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Myasthenia gravis: subgroup classification and therapeutic strategies. Lancet Neurol 2015; 14:1023-36. [DOI: 10.1016/s1474-4422(15)00145-3] [Citation(s) in RCA: 563] [Impact Index Per Article: 62.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 06/02/2015] [Accepted: 06/19/2015] [Indexed: 12/13/2022]
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Bembeeva RT, Zavadenko NN. [Intravenous immunoglobulin in treatment of autoimmune neurological diseases in children]. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:83-93. [PMID: 26356621 DOI: 10.17116/jnevro20151156183-93] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Though the mechanisms of action of intravenous immunoglobulins (IVIG) are not completely understood, these drugs are widely used in treatment of autoimmune diseases. In this review, we have analyzed the literature on the use of IVIG in the treatment of autoimmune diseases of the nervous system in children and discuss the management of patients basing on the recommendation of the European Federation of Neurological Societies. The efficacy of IVIG in children has been shown as first line treatment in Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, multifocal motor neuropathy, dermatomyositis as a second-line drug in the combination with prednisolone or immunosuppressors in patients refractory to treatment with corticosteroids and cytostatics, myasthenic crisis in myasthenia gravis, exacerbations and short-term treatment of severe forms, non-responsiveness to acetylcholinesterase inhibitors, multiple sclerosis as second or third line of treatment in patients with relapsing-remitting course with intolerance to standard immunomodulatory therapy, acute multiple encephalomyelitis with no response to the treatment with high doses of corticosteroids, paraneoplastic syndromes, pharmacoresistant epilepsy and autoimmune encephalitis. Because the right choice of the drug plays a key role, in particular, in children, that determines the efficacy and safety of the treatment, we present the main approaches to the choice of the drug and schemes of treatment of autoimmune diseases of the nervous system in children.
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Affiliation(s)
- R Ts Bembeeva
- Pirogov Russian National Research Medical University, Moscow
| | - N N Zavadenko
- Pirogov Russian National Research Medical University, Moscow
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154
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Miskovic R, Plavsic A, Peric-Popadic A, Raskovic S, Bogic M. Systemic Lupus Erythematosus and Secondary Antiphospholipid Syndrome after Thymectomy for Myasthenia Gravis - A Case Report. Open Access Maced J Med Sci 2015; 3:439-42. [PMID: 27275267 PMCID: PMC4877836 DOI: 10.3889/oamjms.2015.096] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 08/15/2015] [Accepted: 08/23/2015] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION: Systemic lupus erythematosus (SLE) and myasthenia gravis (MG) are autoimmune diseases that show some similarities: a higher incidence in young women, relapsing-remitting course and positive anti-nuclear antibodies (ANA). However, they are two different clinical syndromes, which can coexist or precede each other. Thymectomy is a therapeutic option for patients with severe MG or thymoma. There are many cases of SLE after thymectomy described in the literature, so the question arises whether thymectomy predisposes patients to SLE and what are imunopathogenetic mechanisms behind this process. CASE REPORT: We report a case of a patient who was diagnosed with SLE and secondary antiphospholipid syndrome (APS) 28 years after thymectomy for MG. Clinical picture of SLE was characterized by cutaneous and articular manifestations, polyserositis, lupus nephritis and immunological parameters showed positive ANA, anti-ds-DNA, excessive consumption of complement components, positive cryoglobulins. Clinical and laboratory immunological parameters for the diagnosis of secondary APS where also present. The patient was initially treated with glucocorticoids followed by mycophenolate mofetil. During one year follow-up patient was in a stable remission of SLE. CONCLUSION: Thymectomy for MG may predispose SLE development in some patients. Further studies are needed to better understand the connection between these two autoimmune diseases.
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Affiliation(s)
- Rada Miskovic
- Clinical Center of Serbia, Clinic for Allergology and Immunology, Belgrade, Serbia
| | - Aleksandra Plavsic
- Clinical Center of Serbia, Clinic for Allergology and Immunology, Belgrade, Serbia
| | | | - Sanvila Raskovic
- Clinical Center of Serbia, Clinic for Allergology and Immunology, Belgrade, Serbia
| | - Mirjana Bogic
- Clinical Center of Serbia, Clinic for Allergology and Immunology, Belgrade, Serbia
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Vrinten C, Lipka AF, van Zwet EW, Schimmel KJM, Cornel MC, Kuijpers MR, Hekster YA, Weinreich SS, Verschuuren JJGM. Ephedrine as add-on therapy for patients with myasthenia gravis: protocol for a series of randomised, placebo-controlled n-of-1 trials. BMJ Open 2015; 5:e007863. [PMID: 26185179 PMCID: PMC4513481 DOI: 10.1136/bmjopen-2015-007863] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Myasthenia gravis (MG), a rare neuromuscular disease, is often initially treated using acetylcholinesterase inhibitors. Patients who do not respond adequately depend on the use of corticosteroids or other immunosuppressive medication, but these may have serious side effects. Clinical observations suggest that ephedrine can diminish, postpone or even prevent the need for immunosuppressive therapy when added to acetylcholinesterase inhibitors or low-dose prednisone. In the Netherlands, ephedrine is not licensed for MG nor is reimbursement guaranteed. MG is a rare condition, and ephedrine might be indicated only in a subset of patients. Thus, randomised controlled trials comparing large groups are difficult to conduct. We, therefore, aim to aggregate data from a small series of n-of-1 trials (also known as single patient trials) to assess the effect of ephedrine as add-on treatment for MG. METHODS AND ANALYSIS Single-centre, placebo-controlled, double-blind, randomised, multiple crossover n-of-1 studies in 4 adult patients with generalised MG who show inadequate improvement on pyridostigmine and/or immunosuppressive drugs. Each n-of-1 trial has 3 cycles of two 5-day intervention periods. TREATMENT 25 mg ephedrine or placebo, twice daily. MAIN OUTCOME MEASURE Quantitative Myasthenia Gravis (QMG) test. STATISTICAL ANALYSIS fixed effects linear model for QMG for all patients combined. SECONDARY OUTCOME MEASURES Clinical: effects on MG-Composite and MG-Activities of Daily Living (MG-ADL) scales; QMG at individual level; adverse events. Acceptability of trial design: number of patients eligible and enrolled; number of treatment cycles completed; patients' and caregivers' experiences. ETHICS AND DISSEMINATION This study was approved by the Medical Ethics Committee of Leiden University Medical Center, No. P14.108. Results of the trial will be reported in a peer-reviewed publication. Regulatory stakeholders will comment on the suitability of the trial for market authorisation and reimbursement purposes. TRIAL REGISTRATION NUMBER This study is registered under EudraCT number 2014-001355-23, protocol no. 40960, V.1.0, registration date 27 March 2014.
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Affiliation(s)
- Charlotte Vrinten
- Department of Epidemiology and Public Health, University College London, London, UK
- Department of Clinical Genetics, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Alexander F Lipka
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik W van Zwet
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Kirsten J M Schimmel
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Martina C Cornel
- Department of Clinical Genetics, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Marja R Kuijpers
- Department of Care, Section Pharmaceutical Care, National Health Care Institute, Diemen, The Netherlands
| | - Yechiel A Hekster
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stephanie S Weinreich
- Department of Clinical Genetics, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
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156
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Abstract
Thymic malignancy is often associated with paraneoplastic neurological diseases (PNDs) and recognition of these disorders is important for physicians who treat these patients. The most common thymoma-associated PNDs are myasthenia gravis (MG), acquired neuromyotonia (Isaacs' syndrome), encephalitis, Morvan's syndrome, and myositis. Diagnosis of these disorders is complex but often aided by testing for specific autoantibodies, including those to the acetylcholine receptor for MG and to contactin-associated protein-like 2, protein of the voltage-gated potassium channel complex, in patients with acquired neuromyotonia, Morvan's syndrome, or encephalitis. Patients who manifest these disorders should be screened for thymoma at diagnosis, and worsening of these PNDs may be associated with recurrent thymoma. These disorders can cause profound disability but usually respond to immunotherapy, and often improve with thymoma treatment. Close cooperation among a team of specialists is required to take proper care of these patients.
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157
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Cruz JL, Wolff ML, Vanderman AJ, Brown JN. The emerging role of tacrolimus in myasthenia gravis. Ther Adv Neurol Disord 2015; 8:92-103. [PMID: 25922621 DOI: 10.1177/1756285615571873] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To describe and evaluate the available evidence assessing the role of tacrolimus in the management of patients with myasthenia gravis (MG). DATA SOURCES A literature search of MEDLINE (1946 to September 2014) and EMBASE (1947 to September 2014) was performed using the terms 'tacrolimus' and 'myasthenia gravis'. Citations of retrieved articles were examined for relevance. STUDY SELECTION AND DATA EXTRACTION The search was limited to prospective clinical trials focused on clinical outcomes in patients with generalized MG. Case reports, retrospective evaluations and non-English articles were excluded. DATA SYNTHESIS A total of 12 studies met inclusion criteria, of which seven articles evaluated tacrolimus in steroid-dependent patients and two examined the utility of tacrolimus in patients failing corticosteroids and cyclosporine. Other studies evaluated early initiation of tacrolimus after thymectomy, effectiveness of tacrolimus in de novo MG and the effectiveness of tacrolimus post-thymectomy in thymoma patients versus nonthymoma. A total of eight trials showed statistically significant improvements in quantitative MG score (QMGS) and postintervention status criteria - Myasthenia Gravis Foundation of America (PSC-MGFA). Of the trials examining steroid reduction with tacrolimus, two reported high rates of complete withdrawal; however, the most robust trial was unable to detect a difference in mean steroid dose. Long-term effects of tacrolimus (up to 5 years) were assessed in eight trials, which consistently showed positive effects on QMGS or reduction in adjunct therapies. CONCLUSIONS There is limited yet promising information to suggest a beneficial role for tacrolimus in reducing QMGS and corticosteroid burden in patients with refractory symptoms or new-onset MG. Long-term use appears to be safe in this population.
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Affiliation(s)
- Jennifer L Cruz
- Drug Information, Geriatric Research and Education Clinical Center, Durham VA Medical Center, 508 Fulton Street (119), Durham, NC 27705, USA
| | - Marissa L Wolff
- Geriatrics, Geriatric Research and Education Clinical Center, Durham VA Medical Center, Durham, NC, USA
| | - Adam J Vanderman
- Geriatrics, Geriatric Research and Education Clinical Center, Durham VA Medical Center, Durham, NC, USA
| | - Jamie N Brown
- Pharmacy Service, Durham VA Medical Center, Durham, NC, USA
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158
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Evoli A, Caliandro P, Iorio R, Alboini PE, Damato V, LaTorre G, Provenzano C, Marino M, Lauriola L, Scuderi F, Bartoccioni E. Poly-autoimmunity in patients with myasthenia gravis: A single-center experience. Autoimmunity 2015; 48:412-7. [PMID: 25868386 DOI: 10.3109/08916934.2015.1031890] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We evaluated the co-occurrence of autoimmune diseases (ADs) in a large population of myasthenia gravis (MG) patients from a single center. Our survey included 984 patients, 904 with anti-acetylcholine receptor antibodies and 80 with anti-muscle specific kinase antibodies. The anti-acetylcholine receptor positive population included patients with early-onset (age at onset ≤ 50 years), late-onset and thymoma-associated disease. Follow-up ranged 2-40 years. Two-hundred and fourteen ADs were diagnosed in 185 patients; 26 of them had two or more ADs in association with MG. Thyroid disorders were the most common and, together with vitiligo and thrombocytopenia, occurred in all disease subsets. Otherwise, there was a broad variability with partial overlap among patient groups. The highest rate of ADs was observed in early-onset patients, while clusters, i.e. 2 or more ADs other than MG in the same individual, were more common among thymoma cases. Thirty-four diseases were diagnosed at the same time, 88 occurred before and 92 after the onset of MG. On multivariate analysis, immunosuppressive treatment was the only independent variable which negatively influenced the risk of developing other ADs in our cohort.
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Affiliation(s)
- Amelia Evoli
- a Institute of Neurology, Catholic University , Rome , Italy
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159
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Ramos-Fransi A, Rojas-García R, Segovia S, Márquez-Infante C, Pardo J, Coll-Cantí J, Jericó I, Illa I. Myasthenia gravis: descriptive analysis of life-threatening events in a recent nationwide registry. Eur J Neurol 2015; 22:1056-61. [DOI: 10.1111/ene.12703] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 02/06/2015] [Indexed: 01/17/2023]
Affiliation(s)
- A. Ramos-Fransi
- Neuromuscular Disorders Unit; Neurology Department; Hospital de la Santa Creu i Sant Pau; Barcelona Spain
| | - R. Rojas-García
- Neuromuscular Disorders Unit; Neurology Department; Hospital de la Santa Creu i Sant Pau; Barcelona Spain
- Medicine Department; Universitat Autònoma de Barcelona (UAB); Barcelona Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER); Valencia Spain
| | - S. Segovia
- Neuromuscular Disorders Unit; Neurology Department; Hospital de la Santa Creu i Sant Pau; Barcelona Spain
| | - C. Márquez-Infante
- Department of Neurology and Neurophysiology; Hospital Universitario Virgen del Rocío; Sevilla Spain
| | - J. Pardo
- Department of Neurology; Hospital Clínico de Santiago; Santiago Spain
| | - J. Coll-Cantí
- Department of Neurology; Hospital Universitari Germans Trias i Pujol; Badalona Spain
| | - I. Jericó
- Department of Neurology; Complejo Hospitalario de Navarra; Pamplona Spain
| | - I. Illa
- Neuromuscular Disorders Unit; Neurology Department; Hospital de la Santa Creu i Sant Pau; Barcelona Spain
- Medicine Department; Universitat Autònoma de Barcelona (UAB); Barcelona Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER); Valencia Spain
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Burns TM, Sanders DB, Kaminski HJ, Wolfe GI, Narayanaswami P, Venitz J. Two steps forward, one step back: Mycophenolate mofetil treatment for myasthenia gravis in the united states. Muscle Nerve 2015; 51:635-7. [DOI: 10.1002/mus.24608] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 02/05/2015] [Accepted: 02/10/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Ted M. Burns
- University of Virginia; Department of Neurology; Charlottesville Virginia USA
| | | | | | - Gil I. Wolfe
- University of Buffalo; Dept of Neurology; Buffalo New York USA
| | - Pushpa Narayanaswami
- Beth Israel Deaconess Medical Center/Harvard Medical School; Boston Massachusetts USA
| | - Jurgen Venitz
- School of Pharmacy; Medical College of Virginia of Virginia Commonwealth; Richmond Virginia USA
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161
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Abstract
Isaacs syndrome is a peripheral nerve hyperexcitability (PNH) syndrome that presents as continuous motor activity. Clinical findings include cramps, fasciculations, and myokymia. Electrodiagnosis plays a key role in diagnosis by demonstrating after-discharges on nerve conduction studies, and fasciculation potentials, myokymic discharges, neuromyotonic discharges, and other types of abnormal spontaneous activity on needle examination. Etiopathogenesis involves the interaction of genetic, autoimmune, and paraneoplastic factors, which requires a broad-ranging evaluation for underlying causes. Initial treatment is symptomatic, but immune therapy is often needed and can be effective. The purpose of this review is to describe the syndrome and its pathogenesis, assist the reader in evaluating patients with suspected Isaacs syndrome and distinguishing it from other disorders of PNH, and suggest an approach to management, including both symptomatic and immunomodulating therapy.
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Affiliation(s)
- Aiesha Ahmed
- Department of Neurology, Penn State Hershey Medical Center, EC 037, 30 Hope Drive, Hershey, Pennsylvania, 17033, USA
| | - Zachary Simmons
- Department of Neurology, Penn State Hershey Medical Center, EC 037, 30 Hope Drive, Hershey, Pennsylvania, 17033, USA.,Department of Humanities, Penn State Hershey Medical Center, Hershey, Pennyslvania, USA
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Kadota Y, Horio H, Mori T, Sawabata N, Goto T, Yamashita SI, Nagayasu T, Iwasaki A. Perioperative management in myasthenia gravis: republication of a systematic review and a proposal by the guideline committee of the Japanese Association for Chest Surgery 2014. Gen Thorac Cardiovasc Surg 2015; 63:201-15. [PMID: 25608954 DOI: 10.1007/s11748-015-0518-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Indexed: 01/21/2023]
Abstract
Thymectomy is regarded as a useful therapeutic option for myasthenia gravis (MG), though perioperative management in MG patients is largely empirical. While evidence-based medicine is limited in the perioperative management of MG patients, treatment guidelines are required as a benchmark. We selected issues faced by physicians in clinical practice in the perioperative management of extended thymectomy for MG, and examined them with a review of the literature. The present guidelines have reached the stage of consensus within the Japanese Association for Chest Surgery.
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Affiliation(s)
- Yoshihisa Kadota
- Guidelines Committees of Japanese Association for Chest Surgery, Kyoto, Japan,
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Haroldsen PE, Garovoy MR, Musson DG, Zhou H, Tsuruda L, Hanson B, O'Neill CA. Genetic variation in aryl N-acetyltransferase results in significant differences in the pharmacokinetic and safety profiles of amifampridine (3,4-diaminopyridine) phosphate. Pharmacol Res Perspect 2014; 3:e00099. [PMID: 25692017 PMCID: PMC4317230 DOI: 10.1002/prp2.99] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 09/08/2014] [Accepted: 09/09/2014] [Indexed: 12/16/2022] Open
Abstract
The clinical use of amifampridine phosphate for neuromuscular junction disorders is increasing. The metabolism of amifampridine occurs via polymorphic aryl N-acetyltransferase (NAT), yet its pharmacokinetic (PK) and safety profiles, as influenced by this enzyme system, have not been investigated. The objective of this study was to assess the effect of NAT phenotype and genotype on the PK and safety profiles of amifampridine in healthy volunteers (N = 26). A caffeine challenge test and NAT2 genotyping were used to delineate subjects into slow and fast acetylators for PK and tolerability assessment of single, escalating doses of amifampridine (up to 30 mg) and in multiple daily doses (20 mg QID) of amifampridine. The results showed that fast acetylator phenotypes displayed significantly lower C max, AUC, and shorter t 1/2 for amifampridine than slow acetylators. Plasma concentrations of the N-acetyl metabolite were approximately twofold higher in fast acetylators. Gender differences were not observed. Single doses of amifampridine demonstrated dose linear PKs. Amifampridine achieved steady state plasma levels within 1 day of dosing four times daily. No accumulation or time-dependent changes in amifampridine PK parameters occurred. Overall, slow acetylators reported 73 drug-related treatment-emergent adverse events versus 6 in fast acetylators. Variations in polymorphic NAT corresponding with fast and slow acetylator phenotypes significantly affects the PK and safety profiles of amifampridine.
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Affiliation(s)
| | | | | | - Huiyu Zhou
- BioMarin Pharmaceutical Inc. Novato, California, 94949
| | | | - Boyd Hanson
- BioMarin Pharmaceutical Inc. Novato, California, 94949
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164
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Souza PVSD, Pinto WBVDR, Oliveira ASB. Clinical applications of immunoglobulin in neuromuscular diseases: focus on inflammatory myopathies. ARQUIVOS DE NEURO-PSIQUIATRIA 2014; 72:966-71. [PMID: 25465778 DOI: 10.1590/0004-282x20140160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 09/01/2014] [Indexed: 11/22/2022]
Abstract
UNLABELLED During recent years, an increasing number of neuromuscular diseases have been recognized either to be caused primarily by autoimmune mechanisms, or to have important autoimmune components. The involved pathophysiological mechanisms and clinical manifestations have been better recognized and many of these disorders are potentially treatable by immunosuppression or by immunomodulation with intravenous immunoglobulin (IVIg). IVIg has been tried in a variety of immune-mediated neurological diseases, being target of widespread use in central and peripheral nervous systems diseases. OBJECTIVE To give an overview of the main topics regarding the mechanism of action and different therapeutic uses of IVIg in neurological practice, mainly in neuromuscular diseases.
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Affiliation(s)
- Paulo Victor Sgobbi de Souza
- Divisão de Doencas Neuromusculares, Departamento de Neurologia e Neurocirurgia, Universidade Federal de São Paulo, SP, Brazil
| | | | - Acary Souza Bulle Oliveira
- Divisão de Doencas Neuromusculares, Departamento de Neurologia e Neurocirurgia, Universidade Federal de São Paulo, SP, Brazil
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165
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Heldal AT, Eide GE, Romi F, Owe JF, Gilhus NE. Repeated acetylcholine receptor antibody-concentrations and association to clinical myasthenia gravis development. PLoS One 2014; 9:e114060. [PMID: 25464006 PMCID: PMC4252099 DOI: 10.1371/journal.pone.0114060] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 11/03/2014] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION We aimed to examine the longitudinal association between Myasthenia Gravis (MG) clinical severity and concentration of acetylcholine receptor (AChR)-antibodies to evaluate if AChR-antibody variations correlate to disease severity. A positive AChR-antibody test is specific for MG. MATERIAL AND METHODS All patients from western Norway who had two or more AChR- antibody tests in the period 1983-2013 were identified. The Myasthenia Gravis Foundation of America (MGFA) Clinical Classification was used to grade disease development. Multiple ordinal logistic regression analysis was used to estimate a possible predictive effect for AChR-antibody concentration on MGFA classification result. RESULTS In 67 patients two or more AChR-antibody tests with a corresponding MGFA-score were performed, with a total of 309 tests. 56 patients were treated with immunosuppressive drugs and 11 by pyridostigmine only. There was a positive association between concentration of AChR-antibodies and longitudinal MGFA-score for the subgroup with immunosuppressive treatment, but not for those treated with pyridostigmine only. This association between AChR-antibody concentration and MGFA score declined with increasing time since onset (p = 0.005 for the interaction of group×time×concentration). CONCLUSIONS For MG patients with immunosuppressive treatment, repeated AChR-antibody measurements give information about clinical development, and can therefore be of support in therapeutic decisions.
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Affiliation(s)
| | - Geir Egil Eide
- Centre of Clinical Research, Haukeland University Hospital, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Fredrik Romi
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Jone Furlund Owe
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Nils Erik Gilhus
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
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166
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Lambert–Eaton myasthenic syndrome – Diagnosis, pathogenesis and therapy. Clin Neurophysiol 2014; 125:2328-36. [DOI: 10.1016/j.clinph.2014.06.031] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 06/05/2014] [Accepted: 06/26/2014] [Indexed: 02/07/2023]
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167
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Zhang Z, Guo J, Su G, Li J, Wu H, Xie X. Evaluation of the quality of guidelines for myasthenia gravis with the AGREE II instrument. PLoS One 2014; 9:e111796. [PMID: 25402504 PMCID: PMC4234220 DOI: 10.1371/journal.pone.0111796] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 10/07/2014] [Indexed: 12/21/2022] Open
Abstract
Background Clinical practice guidelines (CPGs) are systematically developed statements to assist practitioners in making decisions about appropriate healthcare in specific clinical circumstances. The methodological quality of CPGs for myasthenia gravis (MG) are unclear. Objective To critically evaluate the methodological quality of CPGs for MG using AGREE II instrument. Method A systematical search strategy on PubMed, EMBASE, DynaMed, the National Guideline Clearinghouse (NGC) and the Chinese Biomedical Literature database (CBM) was performed on September 20th 2013. All guidelines related to MG were evaluated with AGREE II. The software used for analysis was SPSS 17.0. Results A total of 15 CPGs for MG met the inclusion criteria (12 CPGs in English, 3 CPGs in Chinese). The overall agreement among reviews was moderate or high (ICC >0.70). The mean scores (mean ± SD) for al six domains were presented as follows: scope and purpose (60.93% ±16.62%), stakeholder involvement (40.93% ±20.04%), rigor of development (37.22% ±30.46%), clarity of presentation (64.26% ±16.36%), applicability (28.19% ±20.56%) and editorial independence (27.78% ±28.28%). Compared with non-evidence-based CPGs, evidence-based CPGs had statistically significant higher quality scores for all AGREE II domains (P<0.05). All domain scores appear slightly higher for CPGs published after AGREE II instrument development and validation (P>0.05). The quality scores of CPGs developed by NGC/AAN were higher than the quality scores of CPGs developed by other organizations for all domains. The difference was statistically significant for all domains with the exception of clarity of presentation (P = 0.07). Conclusions The qualities of CPGs on MG were generally acceptable with several flaws. The AGREE II instrument should be adopted by guideline developers, particularly in China.
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Affiliation(s)
- Zhenchang Zhang
- School of Basic Medical Sciences, Lanzhou University, Lanzhou, P. R. China
- Department of Neurology, The Second Hospital of Lanzhou University, Lanzhou, P. R. China
| | - Jia Guo
- Department of Neurology, The Second Hospital of Lanzhou University, Lanzhou, P. R. China
| | - Gang Su
- School of Basic Medical Sciences, Lanzhou University, Lanzhou, P. R. China
| | - Jiong Li
- School of Basic Medical Sciences, Lanzhou University, Lanzhou, P. R. China
| | - Hua Wu
- Department of Neurology, The Second Hospital of Lanzhou University, Lanzhou, P. R. China
| | - Xiaodong Xie
- School of Basic Medical Sciences, Lanzhou University, Lanzhou, P. R. China
- * E-mail:
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168
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Chemical shift and fat suppression magnetic resonance imaging of thymus in myasthenia gravis. Can J Neurol Sci 2014; 41:782-6. [PMID: 25385429 DOI: 10.1017/cjn.2014.104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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169
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Eienbröker C, Seitz F, Spengler A, Kurz H, Seipelt M, Sommer N, Oertel WH, Timmesfeld N, Tackenberg B. Intravenous immunoglobulin maintenance treatment in myasthenia gravis: A randomized, controlled trial sample size simulation. Muscle Nerve 2014; 50:999-1004. [DOI: 10.1002/mus.24259] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2014] [Indexed: 11/06/2022]
Affiliation(s)
- Christian Eienbröker
- Clinical Neuroimmunology Group; Department of Neurology; Philipps University; Baldingerstrasse 1 D-35043 Marburg Germany
| | - Florian Seitz
- Clinical Neuroimmunology Group; Department of Neurology; Philipps University; Baldingerstrasse 1 D-35043 Marburg Germany
| | - Anna Spengler
- Clinical Neuroimmunology Group; Department of Neurology; Philipps University; Baldingerstrasse 1 D-35043 Marburg Germany
| | - Heike Kurz
- Clinical Neuroimmunology Group; Department of Neurology; Philipps University; Baldingerstrasse 1 D-35043 Marburg Germany
| | - Maria Seipelt
- Clinical Neuroimmunology Group; Department of Neurology; Philipps University; Baldingerstrasse 1 D-35043 Marburg Germany
| | - Norbert Sommer
- Department of Neurology; Klinikum Christophsbad; Göppingen Germany
| | - Wolfgang H. Oertel
- Clinical Neuroimmunology Group; Department of Neurology; Philipps University; Baldingerstrasse 1 D-35043 Marburg Germany
| | - Nina Timmesfeld
- Institute for Medical Biometry and Epidemiology; Philipps University; Marburg Germany
| | - Björn Tackenberg
- Clinical Neuroimmunology Group; Department of Neurology; Philipps University; Baldingerstrasse 1 D-35043 Marburg Germany
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170
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Gilhus NE, Nacu A, Andersen JB, Owe JF. Myasthenia gravis and risks for comorbidity. Eur J Neurol 2014; 22:17-23. [PMID: 25354676 DOI: 10.1111/ene.12599] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 09/19/2014] [Indexed: 01/21/2023]
Abstract
Myasthenia gravis (MG) is an autoimmune disorder leading to skeletal muscle weakness and fatigability. MG subgroups are defined according to pathogenetic autoantibody (against acetylcholine receptor, muscle-specific tyrosine kinase or lipoprotein receptor-related protein 4), thymus pathology and clinical manifestations. MG patients have an increased risk for concordant autoimmune disease, in particular with early onset MG. Most common comorbidities are thyroid disease, systemic lupus erythematosus and rheumatoid arthritis. Cardiomyositis and subclinical heart dysfunction have been described in patients with thymoma MG and late onset MG but represent no major threat. A thymic lymphoepithelioma implies an increased risk for another cancer. Autoimmune MG represents no distinct cancer risk factor, although lymphomas and a few other cancer types have been reported with slightly increased frequency. Severe MG-related muscle weakness means a risk for respiratory failure and respiratory tract infection. Drug MG treatment can lead to side-effects. Thymectomy is regarded as a safe procedure both short and long term. Non-MG-related comorbidity represents a diagnostic and therapeutic challenge, especially in elderly patients. Diagnostic accuracy and optimal follow-up is necessary to identify and treat all types of coexisting disease in MG.
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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
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171
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Alabdali M, Barnett C, Katzberg H, Breiner A, Bril V. Intravenous immunoglobulin as treatment for myasthenia gravis: current evidence and outcomes. Expert Rev Clin Immunol 2014; 10:1659-65. [PMID: 25331319 DOI: 10.1586/1744666x.2014.971757] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
We examined the current evidence for the efficacy of IV immunoglobulin (IVIG) in myasthenia gravis (MG) and the outcomes used to demonstrate this efficacy. There is class 1 evidence for the use of short-term IVIG in MG patients worsening MG and also good evidence for IVIG use in myasthenic crisis. For long-term maintenance therapy, controlled studies are lacking and the evidence is limited to class III retrospective studies. The clinical scales, serological, electrophysiological, and patient-reported quality of life outcomes with IVIG have been assessed. At this time, the quantitative myasthenia gravis score, a functional scale, remains the preferable outcome measure as it has demonstrated responsiveness in the clinical trial setting, but a scale incorporating patient-reported outcomes and the patients complaint of fatigue is likely to be preferable. The MG-composite is such a scale, but has measurement limitations that may reduce its sensitivity. Across trials, IVIG has generally been well tolerated.
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Affiliation(s)
- Majed Alabdali
- Division of Neurology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth St, Toronto, Ontario, M5A 4H9, Canada
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172
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Iorio R, Damato V, Alboini PE, Evoli A. Efficacy and safety of rituximab for myasthenia gravis: a systematic review and meta-analysis. J Neurol 2014; 262:1115-9. [PMID: 25308632 DOI: 10.1007/s00415-014-7532-3] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 10/03/2014] [Accepted: 10/04/2014] [Indexed: 12/14/2022]
Abstract
Myasthenia gravis is an autoimmune disorder of the neuromuscular junction caused by circulating antibodies specific for the post-synaptic acetylcholine receptor or, in a minority of cases, for the muscle-specific tyrosine-kinase and the low-density lipoprotein receptor-related protein 4. A wide range of symptomatic and immunosuppressive treatments is currently available for MG patients with variable outcome. However, most immunosuppressive treatments are characterized by delayed onset of action and in some cases are not sufficient to induce stable remission of the disease. Rituximab (RTX) is a chimaeric monoclonal antibody specific for the CD20 B-cell surface antigen. Recent studies have provided evidence that RTX may be an effective treatment for patients with myasthenia gravis (MG) who are refractory to standardized immunosuppressive therapy. We performed a systematic review and a meta-analysis of the efficacy and safety of RTX in myasthenia gravis considering the potential predictive factors related to patients' response to RTX in this disease.
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173
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Szczudlik P, Szyluk B, Lipowska M, Ryniewicz B, Kubiszewska J, Dutkiewicz M, Gilhus NE, Kostera-Pruszczyk A. Antititin antibody in early- and late-onset myasthenia gravis. Acta Neurol Scand 2014; 130:229-33. [PMID: 24947881 DOI: 10.1111/ane.12271] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Myasthenia gravis (MG) is an autoimmune disease caused by antibodies against neuromuscular junction proteins, 85% of patients have antibodies against acetylcholine receptor (AChR-MG). Antititin antibodies are present in a subset of patients with MG. We aimed to determine the value of antititin antibodies as severity markers and thymoma predictors in early- and late-onset MG. MATERIALS & METHODS Two-hundred and ninety-five consecutive MG patients (188 F and 107 M) aged 12-89 years (mean 50y) were included. 164 patients had early-onset (EOMG, ≤50 years of age), 131 had late-onset MG (LOMG). Twenty-six patients had thymoma. symptoms, severity graded with MGFA scale, thymus histology, medications, and treatment results were analyzed. RESULTS Antititin antibodies were present in 81 (27%) of all patients: 54% of thymoma MG, 0.6% of non-thymomatous EOMG, and 55% of LOMG, with proportion of titin-positive patients increasing linearly from 40% in the 6th to 88% in the 9th decade of life. Titin-positive patients had more bulbar symptoms (P = 0.003). Severity of MG, need for immunosuppression, myasthenic crisis risk or treatment results were not related to its presence. Antititin antibodies had 56% sensitivity, 99% specificity, 90% positive predictive value (PPV), and 95% negative predictive value (NPV) for thymoma diagnosis in EOMG, and 50% sensitivity, 75% specificity, 71% PPV and 55% NPV in LOMG. CONCLUSIONS Antititin antibodies have high PPV and NPV for thymoma in EOMG. In MG without thymoma, antititin antibodies can be considered as markers of LOMG, but not of a severe course in our MG cohort.
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Affiliation(s)
- P. Szczudlik
- Department of Neurology; Medical University of Warsaw; Warsaw Poland
| | - B. Szyluk
- Department of Neurology; Medical University of Warsaw; Warsaw Poland
| | - M. Lipowska
- Department of Neurology; Medical University of Warsaw; Warsaw Poland
| | - B. Ryniewicz
- Department of Neurology; Medical University of Warsaw; Warsaw Poland
| | - J. Kubiszewska
- Department of Neurology; Medical University of Warsaw; Warsaw Poland
| | - M. Dutkiewicz
- Department of Immunology, Biochemistry and Nutrition; Medical University of Warsaw; Warsaw Poland
| | - N. E. Gilhus
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
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174
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Hoffmann S, Kohler S, Ziegler A, Meisel A. Glucocorticoids in myasthenia gravis - if, when, how, and how much? Acta Neurol Scand 2014; 130:211-21. [PMID: 25069701 DOI: 10.1111/ane.12261] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2014] [Indexed: 12/16/2022]
Abstract
Glucocorticoids (GC) are the most commonly used immune-directed therapy in myasthenia gravis (MG). However, to date, GC have not proven their effectiveness in the setting of a randomized clinical trial that complies with currently accepted standards. The rationale for the use of GC in MG is the autoimmune nature of the disease, which is supported by consistent positive results from retrospective studies. Well-defined recommendations for treatment of MG with GC are lacking and further hampered by inter- and intra-individual differences in the disease course and responses to GC treatment. Uncertainties concerning GC treatment in MG encompass the indication for treatment initiation, exact dosage, dose adjustment in specific conditions (e.g., pregnancy, thymectomy), mode of tapering, and surveillance of adverse events (AE). This review illustrates the mode of action of GC in the treatment for MG, presents the currently available data on GC treatment in MG, and attempts to translate the currently available information into clinical recommendations.
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Affiliation(s)
- S. Hoffmann
- Department of Neurology; Charite - Universitätsmedizin; Berlin Germany
- NeuroCure Clinical Research Center; Charite - Universitätsmedizin; Berlin Germany
| | - S. Kohler
- Department of Neurology; Charite - Universitätsmedizin; Berlin Germany
- NeuroCure Clinical Research Center; Charite - Universitätsmedizin; Berlin Germany
| | - A. Ziegler
- Department of Neurology; Charite - Universitätsmedizin; Berlin Germany
| | - A. Meisel
- Department of Neurology; Charite - Universitätsmedizin; Berlin Germany
- NeuroCure Clinical Research Center; Charite - Universitätsmedizin; Berlin Germany
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175
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Prognostic factors of remission in myasthenia gravis after thymectomy. Eur J Cardiothorac Surg 2014; 48:18-24. [DOI: 10.1093/ejcts/ezu309] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 07/07/2014] [Indexed: 01/05/2023] Open
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176
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Marino M, Maiuri MT, Di Sante G, Scuderi F, La Carpia F, Trakas N, Provenzano C, Zisimopoulou P, Ria F, Tzartos SJ, Evoli A, Bartoccioni E. T cell repertoire in DQ5-positive MuSK-positive myasthenia gravis patients. J Autoimmun 2014; 52:113-21. [DOI: 10.1016/j.jaut.2013.12.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Accepted: 12/08/2013] [Indexed: 11/26/2022]
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177
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Fitzgerald MG, Shafritz AB. Distal myasthenia gravis. J Hand Surg Am 2014; 39:1419-20. [PMID: 24559760 DOI: 10.1016/j.jhsa.2013.12.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 12/04/2013] [Accepted: 12/22/2013] [Indexed: 02/02/2023]
Affiliation(s)
- Michael G Fitzgerald
- Department of Orthopaedic Surgery, University of Vermont College of Medicine Burlington, Vermont
| | - Adam B Shafritz
- Department of Orthopaedic Surgery, University of Vermont College of Medicine Burlington, Vermont.
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178
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Priola A, Priola S. Imaging of thymus in myasthenia gravis: From thymic hyperplasia to thymic tumor. Clin Radiol 2014; 69:e230-45. [DOI: 10.1016/j.crad.2014.01.005] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 01/07/2014] [Accepted: 01/08/2014] [Indexed: 01/17/2023]
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179
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Johnson DB, Saranga-Perry V, Lavin PJM, Burnette WB, Clark SW, Uskavitch DR, Wallace DE, Dickson MA, Kudchadkar RR, Sosman JA. Myasthenia Gravis Induced by Ipilimumab in Patients With Metastatic Melanoma. J Clin Oncol 2014; 33:e122-4. [PMID: 24778401 DOI: 10.1200/jco.2013.51.1683] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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180
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Andersen JB, Owe JF, Engeland A, Gilhus NE. Total drug treatment and comorbidity in myasthenia gravis: a population-based cohort study. Eur J Neurol 2014; 21:948-55. [PMID: 24712740 PMCID: PMC4238850 DOI: 10.1111/ene.12439] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 03/06/2014] [Indexed: 11/29/2022]
Abstract
Background and purpose Comorbidity in myasthenia gravis (MG) is important for diagnosis, treatment and prognosis. Disease complexity was assessed by examining total drug treatment, immune therapy and comorbidity in a complete national MG cohort. Methods All recipients of the MG-specific drug pyridostigmine 2004–2010 registered in the compulsory Norwegian Prescription Database who met the inclusion criteria were included. The pyridostigmine group was compared with the general Norwegian population. Results Myasthenia gravis patients received co-medication more often than the controls for nearly all groups of medication, including insulins (95% confidence interval 2.0–3.7), thyroid therapy (1.7–2.5), antidepressants (1.3–1.7), anti-infectives (1.2–1.4), lipid-modifying agents (1.1–1.4) and immunomodulating agents (6.8–8.8). Conclusions Myasthenia gravis patients are more often treated with non-MG prescription drugs than controls, reflecting frequent co-medication and comorbidity.
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Affiliation(s)
- J B Andersen
- Department of Clinical Medicine, Section for Neurology, University of Bergen, Bergen, Norway
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181
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Lindquist S, Stangel M. 3,4-Diaminopyridine (amifampridine) for the treatment of Lambert–Eaton myasthenic syndrome. Expert Opin Orphan Drugs 2014. [DOI: 10.1517/21678707.2014.887464] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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182
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Fleisher J, Richie M, Price R, Scherer S, Dalmau J, Lancaster E. Acquired neuromyotonia heralding recurrent thymoma in myasthenia gravis. JAMA Neurol 2014; 70:1311-4. [PMID: 23978943 DOI: 10.1001/jamaneurol.2013.2863] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
IMPORTANCE Acquired neuromyotonia is increasingly recognized as an autoimmune disorder, frequently associated with antibodies against voltage-gated potassium channel complex proteins.We present a case of acquired neuromyotonia as the heralding symptom of recurrent thymoma in a patient with myasthenia gravis. OBSERVATIONS A report of a single case of a 53-year-old man with myasthenia gravis and a prior thymectomy presenting with 2 months of diffuse, involuntary muscle twitching in the absence of myasthenic symptoms, electrophysiologically confirmed to be neuromyotonia. Further evaluation revealed the recurrence of malignant thymoma, accompanied by refractory arrhythmia. Serologic and cerebrospinal fluid testing confirmed the presence of antibodies directed against 2 voltage-gated potassium channel–associated proteins: LGI1 and Caspr2. CONCLUSIONS AND RELEVANCE This case highlights the overlap of myasthenia, neuromyotonia, and thymoma, emphasizing the importance of appropriate tumor screening in the presence of either of the former 2 conditions.
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183
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184
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Godoy DA, Mello LJVD, Masotti L, Di Napoli M. The myasthenic patient in crisis: an update of the management in Neurointensive Care Unit. ARQUIVOS DE NEURO-PSIQUIATRIA 2014; 71:627-39. [PMID: 24141444 DOI: 10.1590/0004-282x20130108] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 04/10/2013] [Indexed: 11/21/2022]
Abstract
Myasthenia gravis (MG) is an autoimmune disorder affecting neuromuscular transmission leading to generalized or localized muscle weakness due most frequently to the presence of autoantibodies against acetylcholine receptors in the postsynaptic motor end-plate. Myasthenic crisis (MC) is a complication of MG characterized by worsening muscle weakness, resulting in respiratory failure that requires intubation and mechanical ventilation. It also includes postsurgical patients, in whom exacerbation of muscle weakness from MG causes a delay in extubation. MC is a very important, serious, and reversible neurological emergency that affects 20-30% of the myasthenic patients, usually within the first year of illness and maybe the debut form of the disease. Most patients have a predisposing factor that triggers the crisis, generally an infection of the respiratory tract. Immunoglobulins, plasma exchange, and steroids are the cornerstones of immunotherapy. Today with the modern neurocritical care, mortality rate of MC is less than 5%.
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185
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Ghazanfari N, Morsch M, Tse N, Reddel SW, Phillips WD. Effects of the ß2-adrenoceptor agonist, albuterol, in a mouse model of anti-MuSK myasthenia gravis. PLoS One 2014; 9:e87840. [PMID: 24505322 PMCID: PMC3914858 DOI: 10.1371/journal.pone.0087840] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 12/31/2013] [Indexed: 11/19/2022] Open
Abstract
The β2-adrenergic receptor agonist, albuterol, has been reported beneficial in treating several forms of congenital myasthenia. Here, for the first time, we examined the potential benefit of albuterol in a mouse model of anti-Muscle Specific Kinase (MuSK) myasthenia gravis. Mice received 15 daily injections of IgG from anti-MuSK positive patients, which resulted in whole-body weakness. At neuromuscular junctions in the tibialis anterior and diaphragm muscles the autoantibodies caused loss of postsynaptic acetylcholine receptors, and reduced the amplitudes of the endplate potential and spontaneous miniature endplate potential in the diaphragm muscle. Treatment with albuterol (8 mg/kg/day) during the two-week anti-MuSK injection series reduced the degree of weakness and weight loss, compared to vehicle-treated mice. However, the compound muscle action potential recorded from the gastrocnemius muscle displayed a decremental response in anti-MuSK-injected mice whether treated with albuterol or vehicle. Ongoing albuterol treatment did not increase endplate potential amplitudes compared to vehicle-treated mice nor did it prevent the loss of acetylcholine receptors from motor endplates. On the other hand, albuterol treatment significantly reduced the degree of fragmentation of endplate acetylcholine receptor clusters and increased the extent to which the remaining receptor clusters were covered by synaptophysin-stained nerve terminals. The results provide the first evidence that short-term albuterol treatment can ameliorate weakness in a robust mouse model of anti-MuSK myasthenia gravis. The results also demonstrate that it is possible for albuterol treatment to reduce whole-body weakness without necessarily reversing myasthenic impairment to the structure and function of the neuromuscular junction.
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MESH Headings
- Adrenergic beta-2 Receptor Agonists/pharmacology
- Albuterol/pharmacology
- Animals
- Autoantibodies/immunology
- Autoantibodies/toxicity
- Female
- Humans
- Mice
- Muscle, Skeletal/immunology
- Muscle, Skeletal/pathology
- Myasthenia Gravis, Autoimmune, Experimental/chemically induced
- Myasthenia Gravis, Autoimmune, Experimental/drug therapy
- Myasthenia Gravis, Autoimmune, Experimental/immunology
- Myasthenia Gravis, Autoimmune, Experimental/pathology
- Neuromuscular Junction/immunology
- Neuromuscular Junction/pathology
- Receptor Protein-Tyrosine Kinases/immunology
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Affiliation(s)
- Nazanin Ghazanfari
- Physiology and Bosch Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Marco Morsch
- Physiology and Bosch Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Nigel Tse
- Physiology and Bosch Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Stephen W. Reddel
- Department of Molecular Medicine, Concord Hospital, Concord, New South Wales, Australia
| | - William D. Phillips
- Physiology and Bosch Institute, University of Sydney, Sydney, New South Wales, Australia
- * E-mail:
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186
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Kerty E, Elsais A, Argov Z, Evoli A, Gilhus NE. EFNS/ENS Guidelines for the treatment of ocular myasthenia. Eur J Neurol 2014; 21:687-93. [PMID: 24471489 DOI: 10.1111/ene.12359] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 12/17/2013] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND PURPOSE The symptoms of acquired autoimmune ocular myasthenia are restricted to the extrinsic eye muscles, causing double vision and drooping eyelids. These guidelines are designed to provide advice about best clinical practice based on the current state of clinical and scientific knowledge and the consensus of an expert panel. SEARCH STRATEGY Evidence for these guidelines was collected by searches in the MEDLINE and Cochrane databases. The task force working group reviewed evidence from original articles and systematic reviews. The evidence was classified (I, II, III, IV) and consensus recommendation graded (A, B or C) according to the EFNS guidance. Where there was a lack of evidence but clear consensus, good practice points are provided. CONCLUSIONS The treatment of ocular myasthenia should initially be started with pyridostigmine (good practice point). If this is not successful in relieving symptoms, oral corticosteroids should be used on an alternate-day regimen (recommendation level C). If steroid treatment does not result in good control of the symptoms or if it is necessary to use high steroid doses, steroid-sparing treatment with azathioprine should be started (recommendation level C). If ocular myasthenia gravis is associated with thymoma, thymectomy is indicated. Otherwise, the role of thymectomy in ocular myasthenia is controversial. Steroids and thymectomy may modify the course of ocular myasthenia and prevent myasthenia gravis generalization (good practice point).
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Affiliation(s)
- E Kerty
- Department of Neurology, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
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187
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Park KA, Oh SY. Current treatment for ocular myasthenia gravis. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/17469899.2013.851003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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188
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Intravenous immunoglobulin for prophylaxis of acute exacerbation in Myasthenia Gravis. Neurol Sci 2014; 35:891-6. [DOI: 10.1007/s10072-013-1621-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 12/24/2013] [Indexed: 11/25/2022]
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189
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Yi JS, Guidon A, Sparks S, Osborne R, Juel VC, Massey JM, Sanders DB, Weinhold KJ, Guptill JT. Characterization of CD4 and CD8 T cell responses in MuSK myasthenia gravis. J Autoimmun 2013; 52:130-8. [PMID: 24378287 DOI: 10.1016/j.jaut.2013.12.005] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Accepted: 12/08/2013] [Indexed: 01/22/2023]
Abstract
Muscle specific tyrosine kinase myasthenia gravis (MuSK MG) is a form of autoimmune MG that predominantly affects women and has unique clinical features, including prominent bulbar weakness, muscle atrophy, and excellent response to therapeutic plasma exchange. Patients with MuSK MG have predominantly IgG4 autoantibodies directed against MuSK on the postsynaptic muscle membrane. Lymphocyte functionality has not been reported in this condition. The goal of this study was to characterize T cell responses in patients with MuSK MG. Intracellular production of IFN-gamma, TNF-alpha, IL-2, IL-17, and IL-21 by CD4+ and CD8+ T cells was measured by polychromatic flow cytometry in peripheral blood samples from 11 Musk MG patients and 10 healthy controls. Only one MuSK MG patient was not receiving immunosuppressive therapy. Regulatory T cells (Treg) were also included in our analysis to determine if changes in T cell function were due to altered Treg frequencies. CD8+ T cells from MuSK MG patients had higher frequencies of polyfunctional responses than controls, and CD4+ T cells had higher IL-2, TNF-alpha, and IL-17. MuSK MG patients had a higher percentage of CD4+ T cells producing combinations of IFN-gamma/IL-2/TNF-gamma, TNF-alpha/IL-2, and IFN-gamma/TNF-alpha. Interestingly, Treg numbers and CD39 expression were not different from control values. MuSK MG patients had increased frequencies of Th1 and Th17 cytokines and were primed for polyfunctional proinflammatory responses that cannot be explained by a defect in CD39 expression or Treg number.
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Affiliation(s)
- J S Yi
- Division of Surgical Sciences, Department of Surgery, Duke University Medical Center, 204 SORF (Bldg. 41), 915 S. LaSalle Street, Box 2926, Durham, NC 27710, USA
| | - A Guidon
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, DUMC Box 3403, Durham, NC 27710, USA
| | - S Sparks
- Division of Surgical Sciences, Department of Surgery, Duke University Medical Center, 204 SORF (Bldg. 41), 915 S. LaSalle Street, Box 2926, Durham, NC 27710, USA
| | - R Osborne
- Division of Surgical Sciences, Department of Surgery, Duke University Medical Center, 204 SORF (Bldg. 41), 915 S. LaSalle Street, Box 2926, Durham, NC 27710, USA
| | - V C Juel
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, DUMC Box 3403, Durham, NC 27710, USA
| | - J M Massey
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, DUMC Box 3403, Durham, NC 27710, USA
| | - D B Sanders
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, DUMC Box 3403, Durham, NC 27710, USA
| | - K J Weinhold
- Division of Surgical Sciences, Department of Surgery, Duke University Medical Center, 204 SORF (Bldg. 41), 915 S. LaSalle Street, Box 2926, Durham, NC 27710, USA
| | - J T Guptill
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, DUMC Box 3403, Durham, NC 27710, USA.
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190
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Pedersen EG, Pottegård A, Hallas J, Friis S, Hansen K, Jensen PEH, Gaist D. Risk of non-melanoma skin cancer in myasthenia patients treated with azathioprine. Eur J Neurol 2013; 21:454-8. [DOI: 10.1111/ene.12329] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 11/18/2013] [Indexed: 02/03/2023]
Affiliation(s)
- E. G. Pedersen
- Department of Neurology; Faculty of Health Sciences; Odense University Hospital and Institute of Clinical Research; University of Southern Denmark (SDU); Odense Denmark
| | - A. Pottegård
- Institute of Public Health, Clinical Pharmacology; SDU; Odense Denmark
| | - J. Hallas
- Institute of Public Health, Clinical Pharmacology; SDU; Odense Denmark
| | - S. Friis
- Danish Cancer Society Research Centre and Department of Public Health; University of Copenhagen; Copenhagen Denmark
| | - K. Hansen
- Department of Neurology; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - P. E. H. Jensen
- Neuroimmunology Laboratory; DMSC; Department of Neurology; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - D. Gaist
- Department of Neurology; Faculty of Health Sciences; Odense University Hospital and Institute of Clinical Research; University of Southern Denmark (SDU); Odense Denmark
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191
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Abstract
Ocular myasthenia gravis, although clinically often characterized by typical classical features, can cause considerable diagnostic problems. This article aims to provide a pragmatic approach to the pathogenesis, clinical features, diagnostics and therapeutic strategies in the clinical routine.
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Affiliation(s)
- S Pitz
- Augenklinik der Universitätsmedizin, Johannes Gutenberg-Universität, Langenbeckstr. 1, 55131 Mainz.
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192
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Haider B, von Oertzen J. Neurological disorders. Best Pract Res Clin Obstet Gynaecol 2013; 27:867-75. [DOI: 10.1016/j.bpobgyn.2013.07.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 07/25/2013] [Indexed: 10/26/2022]
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193
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Abstract
PURPOSE OF REVIEW Juvenile myasthenia gravis is a relatively rare autoimmune neuromuscular disorder. The pathophysiology of juvenile myasthenia gravis is similar to that of adult myasthenia gravis, though there remain important differences regarding presentation and therapeutic options. We review the pathophysiology, clinical presentation, and treatment options for juvenile myasthenia gravis. RECENT FINDINGS Randomized clinical studies of myasthenia gravis have been carried out primarily in adult populations. As juvenile myasthenia gravis is rare, it has been difficult to collect prospective randomized controlled data to evaluate treatment outcomes and efficacy. A recent retrospective series suggests that, as in adult myasthenia gravis, thymectomy is a viable therapeutic option for selected cases of generalized juvenile myasthenia gravis. This is corroborated by the clinical experience of the authors in a referral center with a cohort of patients affected by juvenile myasthenia gravis over a number of years. SUMMARY Recent studies illustrate that some, but not all, adult research on myasthenia gravis is applicable to children and adolescents with juvenile myasthenia gravis. Adult research can inform pediatric studies, but should not be regarded as a substitute for dedicated research in those populations.
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194
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Abstract
Myasthenia gravis (MG) is a chronic neuromuscular disorder characterized by fluctuating skeletal muscle weakness and fatigue. This rare autoimmune condition can present a diagnostic challenge for the advanced practice nurse (APN). Because of its low incidence in clinical practice and frequently unrecognized symptoms, a delay of 1 to 2 years prior to diagnosis is not uncommon. Recognition of the clinical features is a key component of prompt diagnosis. To avoid delay in treatment, APNs should be aware of variations in MG symptoms and the tools used to confirm a suspected diagnosis. Because patients benefit from the care of neuromuscular specialists, APNs are not expected to be experts within MG treatment. But knowledge of general treatment principles affords the APN an opportunity to collaborate with the neuromuscular specialist to provide care for patients with MG. Using an individual example, this article reviews the experience of an older adult with MG from clinical presentation through treatment.
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195
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Ariatti A, Stefani M, Miceli P, Benuzzi F, Galassi G. Prognostic factors and health-related quality of life in ocular Myasthenia Gravis (OMG). Int J Neurosci 2013; 124:427-35. [PMID: 24228829 DOI: 10.3109/00207454.2013.853664] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We evaluate the factors predictive of prognosis in 91 Caucasian patients affected by ocular myasthenia gravis (OMG), followed at our Institution during an observational time, ranging from 12 to 240 months. The Myasthenia Gravis Foundation of America (MGFA) clinical classification was used to grade the disease severity. We considered as outcome measures the variation in two subscores, ocular (O-QMG) and nonocular (NO-QMG); the last one reflected bulbar, neck, extremity functions. None of the independent variables evaluated for association with the outcome, as age of onset, type of therapy, length of interval between first and last examinations, and presence of antibodies to acetylcholine receptors (AChR-Abs) significantly affected the evolution of O-QMG and of NO-QMG. Health-related quality of life (HRQol) was assessed in 63 patients. Variations of diplopia or ptosis did not affect significantly physical (PCS) or mental composite subscores (MCS) of the Short-Form Health Survey (SF-36). Human leukocyte antigen (HLA) genotyping was studied to explore whether HLA class I and II allelic distribution differed among MG patients and controls. None of the studied HLA alleles significantly differed between OMG patients and controls. Similarly, none of the alleles with frequencies higher than 15% either in OMG patients or in controls was significantly associated, after Bonferroni correction, with the presence or absence of anti-AChR-Abs in serum.
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Affiliation(s)
- Alessandra Ariatti
- Department of Neurosciences, and Department of Onco-Haematology, University Hospitals of Modena & Reggio Emilia , Italy
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196
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Alkhawajah NM, Oger J. Late-onset myasthenia gravis: A review when incidence in older adults keeps increasing. Muscle Nerve 2013; 48:705-10. [DOI: 10.1002/mus.23964] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2013] [Indexed: 01/26/2023]
Affiliation(s)
- Nuha M. Alkhawajah
- Division of Neurology, Department of Medicine and Brain Research Centre, UBC Hospital; University of British Columbia; 2211 Westbrook Mall Vancouver British Columbia V6T 2B5 Canada
| | - Joel Oger
- Division of Neurology, Department of Medicine and Brain Research Centre, UBC Hospital; University of British Columbia; 2211 Westbrook Mall Vancouver British Columbia V6T 2B5 Canada
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197
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Lewis RA. Myasthenia gravis: New therapeutic approaches based on pathophysiology. J Neurol Sci 2013; 333:93-8. [DOI: 10.1016/j.jns.2013.06.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 06/16/2013] [Accepted: 06/18/2013] [Indexed: 01/14/2023]
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198
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Therapeutic plasma exchange in treatment of neuroimmunologic disorders: Review of 92 cases. Transfus Apher Sci 2013; 49:174-80. [DOI: 10.1016/j.transci.2013.02.043] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Revised: 12/19/2012] [Accepted: 02/13/2013] [Indexed: 11/18/2022]
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200
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Antoine JC, Camdessanché JP. Paraneoplastic disorders of the peripheral nervous system. Presse Med 2013; 42:e235-44. [DOI: 10.1016/j.lpm.2013.01.059] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 12/16/2012] [Accepted: 01/07/2013] [Indexed: 11/28/2022] Open
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