. There was no difference in dietary intake (kJ/day) [Coef. 255, 95% CI: (-380, 891) P = 0.431], body weight (kg) [Coef. -0.38, 95% CI: (-0.81, 0.05) P = 0.083] or body fat (%) [Coef. -0.31, 95% CI: (-0.81, 0.20) P = 0.230]. Symptoms including sleep and gastrointestinal disturbance were reported significantly more often during prednisolone vs. placebo. CONCLUSIONS AND CLINICAL RELEVANCE Short-term OCS in stable asthma did not induce significant changes in appetite, dietary intake, body weight or composition, although other adverse effects may require medical management. This evidence may assist in increasing medication adherence of asthmatics prescribed OCS for exacerbations.
Collapse
Affiliation(s)
- B S Berthon
- Centre for Asthma and Respiratory Disease, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - P G Gibson
- Centre for Asthma and Respiratory Disease, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - P McElduff
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - L K MacDonald-Wicks
- School of Health Sciences, University of Newcastle, Newcastle, NSW, Australia
| | - L G Wood
- Centre for Asthma and Respiratory Disease, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| |
Collapse
|
78
|
Abstract
Immunotherapy has been investigated in a small subset of peripheral neuropathies, including an acute one, Guillain-Barré syndrome, and 3 chronic forms: chronic inflammatory demyelinating polyradiculoneuropathy, multifocal motor neuropathy, and neuropathy associated with IgM anti-myelin-associated glycoprotein. Several experimental studies and clinical data are strongly suggestive of an immune-mediated pathogenesis. Either cell-mediated mechanisms or antibody responses to Schwann cell, compact myelin, or nodal antigens are considered to act together in an aberrant immune response to cause damage to peripheral nerves. Immunomodulatory treatments used in these neuropathies aim to act at various steps of this pathogenic process. However, there are many phenotypic variants and, consequently, there is a significant difference in the response to immunotherapy between these neuropathies, as well as a need to improve our knowledge and long-term management of chronic forms.
Collapse
Affiliation(s)
- Jean-Marc Léger
- National Referral Center for Rare Neuromuscular Diseases, Institut Hospitalo-Universitaire de Neurosciences, University Hospital Pitié-Salpêtrière and University Pierre et Marie Curie (Paris VI), Paris, France.
| | - Raquel Guimarães-Costa
- National Referral Center for Rare Neuromuscular Diseases, Institut Hospitalo-Universitaire de Neurosciences, University Hospital Pitié-Salpêtrière and University Pierre et Marie Curie (Paris VI), Paris, France
| | - Cristina Muntean
- National Referral Center for Rare Neuromuscular Diseases, Institut Hospitalo-Universitaire de Neurosciences, University Hospital Pitié-Salpêtrière and University Pierre et Marie Curie (Paris VI), Paris, France
| |
Collapse
|
79
|
Abstract
Peripheral neuropathies are diseases of the peripheral nervous system that can be divided into mononeuropathies, multifocal neuropathies, and polyneuropathies. Symptoms usually include numbness and paresthesia. These symptoms are often accompanied by weakness and can be painful. Polyneuropathies can be divided into axonal and demyelinating forms, which is important for diagnostic reasons. Most peripheral neuropathies develop over months or years, but some are rapidly progressive. Some patients only suffer from mild, unilateral, slowly progressive tingling in the fingers due to median nerve compression in the wrist (carpal tunnel syndrome), while other patients can be tetraplegic, with respiratory insufficiency within 1-2 days due to Guillain-Barré syndrome. Carpal tunnel syndrome, with a prevalence of 5% and incidence of 1-2 per 1000 person-years, is the most common mononeuropathy. Population-based data for chronic polyneuropathy are relatively scarce. Prevalence is estimated at 1% and increases to 7% in persons over 65 years of age. Incidence is approximately 1 per 1000 person-years. Immune-mediated polyneuropathies like Guillain-Barré syndrome and chronic inflammatory demyelinating polyradiculoneuropathy are rare diseases, with an annual incidence of approximately 1-2 and 0.2-0.5 per 100 000 persons respectively. Most peripheral neuropathies are more prevalent in older adults and in men, except for carpal tunnel syndrome, which is more common in women. Diabetes is a common cause of peripheral neuropathy and is associated with both mono- and polyneuropathies. Among the group of chronic polyneuropathies, in about 20-25% no direct cause can be found. These are slowly progressive axonal polyneuropathies.
Collapse
Affiliation(s)
- R Hanewinckel
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - M A Ikram
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - P A Van Doorn
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
80
|
Rajabally YA. Tailoring of therapy for chronic inflammatory demyelinating polyneuropathy. Neural Regen Res 2015; 10:1399-400. [PMID: 26604894 PMCID: PMC4625499 DOI: 10.4103/1673-5374.165594] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Yusuf A Rajabally
- Regional Neuromuscular Clinic, Queen Elizabeth Hospital, University Hospitals of Birmingham, Birmingham, UK
| |
Collapse
|
81
|
|
82
|
Dyck PJ, Taylor BV, Davies JL, Mauermann ML, Litchy WJ, Klein CJ, Dyck PJB. Office immunotherapy in chronic inflammatory demyelinating polyneuropathy and multifocal motor neuropathy. Muscle Nerve 2015; 52:488-97. [PMID: 25976871 DOI: 10.1002/mus.24707] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2015] [Indexed: 12/13/2022]
Abstract
Intravenous immunoglobulin [IVIg], plasma exchange [PE], and corticosteroids are efficacious treatment in chronic inflammatory demyelinating polyneuropathy [CIDP]. IVIg is effective in multifocal motor neuropathy [MMN]. NIS, NIS-weakness, sum scores of raw amplitudes of motor fiber (CMAPs) amplitudes, and Dyck/Rankin score provided reliable measures to detect and scale abnormality and reflect change; they are therefore ideal for office management of response-based immunotherapy (R-IRx) of CIDP. Using efficacious R-IRx, a large early and late therapeutic response (≥ one-fourth were in remission or had recovered) was demonstrated in CIDP. In MMN only an early improvement with late non-significant worsening was observed. The difference in immunotherapy response supports a fundamental difference between CIDP (immune attack on Schwann cells and myelin) and MMN (attack on nodes of Ranvier and axons).
Collapse
Affiliation(s)
- Peter J Dyck
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905, USA
| | | | - Jenny L Davies
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905, USA
| | - Michelle L Mauermann
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905, USA
| | - William J Litchy
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905, USA
| | - Christopher J Klein
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905, USA
| | - P James B Dyck
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905, USA
| |
Collapse
|
83
|
|
84
|
Guo X, Yasen H, Zhao F, Wang L, Sun M, Pang N, Wang X, Zhang Y, Ding J, Ma X. The effect of single course high dose dexamethasone on CD28/CTLA-4 balance in the treatment of patients with newly diagnosed primary immune thrombocytopenia. Hum Vaccin Immunother 2015. [PMID: 26211942 PMCID: PMC4962720 DOI: 10.1080/21645515.2015.1059975] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
To evaluate the effect of a single course of high dose dexamethasone (HD-DXM) on CD28 and CTLA-4 expression in patients with newly-diagnosed primary immune thrombocytopenia (ITP). Twenty-8 ITP patients (18 females and 10 males, age range 18–65 years, median age 38.5 years) enrolled in this study and 26 healthy volunteers (19 women and 7 men, age range 16–66 years, median age 37 years) served as a control group. The patients were treated with HD-DXM (40 mg/day) for 4 consecutive days. CD28 and CTLA-4 expression was assessed by flow cytometry once-monthly for 6 months. Plasma levels of the cytokines IFN-γ and IL-10 were determined by enzyme-linked immunosorbent assay. One month after treatment, a platelet response was observed in 23 (82%) of the patients. The response rates over the next 5 months were 71%, 57%, 53%, 46%, and 39%, chronologically. We observed a significant decrease in CD28 expression after the first month (34.7 ± 4.8% vs. 44.5 ± 4.4% before treatment), after which the CD28 levels gradually increased. In contrast, CTLA-4 expression increased after the first month (3.2 ± 0.5% vs. 0.8 ± 0.4 before treatment), after which the CTLA-4 levels gradually decreased. Similar dynamic changes were seen in the levels of IFN-γ and IL-10. The dynamic changes of CD28 and CTLA-4 were consistent with those of IFN-γ and IL-10 and with the effectiveness of HD-DXM in the treatment of ITP. Our results suggest that a disturbed CD28/CTLA-4 balance may contribute to the immunopathogenesis of ITP.
Collapse
Affiliation(s)
- Xinhong Guo
- a State Key Laboratory Incubation Base of Xinjiang Major Diseases Research (2010DS890294); Xinjiang Key Laboratory of Echinococcosis; First Affiliated Hospital of Xinjiang Medical University ; Urumqi, Xinjiang , PR China
| | - Halida Yasen
- a State Key Laboratory Incubation Base of Xinjiang Major Diseases Research (2010DS890294); Xinjiang Key Laboratory of Echinococcosis; First Affiliated Hospital of Xinjiang Medical University ; Urumqi, Xinjiang , PR China
| | - Fang Zhao
- a State Key Laboratory Incubation Base of Xinjiang Major Diseases Research (2010DS890294); Xinjiang Key Laboratory of Echinococcosis; First Affiliated Hospital of Xinjiang Medical University ; Urumqi, Xinjiang , PR China
| | - Lei Wang
- a State Key Laboratory Incubation Base of Xinjiang Major Diseases Research (2010DS890294); Xinjiang Key Laboratory of Echinococcosis; First Affiliated Hospital of Xinjiang Medical University ; Urumqi, Xinjiang , PR China
| | - Mingling Sun
- a State Key Laboratory Incubation Base of Xinjiang Major Diseases Research (2010DS890294); Xinjiang Key Laboratory of Echinococcosis; First Affiliated Hospital of Xinjiang Medical University ; Urumqi, Xinjiang , PR China
| | - Nannan Pang
- a State Key Laboratory Incubation Base of Xinjiang Major Diseases Research (2010DS890294); Xinjiang Key Laboratory of Echinococcosis; First Affiliated Hospital of Xinjiang Medical University ; Urumqi, Xinjiang , PR China
| | - Xiujuan Wang
- a State Key Laboratory Incubation Base of Xinjiang Major Diseases Research (2010DS890294); Xinjiang Key Laboratory of Echinococcosis; First Affiliated Hospital of Xinjiang Medical University ; Urumqi, Xinjiang , PR China
| | - Ying Zhang
- a State Key Laboratory Incubation Base of Xinjiang Major Diseases Research (2010DS890294); Xinjiang Key Laboratory of Echinococcosis; First Affiliated Hospital of Xinjiang Medical University ; Urumqi, Xinjiang , PR China
| | - Jianbing Ding
- a State Key Laboratory Incubation Base of Xinjiang Major Diseases Research (2010DS890294); Xinjiang Key Laboratory of Echinococcosis; First Affiliated Hospital of Xinjiang Medical University ; Urumqi, Xinjiang , PR China.,b College of Basic Medicine of Xinjiang Medical University ; Urumqi, Xinjiang , PR China
| | - Xiumin Ma
- a State Key Laboratory Incubation Base of Xinjiang Major Diseases Research (2010DS890294); Xinjiang Key Laboratory of Echinococcosis; First Affiliated Hospital of Xinjiang Medical University ; Urumqi, Xinjiang , PR China.,b College of Basic Medicine of Xinjiang Medical University ; Urumqi, Xinjiang , PR China
| |
Collapse
|
85
|
Allen JA, Lewis RA. CIDP diagnostic pitfalls and perception of treatment benefit. Neurology 2015; 85:498-504. [PMID: 26180143 DOI: 10.1212/wnl.0000000000001833] [Citation(s) in RCA: 159] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 03/27/2015] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE We aimed to explore the diagnosis and misdiagnosis of chronic inflammatory demyelinating polyneuropathy (CIDP) and to identify pitfalls that erroneously lead to a misdiagnosis. METHODS A retrospective study of 59 consecutive patients referred with a diagnosis of CIDP was performed. Patients were classified as having or not having CIDP according to European Federation of Neurological Societies/Peripheral Nerve Society (EFNS/PNS) criteria. Diagnostic and treatment data were compared in the 2 groups. RESULTS Forty-seven percent of patients referred with a diagnosis of CIDP failed to meet minimal CIDP diagnostic requirements. All misdiagnosed patients who satisfied EFNS/PNS clinical criteria would be considered atypical as defined by the EFNS/PNS. CSF cytoalbuminologic dissociation was present in 50% of those without CIDP, although protein elevations were generally mild. Nerve conduction studies in patients without CIDP were heterogeneous, but generally showed demyelinating features better explained by a process other than CIDP. Patients frequently reported improvements after being treated with immunotherapy, even if the CIDP diagnosis was incorrect. CONCLUSIONS CIDP misdiagnosis is common. Over-reliance on subjective patient-reported perception of treatment benefit, liberal electrophysiologic interpretation of demyelination, and placing an overstated importance on mild or moderate cytoalbuminologic dissociation are common diagnostic errors. Utilization of clear and objective indicators of treatment efficacy might improve our ability to make informed treatment decisions.
Collapse
Affiliation(s)
- Jeffrey A Allen
- From the Department of Neurology (J.A.A.), University of Minnesota, Minneapolis; the Department of Neurology (J.A.A.), Northwestern University, Chicago, IL; and the Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Richard A Lewis
- From the Department of Neurology (J.A.A.), University of Minnesota, Minneapolis; the Department of Neurology (J.A.A.), Northwestern University, Chicago, IL; and the Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA
| |
Collapse
|
86
|
Nobile-Orazio E, Cocito D, Jann S, Uncini A, Messina P, Antonini G, Fazio R, Gallia F, Schenone A, Francia A, Pareyson D, Santoro L, Tamburin S, Cavaletti G, Giannini F, Sabatelli M, Beghi E. Frequency and time to relapse after discontinuing 6-month therapy with IVIg or pulsed methylprednisolone in CIDP. J Neurol Neurosurg Psychiatry 2015; 86:729-34. [PMID: 25246645 DOI: 10.1136/jnnp-2013-307515] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Accepted: 08/12/2014] [Indexed: 11/04/2022]
Abstract
BACKGROUND We reported that 6-month therapy with intravenous immunoglobulin (IVIg) was more frequently effective or tolerated than intravenous methylprednisolone (IVMP) in patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). We now retrospectively compared the proportion of patients who eventually worsened after discontinuing therapy and the median time to clinical worsening. METHODS By March 2013, data were available from 41 of the 45 patients completing the trial with a median follow-up after therapy discontinuation of 42 months (range 1-60). Three patients withdrew during the original study and one failed to respond to either of the therapies. No patient received a diagnosis alternative to CIDP during the follow-up. RESULTS Twenty-eight of the 32 patients treated with IVIg (as primary or secondary therapy after failing to respond to IVMP) improved after therapy (87.5%) as compared with 13 of the 24 patients treated with IVMP as primary or secondary therapy (54.2%). After a median follow-up of 42 months (range 1-57), 24 out of 28 patients responsive to IVIg (85.7%) worsened after therapy discontinuation. The same occurred in 10 out of 13 patients (76.9%) responsive to IVMP (p=0.659) after a median follow-up of 43 months (range 7-60). Worsening occurred 1-24 months (median 4.5) after IVIg discontinuation and 1-31 months (median 14) after IVMP discontinuation (p=0.0126). CONCLUSIONS A similarly high proportion of patients treated with IVIg or IVMP eventually relapse after therapy discontinuation but the median time to relapse was significantly longer after IVMP than IVIg. This difference may help to balance the more frequent response to IVIg than to IVMP in patients with CIDP.
Collapse
Affiliation(s)
- Eduardo Nobile-Orazio
- 2nd Neurology, Department of Medical Biotechnology and Translational Medicine, Milan University, Humanitas Clinical and Research Center, Milan, Italy
| | - Dario Cocito
- Department of Neuroscience, A.O. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Stefano Jann
- Department of Neuroscience, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Antonino Uncini
- Department of Neuroscience and Imaging, University "G. D'Annunzio", SS Annunziata Hospital, Chieti, Italy
| | - Paolo Messina
- Laboratory of Neurological Disorders, IRCCS Mario Negri Institute, Milan, Italy
| | - Giovanni Antonini
- Department of Neuroscience, Mental Health and Sensory Organs, Rome University "Sapienza", Sant'Andrea Hospital, Rome, Italy
| | - Raffaella Fazio
- Department of Neurology, San Raffaele Scientific Institute, INSPE, Milan, Italy
| | - Francesca Gallia
- 2nd Neurology, Department of Medical Biotechnology and Translational Medicine, Milan University, Humanitas Clinical and Research Center, Milan, Italy
| | - Angelo Schenone
- Department of Neuroscience, Ophthalmology and Genetics, Genoa University, San Martino Hospital, Genoa, Italy
| | - Ada Francia
- Department of Neurology and Psychiatry, Umberto I° Policlinico, Rome, Italy
| | - Davide Pareyson
- Central and Peripheral Degenerative Neuropathy Unit, IRCCS Foundation, Carlo Besta Neurological Institute, Milan, Italy
| | - Lucio Santoro
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, Federico II° University, Naples, Italy
| | - Stefano Tamburin
- Department of Neurological and Movement Sciences, Verona University, Policlinico G.B. Rossi, Verona, Italy
| | - Guido Cavaletti
- Department of Surgery and Translational Medicine, Milan Bicocca University, San Gerardo Hospital, Monza, Italy
| | - Fabio Giannini
- Department of Medical and Surgical Sciences and Neurosciences, Siena University, Policlinico Le Scotte, Siena, Italy
| | - Mario Sabatelli
- Department of Neurology, Catholic University, Policlinico Gemelli, Rome, Italy
| | - Ettore Beghi
- Laboratory of Neurological Disorders, IRCCS Mario Negri Institute, Milan, Italy
| | | |
Collapse
|
87
|
Abstract
PURPOSE OF REVIEW Acquired immune demyelinating neuropathies refer to a group of disorders that share overlapping sensory, motor, and autonomic clinical, laboratory, and electrodiagnostic features. It is important to recognize acquired immune demyelinating neuropathies as they are generally responsive to immunosuppressive or immunomodulatory therapies. RECENT FINDINGS This article reviews recently developed early prognostic tools in Guillain-Barré syndrome and discusses the evolving understanding of chronic demyelinating phenotypes with differing treatment responsiveness. SUMMARY While weakness and numbness progress over 2 to 4 weeks in Guillain-Barré syndrome, they continue to evolve beyond 8 weeks in chronic inflammatory demyelinating polyradiculoneuropathy and over 4 to 8 weeks in subacute inflammatory demyelinating polyradiculoneuropathy. Acquired immune demyelinating neuropathies present uncommonly as variants with predominance of ocular, bulbar, sensory, autonomic, or motor manifestations in addition to regional variants, such as paraparetic acquired immune demyelinating neuropathies. Establishing the correct diagnosis is important as these immune disorders differ in response to corticosteroids and other immunosuppressive therapies.
Collapse
|
88
|
Klehmet J, Staudt M, Ulm L, Unterwalder N, Meisel A, Meisel C. Circulating lymphocyte and T memory subsets in glucocorticosteroid versus IVIG treated patients with CIDP. J Neuroimmunol 2015; 283:17-22. [DOI: 10.1016/j.jneuroim.2015.03.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 03/10/2015] [Accepted: 03/12/2015] [Indexed: 11/16/2022]
|
89
|
Stoll SS, Rakocevic G. Severe acute inflammatory demyelinating polyradiculoneuropathy with persistent weakness associated with tumor-like nerve root enlargement. J Clin Neuromuscul Dis 2015; 16:220-222. [PMID: 25996968 DOI: 10.1097/cnd.0000000000000076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
We report a 23-year-old woman with rapid onset of proximal and distal limb weakness and areflexia, associated with tumor-like spinal nerve root enlargement and markedly elevated cerebrospinal fluid protein. Our patient developed the inability to walk within days, without preceding illness. Within two weeks, she had near-complete bilateral wrist and foot drop. Her cranial nerves and respiratory function remained intact. She received intravenous immunoglobulin early on for suspected Guillain-barre syndrome but remained wheelchair-bound until 6 Plasma exchange sessions were completed. After that, she continued to improve with intravenous immunoglobulin dosed every 3-4 weeks. Prominent demyelinating features were found on NCS, with cerebrospinal fluid protein of 415 mg/dL. Comprehensive infectious work-up was negative. Magnetic resonance imaging of lumbosacral and cervical spine showed tumor-like masses mistaken for neurofibromatosis (axial diameter, 7.5-10 mm). Repeated magnetic resonance imaging 6 months later showed persistent nerve root enlargement, despite the patient's improved functional status.
Collapse
Affiliation(s)
- Sharon S Stoll
- *Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, PA; and †Department of Neurology, Thomas Jefferson University, Philadelphia, PA
| | | |
Collapse
|
90
|
Chroni E, Veltsista D, Gavanozi E, Vlachou T, Polychronopoulos P, Papathanasopoulos P. Pure sensory chronic inflammatory polyneuropathy: rapid deterioration after steroid treatment. BMC Neurol 2015; 15:27. [PMID: 25885891 PMCID: PMC4359520 DOI: 10.1186/s12883-015-0291-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 02/25/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic inflammatory demyelinating polyneuropathy (CIDP) as a pure sensory variant is rarely encountered. Therefore the best treatment option is hard to define. CASE PRESENTATIONS We reported two middle-aged patients of Caucasian origin, one female and one male, who over a period of several months presented limbs and gait ataxia. Clinical and neurophysiological examination revealed only sensory abnormalities. A diagnosis of atypical CIDP was suggested, considering the elevated CSF protein level and the presence of anti-gangliosides antibodies. Ten and 15 days respectively after initiation of prednisolone treatment both patients experienced exacerbation of sensory symptoms and emerging of muscle weakness. Steroids were then substituted by rituximab in the first patient and intravenous immunoglobulin in the second patient resulting in gradual decrement of symptoms and signs. Two-year follow-up showed no further deterioration. CONCLUSION Caution should be exercised when treating cases of pure sensory polyneuropathy with high dose steroids since an unfavorable outcome is possible.
Collapse
Affiliation(s)
- Elisabeth Chroni
- Department of Neurology, School of Medicine, University of Patras, Patras, Greece. .,Department of Neurology, University Hospital of Patras, Rion, 26504, Greece.
| | - Dimitra Veltsista
- Department of Neurology, School of Medicine, University of Patras, Patras, Greece.
| | - Evangelia Gavanozi
- Department of Neurology, School of Medicine, University of Patras, Patras, Greece.
| | - Tavitha Vlachou
- Department of Neurology, School of Medicine, University of Patras, Patras, Greece.
| | | | | |
Collapse
|
91
|
Hughes RAC, Mehndiratta MM. Corticosteroids for chronic inflammatory demyelinating polyradiculoneuropathy. Cochrane Database Syst Rev 2015; 1:CD002062. [PMID: 25561247 DOI: 10.1002/14651858.cd002062.pub3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a progressive or relapsing and remitting paralysing illness probably due to an autoimmune response which should benefit from corticosteroids. Non-randomised studies suggest that corticosteroids are beneficial. Two commonly used corticosteroids are prednisone and prednisolone. Both are usually given as oral tablets. Prednisone is converted into prednisolone in the liver so that the effect of the two drugs is usually the same. Another corticosteroid, called dexamethasone, is more potent and is used in smaller doses. OBJECTIVES To assess the effects of corticosteroid treatment compared to placebo or no treatment for CIDP and to compare the effects of different corticosteroid regimes. SEARCH METHODS On 27 October 2014 we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, and EMBASE for randomised trials of corticosteroids for CIDP. We searched three other databases for information to include in the Discussion, and clinical trials registries for ongoing trials. SELECTION CRITERIA We included randomised or quasi-randomised trials of treatment with any form of corticosteroids or adrenocorticotrophic hormone for CIDP, diagnosed by an internationally accepted definition. DATA COLLECTION AND ANALYSIS Two authors extracted the data and assessed risk of bias independently. The primary outcome was intended to be change in disability, with change in impairment after 12 weeks as a secondary outcome, and adverse events. MAIN RESULTS In one non-blinded randomised controlled trial (RCT) with 35 eligible participants, the primary outcome for this review was not available. The trial had a high risk of bias. Twelve of 19 participants treated with prednisone, compared with five of 16 participants randomised to no treatment, had improved neuropathy impairment scores after 12 weeks; the risk ratio (RR) for improvement was 2.02 (95% confidence interval (CI) 0.90 to 4.52). Adverse events were not reported in detail, but one prednisone-treated participant died.In a double-blind RCT comparing daily standard-dose oral prednisolone with monthly high-dose oral dexamethasone in 40 participants, none of the outcomes for this review were available. The trial had a low risk of bias. There were no significant differences in remission (RR 1.11; 95% CI 0.50 to 2.45 in favour of monthly dexamethasone) or change in disability or impairment after one year. Eight of 16 in the prednisolone, and seven of 24 in the dexamethasone group deteriorated. Adverse events were similar with each regimen, except that sleeplessness and moon facies (moon-shaped appearance of the face) were significantly less common with monthly dexamethasone.Experience from large non-randomised studies suggests that corticosteroids are beneficial, but long-term use causes serious side effects. AUTHORS' CONCLUSIONS Very low quality evidence from one small, randomised trial did not show a statistically significant benefit from oral prednisone compared with no treatment. Nevertheless, corticosteroids are commonly used in practice. According to moderate quality evidence from one RCT, the efficacy of high-dose monthly oral dexamethasone was not statistically different from that of daily standard-dose oral prednisolone. Most adverse events occurred with similar frequencies in both groups, but sleeplessness and moon facies were significantly less common with monthly dexamethasone. Further research is needed to identify factors which predict response.
Collapse
Affiliation(s)
- Richard A C Hughes
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | | |
Collapse
|
92
|
Kerr J, Quinti I, Eibl M, Chapel H, Späth PJ, Sewell WAC, Salama A, van Schaik IN, Kuijpers TW, Peter HH. Is dosing of therapeutic immunoglobulins optimal? A review of a three-decade long debate in europe. Front Immunol 2014; 5:629. [PMID: 25566244 PMCID: PMC4263903 DOI: 10.3389/fimmu.2014.00629] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 11/25/2014] [Indexed: 12/13/2022] Open
Abstract
The consumption of immunoglobulins (Ig) is increasing due to better recognition of antibody deficiencies, an aging population, and new indications. This review aims to examine the various dosing regimens and research developments in the established and in some of the relevant off-label indications in Europe. The background to the current regulatory settings in Europe is provided as a backdrop for the latest developments in primary and secondary immunodeficiencies and in immunomodulatory indications. In these heterogeneous areas, clinical trials encompassing different routes of administration, varying intervals, and infusion rates are paving the way toward more individualized therapy regimens. In primary antibody deficiencies, adjustments in dosing and intervals will depend on the clinical presentation, effective IgG trough levels and IgG metabolism. Ideally, individual pharmacokinetic profiles in conjunction with the clinical phenotype could lead to highly tailored treatment. In practice, incremental dosage increases are necessary to titrate the optimal dose for more severely ill patients. Higher intravenous doses in these patients also have beneficial immunomodulatory effects beyond mere IgG replacement. Better understanding of the pharmacokinetics of Ig therapy is leading to a move away from simplistic "per kg" dosing. Defective antibody production is common in many secondary immunodeficiencies irrespective of whether the causative factor was lymphoid malignancies (established indications), certain autoimmune disorders, immunosuppressive agents, or biologics. This antibody failure, as shown by test immunization, may be amenable to treatment with replacement Ig therapy. In certain immunomodulatory settings [e.g., idiopathic thrombocytopenic purpura (ITP)], selection of patients for Ig therapy may be enhanced by relevant biomarkers in order to exclude non-responders and thus obtain higher response rates. In this review, the developments in dosing of therapeutic immunoglobulins have been limited to high and some medium priority indications such as ITP, Kawasaki' disease, Guillain-Barré syndrome, chronic inflammatory demyelinating polyradiculoneuropathy, myasthenia gravis, multifocal motor neuropathy, fetal alloimmune thrombocytopenia, fetal hemolytic anemia, and dermatological diseases.
Collapse
Affiliation(s)
- Jacqueline Kerr
- Section Poly- and Monoclonal Antibodies, Paul Ehrlich Institut, Langen, Germany
| | - Isabella Quinti
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Helen Chapel
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Peter J. Späth
- Institute of Pharmacology, University of Bern, Bern, Switzerland
| | | | - Abdulgabar Salama
- Zentrum für Transfusionsmedizin u. Zelltherapie, Charité, Berlin, Germany
| | - Ivo N. van Schaik
- Department of Neurology, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, Netherlands
| | - Taco W. Kuijpers
- Department of Pediatric Hematology, Immunology and Infectious disease, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, Netherlands
| | - Hans-Hartmut Peter
- Centrum für chronische Immunodeficienz (CCI), University Medical Centre, University of Freiburg, Freiburg im Breisgau, Germany
| |
Collapse
|
93
|
Nobile-Orazio E. Chronic inflammatory demyelinating polyradiculoneuropathy and variants: where we are and where we should go. J Peripher Nerv Syst 2014; 19:2-13. [PMID: 24612201 DOI: 10.1111/jns5.12053] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a chronic and often disabling sensory motor neuropathy postulated as caused by an immune attack against peripheral nerve myelin. In addition to a classic sensory–motor polyneuropathy, other phenotypes of CIDP have been described including the Lewis- Sumner syndrome, distal acquired demyelinating symmetric (DADS) neuropathy, pure motor CIDP, pure sensory CIDP including chronic immune sensory polyradiculopathy (CISP), and focal CIDP. These phenotypes are currently considered to be variants of CIDP, even if the possibility that they represent different demyelinating neuropathies cannot be fully excluded considering differences in their response to therapy. Several data support the role of the immune system in the pathogenesis of CIDP even if the precise targets and actors (antibodies and lymphocytes) of this immune response remain uncertain. Recent studies have shown that the therapeutic response may differ in patients with peculiar clinical presentations supporting the hypothesis that different pathogenetic mechanisms may underlie the heterogeneity of CIDP. The majority of patients with CIDP show improvement after immune therapies including corticosteroids, plasma exchange, and high-dose intravenous immunoglobulin (IVIg). It remains unclear why none of the other immune therapies that were reported to be variably effective in other immune disorders proved to be effective also in CIDP.
Collapse
|
94
|
Guimarães-Costa R, Iancu Ferfoglia R, Viala K, Léger JM. Challenges in the treatment of chronic inflammatory demyelinating polyradiculoneuropathy. Rev Neurol (Paris) 2014; 170:595-601. [PMID: 25200479 DOI: 10.1016/j.neurol.2014.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 06/19/2014] [Accepted: 06/24/2014] [Indexed: 11/28/2022]
Abstract
Chronic idiopathic demyelinating polyradiculoneuropathy (CIDP) is a rare disease, the most frequent one within the spectrum of the so-called "chronic immune-mediated neuropathies". Challenges in the treatment of CIDP firstly concern its diagnosis, which may be difficult, mainly for the atypical forms. Secondly, challenges encompass the choice of the first-line treatment, such as corticosteroids, intravenous immunoglobulins (IVIg), and plasma exchanges (PE) that have been proven as efficacious by several randomized controlled trials (RCT). Recent reports have focused on both different regimens of corticosteroids, and the occurrence of relapses following treatment with either corticosteroids or IVIg. These data may be helpful for the choice of the first-line treatment and may result in changing the guidelines for treatment of CIDP in clinical practice. The third and more difficult challenge is to manage long-term treatment for CIDP, since no immunomodulatory treatment has to date been proven as efficacious in this situation. Lastly, challenges in the treatment concern the choice of the best outcome measure for CIDP in RCT and clinical practice. The aim of this article is to overview the results of the more recently reported published trials for CIDP, and to give some insights for the current and future management of CIDP.
Collapse
Affiliation(s)
- R Guimarães-Costa
- Centre national de référence maladies neuromusculaires rares, CHU Pitié-Salpêtrière, bâtiment Babinski, 47, boulevard de l'Hôpital, 75651 Paris cedex 13, France
| | - R Iancu Ferfoglia
- Centre national de référence maladies neuromusculaires rares, CHU Pitié-Salpêtrière, bâtiment Babinski, 47, boulevard de l'Hôpital, 75651 Paris cedex 13, France
| | - K Viala
- Fédération de neurophysiologie clinique, institut hospitalo-universitaire de neurosciences, groupe hospitalier Pitié-Salpêtrière, université Pierre-et-Marie-Curie (Paris VI), 47, boulevard de l'Hôpital, 75651 Paris cedex 13, France
| | - J-M Léger
- Centre national de référence maladies neuromusculaires rares, CHU Pitié-Salpêtrière, bâtiment Babinski, 47, boulevard de l'Hôpital, 75651 Paris cedex 13, France.
| |
Collapse
|
95
|
Rabin M, Mutlu G, Stojkovic T, Maisonobe T, Lenglet T, Fournier E, Bouche P, Léger JM, Viala K. Chronic inflammatory demyelinating polyradiculoneuropathy: search for factors associated with treatment dependence or successful withdrawal. J Neurol Neurosurg Psychiatry 2014; 85:901-6. [PMID: 24309269 DOI: 10.1136/jnnp-2013-306105] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND About 40% of responders to treatment for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) remain treatment dependent and have a relapse if treatment is interrupted. OBJECTIVE To look for factors associated with treatment dependence or successful withdrawal in CIDP patients. METHODS We retrospectively studied 70 responder CIDP patients comprising 34 patients who remained treatment dependent (treatment-dependent group) and 36 patients whose treatment could be discontinued (treatment withdrawal group). Clinical, biological, electrophysiological and therapeutic features were compared between these groups. RESULTS A multifocal deficit was more frequent in the treatment-dependent group (35%) than in the treatment withdrawal group (8%) (p<0.01). The most frequent effective treatment was intravenous immunoglobulin (IVIG) for the treatment-dependent group (79%). In this group, more patients were resistant to corticosteroids in first-line therapy (93%) than in the treatment withdrawal group (40%) (p=0.002). The delay to effective treatment was significantly shorter for the treatment withdrawal group than for the treatment-dependent group (mean 11.1 vs 31.2 months; p<0.01). The rate of successful withdrawal was lower with IVIG (29%) than with corticosteroids (83%) (p<0.001). CONCLUSIONS When compared with the treatment withdrawal group, the treatment-dependent group was more frequently responsive to IVIG, more frequently resistant to corticosteroids in first-line treatment, had a longer delay to effective treatment and was more likely to present a multifocal deficit. The rate of successful withdrawal seems to be higher with corticosteroids, but a prospective study with a long-term follow-up is needed to confirm these features.
Collapse
Affiliation(s)
- Magalie Rabin
- Département de Neurophysiologie Clinique, Groupe Hospitalier Pitié-Salpêtrière Paris, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France
| | - Gurkam Mutlu
- Groupe Hospitalier Pitié-Salpêtrière Paris, Service d'urgence cérébrovasculaire Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France
| | - Tanya Stojkovic
- Département de Neurophysiologie Clinique, Groupe Hospitalier Pitié-Salpêtrière Paris, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France Groupe Hospitalier Pitié-Salpêtrière Paris, Centre de Référence des Pathologies Neuromusculaires Paris Est, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France
| | - Thierry Maisonobe
- Département de Neurophysiologie Clinique, Groupe Hospitalier Pitié-Salpêtrière Paris, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France Centre diagnostique et thérapeutique des neuropathies périphériques, Département de Neurophysiologie et Service de Neurologie 1, Groupe Hospitalier Pitié-Salpêtriére Paris, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France Département de Neuropathologie R Escourolle, Groupe Hospitalier Pitié-Salpêtrière Paris, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France
| | - Timothée Lenglet
- Département de Neurophysiologie Clinique, Groupe Hospitalier Pitié-Salpêtrière Paris, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France Centre diagnostique et thérapeutique des neuropathies périphériques, Département de Neurophysiologie et Service de Neurologie 1, Groupe Hospitalier Pitié-Salpêtriére Paris, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France
| | - Emmanuel Fournier
- Département de Neurophysiologie Clinique, Groupe Hospitalier Pitié-Salpêtrière Paris, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France Groupe Hospitalier Pitié-Salpêtrière Paris, Centre de Référence des Pathologies Neuromusculaires Paris Est, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France Centre diagnostique et thérapeutique des neuropathies périphériques, Département de Neurophysiologie et Service de Neurologie 1, Groupe Hospitalier Pitié-Salpêtriére Paris, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France
| | - Pierre Bouche
- Département de Neurophysiologie Clinique, Groupe Hospitalier Pitié-Salpêtrière Paris, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France
| | - Jean-Marc Léger
- Groupe Hospitalier Pitié-Salpêtrière Paris, Centre de Référence des Pathologies Neuromusculaires Paris Est, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France
| | - Karine Viala
- Département de Neurophysiologie Clinique, Groupe Hospitalier Pitié-Salpêtrière Paris, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France Centre diagnostique et thérapeutique des neuropathies périphériques, Département de Neurophysiologie et Service de Neurologie 1, Groupe Hospitalier Pitié-Salpêtriére Paris, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France
| |
Collapse
|
96
|
Nobile-Orazio E. Treatment dependence in chronic inflammatory demyelinating polyradiculoneuropathy: is it related to disease phenotype or to the therapy used? J Neurol Neurosurg Psychiatry 2014; 85:829. [PMID: 24336789 DOI: 10.1136/jnnp-2013-306499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
97
|
Abstract
Chronic neuropathies are operationally classified as primarily demyelinating or axonal, on the basis of electrodiagnostic or pathological criteria. Demyelinating neuropathies are further classified as hereditary or acquired-this distinction is important, because the acquired neuropathies are immune-mediated and, thus, amenable to treatment. The acquired chronic demyelinating neuropathies include chronic inflammatory demyelinating polyneuropathy (CIDP), neuropathy associated with monoclonal IgM antibodies to myelin-associated glycoprotein (MAG; anti-MAG neuropathy), multifocal motor neuropathy (MMN), and POEMS syndrome. They have characteristic--though overlapping--clinical presentations, are mediated by distinct immune mechanisms, and respond to different therapies. CIDP is the default diagnosis if the neuropathy is demyelinating and no other cause is found. Anti-MAG neuropathy is diagnosed on the basis of the presence of anti-MAG antibodies, MMN is characterized by multifocal weakness and motor conduction blocks, and POEMS syndrome is associated with IgG or IgA λ-type monoclonal gammopathy and osteosclerotic myeloma. The correct diagnosis, however, can be difficult to make in patients with atypical or overlapping presentations, or nondefinitive laboratory studies. First-line treatments include intravenous immunoglobulin (IVIg), corticosteroids or plasmapheresis for CIDP; IVIg for MMN; rituximab for anti-MAG neuropathy; and irradiation or chemotherapy for POEMS syndrome. A correct diagnosis is required for choosing the appropriate treatment, with the aim of preventing progressive neuropathy.
Collapse
Affiliation(s)
- Norman Latov
- Department of Neurology and Neuroscience, Weill Medical College of Cornell University, 1305 York Avenue, Suite 217, New York, NY 10021, USA
| |
Collapse
|
98
|
Chronic inflammatory demyelinating polyradiculoneuropathy: update on clinical features, phenotypes and treatment options. Curr Opin Neurol 2014; 26:496-502. [PMID: 23852276 DOI: 10.1097/wco.0b013e328363bfa4] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW In this review, we focus on less recognised signs and symptoms in typical chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and on the clinical presentation, course of disease and response to treatment of the atypical CIDP phenotypes. RECENT FINDINGS Frequently occurring and often disabling symptoms in CIDP such as fatigue, pain and tremor have recently been emphasised, whereas autonomic dysfunction, if present, is usually mild. Sensory CIDP is probably the most frequent atypical CIDP phenotype and diagnosis can be difficult in the absence of clear demyelinating features on nerve conduction studies. The most important study comparing intravenous immunoglobulin treatment with intravenous methylprednisolone showed a lower rate of discontinuation due to inefficacy, adverse events or intolerance with intravenous immunoglobulin treatment. However, improvement after corticosteroids seems to be more long-lasting than after intravenous immunoglobulin suggesting superior long-term immunosuppressive and immunomodulating effect of corticosteroids in CIDP. SUMMARY Symptoms other than the classical motor and sensory symptoms can lead to significant disability in CIDP patients. Based on limited evidence from largely small retrospective case series, we conclude that atypical CIDP phenotypes often have a different course of disease and sometimes response to treatment when compared with typical CIDP. Prospective multicentre cohort studies using standardised clinical description, electrophysiological parameters and outcome measures are needed to study the natural disease course of these phenotypes including response to different treatments.
Collapse
|
99
|
Panaite PA, Renaud S, Kraftsik R, Steck AJ, Kuntzer T. Impairment and disability in 20 CIDP patients according to disease activity status. J Peripher Nerv Syst 2014; 18:241-6. [PMID: 24028192 DOI: 10.1111/jns5.12038] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Revised: 06/14/2013] [Accepted: 07/30/2013] [Indexed: 11/30/2022]
Abstract
Twenty patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) meeting the EFNS/PNS criteria were examined in order to assess differences/similarities between the various grading systems according to CIDP disease activity status (CDAS). A principal component (PC) analysis and the correlations between the following scores were performed: Neurological Symptom Score; MRC sum score; Neurological Impairment Score; Hammersmith Functional Motor Scale; Inflammatory Neuropathy Cause and Treatment (INCAT) Sensory Sum Score; Overall Disability Sum Score; INCAT Disability Score; Rasch-built Overall Disability Scale. Our analysis outlined two main sets of scales, with high influence in the top two PCs. The first PC that best explained the variability within the cohort consisted of CDAS, general disability scores and motor scores; these parameters were also strongly correlated amongst each other. The second PC explained less the variability and consisted mainly of sensory scores and disease duration; these parameters did not correlate with the scores of the first PC or with the CDAS. Our findings suggest separating screening for motor and sensory deficits when evaluating CIDP patients, as only the motor scores correlate with CDAS.
Collapse
Affiliation(s)
- Petrica-Adrian Panaite
- Department of Clinical Neurosciences, Nerve-Muscle Unit, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | | | | | | | | |
Collapse
|
100
|
Eftimov F, Liesdek MH, Verhamme C, van Schaik IN. Deterioration after corticosteroids in CIDP may be associated with pure focal demyelination pattern. BMC Neurol 2014; 14:72. [PMID: 24708554 PMCID: PMC3977669 DOI: 10.1186/1471-2377-14-72] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 01/27/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the PREDICT study, a randomised controlled trial comparing dexamethasone with prednisolone in patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), almost a quarter of patients deteriorated soon after starting treatment. The primary objective of this post-hoc analysis was to test the hypothesis that a focal demyelination pattern is associated with early deterioration after corticosteroid treatment and to explore whether various clinical characteristics are associated with deterioration after corticosteroid treatment. METHODS Clinical outcome was categorised into early deterioration and non-early deterioration. A neurophysiologist blinded for treatment outcome scored electrophysiological data into following categories: pure focal versus non-focal distribution of demyelination and no/minor versus moderate/severe sensory involvement. Additionally, we compared electrophysiological and clinical baseline parameters, with emphasis on previously reported possible associations. RESULTS Early deterioration was found in 7 out of 33 patients (21%). Ten patients had pure focal distribution of demyelination, of whom 5 had early deterioration; 23 patients had non-focal distribution, of whom 2 had early deterioration (p = 0.02). Higher mean median nerve sensory nerve conduction velocity (SNCV) was found in patients with early deterioration compared to patients with non-early deterioration (52.6 and respectively 40.8 m/s, p = 0.02). CONCLUSION Pure focal distribution of demyelination and lesser sensory electrophysiological abnormalities may be associated with early deterioration in CIDP patients treated with corticosteroids.
Collapse
Affiliation(s)
- Filip Eftimov
- Department of Neurology, Academic Medical Center, University of Amsterdam, Amsterdam, DD, 1100, The Netherlands.
| | | | | | | | | |
Collapse
|