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Basile U, Napodano C, Gulli F, Pocino K, Di Santo R, Todi L, Basile V, Provenzano C, Ciasca G, Marino M. Laboratory Investigation of Hybrid IgG4 k/λ in MuSK Positive Myasthenia Gravis. Int J Mol Sci 2021; 22:ijms22179142. [PMID: 34502051 PMCID: PMC8430634 DOI: 10.3390/ijms22179142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 08/03/2021] [Accepted: 08/14/2021] [Indexed: 12/29/2022] Open
Abstract
Myasthenia gravis with antibodies (Abs) against the muscle-specific tyrosine kinase (MuSK) is a rare autoimmune disorder (AD) of the neuromuscular junction (NMJ) and represents a prototype of AD with proven IgG4-mediated pathogenicity. Thanks to the mechanism of Fab-arm exchange (FAE) occurring in vivo, resulting MuSK IgG4 k/λ Abs increase their interference on NMJ and pathogenicity. The characterization of hybrid MuSK IgG4 as a biomarker for MG management is poorly investigated. Here, we evaluated total IgG4, hybrid IgG4 k/λ, and the hybrid/total ratio in 14 MuSK-MG sera in comparison with 24 from MG with Abs against acetylcholine receptor (AChR) that represents the not IgG4-mediated MG form. In both subtypes of MG, we found that the hybrid/total ratio reflects distribution reported in normal individuals; instead, when we correlated the hybrid/total ratio with specific immune-reactivity we found a positive correlation only with anti-MuSK titer, with a progressive increase of hybrid/total mean values with increasing disease severity, indirectly confirming that most part of hybrid IgG4 molecules are engaged in the anti-MuSK pathogenetic immune-reactivity. Further analysis is necessary to strengthen the significance of this less unknown biomarker, but we retain it is full of a diagnostic-prognostic powerful potential for the management of MuSK-MG.
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Affiliation(s)
- Umberto Basile
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | | | - Francesca Gulli
- Laboratorio di Patologia Clinica, Ospedale Madre Giuseppina Vannini, 00177 Rome, Italy;
| | - Krizia Pocino
- Unità Operativa Complessa Patologia Clinica, Ospedale Generale di Zona, San Pietro Fatebenefratelli, 00189 Rome, Italy;
| | - Riccardo Di Santo
- Dipartimento di Neuroscienze, Sezione di Fisica, Fondazione Policlinico “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (R.D.S.); (G.C.)
| | - Laura Todi
- Dipartimento di Medicina e Chirurgia Traslazionale, Sezione di Patologia Generale, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (L.T.); (C.P.)
| | - Valerio Basile
- Clinical Pathology Unit and Cancer Biobank, Department of Research, Advanced Diagnostics and Technological Innovation, IFO-Regina Elena National Cancer Institute, 00128 Rome, Italy;
| | - Carlo Provenzano
- Dipartimento di Medicina e Chirurgia Traslazionale, Sezione di Patologia Generale, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (L.T.); (C.P.)
| | - Gabriele Ciasca
- Dipartimento di Neuroscienze, Sezione di Fisica, Fondazione Policlinico “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (R.D.S.); (G.C.)
| | - Mariapaola Marino
- Dipartimento di Medicina e Chirurgia Traslazionale, Sezione di Patologia Generale, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (L.T.); (C.P.)
- Correspondence:
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Presynaptic Paraneoplastic Disorders of the Neuromuscular Junction: An Update. Brain Sci 2021; 11:brainsci11081035. [PMID: 34439654 PMCID: PMC8392118 DOI: 10.3390/brainsci11081035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 07/26/2021] [Accepted: 08/02/2021] [Indexed: 01/17/2023] Open
Abstract
The neuromuscular junction (NMJ) is the target of a variety of immune-mediated disorders, usually classified as presynaptic and postsynaptic, according to the site of the antigenic target and consequently of the neuromuscular transmission alteration. Although less common than the classical autoimmune postsynaptic myasthenia gravis, presynaptic disorders are important to recognize due to the frequent association with cancer. Lambert Eaton myasthenic syndrome is due to a presynaptic failure to release acetylcholine, caused by antibodies to the presynaptic voltage-gated calcium channels. Acquired neuromyotonia is a condition characterized by nerve hyperexcitability often due to the presence of antibodies against proteins associated with voltage-gated potassium channels. This review will focus on the recent developments in the autoimmune presynaptic disorders of the NMJ.
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Howard JF, Bril V, Vu T, Karam C, Peric S, Margania T, Murai H, Bilinska M, Shakarishvili R, Smilowski M, Guglietta A, Ulrichts P, Vangeneugden T, Utsugisawa K, Verschuuren J, Mantegazza R. Safety, efficacy, and tolerability of efgartigimod in patients with generalised myasthenia gravis (ADAPT): a multicentre, randomised, placebo-controlled, phase 3 trial. Lancet Neurol 2021; 20:526-536. [PMID: 34146511 DOI: 10.1016/s1474-4422(21)00159-9] [Citation(s) in RCA: 196] [Impact Index Per Article: 65.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 04/23/2021] [Accepted: 05/10/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND There is an unmet need for treatment options for generalised myasthenia gravis that are effective, targeted, well tolerated, and can be used in a broad population of patients. We aimed to assess the safety and efficacy of efgartigimod (ARGX-113), a human IgG1 antibody Fc fragment engineered to reduce pathogenic IgG autoantibody levels, in patients with generalised myasthenia gravis. METHODS ADAPT was a randomised, double-blind, placebo-controlled, phase 3 trial done at 56 neuromuscular academic and community centres in 15 countries in North America, Europe, and Japan. Patients aged at least 18 years with generalised myasthenia gravis were eligible to participate in the study, regardless of anti-acetylcholine receptor antibody status, if they had a Myasthenia Gravis Activities of Daily Living (MG-ADL) score of at least 5 (>50% non-ocular), and were on a stable dose of at least one treatment for generalised myasthenia gravis. Patients were randomly assigned by interactive response technology (1:1) to efgartigimod (10 mg/kg) or matching placebo, administered as four infusions per cycle (one infusion per week), repeated as needed depending on clinical response no sooner than 8 weeks after initiation of the previous cycle. Patients, investigators, and clinical site staff were all masked to treatment allocation. The primary endpoint was proportion of acetylcholine receptor antibody-positive patients who were MG-ADL responders (≥2-point MG-ADL improvement sustained for ≥4 weeks) in the first treatment cycle. The primary analysis was done in the modified intention-to-treat population of all acetylcholine receptor antibody-positive patients who had a valid baseline MG-ADL assessment and at least one post-baseline MG-ADL assessment. The safety analysis included all randomly assigned patients who received at least one dose or part dose of efgartigimod or placebo. This trial is registered at ClinicalTrials.gov (NCT03669588); an open-label extension is ongoing (ADAPT+, NCT03770403). FINDINGS Between Sept 5, 2018, and Nov 26, 2019, 167 patients (84 in the efgartigimod group and 83 in the placebo group) were enrolled, randomly assigned, and treated. 129 (77%) were acetylcholine receptor antibody-positive. Of these patients, more of those in the efgartigimod group were MG-ADL responders (44 [68%] of 65) in cycle 1 than in the placebo group (19 [30%] of 64), with an odds ratio of 4·95 (95% CI 2·21-11·53, p<0·0001). 65 (77%) of 84 patients in the efgartigimod group and 70 (84%) of 83 in the placebo group had treatment-emergent adverse events, with the most frequent being headache (efgartigimod 24 [29%] vs placebo 23 [28%]) and nasopharyngitis (efgartigimod ten [12%] vs placebo 15 [18%]). Four (5%) efgartigimod-treated patients and seven (8%) patients in the placebo group had a serious adverse event. Three patients in each treatment group (4%) discontinued treatment during the study. There were no deaths. INTERPRETATION Efgartigimod was well tolerated and efficacious in patients with generalised myasthenia gravis. The individualised dosing based on clinical response was a unique feature of ADAPT, and translation to clinical practice with longer term safety and efficacy data will be further informed by the ongoing open-label extension. FUNDING argenx.
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Affiliation(s)
- James F Howard
- Department of Neurology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Tuan Vu
- Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Chafic Karam
- Penn Neuroscience Center-Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Stojan Peric
- Neurology Clinic, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Temur Margania
- Department of Neurology and Neurorehabilitation, New Hospitals, Tbilisi, Georgia
| | - Hiroyuki Murai
- Department of Neurology, School of Medicine, International University of Health and Welfare, Narita, Japan
| | - Malgorzata Bilinska
- Department and Clinic of Neurology, Wroclaw Medical University, Wroclaw, Poland
| | | | - Marek Smilowski
- Department of Hematology and Bone Marrow Transplantation, Medical University of Silesia, Katowice, Poland
| | | | | | | | | | - Jan Verschuuren
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Renato Mantegazza
- Department of Neuroimmunology and Neuromuscular Diseases, Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
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Sheckley H, Malhotra K, Katyal N, Narula N, Govindarajan R. Clinical experience with maintenance therapeutic plasma exchange in refractory generalized myasthenia gravis. J Clin Apher 2021; 36:727-736. [PMID: 34241920 DOI: 10.1002/jca.21923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/22/2021] [Accepted: 06/29/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Despite the availability of several immunomodulatory therapies, about 20% of myasthenia gravis (MG) patients remain refractory to conventional treatments. There is limited evidence to support the use of maintenance therapeutic plasma exchange (TPE) therapy for refractory generalized MG. METHODS Retrospective chart review of 14 patients with refractory generalized MG treated for 12 months with maintenance TPE therapy. Outcome measures were myasthenia gravis composite (MGC) score, myasthenia gravis activities of daily living (MG-ADL), number of acute exacerbations, medication changes, and adverse events. Data were collected at 3 monthly intervals for 12 months before and after initiation of TPE therapy. RESULTS Clinically meaningful reductions in mean MG-ADL (>2 points) (mean MG-ADL score: 9.9 ± 0.5; 12-month pre-TPE to 5.2 ± 0.9; 12-month post-TPE) and MGC (>3 points) (mean MGC score: 25.2 ± 1.6; 12-month pre-TPE to 11.7 ± 1.4; 12-month post-TPE) were observed at 3 months following initiation of TPE and were maintained up to 12 months in all patients. After 12 months of TPE therapy, all patients had a significant reduction in daily prednisone and pyridostigmine use. Patients previously on IVIG or rituximab therapy were successfully weaned off both treatments. There was a significant reduction in acute MG exacerbations; 7.8 ± 1.1 mean exacerbations/patient (12-month pre-TPE) to 2 ± 1.1 mean exacerbations/patient (12-month post-TPE). CONCLUSION Over a period of 12 months, maintenance TPE therapy improved MG-ADL, and MGC with decreased immunosuppressant requirement, while being well-tolerated.
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Affiliation(s)
- Hunter Sheckley
- Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Kunal Malhotra
- Division of Nephrology, Department of Internal Medicine, University of Missouri, Columbia, Missouri, USA
| | - Nakul Katyal
- Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Naureen Narula
- Department of Pulmonology and Critical Care Medicine, Staten Island University Hospital, Staten Island, New York, USA
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Classically Described, Paradoxically Underrecognized: A Case of Proximal Weakness, Hyporeflexia/Areflexia, and Dysautonomia. Am J Phys Med Rehabil 2021; 100:e98-e100. [PMID: 33109907 DOI: 10.1097/phm.0000000000001632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT We present a case of chronic, progressive proximal weakness with dysautonomia and hyporeflexia/areflexia ultimately diagnosed with Lambert-Eaton myasthenic syndrome. An approach to neuroanatomical localization is discussed leading to the appropriate selection of electrodiagnostic studies. The electrophysiologic triad of Lambert-Eaton myasthenic syndrome is demonstrated with diffusely reduced motor amplitudes, decrement with low-frequency repetitive nerve stimulation, and increment of motor amplitudes after maximum voluntary contraction. Subsequent serologic testing for P/Q-type voltage-gated calcium channel antibodies are markedly elevated. We highlight the clinical features and pitfalls of examining a patient with Lambert-Eaton myasthenic syndrome when suspecting this challenging diagnosis. The neurophysiological underpinning of the electrodiagnostic results is explained, and the diagnostic utility of single-fiber electromyography is briefly discussed.
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Chowdhury SF, Sium SMA, Anwar S. Research and Management of Rare Diseases in the COVID-19 Pandemic Era: Challenges and Countermeasures. Front Public Health 2021; 9:640282. [PMID: 33937170 PMCID: PMC8082070 DOI: 10.3389/fpubh.2021.640282] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 03/16/2021] [Indexed: 12/11/2022] Open
Abstract
The ongoing coronavirus disease 2019 (COVID-19) pandemic has disrupted every aspect of our life. The need to provide high-level care for an enormous number of patients with COVID-19 infection during this pandemic has impacted resourcing for and restricted the routine care of all non-COVID-19 conditions. Since the beginning of the pandemic, the people living with rare disorders, who represent a marginalized group of the population even in a normal world, have not received enough attention that they deserve. Due to the pandemic situation, they have experienced (and experiencing) an extreme inadequacy of regular clinical services, counseling, and therapies they need, which have made their life more vulnerable and feel more marginalized. Besides, the clinicians, researchers, and scientists working on rare genetic diseases face extra challenges due to the pandemic. Many ongoing research projects and clinical trials for rare and genetic diseases were stalled to avoid patients' and research staff's transmission to COVID-19. Still, with all the odds, telehealth and virtual consultations for rare disease patients have shown hope. The clinical, organizational, and economic challenges faced by institutions, patients, their families, and the caregivers during the pandemic indicate the importance of ensuring continuity of care in managing rare diseases, including adequate diagnostics and priority management strategies for emergencies. In this review, we endeavored to shed light on the issues the rare disease community faces during the pandemic and the adaptations that could help the rare disease community to better sustain in the coming days.
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Affiliation(s)
- Sanjana Fatema Chowdhury
- Department of Genetic Engineering and Biotechnology, School of Life Sciences, Shahjalal University of Science and Technology, Sylhet, Bangladesh
| | - Syed Muktadir Al Sium
- Child Health Research Foundation, Dhaka, Bangladesh.,Department of Biotechnology, Agriculture Faculty, Bangladesh Agricultural University, Mymensingh, Bangladesh
| | - Saeed Anwar
- Department of Medical Genetics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
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Sheikh S, Alvi U, Soliven B, Rezania K. Drugs That Induce or Cause Deterioration of Myasthenia Gravis: An Update. J Clin Med 2021; 10:jcm10071537. [PMID: 33917535 PMCID: PMC8038781 DOI: 10.3390/jcm10071537] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/24/2021] [Accepted: 03/31/2021] [Indexed: 12/20/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune neuromuscular disorder which is characterized by presence of antibodies against acetylcholine receptors (AChRs) or other proteins of the postsynaptic membrane resulting in damage to postsynaptic membrane, decreased number of AChRs or blocking of the receptors by autoantibodies. A number of drugs such as immune checkpoint inhibitors, penicillamine, tyrosine kinase inhibitors and interferons may induce de novo MG by altering the immune homeostasis mechanisms which prevent emergence of autoimmune diseases such as MG. Other drugs, especially certain antibiotics, antiarrhythmics, anesthetics and neuromuscular blockers, have deleterious effects on neuromuscular transmission, resulting in increased weakness in MG or MG-like symptoms in patients who do not have MG, with the latter usually being under medical circumstances such as kidney failure. This review summarizes the drugs which can cause de novo MG, MG exacerbation or MG-like symptoms in nonmyasthenic patients.
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Zhang Z, Wang M, Xu L, Jiang B, Jin T, Shi T, Xu B. Cancer occurrence following azathioprine treatment in myasthenia gravis patients: A systematic review and meta-analysis. J Clin Neurosci 2021; 88:70-74. [PMID: 33992207 DOI: 10.1016/j.jocn.2021.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/22/2021] [Accepted: 03/11/2021] [Indexed: 11/25/2022]
Abstract
Treatments of myasthenia gravis (MG) usually include immunosuppressants such as glucocorticoids, tacrolimus, and azathioprine (AZA). In clinical practice, azathioprine therapy is thought to have a potential risk for developing secondary malignancies in myasthenia gravis patients. However, published data on the long-term safety of azathioprine in myasthenia gravis patients are limited and not consistent among studies. To explore cancer occurrence following azathioprine therapy in myasthenia gravis patients in the long term, we searched Medline, EMBASE, and the Cochrane Library for terms related to azathioprine, myasthenia gravis and cancer occurrence. Two investigators independently extracted trial data. A pooled estimate was calculated from fixed-effects meta-analysis. Our analysis included 1650 azathioprine-treated patients and 2481 non-azathioprine-treated patients. All five studies showed some concerns regarding the risk of bias. In a meta-analysis of 5 studies, we observed no significantly elevated risk of cancer occurrence among individuals with prior myasthenia gravis diagnosis who received long-term azathioprine treatment (OR 1.09; 95% CI 0.86-1.38, p = 0.46). Prospective studies are needed to observe the safety of azathioprine.
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Affiliation(s)
- Zheyu Zhang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Meiping Wang
- Department of Neurology, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Liang'e Xu
- Department of Neurology, The Third Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Bingze Jiang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Tianyu Jin
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Tianming Shi
- Department of Neurology, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Bin Xu
- Department of Neurology, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China.
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Saint-Gerons M, Rubio MA, Martinez A, Matheu A. Quantification of Cover Test Prior and Post Pyridostigmine in Diagnosis of Myasthenia Gravis. J Binocul Vis Ocul Motil 2021; 71:71-76. [PMID: 33877951 DOI: 10.1080/2576117x.2021.1904097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/04/2021] [Accepted: 03/12/2021] [Indexed: 06/12/2023]
Abstract
Objective: To assess the value of measuring diplopia before and after pyridostigmine intake to differentiate myasthenia gravis from sagging eye syndrome.To establish a threshold for a positive response to pyridostigmine in the diagnosis of myasthenia gravis.Methods: 15 patients with myasthenia gravis and 15 with sagging eye syndrome diplopia were evaluated. Diplopia was measured in five positions (upgaze, downgaze, right gaze, left gaze, and primary position). After baseline measurements, the patient received a single dose (60 mg) of pyridostigmine. After 60 minutes the prism measure was performed again in five positions. Horizontal deviation, vertical deviation at distance was compared before and after a single dose of pyridostigmine in each gaze. Ocular deviations were compared between the two groups to identify the threshold with the highest sensitivity and specificity.Results: Differences between pretest deviations and posttest deviations in any gaze were found to be statistically significant only in the MG group. The optimum threshold for a positive response to pyridostigmine was a reduction of 2 prism diopters in any component in any gaze. Sensitivity for the detection of myasthenia diplopia was 80.00% and specificity was 86.67%.Conclusions: Our results suggest that measuring diplopia with prisms before and after pyridostigmine administration can help to detect patients with suspected myasthenia.
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Affiliation(s)
- Marta Saint-Gerons
- Unit of Neurophthalmology, Consorci Parc de Salut MAR de Barcelona, Barcelona, Spain
- Department of Ophthalmology, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Miguel Angel Rubio
- Unit of Neurophthalmology, Consorci Parc de Salut MAR de Barcelona, Barcelona, Spain
- Unit of Neuromuscular Diseases, Consorci Parc de Salut MAR de Barcelona, Barcelona, Spain
| | - Ana Martinez
- Department of Ophthalmology, Universitat Autònoma de Barcelona, Barcelona, Spain
- Ophthalmology, Consorci Parc de Salut MAR de Barcelona, Barcelona, Spain
| | - Ana Matheu
- Unit of Neurophthalmology, Consorci Parc de Salut MAR de Barcelona, Barcelona, Spain
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Howard JF, Vissing J, Gilhus NE, Leite MI, Utsugisawa K, Duda PW, Farzaneh-Far R, Murai H, Wiendl H. Zilucoplan: An Investigational Complement C5 Inhibitor for the Treatment of Acetylcholine Receptor Autoantibody-Positive Generalized Myasthenia Gravis. Expert Opin Investig Drugs 2021; 30:483-493. [PMID: 33792453 DOI: 10.1080/13543784.2021.1897567] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Generalized myasthenia gravis (gMG) is an autoimmune disorder in which pathogenic autoantibodies damage the neuromuscular junction, causing disabling or life-threatening muscle weakness. Most treatments nonspecifically inhibit aspects of the immune system, do not directly address the causal mechanisms of tissue damage, and often have side-effect profiles that negatively impact patients. Understanding of the central pathogenic role of the complement cascade in gMG is advancing, and a new complement-targeting treatment is under investigation. AREAS COVERED We provide an overview of gMG etiology, the complement cascade, current treatments, and the investigational gMG therapy zilucoplan. Zilucoplan is a small, subcutaneously administered, macrocyclic peptide that inhibits cleavage of complement component C5 and the subsequent formation of the membrane attack complex. EXPERT OPINION In a randomized, double-blind, placebo-controlled, phase 2 clinical trial, zilucoplan demonstrated clinically meaningful complement inhibition in patients with acetylcholine receptor-positive gMG. Zilucoplan, a first-of-its-kind cyclic peptide targeting C5, appears to be a therapeutic option for the treatment of gMG based on available pharmacokinetic/pharmacodynamic data and phase 1 and 2 efficacy, safety, and tolerability data with limited long-term follow-up. Zilucoplan use earlier in the treatment paradigm would be suitable in this population should phase 3 efficacy and safety data be equally favorable.
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Affiliation(s)
- James F Howard
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - John Vissing
- Department of Clinical Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Nils E Gilhus
- Department of Clinical Medicine, University of Bergen and Haukeland University Hospital, Bergen, Norway
| | - M Isabel Leite
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kimiaki Utsugisawa
- Department of Neurology, Hanamaki General Hospital, Hanamaki, Iwate, Japan
| | | | | | - Hiroyuki Murai
- Department of Neurology, International University of Health and Welfare, Narita, Chiba, Japan
| | - Heinz Wiendl
- Department of Neurology, Institute of Translational Neurology, University of Münster, Münster, Germany
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Risk Factors for Postoperative Myasthenic Crisis After Thymectomy in Patients With Myasthenia Gravis. J Surg Res 2021; 262:1-5. [PMID: 33530003 DOI: 10.1016/j.jss.2020.12.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 12/11/2020] [Accepted: 12/21/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND The objective of this study is to characterize postoperative myasthenic crisis (POMC), after extended thymectomy and discuss the treatment options for this condition. METHODS Clinical data from patients with generalized myasthenia gravis (MG) who underwent extended thymectomy at Xuanwu Hospital of the Capital Medical University from 2016 to 2018 were reviewed retrospectively. Patients were divided into two groups-POMC and non-POMC. Variables that could potentially predict POMC were analyzed. In the POMC group, the aforementioned variables were compared between patients with and without pneumonia. RESULTS Ninety-seven patients were enrolled. Thirty-eight (39.2%) patients developed POMC. The mean duration of mechanical ventilation (MV), length of intensive care unit stay, and duration of hospital stay were significantly longer in the POMC group (P < 0.001). Multivariate logistic regression analysis showed that disease severity, symptom duration longer than 12 mo, and transsternal thymectomy were independent risk factors for POMC. Postoperative pneumonia significantly prolonged the MV period (P = 0.012) and weaning from MV after intravenous immunoglobin (IVIg) treatment (P = 0.005) in POMC patients. Twenty-four (24.7%) POMC patients who received IVIg were successfully weaned from MV and were discharged. CONCLUSIONS Disease severity, symptom duration longer than 12 mo, and transsternal thymectomy were independent risk factors for POMC. Postoperative pneumonia worsens the prognosis of POMC.
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Weng S, Fan Z, Qiu G, Liu F, Huang L, Li J, Jiang X, Song Z, Gao Y, Zhong Z, He L, Kang L, Wu Y, Chen B, Jiang Q. Therapeutic efficacy and immunoregulatory effect of Qiangji Jianli Capsule for patients with myasthenia gravis: Study protocol for a series of randomized, controlled N-of-1 trials. Medicine (Baltimore) 2020; 99:e23679. [PMID: 33371107 PMCID: PMC7748195 DOI: 10.1097/md.0000000000023679] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 11/13/2020] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Myasthenia gravis (MG) is an autoimmune disease in which antibodies directly target components of the neuromuscular junction, causing neuromuscular conduction damage that leads to muscle weakness. The current pharmaceutical treatment for MG is still not ideal to address the problems of disease progression, high recurrence rate, and drug side effects. Clinical observations suggest that traditional Chinese medicine (TCM) can strengthen immunity and improve symptoms of MG patients, delay the progression of the disease, reduce or even prevent the need for immunosuppressive therapy when used in combination with acetylcholinesterase inhibitors or low-dose prednisone, as well as improve the quality of life of patients. The Qiangji Jianli Capsule (QJC) is a combination of medicinal herbs which is used in traditional Chinese medicine. Since MG is a rare disorder, randomized controlled trials comparing large cohorts are difficult to conduct. Therefore, we proposed to aggregate data from a small series of N-of-1 trials to assess the effect of the Chinese medical prescription QJC, which strengthens the spleen and nourishes Qi, as an add-on treatment for MG with spleen and stomach Qi deficiency syndrome. METHODS AND ANALYSIS Single-center, randomized, double-blind, multiple crossover N-of-1 studies will compare QJC versus placebo in 5 adult MG patients with spleen and stomach Qi deficiency syndrome. Patients will undergo 3 cycles of two 4-week intervention periods. According to the treatment schedule, patients will continue to be treated with pyridine bromide tablets, prednisone acetate, tablets and/or tacrolimus capsules throughout the entire trial. Each period consisting of 4-week oral add-on treatment with QJC will be compared with 4-week add-on treatment with a placebo. The primary endpoints are quantitative myasthenia gravis (QMG) test; measurement of the amount of Treg cells and cytokines such as interferon-γ (IFN-γ), interleukin-4 (IL-4), interleukin-17A (IL-17A), and transforming growth factor-β (TGF-β); and corticosteroid or immunosuppressive agent dosage. Secondary outcome measures: Clinical: Evaluation of the effect of TCM syndromes; MG-activities of daily living (MG-ADL) scales; adverse events. ETHICS AND DISSEMINATION This study was approved by The First Affiliated Hospital of Guangzhou University of Chinese Medicine (GZUCM), No. ZYYECK[2019]038. The results will be published in a peer-reviewed publication. Regulatory stakeholders will comment on the suitability of the trial for market authorization and reimbursement purposes. Trial registration: Chinese Clinical Trial Register, ID: ChiCTR2000033516. Registered on 3 June 2020, http://www.chictr.org.cn/showprojen.aspx?proj=54618.
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Affiliation(s)
- Senhui Weng
- Department of Spleen-Stomach, First Affiliated Hospital of Guangzhou University of Chinese Medicine
| | - Zhixin Fan
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Guoyu Qiu
- Department of Spleen-Stomach, First Affiliated Hospital of Guangzhou University of Chinese Medicine
| | - Fengbin Liu
- Department of Spleen-Stomach, First Affiliated Hospital of Guangzhou University of Chinese Medicine
| | - Linwen Huang
- Department of Spleen-Stomach, First Affiliated Hospital of Guangzhou University of Chinese Medicine
| | - Jinghao Li
- Department of Spleen-Stomach, First Affiliated Hospital of Guangzhou University of Chinese Medicine
| | - Xiaotao Jiang
- Department of Spleen-Stomach, First Affiliated Hospital of Guangzhou University of Chinese Medicine
| | - Zhixuan Song
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yuxia Gao
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhuotai Zhong
- Department of Spleen-Stomach, First Affiliated Hospital of Guangzhou University of Chinese Medicine
| | - Long He
- Department of Spleen-Stomach, First Affiliated Hospital of Guangzhou University of Chinese Medicine
| | - Liping Kang
- Department of Spleen-Stomach, First Affiliated Hospital of Guangzhou University of Chinese Medicine
| | - Yunlong Wu
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Benshu Chen
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qilong Jiang
- Department of Spleen-Stomach, First Affiliated Hospital of Guangzhou University of Chinese Medicine
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Update in immunosuppressive therapy of myasthenia gravis. Autoimmun Rev 2020; 20:102712. [PMID: 33197578 DOI: 10.1016/j.autrev.2020.102712] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 07/19/2020] [Indexed: 11/22/2022]
Abstract
Myasthenia gravis (MG) is an autoimmune disease of the neuromuscular junction. Immunosuppressive treatments are part of the therapeutic armamentarium in MG. Long-term systemic steroid administration carry considerable risks and adverse events. Consequently, steroid-free immunosuppressive therapy is necessary to reduce the dose or discontinue steroids. First immunosuppressive drug trials in MG were performed in the mid-60s using standard and nonspecific immunosuppression. Since then, only few randomized controlled clinical trials were conducted in MG and assesed drug efficacy in terms of its steroid-sparing capacity and the ability to reduce myasthenic signs and symptoms. Treatment strategy in MG is quite challenging, mainly due to the disease heterogeneity in terms of clinical presentation, immunopathogenesis and drug response. To solve this dilemma, emerging treatment are based on biological drugs and use new targets of the immune pathway.
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Garcia-Garcia J, Díaz-Maroto I, Martínez-Martín A, Pardal-Fernández JM, Segura T. A series of patients with refractory myasthenia gravis. Neurologia 2020; 38:S0213-4853(20)30293-0. [PMID: 33172684 DOI: 10.1016/j.nrl.2020.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/15/2020] [Accepted: 08/26/2020] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Advances in the treatment of myasthenia gravis (MG) have improved quality of life and prognosis for the majority of patients. However, 10%-20% of patients present refractory MG, with frequent relapses and significant functional limitations. PATIENTS AND METHODS Patients with refractory MG were selected from a cohort of patients diagnosed with MG between January 2008 and June 2019. Refractory MG was defined as lack of response to treatment with prednisone and at least 2 immunosuppressants, inability to withdraw treatment without relapse in the last 12 months, or intolerance to treatment with severe adverse reactions. RESULTS We identified 84 patients with MG, 11 of whom (13%) met criteria for refractory MG. Mean (standard deviation) age was 47 (18) years; 64% of patients with refractory MG had early-onset generalised myasthenia (as compared to 22% in the group of patients with MG; P<.01), with a higher proportion of women in this group (P<.01). Disease severity at diagnosis and at the time of data analysis was higher among patients with refractory MG, who presented more relapses during follow-up. Logistic regression analysis revealed an independent association between refractory MG and the number of severe relapses. CONCLUSIONS The percentage of patients with refractory MG in our series (13%) is similar to those reported in previous studies; these patients were often women and presented early onset, severe forms of onset, and repeated relapses requiring hospital admission during follow-up.
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Affiliation(s)
- J Garcia-Garcia
- Servicio de Neurología, Complejo Hospitalario Universitario de Albacete, Albacete, España.
| | - I Díaz-Maroto
- Servicio de Neurología, Complejo Hospitalario Universitario de Albacete, Albacete, España
| | - A Martínez-Martín
- Servicio de Neurología, Complejo Hospitalario Universitario de Albacete, Albacete, España
| | - J M Pardal-Fernández
- Servicio de Neurofisiología Clínica, Complejo Hospitalario Universitario de Albacete, Albacete, España
| | - T Segura
- Servicio de Neurología, Complejo Hospitalario Universitario de Albacete, Albacete, España
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Threetong T, Poonyathalang A, Preechawat P, Jindahra P, Padungkiatsagul T, Vanikieti K. Initial Treatment Response in Ocular Myasthenia Gravis: A Comparison Between Low and Moderate Doses of Prednisolone. Clin Ophthalmol 2020; 14:2051-2056. [PMID: 32801613 PMCID: PMC7383101 DOI: 10.2147/opth.s261259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 06/23/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To evaluate the initial treatment response to low doses of prednisolone, compared with moderate doses, in ocular myasthenia gravis (OMG). Patients and Methods A retrospective chart review of patients with adult-onset (age ≥15 years old) OMG, who were treated with prednisolone, was conducted. Subjects were divided into two groups according to their prednisolone dosing regimen. The low-dose group was defined as those with an average 12-week cumulative dose of prednisolone <0.435 mg/kg/day and the moderate-dose group averaged 0.435–1.000 mg/kg/day. The primary outcome of interest was the comparison of clinical response to prednisolone at 12 weeks between the low-dose and moderate-dose groups. The secondary outcome was the difference in adverse events between treatment groups. Results Of 34 subjects, 16 subjects (47.1%) were male. The mean age at onset was 44.0±18.1 years. The most common presenting ocular feature was ptosis with ophthalmoplegia (22 subjects, 64.7%), followed by isolated ptosis (nine subjects, 26.5%) and isolated ophthalmoplegia (three subjects, 8.8%). Half of the subjects were treated with low-dose prednisolone and the other half were treated with moderate-dose prednisolone. There were no substantial differences in baseline characteristics between treatment groups. After 12 weeks of treatment, nine of 17 subjects (52.9%) and 13 of 17 subjects (76.5%) in the low- and moderate-dose groups, respectively, were regarded as responsive to the prednisolone treatment (P=0.28). Adverse events were exclusively observed in the moderate-dose group. Conclusion Treatment of OMG with an average 12-week cumulative dose of prednisolone <0.435 mg/kg/day (low dose) shows a comparable responsive outcome to 0.435–1.000 mg/kg/day of prednisolone (moderate dose). Treating OMG with low-dose prednisolone can minimize prednisolone-related adverse events. However, a prospective randomized controlled trial with a larger study population is warranted in order to gain more insight into the proper dosage of prednisolone for OMG.
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Affiliation(s)
- Thanatporn Threetong
- Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Department of Ophthalmology, Faculty of Medicine, Burapha University, Chonburi, Thailand
| | - Anuchit Poonyathalang
- Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pisit Preechawat
- Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Panitha Jindahra
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Tanyatuth Padungkiatsagul
- Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kavin Vanikieti
- Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Bjørn-Yoshimoto WE, Ramiro IBL, Yandell M, McIntosh JM, Olivera BM, Ellgaard L, Safavi-Hemami H. Curses or Cures: A Review of the Numerous Benefits Versus the Biosecurity Concerns of Conotoxin Research. Biomedicines 2020; 8:E235. [PMID: 32708023 PMCID: PMC7460000 DOI: 10.3390/biomedicines8080235] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/17/2020] [Accepted: 07/19/2020] [Indexed: 01/18/2023] Open
Abstract
Conotoxins form a diverse group of peptide toxins found in the venom of predatory marine cone snails. Decades of conotoxin research have provided numerous measurable scientific and societal benefits. These include their use as a drug, diagnostic agent, drug leads, and research tools in neuroscience, pharmacology, biochemistry, structural biology, and molecular evolution. Human envenomations by cone snails are rare but can be fatal. Death by envenomation is likely caused by a small set of toxins that induce muscle paralysis of the diaphragm, resulting in respiratory arrest. The potency of these toxins led to concerns regarding the potential development and use of conotoxins as biological weapons. To address this, various regulatory measures have been introduced that limit the use and access of conotoxins within the research community. Some of these regulations apply to all of the ≈200,000 conotoxins predicted to exist in nature of which less than 0.05% are estimated to have any significant toxicity in humans. In this review we provide an overview of the many benefits of conotoxin research, and contrast these to the perceived biosecurity concerns of conotoxins and research thereof.
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Affiliation(s)
- Walden E. Bjørn-Yoshimoto
- Department of Biomedical Sciences, University of Copenhagen, 2200 Copenhagen N, Denmark; (W.E.B.-Y.); (I.B.L.R.)
| | - Iris Bea L. Ramiro
- Department of Biomedical Sciences, University of Copenhagen, 2200 Copenhagen N, Denmark; (W.E.B.-Y.); (I.B.L.R.)
| | - Mark Yandell
- Eccles Institute of Human Genetics, University of Utah, Salt Lake City, UT 84112, USA;
- Utah Center for Genetic Discovery, University of Utah, Salt Lake City, UT 84112, USA
| | - J. Michael McIntosh
- School of Biological Sciences, University of Utah, Salt Lake City, UT 84112, USA; (J.M.M.); (B.M.O.)
- George E. Whalen Veterans Affairs Medical Center, Salt Lake City, UT 84148, USA
- Department of Psychiatry, University of Utah, Salt Lake City, UT 84108, USA
| | - Baldomero M. Olivera
- School of Biological Sciences, University of Utah, Salt Lake City, UT 84112, USA; (J.M.M.); (B.M.O.)
| | - Lars Ellgaard
- Department of Biology, Linderstrøm-Lang Centre for Protein Science, University of Copenhagen, 2200 Copenhagen N, Denmark;
| | - Helena Safavi-Hemami
- Department of Biomedical Sciences, University of Copenhagen, 2200 Copenhagen N, Denmark; (W.E.B.-Y.); (I.B.L.R.)
- School of Biological Sciences, University of Utah, Salt Lake City, UT 84112, USA; (J.M.M.); (B.M.O.)
- Department of Biochemistry, University of Utah, Salt Lake City, UT 84112, USA
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Tichy EM, Prosser B, Doyle D. Expanding the Role of the Pharmacist: Immunoglobulin Therapy and Disease Management in Neuromuscular Disorders. J Pharm Pract 2020; 35:106-119. [PMID: 32677504 PMCID: PMC8822190 DOI: 10.1177/0897190020938212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Immunoglobulin G (IgG) is a commonly used treatment for chronic neuromuscular
disorders (NMDs), such as chronic inflammatory demyelinating polyneuropathy and
multifocal motor neuropathy. IgG therapy has also shown promise in treating
other NMDs including myasthenia gravis, polymyositis, and dermatomyositis. IgG
is administered as either intravenous immunoglobulin (IVIg) or subcutaneous
immunoglobulin (SCIg), with SCIg use becoming more popular due to the treatment
burden associated with IVIg. IVIg requires regular venous access; long infusions
(typically 4-6 hours); and can result in systemic adverse events (AEs) for some
patients. In contrast, SCIg can be self-administered at home with shorter
infusions (approximately 1 hour) and fewer systemic AEs. As patient care shifts
toward home-based settings, the role of the pharmacist is paramount in providing
a continuation of care and acting as the bridge between patient and clinic.
Pharmacists with a good understanding of current recommendations, dosing
strategies, and administration routes for IgG therapy are best placed to support
patients. The aims of this review are to highlight the evidence supporting IgG
therapy in the treatment of NMDs and provide practical information on patient
management and IVIg/SCIg dosing in order to guide pharmacists on optimizing
clinical outcomes and patient care.
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Affiliation(s)
- Eric M Tichy
- Pharmacy Supply Solutions, Supply Chain Management, Mayo Clinic, Rochester, MN, USA
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68
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Papageorgiou S, Gnirs K, Quinton JF, Shelton GD. Clinical and serologic remission of acquired myasthenia gravis in a domestic ferret ( Mustela putorius furo). J Am Vet Med Assoc 2020; 254:1192-1195. [PMID: 31039095 DOI: 10.2460/javma.254.10.1192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
CASE DESCRIPTION A 4.5-year-old neutered male domestic ferret (Mustela putorius furo) was examined because of clinical signs compatible with neuromuscular disease. CLINICAL FINDINGS Results of electrophysiologic assessment, including measurement of compound muscle action potentials following repetitive nerve stimulation, and measurement of the anti-acetylcholine receptor antibody titer were consistent with a diagnosis of acquired myasthenia gravis. TREATMENT AND OUTCOME Medical treatment with pyridostigmine and prednisolone was instituted. The first signs of clinical improvement were observed 2 months later, followed by a slow but steady improvement over the next months. Anti-acetylcholine receptor antibody titer was measured 10 months after initiation of treatment and was markedly decreased, compared with the initial titer. Pyridostigmine and prednisolone dosages were tapered over the following 4 months without any evidence of recurrence of clinical signs. Thirty months after initial examination, the ferret was clinically normal and not receiving any treatment. A follow-up anti-acetylcholine receptor antibody titer was similar to previously published values for healthy ferrets. CLINICAL RELEVANCE Findings indicated that clinical and serologic remission can be achieved in ferrets with myasthenia gravis. However, owner willingness to provide extensive supportive care was vital to the outcome for this patient, as was the owner's decision to not euthanize the ferret despite an initial lack of response to treatment.
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69
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Filosso PL, Lyberis P, Guerrera F, Ruffini E. Commentary: Robotic-Re-Thymectomy: A Surgical Effective Chance to Treat Refractory Myasthenia Gravis. Semin Thorac Cardiovasc Surg 2020; 32:603-604. [PMID: 32433988 DOI: 10.1053/j.semtcvs.2020.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/28/2020] [Accepted: 05/01/2020] [Indexed: 01/11/2023]
Affiliation(s)
- Pier Luigi Filosso
- Department of Surgical Sciences Unit of Thoracic Surgery, University of Torino Italy, Torino, Italy.
| | - Paraskevas Lyberis
- Department of Surgical Sciences Unit of Thoracic Surgery, University of Torino Italy, Torino, Italy
| | - Francesco Guerrera
- Department of Surgical Sciences Unit of Thoracic Surgery, University of Torino Italy, Torino, Italy
| | - Enrico Ruffini
- Department of Surgical Sciences Unit of Thoracic Surgery, University of Torino Italy, Torino, Italy
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Na KJ, Hyun K, Kang CH, Park S, Lee HJ, Park IK, Kim YT, Lee GD, Kim HR, Choi SH, Kim YH, Kim DK, Park SI, Shin S, Cho JH, Kim HK, Choi YS, Kim J, Zo JI, Shim YM, Lee CY, Lee JG, Kim DJ, Paik HC, Chung KY. Predictors of post-thymectomy long-term neurological remission in thymomatous myasthenia gravis: an analysis from a multi-institutional database. Eur J Cardiothorac Surg 2020; 57:867-873. [DOI: 10.1093/ejcts/ezz334] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
Abstract
OBJECTIVES
Thymectomy is the treatment of choice for thymomatous myasthenia gravis (MG) for both oncological and neurological aspects. However, only a few studies comprising small numbers of patients have investigated post-thymectomy neurological outcomes. We examined post-thymectomy long-term neurological outcomes and predictors of thymomatous MG using a multi-institutional database.
METHODS
In total, 193 patients (47.3 ± 12.0 years; male:female = 90:103) with surgically resected thymomatous MG between 2000 and 2013 were included. Complete stable remission (CSR) and composite neurological remission (CNR), defined as the achievement of CSR and pharmacological remission after thymectomy, were evaluated. Predictors for CSR and CNR were examined by Cox regression analysis.
RESULTS
The median duration between MG and thymectomy was 3.1 months. In addition, 161 patients (83.4%) had symptoms less than Myasthenia Gravis Foundation of America clinical classification III. All patients underwent an extended thymectomy; there were no perioperative deaths. The 10-year cumulative probability of CSR and CNR was 36.9% and 69.1%, respectively. Mild preoperative symptoms were a significant predictor for CSR (P = 0.040), and a large tumour was a predictor for CNR (P < 0.001). Patients with a large tumour were associated with early MG onset and no steroid treatment. Surgical methods, thymoma stage and histological subtypes were not associated with long-term neurological remission.
CONCLUSIONS
Large tumour size and preoperative mild symptoms were predictors for long-term neurological outcome in thymomatous MG. Considering that patients with early onset of MG and no immunosuppressive treatment tend to have large tumours, early surgical intervention for patients with thymomatous MG having mild symptoms might be beneficial for controlling neurological outcomes.
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Affiliation(s)
- Kwon Joong Na
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kwanyong Hyun
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, Seoul, Republic of Korea
| | - Chang Hyun Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Samina Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyun Joo Lee
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - In Kyu Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young Tae Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Geun Dong Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Hyeong Ryul Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Se Hoon Choi
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Yong-Hee Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Dong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Seung-Il Park
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Sumin Shin
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jong Ho Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yong Soo Choi
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jhingook Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae Il Zo
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Mog Shim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chang Young Lee
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin Gu Lee
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dae Joon Kim
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyo Chae Paik
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyung Young Chung
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Chen J, Chen Z, Miao F, Song Y, Chen G, Zhu Y, Pang L, Xi J, Zhao C, Chen X. A Randomized Control Study on the Efficacy of Thymectomy in Patients with Nonthymomatous (without Chest Tumor) Myasthenia Gravis. Ann Indian Acad Neurol 2020; 23:141-144. [PMID: 32055143 PMCID: PMC7001440 DOI: 10.4103/aian.aian_138_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Ji Chen
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhiming Chen
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Feng Miao
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Yang Song
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Gang Chen
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Yongjun Zhu
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Liewen Pang
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Jianying Xi
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, China
| | - Chongbo Zhao
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaofeng Chen
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
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Patel A, Lynch F, Shepherd SA. Newer Immunotherapies for the Treatment of Acute Neuromuscular Disease in the Critical Care Unit. Curr Treat Options Neurol 2020; 22:7. [PMID: 32052202 DOI: 10.1007/s11940-020-0616-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OPINION STATEMENT PURPOSE OF REVIEW: In this review, we discuss current treatment options for commonly encountered neuromuscular disorders in intensive care units. We will discuss epidemiology, pathophysiology, and acute and chronic treatment options for myasthenia gravis, Guillain-Barré syndrome, West Nile virus, Botulism, and amyotrophic lateral sclerosis. RECENT FINDINGS Eculizumab is the newest immunomodulator therapy approved by the Food and Drug Administration in treatment of myasthenia gravis, shown to improve long-term functional outcomes. Edaravone is the newest therapy in management of amyotrophic lateral sclerosis, shown to slow functional deterioration. Efgartigimod showed great promise in a phase 2 safety and efficacy trial in the treatment of stable generalized myasthenia gravis. Eculizumab was found to be safe in a small phase 2 trial for use in Guillain-Barré syndrome. Currently, therapies such as plasma exchange, intravenous immunoglobulins, and steroids remain the mainstay of treatment in the ICU for many neuromuscular disorders. While there are some newer immunotherapies available, few have been studied in the acute setting. However, with the advent of new immunotherapies and biologics, changes in these approaches may be on the horizon.
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Affiliation(s)
- Alok Patel
- Department of Neurology, Rush University Medical Center, 1725 W Harrison St, Suite 1121, Chicago, IL, 60612, USA
| | - Fiona Lynch
- Department of Neurology, Rush University Medical Center, 1725 W Harrison St, Suite 1121, Chicago, IL, 60612, USA
| | - Starane A Shepherd
- Department of Neurology, Rush University Medical Center, 1725 W Harrison St, Suite 1121, Chicago, IL, 60612, USA.
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242nd ENMC International Workshop: Diagnosis and management of juvenile myasthenia gravis Hoofddorp, the Netherlands, 1-3 March 2019. Neuromuscul Disord 2020; 30:254-264. [PMID: 32173249 DOI: 10.1016/j.nmd.2020.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 02/03/2020] [Indexed: 12/13/2022]
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Beatmung bei neuromuskulären Erkrankungen. NEUROLOGISCHE BEATMUNGSMEDIZIN 2020. [PMCID: PMC7236064 DOI: 10.1007/978-3-662-59014-0_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Neuromuskuläre Erkrankungen betreffen das erste und zweite Motoneuron, die peripheren Nerven, die neuromuskulären Übertragung und die Muskelzelle. Es handelt sich um eine heterogene Gruppe von erblichen, degenerativen und autoimmunen Erkrankungen. Eine korrekte diagnostische Einordnung ist erforderlich, da zentralnervöse, kardiale, endokrine und weitere Begleitsymptome vorliegen können und für einige Erkrankungen bereits medikamentöse Therapien zur Verfügung stehen. Neuromuskuläre Erkrankungen haben eine große Bedeutung in der neuromuskulären Beatmungsmedizin. Die respiratorische Symptomatik resultiert in der Regel aus Paresen der am Atmen, Schlucken oder Husten beteiligten Muskulatur mit konsekutiver ventilatorischer Insuffienz, Dysphagie bis hin zur Speichelaspiration und Sekretretention. Mittels eines strukturierte Sekretmanagements und einer effektive nichtinvasive oder invasive Beatmungstherapie können neuromuskuläre Patienten viele Jahre mit guter Lebensqualität überleben. Themen dieses Kapitels sind ein Überblick über die neuromuskulären Erkrankungen, die Indikationen und Strategien der nichtinvasiven und der invasiven Beatmung und eine ausführliche Darstellung beatmungsmedizinisch besonders relevanter neuromuskulärer Erkrankungen wie der amyotrophe Lateralsklerose, des Guillain-Barré-Syndroms, der Myasthenia gravis und der Critical-Illness-Polyneuropathie/-Myopathie.
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Renjen P, Chaudhari D, Mishra A. The dilemma of thymectomy in myasthenia gravis. APOLLO MEDICINE 2020. [DOI: 10.4103/am.am_23_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Sipilä JO, Soilu-Hänninen M, Rautava P, Kytö V. Hospital admission and prevalence trends of adult myasthenia gravis in Finland in 2004–2014: A retrospective national registry study. J Neurol Sci 2019; 407:116520. [DOI: 10.1016/j.jns.2019.116520] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 10/02/2019] [Accepted: 10/03/2019] [Indexed: 01/09/2023]
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Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, Pham HP, Schneiderman J, Witt V, Wu Y, Zantek ND, Dunbar NM, Schwartz GEJ. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher 2019; 34:171-354. [PMID: 31180581 DOI: 10.1002/jca.21705] [Citation(s) in RCA: 775] [Impact Index Per Article: 155.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.
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Affiliation(s)
- Anand Padmanabhan
- Medical Sciences Institute & Blood Research Institute, Versiti & Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance & University of Washington, Seattle, Washington
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Reinhard Klingel
- Apheresis Research Institute, Cologne, Germany & First Department of Internal Medicine, University of Mainz, Mainz, Germany
| | - Erin Meyer
- Department of Hematology/Oncology/BMT/Pathology, Nationwide Children's Hospital, Columbus, Ohio
| | - Huy P Pham
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jennifer Schneiderman
- Department of Pediatric Hematology/Oncology/Neuro-oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks NW & Department of Laboratory Medicine, University of Washington, Seattle, Washington, Yale University School of Medicine, New Haven, Connecticut
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Surana S, Kumar R, Pitt M, Hafner P, Mclellan A, Davidson J, Prabakhar P, Vincent A, Hacohen Y, Wright S. Acquired neuromyotonia in children with CASPR2 and LGI1 antibodies. Dev Med Child Neurol 2019; 61:1344-1347. [PMID: 30724344 DOI: 10.1111/dmcn.14179] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2018] [Indexed: 11/27/2022]
Abstract
Acquired neuromyotonia is a form of peripheral nerve hyperexcitability. In adults, pathogenic antibodies that target the extracellular domains of leucine-rich glioma-inactivated protein 1 (LGI1) and contactin-associated protein-like 2 (CASPR2) have been reported. We describe three paediatric patients with acquired neuromyotonia and CASPR2 and LGI1 serum antibodies. They all presented with acute-onset myokymia and pain in the lower limbs; one patient also had muscle weakness. Electromyography was suggestive of peripheral nerve hyperexcitability. Two patients improved without immunotherapy; one treated patient remained immunotherapy-dependent. Although not fatal, acquired paediatric neuromyotonia can be disabling. It is amenable to symptomatic treatment or may undergo spontaneous recovery. More severe cases may require rational immunotherapy. WHAT THIS PAPER ADDS: The symptoms of neuromyotonia may resolve spontaneously or may require sodium channel blockers. Patients with debilitating symptoms who are refractory to symptomatic therapy may require immunotherapy.
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Affiliation(s)
- Snehal Surana
- Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Ratna Kumar
- Paediatric Neurology, Birmingham Children's Hospital, Birmingham, UK
| | - Matthew Pitt
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London, UK
| | - Patricia Hafner
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London, UK.,Division of Pediatric Neurology, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Ailsa Mclellan
- Paediatric Neurology, Royal Hospital for Sick Children, Edinburgh, UK
| | - Joyce Davidson
- Paediatric Rheumatology, Royal Hospital for Sick Children, Edinburgh, UK
| | - Prab Prabakhar
- Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Angela Vincent
- Paediatric Neurology, Royal Hospital for Sick Children, Edinburgh, UK
| | - Yael Hacohen
- Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK.,Department of Neuroinflammation, UCL Institute of Neurology, London, UK
| | - Sukhvir Wright
- Paediatric Neurology, Birmingham Children's Hospital, Birmingham, UK.,School of Life and Health Sciences, Aston University, Birmingham, UK
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Souto EB, Lima B, Campos JR, Martins-Gomes C, Souto SB, Silva AM. Myasthenia gravis: State of the art and new therapeutic strategies. J Neuroimmunol 2019; 337:577080. [PMID: 31670062 DOI: 10.1016/j.jneuroim.2019.577080] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 10/04/2019] [Indexed: 12/11/2022]
Abstract
Myasthenia Gravis (MG) - an autoimmune neuromuscular disease - is known by the production of autoantibodies against components of the neuromuscular junction mainly to the acetylcholine receptor, which cause the destruction and compromises the synaptic transmission. This disease is characterized by fluctuating and fatigable muscle weakness, becoming more intensive with activity, but with an improvement under resting. There are many therapeutic strategies used to alleviate MG symptoms, either by improving the transmission of the nerve impulse or by ameliorating autoimmune reactions with e.g. steroids, immunosuppressant drugs, or monoclonal antibodies (rituximab and eculizumab). Many breakthroughs in the discovery of new therapeutic targets have been reported, but MG remains to be a chronic disease where the symptoms are kept in the majority of patients. In this review, we discuss the different therapeutic strategies that have been used over the years to alleviate MG symptoms, as well as innovative therapeutic approaches currently under study.
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Affiliation(s)
- Eliana B Souto
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Coimbra (FFUC), Pólo das Ciências da Saúde, 3000-548 Coimbra, Portugal; CEB - Centre of Biological Engineering, University of Minho, Campus de Gualtar, 4710-057 Braga, Portugal.
| | - Bernardo Lima
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Coimbra (FFUC), Pólo das Ciências da Saúde, 3000-548 Coimbra, Portugal
| | - Joana R Campos
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Coimbra (FFUC), Pólo das Ciências da Saúde, 3000-548 Coimbra, Portugal
| | - Carlos Martins-Gomes
- Department of Biology and Environment, School of Life and Environmental Sciences, University of Trás-os-Montes and Alto Douro, Vila Real, Portugal; Centre for the Research and Technology of Agro-Environmental and Biological Sciences, University of Trás-os-Montes and Alto Douro, Vila Real, Portugal
| | - Selma B Souto
- Department of Endocrinology of S. João Hospital, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Amélia M Silva
- Department of Biology and Environment, School of Life and Environmental Sciences, University of Trás-os-Montes and Alto Douro, Vila Real, Portugal; Centre for the Research and Technology of Agro-Environmental and Biological Sciences, University of Trás-os-Montes and Alto Douro, Vila Real, Portugal.
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80
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Abstract
With specialized care, patients with myasthenia gravis can have very good outcomes. The mainstays of treatment are acetylcholinesterase inhibitors, and immunosuppressive and immunomodulatory therapies. There is good evidence thymectomy is beneficial in thymomatous and nonthymomatous disease. Nearly all of the drugs used for MG are considered "off-label." The 2 exceptions are acetylcholinesterase inhibitors and complement inhibition with eculizumab, which was recently approved by the US Food and Drug Administration for myasthenia gravis. This article reviews the evidence base and provides a framework for the treatment of myasthenia gravis, highlighting recent additions to the literature.
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81
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Nishida Y, Takahashi YK, Kanai T, Nose Y, Ishibashi S, Sanjo N, Uzawa A, Oda F, Ozawa Y, Kuwabara S, Noguchi E, Suzuki S, Nakahara J, Suzuki N, Ogawa T, Yokoyama K, Hattori N, Konno S, Fujioka T, Kawaguchi N, Hatanaka Y, Sonoo M, Kaneko J, Ogino M, Nishiyama K, Nomura K, Yokota T. Safety of tapering tacrolimus dose in patients with well-controlled anti-acetylcholine receptor antibody-positive myasthenia gravis. Eur J Neurol 2019; 27:100-104. [PMID: 31309642 DOI: 10.1111/ene.14039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 07/10/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND PURPOSE Tapering immunosuppressants is desirable in patients with well-controlled myasthenia gravis (MG). However, the association between tapering of calcineurin inhibitor dosage and reduction-associated exacerbation is not known. The aim of this study was to clarify the frequency of reduction-associated exacerbation when tacrolimus is tapered in stable patients with anti-acetylcholine receptor antibody-positive MG, and to determine the factors that predict exacerbations. METHODS We retrospectively analyzed 115 patients in whom tacrolimus dosage was tapered. The reduction-associated exacerbation was defined as the appearance or worsening of one or more MG symptoms <3 months after the reduction. RESULTS Tacrolimus dosage was successfully tapered in 110 patients (96%) without any exacerbation. Five patients (4%) experienced an exacerbation, but symptoms were reversed in all patients when the tacrolimus dose was increased to the previous maintenance level. No patient developed an MG crisis. The age at onset was significantly earlier (30 vs. 56 years, P = 0.025) and the reduction in dosage was significantly larger (2.0 vs. 1.0 mg/day, P = 0.002) in patients with reduction-associated exacerbation than in those without exacerbation. The cut-off values determined in a receiver-operating characteristic curve analysis were 52 years (sensitivity, 57%; specificity, 100%) for the age at onset and 1.5 mg (sensitivity, 80%; specificity, 100%) for the dose reduction. CONCLUSION Tapering of tacrolimus was possible in most patients with well-controlled anti-acetylcholine receptor antibody-positive MG. Early age at onset and a large reduction from maintenance dosage were associated with exacerbation. Reductions ≤1.5 mg/day from the maintenance dosage should be considered for patients with late-onset disease.
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Affiliation(s)
- Y Nishida
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Y K Takahashi
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - T Kanai
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Y Nose
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - S Ishibashi
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - N Sanjo
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - A Uzawa
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - F Oda
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Y Ozawa
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - S Kuwabara
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - E Noguchi
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - S Suzuki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - J Nakahara
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - N Suzuki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - T Ogawa
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - K Yokoyama
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - N Hattori
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - S Konno
- Department of Neurology, Toho University Ohashi Medical Center, Tokyo, Japan
| | - T Fujioka
- Department of Neurology, Toho University Ohashi Medical Center, Tokyo, Japan
| | | | - Y Hatanaka
- Department of Neurology, Teikyo University School of Medicine, Tokyo, Japan
| | - M Sonoo
- Department of Neurology, Teikyo University School of Medicine, Tokyo, Japan
| | - J Kaneko
- Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan
| | - M Ogino
- School of Medicine, Center for Medical Education, International University of Health and Welfare, Chiba, Japan
| | - K Nishiyama
- Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan
| | - K Nomura
- Department of Neurology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - T Yokota
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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82
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Abstract
PURPOSE OF REVIEW Weakness is a common reason patients are seen in neurologic consultation. This article reviews the differential diagnosis of neuromuscular disorders in the intensive care unit (ICU), discusses the intensive care needs and evaluation of respiratory failure in patients with neuromuscular disorders, and provides a practical guide for management. RECENT FINDINGS Although primary neuromuscular disorders used to be the most common cause for weakness from peripheral nervous system disease in the ICU, a shift toward ICU-acquired weakness is observed in today's clinical practice. Therefore, determining the cause of weakness is important and may have significant prognostic implications. Guillain-Barré syndrome and myasthenia gravis remain the most common primary neuromuscular disorders in the ICU. In patients with myasthenia gravis, it is important to be vigilant with the airway and institute noninvasive ventilation early in the course of the disease to attempt to avoid the need for intubation. On the other hand, patients with Guillain-Barré syndrome should be intubated without delay if the airway is at risk to avoid further complications. In patients with ICU-acquired weakness, failure to wean from the ventilator is usually the challenge. Early mobility, glucose control, minimizing sedation, and avoiding neuromuscular blocking agents remain the only therapeutic regimen available for ICU-acquired weakness. SUMMARY Critical care management of neuromuscular disorders requires a multidisciplinary approach engaging members of the ICU and consultative teams. Developing an airway management protocol could have implications on outcome and length of stay for patients with neuromuscular disorders in the ICU. Tending to the appropriate nuances of each patient who is critically ill with a neuromuscular disorder through evidence-based medicine can also have implications on length of stay and outcome.
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Amifampridine Phosphate (Firdapse) Is Effective in a Confirmatory Phase 3 Clinical Trial in LEMS. J Clin Neuromuscul Dis 2019; 20:111-119. [PMID: 30801481 PMCID: PMC6392213 DOI: 10.1097/cnd.0000000000000239] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objective: To assess tolerability and efficacy of amifampridine phosphate versus placebo for symptomatic treatment of Lambert–Eaton Myasthenic Syndrome (LEMS). Methods: This phase 3 randomized, double-blind, placebo-controlled withdrawal trial in 26 adults with LEMS compared efficacy of amifampridine phosphate versus placebo over a 4-day period. The primary endpoints were quantitative myasthenia gravis score (QMG) and subject global impression, and the secondary endpoint was Clinical Global Impression–Improvement. The exploratory endpoints were 3TUG (timed up and go) test and QMG limb domain score. All participants had been receiving amifampridine phosphate (30–80 mg/d divided into 3 or 4 doses daily) in an expanded access protocol and had been titrated to the optimal dose and frequency for at least 1 week before randomization into the current study. After completion of assessments after 4 days of double-blind treatment, patients had the option to return to open-label amifampridine phosphate. The efficacy endpoints were mean changes from baseline in the various evaluation parameters. Results: Amifampridine phosphate (n = 13) demonstrated significant benefit in QMG and subject global impression compared with placebo (n = 13) at 4 days. Other measures of efficacy, including Clinical Global Impression–Improvement, 3TUG, and QMG limb domain score were also improved. The most common “adverse events” in the placebo group were muscle weakness (n = 5) and fatigue (n = 4), as expected from withdrawal of amifampridine phosphate, whereas only back pain (n = 1), pain in extremity (n = 1), and headache (n = 1) were reported in amifampridine phosphate group. Conclusions: This phase 3 randomized, double-blind, placebo-controlled withdrawal trial in adults with LEMS provided class I evidence of efficacy of amifampridine phosphate as symptomatic treatment in LEMS.
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84
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Abstract
Myasthenia gravis (MG) is an autoimmune disease caused by antibodies against the acetylcholine receptor (AChR), muscle-specific kinase (MuSK) or other AChR-related proteins in the postsynaptic muscle membrane. Localized or general muscle weakness is the predominant symptom and is induced by the antibodies. Patients are grouped according to the presence of antibodies, symptoms, age at onset and thymus pathology. Diagnosis is straightforward in most patients with typical symptoms and a positive antibody test, although a detailed clinical and neurophysiological examination is important in antibody-negative patients. MG therapy should be ambitious and aim for clinical remission or only mild symptoms with near-normal function and quality of life. Treatment should be based on MG subgroup and includes symptomatic treatment using acetylcholinesterase inhibitors, thymectomy and immunotherapy. Intravenous immunoglobulin and plasma exchange are fast-acting treatments used for disease exacerbations, and intensive care is necessary during exacerbations with respiratory failure. Comorbidity is frequent, particularly in elderly patients. Active physical training should be encouraged.
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85
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Comacchio GM, Marulli G, Mammana M, Natale G, Schiavon M, Rea F. Surgical Decision Making. Thorac Surg Clin 2019; 29:203-213. [DOI: 10.1016/j.thorsurg.2018.12.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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86
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Mi W, Silvestri NJ, Wolfe GI. A Neurologist's Perspective on Thymectomy for Myasthenia Gravis: Current Perspective and Future Trials. Thorac Surg Clin 2019; 29:143-150. [PMID: 30927995 DOI: 10.1016/j.thorsurg.2018.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The first randomized blinded study of thymectomy in nonthymomatous myasthenia gravis was designed to answer 3 questions: does the combination of prednisone and removal of the thymus gland via extended transsternal thymectomy after 3 years compared with an identical dosing protocol of prednisone alone (1) lead to better disease status for generalized MG patients with antiacetylcholine receptor antibodies, (2) reduce their prednisone requirements, and/or (3) reduce the side-effect burden from medications used to treat the disease? The study demonstrated that thymectomy confers these benefits for patients and sets the stage for inquiries into the benefits of less-invasive approaches to thymic resection.
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Affiliation(s)
- Wentao Mi
- Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo/SUNY, 1010 Main Street, 2nd Floor, Buffalo, NY 14202, USA
| | - Nicholas J Silvestri
- Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo/SUNY, 1010 Main Street, 2nd Floor, Buffalo, NY 14202, USA
| | - Gil I Wolfe
- Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo/SUNY, 1010 Main Street, 2nd Floor, Buffalo, NY 14202, USA.
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87
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Sossa Melo CL, Peña AM, Salazar LA, Jiménez SI, Gómez ED, Chalela CM, Ayala-Castillo M, Peña IM. Autologous hematopoietic stem cell transplantation in a patient with refractory seropositive myasthenia gravis: A case report. Neuromuscul Disord 2019; 29:142-145. [DOI: 10.1016/j.nmd.2018.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 10/02/2018] [Accepted: 11/20/2018] [Indexed: 12/13/2022]
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88
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Chen S, Xu MB, Zhou XL, Rong PQ, Jin TY, Zheng GQ. Chinese Herbal Medicine for Myasthenia Gravis: A Systematic Review and Meta-Analysis. Front Pharmacol 2018; 9:969. [PMID: 30214409 PMCID: PMC6125412 DOI: 10.3389/fphar.2018.00969] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 08/06/2018] [Indexed: 11/13/2022] Open
Abstract
Myasthenia gravis (MG) is an acquired autoimmune disease with the disorder of the neuromuscular junction transmission caused by autoantibodies. Currently, various Chinese herbal medicines (CHMs) are widely used for MG. This meta-analysis was conducted to assess the effectiveness and safety of CHMs for MG and its possible mechanisms. Fourteen studies with 1039 individuals were identified by searching seven databases from inception to March 2017. The methodological quality was assessed by using 7-item criteria from the Cochrane's Collaboration tool, and which assessed ≥4 "yes" in the domains were selected for detailed assessment and meta-analysis. All the data were analyzed using Rev-Man 5.3 software. Meta-analysis showed a significant effect of CHM as adjuvant therapy for improving the effectiveness compared with WCM alone or placebo in treating MG (p < 0.01). Moreover, there were fewer adverse effects and relapse rate in total when compared with the control group. The possible mechanisms of CHM for MG are associated with immunoregulation by reconstituting the functional ability of Tregs. In conclusion, despite the apparent positive results, the present evidence supports, to an extent, that CHM can be used for MG patients because of the methodological flaws and CHM heterogeneity. Further rigorous RCT for MG is needed.
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Affiliation(s)
- Shuang Chen
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Meng-Bei Xu
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiao-Li Zhou
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Pei-Qing Rong
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ting-Yu Jin
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Guo-Qing Zheng
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
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89
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Gilhus NE, Hong Y. Maternal myasthenia gravis represents a risk for the child through autoantibody transfer, immunosuppressive therapy and genetic influence. Eur J Neurol 2018; 25:1402-1409. [PMID: 30133097 DOI: 10.1111/ene.13788] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 08/17/2018] [Indexed: 12/16/2022]
Abstract
Females with myasthenia gravis (MG) worry about their disease having negative consequences for their children. Autoimmune disease mechanisms, treatment and heredity could all have an impact on the child. This is a subject review where Web of Science was searched for relevant keywords and combinations. Controlled and prospective studies were included, and also results from selected and unselected patient cohorts, guidelines, consensus papers and reviews. Neonatal MG with temporary muscle weakness occurs in 10% of newborn babies where the mother has MG, due to transplacental transfer of antibodies against acetylcholine receptor (AChR), muscle-specific kinase (MuSK) or lipoprotein receptor-related protein 4 (LRP4). Arthrogryposis and fetal AChR inactivation syndrome with contractures and permanent myopathy are rare events caused by mother's antibodies against fetal type AChR. The MG drugs pyridostigmine, prednisolone and azathioprine are regarded as safe during pregnancy and breastfeeding. Methotrexate, mycophenolate mofetil and cyclophosphamide are teratogenic. Mother's MG implies at least a 10-fold increased risk for MG and other autoimmune diseases in the child. MG females should receive specific information about pregnancy and giving birth. First-line MG treatments should usually be continued during pregnancy. Intravenous immunoglobulin and plasma exchange represent safe treatments for exacerbations. Neonatal MG risk means that MG women should give birth at hospitals experienced in neonatal intensive care. Neonatal MG needs supportive care, rarely also acetylcholine esterase inhibition or intravenous immunoglobulin. Women with MG should be supported in their wish to have children.
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Affiliation(s)
- N E Gilhus
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Y Hong
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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90
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Galassi G, Mazzoli M, Ariatti A, Kaleci S, Valzania F, Nichelli PF. Antibody profile may predict outcome in ocular myasthenia gravis. Acta Neurol Belg 2018; 118:435-443. [PMID: 29858757 DOI: 10.1007/s13760-018-0943-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 05/15/2018] [Indexed: 02/04/2023]
Abstract
An unsolved issue remains whether there are clinical and immunological features to predict in a single patient the risk of conversion from ocular Myasthenia Gravis (OMG) to generalized disease (GMG) as 50-60% of patients may progress within 1-2 years since onset. Anti-acetylcholine receptor antibodies (AChR Abs) are found in up to 50% of OMG patients; muscle-specific tyrosine kinase antibodies (MuSK-Abs) are present in about 70% of the whole seronegative (SN), who usually develop a severe disease with bulbar involvement. We surveyed a cohort of 175 OMG patients with purely ocular symptoms and we compare the outcome of patients with antibodies to AChR or to MuSK with those seronegative for both Abs (DSN). All patients had purely ocular signs for at least 24 months. Gender, age at onset, time to generalization or to worsening in quantitative ocular QMG scores, electrophysiological results were analyzed. Males were 58.9%, females 41.1%. Patients with late onset of symptoms after 50 years (LOMG) were 78.3%. We assayed anti-MuSK-Abs in 4.7%, anti-AChR Abs in 38.5%; 57.3% were defined DSN. Thirty-seven patients (21.1%) progressed to GMG during the observational time: 23 were females, 62% of the whole group of the generalized subjects, 75% of MuSK-positive OMG converted to GMG versus the 26.2% of AChR positive and 13.7% of DSN. Statistical analysis showed that gender and presence of antibodies either to AChR or to MuSK were independent predictors of worse outcome; the DSN subjects had lower risk of conversion to GMG.
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Affiliation(s)
- Giuliana Galassi
- Department of Biomedical, Metabolic and Neural Sciences, University Hospital, Modena, Italy.
| | - Marco Mazzoli
- Department of Biomedical, Metabolic and Neural Sciences, University Hospital, Modena, Italy
| | - Alessandra Ariatti
- Department of Biomedical, Metabolic and Neural Sciences, University Hospital, Modena, Italy
| | - Shaniko Kaleci
- Department of Diagnostic Clinical Medicine and Public Health, University of Modena, Modena, Italy
| | - Franco Valzania
- Department of Neurology, Arcispedale S. Maria Nuova, Reggio Emilia, Italy
| | - Paolo F Nichelli
- Department of Biomedical, Metabolic and Neural Sciences, University Hospital, Modena, Italy
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91
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Abstract
PURPOSE OF REVIEW Peripheral nerve hyperexcitability (PNH) syndromes are divided into primary and secondary groups based on the presence or absence of demonstrable peripheral nerve disease. In this review, we systematically evaluate the evidence for current therapies and supportive managements based on autoimmune, paraneoplastic, and genetic components in pathophysiology reported in the literature. RECENT FINDINGS Current therapy options are based on symptomatic management as well as focusing the underlying immune/genetic/paraneoplastic pathology by immunosuppressants, chemotherapy, and surgery. Further research is desired to provide treatment options geared specifically towards addressing PNH. Supportive care can also be an area for future research.
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92
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Pedersen EG, Hallas J, Pottegård A, Hald SM, Jensen PEH, Gaist D. Oral Immunosuppressive Treatment of Myasthenia Gravis in Denmark: A Nationwide Drug Utilization Study, 1996-2013. Basic Clin Pharmacol Toxicol 2018; 123:486-493. [PMID: 29732733 DOI: 10.1111/bcpt.13034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 04/23/2018] [Indexed: 11/29/2022]
Abstract
Although immunosuppressants in the treatment of myasthenia have been available for several decades, population-based studies describing drug utilization in myasthenia patients are scarce. We aimed in this study to describe the treatment of myasthenia in Denmark in more recent years with emphasis on use of oral immunosuppressant agents. We identified a nationwide cohort of incident myasthenia patients in Denmark from 1996 to 2013 and tracked their use of drugs over the entire period using data from nationwide registers. Patients with myasthenia were classified according to utilization of specific immunosuppressants (e.g. prednisolone) as 'never user' or 'ever user'. We used Kaplan-Meier (K-M) and proportion of patients covered (PPC) curves to describe treatment onset and termination. We identified 928 patients (52% female) with incident myasthenia in the study period. Overall, 638 (69%) were treated with prednisolone and 506 (55%) with azathioprine. Treatment with prednisolone and azathioprine within 2 years of myasthenia diagnosis was initiated in 462 (56%) and 366 (45%). Only one of four myasthenia patients (n = 231) did not receive oral immunosuppressive treatment at any time in the study period. Prednisolone was stopped in most patients, whereas treatment with azathioprine was often continued throughout follow-up. In conclusion, we found that treatment of myasthenia in Denmark in recent years corresponded well to the expected clinical course of myasthenia and that most patients underwent long-term immunosuppression.
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Affiliation(s)
- Emil Greve Pedersen
- Department of Neurology, Odense University Hospital & Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark (SDU), Odense, Denmark
| | - Jesper Hallas
- Department of Public Health, Clinical Pharmacology, SDU, Odense, Denmark
| | - Anton Pottegård
- Department of Public Health, Clinical Pharmacology, SDU, Odense, Denmark
| | - Stine Munk Hald
- Department of Neurology, Odense University Hospital & Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark (SDU), Odense, Denmark
| | - Poul Erik Hyldgaard Jensen
- Neuroimmunology Laboratory, DMSC, Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - David Gaist
- Department of Neurology, Odense University Hospital & Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark (SDU), Odense, Denmark
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93
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Britton F, Osei-Lah A, Tighe MP. Something for the weak-end? Electromyography appearances of myasthenia gravis. Arch Dis Child Educ Pract Ed 2018; 103:90-91. [PMID: 28179380 DOI: 10.1136/archdischild-2017-312641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 01/12/2017] [Indexed: 11/04/2022]
Affiliation(s)
- F Britton
- Paediatric Department, Poole Hospital NHS Trust, Poole, UK
| | - A Osei-Lah
- Paediatric Department, Poole Hospital NHS Trust, Poole, UK
| | - M P Tighe
- Paediatric Department, Poole Hospital NHS Trust, Poole, UK
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94
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Serological Immunoglobulin-Free Light Chain Profile in Myasthenia Gravis Patients. J Immunol Res 2018; 2018:9646209. [PMID: 29765992 PMCID: PMC5889870 DOI: 10.1155/2018/9646209] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 01/29/2018] [Indexed: 12/12/2022] Open
Abstract
Background Serological levels of free immunoglobulin light chains (FLCs), produced in excess of heavy chains during synthesis of immunoglobulins by plasma cells, can be considered a direct marker of B cell activity in different systemic inflammatory-autoimmune conditions and may represent a useful predictor of rituximab (RTX) therapeutic efficacy, as reported for rheumatoid arthritis and systemic lupus erythematosus. Myasthenia gravis (MG) is an autoimmune disease of the neuromuscular junction with antibodies (abs) targeting the acetylcholine receptor (AChR) or the muscle-specific tyrosine kinase (MuSK), inducing muscle weakness and excessive fatigability. As MG course may be remarkably variable, we evaluated the possible use of FLCs as biomarkers of disease activity. Subjects and Methods We assessed FLC levels in 34 sera from 17 AChR-MG and from 13 MuSK-MG patients, in comparison with 20 sera from patients with systemic autoimmune rheumatic diseases and 18 from healthy blood donors, along with titers of specific auto-abs and IgG subclass distribution. Results We found a statistically significant increase in free κ chains in both AChR- and MuSK-MG patients, while free λ chain levels were increased only in AChR-MG. We also observed a significant reduction of both free κ and λ chains in 1/4 MuSK-MG patients along with specific abs titer, two months after RTX treatment. Conclusions From our data, FLCs appear to be a sensitive marker of B cell activation in MG. Further investigations are necessary to exploit their potential as reliable biomarkers of disease activity.
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95
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Martínez Torre S, Gómez Molinero I, Martínez Girón R. [An update on myasthenia gravis]. Semergen 2018; 44:351-354. [PMID: 29555378 DOI: 10.1016/j.semerg.2018.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 12/13/2017] [Accepted: 01/09/2018] [Indexed: 01/04/2023]
Abstract
Myasthenia gravis is one of the most common disorders that affect neuromuscular transmission. It is currently one of the most understood and characterised autoimmune disorders Its typical symptoms are fluctuating weakness and fatigue that affects a combination of ocular muscles, bulbar functions, as well as limb and respiratory muscles, which are due to an immune attack against the postsynaptic membrane of the neuromuscular junction. The diagnosis of myasthenia gravis is based on clinical and serological test. It is a disease that can be effectively controlled with the current therapeutic lines, even achieving a complete remission. An update of this interesting disorder is now presented.
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96
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Abstract
PURPOSE OF REVIEW This article discusses the pathogenesis, diagnosis, and management of autoimmune myasthenia gravis (MG) and Lambert-Eaton myasthenic syndrome (LEMS). RECENT FINDINGS Recognition of new antigenic targets and improved diagnostic methods promise to improve the diagnosis of MG, although the clinical phenotypes associated with newer antibodies have not yet been defined. Future therapies might specifically target the aberrant immune response. The apparent increase in the prevalence of MG is not fully explained. Results of a long-awaited trial of thymectomy support the practice of performing a thymectomy under specific conditions. SUMMARY The current treatment options are so effective in most patients with MG or LEMS that in patients with refractory disease the diagnosis should be reconsidered. The management of MG is individualized, and familiarity with mechanisms, adverse effects, and strategies to manage these commonly used treatments improves outcome. Patient education is important. LEMS, frequently associated with an underlying small cell lung cancer, is uncommon, and the mainstay of treatment is symptomatic in most patients.
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97
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Myasthenia Gravis. Neuromuscul Disord 2018. [DOI: 10.1007/978-981-10-5361-0_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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98
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99
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Na SJ. Corticosteroids Treatment in Spinal Cord and Neuromuscular Disorders. JOURNAL OF NEUROCRITICAL CARE 2017. [DOI: 10.18700/jnc.170032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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100
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Prior DE, Nurre E, Roller SL, Kline D, Panara R, Stino AM, Davis JA, Freimer ML, Arnold WD. Infections and the relationship to treatment in neuromuscular autoimmunity. Muscle Nerve 2017; 57:927-931. [PMID: 29211921 DOI: 10.1002/mus.26032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2017] [Indexed: 12/30/2022]
Abstract
INTRODUCTION This study aimed to identify infections in patients with myasthenia gravis, dermatomyositis, and chronic inflammatory demyelinating polyradiculoneuropathy, and to investigate the relationship between infection and immunomodulation. METHODS A retrospective chart review examined 631 patients with myasthenia gravis (n = 358), chronic inflammatory demyelinating polyradiculoneuropathy (n = 124), and dermatomyositis (n = 149) patients over a 10-year time period. RESULTS Infection rates were similar at approximately 19% in all 3 diseases. Of the infections in which a causative organism was identified, pneumonia, sepsis, and opportunistic infections were the leading diagnoses. A multivariate model demonstrated a significant association between infection and an increased dose of plasma exchange, mycophenolate mofetil, and corticosteroid therapy. DISCUSSION There are few large studies investigating rates of infections in patients with autoimmune neuromuscular disorders and the relationship to immunomodulation. This study not only demonstrates the remarkably similar infection rates across the 3 diseases studied, but also shows their relationship to commonly used immunotherapies. Muscle Nerve 57: 927-931, 2018.
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Affiliation(s)
- Devin E Prior
- Department of Neuroscience, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Emily Nurre
- Department of Neuroscience, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Stephanie L Roller
- Department of Neuroscience, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - David Kline
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio, USA
| | - Ramit Panara
- Department of Neuroscience, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Amro M Stino
- Department of Neuroscience, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - John A Davis
- Department of Infectious Disease, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Miriam L Freimer
- Department of Neuroscience, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Department of Neurology, Division of Neuromuscular Medicine, The Ohio State University Wexner Medical Center, 395 West 12th Avenue Columbus, Ohio, 43210, USA
| | - W David Arnold
- Department of Neuroscience, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Department of Neurology, Division of Neuromuscular Medicine, The Ohio State University Wexner Medical Center, 395 West 12th Avenue Columbus, Ohio, 43210, USA.,Department of Physical Medicine and Rehabilitation, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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