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Uysal SP, Morren JA. Promising therapies for the treatment of myasthenia gravis. Expert Opin Pharmacother 2024; 25:395-408. [PMID: 38523508 DOI: 10.1080/14656566.2024.2332610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 03/14/2024] [Indexed: 03/26/2024]
Abstract
INTRODUCTION Myasthenia gravis (MG) is an autoimmune condition targeting the neuromuscular junction, which manifests with neuromuscular symptoms of varying severity and significant morbidity. The mainstay of treatment in MG is mitigation of the immune cascade with steroids and non-steroidal immunosuppressive therapies. The therapeutic strategies in MG are transitioning from broad and indiscriminate immunosuppression to novel agents targeting key steps in MG pathogenesis, including T cell activation, B cell proliferation, complement activation, maintenance of pathogenic antibody production, and proinflammatory cytokine production. AREAS COVERED In this review, an overview of the pathogenesis of MG and traditional MG therapies is presented, followed by a discussion of the novel MG drugs that have been evaluated in phase 3 clinical trials with an emphasis on those which have received regulatory approval. EXPERT OPINION Novel MG therapeutics belonging to the classes of complement inhibitors, neonatal Fc receptor (FcRn) inhibitors and B cell depletors, as well as the other emerging MG drugs in the pipeline constitute promising treatment strategies with potentially better efficacy and safety compared to the conventional MG treatments. However, further long-term research is needed in order to optimize the implementation of these new treatment options for the appropriate patient populations.
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Affiliation(s)
- Sanem Pinar Uysal
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John A Morren
- Neuromuscular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
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Narayanaswami P, Sanders DB, Thomas L, Thibault D, Blevins J, Desai R, Krueger A, Bibeau K, Liu B, Guptill JT. Comparative effectiveness of azathioprine and mycophenolate mofetil for myasthenia gravis (PROMISE-MG): a prospective cohort study. Lancet Neurol 2024; 23:267-276. [PMID: 38365379 DOI: 10.1016/s1474-4422(24)00028-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 01/01/2024] [Accepted: 01/02/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND Myasthenia gravis is an autoimmune disorder of the neuromuscular junction. Treatment typically includes symptomatic oral cholinesterase inhibitors, immunosuppression, and immunomodulation. In addition to corticosteroids, azathioprine and mycophenolate mofetil are the most frequently used immunosuppressants in North America. We aimed to evaluate the comparative effectiveness of these two drugs, and to assess the effect of the dose and duration of treatment. METHODS We did a prospective cohort study at 19 academic centres in Canada and the USA. We included patients (aged ≥18 years) with autoimmune myasthenia gravis, who were never treated with immunosuppressants. Treating clinicians determined the choice of medication, dose, follow-up intervals, and drug monitoring. Outcome measures and adverse events were recorded at each visit. We assessed two co-primary outcomes. The first was the patient-reported Myasthenia Gravis-Quality of Life 15-revised (MGQOL-15r) score, measured as the mean change from treatment initiation to the follow-up visit with the lowest score. A clinically meaningful reduction (CMR) in MGQOL-15r was defined as a 5-point decrease. The second was a composite clinical outcome of disease improvement (Myasthenia Gravis Foundation of America Post-Intervention Status Minimal Manifestations or better) and low adverse event burden (defined as grade ≤1 Common Terminology Criteria for Adverse Events). We also compared these outcomes in patients receiving an adequate dose and duration of azathioprine (≥2 mg/kg per day for at least 12 months) or mycophenolate mofetil (≥2 g per day for at least 8 months) and a lower dose or shorter duration of these agents. We used propensity score weighting with generalised linear regression models. This study is registered with ClinicalTrials.gov (NCT03490539). FINDINGS Between May 1, 2018, and Aug 31, 2020, 167 patients were enrolled; 85 did not receive azathioprine or mycophenolate mofetil and were excluded. Four were excluded from outcome analyses because they had scores of 0 on an outcome measure at treatment initiation. Of the 78 patients included in analyses, 47 received mycophenolate mofetil (median follow-up 25 months [IQR 13·5-31·5]) and 31 received azathioprine (median follow-up 20 months [IQR 13-30]). The mean change in MG-QOL15r was -10·4 (95% CI -18·9 to -1·3) with mycophenolate mofetil and -6·8 (-17·2 to 3·6) with azathioprine (mean difference -3·3, 95% CI -7·7 to 1·2; p=0·15). 38 (81%) of 47 patients receiving mycophenolate mofetil and 18 (57%) of 31 receiving azathioprine had a CMR in MG-QOL15r (risk difference 24·0%; 95% CI -0·2 to 48·0; p=0·052). The clinical composite outcome was achieved in 22 (47·7%) of 47 patients who received mycophenolate mofetil and nine (28·1%) of 31 who received azathioprine (risk difference 19·6%, 95% CI -4·9 to 44·2; p=0·12). Descriptive analysis did not find a difference in the proportion of patients reaching a CMR in MG-QOL15r between the adequate dose and duration group and the lower dose or shorter duration group. Adverse events occurred in 11 (32%) of 34 patients who received azathioprine and nine (19%) of 48 who received mycophenolate mofetil. The most frequent adverse events were hepatotoxicity with azathioprine (five [15%] of 34) and gastrointestinal disturbances (seven [15%] of 48) with mycophenolate mofetil. There were no study-related deaths. INTERPRETATION More than half of patients treated with azathioprine and mycophenolate mofetil felt their quality of life improved; no difference in clinical outcomes was noted between the two drugs. Adverse events associated with azathioprine were potentially more serious than those with mycophenolate mofetil, although mycophenolate mofetil is teratogenic. Lower than recommended doses of azathioprine might be effective, with reduced dose-dependent adverse events. More comparative effectiveness studies are required to inform treatment choices in myasthenia gravis. FUNDING Patient-Centered Outcomes Research Institute, Myasthenia Gravis Foundation of America.
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Affiliation(s)
| | - Donald B Sanders
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Laine Thomas
- Duke Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | | | | | - Rishi Desai
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA USA
| | - Andrew Krueger
- Accordant Health Services, CVS Health, High Point, NC, USA
| | - Kathie Bibeau
- Myasthenia Gravis Foundation of America, Seattle, WA, USA
| | - Bo Liu
- Duke Department of Statistical Science, Duke University, Durham, NC, USA
| | - Jeffrey T Guptill
- Department of Neurology, Duke University Medical Center, Durham, NC, USA; Argenx US, Boston, MA, USA
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Masanneck L, Pawlitzki MG, Meuth SG. [Digital medicine in neurological research-Between hype and evidence]. DER NERVENARZT 2024; 95:230-235. [PMID: 38095660 DOI: 10.1007/s00115-023-01581-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 03/06/2024]
Abstract
BACKGROUND The rapid advancement of digital medicine and health technologies in neurology offers both significant potential and challenges. This article outlines fundamental aspects of digital medicine related to neurological research and highlights application examples of digital technologies in neurological research. AIM To provide a comprehensive overview of current digital developments in neurology and their impact on neurological research. MATERIAL AND METHODS In this narrative review articles from various sources and references related to digital medicine and health technologies in neurology were compiled and analyzed. RESULTS AND DISCUSSION The data presented indicate that digital health technologies and digital therapeutics have the potential to decisively shape neurological care and research; however, it is emphasized that a critical evaluation and evidence-based approach to these technologies are essential to determine their actual value in neurology.
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Affiliation(s)
- Lars Masanneck
- Klinik für Neurologie, Medizinische Fakultät und Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland.
- Hasso-Plattner-Institut, Potsdam, Deutschland.
| | - Marc G Pawlitzki
- Klinik für Neurologie, Medizinische Fakultät und Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
| | - Sven G Meuth
- Klinik für Neurologie, Medizinische Fakultät und Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland.
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Zadeh S, Price H, Drews R, Bouffard MA, Young LH, Narayanaswami P. Novel uses of complement inhibitors in myasthenia gravis-Two case reports. Muscle Nerve 2024; 69:368-372. [PMID: 38205840 DOI: 10.1002/mus.28037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/26/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024]
Abstract
INTRODUCTION/AIMS Myasthenia gravis (MG) is a rare, life-threatening immune-related adverse effect (irAE) of immune checkpoint inhibitor (ICI) treatment. C5-complement inhibitors are effective treatments for acetylcholine receptor antibody (AChR ab) positive generalized MG. We describe the use of eculizumab/ravulizumab in two patients with MG receiving concomitant pembrolizumab. METHODS This was a retrospective review of two medical records. RESULTS Patient 1: An 80-year-old male with recurrent, non-muscle invasive transitional cell carcinoma of the bladder developed ICI-induced AChR ab positive MG (ICI-MG), myositis, and myocarditis 2 weeks after the first dose of pembrolizumab. Myositis responded to corticosteroids. MG responded to eculizumab, followed by ravulizumab. He died of metastatic cancer 8 months later. Patient 2: A 58-year-old male had refractory thymoma-associated AChR ab-positive MG, which responded to eculizumab. He developed metastatic Merkel cell cancer necessitating pembrolizumab. MG remained stable on eculizumab. He had no irAEs for 22 months, with positron emission tomographic resolution of cancer. He then developed mild, indolent retinal vasculitis, which responded to prednisone. Discontinuation of pembrolizumab for 5 months resulted in cancer recurrence; pembrolizumab was resumed with peri-infusion pulse prednisone. MG remained stable and he continues eculizumab. DISCUSSION In the first patient, eculizumab, followed by ravulizumab, improved ICI-MG. In the second patient, eculizumab treatment may have had a prophylactic effect on the development of ICI-induced irAEs. The effect of complement inhibition on cancer outcomes of ICI therapy is unknown. A possible biologic basis for complement inhibitors in reducing irAEs of ICI, especially in the presence of underlying autoimmune disease, merits evaluation.
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Affiliation(s)
- Sean Zadeh
- Department of Neurology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA
| | - Hayley Price
- Department of Neurology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA
| | - Reed Drews
- Department of Hematology/Oncology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA
| | - Marc A Bouffard
- Department of Neurology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA
| | - Lucy H Young
- Retina Services, Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston, Massachusetts, USA
| | - Pushpa Narayanaswami
- Department of Neurology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA
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Kuroda Y, Watanabe G, Satou K, Ono H, Tsukita K, Suzuki Y. [Eculizumab led to beneficial clinical course in a patient with generalized myasthenia gravis who developed COVID 19-associated pneumonia]. Rinsho Shinkeigaku 2024; 64:109-112. [PMID: 38281749 DOI: 10.5692/clinicalneurol.cn-001922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
A 74-year-old woman developed myasthenia gravis (MG) at the age of 32. She had a thymoma removed the following year, but her MG symptoms did not stabilize, and she required frequent hospitalization for fast-acting treatment (FT). She started eculizumab in March of two years ago and was followed up on an outpatient basis as her MG symptoms became milder. In February of this year, she was admitted to our hospital due to mild COVID-19-associated pneumonia with general malaise and fever. Her COVID-19-associated pneumonia was treated with intravenous sotrovimab, dexamethasone, and unfractionated heparin, and oral therapy for MG stayed the same. Eculizumab was not administered during hospitalization due to the combination of stable MG symptoms and the fact that the drug is not paid for by the Japanese insurance system. The patient's MG and COVID-19-associated pneumonia were not severe during hospitalization. However, the risk of myasthenic crisis and death is high when patients with MG develop COVID-19-associated pneumonia. Several reports suggest that the condition of patients with eculizumab-treated MG who develop COVID-19-associated pneumonia is not severe, and that that inhibition of the complement pathway with eculizumab is effective for COVID-19-associated pneumonia. Complement deposition in organ microvessels has been observed in patients with COVID-19, which suggests that complement overload may be a risk factor for COVID-19-associated pneumonia. Excessive complement activation may be involved in the pathogenesis; thus, eculizumab may function by inhibiting this pathway. In this case, eculizumab was discontinued while the patient had COVID-19-associated pneumonia, however, CH50, which is an indicator of complement, was suppressed during hospitalization due to the COVID-19-associated pneumonia. Therefore, eculizumab may have interfered with this course of events. This case demonstrates that eculizumab may be safe for and tolerated by patients with MG and COVID-19-associated pneumonia, but more cases need to be accumulated to support this conclusion.
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Affiliation(s)
- Yusuke Kuroda
- Department of neurology, NHO Sendai Medical Center
- Department of neurology, Tohoku University Hospital
| | | | - Kazuki Satou
- Department of neurology, Tohoku University Hospital
| | - Hirohiko Ono
- Department of neurology, Tohoku University Hospital
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Peng Y, Yang H, Chen Q, Jin H, Xue YH, Du MQ, Liu S, Yao SY. An angel or a devil? Current view on the role of CD8 + T cells in the pathogenesis of myasthenia gravis. J Transl Med 2024; 22:183. [PMID: 38378668 PMCID: PMC10877804 DOI: 10.1186/s12967-024-04965-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 02/07/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Myasthenia gravis (MG) and the experimental autoimmune MG (EAMG) animal model are characterized by T-cell-induced and B-cell-dominated autoimmune diseases that affect the neuromuscular junction. Several subtypes of CD4+ T cells, including T helper (Th) 17 cells, follicular Th cells, and regulatory T cells (Tregs), contribute to the pathogenesis of MG. However, increasing evidence suggests that CD8+ T cells also play a critical role in the pathogenesis and treatment of MG. MAIN BODY Herein, we review the literature on CD8+ T cells in MG, focusing on their potential effector and regulatory roles, as well as on relevant evidence (peripheral, in situ, cerebrospinal fluid, and under different treatments), T-cell receptor usage, cytokine and chemokine expression, cell marker expression, and Treg, Tc17, CD3+CD8+CD20+ T, and CXCR5+ CD8+ T cells. CONCLUSIONS Further studies on CD8+ T cells in MG are necessary to determine, among others, the real pattern of the Vβ gene usage of autoantigen-specific CD8+ cells in patients with MG, real images of the physiology and function of autoantigen-specific CD8+ cells from MG/EAMG, and the subset of autoantigen-specific CD8+ cells (Tc1, Tc17, and IL-17+IFN-γ+CD8+ T cells). There are many reports of CD20-expressing T (or CD20 + T) and CXCR5+ CD8 T cells on autoimmune diseases, especially on multiple sclerosis and rheumatoid arthritis. Unfortunately, up to now, there has been no report on these T cells on MG, which might be a good direction for future studies.
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Affiliation(s)
- Yong Peng
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China.
- Department of Neurology, The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, 412000, Hunan, China.
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Quan Chen
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China
- Department of Neurology, The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, 412000, Hunan, China
| | - Hong Jin
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China
- Department of Neurology, The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, 412000, Hunan, China
| | - Ya-Hui Xue
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China
- Department of Neurology, The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, 412000, Hunan, China
| | - Miao-Qiao Du
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China
- Department of Neurology, The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, 412000, Hunan, China
| | - Shu Liu
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China
- Department of Neurology, The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, 412000, Hunan, China
| | - Shun-Yu Yao
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China
- Department of Neurology, The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, 412000, Hunan, China
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Konno S, Fujioka T. Serum immunoglobulin G level reduction is a predictor of short-term improvement in patients with myasthenia gravis undergoing plasmapheresis. Ther Apher Dial 2024; 28:131-140. [PMID: 37731293 DOI: 10.1111/1744-9987.14065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 05/13/2023] [Accepted: 09/04/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVES The aim of the study was to investigate the serological factors in predicting symptom improvement in myasthenia gravis (MG) patients who underwent plasmapheresis (PP). METHODS The relationship between symptom improvement and change in immunoglobin G (IgG) and acetylcholine receptor antibody (AchR-Ab) levels in 21 MG patients after PP was analyzed. RESULTS Patients were divided into two groups: the favorable (n = 11) or unfavorable (n = 10) response groups around the median MG composite improvement rate (50 [29, 56]%) 2 weeks after a PP course. In all patients, the IgG reduction rate before and after PP was higher in the favorable than the unfavorable response group. In AChR-Ab-positive patients, IgG and AChR-Ab reduction rates were higher in the favorable than the unfavorable response group. CONCLUSION IgG reduction rate is a predictor of symptom improvement in MG patients who underwent PP.
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Affiliation(s)
- Shingo Konno
- Department of Neurology, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Toshiki Fujioka
- Department of Neurology, Toho University Ohashi Medical Center, Tokyo, Japan
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Iorio R. Myasthenia gravis: the changing treatment landscape in the era of molecular therapies. Nat Rev Neurol 2024; 20:84-98. [PMID: 38191918 DOI: 10.1038/s41582-023-00916-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2023] [Indexed: 01/10/2024]
Abstract
Myasthenia gravis (MG) is an autoimmune disorder that affects the neuromuscular junction, leading to muscle weakness and fatigue. MG is caused by antibodies against the acetylcholine receptor (AChR), the muscle-specific kinase (MuSK) or other AChR-related proteins that are expressed in the postsynaptic muscle membrane. The standard therapeutic approach for MG has relied on acetylcholinesterase inhibitors, corticosteroids and immunosuppressants, which have shown good efficacy in improving MG-related symptoms in most people with the disease; however, these therapies can carry a considerable burden of long-term adverse effects. Moreover, up to 15% of individuals with MG exhibit limited or no response to these standard therapies. The emergence of molecular therapies, including monoclonal antibodies, B cell-depleting agents and chimeric antigen receptor T cell-based therapies, has the potential to revolutionize the MG treatment landscape. This Review provides a comprehensive overview of the progress achieved in molecular therapies for MG associated with AChR antibodies and MuSK antibodies, elucidating both the challenges and the opportunities these therapies present to the field. The latest developments in MG treatment are described, exploring the potential for personalized medicine approaches.
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Affiliation(s)
- Raffaele Iorio
- Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy.
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
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Rogalewski A, Klein N, Friedrich A, Kitsiou A, Schäbitz M, Zuhorn F, Gess B, Berger B, Klingebiel R, Schäbitz WR. Functional long-term outcome following endovascular thrombectomy in patients with acute ischemic stroke. Neurol Res Pract 2024; 6:2. [PMID: 38297374 PMCID: PMC10832147 DOI: 10.1186/s42466-023-00301-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 12/11/2023] [Indexed: 02/02/2024] Open
Abstract
Endovascular thrombectomy (EVT) is the most effective treatment for acute ischemic stroke caused by large vessel occlusion (LVO). Yet, long-term outcome (LTO) and health-related quality of life (HRQoL) in these patients have rarely been addressed, as opposed to modified Rankin scale (mRS) recordings. We analysed demographic data, treatment and neuroimaging parameters in 694 consecutive stroke patients in a maximum care hospital. In 138 of these patients with respect on receipt of written informed consent, LTO and HRQoL were collected over a period of 48 months after EVT using a standardised telephone survey (median 2.1 years after EVT). Age < 70 years (OR 4.82), lower NIHSS on admission (OR 1.11), NIHSS ≤ 10 after 24 h (OR 11.23) and complete recanalisation (mTICI3) (OR 7.79) were identified as independent predictors of favourable LTO. Occurrence of an infection requiring treatment within the first 72 h was recognised as a negative predictor for good long-term outcome (OR 0.22). Patients with mRS > 2 according to the telephone survey more often had complaints regarding mobility, self-care, and usual activity domains of the HRQoL. Our results underline a sustainable positive effect of effective EVT on the quality of life in LVO stroke. Additionally, predictive parameters of outcome were identified, that may support clinical decision making in LVO stroke.
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Affiliation(s)
- Andreas Rogalewski
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Schildescher Str. 99, 33611, Bielefeld, Germany.
- Department of Neurology, Sankt Elisabeth Hospital Gütersloh, Catholic Hospital Association of East Westfalia (KHO), Gütersloh, Germany.
| | - Nele Klein
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Schildescher Str. 99, 33611, Bielefeld, Germany
- Department of Neurology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Anja Friedrich
- Department of Psychology, Bielefeld University, Bielefeld, Germany
| | - Alkisti Kitsiou
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Schildescher Str. 99, 33611, Bielefeld, Germany
| | - Marie Schäbitz
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Schildescher Str. 99, 33611, Bielefeld, Germany
| | - Frédéric Zuhorn
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Schildescher Str. 99, 33611, Bielefeld, Germany
| | - Burkhard Gess
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Schildescher Str. 99, 33611, Bielefeld, Germany
- Department of Neurology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Björn Berger
- Department of Neuroradiology, Evangelisches Klinikum Bethel EvKB, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Bielefeld, Germany
| | - Randolf Klingebiel
- Department of Neuroradiology, Evangelisches Klinikum Bethel EvKB, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Bielefeld, Germany
| | - Wolf-Rüdiger Schäbitz
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Schildescher Str. 99, 33611, Bielefeld, Germany
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Ma Y, Nie X, Zhu G, Qi W, Hao L, Guo X. The Efficacy and Safety of Different Targeted Drugs for the Treatment of Generalized Myasthenia Gravis: A Systematic Review and Bayesian Network Meta-analysis. CNS Drugs 2024; 38:93-104. [PMID: 38300476 DOI: 10.1007/s40263-024-01062-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND The treatment of generalized myasthenia gravis (gMG) has been transformed by the development and approval of new targeted therapies. This analysis aimed to rank and compare the new therapies for gMG using efficacy and safety data from randomized controlled trials (RCTs). METHODS We searched PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov (up to November 2022) for RCTs of targeted drugs for gMG. We used a Bayesian random-effects network meta-analysis (NMA) model and a Markov chain Monte Carlo (MCMC) model for statistical analysis. The primary outcome was the change in quantitative myasthenia gravis score (QMGS) from baseline, while the secondary outcome was the risk ratio (RR) of adverse events (AEs) during treatment. The surface under the cumulative ranking curve (SUCRA) was used to rank these targeted drugs, with higher SUCRA values indicating better efficacy or lower likelihood of AEs. RESULTS In total, 13 studies (872 subjects) were included in this analysis evaluating 10 targeted drugs (batoclimab, belimumab, CFZ533, eculizumab, efgartigimod, nipocalimab, rituximab, ravulizumab, rozanolixizumab, and zilucoplan). With regards to the primary outcome, batoclimab [standardized mean difference (SMD), - 1.61; 95% credible interval (CrI), - 2.78, - 0.43] significantly reduced QMGS in patients with gMG when compared with placebo and was ranked as the most efficacious drug. Ranked second and third were eculizumab (SMD, - 0.67; 95% CrI, 1.43, 0.01) and zilucoplan (SMD, - 0.54; 95% CrI, - 1.56, 0.46), respectively. Nipoclimab (SMD, - 0.02; 95% CrI, - 1.04, 1.00) had the worst efficacy and ranked last among all targeted drugs. In our study, except for batoclimab, there was no statistically significant difference in the reduction of patient QMGS for the remaining targeted agents compared with placebo. With regards to the secondary outcomes, only batoclimab (RR, 0.19; 95% CrI, 0, 0.97) led to a significant reduction in the incidence of AEs when compared with the placebo. Belimumab (RR, 0.85; 95% CrI, 0.57, 1.19), CFZ533 (RR, 0.95; 95% CrI, 0.72, 1.25), eculizumab (RR, 0.99; 95% CrI, 0.85, 1.21), and efgartigimod (RR, 0.93; 95% CrI, 0.76, 1.15) also led to a lower incidence of AEs, although these effects were not significantly different from the placebo. CONCLUSIONS Batoclimab had the best efficacy and safety for the treatment of gMG and was ranked first out of the 10 targeted drugs included in this study. Eculizumab was ranked second, and nipocalimab had the worst efficacy. With the exception of batoclimab, the incidence of AEs for the remaining drugs was not statistically significantly different from placebo. We note, however, that wide CrIs reflect the uncertainty in this analysis owing to the small number of available studies and low numbers of study participants; moreover, batoclimab had the widest CrI of all drugs in this analysis. More well-designed studies with long-term follow-up are needed to further evaluate and compare the efficacy and safety of these drugs in the future.
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Affiliation(s)
- Yongbo Ma
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Xiangtao Nie
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Geke Zhu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Wenjing Qi
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Lei Hao
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuzhong District, Chongqing, 400016, China.
| | - Xiuming Guo
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuzhong District, Chongqing, 400016, China.
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Parthan A, Royston M, Thanataveerat A, East EL, Parzynski CS, Habib AA. Burden of illness and costs in patients with myasthenia gravis currently receiving treatment in the United States. Muscle Nerve 2024; 69:157-165. [PMID: 38018505 DOI: 10.1002/mus.27992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 11/30/2023]
Abstract
INTRODUCTION/AIMS If myasthenia gravis (MG) symptoms are inadequately controlled, patients may experience exacerbations or life-threatening myasthenic crises. Patients with inadequately controlled MG symptoms tend to be treated with chronic intravenous immunoglobulin (IVIg) therapy and/or multiple immunosuppressant therapies (ISTs). This study aimed to examine disease burden, healthcare resource utilization, and associated costs in these patients. METHODS This was a retrospective observational study using a claims database. Patients with MG were classified into three cohorts based on treatment over a 1-y follow-up period: (a) treated with four or more IVIg episodes (chronic IVIg cohort); (b) received two or more non-steroidal ISTs (NSISTs) sequentially (multiple NSIST cohort); (c) received neither chronic IVIg nor multiple NSISTs (reference cohort). Incidences of crises and exacerbations and annual healthcare costs in each cohort were estimated. RESULTS In total, 3516 patients with MG were included in the analysis. Compared with the reference cohort (n = 2992), the MG crisis rate was approximately twice as high in both the chronic IVIg (n = 324) and multiple NSIST (n = 291) cohorts (p < 0.001); and the MG exacerbation rate was approximately four-fold higher in the chronic IVIg cohort (p < 0.001) and three-fold higher in the multiple NSIST cohort (p < 0.001). Median annual MG-related inflation-adjusted total healthcare costs were higher in the chronic IVIg ($81,900) and multiple NSIST ($30,300) cohorts than in the reference cohort ($2540). DISCUSSION The burden of crises/exacerbations was substantially higher and healthcare costs were considerably greater in patients with MG treated with chronic IVIg or multiple NSISTs than in patients not receiving these treatments.
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Affiliation(s)
- A Parthan
- Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, USA
| | - M Royston
- Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, USA
| | | | - E L East
- Genesis Research Group, Hoboken, New Jersey, USA
| | | | - A A Habib
- University of California, Irvine, California, USA
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Qiu L, Chen P, Ou C, Deng J, Huang Z, Lin Z, Ma Q, Huang X, Yu L, Ran H, Liu W. Long-term efficacy and safety of leflunomide combined with low-dose prednisone in treatment of myasthenia gravis: a retrospective study. Acta Neurol Belg 2024; 124:175-182. [PMID: 37656361 DOI: 10.1007/s13760-023-02367-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 08/16/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Leflunomide and low-dose prednisone (0.25 mg/kg/day) (LEF + Pred) rapidly improved the clinical symptoms of myasthenia gravis (MG) patients. Here, we aimed to analyze the long-term efficacy and safety of LEF + Pred in MG patients. METHODS This retrospective cohort study enrolled MG patients treated with LEF + Pred in our center between 2012 and 2020. We reviewed all the MG patients continuously treated with LEF + Pred for more than 1 year. MG activities of daily living (MG-ADL) profile score and quantitative MG scale (QMG) score in each clinical follow-up visits were collected for the efficacy analysis. The laboratory testing results of MG patients, the relevant chief complain and physical examination results in each follow-up visits were collected for the safety evaluation. RESULTS In total, 103 patients were examined. Effective treatment was achieved in 58.3% of patients after 1 month and in 88.4% after 12 months. Overall, 63 patients (61.2%) exhibited only minimal manifestations after 12 months of treatment. The average MG-ADL score decreased from 6.0 to 1.0, while the average QMG score decreased from 10.0 to 4.0. The decrease in MG-ADL and QMG scores of patients with generalized MG was more pronounced than those of the ocular MG patients. Patients with MG who had a thymectomy had a smaller decrease in MG-ADL and QMG scores than those who did not have a thymectomy. Sixteen adverse effects associated with LEF + Pred were observed; none was severe. CONCLUSIONS Long-term LEF + Pred therapy could considerably improve clinical symptoms in MG patients while being well tolerated with just few side effects.
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Affiliation(s)
- Li Qiu
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Guangzhou, China
- National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Pei Chen
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Guangzhou, China
- National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Changyi Ou
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Guangzhou, China
- National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Juan Deng
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Guangzhou, China
- National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Zhidong Huang
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Guangzhou, China
- National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Zhongqiang Lin
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Guangzhou, China
- National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Qian Ma
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Guangzhou, China
- National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Xin Huang
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Guangzhou, China
- National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Lu Yu
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Guangzhou, China
- National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Hao Ran
- School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, China.
| | - Weibin Liu
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Guangzhou, China.
- National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China.
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West EE, Woodruff T, Fremeaux-Bacchi V, Kemper C. Complement in human disease: approved and up-and-coming therapeutics. Lancet 2024; 403:392-405. [PMID: 37979593 PMCID: PMC10872502 DOI: 10.1016/s0140-6736(23)01524-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/07/2023] [Accepted: 07/20/2023] [Indexed: 11/20/2023]
Abstract
The complement system is recognised as a protector against blood-borne pathogens and a controller of immune system and tissue homoeostasis. However, dysregulated complement activity is associated with unwanted or non-resolving immune responses and inflammation, which induce or exacerbate the pathogenesis of a broad range of inflammatory and autoimmune diseases. Although the merit of targeting complement clinically has long been acknowledged, the overall complement drug approval rate has been modest. However, the success of the humanised anti-C5 antibody eculizumab in effectively treating paroxysmal nocturnal haemoglobinuria and atypical haemolytic syndrome has revitalised efforts to target complement therapeutically. Increased understanding of complement biology has led to the identification of novel targets for drug development that, in combination with advances in drug discovery and development technologies, has resulted in a surge of interest in bringing new complement therapeutics into clinical use. The rising number of approved drugs still almost exclusively target rare diseases, but the substantial pipeline of up-and-coming treatment options will possibly provide opportunities to also expand the clinical targeting of complement to common diseases.
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Affiliation(s)
- Erin E West
- Complement and Inflammation Research Section, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Trent Woodruff
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Veronique Fremeaux-Bacchi
- Inserm UMRS1138, Centre de Recherche des Cordeliers, Inflammation, Complement, and Cancer Team, Paris, France; Department of Immunology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Claudia Kemper
- Complement and Inflammation Research Section, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
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Li X, Chen J, Wang Y, Zheng S, Wan K, Liu X. Registered trials on novel therapies for myasthenia gravis: a cross-sectional study on ClinicalTrials.gov. Sci Rep 2024; 14:2067. [PMID: 38267496 PMCID: PMC10808105 DOI: 10.1038/s41598-024-52539-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 01/19/2024] [Indexed: 01/26/2024] Open
Abstract
Novel biologics in MG therapy research is on the rise. This research aimed to investigate the characteristics of registered trials on novel therapies for myasthenia gravis on ClinicalTrials.gov. This cross-sectional study used a descriptive approach to assess the features of the included trials on ClinicalTrials.gov. We found 62 registered trials from 2007 to 2023 on ClinicalTrials.gov. The results showed a yearly rise in the number of registered trials (r = 0.76, p < 0.001). Following 2017, more industry-sponsored trials were conducted (91.5% [43] vs. 60% [9], p = 0.009), fewer results were released (10.6% [5] vs. 60% [9], p = 0.001), and more trials entered phase 3 (67.4% [31] vs. 20% [2], p = 0.001). The most researched novel medications were neonatal Fc receptor inhibitors (51.2% [21]), complement inhibitors (39.0% [16]), and B cell depletors (14.6% [6]). According to the website's data, the neonatal Fc receptor inhibitors and complement inhibitors were effective in treating myasthenia gravis patients in three trials (NCT03315130, NCT03669588, and NCT00727194). This study provides valuable insights into the profile of registered trials on novel therapies for myasthenia gravis. More clinical studies are needed in the future to prove the value of its application.
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Affiliation(s)
- Xingyue Li
- Department of Neurology, Xiangyang No.1 People's Hospital, Hubei University of Medicine, Xiangyang, China
| | | | | | | | - Kun Wan
- Hubei University of Medicine, Shiyan, China
| | - Xiaodong Liu
- Department of Neurology, Taihe Hospital, Hubei University of Medicine, Shiyan, China.
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Marignier R, Laplaud D, Zéphir H, Papeix C, Leray E, Amri E, Piotaix M, de Sèze J. Real-life study to assess effectiveness and safety of eculizumab in patients with neuromyelitis optica spectrum disorders in France: protocol for ECUP4, an observational study. Front Neurol 2024; 14:1303874. [PMID: 38318238 PMCID: PMC10839895 DOI: 10.3389/fneur.2023.1303874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/20/2023] [Indexed: 02/07/2024] Open
Abstract
Background Eculizumab, a humanized monoclonal antibody targeting the C5 complement protein, has been approved for the treatment of neuromyelitis optica spectrum disorders (NMOSD) in adult patients who are anti-aquaporin-4 (AQP4) antibody positive (Ab+). The aim of this study is to evaluate the long-term effectiveness and safety of eculizumab in French adults with NMOSD and to describe patients' characteristics, disability, and quality of life using data collected in a real-world setting. Methods This is the protocol for ECUP4, an ongoing prospective, observational, non-comparative, multicenter study conducted in 32 reference centers in France. Eligible patients must also be enrolled in NOMADMUS, a nested cohort of the French national multiple sclerosis registry (OFSEP). The primary endpoint is the annualized relapse rate. Secondary endpoints include the long-term safety of eculizumab, as well as patients' characteristics, treatment outcomes, disability, pain, visual acuity, and quality of life. Visits and treatments follow routine clinical practice. The case report forms (CRF) comprise data recorded in the context of the NOMADMUS cohort, collected during routine visits. The inclusion period is planned for 3 years, with no limitation on the number of patients enrolled. The maximum follow-up duration will be 5.5 years. Conclusion The efficacy and safety of eculizumab in patients with AQP4+ NMOSD have been demonstrated in randomized clinical trials that showed a significant reduction in the risk of relapse, with a safety profile consistent with other indications. This study will provide clinical and patient-reported evidence of the benefits of eculizumab, using data from a real-world setting in France. Trial registration number This study is registered at the French public repertory Health data Hub, N° F20211228123801. All information can be accessed at: https://www.health-data-hub.fr/.
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Affiliation(s)
- Romain Marignier
- Service de Neurologie, SEP Neuroinflammation et Pathologies de la Myéline, Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM) - Hôpital Pierre Wertheimer, Bron, France
| | - David Laplaud
- Service de Neurologie du CHU de Nantes, CR2TI-Inserm U1064, CRC-SEP Pays de la Loire, Nantes Université, Nantes, France
| | - Hélène Zéphir
- Service de Neurologie du CHU Hôpital Roger Salengro, Lille, France
| | - Caroline Papeix
- Service de Neurologie, Hôpital Fondation A. de Rothshchild, Paris, France
| | - Emmanuelle Leray
- Univ Rennes, EHESP, CNRS, Inserm, ARENES UMR 6051, RSMS U 1309, Rennes, France
| | - Ekbel Amri
- Alexion, AstraZeneca Rare Disease, Levallois Perret, France
| | | | - Jérôme de Sèze
- Service de Neurologie du Centre Hospitalier Universitaire de Strasbourg, Strasbourg, France
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Day WG, Horn C, Hogue JS, Magee J, Shayegan S, Pittman L. Novel Pathogenic C5 Gene Variants in a Patient with Neisseria Meningitis and Diffuse Cutaneous HSV-1 Infection. J Clin Immunol 2024; 44:52. [PMID: 38231272 DOI: 10.1007/s10875-024-01651-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/06/2024] [Indexed: 01/18/2024]
Affiliation(s)
- W Grant Day
- Department of Allergy and Immunology, Walter Reed National Military Medical Center, 4944 North Palmer Road, Bethesda, MD, 20814, USA.
| | - Christian Horn
- Department of Gastroenterology, San Antonio Military Medical Center, San Antonio, TX, USA
| | - Jacob S Hogue
- Department of Genetics, Madigan Army Medical Center, Tacoma, WA, USA
| | - Jared Magee
- Department of Gastroenterology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | | | - Luke Pittman
- Department of Allergy and Immunology, Walter Reed National Military Medical Center, 4944 North Palmer Road, Bethesda, MD, 20814, USA
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Nelke C, Schmid S, Kleefeld F, Schroeter CB, Goebel HH, Hoffmann S, Preuße C, Kölbel H, Meuth SG, Ruck T, Stenzel W. Complement and MHC patterns can provide the diagnostic framework for inflammatory neuromuscular diseases. Acta Neuropathol 2024; 147:15. [PMID: 38214778 PMCID: PMC10786976 DOI: 10.1007/s00401-023-02669-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/12/2023] [Accepted: 12/12/2023] [Indexed: 01/13/2024]
Abstract
Histopathological analysis stands as the gold standard for the identification and differentiation of inflammatory neuromuscular diseases. These disorders continue to constitute a diagnostic challenge due to their clinical heterogeneity, rarity and overlapping features. To establish standardized protocols for the diagnosis of inflammatory neuromuscular diseases, the development of cost-effective and widely applicable tools is crucial, especially in settings constrained by limited resources. The focus of this review is to emphasize the diagnostic value of major histocompatibility complex (MHC) and complement patterns in the immunohistochemical analysis of these diseases. We explore the immunological background of MHC and complement signatures that characterize inflammatory features, with a specific focus on idiopathic inflammatory myopathies. With this approach, we aim to provide a diagnostic algorithm that may improve and simplify the diagnostic workup based on a limited panel of stainings. Our approach acknowledges the current limitations in the field of inflammatory neuromuscular diseases, particularly the scarcity of large-scale, prospective studies that validate the diagnostic potential of these markers. Further efforts are needed to establish a consensus on the diagnostic protocol to effectively distinguish these diseases.
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Affiliation(s)
- Christopher Nelke
- Department of Neurology, Medical Faculty, Heinrich Heine University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Simone Schmid
- Department of Neuropathology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), Charitéplatz 1, 10117, Berlin, Germany
| | - Felix Kleefeld
- Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), Charitéplatz 1, 10117, Berlin, Germany
| | - Christina B Schroeter
- Department of Neurology, Medical Faculty, Heinrich Heine University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Hans-Hilmar Goebel
- Department of Neuropathology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), Charitéplatz 1, 10117, Berlin, Germany
| | - Sarah Hoffmann
- Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), Charitéplatz 1, 10117, Berlin, Germany
| | - Corinna Preuße
- Department of Neuropathology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), Charitéplatz 1, 10117, Berlin, Germany
- Department of Neuropediatrics, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), Augustenburger Platz 1, 13353, Berlin, Germany
| | - Heike Kölbel
- Department of Neuropaediatrics, Klinik für Kinderheilkunde I, Universitätsklinikum Essen, Essen, Germany
| | - Sven G Meuth
- Department of Neurology, Medical Faculty, Heinrich Heine University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Tobias Ruck
- Department of Neurology, Medical Faculty, Heinrich Heine University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Werner Stenzel
- Department of Neuropathology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), Charitéplatz 1, 10117, Berlin, Germany.
- Leibniz Science Campus Chronic Inflammation, Berlin, Germany.
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Pisc J, Ting A, Skornicki M, Sinno O, Lee E. Healthcare resource utilization, costs and treatment associated with myasthenia gravis exacerbations among patients with myasthenia gravis in the USA: a retrospective analysis of claims data. J Comp Eff Res 2024; 13:e230108. [PMID: 38099519 PMCID: PMC10842297 DOI: 10.57264/cer-2023-0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 11/27/2023] [Indexed: 01/06/2024] Open
Abstract
Aim: There are limited data on the clinical and economic burden of exacerbations in patients with myasthenia gravis (MG). We assessed patient clinical characteristics, treatments and healthcare resource utilization (HCRU) associated with MG exacerbation. Patients & methods: This was a retrospective analysis of adult patients with MG identified by commercial, Medicare or Medicaid insurance claims from the IBM® MarketScan® database. Eligible patients had two or more MG diagnosis codes, without evidence of exacerbation or crisis in the baseline period (12 months prior to index [first eligible MG diagnosis]). Clinical characteristics were evaluated at baseline and 12 weeks before each exacerbation. Number of exacerbations, MG treatments and HCRU costs associated with exacerbation were described during a 2-year follow-up period. Results: Among 9352 prevalent MG patients, 34.4% (n = 3218) experienced ≥1 exacerbation after index: commercial, 53.0% (n = 1706); Medicare, 39.4% (n = 1269); and Medicaid, 7.6% (n = 243). During follow-up, the mean (standard deviation) number of exacerbations per commercial and Medicare patient was 3.7 (7.0) and 2.7 (4.1), respectively. At least two exacerbations were experienced by approximately half of commercial and Medicare patients with ≥1 exacerbation. Mean total MG-related healthcare costs per exacerbation ranged from $26,078 to $51,120, and from $19,903 to $49,967 for commercial and Medicare patients, respectively. AChEI use decreased in patients with multiple exacerbations, while intravenous immunoglobulin use increased with multiple exacerbations. Conclusion: Despite utilization of current treatments for MG, MG exacerbations are associated with a high clinical and economic burden in both commercial and Medicare patients. Additional treatment options and improved disease management may help to reduce exacerbations and disease burden.
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Crisafulli S, Boccanegra B, Carollo M, Bottani E, Mantuano P, Trifirò G, De Luca A. Myasthenia Gravis Treatment: From Old Drugs to Innovative Therapies with a Glimpse into the Future. CNS Drugs 2024; 38:15-32. [PMID: 38212553 DOI: 10.1007/s40263-023-01059-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2023] [Indexed: 01/13/2024]
Abstract
Myasthenia gravis (MG) is a rare autoimmune disease that causes debilitating muscle weakness due to impaired neuromuscular transmission. Since most (about 80-90%) MG patients present autoantibodies against the acetylcholine receptor, standard medical therapy consists of symptomatic treatment with acetylcholinesterase inhibitors (e.g., pyridostigmine). In addition, considering the autoimmune basis of MG, standard therapy includes immunomodulating agents, such as corticosteroids, azathioprine, cyclosporine A, and cyclophosphamide. New strategies have been proposed for the treatment of MG and include complement blockade (i.e., eculizumab, ravulizumab, and zilucoplan) and neonatal Fc receptor antagonism (i.e., efgartigimod and rozanolixizumab). The aim of this review is to provide a detailed overview of the pre- and post-marketing evidence on the five pharmacological treatments most recently approved for the treatment of MG, by identifying both preclinical and clinical studies registered in clinicaltrials.gov. A description of the molecules currently under evaluation for the treatment of MG is also provided.
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Affiliation(s)
| | - Brigida Boccanegra
- Department of Pharmacy-Drug Sciences, University of Bari "Aldo Moro", Bari, Italy
| | - Massimo Carollo
- Department of Diagnostics and Public Health, University of Verona, P.le L.A. Scuro 10, 37124, Verona, Italy
| | - Emanuela Bottani
- Department of Diagnostics and Public Health, University of Verona, P.le L.A. Scuro 10, 37124, Verona, Italy
| | - Paola Mantuano
- Department of Pharmacy-Drug Sciences, University of Bari "Aldo Moro", Bari, Italy
| | - Gianluca Trifirò
- Department of Diagnostics and Public Health, University of Verona, P.le L.A. Scuro 10, 37124, Verona, Italy.
| | - Annamaria De Luca
- Department of Pharmacy-Drug Sciences, University of Bari "Aldo Moro", Bari, Italy
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Dejanovic B, Sheng M, Hanson JE. Targeting synapse function and loss for treatment of neurodegenerative diseases. Nat Rev Drug Discov 2024; 23:23-42. [PMID: 38012296 DOI: 10.1038/s41573-023-00823-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2023] [Indexed: 11/29/2023]
Abstract
Synapse dysfunction and loss are hallmarks of neurodegenerative diseases that correlate with cognitive decline. However, the mechanisms and therapeutic strategies to prevent or reverse synaptic damage remain elusive. In this Review, we discuss recent advances in understanding the molecular and cellular pathways that impair synapses in neurodegenerative diseases, including the effects of protein aggregation and neuroinflammation. We also highlight emerging therapeutic approaches that aim to restore synaptic function and integrity, such as enhancing synaptic plasticity, preventing synaptotoxicity, modulating neuronal network activity and targeting immune signalling. We discuss the preclinical and clinical evidence for each strategy, as well as the challenges and opportunities for developing effective synapse-targeting therapeutics for neurodegenerative diseases.
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Affiliation(s)
| | - Morgan Sheng
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Jesse E Hanson
- Department of Neuroscience, Genentech, South San Francisco, CA, USA.
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71
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Nelke C, Pawlitzki M, Kerkhoff R, Schroeter CB, Aktas O, Neuen-Jacob E, Polzin A, Meuth SG, Ruck T. Immune Checkpoint Inhibition-Related Myasthenia-Myositis-Myocarditis Responsive to Complement Blockade. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200177. [PMID: 37884388 PMCID: PMC10602369 DOI: 10.1212/nxi.0000000000200177] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/05/2023] [Indexed: 10/28/2023]
Abstract
OBJECTIVE Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy but come with immune-related adverse events (irAEs) that provide a novel challenge for treating physicians. Neuromuscular irAEs, including myositis, myasthenia gravis (MG), and demyelinating polyradiculoneuropathy, lead to significant morbidity and mortality. METHODS We present a case of severe myasthenia-myositis-myocarditis overlap in a patient receiving ICIs for breast cancer. Clinical findings were recorded. RESULTS A 47-year-old woman developed tetraparesis, dysphagia, and muscle pain during ICI treatment. MG with a thymoma had been diagnosed earlier. Neuromuscular overlap irAEs with cardiac affection was confirmed, and ICI treatment was discontinued. Given a lack of clinical response to standard therapies, a muscle biopsy was performed demonstrating complement deposition. Eculizumab treatment led to rapid improvement in muscle strength and cardiac function. DISCUSSION Neuromuscular irAEs are associated with a high in-hospital mortality, and specific treatment strategies remain an unmet need. Here, early muscle biopsy enabled targeted therapy after standard approaches failed, thereby highlighting the value of identifying a specific treatment target. To improve therapeutic outcomes, the development of patient-tailored strategies for neuromuscular irAEs requires further studies.
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Affiliation(s)
- Christopher Nelke
- From the Department of Neurology (C.N., M.P., R.K., C.B.S., O.A., S.G.M., T.R.); Institute of Neuropathology (E.N.-J.); and Division of Cardiology, Pulmonology, and Vascular Medicine (A.P.), Medical Faculty, Heinrich Heine University Dusseldorf, Germany
| | - Marc Pawlitzki
- From the Department of Neurology (C.N., M.P., R.K., C.B.S., O.A., S.G.M., T.R.); Institute of Neuropathology (E.N.-J.); and Division of Cardiology, Pulmonology, and Vascular Medicine (A.P.), Medical Faculty, Heinrich Heine University Dusseldorf, Germany
| | - Ruth Kerkhoff
- From the Department of Neurology (C.N., M.P., R.K., C.B.S., O.A., S.G.M., T.R.); Institute of Neuropathology (E.N.-J.); and Division of Cardiology, Pulmonology, and Vascular Medicine (A.P.), Medical Faculty, Heinrich Heine University Dusseldorf, Germany
| | - Christina B Schroeter
- From the Department of Neurology (C.N., M.P., R.K., C.B.S., O.A., S.G.M., T.R.); Institute of Neuropathology (E.N.-J.); and Division of Cardiology, Pulmonology, and Vascular Medicine (A.P.), Medical Faculty, Heinrich Heine University Dusseldorf, Germany
| | - Orhan Aktas
- From the Department of Neurology (C.N., M.P., R.K., C.B.S., O.A., S.G.M., T.R.); Institute of Neuropathology (E.N.-J.); and Division of Cardiology, Pulmonology, and Vascular Medicine (A.P.), Medical Faculty, Heinrich Heine University Dusseldorf, Germany
| | - Eva Neuen-Jacob
- From the Department of Neurology (C.N., M.P., R.K., C.B.S., O.A., S.G.M., T.R.); Institute of Neuropathology (E.N.-J.); and Division of Cardiology, Pulmonology, and Vascular Medicine (A.P.), Medical Faculty, Heinrich Heine University Dusseldorf, Germany
| | - Amin Polzin
- From the Department of Neurology (C.N., M.P., R.K., C.B.S., O.A., S.G.M., T.R.); Institute of Neuropathology (E.N.-J.); and Division of Cardiology, Pulmonology, and Vascular Medicine (A.P.), Medical Faculty, Heinrich Heine University Dusseldorf, Germany
| | - Sven G Meuth
- From the Department of Neurology (C.N., M.P., R.K., C.B.S., O.A., S.G.M., T.R.); Institute of Neuropathology (E.N.-J.); and Division of Cardiology, Pulmonology, and Vascular Medicine (A.P.), Medical Faculty, Heinrich Heine University Dusseldorf, Germany
| | - Tobias Ruck
- From the Department of Neurology (C.N., M.P., R.K., C.B.S., O.A., S.G.M., T.R.); Institute of Neuropathology (E.N.-J.); and Division of Cardiology, Pulmonology, and Vascular Medicine (A.P.), Medical Faculty, Heinrich Heine University Dusseldorf, Germany.
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Hehir MK, Conaway M, St Sauveur AB, Feb K, Kolb NA, Waheed W, McNeish BL, Tweedy N, Burns TM. Measuring treatment adverse event burden in myasthenia gravis: Single-center prospective evaluation utilizing the Adverse Event Unit (AEU). Muscle Nerve 2024; 69:32-39. [PMID: 37676119 DOI: 10.1002/mus.27966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 08/15/2023] [Accepted: 08/16/2023] [Indexed: 09/08/2023]
Abstract
INTRODUCTION/AIMS We developed a patient- and physician-weighted consensus unit called the adverse event unit (AEU) that quantifies and compares adverse event (AE) burden among any group of medications in neurological patients. In this study we evaluated preliminary validity and feasibility of measuring AE burden with the AEU in myasthenia gravis (MG). METHODS This is a single-center, prospective, 1-year, observational study of adult MG patients presenting for routine care between April 1, 2021 and March 31, 2022. The MG Activities of Daily Living (MG-ADL), the 15-item MG Quality of Life revised (MG-QOL15r), MG-Composite, and AEU scores were obtained at all visits. A priori primary feasibility metric was AEU completion rate equal to (within 3.8%, one-sided 95% confidence interval [CI]) or better than MG-ADL completion rate. Time to administer AEU and MG-ADL/MG-QOL15r, correlation between AEU total score and MG-QOL15r, and median AEU scores for each MG medication were evaluated. RESULTS Fifty-four patients completed 67 study visits; side effects were reported at 75% of the visits. The study met the primary feasibility endpoint; AEU and MG-ADL were recorded at all visits. Times to administer the AEU (median 5 minutes) and MG-ADL/MG-QOL15r were similar. We observed a weak correlation of 0.29 (95% CI 0.03 to 0.51, P = .032) between AEU and MG-QOL15r scores. Non-statistically significant differences in median AEU scores were observed among MG medications. DISCUSSION Our data demonstrate preliminary feasibility and validity of using the AEU to measure AE burden in MG. Future studies will compare AE burden among MG treatments and evaluate clinically meaningful AEU scores in MG.
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Affiliation(s)
- Michael K Hehir
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Mark Conaway
- Division of Translational Research and Applied Statistics, University of Virginia, Charlottesville, Virginia, USA
| | - Avery B St Sauveur
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Kendall Feb
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Noah A Kolb
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Waqar Waheed
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Brendan L McNeish
- Departments of Physical Medicine and Rehabilitation and Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nicole Tweedy
- Mission Health Neurology, Asheville, North Carolina, USA
| | - Ted M Burns
- Department of Neurology, University of Virginia, Charlottesville, Virginia, USA
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Tannemaat MR, Huijbers MG, Verschuuren JJGM. Myasthenia gravis-Pathophysiology, diagnosis, and treatment. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:283-305. [PMID: 38494283 DOI: 10.1016/b978-0-12-823912-4.00026-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Myasthenia gravis (MG) is an autoimmune disease characterized by dysfunction of the neuromuscular junction resulting in skeletal muscle weakness. It is equally prevalent in males and females, but debuts at a younger age in females and at an older age in males. Ptosis, diplopia, facial bulbar weakness, and limb weakness are the most common symptoms. MG can be classified based on the presence of serum autoantibodies. Acetylcholine receptor (AChR) antibodies are found in 80%-85% of patients, muscle-specific kinase (MuSK) antibodies in 5%-8%, and <1% may have low-density lipoprotein receptor-related protein 4 (Lrp4) antibodies. Approximately 10% of patients are seronegative for antibodies binding the known disease-related antigens. In patients with AChR MG, 10%-20% have a thymoma, which is usually detected at the onset of the disease. Important differences between clinical presentation, treatment responsiveness, and disease mechanisms have been observed between these different serologic MG classes. Besides the typical clinical features and serologic testing, the diagnosis can be established with additional tests, including repetitive nerve stimulation, single fiber EMG, and the ice pack test. Treatment options for MG consist of symptomatic treatment (such as pyridostigmine), immunosuppressive treatment, or thymectomy. Despite the treatment with symptomatic drugs, steroid-sparing immunosuppressants, intravenous immunoglobulins, plasmapheresis, and thymectomy, a large proportion of patients remain chronically dependent on corticosteroids (CS). In the past decade, the number of treatment options for MG has considerably increased. Advances in the understanding of the pathophysiology have led to new treatment options targeting B or T cells, the complement cascade, the neonatal Fc receptor or cytokines. In the future, these new treatments are likely to reduce the chronic use of CS, diminish side effects, and decrease the number of patients with refractory disease.
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Affiliation(s)
- Martijn R Tannemaat
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Maartje G Huijbers
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands; Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
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Zhou A, Ho S, Vickers A. Eculizumab in myasthenia gravis: A review. Saudi J Ophthalmol 2024; 38:34-40. [PMID: 38628404 PMCID: PMC11016999 DOI: 10.4103/sjopt.sjopt_74_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 10/09/2023] [Accepted: 10/10/2023] [Indexed: 04/19/2024] Open
Abstract
Eculizumab, a monoclonal antibody against complement C5, is a novel therapy to treat refractory myasthenia gravis (MG). The present review was undertaken to study the role of eculizumab in MG. This includes the drug's mechanism, pharmacokinetics, clinical trial findings, tolerability, side effects, safety, dosage, administration, and cost. An English-language search for relevant items was undertaken using Embase and PubMed from 1946 to present. Clinical trial registries/databases and websites were also searched for relevant data. Keywords were eculizumab and MG. The present review found 103 articles after initial screening. Current data support eculizumab as an effective, safe, and tolerable drug in cases of refractory MG. However, its cost can prevent it from being widely accessible to a majority of the general population.
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Affiliation(s)
- Avery Zhou
- Kirk Kerkorian School of Medicine, Las Vegas, NV, USA
| | - Sabrina Ho
- Kirk Kerkorian School of Medicine, Las Vegas, NV, USA
| | - Aroucha Vickers
- Department of Neurology, Valley Hospital Medical Center, Las Vegas, NV, USA
- Department of Neuro-Ophthalmology, Las Vegas Neurology Center, Las Vegas, NV, USA
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Jindal S, Pedersen DV, Gera N, Chandler J, Patel R, Neill A, Cone J, Zhang Y, Yuan CX, Millman EE, Carlin D, Puffer B, Sheridan D, Andersen GR, Tamburini P. Characterization of the bispecific VHH antibody gefurulimab (ALXN1720) targeting complement component 5, and designed for low volume subcutaneous administration. Mol Immunol 2024; 165:29-41. [PMID: 38142486 DOI: 10.1016/j.molimm.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 09/29/2023] [Accepted: 12/09/2023] [Indexed: 12/26/2023]
Abstract
The bispecific antibody gefurulimab (also known as ALXN1720) was developed to provide patients with a subcutaneous treatment option for chronic disorders involving activation of the terminal complement pathway. Gefurulimab blocks the enzymatic cleavage of complement component 5 (C5) into the biologically active C5a and C5b fragments, which triggers activation of the terminal complement cascade. Heavy-chain variable region antigen-binding fragment (VHH) antibodies targeting C5 and human serum albumin (HSA) were isolated from llama immune-based libraries and humanized. Gefurulimab comprises an N-terminal albumin-binding VHH connected to a C-terminal C5-binding VHH via a flexible linker. The purified bispecific VHH antibody has the expected exact size by mass spectrometry and can be formulated at greater than 100 mg/mL. Gefurulimab binds tightly to human C5 and HSA with dissociation rate constants at pH 7.4 of 54 pM and 0.9 nM, respectively, and cross-reacts with C5 and serum albumin from cynomolgus monkeys. Gefurulimab can associate with C5 and albumin simultaneously, and potently inhibits the terminal complement activity from human serum initiated by any of the three complement pathways in Wieslab assays. Electron microscopy and X-ray crystallography revealed that the isolated C5-binding VHH recognizes the macroglobulin (MG) 4 and MG5 domains of the antigen and thereby is suggested to sterically prevent C5 binding to its activating convertase. Gefurulimab also inhibits complement activity supported by the rare C5 allelic variant featuring an R885H substitution in the MG7 domain. Taken together, these data suggest that gefurulimab may be a promising candidate for the potential treatment of complement-mediated disorders.
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Affiliation(s)
- Siddharth Jindal
- Alexion, AstraZeneca Rare Disease, 100 College Street, New Haven, CT 06510, USA
| | | | - Nimish Gera
- Alexion, AstraZeneca Rare Disease, 100 College Street, New Haven, CT 06510, USA
| | - Julian Chandler
- Alexion, AstraZeneca Rare Disease, 100 College Street, New Haven, CT 06510, USA
| | - Rekha Patel
- Alexion, AstraZeneca Rare Disease, 100 College Street, New Haven, CT 06510, USA
| | - Alyssa Neill
- Alexion, AstraZeneca Rare Disease, 100 College Street, New Haven, CT 06510, USA
| | - Josh Cone
- Alexion, AstraZeneca Rare Disease, 100 College Street, New Haven, CT 06510, USA
| | - Yuchun Zhang
- Alexion, AstraZeneca Rare Disease, 100 College Street, New Haven, CT 06510, USA
| | - Chao-Xing Yuan
- Alexion, AstraZeneca Rare Disease, 100 College Street, New Haven, CT 06510, USA
| | - Ellen E Millman
- Alexion, AstraZeneca Rare Disease, 100 College Street, New Haven, CT 06510, USA
| | - Dan Carlin
- Alexion, AstraZeneca Rare Disease, 100 College Street, New Haven, CT 06510, USA.
| | - Bridget Puffer
- Alexion, AstraZeneca Rare Disease, 100 College Street, New Haven, CT 06510, USA
| | - Douglas Sheridan
- Alexion, AstraZeneca Rare Disease, 100 College Street, New Haven, CT 06510, USA
| | - Gregers Rom Andersen
- Department of Molecular Biology and Genetics, Universitetsbyen 83, Aarhus University, Aarhus, Denmark
| | - Paul Tamburini
- Alexion, AstraZeneca Rare Disease, 100 College Street, New Haven, CT 06510, USA
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Tian Y, Shen Q, Peng S, Meng L, Fang R, Xiong A, Li S, Yang Y, Chang W, Ni J, Zhu W. Mapping current trends and hotspots in myasthenia gravis from 2003 to 2022: a bibliometric analysis. Front Neurol 2023; 14:1320344. [PMID: 38213833 PMCID: PMC10782526 DOI: 10.3389/fneur.2023.1320344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/15/2023] [Indexed: 01/13/2024] Open
Abstract
Introduction Research on myasthenia gravis (MG) has undergone rapid development in recent years. This article aimed to elucidate the characteristics of MG publications over the past 20 years and analyze emerging trends using bibliometric methods. Methods Information on MG articles was obtained from the Web of Science Core Collection and stored in Excel for quantitative analyses. Bibliometric analyses were performed using CiteSpace and VOSviewer to visualize publications according to countries/regions, institutions, journals, and authors. Results A total of 3,610 publications were included in the analysis. The USA had the highest number of publications (NP) and H-index. Among the institutions, the University of Oxford had the highest NP, followed by the University of Toronto and Duke University. Close cooperation was observed among countries and institutions. The most productive author was Renato Mantegazza, followed by Jan J. Verschuuren, and Amelia Evoli. Muscle & Nerve published the most articles on MG, followed by the Journal of Neuroimmunology and Neuromuscular Disorders. The keyword with the highest strength is "neuromuscular transmission," followed by "safety" and "rituximab." Co-citation analysis includes 103 publications cited at least 65 times, categorized into four clusters. Additionally, 123 keywords cited more than 40 times were analyzed and divided into five clusters. Conclusion This bibliometric analysis shows the framework of research over the past 20 years by mapping the scholarly contributions of various countries or regions, institutions, journals, and authors in MG. The analysis also explores future trends and prospective directions, emphasizing individualized treatment based on subtypes, novel immunotherapeutic approaches, and thymectomy.
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Affiliation(s)
- Yukun Tian
- Department of Acupuncture, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Qiqi Shen
- Department of Acupuncture, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Siyang Peng
- Department of Acupuncture, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Linghao Meng
- Department of Acupuncture, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Ruiying Fang
- Department of Acupuncture, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Anni Xiong
- Department of Acupuncture, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Shaohong Li
- Treatment Center of Traditional Chinese Medicine Bo’ai Hospital, China Rehabilitation Research Center, Beijing, China
| | - Yajing Yang
- Department of Traditional Chinese Medicine, Yuyuantan Community Health Center, Beijing, China
| | - Weiqian Chang
- Department of Acupuncture, Guang’anmen Hospital, Chinese Academy of Traditional Chinese Medicine Ji’nan Hospital (Ji’nan Hospital of Traditional Chinese Medicine), Jinan, Shandong, China
| | - Jinxia Ni
- Department of Acupuncture, Dongzhimen Hospital of Beijing University of Traditional Chinese Medicine, Beijing, China
| | - Wenzeng Zhu
- Department of Acupuncture, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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Wiendl H, Abicht A, Chan A, Della Marina A, Hagenacker T, Hekmat K, Hoffmann S, Hoffmann HS, Jander S, Keller C, Marx A, Melms A, Melzer N, Müller-Felber W, Pawlitzki M, Rückert JC, Schneider-Gold C, Schoser B, Schreiner B, Schroeter M, Schubert B, Sieb JP, Zimprich F, Meisel A. Guideline for the management of myasthenic syndromes. Ther Adv Neurol Disord 2023; 16:17562864231213240. [PMID: 38152089 PMCID: PMC10752078 DOI: 10.1177/17562864231213240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 10/23/2023] [Indexed: 12/29/2023] Open
Abstract
Myasthenia gravis (MG), Lambert-Eaton myasthenic syndrome (LEMS), and congenital myasthenic syndromes (CMS) represent an etiologically heterogeneous group of (very) rare chronic diseases. MG and LEMS have an autoimmune-mediated etiology, while CMS are genetic disorders. A (strain dependent) muscle weakness due to neuromuscular transmission disorder is a common feature. Generalized MG requires increasingly differentiated therapeutic strategies that consider the enormous therapeutic developments of recent years. To include the newest therapy recommendations, a comprehensive update of the available German-language guideline 'Diagnostics and therapy of myasthenic syndromes' has been published by the German Neurological society with the aid of an interdisciplinary expert panel. This paper is an adapted translation of the updated and partly newly developed treatment guideline. It defines the rapid achievement of complete disease control in myasthenic patients as a central treatment goal. The use of standard therapies, as well as modern immunotherapeutics, is subject to a staged regimen that takes into account autoantibody status and disease activity. With the advent of modern, fast-acting immunomodulators, disease activity assessment has become pivotal and requires evaluation of the clinical course, including severity and required therapies. Applying MG-specific scores and classifications such as Myasthenia Gravis Activities of Daily Living, Quantitative Myasthenia Gravis, and Myasthenia Gravis Foundation of America allows differentiation between mild/moderate and (highly) active (including refractory) disease. Therapy decisions must consider age, thymic pathology, antibody status, and disease activity. Glucocorticosteroids and the classical immunosuppressants (primarily azathioprine) are the basic immunotherapeutics to treat mild/moderate to (highly) active generalized MG/young MG and ocular MG. Thymectomy is indicated as a treatment for thymoma-associated MG and generalized MG with acetylcholine receptor antibody (AChR-Ab)-positive status. In (highly) active generalized MG, complement inhibitors (currently eculizumab and ravulizumab) or neonatal Fc receptor modulators (currently efgartigimod) are recommended for AChR-Ab-positive status and rituximab for muscle-specific receptor tyrosine kinase (MuSK)-Ab-positive status. Specific treatment for myasthenic crises requires plasmapheresis, immunoadsorption, or IVIG. Specific aspects of ocular, juvenile, and congenital myasthenia are highlighted. The guideline will be further developed based on new study results for other immunomodulators and biomarkers that aid the accurate measurement of disease activity.
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Affiliation(s)
- Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, Münster 48149, Germany
| | - Angela Abicht
- Friedrich-Baur-Institut an der Neurologischen Klinik und Poliklinik, LMU Munich, Munich, Germany
| | - Andrew Chan
- Universitätsklinik für Neurologie, Inselspital Bern, Bern, Switzerland
| | - Adela Della Marina
- Klinik für Kinderheilkunde I, Universitätsklinikum Essen, Essen, Germany
| | - Tim Hagenacker
- Klinik für Neurologie, Universitätsklinikum Essen, Essen, Germany
| | | | - Sarah Hoffmann
- Charité – Universitätsmedizin Berlin, Klinik für Neurologie mit Experimenteller Neurologie, Berlin, Germany
| | | | - Sebastian Jander
- Klinik für Neurologie, Marien Hospital Düsseldorf, Düsseldorf, Germany
| | - Christian Keller
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Alexander Marx
- Pathologisches Institut, Universitätsklinikum Mannheim, Mannheim, Germany
| | - Arthur Melms
- Facharztpraxis für Neurologie und Psychiatrie, Stuttgart, Germany
| | - Nico Melzer
- Klinik für Neurologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Wolfgang Müller-Felber
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, LMU Munich, Munich, Germany
| | - Marc Pawlitzki
- Klinik für Neurologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | | | | | - Benedikt Schoser
- Friedrich-Baur-Institut an der Neurologischen Klinik und Poliklinik, LMU Munich, Munich, Germany
| | - Bettina Schreiner
- Klinik für Neurologie, Universitätsspital Zürich, Zürich, Switzerland
| | - Michael Schroeter
- Klinik und Poliklinik für Neurologie, Uniklinik Cologne, Cologne, Germany
| | | | | | - Fritz Zimprich
- Universitätsklinik für Neurologie, AKH-Wien, Wien, Austria
| | - Andreas Meisel
- Charité – Universitätsmedizin Berlin, Klinik für Neurologie mit Experimenteller Neurologie, Berlin, Germany
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Kawama K, Warabi Y, Bokuda K, Kimura H, Takahashi K. Exacerbation of Thymoma-Associated Myasthenia Gravis Following Efgartigimod Treatment Related to Anti-acetylcholine Receptor Antibody Overshoot: A Report of Two Cases. Cureus 2023; 15:e50692. [PMID: 38229781 PMCID: PMC10791222 DOI: 10.7759/cureus.50692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2023] [Indexed: 01/18/2024] Open
Abstract
Myasthenia gravis (MG), a chronic, autoimmune disease affecting the neuromuscular junction, arises from various autoantibodies, including those against the acetylcholine receptor (AChR). Recently, efgartigimod, a human IgG1 antibody Fc fragment engineered to reduce the pathogenic IgG autoantibody level, was developed as a treatment for MG. However, the long-term effects of the treatment are still unclear. The present report describes two novel cases of thymoma-associated MG exacerbation following efgartigimod treatment related to anti-AChR antibody overshoot. Both cases shared certain characteristics, including anti-AChR antibody positivity and post-thymectomy status. After a few cycles of efgartigimod treatment, their MG deteriorated, and their anti-AChR antibody titer exceeded the level before efgartigimod therapy. Prior studies show that anti-AChR antibody titer does not correlate with the disease severity of MG. However, previous studies have reported antibody overshoot following plasma exchange, which, like efgartigimod, reduces the level of plasma IgG and autoantibodies. Thus, MG exacerbation with anti-AChR antibody overshoot may be an adverse effect of both efgartigimod and plasma exchange. When clinical symptoms in patients with thymoma-associated MG receiving efgartigimod deteriorate despite low IgG, assessing the anti-AChR antibody level can be important for reconsidering the treatment strategy.
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Affiliation(s)
- Kentaro Kawama
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, JPN
| | - Yoko Warabi
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, JPN
| | - Kota Bokuda
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, JPN
| | - Hideki Kimura
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, JPN
| | - Kazushi Takahashi
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, JPN
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79
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Vu T, Wiendl H, Katsuno M, Reddel SW, Howard JF. Ravulizumab in Myasthenia Gravis: A Review of the Current Evidence. Neuropsychiatr Dis Treat 2023; 19:2639-2655. [PMID: 38059203 PMCID: PMC10697093 DOI: 10.2147/ndt.s374694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/17/2023] [Indexed: 12/08/2023] Open
Abstract
The terminal complement C5 inhibitor ravulizumab was engineered from the humanized monoclonal antibody eculizumab to have an extended half-life and duration of action. It binds to human terminal complement protein C5, inhibiting its cleavage into C5a and C5b, thus preventing the cascade of events that lead to architectural destruction of the postsynaptic neuromuscular junction membrane by the membrane attack complex, and consequent muscle weakness in patients with anti-acetylcholine receptor (AChR) antibody-positive generalized myasthenia gravis (gMG). The 26-week randomized, placebo-controlled period (RCP) of the phase 3 CHAMPION MG study demonstrated the rapid efficacy of ravulizumab in reducing MG symptoms. Weight-based dosing of ravulizumab every 8 weeks provided sustained efficacy, in terms of patient-reported (Myasthenia Gravis-Activities of Daily Living) and clinician-reported (Quantitative Myasthenia Gravis) endpoints in patients with anti-AChR antibody-positive gMG. Pharmacokinetic and pharmacodynamic analyses showed therapeutic serum ravulizumab concentrations (>175 µg/mL) were achieved immediately after the first dose and were maintained throughout 26 weeks, irrespective of patient body weight; inhibition of serum free C5 was immediate, complete (<0.5 μg/mL), and sustained in all patients. Interim results from the open-label extension (OLE) showed that after 60 weeks, efficacy was maintained in patients continuing on ravulizumab. Rapid and sustained improvements in efficacy, similar to those seen in patients initiating ravulizumab in the RCP, were observed after initiation of ravulizumab treatment in patients who switched from placebo in the RCP to ravulizumab in the OLE. The findings from the RCP and OLE support ravulizumab's favorable safety profile. In conclusion, ravulizumab has a simple weight-based administration and long dosing interval. Its targeted mechanism of action without generalized immunosuppression is reflected in its rapid onset of symptom improvement, sustained efficacy and good safety profile in the treatment of patients with anti-AChR antibody-positive gMG.
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Affiliation(s)
- Tuan Vu
- Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Stephen W Reddel
- Department of Neurology, Concord Hospital, University of Sydney, Sydney, NSW, Australia
| | - James F Howard
- Department of Neurology, The University of North Carolina, Chapel Hill, NC, USA
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80
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Koopman I, Tack RWP, Wunderink HF, Bruns AHW, van der Schaaf IC, Cianci D, Gelderman KA, van de Ridder IM, Hol EM, Rinkel GJE, Vergouwen MDI. Safety and pharmacodynamic efficacy of eculizumab in aneurysmal subarachnoid hemorrhage (CLASH): A phase 2a randomized clinical trial. Eur Stroke J 2023; 8:1097-1106. [PMID: 37606053 PMCID: PMC10683736 DOI: 10.1177/23969873231194123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/25/2023] [Indexed: 08/23/2023] Open
Abstract
INTRODUCTION Complement C5 antibodies reduce brain injury after experimental subarachnoid hemorrhage. PATIENTS AND METHODS In this randomized, controlled, open-label, phase 2a clinical trial with blinded-outcome assessment, we included adult aneurysmal subarachnoid hemorrhage (aSAH) patients admitted to a tertiary referral center ⩽11 h after ictus. Patients were randomized (1:1) to eculizumab plus care as usual or to care as usual. Eculizumab (1200 mg) was administered <12 h, and on days 3 and 7 after ictus. In the intervention group, all patients received prophylactic antibiotics and, after a protocol amendment, fluconazole if indicated. Primary outcome was C5a concentration in cerebrospinal fluid (CSF) on day 3 after ictus. Safety was monitored during 4 weeks. In each group, 13 patients with CSF assessments were needed to detect a 55% reduction in CSF C5a concentration. RESULTS From October 2018 to May 2021, we enrolled 31 patients of whom 26 with CSF samples, 13 per group. Median C5a concentration in CSF on day 3 was 251 pg/ml [IQR: 103-402] in the intervention group and 371 pg/ml [IQR: 131-534] in the control group (p = 0.29). Infections occurred in two patients in the intervention group and four patients in the control group. One patient in the intervention group developed a C. albicans meningitis prior to the protocol amendment. DISCUSSION AND CONCLUSION One dose of eculizumab did not result in a ⩾ 55% decrease in C5a concentration in CSF on day 3 after aSAH. The study did not reveal new safety concerns, except for a C. albicans drain-related infection prior to antifungal monitoring and treatment. TRIAL REGISTRATION EudraCT 2017-004307-51, https://www.clinicaltrialsregister.eu/.
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Affiliation(s)
- Inez Koopman
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Reinier WP Tack
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Herman F Wunderink
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Anke HW Bruns
- Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Irene C van der Schaaf
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Daniela Cianci
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Inge M van de Ridder
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Elly M Hol
- Department of Translational Neuroscience, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Gabriel JE Rinkel
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Mervyn DI Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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81
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Kim S, Lee JJ, Seok HY. Eculizumab as a promising rescue therapy for acute exacerbations of myasthenia gravis. Neurol Sci 2023; 44:4573-4574. [PMID: 37537418 DOI: 10.1007/s10072-023-06993-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 07/29/2023] [Indexed: 08/05/2023]
Affiliation(s)
- Sohyeon Kim
- Department of Neurology, Dongsan Hospital, Keimyung University School of Medicine, 1035 Dalgubeol-daero, Dalseo-gu, Daegu, 42601, Republic of Korea
| | - Jae-Joon Lee
- Department of Neurology, Dongsan Hospital, Keimyung University School of Medicine, 1035 Dalgubeol-daero, Dalseo-gu, Daegu, 42601, Republic of Korea
| | - Hung Youl Seok
- Department of Neurology, Dongsan Hospital, Keimyung University School of Medicine, 1035 Dalgubeol-daero, Dalseo-gu, Daegu, 42601, Republic of Korea.
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Saccà F, Pane C, Espinosa PE, Sormani MP, Signori A. Efficacy of innovative therapies in myasthenia gravis: A systematic review, meta-analysis and network meta-analysis. Eur J Neurol 2023; 30:3854-3867. [PMID: 37204031 DOI: 10.1111/ene.15872] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/17/2023] [Accepted: 05/15/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND AND PURPOSE Therapy for myasthenia gravis (MG) is undergoing a profound change, with new treatments being tested. These include complement inhibitors and neonatal Fc receptor (FcRn) blockers. The aim of this study was to perform a meta-analysis and network meta-analysis of randomized and placebo-controlled trials of innovative therapies in MG with available efficacy data. METHODS We assessed statistical heterogeneity across trials based on the Cochrane Q test and I2 values, and mean differences were pooled using the random-effects model. Treatment efficacy was assessed after 26 weeks of eculizumab and ravulizumab, 28 days of efgartigimod, 43 days of rozanolixizumab, 12 weeks of zilucoplan, and 16, 24 or 52 weeks of rituximab treatment. RESULTS We observed an overall mean Myasthenia Gravis-Activities of Daily Living scale (MG-ADL) score change of -2.17 points (95% confidence interval [CI] -2.67, -1.67; p < 0.001) as compared to placebo. No significant difference emerged between complement inhibitors and anti-FcRn treatment (p = 0.16). The change in Quantitative Myasthenia Gravis scale (QMG) score was -3.46 (95% CI -4.53, -2.39; p < 0.001), with a higher reduction with FcRns (-4.78 vs. -2.60; p < 0.001). Rituximab did not significantly improve the MG-ADL (-0.92 [95% CI -2.24, 0.39]; p = 0.17) or QMG scores (-1.9 [95% CI -3.97, 0.18]; p = 0.07). In the network meta-analysis, efgartigimod had the highest probability of being the best treatment, followed by rozanolixizumab. CONCLUSION Anti-complement and FcRn treatments both proved to be effective in MG patients, whereas rituximab did not show a significant benefit for patients. Within the limitations of this meta-analysis, including efficacy time points, FcRn treatments showed a greater effect on QMG score in the short term. Real-life studies with long-term measurements are needed to confirm our results.
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Affiliation(s)
- Francesco Saccà
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, University "Federico II", Naples, Italy
| | - Chiara Pane
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, University "Federico II", Naples, Italy
| | | | | | - Alessio Signori
- Department of Health Sciences, University of Genoa, Genoa, Italy
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83
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Habib AA, Schneider-Gold C. Advancements in targeted therapies for generalized acetylcholine receptor antibody positive myasthenia gravis: Beginnings of a paradigm shift. Eur J Neurol 2023; 30:3644-3645. [PMID: 37578121 DOI: 10.1111/ene.16037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 08/15/2023]
Affiliation(s)
- Ali A Habib
- MDA ALS and Neuromuscular Center, University of California, Irvine, California, USA
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84
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Pavlekovics M, Engh MA, Lugosi K, Szabo L, Hegyi P, Terebessy T, Csukly G, Molnar Z, Illes Z, Lovas G. Plasma Exchange versus Intravenous Immunoglobulin in Worsening Myasthenia Gravis: A Systematic Review and Meta-Analysis with Special Attention to Faster Relapse Control. Biomedicines 2023; 11:3180. [PMID: 38137401 PMCID: PMC10740589 DOI: 10.3390/biomedicines11123180] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 11/21/2023] [Accepted: 11/25/2023] [Indexed: 12/24/2023] Open
Abstract
Currently used rescue interventions to prevent rapid myasthenic deterioration are plasma exchange (PLEX) and intravenous immunoglobulin (IVIG). We investigated the evidence to determine whether the two methods were interchangeable or whether one was superior to the other. This review was registered on PROSPERO (CRD42021285985). Only randomized controlled trials (RCTs) comparing the efficacy and safety of PLEX and IVIG in patients with moderate-to-severe myasthenia gravis (MG) were included. Five major databases were systematically searched (PubMed, CENTRAL, Embase, Scopus, and Web of Science). Odds ratios (OR) with 95% confidence intervals (CI) were calculated for adverse events and mean differences (MD) for changes in quantitative myasthenia gravis scores (QMG). Three RCTs met the inclusion criteria. Two investigating 114 patients in total were eligible for meta-analysis to analyze efficacy and safety. For the change in QMG score, the MD was -2.8 (95% CI: -5.614-0.113), with PLEX performing better. For adverse events, an OR of 1.04 was found (95% CI: 0.25-4.27). This study demonstrated a low risk of bias in evaluating treatment efficacy but indicated a high risk of bias in assessing procedural safety outcomes. Although the results did not show any significant difference, there was a tendency indicating faster efficacy of PLEX in the first two weeks of treatment. In such a critical clinical condition, this tendency may be clinically meaningful, but further studies should clarify this benefit.
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Affiliation(s)
- Mark Pavlekovics
- Center for Translational Medicine, Semmelweis University, Üllöi út 26, 1085 Budapest, Hungary; (M.P.)
- Department of Neurology, Jahn Ferenc Teaching Hospital, Köves út 1, 1204 Budapest, Hungary
| | - Marie Anne Engh
- Center for Translational Medicine, Semmelweis University, Üllöi út 26, 1085 Budapest, Hungary; (M.P.)
| | - Katalin Lugosi
- Center for Translational Medicine, Semmelweis University, Üllöi út 26, 1085 Budapest, Hungary; (M.P.)
- Department of Neurology, Bajcsy-Zsilinszky Hospital, Maglódi út 89–91, 1106 Budapest, Hungary
| | - Laszlo Szabo
- Center for Translational Medicine, Semmelweis University, Üllöi út 26, 1085 Budapest, Hungary; (M.P.)
| | - Peter Hegyi
- Center for Translational Medicine, Semmelweis University, Üllöi út 26, 1085 Budapest, Hungary; (M.P.)
- Institute of Pancreatic Diseases, Semmelweis University, Baross utca 22–24, 1085 Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, 12 Szigeti Street, 7623 Pécs, Hungary
| | - Tamas Terebessy
- Center for Translational Medicine, Semmelweis University, Üllöi út 26, 1085 Budapest, Hungary; (M.P.)
- Department of Orthopedics, Semmelweis University, Üllői út 78/b, 1082 Budapest, Hungary
| | - Gabor Csukly
- Center for Translational Medicine, Semmelweis University, Üllöi út 26, 1085 Budapest, Hungary; (M.P.)
- Department of Psychiatry and Psychotherapy, Semmelweis University, Balassa utca 6, 1083 Budapest, Hungary
| | - Zsolt Molnar
- Center for Translational Medicine, Semmelweis University, Üllöi út 26, 1085 Budapest, Hungary; (M.P.)
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 78 Üllöi St, 1085 Budapest, Hungary
| | - Zsolt Illes
- Department of Neurology, Odense University Hospital, Winslows Vej 4, 5000 Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Campusvej 55, 5230 Odense, Denmark
| | - Gabor Lovas
- Center for Translational Medicine, Semmelweis University, Üllöi út 26, 1085 Budapest, Hungary; (M.P.)
- Department of Neurology, Jahn Ferenc Teaching Hospital, Köves út 1, 1204 Budapest, Hungary
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85
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Schäbitz M, Möller L, Friedrich A, Klein N, Kitsiou A, Greeve I, Gerstner A, Wulff L, Schäbitz WR, Timmermann L, Rogalewski A. Long-term functional outcome and quality of life 2.5 years after thrombolysis in acute ischemic stroke. Neurol Res Pract 2023; 5:62. [PMID: 37941023 PMCID: PMC10633897 DOI: 10.1186/s42466-023-00291-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/16/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Evaluation of outcome after stroke is largely based on assessment of gross function 3 months after stroke onset using scales such as mRS. Cognitive or social functions, level of symptom burden or emotional health are not usually assessed, nor are data available on long-term functional outcomes years after stroke. METHODS Analysis of 1141 patients with AIS treated with IVT from two major German university hospitals between 2017 and 2020. Patient characteristics and short-term outcome were analysed from patient records. Long-term outcome of 228 patients with prior written informed consent was assessed via telephone survey using mRS and PROMs (EQ-5D-5L, EQ-VAS) 2.5 years after stroke. RESULTS Predictors of excellent to good long-term outcome were younger age, event to door time ≤ 2 h, NIHSS ≤ 6 on admission and NIHSS ≤ 6 after IVT. Stroke recurrence was a negative predictor. Predictors of excellent quality of life at 2.5 years included age < 73 years, lower NIHSS after IVT, absence of hypertension. Quality of life was rated in all dimensions with a medium score of 1 and a medium EQ-VAS of 70, representing the good general health status of this stroke population. CONCLUSION Main predictors of an excellent to good long-term outcome and excellent QoL 2.5 years after stroke are younger age, lower NIHSS, and event to door time ≤ 2 h. Research on long-term outcome after disease and treatment is of utmost importance, as it has the ability to reveal the patient true functional outcome and quality of life and to provide information on the status of independence and self-esteem.
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Affiliation(s)
- Marie Schäbitz
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Burgsteig 13, 33617, Bielefeld, Germany
- Department of Neurology, Philipps University Marburg, Marburg, Germany
| | - Leona Möller
- Department of Neurology, Philipps University Marburg, Marburg, Germany
| | - Anja Friedrich
- Department of Psychology, Bielefeld University, Bielefeld, Germany
| | - Nele Klein
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Burgsteig 13, 33617, Bielefeld, Germany
| | - Alkisti Kitsiou
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Burgsteig 13, 33617, Bielefeld, Germany
| | - Isabell Greeve
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Burgsteig 13, 33617, Bielefeld, Germany
| | - Anja Gerstner
- Department of Neurology, Philipps University Marburg, Marburg, Germany
| | - Leonard Wulff
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Burgsteig 13, 33617, Bielefeld, Germany
| | - Wolf-Rüdiger Schäbitz
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Burgsteig 13, 33617, Bielefeld, Germany
| | - Lars Timmermann
- Department of Neurology, Philipps University Marburg, Marburg, Germany
| | - Andreas Rogalewski
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Burgsteig 13, 33617, Bielefeld, Germany.
- Department of Neurology, Sankt Elisabeth Hospital Gütersloh, Catholic Hospital Association of East Westfalia (KHO), Gütersloh, Germany.
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Chen H, Qiu Y, Yin Z, Wang Z, Tang Y, Ni H, Lu J, Chen Z, Kong Y, Wang Z. Efficacy and safety of the innovative monoclonal antibodies in adults with generalized myasthenia gravis: a Bayesian network analysis. Front Immunol 2023; 14:1280226. [PMID: 38022544 PMCID: PMC10663412 DOI: 10.3389/fimmu.2023.1280226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 10/26/2023] [Indexed: 12/01/2023] Open
Abstract
Background A series of clinical trials support the effectiveness of monoclonal antibodies for generalized myasthenia gravis (MG) compared to the placebo, but the priority among drugs remains unclear. Therefore, we conduct a frequentist network meta-analysis (NMA) to compare the relative effects of different drugs for generalized MG. Methods PubMed, Embase, Cochrane Library, and clinicaltrials.gov were systematically searched for eligible studies up to 1 June 2023. The primary outcome was efficacy (Myasthenia Gravis Activities of Daily Living [MG-ADL] score and Quantitative Myasthenia Gravis [QMG] score) and safety (adverse events [AEs]). Mean difference (MD) and risk ratio (RR) with their 95% credible intervals (95%CrIs) were used to show the effect size of continuous and categorical variables, respectively. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results Thirteen studies involving 1167 individuals were identified for NMA. For efficacy outcomes, belimumab, efgartigimod, mezagitamab 600mg, and nipocalimab 60mg/kg were inferior to rozanolixzumab 7mg/kg (MD ranged from 2 to 3.69) and rozanolixzumab 10mg/kg (MD ranged from 2.04 to 3.72) in MG-ADL score, and rozanolixzumab had the highest rank probability (83%) according to the subjective surface under the curve ranking area (SUCRA). For QMG score, batoclimab 340mg (MD ranged from 4.32 to 8.52) and batoclimab 680mg (MD ranged from 4.11 to 9.31) were more effective than placebo and other monoclonal antibodies except for rozanolixzumab, with the highest SUCRA value (93% and 97% respectively). For safety outcomes, belimumab achieved the highest SUCRA value (89.8%) with significant statistical difference compared to rozanolixzumab 7mg/kg (RR 0.08, 95%CrI 0.01 to 0.94) and rozanolixzumab 10mg/kg (RR 0.08, 95%CrI 0.01 to 0.86). Conclusion While all monoclonal antibodies were superior to the placebo, rozanolixzumab and batoclimab might be the most effective for generalized MG. However, rozanolixzumab was associated with higher incidence of AEs. Given the limitations inherent in indirect comparisons, further head-to-head and extensive observational studies are necessary to confirm our findings. Systematic review registration https://inplasy.com/?s=202370112, identifier 202370112.
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Affiliation(s)
- Huiru Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Youjia Qiu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Ziqian Yin
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Zilan Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yanbing Tang
- Suzhou Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Hanyu Ni
- Suzhou Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Jiaye Lu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Zhouqing Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yan Kong
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Zhong Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
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Ozawa Y, Uzawa A, Onishi Y, Yasuda M, Kojima Y, Kuwabara S. Activation of the classical complement pathway in myasthenia gravis with acetylcholine receptor antibodies. Muscle Nerve 2023; 68:798-804. [PMID: 37705312 DOI: 10.1002/mus.27973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 08/20/2023] [Accepted: 08/23/2023] [Indexed: 09/15/2023]
Abstract
INTRODUCTION/AIMS Myasthenia gravis (MG) is an autoimmune disease affecting the neuromuscular junction (NMJ) of skeletal muscle. Complement activation is one of the mechanisms by which anti-acetylcholine receptor (anti-AChR) autoantibodies reduce synaptic transmission at the NMJ. In this study, we aimed to examine the activation of the complement pathways, including the classical pathway, as potential contributors to the pathogenesis of MG with anti-AChR antibodies. METHODS In this single-center, observational study of 45 patients with anti-AChR-antibody-positive generalized MG, serum concentrations of major components of the complement pathways, including C1q, C5, C5a, soluble C5b-9 (sC5b-9), Ba, and complement factor H, were measured using an enzyme-linked immunosorbent assay. A total of 25 patients with a non-inflammatory neurological disorder served as controls. In addition, the relationships of complement activation with clinical characteristics were examined. RESULTS The patients with MG exhibited lower serum levels of C5 (p = .0001) and higher serum levels of sC5b-9 (p = .004) compared with the control group. At about 6 months (range, 172-209 days) after the start of immunotherapy, serum levels of Ba were significantly higher than baseline levels (p = .002) and were associated with improvement in MG clinical scores. DISCUSSION Herein, we provide evidence for the activation of the classical complement pathway and its association with disease activity in anti-AChR-antibody-positive generalized MG.
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Affiliation(s)
- Yukiko Ozawa
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Akiyuki Uzawa
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yosuke Onishi
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Manato Yasuda
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yuta Kojima
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
- Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoshi Kuwabara
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
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88
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Li HF, Hu SM, Yin J, Yang H. Score fluctuation might be associated with a higher placebo rate in the RAISE trial. Lancet Neurol 2023; 22:982. [PMID: 37863601 DOI: 10.1016/s1474-4422(23)00364-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 09/18/2023] [Indexed: 10/22/2023]
Affiliation(s)
- Hai-Feng Li
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China.
| | - Shi-Min Hu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Jian Yin
- Department of Neurology, Beijing Hospital, Beijing, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
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89
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Howard JF, Boroojerdi B, de la Borderie G, Leite MI, Utsugisawa K. Score fluctuation might be associated with a higher placebo rate in the RAISE trial - Authors' reply. Lancet Neurol 2023; 22:982-983. [PMID: 37863600 DOI: 10.1016/s1474-4422(23)00365-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 09/18/2023] [Indexed: 10/22/2023]
Affiliation(s)
- James F Howard
- Department of Neurology, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7025, USA.
| | | | | | - M Isabel Leite
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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90
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Antozzi C, Mantegazza R. Impact of Ravulizumab on Patient Outcomes and Quality of Life in Generalized Myasthenia Gravis. Patient Relat Outcome Meas 2023; 14:305-312. [PMID: 37876920 PMCID: PMC10590807 DOI: 10.2147/prom.s408175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/21/2023] [Indexed: 10/26/2023] Open
Abstract
Myasthenia gravis (MG) is an autoimmune ion channel disorder in which antibodies to different end-plate antigens impair neuromuscular transmission, ultimately leading to muscle weakness and fatigability. In about 85% of patients with MG, autoantibodies against the acetylcholine receptor (AChR) activate the complement cascade, causing damage to the neuromuscular junction. MG is a chronic disorder for which standard therapies with corticosteroids, immunosuppressive drugs, and immunomodulation with plasma exchange or intravenous immunoglobulins modify the course of the disease, but the residual burden of physical, psychological, and social disability highlights several unmet needs, among these the need for specific, targeted, and well tolerated therapies able to improve the patients' quality of life. Complement inhibition paved the way to precision medicine in MG since, for the first time, a specific therapy targeting a crucial pathogenetic step has been designed, tested, and proven to be effective in a controlled fashion. Ravulizumab represents the first long-acting complement inhibitor approved for treatment of patients with generalized MG, able to provide rapid, complete, and sustained complement inhibition. Ravulizumab improved the MG Activity of Daily Living scale and other clinical parameters up to 26 weeks as shown by the CHAMPION MG trial, and by its open label extension, with the added value of being administered every 8 weeks. The schedule of administration is likely to improve patients' adherence and hence their quality of life. The introduction of complement inhibition will considerably change the traditional therapeutic strategy for MG.
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Affiliation(s)
- Carlo Antozzi
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- Immunotherapy and Apheresis Departmental Unit, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Renato Mantegazza
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
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91
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Wilcke H, Glaubitz S, Kück F, Anten C, Liebetanz D, Schmidt J, Zschüntzsch J. Female sex and overweight are associated with a lower quality of life in patients with myasthenia gravis: a single center cohort study. BMC Neurol 2023; 23:366. [PMID: 37817097 PMCID: PMC10563278 DOI: 10.1186/s12883-023-03406-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 09/27/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Myasthenia gravis (MG) affects individuals as a chronic autoimmune disease for many years. Commonly, chronic diseases significantly reduce the patients' quality of life. Aiming to improve the future quality of life in MG, this study assessed the factors impacting quality of life. As gender-specific medicine is becoming increasingly important, this study also focused on understanding gender differences in the outcome of MG. METHODS The study is a combined monocentric, retrospective and prospective database analysis of patient records based on 2,370 presentations of 165 patients with clinically, serologically and/or electrophysiologically confirmed MG over an observation period of up to 47 years. The data collection included the following parameters: antibody status, disease severity, age, medication use, gender, and disease duration. In addition, a prospective survey was conducted on the quality of life using the Myasthenia gravis-specific 15-item Quality of Life scale (MG-QoL15) and on the activities of daily living using the MG-specific Activities of Daily Living scale (MG-ADL). RESULTS Of the 165 patients, 85 were male (51.5%) and 80 were female (48.5%). The remaining baseline characteristics (e.g. age and antibody status) were consistent with other myasthenia gravis cohorts. A high body mass index (BMI) (p = 0.005) and a high disease severity (p < 0.001) were significantly associated with lower disease-specific quality of life. Additionally, the quality of life in women with MG was significantly reduced compared to male patients (19.7 vs. 13.0 points in the MG-QoL15, p = 0.024). Gender differences were also observable in terms of the period between initial manifestation and initial diagnosis and women were significantly more impaired in their activities of daily living (MG-ADL) than men (4.8 vs. 3.0 points, p = 0.032). CONCLUSION Women with MG had significantly poorer disease specific quality of life compared to men as well as patients with a higher BMI. In order to improve the quality of life, gender-specific medicine and further investigation regarding a modification of the quality of life by lowering the BMI are essential and necessary. TRIAL REGISTRATION Study approval by the Ethics Committee of the University Medical Center Göttingen was granted (number 6/5/18).
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Affiliation(s)
- Hannah Wilcke
- Department of Neurology, University Medical Center, Göttingen, Germany
| | - Stefanie Glaubitz
- Department of Neurology, University Medical Center, Göttingen, Germany
| | - Fabian Kück
- Department of Medical Statistics, University Medical Center, Göttingen, Germany
| | - Christoph Anten
- Department of Medical Statistics, University Medical Center, Göttingen, Germany
| | - David Liebetanz
- Department of Neurology, University Medical Center, Göttingen, Germany
| | - Jens Schmidt
- Department of Neurology, University Medical Center, Göttingen, Germany
- Department of Neurology and Pain Treatment, Immanuel Clinic Rüdersdorf, University Hospital of the Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
| | - Jana Zschüntzsch
- Department of Neurology, University Medical Center, Göttingen, Germany.
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92
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San PP, Jacob S. Role of complement in myasthenia gravis. Front Neurol 2023; 14:1277596. [PMID: 37869140 PMCID: PMC10585143 DOI: 10.3389/fneur.2023.1277596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/18/2023] [Indexed: 10/24/2023] Open
Abstract
Myasthenia gravis is a prototypic neuroimmune disorder with autoantibodies targeting the acetylcholine receptor complex at the neuromuscular junction. Patients present with mainly ocular muscle weakness and tend to have a generalized muscle weakness later in the clinical course. The weakness can be severe and fatal when bulbar muscles are heavily involved. Acetylcholine receptor antibodies are present in the majority of patients and are of IgG1 and IgG3 subtypes which can activate the complement system. The complement involvement plays a major role in the neuromuscular junction damage and the supporting evidence in the literature is described in this article. Complement therapies were initially studied and approved for paroxysmal nocturnal hemoglobinuria and in the past decade, those have also been studied in myasthenia gravis. The currently available randomized control trial and real-world data on the efficacy and safety of the approved and investigational complement therapies are summarized in this review.
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Affiliation(s)
- Pyae Phyo San
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Saiju Jacob
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
- Department of Neurology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
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93
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Vanoli F, Mantegazza R. Current drug treatment of myasthenia gravis. Curr Opin Neurol 2023; 36:410-415. [PMID: 37678337 DOI: 10.1097/wco.0000000000001196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
PURPOSE OF REVIEW Myasthenia Gravis (MG) is a rare neurological disorder affecting the neuromuscular junction. Clinical hallmarks are fatigability and weakness affecting the extraocular, axial, limb and/or respiratory muscles. Despite immunosuppressive treatment, mainly based on corticosteroids and nonsteroidal immunosuppressants, the burden of MG is still significant, both in terms of inadequate disease control and burdensome side effects. Driven by such limits, the past years have been characterized by an escalation of MG drug development, with novel molecules which now focuses on having a more targeted effect, with a higher safety and efficacy profile. RECENT FINDINGS As the pathogenic mechanism of MG are slowly being unravelled, new potential targets for treatments are being considered. This has led since 2017 to the Food and Drug Administration (FDA)-approval of three new drugs that either act by blocking the complement system (i.e., eculizumab and ravulizumab) or by blocking the neonatal Fc receptor thus preventing immunoglobulin recycling and reducing imunoglobulin G (IgG) antibodies (i.e., efgartigimod). Other drugs, with similar mechanism of action, are currently under review for approval. SUMMARY The repertoire of available and developmental therapies for MG is rapidly expanding, finally responding to the unmet need of a more targeted and effective therapeutic approach in MG.
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Affiliation(s)
- Fiammetta Vanoli
- Neuroimmunology and Neuromuscular Disease Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan
- Department of Human Neurosciences Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
| | - Renato Mantegazza
- Neuroimmunology and Neuromuscular Disease Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan
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94
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Anwendung von humanen Immunglobulinpräparaten bei Lieferengpässen. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2023; 66:1184-1189. [PMID: 37768373 DOI: 10.1007/s00103-023-03759-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
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95
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Almodovar JL, Mehrabyan A. Disease-Based Prognostication: Myasthenia Gravis. Semin Neurol 2023; 43:799-806. [PMID: 37751854 DOI: 10.1055/s-0043-1775791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
Myasthenia gravis (MG) is an acquired autoimmune neuromuscular junction transmission disorder that clinically presents as fluctuating or persistent weakness in various skeletal muscle groups. Neuroprognostication in MG begins with some basic observations on the natural history of the disease and known treatment outcomes. Our objective is to provide a framework that can assist a clinician who encounters the MG patient for the first time and attempts to prognosticate probable outcomes in individual patients. In this review article, we explore clinical type, age of onset, antibody status, severity of disease, thymus pathology, autoimmune, and other comorbidities as prognostic factors in MG.
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Affiliation(s)
- Jorge L Almodovar
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Anahit Mehrabyan
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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96
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Nishimura JI, Kawaguchi T, Ito S, Murai H, Shimono A, Matsuda T, Fukamizu Y, Akiyama H, Hayashi H, Nakano T, Maruyama S. Real-world safety profile of eculizumab in patients with paroxysmal nocturnal hemoglobinuria, atypical hemolytic uremic syndrome, or generalized myasthenia gravis: an integrated analysis of post-marketing surveillance in Japan. Int J Hematol 2023; 118:419-431. [PMID: 37515657 DOI: 10.1007/s12185-023-03630-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/19/2023] [Accepted: 06/20/2023] [Indexed: 07/31/2023]
Abstract
Eculizumab is a C5 inhibitor approved for the treatment of paroxysmal nocturnal hemoglobinuria (PNH), atypical hemolytic uremic syndrome (aHUS), and anti-acetylcholine receptor antibody-positive generalized myasthenia gravis (AChR + gMG) in Japan. We report integrated safety data from post-marketing surveillance in these three indications, focusing on commonly occurring adverse events (AEs) and infection-related AEs. Of 1219 patients registered, 1055 (PNH: 780; aHUS: 192; AChR + gMG: 83) had available safety data. Total eculizumab exposure was 3977.361 patient-years. AEs were reported in 74.03% of patients. AEs with an incidence of ≥ 1.0 per 100 patient-years included hemolysis, headache, nasopharyngitis, renal impairment, anemia, pneumonia, upper respiratory tract inflammation, influenza, condition aggravated, and infection. The incidence of infection-related AEs was 21.30 per 100 patient-years, the most frequent types (≥ 1.0 per 100 patient-years) being nasopharyngitis, pneumonia, influenza, and infection. Meningococcal infections were reported in four patients (0.10 per 100 patient-years). Two patients died from meningococcal sepsis, with a mortality rate of 0.05 per 100 patient-years. This is the largest safety dataset on eculizumab in Japan derived from more than 10 years of clinical experience. No new safety signals were observed and the safety profile of eculizumab was consistent with that in previous clinical trials and international real-world safety analyses.
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Affiliation(s)
- Jun-Ichi Nishimura
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Suita, Japan.
| | - Tatsuya Kawaguchi
- Department of Medical Technology, Kumamoto Health Science University, Kumamoto, Japan
| | - Shuichi Ito
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Hiroyuki Murai
- Department of Neurology, International University of Health and Welfare, Narita, Japan
| | | | | | | | | | | | - Takashi Nakano
- Department of Pediatrics, Kawasaki Medical School, Okayama, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Vinciguerra C, Bevilacqua L, Toriello A, Iovino A, Piscosquito G, Calicchio G, Barone P. Starting eculizumab as rescue therapy in refractory myasthenic crisis. Neurol Sci 2023; 44:3707-3709. [PMID: 37306795 DOI: 10.1007/s10072-023-06900-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/03/2023] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Myasthenia gravis is a long-lasting autoimmune neuromuscular disease caused by antibodies attacking the neuromuscular junction, which can result in muscle weakness, fatigue, and respiratory failure in severe cases. Myasthenic crisis is a life-threatening event that requires hospitalization and treatments with intravenous immunoglobulin or plasma exchange. We reported the case of an AChR-Ab-positive myasthenia gravis patient with refractory myasthenic crisis, in which starting eculizumab as rescue therapy led to a complete resolution of the acute neuromuscular condition. CASE PRESENTATION A 74-year-old man diagnosed with myasthenia gravis. ACh-receptor antibodies positivity comes to our observation for a recrudescence of symptoms, unresponsive to conventional rescue therapies. Due to the clinical worsening over the following weeks, the patient was admitted to intensive care unit, where he underwent therapy with eculizumab. About 5 days after the treatment, there was a significant and complete recovery of clinical condition with weaning-off from invasive ventilation and discharge to outpatient regimen, with reduction of steroid intake and biweekly maintenance with eculizumab. DISCUSSION Eculizumab, a humanized monoclonal antibody that inhibits complement activation, is now approved as treatment for refractory generalized myasthenia gravis with anti-AChR antibodies. The use of eculizumab in myasthenic crisis is still investigational, but this case report suggests that it may be a promising treatment option for patients with severe clinical condition. Ongoing clinical trials will be needed to further evaluate the safety and efficacy of eculizumab in myasthenic crisis.
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Affiliation(s)
- Claudia Vinciguerra
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Largo Città di Ippocrate, 84100, Salerno, Italy.
| | - Liliana Bevilacqua
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Largo Città di Ippocrate, 84100, Salerno, Italy
| | - Antonella Toriello
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Largo Città di Ippocrate, 84100, Salerno, Italy
| | - Aniello Iovino
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Largo Città di Ippocrate, 84100, Salerno, Italy
| | - Giuseppe Piscosquito
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Largo Città di Ippocrate, 84100, Salerno, Italy
| | - Giuseppe Calicchio
- Anesthesia and Intensive Care Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Paolo Barone
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Largo Città di Ippocrate, 84100, Salerno, Italy
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98
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Hughes T, Howard JF, Silvestri NJ, Anderson AEL, Sato M, Suchotliff S, Guptill JT, Phillips G. The economic burden of individuals living with generalized myasthenia gravis and facing social determinants of health challenges. Front Public Health 2023; 11:1247931. [PMID: 37766748 PMCID: PMC10520715 DOI: 10.3389/fpubh.2023.1247931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023] Open
Abstract
Objective Better understanding the impact of social determinants of health (SDOH) barriers from the patient perspective is crucial to improve holistic patient support in generalized myasthenia gravis (gMG), a rare autoimmune disorder with high disease and treatment burden. The objective of this study was to identify economic challenges experienced by individuals living with gMG and SDOH barriers to better address current unmet needs. Methods Adults (18-75 years) living with gMG and experiencing SDOH barriers in the United States were recruited to a mixed-methods study including qualitative interviews and a web-based quantitative survey. Quotas were implemented to include a balanced spread of baseline demographic categories including insurance type, living environment, and employment status among the study sample. Direct and indirect economic challenges were identified by degree of concern. Results The survey was completed by 38 individuals living with gMG, the majority of whom were enrolled in public insurance and not employed. The most commonly reported major economic concerns were managing funds for emergency care (66%), loss of income (61%), and non-medical expenses (58%), highlighting the diversity of economic challenges. Individuals who were using public insurance plans, living in non-urban environments, and unemployed experienced pronounced challenges around managing non-medical costs and accessing government assistance. Conclusion Both direct and indirect costs were emphasized as major concerns among individuals living with gMG and SDOH barriers. Increasing access to relevant, personalized, and holistic resources, including care management, should be prioritized to improve disease management and outcomes for individuals living with gMG.
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Affiliation(s)
- Tom Hughes
- Argenx US Inc., Boston, MA, United States
| | - James F. Howard
- Department of Neurology, University of North Carolina, Chapel Hill, NC, United States
| | | | | | - Mai Sato
- ZS Associates, New York, NY, United States
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99
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Guptill JT, Benatar M, Granit V, Habib AA, Howard JF, Barnett-Tapia C, Nowak RJ, Lee I, Ruzhansky K, Dimachkie MM, Cutter GR, Kaminski HJ. Addressing Outcome Measure Variability in Myasthenia Gravis Clinical Trials. Neurology 2023; 101:442-451. [PMID: 37076302 PMCID: PMC10491448 DOI: 10.1212/wnl.0000000000207278] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 02/23/2023] [Indexed: 04/21/2023] Open
Abstract
An increasing number of clinical trials are enrolling patients with myasthenia gravis (MG). A lack of standardization in the performance of outcome measures leads to confusion among site research teams and is a source of variability in clinical trial data. MGNet, the NIH-supported Rare Disease Clinical Research Network for MG, views standardization of MG outcome measures as a critical need. To address this issue, a group of experts summarized key outcome measures used in MG clinical trials and a symposium was convened to address issues contributing to outcome measure variability. Consensus recommendations resulted in changes to outcome measure instructions and, in some cases, modifications to specific instruments. Recommended changes were posted for public commentary before finalization. Changes to the MG-Activities of Daily Living, MG-Quality of Life-15r, and MG-Impairment Index were limited to adding details to the administration instructions. Recommendations for proper positioning of participants and how to score items that could not be performed because of non-MG reasons were provided for the MG Composite. The Quantitative MG (QMG) score required the most attention, and changes were made both to the instructions and the performance of certain items resulting in the QMG-Revised. The Postintervention Status was believed to have a limited role in clinical trials, except for the concept of minimal manifestation status. As a next step, training materials and revised source documents, which will be freely available to study teams, will be created and posted on the MGNet website. Further studies are needed to validate changes made to the QMG-Revised.
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Affiliation(s)
- Jeffrey T Guptill
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC.
| | - Michael Benatar
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Volkan Granit
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Ali A Habib
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - James F Howard
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Carolina Barnett-Tapia
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Richard J Nowak
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Ikjae Lee
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Katherine Ruzhansky
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Mazen M Dimachkie
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Gary R Cutter
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Henry J Kaminski
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
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Schanzenbacher J, Hendrika Kähler K, Mesler E, Kleingarn M, Marcel Karsten C, Leonard Seiler D. The role of C5a receptors in autoimmunity. Immunobiology 2023; 228:152413. [PMID: 37598588 DOI: 10.1016/j.imbio.2023.152413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/04/2023] [Accepted: 06/10/2023] [Indexed: 08/22/2023]
Abstract
The complement system is an essential component of the innate immune response and plays a vital role in host defense and inflammation. Dysregulation of the complement system, particularly involving the anaphylatoxin C5a and its receptors (C5aR1 and C5aR2), has been linked to several autoimmune diseases, indicating the potential for targeted therapies. C5aR1 and C5aR2 are seven-transmembrane receptors with distinct signaling mechanisms that play both partially overlapping and opposing roles in immunity. Both receptors are expressed on a broad spectrum of immune and non-immune cells and are involved in cellular functions and physiological processes during homeostasis and inflammation. Dysregulated C5a-mediated inflammation contributes to autoimmune diseases such as rheumatoid arthritis, systemic lupus erythematosus, multiple sclerosis, epidermolysis bullosa acquisita, antiphospholipid syndrome, and others. Therefore, targeting C5a or its receptors may yield therapeutic innovations in these autoimmune diseases by reducing the recruitment and activation of immune cells that lead to tissue inflammation and injury, thereby exacerbating the autoimmune response. Clinical trials focused on the inhibition of C5 cleavage or the C5a/C5aR1-axis using small molecules or monoclonal antibodies hold promise for bringing novel treatments for autoimmune diseases into practice. However, given the heterogeneous nature of (systemic) autoimmune diseases, there are still several challenges, such as patient selection, optimal dosing, and treatment duration, that require further investigation and development to realize the full therapeutic potential of C5a receptor inhibition, ideally in the context of a personalized medicine approach. Here, we aim to provide a brief overview of the current knowledge on the function of C5a receptors, the involvement of C5a receptors in autoimmune disorders, the molecular mechanisms underlying C5a receptor-mediated autoimmunity, and the potential for targeted therapies to modulate their activity.
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Affiliation(s)
- Jovan Schanzenbacher
- Institute for Systemic Inflammation Research (ISEF), University of Lübeck, Lübeck, Germany
| | - Katja Hendrika Kähler
- Institute for Systemic Inflammation Research (ISEF), University of Lübeck, Lübeck, Germany
| | - Evelyn Mesler
- Institute for Systemic Inflammation Research (ISEF), University of Lübeck, Lübeck, Germany
| | - Marie Kleingarn
- Institute for Systemic Inflammation Research (ISEF), University of Lübeck, Lübeck, Germany
| | | | - Daniel Leonard Seiler
- Institute for Systemic Inflammation Research (ISEF), University of Lübeck, Lübeck, Germany.
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