351
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Yanagidaira M, Nishida Y, Yokota T. Temporal correlation between serum CH 50 level and symptom severity of myasthenia gravis during eculizumab therapy. Clin Neurol Neurosurg 2019; 189:105630. [PMID: 31830679 DOI: 10.1016/j.clineuro.2019.105630] [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] [Received: 09/27/2019] [Revised: 11/27/2019] [Accepted: 11/30/2019] [Indexed: 12/11/2022]
Abstract
The correlation between serum 50 % hemolytic complement (CH50) level and myasthenic symptom severity has not been known in patients with anti-acetylcholine receptor (anti-AChR)-positive myasthenia gravis (MG) during eculizumab treatment. A patient with anti-AChR-positive MG showed severe bulbar symptoms. Eculizumab administration decreased CH50 level and improved the symptoms. However, shortly after the second administration of eculizumab was postponed due to the development of pneumonia, his serum CH50 level returned almost to the level it was at before the initiation of eculizumab therapy and myasthenic symptoms worsened. Even after his pneumonia was completely cleared in response to an antibiotic, the severe myasthenic symptoms persisted. After eculizumab was resumed, serum CH50 level was reduced to below the limit of detection within 24 h, and the symptom steadily improved. His symptom severity was correlated temporally with serum CH50 level during eculizumab therapy. Our case suggests that serum CH50 level may be a marker of eculizumab-induced complement blockade and an indicator of a potential worsening of myasthenic symptoms during eculizumab treatment.
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Affiliation(s)
- Mitsugu Yanagidaira
- Department of Neurology and Neurological Sciences, Tokyo Medical and Dental University, Graduate School of Medical and Dental Sciences, Japan
| | - Yoichiro Nishida
- Department of Neurology and Neurological Sciences, Tokyo Medical and Dental University, Graduate School of Medical and Dental Sciences, Japan.
| | - Takanori Yokota
- Department of Neurology and Neurological Sciences, Tokyo Medical and Dental University, Graduate School of Medical and Dental Sciences, Japan
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352
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Li F, Li Z, Takahashi R, Ioannis A, Ismail M, Meisel A, Rueckert JC. Robotic-Extended Rethymectomy for Refractory Myasthenia Gravis: A Case Series. Semin Thorac Cardiovasc Surg 2019; 32:593-602. [PMID: 31682904 DOI: 10.1053/j.semtcvs.2019.10.016] [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] [Received: 10/25/2019] [Accepted: 10/25/2019] [Indexed: 11/11/2022]
Abstract
To assess the safety and efficacy of robotic-extended rethymectomy in selected refractory myasthenia gravis (MG) patients with suspected residual thymic tissue. Robotic-extended rethymectomy was performed in 6 MG patients with seropositive acetylcholine receptors (AChR) antibody who had undergone a previous thymectomy (1 cervicotomy, 2 video-assisted thoracoscopic surgeries, and 3 sternotomies). The median observation time before robotic rethymectomy was 108 (24-171) months. The main outcomes were perioperative morbidity, mortality, conversion to open surgery, and clinical outcomes according to the Myasthenia Gravis Foundation of America Post-Intervention Status (MGFA-PIS). Before rethymectomy, all patients required immunosuppressants and 5 patients (83.3%) required intravenous immune globulin and/or plasma exchange to control the symptoms. The median specimen weight was 24.5 (14-144) g after rethymectomy, and residual thymic tissue was found in 5 patients (83.3%). No conversion to open surgery or perioperative morbidity and mortality was observed. With a median follow-up time of 46.5 (13-155) months, 3 patients (50%) achieved "improved" and 3 (50%) were "unchanged" according to the MGFA-PIS. Compared with preoperative use, the median daily dose of corticosteroids statistically decreased (25 [7.5-60] vs 0 [0-5] mg, P = 0.002) without significant change in azathioprine use (100 [0-200] vs 50 [0-150] mg, P = 0.360). AChR antibody positive MG patients with a treatment refractory long-term course after thymectomy might have remaining thymic tissue with the 2 commonly associated thymus pathologies, thymoma, and follicular hyperplasia. Robotic-extended rethymectomy might be considered as a safe and beneficial treatment option in these patients.
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Affiliation(s)
- Feng Li
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Zhongmin Li
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Reona Takahashi
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | | | - Mahmoud Ismail
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology Berlin, Charité University Hospital Berlin, Berlin, Germany
| | - Jens-C Rueckert
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany.
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353
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Farmakidis C, Dimachkie MM, Pasnoor M, Barohn RJ. Immunosuppressive and immunomodulatory therapies for neuromuscular diseases. Part II: New and novel agents. Muscle Nerve 2019; 61:17-25. [PMID: 31531874 DOI: 10.1002/mus.26711] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 09/09/2019] [Accepted: 09/10/2019] [Indexed: 12/30/2022]
Abstract
While traditional immunosuppressive and immunomodulatory therapies remain the cornerstone of immune-mediated neuromuscular disease management, new and novel agents including antigen-specific, monoclonal antibody drugs, have emerged as important treatment options. This article is the second of a two-part series that reviews immune-based therapies in neuromuscular diseases. The first article provides an update on the use of traditional immune-based therapies such as corticosteroids, plasma exchange, steroid-sparing immunosuppressive drugs, and intravenous immunoglobulin G. This second article focuses on new and novel immune-based therapies, including eculizumab, a complement inhibitor approved for acetylcholine receptor antibody-positive myasthenia gravis; rituximab, a B-cell depletion therapy with evolving indications in neuromuscular diseases; and the subcutaneous formulation of immunoglobulin G that gained approval for use in chronic inflammatory demyelinating polyradiculoneuropathy in 2018. Finally, several novel antigen-specific drugs at different stages of investigation in neuromuscular disease are also reviewed.
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Affiliation(s)
| | - Mazen M Dimachkie
- Neurology Department, The University of Kansas Medical Center, Kansas City, Kansas
| | - Mamatha Pasnoor
- Neurology Department, The University of Kansas Medical Center, Kansas City, Kansas
| | - Richard J Barohn
- Neurology Department, The University of Kansas Medical Center, Kansas City, Kansas
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354
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Garzón-Orjuela N, van der Werf L, Prieto-Pinto LC, Lasalvia P, Castañeda-Cardona C, Rosselli D. Quality of life in refractory generalized myasthenia gravis: A rapid review of the literature. Intractable Rare Dis Res 2019; 8:231-238. [PMID: 31890449 PMCID: PMC6929598 DOI: 10.5582/irdr.2019.01121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Generalized myasthenia gravis (GMG) is a neuromuscular transmission disorder that creates a fluctuating weakness of the voluntary muscles. This study is aimed at understanding the effect that refractory GMG has on the quality of life of patients who suffer from it, and the effect of eculizumab on it. A systematic literature search was conducted in MEDLINE (Ovid), EMBASE and the Cochrane Database of Systematic Reviews (Ovid). Eligibility criteria were verified via the title and summary and afterward through the full text. The risk of bias of the included randomized clinical trials was evaluated and the data were synthesized in a descriptive manner. Nine studies were identified that evaluated the quality of life of patients with GMG. Regarding the effect of eculizumab, two studies were identified. The quality of life in patients with GMG is lower compared to ocular myasthenia gravis (MG) and MG in remission, especially in the domains of physical function, physical role, bodily pain, vitality, and social function. Patients treated with eculizumab had a better perception of their quality of life compared to those who received placebo. GMG affects the quality of life more than other types of MG. This outcome is of great importance for the choice of therapeutic options in patients with refractory GMG. Eculizumab generates improvements in the perception of patients' quality of life compared to placebo, making it a relevant therapeutic option in the management of refractory GMG.
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Affiliation(s)
- Nathaly Garzón-Orjuela
- . Department of Evidence-Based Medicine, NeuroEconomix, Bogotá, Colombia
- Address correspondence to:Nathaly Garzón-Orjuela, Department of Evidence-Based Medicine, NeuroEconomix, Bogotá, Colombia. E-mail:
| | - Laura van der Werf
- . Department of Evidence-Based Medicine, NeuroEconomix, Bogotá, Colombia
| | | | - Pieralessandro Lasalvia
- . Department of Evidence-Based Medicine, NeuroEconomix, Bogotá, Colombia
- . Clinical Epidemiology and Biostatistics Department, Medical School, Pontificia Universidad Javeriana, Bogotá, Colombia
| | | | - Diego Rosselli
- . Department of Evidence-Based Medicine, NeuroEconomix, Bogotá, Colombia
- . Clinical Epidemiology and Biostatistics Department, Medical School, Pontificia Universidad Javeriana, Bogotá, Colombia
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355
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Barnett C, Tabasinejad R, Bril V. Current pharmacotherapeutic options for myasthenia gravis. Expert Opin Pharmacother 2019; 20:2295-2303. [PMID: 31670984 DOI: 10.1080/14656566.2019.1682548] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Novel options for immune-based therapy in myasthenia gravis are improving the therapeutic outlook for patients. Multiple clinical trials on immunomodulation, complement inhibitors, and FcR inhibitors are providing evidence for novel immune-based therapies that promise to improve outcomes in myasthenia patients. These more focused immune treatments are reviewed in this paper.Areas covered: This paper outlines classical treatment for myasthenia gravis and then reviews recent clinical trial evidence for novel immune therapies, particularly complement inhibitors and FcR inhibitors. Further, as immune therapies expand in other areas of medicine, such as oncology, iatrogenic myasthenia is being observed as a complication of some novel treatments.Expert opinion: Exciting new options to help patients with myasthenia gravis are now available or in phase 3 trials based on promising phase 2 results. Manipulation of the immune system can also lead to iatrogenic MG. Although novel treatments can improve care for myasthenia gravis patients, future developments that prevent the production of specific abnormal auto-antibodies are desirable.
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Affiliation(s)
- Carolina Barnett
- Department of Medicine (Neurology), University Health Network, University of Toronto - Neurology, Toronto, Ontario, Canada
| | - Raha Tabasinejad
- Department of Medicine (Neurology), University Health Network, University of Toronto - Neurology, Toronto, Ontario, Canada
| | - Vera Bril
- Department of Medicine (Neurology), University Health Network, University of Toronto - Neurology, Toronto, Ontario, Canada
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356
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Harris L, Aban IB, Xin H, Cutter G. Employment in refractory myasthenia gravis: A Myasthenia Gravis Foundation of America Registry analysis. Muscle Nerve 2019; 60:700-706. [PMID: 31478207 PMCID: PMC6900169 DOI: 10.1002/mus.26694] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 08/28/2019] [Accepted: 08/28/2019] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Labor-market participation is potentially very difficult for patients with refractory myasthenia gravis (MG). In this study, employment status and work absences are compared between refractory and nonrefractory MG. METHODS Adults (aged 18-64 years, all diagnosed ≥2 years previously) were included if enrolled in the Myasthenia Gravis Foundation of America Patient Registry during July 2013 to February 2018. RESULTS Seventy-six patients (9.2%) had refractory and 749 (90.8%) had nonrefractory disease; demographic data did not differ between groups. Relative to the nonrefractory group, the refractory group patients were more than twice as likely to work fewer hours per week (odds ratio [95% confidence interval]: currently employed, 2.777 [1.640-4.704]; employed over previous 6 months, 2.643 [1.595-4.380]), but those employed were not more likely to be absent from work. DISCUSSION Because absence from the labor market adversely affects quality of life and personal finances, these findings reaffirm the considerable disease burden associated with refractory MG.
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Affiliation(s)
- Linda Harris
- Formerly of Alexion Pharmaceuticals, Inc., Boston, Massachusetts
| | - Inmaculada B Aban
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Haichang Xin
- Formerly of the Department of Health Care Organization and Policy, University of Alabama at Birmingham, Birmingham, Alabama
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
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357
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Patriquin CJ, Kuo KHM. Eculizumab and Beyond: The Past, Present, and Future of Complement Therapeutics. Transfus Med Rev 2019; 33:256-265. [PMID: 31703946 DOI: 10.1016/j.tmrv.2019.09.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 09/04/2019] [Accepted: 09/05/2019] [Indexed: 12/18/2022]
Abstract
Dysregulation of the complement system underlies the pathophysiology of many diseases. Renewed interest in complement occurred with the recognition that its therapeutic inhibition was possible. Terminal complement blockade with the anti-C5 monoclonal antibody eculizumab significantly changed management and clinical outcomes of patients with paroxysmal nocturnal hemoglobinuria, and served as a proof of concept for other complement-mediated diseases. Eculizumab is also approved for atypical hemolytic uremic syndrome and myasthenia gravis. Multiple new disease indications have been identified, and novel complement inhibitors are in various stages of development, with several currently in human trials. Beyond C5, these new drugs block proximal complement, pathway-specific targets, convertase activity, and anaphylatoxin function. Though monoclonal antibodies are still common, peptides, RNAi, and small molecule inhibitors provide the opportunity for different administration routes and schedules. Several challenges still exist or will soon present themselves, including mitigation of infection risk, effective monitoring strategies, and how to choose between therapeutics when more than one is available. In this review, we will describe the lessons learned from the "eculizumab era," present many of the novel therapeutics currently or soon to be in trials, and highlight some of the challenges that will require attention as the field progresses.
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Affiliation(s)
- Christopher J Patriquin
- Division of Hematology, University of Toronto, Toronto, Ontario, Canada; Divison of Medical Oncology & Hematology, University Health Network, Toronto, Ontario, Canada.
| | - Kevin H M Kuo
- Division of Hematology, University of Toronto, Toronto, Ontario, Canada; Divison of Medical Oncology & Hematology, University Health Network, Toronto, Ontario, Canada
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358
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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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359
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Beecher G, Putko BN, Wagner AN, Siddiqi ZA. Therapies Directed Against B-Cells and Downstream Effectors in Generalized Autoimmune Myasthenia Gravis: Current Status. Drugs 2019; 79:353-364. [PMID: 30762205 DOI: 10.1007/s40265-019-1065-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Myasthenia gravis is a rare, heterogeneous, classical autoimmune disease characterized by fatigable skeletal muscle weakness, which is directly mediated by autoantibodies targeting various components of the neuromuscular junction, including the acetylcholine receptor, muscle specific tyrosine kinase, and lipoprotein-related protein 4. Subgrouping of myasthenia gravis is dependent on the age of onset, pattern of clinical weakness, autoantibody detected, type of thymic pathology, and response to immunotherapy. Generalized immunosuppressive therapies are effective in all subgroups of myasthenia gravis; however, approximately 15% remain refractory and more effective treatments with improved safety profiles are needed. In recent years, successful utilization of targeted B-cell therapies in this disease has triggered renewed focus in unraveling the underlying immunopathology in attempts to identify newer therapeutic targets. While myasthenia gravis is predominantly B-cell mediated, T cells, T cell-B cell interactions, and B-cell-related factors are increasingly recognized to play key roles in its immunopathology, particularly in autoantibody production, and novel therapies have focused on targeting these specific immune system components. This overview describes the current understanding of myasthenia gravis immunopathology before discussing B-cell-related therapies, their therapeutic targets, and the rationale and evidence for their use. Several prospective studies demonstrated efficacy of rituximab in various myasthenia gravis subtypes, particularly that characterized by antibodies against muscle-specific tyrosine kinase. However, a recent randomized control trial in patients with acetylcholine receptor antibodies was negative. Eculizumab, a complement inhibitor, has recently gained regulatory approval for myasthenia gravis based on a phase III trial that narrowly missed its primary endpoint while achieving robust results in all secondary endpoints. Zilucoplan is a subcutaneously administered terminal complement inhibitor that recently demonstrated significant improvements in functional outcome measures in a phase II trial. Rozanolixizumab, CFZ533, belimumab, and bortezomib are B-cell-related therapies that are in the early stages of evaluation in treating myasthenia gravis. The rarity of myasthenia gravis, heterogeneity in its clinical manifestations, and variability in immunosuppressive regimens are challenges to conducting successful trials. Nonetheless, these are promising times for myasthenia gravis, as renewed research efforts provide novel insights into its immunopathology, allowing for development of targeted therapies with increased efficacy and safety.
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Affiliation(s)
- Grayson Beecher
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta Hospital, 7-112 Clinical Sciences Building, 11350-83 Ave, Edmonton, AB, T6G 2G3, Canada
| | - Brendan Nicholas Putko
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta Hospital, 7-112 Clinical Sciences Building, 11350-83 Ave, Edmonton, AB, T6G 2G3, Canada
| | - Amanda Nicole Wagner
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta Hospital, 7-112 Clinical Sciences Building, 11350-83 Ave, Edmonton, AB, T6G 2G3, Canada
| | - Zaeem Azfer Siddiqi
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta Hospital, 7-112 Clinical Sciences Building, 11350-83 Ave, Edmonton, AB, T6G 2G3, Canada.
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360
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Raja SM, Howard JF, Juel VC, Massey JM, Chopra M, Guptill JT. Clinical outcome measures following plasma exchange for MG exacerbation. Ann Clin Transl Neurol 2019; 6:2114-2119. [PMID: 31560178 PMCID: PMC6801175 DOI: 10.1002/acn3.50901] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 08/29/2019] [Accepted: 09/01/2019] [Indexed: 11/10/2022] Open
Abstract
Our objective is to report longitudinal results of the MG‐ADL, MG‐Composite, MG‐MMT, and MG‐QoL15 in an open‐label trial of therapeutic plasma exchange in myasthenia gravis. Ten MG patients experiencing exacerbation had assessments prior to, immediately following, and at selected time points post‐TPE. Changes from baseline to 2 weeks post‐TPE were: MG‐ADL median −5.0, P < 0.0033, MG‐QoL15 median −13.0, P < 0.001, MG‐MMT median −10.0, P < 0.0001, and MG‐Composite median −10.0, P < 0.005. TPE produced a rapid, clinically significant change in all instruments, indicating these outcome measures are robust endpoints for clinical trials of rapidly efficacious MG therapies.
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Affiliation(s)
- Shruti M Raja
- Division of Neuromuscular Medicine, Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - James F Howard
- Neuromuscular Disease Section, Department of Neurology, The University of North Carolina, Chapel Hill, North Carolina
| | - Vern C Juel
- Division of Neuromuscular Medicine, Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Janice M Massey
- Division of Neuromuscular Medicine, Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Manisha Chopra
- Neuromuscular Disease Section, Department of Neurology, The University of North Carolina, Chapel Hill, North Carolina
| | - Jeffrey T Guptill
- Division of Neuromuscular Medicine, Department of Neurology, Duke University Medical Center, Durham, North Carolina.,Neurosciences Medicine, Duke Clinical Research Institute, Durham, North Carolina
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361
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Abstract
Myasthenia gravis (MG) is an autoimmune disorder caused by antibodies against acetylcholine receptors (AChR) or other structural proteins of the neuromuscular junction. This diminishes cholinergic transmission, thus leading to exercise-induced fatigue and sometimes manifest muscle weakness, including the bulbar and ocular musculature. Whereas ocular MG is as a rule initially symptomatically treated with acetylcholine esterase inhibitors, generalized MG requires long-term immunosuppression. The thymus plays a particular role in the pathophysiology of AChR antibody-positive MG, which can also manifest as a paraneoplastic disorder in the context of a thymoma. This article reviews the basic and advanced treatment options of the different disease subtypes including plasma exchange and immunoglobulins for treatment in a myasthenic crisis. Recently, clinical approval of eculizumab, a complement inhibitor, enriched the pharmacological armamentarium for AChR antibody-positive MG patients not appropriately responding to immunosuppression alone.
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362
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Choi K, Hong YH, Ahn SH, Baek SH, Kim JS, Shin JY, Sung JJ. Repeated low-dose rituximab treatment based on the assessment of circulating B cells in patients with refractory myasthenia gravis. Ther Adv Neurol Disord 2019; 12:1756286419871187. [PMID: 31555344 PMCID: PMC6751534 DOI: 10.1177/1756286419871187] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 07/29/2019] [Indexed: 01/28/2023] Open
Abstract
Background: The objective of this study was to evaluate the efficacy and safety of
repeated low-dose rituximab treatment guided by monitoring circulating CD19+
B cells in patients with refractory myasthenia gravis (MG). Methods: Patients with refractory MG who had received rituximab treatment at two
teaching hospitals between September 2013 and January 2017 were reviewed
retrospectively. The treatment protocol consisted of an induction treatment
with low-dose rituximab (375 mg/m2 twice with a 2-week interval),
followed by retreatment (375 mg/m2 once). Retreatment was based
on either circulating CD19+ B-cell repopulation or clinical relapse. Outcome
measures included the MG Foundation of America (MGFA) clinical
classification and postintervention status, prednisolone dose, CD19+ B-cell
counts, clinical relapse, and adverse effects. Results: Of 17 patients, 11 (65%) achieved the primary endpoint, defined as the
minimal manifestation or better status with prednisolone ⩽5 mg/day, after
median 7.6 months (range, 2–17 months) following rituximab treatment. Over a
median follow up of 24 months (range, 7–49 months), a total of 30
retreatments were undertaken due to clinical relapse without B-cell
repopulation (n = 6), on the basis of B-cell repopulation
alone (n = 16) and both (n = 8). B-cell
recovery appeared to be in parallel with clinical relapse on the group
level, although the individual-level association appeared to be modest, with
B-cell repopulation observed only at 57% (8/14) of clinical relapses. Conclusions: The repeated low-dose rituximab treatment based on the assessment of
circulating B-cell depletion could be a cost-effective therapeutic option
for refractory MG. Further studies are needed to verify the potentially
better cost-effectiveness of low-dose rituximab, and to identify biomarkers
that help optimize treatment in MG patients.
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Affiliation(s)
- Kyomin Choi
- Department of Neurology, Konkuk University School of Medicine, Konkuk University Medical Center, Seoul, Republic of Korea
| | - Yoon-Ho Hong
- Department of Neurology, Neuroscience Research Institute, Seoul National University Medical Research Council, Seoul National University College of Medicine, Seoul Metropolitan Boramae Medical Center, Seoul, Republic of Korea
| | - So-Hyun Ahn
- Department of Neurology, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
| | - Seol-Hee Baek
- Department of Neurology, Korea University College of Medicine, Korea University Medical Center, Seoul, Republic of Korea
| | - Jun-Soon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Je-Young Shin
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jung-Joon Sung
- Department of Neurology, Neuroscience Research Institute, Seoul National University Medical Research Council, Seoul National University College of Medicine, Seoul National University Hospital, 28 Yeongeon-dong, Jongno-gu, Seoul, 03080, Republic of Korea
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363
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Prevalence and Associated Factors of Depressive Symptoms in Patients with Myasthenia Gravis: A Cross-Sectional Study of Two Tertiary Hospitals in Riyadh, Saudi Arabia. Behav Neurol 2019; 2019:9367453. [PMID: 31636730 PMCID: PMC6766166 DOI: 10.1155/2019/9367453] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/24/2019] [Accepted: 09/06/2019] [Indexed: 01/13/2023] Open
Abstract
Objectives This study is aimed at elucidating the prevalence of depression in patients with myasthenia gravis (MG) and examining the risk factors associated with depression. Methods We evaluated adult patients with MG who were recruited from two tertiary hospitals in the central region (Riyadh) of Saudi Arabia. Data were collected with a two-part standardized questionnaire: the first part included data on sociodemographic and clinical features of MG including disease type and duration, therapies, prednisolone dose, time of the last relapse, previous critical care unit admissions, MG status (controlled, partially controlled, or uncontrolled), and comorbid diseases; the second part included items from the previously validated Arabic version of the Patient Health Questionnaire-9 (PHQ-9). Results In total, 104/150 (69.3%) patients participated (72 females) with a mean age of 38.0 ± 16.0 years. The mean PHQ-9 score was 7.02 ± 6.1. Among all the participants, 27 (26.0%) patients had depression (PHQ-9 ≥ 10). Multiple logistic regression analysis revealed that uncontrolled MG status (OR = 12.31, 95%CI = 1.13-133.8, P = 0.04) was the only factor independently associated with depression. Collectively, the prevalence of depression among patients of the primary care clinics (PCC) as reported by 5 previous studies across multiple regions of the country was 15.8%. The odds of depression among MG patients were twofold higher than those among PCC patients (OR = 2.05, 95%CI = 1.30-3.22, P = 0.002). Conclusions Approximately a quarter of MG patients have depression. Achieving a minimal manifestation or better MG status may decrease the depression rate in these patients.
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364
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Chamberlain JL, Huda S, Whittam DH, Matiello M, Morgan BP, Jacob A. Role of complement and potential of complement inhibitors in myasthenia gravis and neuromyelitis optica spectrum disorders: a brief review. J Neurol 2019; 268:1643-1664. [PMID: 31482201 DOI: 10.1007/s00415-019-09498-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 08/02/2019] [Accepted: 08/05/2019] [Indexed: 02/08/2023]
Abstract
The complement system is a powerful member of the innate immune system. It is highly adept at protecting against pathogens, but exists in a delicate balance between its protective functions and overactivity, which can result in autoimmune disease. A cascade of complement proteins that requires sequential activation, and numerous complement regulators, exists to regulate a proportionate response to pathogens. In spite of these mechanisms there is significant evidence for involvement of the complement system in driving the pathogenesis of variety of diseases including neuromyelitis optica spectrum disorders (NMOSD) and myasthenia gravis (MG). As an amplification cascade, there are an abundance of molecular targets that could be utilized for therapeutic intervention. Clinical trials assessing complement pathway inhibition in both these conditions have recently been completed and include the first randomized placebo-controlled trial in NMOSD showing positive results. This review aims to review and update the reader on the complement system and the evolution of complement-based therapeutics in these two disorders.
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Affiliation(s)
| | - Saif Huda
- Department of Neurology, The Walton Centre, Lower Lane, Liverpool, L9 7LJ, UK
| | - Daniel H Whittam
- Department of Neurology, The Walton Centre, Lower Lane, Liverpool, L9 7LJ, UK
| | - Marcelo Matiello
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - B Paul Morgan
- School of Medicine, Henry Wellcome Building for Biomedical Research, University Hospital of Wales, Heath Park, Cardiff, CF14 4XN, UK
| | - Anu Jacob
- Department of Neurology, The Walton Centre, Lower Lane, Liverpool, L9 7LJ, UK.,University of Liverpool, Liverpool, UK
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365
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Abstract
This article discusses antibodies associated with immune-mediated myasthenia gravis and the pathologic action of these antibodies at the neuromuscular junctions of skeletal muscle. To explain how these antibodies act, we consider the physiology of neuromuscular transmission with emphasis on 4 features: the structure of the neuromuscular junction; the roles of postsynaptic acetylcholine receptors and voltage-gated Na+ channels and in converting the chemical signal from the nerve terminal into a propagated action potential on the muscle fiber that triggers muscle contraction; the safety factor for neuromuscular transmission; and how the safety factor is reduced in different forms of autoimmune myasthenia gravis.
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Affiliation(s)
- Robert L Ruff
- Department of Neurology, Case Western University School of Medicine, The Metro Health System, 2500 Metro Health Drive, Cleveland, OH 44109, USA; Department of Neurosciences, Case Western Reserve University, Cleveland, OH, USA
| | - Robert P Lisak
- Department of Neurology, Wayne State University School of Medicine, 8D University Health Center, 4201 St Antoine, Detroit, MI 48201, USA; Department of Biochemistry, Microbiology and Immunology, Wayne State University, Detroit, MI, USA.
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366
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Nguyen-Cao TM, Gelinas D, Griffin R, Mondou E. Myasthenia gravis: Historical achievements and the "golden age" of clinical trials. J Neurol Sci 2019; 406:116428. [PMID: 31574325 DOI: 10.1016/j.jns.2019.116428] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/17/2019] [Accepted: 08/14/2019] [Indexed: 02/07/2023]
Abstract
Since the death of Chief Opechankanough >350 years ago, the myasthenia gravis (MG) community has gained extensive knowledge about MG and how to treat it. This review highlights key milestones in the history of treatment and discusses the current "golden age" of clinical trials. Although originally thought by many clinicians to be a disorder of hysteria and fluctuating weakness without observable cause, MG is one the most understood autoimmune neurologic disorders. However, studying it in clinical trials has been challenging due to the fluctuating nature of the medical condition which impacts MG clinical outcomes. Clinical trials must also account for the possibility of a placebo effect. Because MG is a rare incurable autoimmune disorder, it limits the number of potential patients available to participate in clinical trials. In the last 15 years, however, significant progress has been made with MG randomized clinical trials, resulting in a new drug (eculizumab) for physicians' treatment repertoire and an old technique (thymectomy) confirmed effective for MG. Some of the therapies (eg, thymectomy, corticosteroids, plasma exchange, and intravenous immunoglobulin [IVIg]) have survived the test of time. Others (eg, eculizumab and neonatal Fc receptor inhibitor) are novel and hold promise.
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Affiliation(s)
- Tam M Nguyen-Cao
- Scientific and Medical Affairs, Grifols, 79 TW Alexander Drive 4101 Research Commons, Research Triangle Park, NC 27709, USA.
| | - Deborah Gelinas
- Scientific and Medical Affairs, Grifols, 79 TW Alexander Drive 4101 Research Commons, Research Triangle Park, NC 27709, USA.
| | - Rhonda Griffin
- Grifols Bioscience Research Group, Grifols, 79 TW Alexander Drive 4201 Research Commons, Research Triangle Park, NC 27709, USA.
| | - Elsa Mondou
- Grifols Bioscience Research Group, Grifols, 79 TW Alexander Drive 4201 Research Commons, Research Triangle Park, NC 27709, USA.
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367
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Cai X, Li Z, Xi J, Song H, Liu J, Zhu W, Guo Y, Jiao Z. Myasthenia gravis and specific immunotherapy: monoclonal antibodies. Ann N Y Acad Sci 2019; 1452:18-33. [PMID: 31393614 DOI: 10.1111/nyas.14195] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/23/2019] [Accepted: 06/25/2019] [Indexed: 01/21/2023]
Affiliation(s)
- Xiao‐Jun Cai
- Department of Clinical Pharmacy, Huashan HospitalFudan University Shanghai P. R. China
- Department of Pharmacythe Affiliated Wuxi People's Hospital of Nanjing Medical University Wuxi P. R. China
| | - Zai‐Wang Li
- Department of Neurology, Shenzhen People's Hospital, the Second Clinical Medical College of Jinan Universitythe First Affiliated Hospital of Southern University of Science and Technology Shenzhen P. R. China
- Department of Neurologythe Affiliated Wuxi People's Hospital of Nanjing Medical University Wuxi P. R. China
| | - Jian‐Ying Xi
- Department of Neurology, Huashan HospitalFudan University Shanghai P. R. China
| | - Hui‐Zhu Song
- Department of Pharmacythe Affiliated Wuxi People's Hospital of Nanjing Medical University Wuxi P. R. China
| | - Jue Liu
- Department of Clinical Pharmacy, Huashan HospitalFudan University Shanghai P. R. China
| | - Wen‐Hua Zhu
- Department of Neurology, Huashan HospitalFudan University Shanghai P. R. China
| | - Yi Guo
- Department of Neurology, Shenzhen People's Hospital, the Second Clinical Medical College of Jinan Universitythe First Affiliated Hospital of Southern University of Science and Technology Shenzhen P. R. China
| | - Zheng Jiao
- Department of Clinical Pharmacy, Huashan HospitalFudan University Shanghai P. R. China
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368
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Long-term efficacy and safety of eculizumab in Japanese patients with generalized myasthenia gravis: A subgroup analysis of the REGAIN open-label extension study. J Neurol Sci 2019; 407:116419. [PMID: 31698177 DOI: 10.1016/j.jns.2019.08.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 08/01/2019] [Accepted: 08/02/2019] [Indexed: 12/31/2022]
Abstract
The terminal complement inhibitor eculizumab was shown to improve myasthenia gravis-related symptoms in the 26-week, phase 3, randomized, double-blind, placebo-controlled REGAIN study (NCT01997229). In this 52-week sub-analysis of the open-label extension of REGAIN (NCT02301624), eculizumab's efficacy and safety were assessed in 11 Japanese and 88 Caucasian patients with anti-acetylcholine receptor antibody-positive refractory generalized myasthenia gravis. For patients who had received placebo during REGAIN, treatment with open-label eculizumab resulted in generally similar outcomes in the Japanese and Caucasian populations. Rapid improvements were maintained for 52 weeks, assessed by change in score from open-label extension baseline to week 52 (mean [standard error]) using the following scales (in Japanese and Caucasian patients, respectively): Myasthenia Gravis Activities of Daily Living (-2.4 [1.34] and - 3.3 [0.65]); Quantitative Myasthenia Gravis (-2.9 [1.98] and - 4.3 [0.79]); Myasthenia Gravis Composite (-4.5 [2.63] and - 4.9 [1.19]); and Myasthenia Gravis Quality of Life 15-item questionnaire (-8.6 [5.68] and - 6.5 [1.93]). Overall, the safety of eculizumab was consistent with its known safety profile. In this interim sub-analysis, the efficacy and safety of eculizumab in Japanese and Caucasian patients were generally similar, and consistent with the overall REGAIN population.
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369
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Clinical promise of next-generation complement therapeutics. Nat Rev Drug Discov 2019; 18:707-729. [PMID: 31324874 DOI: 10.1038/s41573-019-0031-6] [Citation(s) in RCA: 209] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2019] [Indexed: 02/07/2023]
Abstract
The complement system plays a key role in pathogen immunosurveillance and tissue homeostasis. However, subversion of its tight regulatory control can fuel a vicious cycle of inflammatory damage that exacerbates pathology. The clinical merit of targeting the complement system has been established for rare clinical disorders such as paroxysmal nocturnal haemoglobinuria and atypical haemolytic uraemic syndrome. Evidence from preclinical studies and human genome-wide analyses, supported by new molecular and structural insights, has revealed new pathomechanisms and unmet clinical needs that have thrust a new generation of complement inhibitors into clinical development for a variety of indications. This review critically discusses recent clinical milestones in complement drug discovery, providing an updated translational perspective that may guide optimal target selection and disease-tailored complement intervention.
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Levine TD. Safety of an Abbreviated Transition Period When Switching From Intravenous Immunoglobulin to Eculizumab in Patients with Treatment-Refractory Myasthenia Gravis: A Case Series. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:965-970. [PMID: 31278249 PMCID: PMC6628751 DOI: 10.12659/ajcr.916424] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 04/26/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Eculizumab is a terminal complement inhibitor used to treat myasthenia gravis in patients refractory (because of insufficient efficacy or intolerance) to other therapies, including intravenous immunoglobulin. However, information is lacking on how to transition patients from intravenous immunoglobulin to eculizumab, while avoiding a crossover effect of intravenous immunoglobulin and minimizing the risk of a transient worsening of symptoms if treatment that may be at least partially effective is interrupted. The aim of this study was to determine whether eculizumab can be safely initiated before complete intravenous immunoglobulin washout, using a standardized protocol. CASE REPORT A series of 13 patients with generalized treatment-refractory myasthenia gravis were transitioned to eculizumab 10-14 days after their last intravenous immunoglobulin infusion. Patients' clinical status was assessed before and 6 weeks after transition using the Myasthenia Gravis Composite Score. Most patients (8/13; 62%) had received ≥3 immunosuppressants as well as intravenous immunoglobulin. The median (range) Myasthenia Gravis Composite Score before and 6 weeks after transition was 21 (11-29) and 12 (6-18), respectively. Clinically significant improvements (score decrease ≥3) were observed in all patients. Two patients experienced mild myalgia during transition. CONCLUSIONS In this case series, patients with treatment-refractory myasthenia gravis were successfully transitioned to eculizumab 10-14 days after their last intravenous immunoglobulin infusion without any significant safety concerns.
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Myasthenia Gravis: Pathogenic Effects of Autoantibodies on Neuromuscular Architecture. Cells 2019; 8:cells8070671. [PMID: 31269763 PMCID: PMC6678492 DOI: 10.3390/cells8070671] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 06/26/2019] [Accepted: 06/28/2019] [Indexed: 12/13/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disease of the neuromuscular junction (NMJ). Autoantibodies target key molecules at the NMJ, such as the nicotinic acetylcholine receptor (AChR), muscle-specific kinase (MuSK), and low-density lipoprotein receptor-related protein 4 (Lrp4), that lead by a range of different pathogenic mechanisms to altered tissue architecture and reduced densities or functionality of AChRs, reduced neuromuscular transmission, and therefore a severe fatigable skeletal muscle weakness. In this review, we give an overview of the history and clinical aspects of MG, with a focus on the structure and function of myasthenic autoantigens at the NMJ and how they are affected by the autoantibodies' pathogenic mechanisms. Furthermore, we give a short overview of the cells that are implicated in the production of the autoantibodies and briefly discuss diagnostic challenges and treatment strategies.
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372
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Varma A, Zis P. Nocebo effect in myasthenia gravis: systematic review and meta-analysis of placebo-controlled clinical trials. Acta Neurol Belg 2019; 119:257-264. [PMID: 31004288 DOI: 10.1007/s13760-019-01143-1] [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] [Received: 01/10/2019] [Accepted: 04/11/2019] [Indexed: 12/17/2022]
Abstract
Nocebo refers to the adverse events (AEs) experienced when taking a placebo drug and is believed to be a centrally mediated process. We sought to examine the AEs following placebo administration in Randomised Controlled Trials (RCTs) for Myasthenia Gravis (MG) patients. A systematic literature search was performed on Medline and Web of Science for RCTs for MG pharmacological treatments. We assessed the number of placebo-treated patients reporting at least one AE and the number of dropouts because of AEs. Data were extracted from six RCTs fulfilling the search criteria. Four out of five placebo-treated participants (80.1%) reported at least one AE and one in 40 (2.4%) discontinued placebo treatment because of AE. All patients participating in the MG trials reported similar AEs independent of the study arm to which they belonged (placebo or active treatment). This meta-analysis demonstrates a low nocebo dropout rate in MG compared to central nervous system disorders.
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373
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Boscoe AN, Xin H, L'Italien GJ, Harris LA, Cutter GR. Impact of Refractory Myasthenia Gravis on Health-Related Quality of Life. J Clin Neuromuscul Dis 2019; 20:173-181. [PMID: 31135620 PMCID: PMC6571178 DOI: 10.1097/cnd.0000000000000257] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Myasthenia gravis (MG) may be refractory to traditional therapies. Quality of life (QOL) and disease burden in patients with refractory and nonrefractory MG were compared using Myasthenia Gravis Foundation of America MG Patient Registry data. METHODS Adults aged 18 years or older with MG diagnosed ≥2 years before enrollment were included. Participants with refractory MG had received ≥2 previous and 1 current MG treatment and had MG Activities of Daily Living Scale total score ≥6 at enrollment; other participants had nonrefractory MG. MG QOL 15-item scale (MG-QOL15) scores were compared. RESULTS In total, 56 participants with refractory and 717 participants with nonrefractory MG enrolled. Participants with refractory MG had significantly higher mean (SD) MG-QOL15 total scores [31.4 (11.1) vs. 20.8 (15.0), P < 0.0001] and were more likely to have had exacerbations, emergency department visits, and recent hospitalizations. CONCLUSIONS Participants with refractory MG experience worse QOL and greater clinical burden than those with nonrefractory disease.
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Affiliation(s)
- Audra N. Boscoe
- Alexion Pharmaceuticals, New Haven, CT. Dr. Boscoe is now with Agios Pharmaceuticals, Cambridge, MA. Dr. L'Italien is now with Biohaven Pharmaceuticals, New Haven, CT
| | - Haichang Xin
- Department of Health Care Organization and Policy, University of Alabama at Birmingham, Birmingham, AL; and
| | - Gilbert J. L'Italien
- Alexion Pharmaceuticals, New Haven, CT. Dr. Boscoe is now with Agios Pharmaceuticals, Cambridge, MA. Dr. L'Italien is now with Biohaven Pharmaceuticals, New Haven, CT
| | - Linda A. Harris
- Alexion Pharmaceuticals, New Haven, CT. Dr. Boscoe is now with Agios Pharmaceuticals, Cambridge, MA. Dr. L'Italien is now with Biohaven Pharmaceuticals, New Haven, CT
| | - Gary R. Cutter
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL
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Howard JF, Bril V, Burns TM, Mantegazza R, Bilinska M, Szczudlik A, Beydoun S, Garrido FJRDR, Piehl F, Rottoli M, Van Damme P, Vu T, Evoli A, Freimer M, Mozaffar T, Ward ES, Dreier T, Ulrichts P, Verschueren K, Guglietta A, de Haard H, Leupin N, Verschuuren JJGM. Randomized phase 2 study of FcRn antagonist efgartigimod in generalized myasthenia gravis. Neurology 2019; 92:e2661-e2673. [PMID: 31118245 DOI: 10.1212/wnl.0000000000007600] [Citation(s) in RCA: 153] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 01/31/2019] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To investigate safety and explore efficacy of efgartigimod (ARGX-113), an anti-neonatal Fc receptor immunoglobulin G1 Fc fragment, in patients with generalized myasthenia gravis (gMG) with a history of anti-acetylcholine receptor (AChR) autoantibodies, who were on stable standard-of-care myasthenia gravis (MG) treatment. METHODS A phase 2, exploratory, randomized, double-blind, placebo-controlled, 15-center study is described. Eligible patients were randomly assigned (1:1) to receive 4 doses over a 3-week period of either 10 mg/kg IV efgartigimod or matched placebo combined with their standard-of-care therapy. Primary endpoints were safety and tolerability. Secondary endpoints included efficacy (change from baseline to week 11 of Myasthenia Gravis Activities of Daily Living, Quantitative Myasthenia Gravis, and Myasthenia Gravis Composite disease severity scores, and of the revised 15-item Myasthenia Gravis Quality of Life scale), pharmacokinetics, pharmacodynamics, and immunogenicity. RESULTS Of the 35 screened patients, 24 were enrolled and randomized: 12 received efgartigimod and 12 placebo. Efgartigimod was well-tolerated in all patients, with no serious or severe adverse events reported, no relevant changes in vital signs or ECG findings observed, and no difference in adverse events between efgartigimod and placebo treatment. All patients treated with efgartigimod showed a rapid decrease in total immunoglobulin G (IgG) and anti-AChR autoantibody levels, and assessment using all 4 efficacy scales consistently demonstrated that 75% showed a rapid and long-lasting disease improvement. CONCLUSIONS Efgartigimod was safe and well-tolerated. The correlation between reduction of levels of pathogenic IgG autoantibodies and disease improvement suggests that reducing pathogenic autoantibodies with efgartigimod may offer an innovative approach to treat MG. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that efgartigimod is safe and well-tolerated in patients with gMG.
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Affiliation(s)
- James F Howard
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Vera Bril
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Ted M Burns
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Renato Mantegazza
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Malgorzata Bilinska
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Andrzej Szczudlik
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Said Beydoun
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Francisco Javier Rodriguez De Rivera Garrido
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Fredrik Piehl
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Mariarosa Rottoli
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Philip Van Damme
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Tuan Vu
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Amelia Evoli
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Miriam Freimer
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Tahseen Mozaffar
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - E Sally Ward
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Torsten Dreier
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Peter Ulrichts
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Katrien Verschueren
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Antonio Guglietta
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Hans de Haard
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Nicolas Leupin
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands.
| | - Jan J G M Verschuuren
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
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375
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Daher A, Matsuoka CK, Loghin ME, Penas-Prado M, Tummala S. Neuromuscular Weakness Syndromes from Immune Checkpoint Inhibitors: A Case Series and Literature Review. ACTA ACUST UNITED AC 2019. [DOI: 10.4103/jipo.jipo_3_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Abstract
Immune checkpoint inhibitors (CPIs) (anti-cytotoxic T-lymphocyte antigen-4, anti-programmed death 1, and anti-programmed death-ligand 1) have transformed the landscape of cancer therapy. However, their increasing use has unleashed immune-related adverse events in various organs, among which neurologic ones, while rare, are increasingly being recognized and remain incompletely characterized. Herein, we report five patients with nonmelanoma cancers who developed weakness after receiving CPIs. The etiology was attributed to radiculoneuritis (one patient), myositis (one patient), Miller Fisher/myasthenia gravis (MG) (one patient), neuropathy/myositis/MG (one patient), and myositis/MG (one patient). Weakness developed after a median of two doses (range: 1–3) and 4 weeks (range: 3–10) from initiation of therapy. Two patients had severe manifestations without improvement while the other three experienced partial improvement despite discontinuation of the CPI (s) and initiation of immunosuppressive therapy. A review of literature identified 62 similar cases. This report highlights the challenges in the diagnosis and management of neurologic adverse events related to the use of CPIs. It also addresses the crucial need for early recognition, proper workup, and better biomarkers to help improve the outcomes of these adverse events.
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Affiliation(s)
- Ahmad Daher
- Department of Neuro-Oncology, Hartford Health Care Medical Group, Hartford Hospital, Hartford, CT
| | - Carlos Kamiya Matsuoka
- Department of Neuro-Oncology, Hartford Health Care Medical Group, Hartford Hospital, Hartford, CT
- Neuro-Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Monica Elena Loghin
- Department of Neuro-Oncology, Hartford Health Care Medical Group, Hartford Hospital, Hartford, CT
- Neuro-Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Marta Penas-Prado
- Department of Neuro-Oncology, Hartford Health Care Medical Group, Hartford Hospital, Hartford, CT
- Department of Neuro-Oncology Branch, National Cancer Institute, Bethesda, MD, USA
| | - Sudhakar Tummala
- Neuro-Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
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376
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Edmundson C, Guidon AC. Eculizumab: A Complementary addition to existing long-term therapies for myasthenia gravis. Muscle Nerve 2019; 60:7-9. [PMID: 31074870 DOI: 10.1002/mus.26512] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Christyn Edmundson
- Division of Neuromuscular Medicine, Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amanda C Guidon
- Division of Neuromuscular Medicine, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 820, Boston, Massachusetts, 02114, USA
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377
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Park DH, Connor KM, Lambris JD. The Challenges and Promise of Complement Therapeutics for Ocular Diseases. Front Immunol 2019; 10:1007. [PMID: 31156618 PMCID: PMC6529562 DOI: 10.3389/fimmu.2019.01007] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 04/18/2019] [Indexed: 01/08/2023] Open
Abstract
Ocular inflammation is a defining feature of sight threating diseases and its dysregulation can catalyze and or propagate ocular neurodegenerative maladies such as age-related macular degeneration (AMD). The complement system, an intrinsic component of the innate immunity, has an integral role in maintaining immune-surveillance and homeostasis in the ocular microenvironment; however, overstimulation can drive ocular inflammatory diseases. The mechanism for complement disease propagation in AMD is not fully understood, although there is accumulating evidence showing that targeted modulation of complement-specific proteins has the potential to become a viable therapeutic approach. To date, a major focus of complement therapeutics has been on targeting the alternative complement system in AMD. Recent studies have outlined potential complement cascade inhibitors that might mitigate AMD disease progression. First-in-class complement inhibitors target the modulation of complement proteins C3, C5, factor B, factor D, and properdin. Herein, we will summarize ocular inflammation in the context of AMD disease progression, current clinical outcomes and complications of complement-mediated therapeutics. Given the need for additional therapeutic approaches for ocular inflammatory diseases, targeted complement modulation has emerged as a leading candidate for eliminating inflammation-driven ocular maladies.
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Affiliation(s)
- Dong Ho Park
- Department of Ophthalmology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Kip M. Connor
- Angiogenesis Laboratory, Department of Ophthalmology, Massachusetts Eye & Ear Infirmary, Boston, MA, United States
- Department of Ophthalmology, Harvard Medical School, Boston, MA, United States
| | - John D. Lambris
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Stellar Chance Laboratories, Philadelphia, PA, United States
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378
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Kusner LL, Yucius K, Sengupta M, Sprague AG, Desai D, Nguyen T, Charisse K, Kuchimanchi S, Kallanthottathil R, Fitzgerald K, Kaminski HJ, Borodovsky A. Investigational RNAi Therapeutic Targeting C5 Is Efficacious in Pre-clinical Models of Myasthenia Gravis. MOLECULAR THERAPY-METHODS & CLINICAL DEVELOPMENT 2019; 13:484-492. [PMID: 31193726 PMCID: PMC6539425 DOI: 10.1016/j.omtm.2019.04.009] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 04/26/2019] [Indexed: 10/26/2022]
Abstract
Complement-mediated damage to the neuromuscular junction (NMJ) is a key mechanism of pathology in myasthenia gravis (MG), and therapeutics inhibiting complement have shown evidence of efficacy in the treatment of MG. In this study, we describe the development of a subcutaneously administered N-acetylgalactosamine (GalNAc)-conjugated small interfering RNA (siRNA) targeting the C5 component of complement that silences C5 expression in the liver (ALN-CC5). Treatment of wild-type rodents with ALN-CC5 resulted in robust and durable suppression of liver C5 expression. Dose-dependent serum C5 suppression was observed in non-human primates, with a lowering of serum C5 of up to 97.5% and the concomitant inhibition of serum complement activity. C5 silencing was efficacious in ameliorating disease symptoms in two standard rat models of MG, demonstrating the key role of circulating C5 in pathology at the NMJ. Improvement in disease activity scores and NMJ pathology was observed at intermediate levels of complement activity inhibition, suggesting that complete ablation of complement activity may not be required for efficacy in MG. The pre-clinical studies of ALN-CC5 and efficacy of C5 silencing in rat models of MG support further clinical development of ALN-CC5 as a potential therapeutic for the treatment of MG and other complement-mediated disorders.
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Affiliation(s)
- Linda L Kusner
- Department of Pharmacology and Physiology, George Washington University, Washington, DC 20037, USA
| | | | - Manjistha Sengupta
- Department of Neurology, George Washington University, Washington, DC 20037, USA
| | | | - Dhruv Desai
- Alnylam Pharmaceuticals, Cambridge, MA 02142, USA
| | - Tuyen Nguyen
- Alnylam Pharmaceuticals, Cambridge, MA 02142, USA
| | | | | | | | | | - Henry J Kaminski
- Department of Neurology, George Washington University, Washington, DC 20037, USA
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379
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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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380
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Wang L, Huan X, Xi J, Wu H, Zhou L, Lu J, Zhang T, Zhao C. Immunosuppressive and monoclonal antibody treatment for myasthenia gravis: A network meta-analysis. CNS Neurosci Ther 2019; 25:647-658. [PMID: 30809966 PMCID: PMC6488910 DOI: 10.1111/cns.13110] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/22/2019] [Accepted: 01/23/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND We intended to compare and rank all the immunotherapies including immunosuppressant agents or monoclonal antibodies for myasthenia gravis (MG). METHODS A network meta-analysis was performed to synthesize the direct evidence and indirect evidence. Quantitative MG score (QMGS) was defined as the primary outcome. The secondary outcomes included the glucocorticoid reduction and hazard ratios (HR) from the counts of adverse events (AEs). RESULTS We identified 14 studies including 808 MG patients. For the primary outcome, cyclosporine A (CsA) was hierarchically the best with statistical significances of -1.18 (-1.81, -0.59) vs placebo (PLA), -0.98 (-1.72, -0.23) vs mycophenolate mofetil, and -0.77 (-1.57, -0.032) vs tacrolimus (TAC). When the intervention periods were controlled, both eculizumab (ECZ) of -1.50 (-2.81, -0.18) and CsA of -1.23 (-1.81, -0.64) vs PLA reached a statistical significance. Belimumab and ECZ ranked the most tolerable therapies while CsA of 2.41 (0.58, 10.01) ranked the last vs PLA. CONCLUSION These findings demonstrated that ECZ represented the most effective and tolerable therapeutic alternative to be recommended for refractory MG. TAC may be a beneficial therapy to treat MG extensively while the efficacy of CsA and cyclophosphamide may be limited by their multiple or severe AEs.
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Affiliation(s)
- Liang Wang
- Department of Neurology, Huashan HospitalFudan UniversityShanghaiChina
| | - Xiao Huan
- Department of Neurology, Huashan HospitalFudan UniversityShanghaiChina
| | - Jian‐Ying Xi
- Department of Neurology, Huashan HospitalFudan UniversityShanghaiChina
| | - Hui Wu
- Department of Neurology, Jing’an District Centre Hospital of ShanghaiFudan UniversityShanghaiChina
| | - Lei Zhou
- Department of Neurology, Huashan HospitalFudan UniversityShanghaiChina
| | - Jia‐Hong Lu
- Department of Neurology, Huashan HospitalFudan UniversityShanghaiChina
| | - Tian‐Song Zhang
- Department of Chinese Traditional Medicine, Jing’an District Centre Hospital of ShanghaiFudan UniversityShanghaiChina
| | - Chong‐Bo Zhao
- Department of Neurology, Huashan HospitalFudan UniversityShanghaiChina
- Department of Neurology, Jing’an District Centre Hospital of ShanghaiFudan UniversityShanghaiChina
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381
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Abstract
PURPOSE OF REVIEW The current article reviews the recent advances in the field of myasthenia gravis, which span from autoantibody profiling and pathogenic mechanisms to therapy innovation. The overview is highlighting specifically the data and the needs of targeted treatments in the light of precision medicine in myasthenia gravis. RECENT FINDINGS Novel data published recently further increased our knowledge on myasthenia gravis. The use of cell-based assays has greatly improved autoantibody detection in myasthenia gravis patients, and the mechanisms of action of these antibodies have been described. The role of Toll-like receptor activation in the generation of thymic alterations and anti-acetylcholine receptor autosensitization has been further investigated implementing our understanding on the relationships between innate immunity and autoimmunity. Additional studies have been focused on the alterations of T-cell/B-cell regulatory mechanisms in thymus and peripheral blood of myasthenia gravis patients. microRNAs and genetic factors are also emerging as key biomarkers in myasthenia gravis pathogenesis and prediction of drug efficacy in individual patients. SUMMARY The recent immunological and pathological findings in myasthenia gravis promise to improve myasthenia gravis treatment, via the development of more precise and personalized therapies.
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382
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Soltys J, Liu Y, Ritchie A, Wemlinger S, Schaller K, Schumann H, Owens GP, Bennett JL. Membrane assembly of aquaporin-4 autoantibodies regulates classical complement activation in neuromyelitis optica. J Clin Invest 2019; 129:2000-2013. [PMID: 30958797 DOI: 10.1172/jci122942] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 02/26/2019] [Indexed: 01/29/2023] Open
Abstract
Neuromyelitis optica (NMO) is an autoimmune CNS disorder mediated by pathogenic aquaporin-4 (AQP4) water channel autoantibodies (AQP4-IgG). Although AQP4-IgG-driven complement-dependent cytotoxicity (CDC) is critical for the formation of NMO lesions, the molecular mechanisms governing optimal classical pathway activation are unknown. We investigated the molecular determinants driving CDC in NMO using recombinant AQP4-specific autoantibodies (AQP4 rAbs) derived from affected patients. We identified a group of AQP4 rAbs targeting a distinct extracellular loop C epitope that demonstrated enhanced CDC on target cells. Targeted mutations of AQP4 rAb Fc domains that enhance or diminish C1q binding or antibody Fc-Fc interactions showed that optimal CDC was driven by the assembly of multimeric rAb platforms that increase multivalent C1q binding and facilitate C1q activation. A peptide that blocks antibody Fc-Fc interaction inhibited CDC induced by AQP4 rAbs and polyclonal NMO patient sera. Super-resolution microscopy revealed that AQP4 rAbs with enhanced CDC preferentially formed organized clusters on supramolecular AQP4 orthogonal arrays, linking epitope-dependent multimeric assembly with enhanced C1q binding and activation. The resulting model of AQP4-IgG CDC provides a framework for understanding classical complement activation in human autoantibody-mediated disorders and identifies a potential new therapeutic avenue for treating NMO.
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Affiliation(s)
- John Soltys
- Neuroscience and Medical Scientist Training Programs
| | | | | | | | | | | | | | - Jeffrey L Bennett
- Neuroscience and Medical Scientist Training Programs.,Department of Neurology, and.,Department of Ophthalmology, University of Colorado at Anschutz Medical Campus, Aurora, Colorado, USA
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383
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Affiliation(s)
- Amelia Evoli
- Institute of Neurology, Università Cattolica del Sacro Cuore, Roma, Italy
- Fondazione Policlinico Gemelli, IRCCS, Roma, Italy
| | - Elisa Meacci
- Fondazione Policlinico Gemelli, IRCCS, Roma, Italy
- Institute of Thoracic Surgery, Università Cattolica del Sacro Cuore, Roma, Italy
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384
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Abstract
The humanized monoclonal antibody eculizumab (Soliris®) is a complement inhibitor indicated for use in anti-acetylcholine receptor (AChR) antibody-positive adults with generalized myasthenia gravis (gMG) in the USA, refractory gMG in the EU, or gMG with symptoms that are difficult to control with high-dose IVIg therapy or PLEX in Japan. It is the first complement inhibitor to be approved for use in these patients. In the well-designed, 26-week REGAIN study in patients with anti-AChR-positive refractory gMG, although a statistically significant benefit of eculizumab over placebo in the prespecified primary endpoint analysis (change from baseline in MG-activities of daily living (ADL) score assessed by worst-rank ANCOVA) was not formally demonstrated, preplanned and post hoc sensitivity analyses of this outcome, as well as other secondary outcomes supported the efficacy of eculizumab. Overall, patients receiving eculizumab experienced significant improvements in the ADL, muscle strength and health-related quality of life (HR-QOL) parameters relative to patients receiving placebo. Moreover, an ongoing extension of REGAIN showed that treatment benefits with eculizumab were sustained during continued therapy for at least 52 weeks. Eculizumab was generally well tolerated in these studies, with a tolerability profile similar to that reported previously in other indications. Although several questions remain, such as duration of treatment, cost effectiveness and long-term efficacy and tolerability, current evidence indicates that eculizumab is a valuable emerging therapy for patients with refractory gMG.
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Affiliation(s)
- Sohita Dhillon
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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385
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Thurman JM, Yapa R. Complement Therapeutics in Autoimmune Disease. Front Immunol 2019; 10:672. [PMID: 31001274 PMCID: PMC6456694 DOI: 10.3389/fimmu.2019.00672] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 03/12/2019] [Indexed: 12/17/2022] Open
Abstract
Many autoimmune diseases are characterized by generation of autoantibodies that bind to host proteins or deposit within tissues as a component of immune complexes. The autoantibodies can activate the complement system, which can mediate tissue damage and trigger systemic inflammation. Complement inhibitory drugs may, therefore, be beneficial across a large number of different autoimmune diseases. Many new anti-complement drugs that target specific activation mechanisms or downstream activation fragments are in development. Based on the shared pathophysiology of autoimmune diseases, some of these complement inhibitory drugs may provide benefit across multiple different diseases. In some antibody-mediated autoimmune diseases, however, unique features of the autoantibodies, the target antigens, or the affected tissues may make it advantageous to block individual components or pathways of the complement system. This paper reviews the evidence that complement is involved in various autoimmune diseases, as well as the studies that have examined whether or not complement inhibitors are effective for treating these diseases.
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Affiliation(s)
- Joshua M Thurman
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Roshini Yapa
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, United States
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386
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Rituximab as induction therapy in refractory myasthenia gravis: 18 month follow-up study. J Neurol 2019; 266:1596-1600. [DOI: 10.1007/s00415-019-09296-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 03/19/2019] [Accepted: 03/21/2019] [Indexed: 10/27/2022]
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387
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Abstract
Purpose To evaluate the effect of eculizumab on perceived fatigue in patients with anti-acetylcholine receptor antibody-positive, refractory, generalized myasthenia gravis (MG) using the Quality of Life in Neurological Disorders (Neuro-QOL) Fatigue subscale, and to evaluate correlations between improvements in Neuro-QOL Fatigue and other clinical endpoints. Methods Neuro-QOL Fatigue, MG Activities of Daily Living (MG-ADL), Quantitative MG (QMG), and the 15-item MG Quality of Life (MG-QOL15) scales were administered during the phase 3, randomized, placebo-controlled REGAIN study (eculizumab, n = 62; placebo, n = 63) and subsequent open-label extension (OLE). Data were analyzed using repeated-measures models. Correlations between changes in Neuro-QOL Fatigue and in MG-ADL, QMG, and MG-QOL15 scores were determined at REGAIN week 26. Results At REGAIN week 26, eculizumab-treated patients showed significantly greater improvements in Neuro-QOL Fatigue scores than placebo-treated patients (consistent with improvements in MG-ADL, QMG, and MG-QOL15 scores previously reported in REGAIN). Improvements with eculizumab were sustained through OLE week 52. Correlations between Neuro-QOL Fatigue and MG-QOL15, MG-ADL, and QMG scores were strong for eculizumab-treated patients at REGAIN week 26, and strong, moderate, and weak, respectively, for placebo-treated patients. Conclusions Compared with placebo, eculizumab was associated with improvements in perceived fatigue that strongly correlated with improvements in MG-specific outcome measures. Trial ID Registration: NCT01997229, NCT02301624. Electronic supplementary material The online version of this article (10.1007/s11136-019-02148-2) contains supplementary material, which is available to authorized users.
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van den Berg LH, Sorenson E, Gronseth G, Macklin EA, Andrews J, Baloh RH, Benatar M, Berry JD, Chio A, Corcia P, Genge A, Gubitz AK, Lomen-Hoerth C, McDermott CJ, Pioro EP, Rosenfeld J, Silani V, Turner MR, Weber M, Brooks BR, Miller RG, Mitsumoto H. Revised Airlie House consensus guidelines for design and implementation of ALS clinical trials. Neurology 2019; 92:e1610-e1623. [PMID: 30850440 PMCID: PMC6448453 DOI: 10.1212/wnl.0000000000007242] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 12/06/2018] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To revise the 1999 Airlie House consensus guidelines for the design and implementation of preclinical therapeutic studies and clinical trials in amyotrophic lateral sclerosis (ALS). METHODS A consensus committee comprising 140 key members of the international ALS community (ALS researchers, clinicians, patient representatives, research funding representatives, industry, and regulatory agencies) addressed 9 areas of need within ALS research: (1) preclinical studies; (2) biological and phenotypic heterogeneity; (3) outcome measures; (4) disease-modifying and symptomatic interventions; (5) recruitment and retention; (6) biomarkers; (7) clinical trial phases; (8) beyond traditional trial designs; and (9) statistical considerations. Assigned to 1 of 8 sections, committee members generated a draft set of guidelines based on a "background" of developing a (pre)clinical question and a "rationale" outlining the evidence and expert opinion. Following a 2-day, face-to-face workshop at the Airlie House Conference Center, a modified Delphi process was used to develop draft consensus research guidelines, which were subsequently reviewed and modified based on comments from the public. Statistical experts drafted a separate document of statistical considerations (section 9). RESULTS In this report, we summarize 112 guidelines and their associated backgrounds and rationales. The full list of guidelines, the statistical considerations, and a glossary of terms can be found in data available from Dryad (appendices e-3-e-5, doi.org/10.5061/dryad.32q9q5d). The authors prioritized 15 guidelines with the greatest potential to improve ALS clinical research. CONCLUSION The revised Airlie House ALS Clinical Trials Consensus Guidelines should serve to improve clinical trial design and accelerate the development of effective treatments for patients with ALS.
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Affiliation(s)
- Leonard H van den Berg
- From the Department of Neurology (L.H.v.d.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (E.S.), Mayo Clinic, Rochester, MN; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Medicine (E.A.M.), Massachusetts General Hospital, Biostatistics Center, Harvard Medical School, Boston; Department of Neurology (J.A., H.M.), Columbia University, Eleanor and Lou Gehrig ALS Center, New York, NY; Department of Neurology (R.H.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (M.B.), University of Miami, FL; Neurological Clinical Research Institute (J.D.B.), Massachusetts General Hospital, Boston; Rita Levi Montalcini Department of Neuroscience (A.C.), University of Torino, Italy; Centre Constitutif SLA (P.C.), Université de Tours, France; Department of Neurology (A.G.), Clinical Research Unit, Montreal Neurological Institute, Neurosurgery, McGill University, Montreal, Canada; National Institute of Neurological Disorders and Stroke (A.K.G.), National Institutes of Health, Bethesda, MD; ALS Center (C.L.-H.), University of California San Francisco; Department of Neuroscience (C.J.M.), Sheffield Institute for Translational Neuroscience, University of Sheffield, UK; Department of Neurology (E.P.P.), Section of ALS & Related Disorders, Cleveland Clinic, OH; Department of Neurology (J.R.), The Center for Restorative Neurology, Loma Linda University School of Medicine, CA; Department of Neurology and Laboratory of Neuroscience (V.S.), Istituto Auxologico Italiano, IRCCS, Milan; Department of Pathophysiology and Transplantation (V.S.), "Dino Ferrari" Centre, Università degli Studi di Milano, Milan, Italy; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford, UK; Neuromuscular Diseases Unit/ALS Clinic (M.W.), Kantonsspital St. Gallen, Switzerland; Carolinas Neuromuscular/ALS-MDA Care Center (B.R.B.), Charlotte; Department of Neurology (B.R.B.), Carolinas Medical Center, University of North Carolina School of Medicine, Charlotte; Forbes Norris ALS Treatment and Research Center (R.G.M.), California Pacific Medical Center San Francisco; and Department of Neurosciences (R.G.M.), Stanford University, CA.
| | - Eric Sorenson
- From the Department of Neurology (L.H.v.d.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (E.S.), Mayo Clinic, Rochester, MN; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Medicine (E.A.M.), Massachusetts General Hospital, Biostatistics Center, Harvard Medical School, Boston; Department of Neurology (J.A., H.M.), Columbia University, Eleanor and Lou Gehrig ALS Center, New York, NY; Department of Neurology (R.H.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (M.B.), University of Miami, FL; Neurological Clinical Research Institute (J.D.B.), Massachusetts General Hospital, Boston; Rita Levi Montalcini Department of Neuroscience (A.C.), University of Torino, Italy; Centre Constitutif SLA (P.C.), Université de Tours, France; Department of Neurology (A.G.), Clinical Research Unit, Montreal Neurological Institute, Neurosurgery, McGill University, Montreal, Canada; National Institute of Neurological Disorders and Stroke (A.K.G.), National Institutes of Health, Bethesda, MD; ALS Center (C.L.-H.), University of California San Francisco; Department of Neuroscience (C.J.M.), Sheffield Institute for Translational Neuroscience, University of Sheffield, UK; Department of Neurology (E.P.P.), Section of ALS & Related Disorders, Cleveland Clinic, OH; Department of Neurology (J.R.), The Center for Restorative Neurology, Loma Linda University School of Medicine, CA; Department of Neurology and Laboratory of Neuroscience (V.S.), Istituto Auxologico Italiano, IRCCS, Milan; Department of Pathophysiology and Transplantation (V.S.), "Dino Ferrari" Centre, Università degli Studi di Milano, Milan, Italy; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford, UK; Neuromuscular Diseases Unit/ALS Clinic (M.W.), Kantonsspital St. Gallen, Switzerland; Carolinas Neuromuscular/ALS-MDA Care Center (B.R.B.), Charlotte; Department of Neurology (B.R.B.), Carolinas Medical Center, University of North Carolina School of Medicine, Charlotte; Forbes Norris ALS Treatment and Research Center (R.G.M.), California Pacific Medical Center San Francisco; and Department of Neurosciences (R.G.M.), Stanford University, CA
| | - Gary Gronseth
- From the Department of Neurology (L.H.v.d.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (E.S.), Mayo Clinic, Rochester, MN; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Medicine (E.A.M.), Massachusetts General Hospital, Biostatistics Center, Harvard Medical School, Boston; Department of Neurology (J.A., H.M.), Columbia University, Eleanor and Lou Gehrig ALS Center, New York, NY; Department of Neurology (R.H.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (M.B.), University of Miami, FL; Neurological Clinical Research Institute (J.D.B.), Massachusetts General Hospital, Boston; Rita Levi Montalcini Department of Neuroscience (A.C.), University of Torino, Italy; Centre Constitutif SLA (P.C.), Université de Tours, France; Department of Neurology (A.G.), Clinical Research Unit, Montreal Neurological Institute, Neurosurgery, McGill University, Montreal, Canada; National Institute of Neurological Disorders and Stroke (A.K.G.), National Institutes of Health, Bethesda, MD; ALS Center (C.L.-H.), University of California San Francisco; Department of Neuroscience (C.J.M.), Sheffield Institute for Translational Neuroscience, University of Sheffield, UK; Department of Neurology (E.P.P.), Section of ALS & Related Disorders, Cleveland Clinic, OH; Department of Neurology (J.R.), The Center for Restorative Neurology, Loma Linda University School of Medicine, CA; Department of Neurology and Laboratory of Neuroscience (V.S.), Istituto Auxologico Italiano, IRCCS, Milan; Department of Pathophysiology and Transplantation (V.S.), "Dino Ferrari" Centre, Università degli Studi di Milano, Milan, Italy; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford, UK; Neuromuscular Diseases Unit/ALS Clinic (M.W.), Kantonsspital St. Gallen, Switzerland; Carolinas Neuromuscular/ALS-MDA Care Center (B.R.B.), Charlotte; Department of Neurology (B.R.B.), Carolinas Medical Center, University of North Carolina School of Medicine, Charlotte; Forbes Norris ALS Treatment and Research Center (R.G.M.), California Pacific Medical Center San Francisco; and Department of Neurosciences (R.G.M.), Stanford University, CA
| | - Eric A Macklin
- From the Department of Neurology (L.H.v.d.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (E.S.), Mayo Clinic, Rochester, MN; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Medicine (E.A.M.), Massachusetts General Hospital, Biostatistics Center, Harvard Medical School, Boston; Department of Neurology (J.A., H.M.), Columbia University, Eleanor and Lou Gehrig ALS Center, New York, NY; Department of Neurology (R.H.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (M.B.), University of Miami, FL; Neurological Clinical Research Institute (J.D.B.), Massachusetts General Hospital, Boston; Rita Levi Montalcini Department of Neuroscience (A.C.), University of Torino, Italy; Centre Constitutif SLA (P.C.), Université de Tours, France; Department of Neurology (A.G.), Clinical Research Unit, Montreal Neurological Institute, Neurosurgery, McGill University, Montreal, Canada; National Institute of Neurological Disorders and Stroke (A.K.G.), National Institutes of Health, Bethesda, MD; ALS Center (C.L.-H.), University of California San Francisco; Department of Neuroscience (C.J.M.), Sheffield Institute for Translational Neuroscience, University of Sheffield, UK; Department of Neurology (E.P.P.), Section of ALS & Related Disorders, Cleveland Clinic, OH; Department of Neurology (J.R.), The Center for Restorative Neurology, Loma Linda University School of Medicine, CA; Department of Neurology and Laboratory of Neuroscience (V.S.), Istituto Auxologico Italiano, IRCCS, Milan; Department of Pathophysiology and Transplantation (V.S.), "Dino Ferrari" Centre, Università degli Studi di Milano, Milan, Italy; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford, UK; Neuromuscular Diseases Unit/ALS Clinic (M.W.), Kantonsspital St. Gallen, Switzerland; Carolinas Neuromuscular/ALS-MDA Care Center (B.R.B.), Charlotte; Department of Neurology (B.R.B.), Carolinas Medical Center, University of North Carolina School of Medicine, Charlotte; Forbes Norris ALS Treatment and Research Center (R.G.M.), California Pacific Medical Center San Francisco; and Department of Neurosciences (R.G.M.), Stanford University, CA
| | - Jinsy Andrews
- From the Department of Neurology (L.H.v.d.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (E.S.), Mayo Clinic, Rochester, MN; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Medicine (E.A.M.), Massachusetts General Hospital, Biostatistics Center, Harvard Medical School, Boston; Department of Neurology (J.A., H.M.), Columbia University, Eleanor and Lou Gehrig ALS Center, New York, NY; Department of Neurology (R.H.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (M.B.), University of Miami, FL; Neurological Clinical Research Institute (J.D.B.), Massachusetts General Hospital, Boston; Rita Levi Montalcini Department of Neuroscience (A.C.), University of Torino, Italy; Centre Constitutif SLA (P.C.), Université de Tours, France; Department of Neurology (A.G.), Clinical Research Unit, Montreal Neurological Institute, Neurosurgery, McGill University, Montreal, Canada; National Institute of Neurological Disorders and Stroke (A.K.G.), National Institutes of Health, Bethesda, MD; ALS Center (C.L.-H.), University of California San Francisco; Department of Neuroscience (C.J.M.), Sheffield Institute for Translational Neuroscience, University of Sheffield, UK; Department of Neurology (E.P.P.), Section of ALS & Related Disorders, Cleveland Clinic, OH; Department of Neurology (J.R.), The Center for Restorative Neurology, Loma Linda University School of Medicine, CA; Department of Neurology and Laboratory of Neuroscience (V.S.), Istituto Auxologico Italiano, IRCCS, Milan; Department of Pathophysiology and Transplantation (V.S.), "Dino Ferrari" Centre, Università degli Studi di Milano, Milan, Italy; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford, UK; Neuromuscular Diseases Unit/ALS Clinic (M.W.), Kantonsspital St. Gallen, Switzerland; Carolinas Neuromuscular/ALS-MDA Care Center (B.R.B.), Charlotte; Department of Neurology (B.R.B.), Carolinas Medical Center, University of North Carolina School of Medicine, Charlotte; Forbes Norris ALS Treatment and Research Center (R.G.M.), California Pacific Medical Center San Francisco; and Department of Neurosciences (R.G.M.), Stanford University, CA
| | - Robert H Baloh
- From the Department of Neurology (L.H.v.d.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (E.S.), Mayo Clinic, Rochester, MN; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Medicine (E.A.M.), Massachusetts General Hospital, Biostatistics Center, Harvard Medical School, Boston; Department of Neurology (J.A., H.M.), Columbia University, Eleanor and Lou Gehrig ALS Center, New York, NY; Department of Neurology (R.H.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (M.B.), University of Miami, FL; Neurological Clinical Research Institute (J.D.B.), Massachusetts General Hospital, Boston; Rita Levi Montalcini Department of Neuroscience (A.C.), University of Torino, Italy; Centre Constitutif SLA (P.C.), Université de Tours, France; Department of Neurology (A.G.), Clinical Research Unit, Montreal Neurological Institute, Neurosurgery, McGill University, Montreal, Canada; National Institute of Neurological Disorders and Stroke (A.K.G.), National Institutes of Health, Bethesda, MD; ALS Center (C.L.-H.), University of California San Francisco; Department of Neuroscience (C.J.M.), Sheffield Institute for Translational Neuroscience, University of Sheffield, UK; Department of Neurology (E.P.P.), Section of ALS & Related Disorders, Cleveland Clinic, OH; Department of Neurology (J.R.), The Center for Restorative Neurology, Loma Linda University School of Medicine, CA; Department of Neurology and Laboratory of Neuroscience (V.S.), Istituto Auxologico Italiano, IRCCS, Milan; Department of Pathophysiology and Transplantation (V.S.), "Dino Ferrari" Centre, Università degli Studi di Milano, Milan, Italy; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford, UK; Neuromuscular Diseases Unit/ALS Clinic (M.W.), Kantonsspital St. Gallen, Switzerland; Carolinas Neuromuscular/ALS-MDA Care Center (B.R.B.), Charlotte; Department of Neurology (B.R.B.), Carolinas Medical Center, University of North Carolina School of Medicine, Charlotte; Forbes Norris ALS Treatment and Research Center (R.G.M.), California Pacific Medical Center San Francisco; and Department of Neurosciences (R.G.M.), Stanford University, CA
| | - Michael Benatar
- From the Department of Neurology (L.H.v.d.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (E.S.), Mayo Clinic, Rochester, MN; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Medicine (E.A.M.), Massachusetts General Hospital, Biostatistics Center, Harvard Medical School, Boston; Department of Neurology (J.A., H.M.), Columbia University, Eleanor and Lou Gehrig ALS Center, New York, NY; Department of Neurology (R.H.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (M.B.), University of Miami, FL; Neurological Clinical Research Institute (J.D.B.), Massachusetts General Hospital, Boston; Rita Levi Montalcini Department of Neuroscience (A.C.), University of Torino, Italy; Centre Constitutif SLA (P.C.), Université de Tours, France; Department of Neurology (A.G.), Clinical Research Unit, Montreal Neurological Institute, Neurosurgery, McGill University, Montreal, Canada; National Institute of Neurological Disorders and Stroke (A.K.G.), National Institutes of Health, Bethesda, MD; ALS Center (C.L.-H.), University of California San Francisco; Department of Neuroscience (C.J.M.), Sheffield Institute for Translational Neuroscience, University of Sheffield, UK; Department of Neurology (E.P.P.), Section of ALS & Related Disorders, Cleveland Clinic, OH; Department of Neurology (J.R.), The Center for Restorative Neurology, Loma Linda University School of Medicine, CA; Department of Neurology and Laboratory of Neuroscience (V.S.), Istituto Auxologico Italiano, IRCCS, Milan; Department of Pathophysiology and Transplantation (V.S.), "Dino Ferrari" Centre, Università degli Studi di Milano, Milan, Italy; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford, UK; Neuromuscular Diseases Unit/ALS Clinic (M.W.), Kantonsspital St. Gallen, Switzerland; Carolinas Neuromuscular/ALS-MDA Care Center (B.R.B.), Charlotte; Department of Neurology (B.R.B.), Carolinas Medical Center, University of North Carolina School of Medicine, Charlotte; Forbes Norris ALS Treatment and Research Center (R.G.M.), California Pacific Medical Center San Francisco; and Department of Neurosciences (R.G.M.), Stanford University, CA
| | - James D Berry
- From the Department of Neurology (L.H.v.d.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (E.S.), Mayo Clinic, Rochester, MN; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Medicine (E.A.M.), Massachusetts General Hospital, Biostatistics Center, Harvard Medical School, Boston; Department of Neurology (J.A., H.M.), Columbia University, Eleanor and Lou Gehrig ALS Center, New York, NY; Department of Neurology (R.H.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (M.B.), University of Miami, FL; Neurological Clinical Research Institute (J.D.B.), Massachusetts General Hospital, Boston; Rita Levi Montalcini Department of Neuroscience (A.C.), University of Torino, Italy; Centre Constitutif SLA (P.C.), Université de Tours, France; Department of Neurology (A.G.), Clinical Research Unit, Montreal Neurological Institute, Neurosurgery, McGill University, Montreal, Canada; National Institute of Neurological Disorders and Stroke (A.K.G.), National Institutes of Health, Bethesda, MD; ALS Center (C.L.-H.), University of California San Francisco; Department of Neuroscience (C.J.M.), Sheffield Institute for Translational Neuroscience, University of Sheffield, UK; Department of Neurology (E.P.P.), Section of ALS & Related Disorders, Cleveland Clinic, OH; Department of Neurology (J.R.), The Center for Restorative Neurology, Loma Linda University School of Medicine, CA; Department of Neurology and Laboratory of Neuroscience (V.S.), Istituto Auxologico Italiano, IRCCS, Milan; Department of Pathophysiology and Transplantation (V.S.), "Dino Ferrari" Centre, Università degli Studi di Milano, Milan, Italy; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford, UK; Neuromuscular Diseases Unit/ALS Clinic (M.W.), Kantonsspital St. Gallen, Switzerland; Carolinas Neuromuscular/ALS-MDA Care Center (B.R.B.), Charlotte; Department of Neurology (B.R.B.), Carolinas Medical Center, University of North Carolina School of Medicine, Charlotte; Forbes Norris ALS Treatment and Research Center (R.G.M.), California Pacific Medical Center San Francisco; and Department of Neurosciences (R.G.M.), Stanford University, CA
| | - Adriano Chio
- From the Department of Neurology (L.H.v.d.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (E.S.), Mayo Clinic, Rochester, MN; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Medicine (E.A.M.), Massachusetts General Hospital, Biostatistics Center, Harvard Medical School, Boston; Department of Neurology (J.A., H.M.), Columbia University, Eleanor and Lou Gehrig ALS Center, New York, NY; Department of Neurology (R.H.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (M.B.), University of Miami, FL; Neurological Clinical Research Institute (J.D.B.), Massachusetts General Hospital, Boston; Rita Levi Montalcini Department of Neuroscience (A.C.), University of Torino, Italy; Centre Constitutif SLA (P.C.), Université de Tours, France; Department of Neurology (A.G.), Clinical Research Unit, Montreal Neurological Institute, Neurosurgery, McGill University, Montreal, Canada; National Institute of Neurological Disorders and Stroke (A.K.G.), National Institutes of Health, Bethesda, MD; ALS Center (C.L.-H.), University of California San Francisco; Department of Neuroscience (C.J.M.), Sheffield Institute for Translational Neuroscience, University of Sheffield, UK; Department of Neurology (E.P.P.), Section of ALS & Related Disorders, Cleveland Clinic, OH; Department of Neurology (J.R.), The Center for Restorative Neurology, Loma Linda University School of Medicine, CA; Department of Neurology and Laboratory of Neuroscience (V.S.), Istituto Auxologico Italiano, IRCCS, Milan; Department of Pathophysiology and Transplantation (V.S.), "Dino Ferrari" Centre, Università degli Studi di Milano, Milan, Italy; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford, UK; Neuromuscular Diseases Unit/ALS Clinic (M.W.), Kantonsspital St. Gallen, Switzerland; Carolinas Neuromuscular/ALS-MDA Care Center (B.R.B.), Charlotte; Department of Neurology (B.R.B.), Carolinas Medical Center, University of North Carolina School of Medicine, Charlotte; Forbes Norris ALS Treatment and Research Center (R.G.M.), California Pacific Medical Center San Francisco; and Department of Neurosciences (R.G.M.), Stanford University, CA
| | - Philippe Corcia
- From the Department of Neurology (L.H.v.d.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (E.S.), Mayo Clinic, Rochester, MN; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Medicine (E.A.M.), Massachusetts General Hospital, Biostatistics Center, Harvard Medical School, Boston; Department of Neurology (J.A., H.M.), Columbia University, Eleanor and Lou Gehrig ALS Center, New York, NY; Department of Neurology (R.H.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (M.B.), University of Miami, FL; Neurological Clinical Research Institute (J.D.B.), Massachusetts General Hospital, Boston; Rita Levi Montalcini Department of Neuroscience (A.C.), University of Torino, Italy; Centre Constitutif SLA (P.C.), Université de Tours, France; Department of Neurology (A.G.), Clinical Research Unit, Montreal Neurological Institute, Neurosurgery, McGill University, Montreal, Canada; National Institute of Neurological Disorders and Stroke (A.K.G.), National Institutes of Health, Bethesda, MD; ALS Center (C.L.-H.), University of California San Francisco; Department of Neuroscience (C.J.M.), Sheffield Institute for Translational Neuroscience, University of Sheffield, UK; Department of Neurology (E.P.P.), Section of ALS & Related Disorders, Cleveland Clinic, OH; Department of Neurology (J.R.), The Center for Restorative Neurology, Loma Linda University School of Medicine, CA; Department of Neurology and Laboratory of Neuroscience (V.S.), Istituto Auxologico Italiano, IRCCS, Milan; Department of Pathophysiology and Transplantation (V.S.), "Dino Ferrari" Centre, Università degli Studi di Milano, Milan, Italy; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford, UK; Neuromuscular Diseases Unit/ALS Clinic (M.W.), Kantonsspital St. Gallen, Switzerland; Carolinas Neuromuscular/ALS-MDA Care Center (B.R.B.), Charlotte; Department of Neurology (B.R.B.), Carolinas Medical Center, University of North Carolina School of Medicine, Charlotte; Forbes Norris ALS Treatment and Research Center (R.G.M.), California Pacific Medical Center San Francisco; and Department of Neurosciences (R.G.M.), Stanford University, CA
| | - Angela Genge
- From the Department of Neurology (L.H.v.d.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (E.S.), Mayo Clinic, Rochester, MN; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Medicine (E.A.M.), Massachusetts General Hospital, Biostatistics Center, Harvard Medical School, Boston; Department of Neurology (J.A., H.M.), Columbia University, Eleanor and Lou Gehrig ALS Center, New York, NY; Department of Neurology (R.H.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (M.B.), University of Miami, FL; Neurological Clinical Research Institute (J.D.B.), Massachusetts General Hospital, Boston; Rita Levi Montalcini Department of Neuroscience (A.C.), University of Torino, Italy; Centre Constitutif SLA (P.C.), Université de Tours, France; Department of Neurology (A.G.), Clinical Research Unit, Montreal Neurological Institute, Neurosurgery, McGill University, Montreal, Canada; National Institute of Neurological Disorders and Stroke (A.K.G.), National Institutes of Health, Bethesda, MD; ALS Center (C.L.-H.), University of California San Francisco; Department of Neuroscience (C.J.M.), Sheffield Institute for Translational Neuroscience, University of Sheffield, UK; Department of Neurology (E.P.P.), Section of ALS & Related Disorders, Cleveland Clinic, OH; Department of Neurology (J.R.), The Center for Restorative Neurology, Loma Linda University School of Medicine, CA; Department of Neurology and Laboratory of Neuroscience (V.S.), Istituto Auxologico Italiano, IRCCS, Milan; Department of Pathophysiology and Transplantation (V.S.), "Dino Ferrari" Centre, Università degli Studi di Milano, Milan, Italy; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford, UK; Neuromuscular Diseases Unit/ALS Clinic (M.W.), Kantonsspital St. Gallen, Switzerland; Carolinas Neuromuscular/ALS-MDA Care Center (B.R.B.), Charlotte; Department of Neurology (B.R.B.), Carolinas Medical Center, University of North Carolina School of Medicine, Charlotte; Forbes Norris ALS Treatment and Research Center (R.G.M.), California Pacific Medical Center San Francisco; and Department of Neurosciences (R.G.M.), Stanford University, CA
| | - Amelie K Gubitz
- From the Department of Neurology (L.H.v.d.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (E.S.), Mayo Clinic, Rochester, MN; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Medicine (E.A.M.), Massachusetts General Hospital, Biostatistics Center, Harvard Medical School, Boston; Department of Neurology (J.A., H.M.), Columbia University, Eleanor and Lou Gehrig ALS Center, New York, NY; Department of Neurology (R.H.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (M.B.), University of Miami, FL; Neurological Clinical Research Institute (J.D.B.), Massachusetts General Hospital, Boston; Rita Levi Montalcini Department of Neuroscience (A.C.), University of Torino, Italy; Centre Constitutif SLA (P.C.), Université de Tours, France; Department of Neurology (A.G.), Clinical Research Unit, Montreal Neurological Institute, Neurosurgery, McGill University, Montreal, Canada; National Institute of Neurological Disorders and Stroke (A.K.G.), National Institutes of Health, Bethesda, MD; ALS Center (C.L.-H.), University of California San Francisco; Department of Neuroscience (C.J.M.), Sheffield Institute for Translational Neuroscience, University of Sheffield, UK; Department of Neurology (E.P.P.), Section of ALS & Related Disorders, Cleveland Clinic, OH; Department of Neurology (J.R.), The Center for Restorative Neurology, Loma Linda University School of Medicine, CA; Department of Neurology and Laboratory of Neuroscience (V.S.), Istituto Auxologico Italiano, IRCCS, Milan; Department of Pathophysiology and Transplantation (V.S.), "Dino Ferrari" Centre, Università degli Studi di Milano, Milan, Italy; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford, UK; Neuromuscular Diseases Unit/ALS Clinic (M.W.), Kantonsspital St. Gallen, Switzerland; Carolinas Neuromuscular/ALS-MDA Care Center (B.R.B.), Charlotte; Department of Neurology (B.R.B.), Carolinas Medical Center, University of North Carolina School of Medicine, Charlotte; Forbes Norris ALS Treatment and Research Center (R.G.M.), California Pacific Medical Center San Francisco; and Department of Neurosciences (R.G.M.), Stanford University, CA
| | - Catherine Lomen-Hoerth
- From the Department of Neurology (L.H.v.d.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (E.S.), Mayo Clinic, Rochester, MN; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Medicine (E.A.M.), Massachusetts General Hospital, Biostatistics Center, Harvard Medical School, Boston; Department of Neurology (J.A., H.M.), Columbia University, Eleanor and Lou Gehrig ALS Center, New York, NY; Department of Neurology (R.H.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (M.B.), University of Miami, FL; Neurological Clinical Research Institute (J.D.B.), Massachusetts General Hospital, Boston; Rita Levi Montalcini Department of Neuroscience (A.C.), University of Torino, Italy; Centre Constitutif SLA (P.C.), Université de Tours, France; Department of Neurology (A.G.), Clinical Research Unit, Montreal Neurological Institute, Neurosurgery, McGill University, Montreal, Canada; National Institute of Neurological Disorders and Stroke (A.K.G.), National Institutes of Health, Bethesda, MD; ALS Center (C.L.-H.), University of California San Francisco; Department of Neuroscience (C.J.M.), Sheffield Institute for Translational Neuroscience, University of Sheffield, UK; Department of Neurology (E.P.P.), Section of ALS & Related Disorders, Cleveland Clinic, OH; Department of Neurology (J.R.), The Center for Restorative Neurology, Loma Linda University School of Medicine, CA; Department of Neurology and Laboratory of Neuroscience (V.S.), Istituto Auxologico Italiano, IRCCS, Milan; Department of Pathophysiology and Transplantation (V.S.), "Dino Ferrari" Centre, Università degli Studi di Milano, Milan, Italy; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford, UK; Neuromuscular Diseases Unit/ALS Clinic (M.W.), Kantonsspital St. Gallen, Switzerland; Carolinas Neuromuscular/ALS-MDA Care Center (B.R.B.), Charlotte; Department of Neurology (B.R.B.), Carolinas Medical Center, University of North Carolina School of Medicine, Charlotte; Forbes Norris ALS Treatment and Research Center (R.G.M.), California Pacific Medical Center San Francisco; and Department of Neurosciences (R.G.M.), Stanford University, CA
| | - Christopher J McDermott
- From the Department of Neurology (L.H.v.d.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (E.S.), Mayo Clinic, Rochester, MN; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Medicine (E.A.M.), Massachusetts General Hospital, Biostatistics Center, Harvard Medical School, Boston; Department of Neurology (J.A., H.M.), Columbia University, Eleanor and Lou Gehrig ALS Center, New York, NY; Department of Neurology (R.H.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (M.B.), University of Miami, FL; Neurological Clinical Research Institute (J.D.B.), Massachusetts General Hospital, Boston; Rita Levi Montalcini Department of Neuroscience (A.C.), University of Torino, Italy; Centre Constitutif SLA (P.C.), Université de Tours, France; Department of Neurology (A.G.), Clinical Research Unit, Montreal Neurological Institute, Neurosurgery, McGill University, Montreal, Canada; National Institute of Neurological Disorders and Stroke (A.K.G.), National Institutes of Health, Bethesda, MD; ALS Center (C.L.-H.), University of California San Francisco; Department of Neuroscience (C.J.M.), Sheffield Institute for Translational Neuroscience, University of Sheffield, UK; Department of Neurology (E.P.P.), Section of ALS & Related Disorders, Cleveland Clinic, OH; Department of Neurology (J.R.), The Center for Restorative Neurology, Loma Linda University School of Medicine, CA; Department of Neurology and Laboratory of Neuroscience (V.S.), Istituto Auxologico Italiano, IRCCS, Milan; Department of Pathophysiology and Transplantation (V.S.), "Dino Ferrari" Centre, Università degli Studi di Milano, Milan, Italy; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford, UK; Neuromuscular Diseases Unit/ALS Clinic (M.W.), Kantonsspital St. Gallen, Switzerland; Carolinas Neuromuscular/ALS-MDA Care Center (B.R.B.), Charlotte; Department of Neurology (B.R.B.), Carolinas Medical Center, University of North Carolina School of Medicine, Charlotte; Forbes Norris ALS Treatment and Research Center (R.G.M.), California Pacific Medical Center San Francisco; and Department of Neurosciences (R.G.M.), Stanford University, CA
| | - Erik P Pioro
- From the Department of Neurology (L.H.v.d.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (E.S.), Mayo Clinic, Rochester, MN; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Medicine (E.A.M.), Massachusetts General Hospital, Biostatistics Center, Harvard Medical School, Boston; Department of Neurology (J.A., H.M.), Columbia University, Eleanor and Lou Gehrig ALS Center, New York, NY; Department of Neurology (R.H.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (M.B.), University of Miami, FL; Neurological Clinical Research Institute (J.D.B.), Massachusetts General Hospital, Boston; Rita Levi Montalcini Department of Neuroscience (A.C.), University of Torino, Italy; Centre Constitutif SLA (P.C.), Université de Tours, France; Department of Neurology (A.G.), Clinical Research Unit, Montreal Neurological Institute, Neurosurgery, McGill University, Montreal, Canada; National Institute of Neurological Disorders and Stroke (A.K.G.), National Institutes of Health, Bethesda, MD; ALS Center (C.L.-H.), University of California San Francisco; Department of Neuroscience (C.J.M.), Sheffield Institute for Translational Neuroscience, University of Sheffield, UK; Department of Neurology (E.P.P.), Section of ALS & Related Disorders, Cleveland Clinic, OH; Department of Neurology (J.R.), The Center for Restorative Neurology, Loma Linda University School of Medicine, CA; Department of Neurology and Laboratory of Neuroscience (V.S.), Istituto Auxologico Italiano, IRCCS, Milan; Department of Pathophysiology and Transplantation (V.S.), "Dino Ferrari" Centre, Università degli Studi di Milano, Milan, Italy; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford, UK; Neuromuscular Diseases Unit/ALS Clinic (M.W.), Kantonsspital St. Gallen, Switzerland; Carolinas Neuromuscular/ALS-MDA Care Center (B.R.B.), Charlotte; Department of Neurology (B.R.B.), Carolinas Medical Center, University of North Carolina School of Medicine, Charlotte; Forbes Norris ALS Treatment and Research Center (R.G.M.), California Pacific Medical Center San Francisco; and Department of Neurosciences (R.G.M.), Stanford University, CA
| | - Jeffrey Rosenfeld
- From the Department of Neurology (L.H.v.d.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (E.S.), Mayo Clinic, Rochester, MN; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Medicine (E.A.M.), Massachusetts General Hospital, Biostatistics Center, Harvard Medical School, Boston; Department of Neurology (J.A., H.M.), Columbia University, Eleanor and Lou Gehrig ALS Center, New York, NY; Department of Neurology (R.H.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (M.B.), University of Miami, FL; Neurological Clinical Research Institute (J.D.B.), Massachusetts General Hospital, Boston; Rita Levi Montalcini Department of Neuroscience (A.C.), University of Torino, Italy; Centre Constitutif SLA (P.C.), Université de Tours, France; Department of Neurology (A.G.), Clinical Research Unit, Montreal Neurological Institute, Neurosurgery, McGill University, Montreal, Canada; National Institute of Neurological Disorders and Stroke (A.K.G.), National Institutes of Health, Bethesda, MD; ALS Center (C.L.-H.), University of California San Francisco; Department of Neuroscience (C.J.M.), Sheffield Institute for Translational Neuroscience, University of Sheffield, UK; Department of Neurology (E.P.P.), Section of ALS & Related Disorders, Cleveland Clinic, OH; Department of Neurology (J.R.), The Center for Restorative Neurology, Loma Linda University School of Medicine, CA; Department of Neurology and Laboratory of Neuroscience (V.S.), Istituto Auxologico Italiano, IRCCS, Milan; Department of Pathophysiology and Transplantation (V.S.), "Dino Ferrari" Centre, Università degli Studi di Milano, Milan, Italy; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford, UK; Neuromuscular Diseases Unit/ALS Clinic (M.W.), Kantonsspital St. Gallen, Switzerland; Carolinas Neuromuscular/ALS-MDA Care Center (B.R.B.), Charlotte; Department of Neurology (B.R.B.), Carolinas Medical Center, University of North Carolina School of Medicine, Charlotte; Forbes Norris ALS Treatment and Research Center (R.G.M.), California Pacific Medical Center San Francisco; and Department of Neurosciences (R.G.M.), Stanford University, CA
| | - Vincenzo Silani
- From the Department of Neurology (L.H.v.d.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (E.S.), Mayo Clinic, Rochester, MN; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Medicine (E.A.M.), Massachusetts General Hospital, Biostatistics Center, Harvard Medical School, Boston; Department of Neurology (J.A., H.M.), Columbia University, Eleanor and Lou Gehrig ALS Center, New York, NY; Department of Neurology (R.H.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (M.B.), University of Miami, FL; Neurological Clinical Research Institute (J.D.B.), Massachusetts General Hospital, Boston; Rita Levi Montalcini Department of Neuroscience (A.C.), University of Torino, Italy; Centre Constitutif SLA (P.C.), Université de Tours, France; Department of Neurology (A.G.), Clinical Research Unit, Montreal Neurological Institute, Neurosurgery, McGill University, Montreal, Canada; National Institute of Neurological Disorders and Stroke (A.K.G.), National Institutes of Health, Bethesda, MD; ALS Center (C.L.-H.), University of California San Francisco; Department of Neuroscience (C.J.M.), Sheffield Institute for Translational Neuroscience, University of Sheffield, UK; Department of Neurology (E.P.P.), Section of ALS & Related Disorders, Cleveland Clinic, OH; Department of Neurology (J.R.), The Center for Restorative Neurology, Loma Linda University School of Medicine, CA; Department of Neurology and Laboratory of Neuroscience (V.S.), Istituto Auxologico Italiano, IRCCS, Milan; Department of Pathophysiology and Transplantation (V.S.), "Dino Ferrari" Centre, Università degli Studi di Milano, Milan, Italy; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford, UK; Neuromuscular Diseases Unit/ALS Clinic (M.W.), Kantonsspital St. Gallen, Switzerland; Carolinas Neuromuscular/ALS-MDA Care Center (B.R.B.), Charlotte; Department of Neurology (B.R.B.), Carolinas Medical Center, University of North Carolina School of Medicine, Charlotte; Forbes Norris ALS Treatment and Research Center (R.G.M.), California Pacific Medical Center San Francisco; and Department of Neurosciences (R.G.M.), Stanford University, CA
| | - Martin R Turner
- From the Department of Neurology (L.H.v.d.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (E.S.), Mayo Clinic, Rochester, MN; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Medicine (E.A.M.), Massachusetts General Hospital, Biostatistics Center, Harvard Medical School, Boston; Department of Neurology (J.A., H.M.), Columbia University, Eleanor and Lou Gehrig ALS Center, New York, NY; Department of Neurology (R.H.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (M.B.), University of Miami, FL; Neurological Clinical Research Institute (J.D.B.), Massachusetts General Hospital, Boston; Rita Levi Montalcini Department of Neuroscience (A.C.), University of Torino, Italy; Centre Constitutif SLA (P.C.), Université de Tours, France; Department of Neurology (A.G.), Clinical Research Unit, Montreal Neurological Institute, Neurosurgery, McGill University, Montreal, Canada; National Institute of Neurological Disorders and Stroke (A.K.G.), National Institutes of Health, Bethesda, MD; ALS Center (C.L.-H.), University of California San Francisco; Department of Neuroscience (C.J.M.), Sheffield Institute for Translational Neuroscience, University of Sheffield, UK; Department of Neurology (E.P.P.), Section of ALS & Related Disorders, Cleveland Clinic, OH; Department of Neurology (J.R.), The Center for Restorative Neurology, Loma Linda University School of Medicine, CA; Department of Neurology and Laboratory of Neuroscience (V.S.), Istituto Auxologico Italiano, IRCCS, Milan; Department of Pathophysiology and Transplantation (V.S.), "Dino Ferrari" Centre, Università degli Studi di Milano, Milan, Italy; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford, UK; Neuromuscular Diseases Unit/ALS Clinic (M.W.), Kantonsspital St. Gallen, Switzerland; Carolinas Neuromuscular/ALS-MDA Care Center (B.R.B.), Charlotte; Department of Neurology (B.R.B.), Carolinas Medical Center, University of North Carolina School of Medicine, Charlotte; Forbes Norris ALS Treatment and Research Center (R.G.M.), California Pacific Medical Center San Francisco; and Department of Neurosciences (R.G.M.), Stanford University, CA
| | - Markus Weber
- From the Department of Neurology (L.H.v.d.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (E.S.), Mayo Clinic, Rochester, MN; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Medicine (E.A.M.), Massachusetts General Hospital, Biostatistics Center, Harvard Medical School, Boston; Department of Neurology (J.A., H.M.), Columbia University, Eleanor and Lou Gehrig ALS Center, New York, NY; Department of Neurology (R.H.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (M.B.), University of Miami, FL; Neurological Clinical Research Institute (J.D.B.), Massachusetts General Hospital, Boston; Rita Levi Montalcini Department of Neuroscience (A.C.), University of Torino, Italy; Centre Constitutif SLA (P.C.), Université de Tours, France; Department of Neurology (A.G.), Clinical Research Unit, Montreal Neurological Institute, Neurosurgery, McGill University, Montreal, Canada; National Institute of Neurological Disorders and Stroke (A.K.G.), National Institutes of Health, Bethesda, MD; ALS Center (C.L.-H.), University of California San Francisco; Department of Neuroscience (C.J.M.), Sheffield Institute for Translational Neuroscience, University of Sheffield, UK; Department of Neurology (E.P.P.), Section of ALS & Related Disorders, Cleveland Clinic, OH; Department of Neurology (J.R.), The Center for Restorative Neurology, Loma Linda University School of Medicine, CA; Department of Neurology and Laboratory of Neuroscience (V.S.), Istituto Auxologico Italiano, IRCCS, Milan; Department of Pathophysiology and Transplantation (V.S.), "Dino Ferrari" Centre, Università degli Studi di Milano, Milan, Italy; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford, UK; Neuromuscular Diseases Unit/ALS Clinic (M.W.), Kantonsspital St. Gallen, Switzerland; Carolinas Neuromuscular/ALS-MDA Care Center (B.R.B.), Charlotte; Department of Neurology (B.R.B.), Carolinas Medical Center, University of North Carolina School of Medicine, Charlotte; Forbes Norris ALS Treatment and Research Center (R.G.M.), California Pacific Medical Center San Francisco; and Department of Neurosciences (R.G.M.), Stanford University, CA
| | - Benjamin Rix Brooks
- From the Department of Neurology (L.H.v.d.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (E.S.), Mayo Clinic, Rochester, MN; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Medicine (E.A.M.), Massachusetts General Hospital, Biostatistics Center, Harvard Medical School, Boston; Department of Neurology (J.A., H.M.), Columbia University, Eleanor and Lou Gehrig ALS Center, New York, NY; Department of Neurology (R.H.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (M.B.), University of Miami, FL; Neurological Clinical Research Institute (J.D.B.), Massachusetts General Hospital, Boston; Rita Levi Montalcini Department of Neuroscience (A.C.), University of Torino, Italy; Centre Constitutif SLA (P.C.), Université de Tours, France; Department of Neurology (A.G.), Clinical Research Unit, Montreal Neurological Institute, Neurosurgery, McGill University, Montreal, Canada; National Institute of Neurological Disorders and Stroke (A.K.G.), National Institutes of Health, Bethesda, MD; ALS Center (C.L.-H.), University of California San Francisco; Department of Neuroscience (C.J.M.), Sheffield Institute for Translational Neuroscience, University of Sheffield, UK; Department of Neurology (E.P.P.), Section of ALS & Related Disorders, Cleveland Clinic, OH; Department of Neurology (J.R.), The Center for Restorative Neurology, Loma Linda University School of Medicine, CA; Department of Neurology and Laboratory of Neuroscience (V.S.), Istituto Auxologico Italiano, IRCCS, Milan; Department of Pathophysiology and Transplantation (V.S.), "Dino Ferrari" Centre, Università degli Studi di Milano, Milan, Italy; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford, UK; Neuromuscular Diseases Unit/ALS Clinic (M.W.), Kantonsspital St. Gallen, Switzerland; Carolinas Neuromuscular/ALS-MDA Care Center (B.R.B.), Charlotte; Department of Neurology (B.R.B.), Carolinas Medical Center, University of North Carolina School of Medicine, Charlotte; Forbes Norris ALS Treatment and Research Center (R.G.M.), California Pacific Medical Center San Francisco; and Department of Neurosciences (R.G.M.), Stanford University, CA
| | - Robert G Miller
- From the Department of Neurology (L.H.v.d.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (E.S.), Mayo Clinic, Rochester, MN; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Medicine (E.A.M.), Massachusetts General Hospital, Biostatistics Center, Harvard Medical School, Boston; Department of Neurology (J.A., H.M.), Columbia University, Eleanor and Lou Gehrig ALS Center, New York, NY; Department of Neurology (R.H.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (M.B.), University of Miami, FL; Neurological Clinical Research Institute (J.D.B.), Massachusetts General Hospital, Boston; Rita Levi Montalcini Department of Neuroscience (A.C.), University of Torino, Italy; Centre Constitutif SLA (P.C.), Université de Tours, France; Department of Neurology (A.G.), Clinical Research Unit, Montreal Neurological Institute, Neurosurgery, McGill University, Montreal, Canada; National Institute of Neurological Disorders and Stroke (A.K.G.), National Institutes of Health, Bethesda, MD; ALS Center (C.L.-H.), University of California San Francisco; Department of Neuroscience (C.J.M.), Sheffield Institute for Translational Neuroscience, University of Sheffield, UK; Department of Neurology (E.P.P.), Section of ALS & Related Disorders, Cleveland Clinic, OH; Department of Neurology (J.R.), The Center for Restorative Neurology, Loma Linda University School of Medicine, CA; Department of Neurology and Laboratory of Neuroscience (V.S.), Istituto Auxologico Italiano, IRCCS, Milan; Department of Pathophysiology and Transplantation (V.S.), "Dino Ferrari" Centre, Università degli Studi di Milano, Milan, Italy; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford, UK; Neuromuscular Diseases Unit/ALS Clinic (M.W.), Kantonsspital St. Gallen, Switzerland; Carolinas Neuromuscular/ALS-MDA Care Center (B.R.B.), Charlotte; Department of Neurology (B.R.B.), Carolinas Medical Center, University of North Carolina School of Medicine, Charlotte; Forbes Norris ALS Treatment and Research Center (R.G.M.), California Pacific Medical Center San Francisco; and Department of Neurosciences (R.G.M.), Stanford University, CA
| | - Hiroshi Mitsumoto
- From the Department of Neurology (L.H.v.d.B.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (E.S.), Mayo Clinic, Rochester, MN; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Medicine (E.A.M.), Massachusetts General Hospital, Biostatistics Center, Harvard Medical School, Boston; Department of Neurology (J.A., H.M.), Columbia University, Eleanor and Lou Gehrig ALS Center, New York, NY; Department of Neurology (R.H.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (M.B.), University of Miami, FL; Neurological Clinical Research Institute (J.D.B.), Massachusetts General Hospital, Boston; Rita Levi Montalcini Department of Neuroscience (A.C.), University of Torino, Italy; Centre Constitutif SLA (P.C.), Université de Tours, France; Department of Neurology (A.G.), Clinical Research Unit, Montreal Neurological Institute, Neurosurgery, McGill University, Montreal, Canada; National Institute of Neurological Disorders and Stroke (A.K.G.), National Institutes of Health, Bethesda, MD; ALS Center (C.L.-H.), University of California San Francisco; Department of Neuroscience (C.J.M.), Sheffield Institute for Translational Neuroscience, University of Sheffield, UK; Department of Neurology (E.P.P.), Section of ALS & Related Disorders, Cleveland Clinic, OH; Department of Neurology (J.R.), The Center for Restorative Neurology, Loma Linda University School of Medicine, CA; Department of Neurology and Laboratory of Neuroscience (V.S.), Istituto Auxologico Italiano, IRCCS, Milan; Department of Pathophysiology and Transplantation (V.S.), "Dino Ferrari" Centre, Università degli Studi di Milano, Milan, Italy; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford, UK; Neuromuscular Diseases Unit/ALS Clinic (M.W.), Kantonsspital St. Gallen, Switzerland; Carolinas Neuromuscular/ALS-MDA Care Center (B.R.B.), Charlotte; Department of Neurology (B.R.B.), Carolinas Medical Center, University of North Carolina School of Medicine, Charlotte; Forbes Norris ALS Treatment and Research Center (R.G.M.), California Pacific Medical Center San Francisco; and Department of Neurosciences (R.G.M.), Stanford University, CA
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Muppidi S, Utsugisawa K, Benatar M, Murai H, Barohn RJ, Illa I, Jacob S, Vissing J, Burns TM, Kissel JT, Nowak RJ, Andersen H, Casasnovas C, de Bleecker JL, Vu TH, Mantegazza R, O'Brien FL, Wang JJ, Fujita KP, Howard JF. Long-term safety and efficacy of eculizumab in generalized myasthenia gravis. Muscle Nerve 2019; 60:14-24. [PMID: 30767274 PMCID: PMC6619057 DOI: 10.1002/mus.26447] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2019] [Indexed: 01/16/2023]
Abstract
Introduction: Eculizumab is effective and well tolerated in patients with antiacetylcholine receptor antibody‐positive refractory generalized myasthenia gravis (gMG; REGAIN; NCT01997229). We report an interim analysis of an open‐label extension of REGAIN, evaluating eculizumab's long‐term safety and efficacy. Methods: Eculizumab (1,200 mg every 2 weeks for 22.7 months [median]) was administered to 117 patients. Results: The safety profile of eculizumab was consistent with REGAIN; no cases of meningococcal infection were reported during the interim analysis period. Myasthenia gravis exacerbation rate was reduced by 75% from the year before REGAIN (P < 0.0001). Improvements with eculizumab in activities of daily living, muscle strength, functional ability, and quality of life in REGAIN were maintained through 3 years; 56% of patients achieved minimal manifestations or pharmacological remission. Patients who had received placebo during REGAIN experienced rapid and sustained improvements during open‐label eculizumab (P < 0.0001). Discussion: These findings provide evidence for the long‐term safety and sustained efficacy of eculizumab for refractory gMG. Muscle Nerve 2019 See editorial on pages 7–9 in this issue.
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Affiliation(s)
- Srikanth Muppidi
- Department of Neurology and Neurosciences, Stanford University School of Medicine, Stanford, California, USA
| | | | - Michael Benatar
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Hiroyuki Murai
- Department of Neurology, International University of Health and Welfare, Narita, Japan
| | - Richard J Barohn
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Isabel Illa
- Neurology Department, Hospital Sant Pau, Autonomous University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Spain
| | - Saiju Jacob
- Queen Elizabeth Neuroscience Centre and Wellcome Trust Clinical Research Facility, University Hospital Birmingham, Birmingham, United Kingdom
| | - John Vissing
- Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ted M Burns
- Department of Neurology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - John T Kissel
- Department of Neurology, The Ohio State University, Columbus, Ohio, USA
| | - Richard J Nowak
- Department of Neurology, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Henning Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Carlos Casasnovas
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Spain.,Department of Neurology, Bellvitge University Hospital, Barcelona, Spain
| | - Jan L de Bleecker
- Neuromuscular Reference Centre, Ghent University Hospital, Ghent, Belgium
| | - Tuan H Vu
- Department of Neurology, University of South Florida, Tampa, Florida, USA
| | - Renato Mantegazza
- Foundation of the Carlo Besta Neurological Institute, IRCSS, Milan, Italy
| | | | | | | | - James F Howard
- Department of Neurology, University of North Carolina, Chapel Hill, North Carolina, USA
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390
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A Neurologist's Perspective on Understanding Myasthenia Gravis: Clinical Perspectives of Etiologic Factors, Diagnosis, and Preoperative Treatment. Thorac Surg Clin 2019; 29:133-141. [PMID: 30927994 DOI: 10.1016/j.thorsurg.2018.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Myasthenia gravis (MG) is a disease of neuromuscular transmission caused by antibodies directed toward proteins concentrated at the neuromuscular junction. Mild to life-threatening weakness varies in severity over time and with level of activity. Therefore, clinical diagnosis is often challenging. MG may be categorized by autoantibody type, thymic pathologic condition, and age of onset. Treatments are tailored for each group. A key management concern is severe exacerbation of weakness resulting from infections or exposure to certain medications, including antibiotics, which may be severe enough to produce respiratory decompensation. The article reviews key diagnostic issues and treatment options.
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391
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Schneider-Gold C, Hagenacker T, Melzer N, Ruck T. Understanding the burden of refractory myasthenia gravis. Ther Adv Neurol Disord 2019; 12:1756286419832242. [PMID: 30854027 PMCID: PMC6399761 DOI: 10.1177/1756286419832242] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 01/28/2019] [Indexed: 11/15/2022] Open
Abstract
Myasthenia gravis (MG) is an autoantibody-mediated disease that compromises the acetylcholine receptors or associated structures of the postsynaptic membrane of the neuromuscular junction. This leads to impaired neuromuscular transmission and subsequent fluctuating fatigability and weakness of ocular, bulbar, and limb skeletal muscles. Over the past few decades, there have been significant advances in our understanding of the disease pathophysiology and improvements in prognosis due to intensive care medicine and immunomodulation. Despite this, an estimated 10-20% of patients with MG do not achieve an adequate response, are intolerant to conventional treatment, or require chronic treatment with intravenous immunoglobulins or plasma separation procedures. Such patients are regarded as having MG that is 'refractory' to treatment and may represent a distinct clinical subgroup. Because the majority of patients with MG have well-controlled disease, the burden of illness in the minority with refractory disease is poorly understood and may be underestimated. However, clinically these patients are liable to experience extreme fatigue, considerable disability owing to uncontrolled symptoms, and frequent myasthenic crises and hospitalizations. Both acute adverse effects and an increased risk of comorbidity from treatment regimens may contribute to reduced quality of life. As yet, little is known concerning the impact of refractory MG on mental health and health-related quality of life. This review aims to highlight the burden of disease and unmet needs in patients with refractory MG.
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Affiliation(s)
- Christiane Schneider-Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, Bochum, D-44791, Germany
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392
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Italian recommendations for the diagnosis and treatment of myasthenia gravis. Neurol Sci 2019; 40:1111-1124. [PMID: 30778878 DOI: 10.1007/s10072-019-03746-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 01/31/2019] [Indexed: 12/30/2022]
Abstract
Myasthenia gravis is a well-treatable disease, in which a prompt diagnosis and an adequate management can achieve satisfactory control of symptoms in the great majority of patients. Improved knowledge of the disease pathogenesis has led to recognition of patient subgroups, according to associated antibodies, age at onset and thymus pathology, and to a more personalized treatment. When myasthenia gravis is suspected on clinical grounds, diagnostic confirmation relies mainly on the detection of specific antibodies. Neurophysiological studies and, to a lesser extent, clinical response to cholinesterase inhibitors support the diagnosis in seronegative patients. In these cases, the differentiation from congenital myasthenia can be challenging. Treatment planning must consider weakness extension and severity, disease subtype, thymus pathology, together with patient characteristics and comorbidities. Since most subjects with myasthenia gravis require long-term immunosuppressive therapy, surveillance of expected and potential adverse events is critical. For patients refractory to conventional immunosuppression, the use of biologic agents is highly promising. These recommendations are addressed to non-experts on neuromuscular transmission disorders. The diagnostic procedures and therapeutic approaches hereafter described are largely accessible in Italy.
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393
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de Meel RHP, Verschuuren JJGM, Tannemaat MR. Distinct representation of muscle weakness in QMG and MG-ADL. Lancet Neurol 2019; 17:204-205. [PMID: 29452679 DOI: 10.1016/s1474-4422(18)30037-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 01/17/2018] [Accepted: 01/23/2018] [Indexed: 11/29/2022]
Affiliation(s)
| | - Jan J G M Verschuuren
- Department of Neurology, Leiden University Medical Centre, 2333 ZA Leiden, Netherlands
| | - Martijn R Tannemaat
- Department of Neurology, Leiden University Medical Centre, 2333 ZA Leiden, Netherlands
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394
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High efficacy of rituximab for myasthenia gravis: a comprehensive nationwide study in Austria. J Neurol 2019; 266:699-706. [DOI: 10.1007/s00415-019-09191-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 01/01/2019] [Accepted: 01/06/2019] [Indexed: 01/09/2023]
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395
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Amano E, Otsu S, Suzuki S, Machida A. Eculizumab improved weakness and taste disorder in thymoma-associated generalized myasthenia gravis with anti-striational antibodies: A case report. eNeurologicalSci 2019; 14:72-73. [PMID: 30705973 PMCID: PMC6348763 DOI: 10.1016/j.ensci.2019.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 01/07/2019] [Indexed: 11/26/2022] Open
Affiliation(s)
- Eiichiro Amano
- Department of Neurology, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura-shi, Ibaraki, 300-0028, Japan
| | - Shinichi Otsu
- Department of Neurology, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura-shi, Ibaraki, 300-0028, Japan
| | - Shigeaki Suzuki
- Department of Neurology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Akira Machida
- Department of Neurology, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura-shi, Ibaraki, 300-0028, Japan
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396
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General Principles of Immunotherapy in Neurological Diseases. CONTEMPORARY CLINICAL NEUROSCIENCE 2019. [DOI: 10.1007/978-3-030-19515-1_12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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397
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Xin H, Harris LA, Aban IB, Cutter G. Examining the Impact of Refractory Myasthenia Gravis on Healthcare Resource Utilization in the United States: Analysis of a Myasthenia Gravis Foundation of America Patient Registry Sample. J Clin Neurol 2019; 15:376-385. [PMID: 31286711 PMCID: PMC6620464 DOI: 10.3988/jcn.2019.15.3.376] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 03/08/2019] [Accepted: 03/12/2019] [Indexed: 12/12/2022] Open
Abstract
Background and Purpose Patients with refractory myasthenia gravis (MG) experience ongoing disease burden that might be reflected in their healthcare utilization. Here we examine the impact of refractory MG on healthcare utilization. Methods The 825 included participants were aged 18–64 years, enrolled in the Myasthenia Gravis Foundation of America Patient Registry between July 2013 and February 2018, and had been diagnosed with MG ≥2 years previously. Results Participants comprised 76 (9.2%) with refractory MG and 749 (90.8%) with nonrefractory MG. During the 6 months before enrollment, participants with refractory MG were significantly more likely than those with nonrefractory MG to have experienced at least one exacerbation [67.1% vs. 52.0%, respectively, p=0.01; odds ratio (OR)=1.882, 95% confidence interval (CI)=1.141–3.104], visited an emergency room at least once [43.4% vs. 27.1%, p<0.01; OR=2.065, 95% CI=1.276–3.343], been hospitalized overnight at least once (32.9% vs. 20.5%, p=0.01; OR=1.900, 95% CI=1.140–3.165), ever been admitted to an intensive care unit (ICU) (61.8% vs. 33.4%, p<0.01; OR=3.233, 95% CI=1.985–5.266), or ever required a feeding tube (21.1% vs. 9.1%, p<0.01; OR=2.671, 95% CI=1.457–4.896). A total of 75.8% younger females with refractory disease (<51 years, n=33) experienced at least one exacerbation, 69.7% had been admitted to an ICU, and 30.3% had required a feeding tube. For older females with refractory disease (≥51 years, n=33), 60.6%, 54.6%, and 6.1% experienced these outcomes, respectively (between-group differences were not significant). Conclusions Refractory MG is associated with higher disease burden and healthcare utilization than nonrefractory MG.
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Affiliation(s)
- Haichang Xin
- Department of Health Care Organization and Policy, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Inmaculada B Aban
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
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398
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de Meel RHP, Raadsheer WF, van Zwet EW, Verschuuren JJGM, Tannemaat MR. Sensitivity of MG-ADL for generalized weakness in myasthenia gravis. Eur J Neurol 2018; 26:947-950. [PMID: 30417962 PMCID: PMC6590478 DOI: 10.1111/ene.13867] [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: 09/29/2018] [Accepted: 11/07/2018] [Indexed: 11/29/2022]
Abstract
Background and purpose Myasthenia gravis activities of daily living (MG‐ADL) is a commonly used questionnaire in MG trials. To investigate whether MG‐ADL is equally sensitive to oculobulbar and generalized weakness, its correlation with the oculobulbar and generalized domain of the quantitative myasthenia gravis (QMG) score was analyzed (QMGob and QMGgen, respectively). To test whether the sensitivity of MG‐ADL for generalized weakness could be improved, the additional value of ACTIVLIM on top of MG‐ADL in the prediction QMGgen in was investigated. Methods MG‐ADL, QMG and ACTIVLIM, an ADL questionnaire focusing on generalized weakness, were analyzed in a prospective cohort of 112 MG patients. A generalized linear model was used to calculate the correlation of MG‐ADL with QMGob and QMGgen and to assess the additional value of ACTIVLIM on top of MG‐ADL for its correlation with QMGgen. Results MG‐ADL had a higher correlation with QMGob than with QMGgen (B = 0.68, P < 0.001, and B = 0.38, P < 0.001, respectively). A similar trend was found for changes in the scores (B = 0.68, P = 0.132, and B = 0.39, P = 0.492, respectively). ACTIVLIM had a significant additional value on top of MG‐ADL in the prediction of QMGgen, both cross‐sectionally (B = −0.61, P < 0.001) and for changes within individual patients (B = −0.93, P = 0.041). Conclusion MG‐ADL has a lower sensitivity for generalized weakness than for oculobulbar weakness. Adding questions on generalized weakness would improve the sensitivity of the MG‐ADL for generalized weakness.
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Affiliation(s)
- R H P de Meel
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - W F Raadsheer
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - E W van Zwet
- Department of Biostatistics, Leiden University Medical Center, Leiden, The Netherlands
| | - J J G M Verschuuren
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - M R Tannemaat
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
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399
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Ravulizumab (ALXN1210) vs eculizumab in C5-inhibitor-experienced adult patients with PNH: the 302 study. Blood 2018; 133:540-549. [PMID: 30510079 DOI: 10.1182/blood-2018-09-876805] [Citation(s) in RCA: 215] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 11/18/2018] [Indexed: 12/13/2022] Open
Abstract
Ravulizumab, a new complement component C5 inhibitor administered every 8 weeks, was noninferior to eculizumab administered every 2 weeks in complement-inhibitor-naive patients with paroxysmal nocturnal hemoglobinuria (PNH). This study assessed noninferiority of ravulizumab to eculizumab in clinically stable PNH patients during previous eculizumab therapy. In this phase 3, open-label, multicenter study, 195 PNH patients on labeled-dose (900 mg every 2 weeks) eculizumab for >6 months were randomly assigned 1:1 to switch to ravulizumab (n = 97) or continue eculizumab (n = 98). Primary efficacy end point was percentage change in lactate dehydrogenase (LDH) from baseline to day 183. Key secondary end points included proportion of patients with breakthrough hemolysis, change in Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue score, transfusion avoidance, and stabilized hemoglobin. In 191 patients completing 183 days of treatment, ravulizumab was noninferior to eculizumab (P inf < .0006 for all end points), including percentage change in LDH (difference, 9.21% [95% confidence interval (CI), -0.42 to 18.84], P = .058 for superiority), breakthrough hemolysis (difference, 5.1 [95% CI, -8.89 to 18.99]), change in FACIT-Fatigue score (difference, 1.47 [95% CI, -0.21 to 3.15]), transfusion avoidance (difference, 5.5 [95% CI, -4.27 to 15.68]), and stabilized hemoglobin (difference, 1.4 [95% CI, -10.41 to 13.31]). The most frequently reported adverse event was headache (26.8%, ravulizumab; 17.3%, eculizumab). No meningococcal infections or discontinuations due to adverse events occurred. Patients with PNH may be safely and effectively switched from labeled-dose eculizumab administered every 2 weeks to ravulizumab administered every 8 weeks. This trial was funded by Alexion Pharmaceuticals, Inc., and is registered at www.clinicaltrials.gov as #NCT03056040.
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400
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Barnett C, Bril V, Bayoumi AM. EQ-5D-5L and SF-6D health utility index scores in patients with myasthenia gravis. Eur J Neurol 2018; 26:452-459. [PMID: 30315714 DOI: 10.1111/ene.13836] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 10/08/2018] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Health utilities are a preference-based method of valuing health states that are used in healthcare research, such as economic evaluations. There are limited health utility valuation data for patients with myasthenia gravis (MG). The aim of the study was to describe health utilities for patients with MG and different health states, using the EQ-5D-5L and SF-6D utility instruments, and to explore clinical and demographic determinants of utilities in this population. METHODS Patients completed the EQ-5D-5L and SF-6D. In addition, patients were assessed with the Myasthenia Gravis Foundation of America classification, Myasthenia Gravis Impairment Index and MG-QOL15 as disease-specific measures, and the Neuro-QoL Fatigue scale. We calculated mean utilities for each Myasthenia Gravis Foundation of America severity class. We built regression models for the EQ-5D-5L and SF-6D to determine the clinical and demographic factors that determine patients' valuation of their health state. RESULTS Among 254 patients, mean EQ-5D-5L health utilities were as follows: Remission, 0.94 ± 0.03; Minimal Manifestations, 0.92 ± 0.04; Class I, 0.89 ± 0.06; Class II, 0.78 ± 0.16; Class III, 0.58 ± 0.24 and Class IV, 0.61 ± 0.22. Mean SF-6D health utilities were as follows: Remission, 0.83 ± 0.07; Minimal Manifestations, 0.86 ± 0.14; Class I, 0.82 ± 0.14; Class II, 0.67 ± 0.12; Class III, 0.56 ± 0.11 and Class IV, 0.50 ± 0.10. The limb/axial scores were more highly correlated to health utilities than ocular or bulbar scores. CONCLUSIONS We present estimates of health utilities for patients with MG that can be used in cost-utility and decision analyses. Limb/axial symptoms had a higher impact on health utilities than ocular or bulbar symptoms, which might reflect the impact of mobility on health valuation.
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Affiliation(s)
- C Barnett
- Division of Neurology, Department of Medicine, University of Toronto and University Health Network, Toronto, ON.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
| | - V Bril
- Division of Neurology, Department of Medicine, University of Toronto and University Health Network, Toronto, ON
| | - A M Bayoumi
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON.,Division of General Internal Medicine, Department of Medicine, St, Michael's Hospital, Toronto, ON.,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON.,Department of Medicine, University of Toronto, Toronto, ON, Canada
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