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Carnero Contentti E, Lopez PA, Patrucco L, Cristiano E, Miguez J, Silva B, Liwacki S, Tkachuk V, Balbuena ME, Vrech C, Deri N, Correale J, Marrodan M, Ysrraelit MC, Fiol M, Leguizamon F, Luetic G, Tavolini D, Mainella C, Zanga G, Burgos M, Hryb J, Barboza A, Lazaro L, Alonso R, Fernández Liguori N, Nadur D, Martinez A, Steinberg J, Carrá A, Alonso Serena M, Rojas JI. Traditional first-line treatment failure rates in neuromyelitis optica spectrum disorder patients included in the Argentinean registry (RelevarEM). Mult Scler Relat Disord 2024; 89:105771. [PMID: 39033591 DOI: 10.1016/j.msard.2024.105771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/29/2024] [Accepted: 07/14/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Immunosuppressive therapies as azathioprine (AZA), mycophenolate mofetil (MMF) and rituximab (RTX) are widely prescribed as first-line treatment to prevent relapses in NMOSD. However, the rate of response to these traditional therapies is unknown in Argentina. We aimed to describe and compare treatment failure rates in NMOSD patients included in the Argentinean MS and NMOSD registry (RelevarEM, NCT03375177). METHODS A retrospective cohort study was conducted in NMOSD patients included in RelevarEM (a nationwide, longitudinal, observational, non-mandatory registry of MS and NMOSD in Argentina). NMOSD patients were defined based on validate diagnostic criteria. Only NMOSD patients who received AZA or MMF for at least 6 months or RTX for at least 1 month were included. Patients who were receiving AZA, MMF, or RTX and then switched to another 1 of these 3 therapies were included if the above-mentioned criteria for each drug were fulfilled. Data on patient demographics, clinical, neuroradiological findings, and treatments administered were collected. Treatment failure was defined as any new attack/relapse that occurred despite immunosuppressive treatment. RESULTS We included 139 NMOSD patients who were receiving AZA (n = 105), MMF (n = 5) or RTX (n = 29) with a mean follow-up time of 41.3 ± 11.4 months and median of EDSS at treatment initiation of 3. We observed a reduction in the annualized relapse rate from pre-treatment to post-treatment of 51.1 %, 48.4 %, and 79.1 % respectively with a Hazard Risk relative to RTX (95 % CI) of 1.67 (1.34-3.54, p = 0.01) for AZA and 2.01 (1.86-4.43, p = 0.008) for MMF. AZA, MMF and RTX failure was observed in 45/105 (42.8 %), 2/5 (40 %) and 3/29 (10.3 %) patients, respectively. CONCLUSIONS Treatment failure rates were higher for AZA and MMF than RTX in Argentinean NMOSD patients in a real-world setting. High-efficacy treatment increases the opportunity to prevent attacks of NMOSD.
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Affiliation(s)
- Edgar Carnero Contentti
- Neuroimmunology Unit, Department of Neurosciences, Hospital Aleman, Buenos Aires, Argentina.
| | - Pablo A Lopez
- Neuroimmunology Unit, Department of Neurosciences, Hospital Aleman, Buenos Aires, Argentina
| | - Liliana Patrucco
- Centro Esclerosis Múltiple Buenos Aires (CEMBA)Buenos Aires, Argentina
| | - Edgardo Cristiano
- Centro Esclerosis Múltiple Buenos Aires (CEMBA)Buenos Aires, Argentina
| | - Jimena Miguez
- Neurology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Berenice Silva
- Neurology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Neurology Department, Hospital JM Ramos Mejia, Buenos Aires, Argentina
| | - Susana Liwacki
- Neurology Unit, Hospital Córdoba, Córdoba, Argentina; Clínica Universitaria Reina Fabiola, Córdoba, Argentina
| | - Verónica Tkachuk
- Neuroimmunology Unit, Neurology Department, Hospital de Clínicas, Buenos Aires, Argentina
| | - María E Balbuena
- Neuroimmunology Unit, Neurology Department, Hospital de Clínicas, Buenos Aires, Argentina
| | - Carlos Vrech
- Neurology Department, Sanatorio Allende, Córdoba, Argentina
| | - Norma Deri
- CENyR, Ciudad de Buenos Aires, Buenos Aires, Argentina
| | | | | | | | - Marcela Fiol
- Neurology Department, Fleni, Buenos Aires, Argentina
| | - Felisa Leguizamon
- Neurology Department, Hospital de Agudos Dr. Teodoro Álvarez, Buenos Aires, Argentina
| | - Geraldine Luetic
- Neurology Department, Instituto de Neurocienciencias, Rosario, Argentina
| | - Darío Tavolini
- Neurology Department, INECO Neurociencias Oroño, Santa Fe, Argentina
| | - Carolina Mainella
- Neurology Department, Hospital Español de Rosario, Santa Fe, Argentina
| | - Gisela Zanga
- Neurology Department, Unidad Asistencial César Milstein, Buenos Aires, Argentina
| | - Marcos Burgos
- Neurology Department, Hospital San Bernardo, Salta, Argentina
| | - Javier Hryb
- Neurology Department, Hospital de Agudos Dr. Carlos G. Durand, Buenos Aires, Argentina
| | - Andrés Barboza
- Neurology Department, Hospital Central de Mendoza, Mendoza, Argentina
| | - Luciana Lazaro
- Neurology Department, Sanatorio Guemes, Buenos Aires, Argentina
| | - Ricardo Alonso
- Neurology Department, Hospital JM Ramos Mejia, Buenos Aires, Argentina; Neurology Department, Sanatorio Guemes, Buenos Aires, Argentina
| | | | - Débora Nadur
- Neuroimmunology Unit, Neurology Department, Hospital de Clínicas, Buenos Aires, Argentina
| | - Alejandra Martinez
- Neurology Department, Hospital Britanico de Buenos Aires, Buenos Aires, Argentina
| | - Judith Steinberg
- Neurology Department, Private office, Lujan, Buenos Aires, Argentina
| | - Adriana Carrá
- Neurology Department, Hospital Britanico de Buenos Aires, Buenos Aires, Argentina
| | - Marina Alonso Serena
- Neurology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Juan I Rojas
- Centro Esclerosis Múltiple Buenos Aires (CEMBA)Buenos Aires, Argentina
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2
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Deschamps R, Papeix C, Ayrignac X, Bourre B, Ciron J, Cohen M, Collongues N, Deiva K, Durand Dubief F, Laplaud DA, Maillart E, Michel L, Pique J, Ruet A, Thouvenot E, Zéphir H, Marignier R, Audoin B. Advocating for rituximab as first-line treatment for NMOSD-AQP4 patients in France: Cost and efficacy considerations. Rev Neurol (Paris) 2024:S0035-3787(24)00556-3. [PMID: 38969609 DOI: 10.1016/j.neurol.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 06/05/2024] [Accepted: 06/14/2024] [Indexed: 07/07/2024]
Affiliation(s)
- Romain Deschamps
- Department of Neurology, hôpital Fondation Adolphe-de-Rothschild, Paris, France.
| | - Caroline Papeix
- Department of Neurology, hôpital Fondation Adolphe-de-Rothschild, Paris, France
| | - Xavier Ayrignac
- Department of Neurology, University Hospital of Montpellier, Montpellier, France
| | - Bertrand Bourre
- Department of Neurology, University Hospital of Rouen, Rouen, France
| | - Jonathan Ciron
- Department of Neurology, University Hospital of Toulouse, Toulouse, France
| | - Mikael Cohen
- CRC-SEP neurologie Pasteur 2, CHU de Nice, université Cote d'Azur, UMR2CA (URRIS), Nice, France
| | - Nicolas Collongues
- Department of Neurology and Department of Pharmacology, Addictology, Toxicology and Therapeutics, Center for Clinical Investigation, Inserm U1434, Biopathology of Myelin, Neuroprotection and Therapeutic Strategy, Inserm U1119, Strasbourg University, Strasbourg, France
| | - Kumaran Deiva
- Department of Pediatric Neurology, Bicêtre Hospital, Assistance publique-Hôpitaux de Paris, University Hospitals Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Françoise Durand Dubief
- Service de neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation, centre de référence des maladies inflammatoires rares du cerveau et de la moelle (MIRCEM), hôpital neurologique Pierre-Wertheimer, Lyon University Hospital, Lyon, France
| | - David-Axel Laplaud
- Department of Neurology, CR2TI-Inserm U1064, CIC1314, CHU de Nantes, Nantes université, Nantes, France
| | - Elisabeth Maillart
- Department of Neurology, centre de référence des maladies inflammatoires rares du cerveau et de la moelle (MIRCEM), hôpital Pitié-Salpêtrière, AP-HP, Paris, France
| | - Laure Michel
- Department of Neurology, Inserm UMR 1236, CHU de Rennes, université de Rennes 1, Rennes, France
| | - Julie Pique
- Service de neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation, centre de référence des maladies inflammatoires rares du cerveau et de la moelle (MIRCEM), hôpital neurologique Pierre-Wertheimer, Lyon University Hospital, Lyon, France
| | - Aurélie Ruet
- Department of Neurology, University Hospital of Bordeaux, Bordeaux, France
| | - Eric Thouvenot
- Department of Neurology, University Hospital of Nîmes, Nîmes, France
| | - Hélène Zéphir
- Department of Neurology, U 1172, CRC-SEP, University Hospital of Lille, Lille, France
| | - Romain Marignier
- Service de neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation, centre de référence des maladies inflammatoires rares du cerveau et de la moelle (MIRCEM), hôpital neurologique Pierre-Wertheimer, Lyon University Hospital, Lyon, France
| | - Bertrand Audoin
- Department of Neurology, pôle de neurosciences cliniques, hôpital de la Timone, Marseille, AP-HM, Aix Marseille University, Marseille, France
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3
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Nasir M, Hone L, Tallantyre E, Kelly P, Leite MI, Robertson N, Bestwick J, Huda S, Palace J, Dobson R. Impact of rituximab treatment regime on time to relapse in aquaporin-4 antibody positive neuromyelitis optica spectrum disorder. Mult Scler Relat Disord 2024; 85:105528. [PMID: 38479046 DOI: 10.1016/j.msard.2024.105528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 01/23/2024] [Accepted: 02/26/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND Aquaporin-4 (AQP4) antibody associated neuromyelitis optica (NMOSD) requires long-term immunosuppression. Rituximab is increasingly used worldwide, however the optimal regime is not established. METHODS We retrospectively examined different rituximab regimens in AQP4-NMOSD. Standard monotherapy (SM; 6 monthly infusions), SM plus oral steroids (SM+S), extended interval dosing (EID; guided by CD19 repopulation) and EID with oral steroids (EID+S) were compared. The primary outcome was time to first clinical relapse. Potential confounders including age, gender, number of previous relapses, and onset phenotype were included. RESULTS 77 patients were included: 67 females, median onset age 35.6, median DSS at rituximab initiation 5.0. 39 were on SM+S, 20 SM, 6 EID, and 12 EID+S. 25/77 patients relapsed during a median follow-up of 44.0 months. No significant difference in time to first relapse was observed between any rituximab regimen. Pooled analyses to compare regimens that use standard monotherapy (SM and SM+S) against those that use extended interval dosing (EID and EID+S) showed no significant difference. Pooled analysis of regimens using steroids with those not using steroids also showed no significant difference. Adjusted Cox proportional hazard model revealed no significant difference between rituximab regimens or influence of demographic factors. 9 significant adverse events were recorded, 5 in the SM group and 4 in SM+S. CONCLUSIONS This study provides some basis for further exploring EID as a viable option for long term treatment of AQP4-NMOSD. This may improve patient experience and consolidate use of hospital resources.
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Affiliation(s)
- Moneeb Nasir
- Department of Neurology, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Luke Hone
- Centre for Preventive Neurology, Queen Mary University London, London, United Kingdom
| | - Emma Tallantyre
- Department of Neurology, University Hospital Wales, Cardiff, United Kingdom; Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, United Kingdom
| | - Patricia Kelly
- Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Maria Isabel Leite
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, United Kingdom
| | - Neil Robertson
- Department of Neurology, University Hospital Wales, Cardiff, United Kingdom; Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, United Kingdom
| | - Jonathan Bestwick
- Centre for Preventive Neurology, Queen Mary University London, London, United Kingdom
| | - Saif Huda
- Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Jacqueline Palace
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, United Kingdom
| | - Ruth Dobson
- Department of Neurology, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom; Centre for Preventive Neurology, Queen Mary University London, London, United Kingdom.
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Rees JH, Rempe T, Tuna IS, Perero MM, Sabat S, Massini T, Yetto JM. Neuromyelitis Optica Spectrum Disorders and Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease. Magn Reson Imaging Clin N Am 2024; 32:233-251. [PMID: 38555139 DOI: 10.1016/j.mric.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
For over two centuries, clinicians have been aware of various conditions affecting white matter which had come to be grouped under the umbrella term multiple sclerosis. Within the last 20 years, specific scientific advances have occurred leading to more accurate diagnosis and differentiation of several of these conditions including, neuromyelitis optica spectrum disorders and myelin oligodendrocyte glycoprotein antibody disease. This new understanding has been coupled with advances in disease-modifying therapies which must be accurately applied for maximum safety and efficacy.
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Affiliation(s)
- John H Rees
- Neuroradiology, Department of Radiology, University of Florida College of Medicine.
| | - Torge Rempe
- UF Multiple Sclerosis / Neuroimmunology Fellowship, Department of Neurology, University of Florida, College of Medicine
| | | | | | | | | | - Joseph M Yetto
- University of Florida at Gainesville, Gainesville, FL, USA
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5
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Yu Y, Zhong M, Quan C, Ma C. Treatment access and satisfaction on disease-modifying therapies of neuromyelitis optica spectrum disorder patients in China: a cross-sectional survey. Ther Adv Neurol Disord 2024; 17:17562864241239105. [PMID: 38525489 PMCID: PMC10960978 DOI: 10.1177/17562864241239105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 02/14/2024] [Indexed: 03/26/2024] Open
Abstract
Background Neuromyelitis optica spectrum disorder (NMOSD) is a rare and debilitating disease that has become more widely recognized in China. Legislative measures have been implemented by the government to improve treatment access for rare diseases. Objectives To investigate the diagnostic journey, treatment status, treatment accessibility, and treatment satisfaction of the NMOSD patients on disease-modifying therapies (DMTs) in China. Design A patient online survey. Methods This cross-sectional online survey was conducted between November 2022 and January 2023. Patients over 18 years old and diagnosed with NMOSD were included. The questionnaire consisted of five sections covering demographics, diagnostic and treatment experiences, DMTs availability, cost and affordability, and treatment satisfaction using the Treatment Satisfaction Questionnaire for Medication (version II). Patient opinions and demands were also collected at the end of the survey. Results A total of 375 patients diagnosed with NMOSD were recruited, of which 321 patients used DMTs. It required 1.22 ± 3.22 years and 3.58 ± 4.24 hospital visits for a definitive diagnosis. One-third of the patients still needed to travel for over 2 h to access DMTs. The total treatment expenditure was estimated to be CNY 59,827.00 (USD 8315.95) a year. Drug expenses alone accounted for 52.22% of the average annual household income. The most common challenges perceived were the inability to afford treatment and a lack of effective options. No significant difference was found in treatment satisfaction among DMTs, except that rituximab scored lowest in convenience compared to other DMTs. Patients' age and travel time required to obtain medications were negatively associated with global treatment satisfaction. Conclusion In China, patients with NMOSD face challenges in obtaining proper treatment due to diagnostic difficulties, distant medication access, and high costs. Policies should prioritize improving disease education and alleviating financial burdens for the patients.
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Affiliation(s)
- Yue Yu
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Mingkang Zhong
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
| | - Chao Quan
- Department of Neurology, National Center for Neurological Disorders, Huashan Hospital, Fudan University, 12 Middle Wulumuqi Road, Shanghai 200040, China
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Chunlai Ma
- Department of Pharmacy, Huashan Hospital, Fudan University, 12 Middle Wulumuqi Road, Shanghai 200040, China
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China
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6
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Ramdas S, Palace J. PROMISE of low-cost immunosuppressants for myasthenia gravis. Lancet Neurol 2024; 23:223-225. [PMID: 38365362 DOI: 10.1016/s1474-4422(24)00034-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 01/23/2024] [Indexed: 02/18/2024]
Affiliation(s)
- Sithara Ramdas
- Department of Paediatric Neurology, John Radcliffe Hospital, Oxford, UK; MDUK Neuromuscular Centre, Department of Paediatrics, University of Oxford, Oxford UK.
| | - Jacqueline Palace
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
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7
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Zhang C, Liu R, Gao B, Li T, Wang H, Song T, Ma Y, Xu W, Liu Y, Zhang X, Tian DC, Yang C, Shi K. Efficacy and safety of low- and ultralow-dose rituximab in neuromyelitis optica spectrum disorder. J Neuroimmunol 2024; 387:578285. [PMID: 38219400 DOI: 10.1016/j.jneuroim.2024.578285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/22/2023] [Accepted: 01/06/2024] [Indexed: 01/16/2024]
Abstract
BACKGROUND Rituximab effectively targets B cells and reduces relapses in neuromyelitis optica spectrum disorder (NMOSD). But the ideal dosage and treatment intervals remain unanswered. We aimed to assess the efficacy and safety of low and ultralow-dose rituximab in NMOSD. METHODS We conducted a retrospective analysis of NMOSD patients treated with rituximab at two Chinese tertiary hospitals. Patients received either a low-dose regimen (500 mg reinfusion every 6 months) or an ultralow-dose regimen: 100 to 300 mg rituximab based on CD19+B cells (100 mg for 1-1.5% of peripheral blood mononuclear cells, 200 mg for 1.5-5%, and 300 mg for over 5%). RESULTS We analyzed data from 136 patients (41 in the low-dose group, 95 in the ultralow-dose group) with median follow-up durations of 43 and 34.2 months, respectively. Both groups exhibited similar sex distribution, age at disease onset, annual relapse rate, and baseline disease duration. Survival analysis showed that ultralow-dose rituximab was noninferior to low-dose rituximab in preventing relapses. Infusion reactions occurred in 20 of 173 (11.6%) low-dose treatments and 9 of 533 (1.7%) ultralow-dose treatments. B-cell re-emergence was observed in 137 of 236 (58.1%) monitors in the low-dose group and 367 of 1136 (32.3%) monitors in the ultralow-dose group. CONCLUSION Ultralow dose rituximab was noninferior to low-dose rituximab in preventing NMOSD relapses. A randomized controlled trial is essential to validate these findings.
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Affiliation(s)
- Chengyi Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Rui Liu
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
| | - Bin Gao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ting Li
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
| | - Huabing Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tian Song
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuetao Ma
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wangshu Xu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yun Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinghu Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - De-Cai Tian
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chunsheng Yang
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China.
| | - Kaibin Shi
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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8
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Kümpfel T, Giglhuber K, Aktas O, Ayzenberg I, Bellmann-Strobl J, Häußler V, Havla J, Hellwig K, Hümmert MW, Jarius S, Kleiter I, Klotz L, Krumbholz M, Paul F, Ringelstein M, Ruprecht K, Senel M, Stellmann JP, Bergh FT, Trebst C, Tumani H, Warnke C, Wildemann B, Berthele A. Update on the diagnosis and treatment of neuromyelitis optica spectrum disorders (NMOSD) - revised recommendations of the Neuromyelitis Optica Study Group (NEMOS). Part II: Attack therapy and long-term management. J Neurol 2024; 271:141-176. [PMID: 37676297 PMCID: PMC10770020 DOI: 10.1007/s00415-023-11910-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/27/2023] [Accepted: 07/27/2023] [Indexed: 09/08/2023]
Abstract
This manuscript presents practical recommendations for managing acute attacks and implementing preventive immunotherapies for neuromyelitis optica spectrum disorders (NMOSD), a rare autoimmune disease that causes severe inflammation in the central nervous system (CNS), primarily affecting the optic nerves, spinal cord, and brainstem. The pillars of NMOSD therapy are attack treatment and attack prevention to minimize the accrual of neurological disability. Aquaporin-4 immunoglobulin G antibodies (AQP4-IgG) are a diagnostic marker of the disease and play a significant role in its pathogenicity. Recent advances in understanding NMOSD have led to the development of new therapies and the completion of randomized controlled trials. Four preventive immunotherapies have now been approved for AQP4-IgG-positive NMOSD in many regions of the world: eculizumab, ravulizumab - most recently-, inebilizumab, and satralizumab. These new drugs may potentially substitute rituximab and classical immunosuppressive therapies, which were as yet the mainstay of treatment for both, AQP4-IgG-positive and -negative NMOSD. Here, the Neuromyelitis Optica Study Group (NEMOS) provides an overview of the current state of knowledge on NMOSD treatments and offers statements and practical recommendations on the therapy management and use of all available immunotherapies for this disease. Unmet needs and AQP4-IgG-negative NMOSD are also discussed. The recommendations were developed using a Delphi-based consensus method among the core author group and at expert discussions at NEMOS meetings.
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Affiliation(s)
- Tania Kümpfel
- Institute of Clinical Neuroimmunology, LMU Hospital, Ludwig-Maximilians-Universität München, Munich, Germany.
| | - Katrin Giglhuber
- Department of Neurology, School of Medicine, Technical University Munich, Klinikum Rechts der Isar, Munich, Germany
| | - Orhan Aktas
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Ilya Ayzenberg
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Judith Bellmann-Strobl
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Experimental and Clinical Research Center, a cooperation between the Max Delbrück Center for Molecular Medicine in the Helmholtz Association and Charité-Universitätsmedizin Berlin, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
- NeuroCure Clinical Research Center, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, and Berlin Institute of Health, and Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Vivien Häußler
- Department of Neurology and Institute of Neuroimmunology and MS (INIMS), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joachim Havla
- Institute of Clinical Neuroimmunology, LMU Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Martin W Hümmert
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Sven Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Ingo Kleiter
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
- Marianne-Strauß-Klinik, Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Luisa Klotz
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Markus Krumbholz
- Department of Neurology and Pain Treatment, Immanuel Klinik Rüdersdorf, University Hospital of the Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
- Department of Neurology & Stroke, University Hospital of Tübingen, Tübingen, Germany
| | - Friedemann Paul
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Experimental and Clinical Research Center, a cooperation between the Max Delbrück Center for Molecular Medicine in the Helmholtz Association and Charité-Universitätsmedizin Berlin, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
- NeuroCure Clinical Research Center, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, and Berlin Institute of Health, and Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Marius Ringelstein
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Neurology, Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Klemens Ruprecht
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Makbule Senel
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Jan-Patrick Stellmann
- Department of Neurology and Institute of Neuroimmunology and MS (INIMS), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- APHM, Hopital de la Timone, CEMEREM, Marseille, France
- Aix Marseille University, CNRS, CRMBM, Marseille, France
| | | | - Corinna Trebst
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | | | - Clemens Warnke
- Department of Neurology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Brigitte Wildemann
- Marianne-Strauß-Klinik, Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Achim Berthele
- Department of Neurology, School of Medicine, Technical University Munich, Klinikum Rechts der Isar, Munich, Germany.
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Kopp CR, Prasad CB, Naidu S, Sharma V, Misra DP, Agarwal V, Sharma A. Overlap syndrome of anti-aquaporin-4 positive neuromyelitis optica spectrum disorder and systemic lupus erythematosus: A systematic review of individual patient data. Lupus 2023; 32:1164-1172. [PMID: 37487596 DOI: 10.1177/09612033231191180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
BACKGROUND Neurological involvement can occur in systemic lupus erythematosus (SLE) due to co-existing neuromyelitis optica spectrum disorder (NMOSD). The symptoms can mimic those of neuropsychiatric manifestations of SLE. Pathogenic anti-aquaporin-4 (AQP4) antibodies, commonly found in NMOSD, are responsible for the neuroinflammatory response and secondary demyelinating lesions. These anti-AQP4 antibodies can be the drivers of neuroinflammatory process in SLE patients, which is distinct from the immunopathogenesis seen in traditional neuropsychiatric SLE. The clinical course is often a relapsing one and is managed differently. In this review, we describe and outline the clinical course and outcomes of AQP4+ NMOSD/SLE overlap cases. METHODS To investigate the co-existence of SLE with AQP4+NMOSD, we conducted a systematic review of individual patient data from case reports and case series reported in major databases. The study extracted clinic-demographic features, imaging and laboratory profiles, treatment approaches, and outcomes of these patients. Inclusion criteria for the review required patients to have positivity for AQP4 or NMO in the blood and/or cerebrospinal fluid (CSF) and exhibit at least one manifestation of both NMOSD and SLE. RESULTS In this overlap between SLE and AQP4+NMOSD, a high female preponderance was observed, with 42 out of 46 patients (91.3%) being female. Nearly half of the NMOSD cases (47.8%) had onset after lupus, with a median of 5 years between the two diagnoses. Hematological manifestations were seen in the majority of patients (63%), as well as longitudinally extensive transverse myelitis (87%), and brainstem involvement on imaging (29.6%). Cerebrospinal fluid analysis showed a dominantly lymphocytic pleocytosis, with oligoclonal bands being reported scarcely. Although cyclophosphamide was the most common steroid sparing agent used for maintenance, robust evidence for both efficacy and safety in AQP4+NMOSD is available for mycophenolate mofetil, azathioprine, and rituximab. The majority of reported cases showed a relapsing course, while one patient had a monophasic course. CONCLUSION AQP4+NMOSD in SLE patients is a relapsing and neurologically disabling disorder that can mimic neuropsychiatric manifestations, frequently occurs after the onset of lupus or may predate, responds to immunosuppressants, and necessitates indefinite treatment.
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Affiliation(s)
- Chirag Rajkumar Kopp
- Clinical Immunology and Rheumatology Division, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Chandra Bhushan Prasad
- Clinical Immunology and Rheumatology Division, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shankar Naidu
- Clinical Immunology and Rheumatology Division, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Adult Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Durga Prasanna Misra
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Vikas Agarwal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Aman Sharma
- Clinical Immunology and Rheumatology Division, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Ashtari F, Mehdipour R, Eini A, Ghalamkari A. Epidemiologic and clinical characteristics of neuromyelitis optica spectrum disorder patients, A seven years follow-up study from Iran. Mult Scler Relat Disord 2023; 77:104852. [PMID: 37399672 DOI: 10.1016/j.msard.2023.104852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 06/15/2023] [Accepted: 06/22/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Neuromyelitis Optica Spectrum Disorder (NMOSD) is a rare neuroinflammatory disease characterized by recurrent relapses. The most common signs are myelitis and optic neuritis. It can also present by cerebral or brain stem syndromes. There are still many challenges in its diagnosis and treatment, and long-term follow-up studies are needed to see the disease course over time. METHODS We established an electronic registration system of NMOSD patients starting from October 2015 in Kashani hospital, Isfahan, Iran. Every suspected patient was documented and included in the follow-up system to survey their disease course. Anti-aquaporine 4 (AQP4) antibody checked for all by cell-based assay method. All information such as demographic and clinical data and laboratory and MRI findings were documented. Participants were followed up for any relapses, new paraclinical tests and drug changes. This study is based on the definite NMOSD cases (according to the 2015 criteria) characteristics and clinical course during 7 years of registration. RESULTS The study included 173 NMOSD cases and 56 ones were seropositive for AQP4 Ab. Their mean age was 40.02±11.11 years (45.78 in the seropositive group). The mean age at disease onset was about 30.16 years. The mean time of follow-up by our registration system is 55.84 ± 18.94 months (54.82 months in seropositive ones). The annual relapse rate is estimated as 0.47±0.36. Long extended transvers myelitis (LETM) was present in the baseline MRI of 77 patients (44.5%), while 32 of them did not show any related clinical symptoms. 124 patients revealed an abnormality in the first brain MRI. 27 individuals suffer hypothyroidism as the most common comorbid disease. The disease seems to be more prevalent in the west and southwest areas of Isfahan province. CONCLUSION The mean age of onset is higher than Multiple Sclerosis (MS) patients, but there are notable pediatric cases too. It should also be noticed that cervical LETM can be asymptomatic at first. Brain MRI abnormalities are frequently observed. The disease is more prevalent in the geographical areas where showing high MS prevalence.
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Affiliation(s)
- Fereshteh Ashtari
- Neurology Department(,)Isfahan Neuroscience Research Center(,)Isfahan University of Medical Science(,) Iran
| | - Roshanak Mehdipour
- Isfahan Neuroscience Research Center(,) Isfahan University of Medical Science(,)Iran.
| | - Ahmad Eini
- Isfahan Neuroscience Research Center(,) Isfahan University of Medical Science(,)Iran
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11
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Jagannath P, K MS, S SMA, Kulkarni A, Prashanth PSSS, Madan H, Anand A. Neuromyelitis optica spectrum disorder with AQP4-IgG presenting as area postrema syndrome and progressing to myelitis: A rare case report. Clin Case Rep 2023; 11:e7636. [PMID: 37415585 PMCID: PMC10319961 DOI: 10.1002/ccr3.7636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/13/2023] [Accepted: 06/20/2023] [Indexed: 07/08/2023] Open
Abstract
Key Clinical Message Neuromyelitis optica spectrum disorders can less commonly present with area postrema syndrome progressing to myelitis. Management involves intravenous glucocorticoids, plasma exchange, and preventive immunotherapy. Abstract Neuromyelitis optica spectrum disorders can less commonly present with area postrema syndrome progressing to myelitis. The majority of patients have positive AQP4-Ab. Diagnosis is based on clinical and imaging findings. These patients can be treated with intravenous glucocorticoids, plasma exchange, and preventive immunotherapy.
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Affiliation(s)
| | - Mohammed Suhail K
- Department of General MedicineM S Ramaiah Medical CollegeBengaluruIndia
| | | | - Ashwin Kulkarni
- Department of General MedicineM S Ramaiah Medical CollegeBengaluruIndia
| | | | - Hritik Madan
- Adesh Medical College and HospitalKurukshetraHaryanaIndia
| | - Ayush Anand
- BP Koirala Institute of Health SciencesDharanNepal
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12
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Aungsumart S, Youngkong S, Dejthevaporn C, Chaikledkaew U, Thadanipon K, Tansawet A, Khieukhajee J, Attia J, McKay GJ, Thakkinstian A. Efficacy and safety of monoclonal antibody therapy in patients with neuromyelitis optica spectrum disorder: A systematic review and network meta-analysis. Front Neurol 2023; 14:1166490. [PMID: 37082442 PMCID: PMC10110910 DOI: 10.3389/fneur.2023.1166490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 03/20/2023] [Indexed: 04/07/2023] Open
Abstract
IntroductionNeuromyelitis optica spectrum disorder (NMOSD) is a devastating inflammatory CNS demyelinating disease. Two groups of monoclonal antibodies (mAbs) are used to prevent disease relapse, i.e., Food and Drug Administration (FDA)-approved mAbs (e.g., eculizumab satralizumab, inebilizumab), and off-label mAb drugs (e.g., rituximab and tocilizumab). The FDA-approved mAbs have high efficacy but more expensive compared to the off-labels, and thus are less accessible. This systematic review and network meta-analysis (NMA) was to assess the efficacy and safety of both classes of mAbs compared to the current standard treatments.MethodsSystematically searches were conducted in MEDLINE and SCOPUS from inception until July 2021. Randomized-controlled trials (RCTs) were eligible if they compared any pair of treatments (mAbs, immunosuppressive drugs, or placebo) in adult patients with NMOSD. Studies with AQP4-IgG positive or negative were used in the analysis. Probability of relapse and time to event were extracted from the Kaplan-Meier curves using Digitizer. These data were then converted into individual patient time-to-event data. A one-stage mixed-effect survival model was applied to estimate the median time to relapse and relative treatment effects using hazard ratios (HR). Two-stage NMA was used to determine post-treatment annualized relapse rate (ARR), expanded disability status score (EDSS) change, and serious adverse events (SAE). Risk of bias was assessed using the revised cochrane risk of bias tool.ResultsA total of 7 RCTs with 776 patients were eligible in the NMA. Five of the seven studies were rated low risk of bias. Both FDA-approved and off-label mAbs showed significantly lower risk of relapse than standard treatments, with HR (95% CI) of 0.13 (0.07, 0.24) and 0.16 (0.07, 0.37) respectively. In addition, the FDA-approved mAbs had 20% lower risk of relapse than the off-label mAbs, but this did not reach statistical significance. The ARRs were also lower in FDA-approved and off-label mAbs than the standard treatments with the mean-difference of−0.27 (-0.37,−0.16) and−0.31(-0.46,−0.16), respectively.ConclusionThe off-label mAbs may be used as the first-line treatment for improving clinical outcomes including disease relapse, ARR, and SAEs for NMOSD in countries where resources and accessibility of the FDA-approved mAbs are limited.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?RecordID=283424, identifier: CRD42021283424.
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Affiliation(s)
- Saharat Aungsumart
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
- Department of Neurology, Prasat Neurological Institute, Bangkok, Thailand
| | - Sitaporn Youngkong
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
- Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
- *Correspondence: Sitaporn Youngkong
| | - Charungthai Dejthevaporn
- Division of Neurology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Charungthai Dejthevaporn
| | - Usa Chaikledkaew
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
- Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Kunlawat Thadanipon
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Amarit Tansawet
- Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | | | - John Attia
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
| | - Gareth J. McKay
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, United Kingdom
| | - Ammarin Thakkinstian
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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13
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Ramanathan S, Brilot F, Irani SR, Dale RC. Origins and immunopathogenesis of autoimmune central nervous system disorders. Nat Rev Neurol 2023; 19:172-190. [PMID: 36788293 DOI: 10.1038/s41582-023-00776-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2023] [Indexed: 02/16/2023]
Abstract
The field of autoimmune neurology is rapidly evolving, and recent discoveries have advanced our understanding of disease aetiologies. In this article, we review the key pathogenic mechanisms underlying the development of CNS autoimmunity. First, we review non-modifiable risk factors, such as age, sex and ethnicity, as well as genetic factors such as monogenic variants, common variants in vulnerability genes and emerging HLA associations. Second, we highlight how interactions between environmental factors and epigenetics can modify disease onset and severity. Third, we review possible disease mechanisms underlying triggers that are associated with the loss of immune tolerance with consequent recognition of self-antigens; these triggers include infections, tumours and immune-checkpoint inhibitor therapies. Fourth, we outline how advances in our understanding of the anatomy of lymphatic drainage and neuroimmune interfaces are challenging long-held notions of CNS immune privilege, with direct relevance to CNS autoimmunity, and how disruption of B cell and T cell tolerance and the passage of immune cells between the peripheral and intrathecal compartments have key roles in initiating disease activity. Last, we consider novel therapeutic approaches based on our knowledge of the immunopathogenesis of autoimmune CNS disorders.
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Affiliation(s)
- Sudarshini Ramanathan
- Translational Neuroimmunology Group, Kids Neuroscience Centre, Children's Hospital at Westmead, Sydney, New South Wales, Australia
- Sydney Medical School, Faculty of Medicine and Health and Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
- Department of Neurology, Concord Hospital, Sydney, New South Wales, Australia
| | - Fabienne Brilot
- Translational Neuroimmunology Group, Kids Neuroscience Centre, Children's Hospital at Westmead, Sydney, New South Wales, Australia
- School of Medical Science, Faculty of Medicine and Health and Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Russell C Dale
- Translational Neuroimmunology Group, Kids Neuroscience Centre, Children's Hospital at Westmead, Sydney, New South Wales, Australia.
- Sydney Medical School, Faculty of Medicine and Health and Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia.
- TY Nelson Department of Paediatric Neurology, Children's Hospital Westmead, Sydney, New South Wales, Australia.
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14
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Luo Y, Deng Y, Ran H, Yu L, Ma C, Zhao L, Li Y. Effectiveness and Safety of Immunosuppressive Drug Therapy for Neuromyelitis Optica Spectrum Disorders: An Overview of Meta-Analyses and Systematic Reviews. Curr Neuropharmacol 2023; 21:1827-1834. [PMID: 36154604 PMCID: PMC10514536 DOI: 10.2174/1570159x20666220922151442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 08/14/2022] [Accepted: 08/16/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE This study aims to provide an overview of meta-analyses and systematic reviews on the effectiveness and safety of immunosuppressive drug therapy for neuromyelitis optica spectrum disorders (NMOSD) by evaluating the methodological quality and reporting quality of reviews. METHODS The Chinese National Knowledge Infrastructure (CNKI), WanFang Data, China Science and Technology Journal Database, Web of Science, the Cochrane Library, PubMed, and Embase databases were searched to collect systematic reviews or meta-analyses on the effectiveness and safety of immunosuppressive therapy for NMOSD from inception to December 2, 2021. Two researchers independently screened reviews and extracted data. Any differences in the procession of review assessment between the two researchers were re-evaluated, and the disagreement was resolved by discussion with other researchers. The following data were extracted: author, year of publication, the country where the study was conducted, study type, the number of included studies, sample size, risk bias tools, medication of immunosuppressive therapy, and main outcomes. Then, the AMSTAR-2, which is a critical appraisal tool for systematic reviews (2nd edition), and Grades of Recommendation, Assessment, Development and Evaluation (GRADE) were used to evaluate the methodological quality and reporting quality of evidence. A comprehensive analysis was conducted on the outcomes for all included reviews. RESULTS A total of 15 reviews were included. Of the included reviews, 3 were systematic reviews, 7 were meta-analyses, and 5 were systematic reviews and meta-analyses. According to the AMSTAR-2 criteria, 6 studies had high quality, 1 study had moderate quality, 4 studies had low quality, and 4 studies had critically low quality. Based on the GRADE, neither evidence quality for effectiveness nor safety was high. CONCLUSION Immunosuppressive drug therapy is effective for patients with NMOSD, but its safety is controversial. Due to the poor quality of evidence, reliability needs to be considered. Thus, large sample, multi-center, double-blind, randomized controlled studies are still needed in the future.
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Affiliation(s)
- Yuan Luo
- The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, 410011, China
- Xiangya School of Nursing, Central South University, Changsha, Hunan Province, 410013, China
| | - Yuqian Deng
- Xiangya School of Nursing, Central South University, Changsha, Hunan Province, 410013, China
| | - Haiye Ran
- Xiangya School of Nursing, Central South University, Changsha, Hunan Province, 410013, China
| | - Lei Yu
- Xiangya School of Medicine, Central South University, Changsha, Hunan Province, 410013, China
| | - Caili Ma
- The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, 410011, China
| | - Liping Zhao
- The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, 410011, China
| | - Yunchen Li
- The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, 410011, China
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15
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Kim W, Kim HJ. An update on biologic treatments for neuromyelitis optica spectrum disorder. Expert Rev Clin Immunol 2023; 19:111-121. [PMID: 36414430 DOI: 10.1080/1744666x.2023.2151441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune disease of the central nervous system mediated by antibodies targeting the aquaporin-4 (AQP4) water channel expressed on astrocytes. The binding of specific antibodies to AQP4 causes complement-dependent cytotoxicity, leading to inflammation and demyelination. Several recent phase 2 and 3 randomized placebo-controlled trials showed the efficacy and safety of monoclonal antibody therapies targeting B-cells, interleukin-6 receptor, and complement. AREAS COVERED Current biologic treatments for NMOSD and developments therein, and unresolved issues in NMOSD treatment. EXPERT OPINION New biologic treatments demonstrate high efficacy and good safety for patients with AQP4-IgG-positive NMOSD. The optimal therapeutics for seronegative NMOSD, pediatric patients, and female patients who are pregnant or wish to be are unclear, and further research is needed. Also, real-world studies of new biological agents and the data on the durability of their beneficial effects and their long-term safety are required. Effective rescue therapy for an acute attack is critical given permanent disability in NMOSD is attack-related, and biologic agents that treat acute attack are emerging. If such treatments are to become widely applied, studies on the most cost-effective treatment strategies are needed.
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Affiliation(s)
- Woojun Kim
- Department of Neurology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ho Jin Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, Korea
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16
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Different doses of Rituximab for the therapy of Neuromyelitis optica spectrum disorder: A systematic review and meta-analysis. Mult Scler Relat Disord 2022; 68:104127. [PMID: 36044828 DOI: 10.1016/j.msard.2022.104127] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/27/2022] [Accepted: 08/16/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Neuromyelitis optica spectrum disease(NMOSD) is an autoimmune neurological disease that primarily affects the spinal cord, optic nerve, and periventricular organs. Rituximab plays an important role in the prevention of relapse in NMOSD. In this study, we evaluated the efficacy and safety of different doses of the anti-monoclonal antibody rituximab in NMOSD. OBJECTS Our study aimed to implement a meta-analysis to systematically assess the efficacy and safety of different doses of rituximab in the treatment of NMOSD. METHODS We searched Pubmed, Embase, the Cochrane Library, and Clinicaltrials.gov for relevant studies evaluating rituximab for NMOSD up to March 2022. Data were assessed using Review Manager 5.3 and Stata 14 softwares. Means and standard deviations(SD) were analyzed using random effects models with continuous outcomes. Risk radio was analyzed using random effects models with dichotomous outcomes. RESULTS We collected 576 patients from 17 studies. The endpoint of efficacy was the change in annual recurrence rate(ARR), expanded disability status scale (EDSS), and the number of patients free of relapse between pre-treatment and post-treatment of rituximab. We found that rituximab reduced ARR and EDSS, with a significant reduction in ARR(MD= -1.79, 95% CI: -3.18 ∼ -0.39, P= 0.01) and EDSS(MD= -1.35, 95% CI: -1.5 ∼ -1.19, P < 0.00001) at 100 mg intravenous infusion per week for 3 consecutive weeks, meanwhile making the number of patients free of relapse increased (RR= 24.61 [5.11, 118.55], P<0.0001) and being relatively safe and without serious adverse events(SAEs). In terms of safety, we compared and summarised the adverse events(AEs) and SAEs from 17 studies. CONCLUSION In this study, we found rituximab to be relatively safe and efficacious in the treatment of NMOSD, particularly at a dose of 100mg intravenous infusion per week for 3 consecutive weeks.
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17
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Stathopoulos P, Dalakas MC. The role of complement and complement therapeutics in neuromyelitis optica spectrum disorders. Expert Rev Clin Immunol 2022; 18:933-945. [PMID: 35899480 DOI: 10.1080/1744666x.2022.2105205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Neuromyelitis optica spectrum disorders (NMOSD) are characterized in the majority of cases by the presence of IgG1 autoantibodies against aquaporin 4 (AQP4) and myelin-oligodendrocyte glycoprotein (MOG), both capable of activating complement. AREAS COVERED We review evidence of complement involvement in NMOSD pathophysiology from pathological, in vitro, in vivo, human studies, and clinical trials. EXPERT OPINION In AQP4 NMOSD, complement deposition is a prominent pathological feature, while in vitro and in vivo studies have demonstrated complement-dependent pathogenicity of AQP4 antibodies. Consistent with these studies, the anti-C5 monoclonal antibody eculizumab was remarkably effective and safe in a phase 2/3 trial of AQP4-NMOSD patents leading to FDA-approved indication. Several other anti-complement agents, either approved or in trials for other neuro-autoimmunities, like myasthenia, CIDP, and GBS, are also relevant to NMOSD generating an exciting group of evolving immunotherapies. Limited but compelling in vivo and in vitro data suggest that anti-complement therapeutics may be also applicable to a subset of MOG NMOSD patients with severe disease. Overall, anticomplement agents, along with the already approved anti-IL6 and anti-CD19 monoclonal antibodies sartralizumab and inebilizumab, are rapidly changing the therapeutic algorithm in NMOSD, a previously difficult-to-treat autoimmune neurological disorder.
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Affiliation(s)
- Panos Stathopoulos
- Department of Neurology, National and Kapodistrian University of Athens, Athens, Greece
| | - Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.,Neuroimmunology Unit, National and Kapodistrian University of Athens, Athens, Greece
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18
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Giglhuber K, Berthele A. Adverse Events in NMOSD Therapy. Int J Mol Sci 2022; 23:ijms23084154. [PMID: 35456972 PMCID: PMC9029040 DOI: 10.3390/ijms23084154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/06/2022] [Accepted: 04/06/2022] [Indexed: 11/16/2022] Open
Abstract
Neuromyelitis optica spectrum disorders (NMOSD) are rare neurologic autoimmune diseases that have a poor prognosis if left untreated. For many years, generic oral immunosuppressants and repurposed monoclonal antibodies that target the interleukin-6 pathway or B cells were the mainstays of drug treatment. Recently, these drug treatments have been complemented by new biologics developed and approved specifically for NMOSD. In principle, all of these drugs are effective, but treatment recommendations that take this into account are still pending. Instead, the choice of a drug may depend on other criteria such as drug safety or tolerability. In this review, we summarise current knowledge on the adverse effects of azathioprine, mycophenolate mofetil, rituximab, tocilizumab, eculizumab, satralizumab, and inebilizumab in NMOSD. Infections, cytopenias, and infusion-related reactions are most common, but the data are as heterogeneous as the manifestations are diverse. Nevertheless, knowledge of safety issues may facilitate treatment choices for individual patients.
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Pittock SJ, Zekeridou A, Weinshenker BG. Hope for patients with neuromyelitis optica spectrum disorders - from mechanisms to trials. Nat Rev Neurol 2021; 17:759-773. [PMID: 34711906 DOI: 10.1038/s41582-021-00568-8] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2021] [Indexed: 02/07/2023]
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is a rare inflammatory CNS disease that primarily manifests as relapsing episodes of severe optic neuritis and myelitis. Diagnosis of NMOSD is supported by the detection of IgG autoantibodies that target the aquaporin 4 (AQP4) water channel, which, in the CNS, is an astrocyte-specific protein. AQP4 antibody binding leads to AQP4 internalization, complement-dependent and antibody-dependent cellular cytotoxicity, and water channel dysfunction. Cumulative attack-related injury causes disability in NMOSD, so the prevention of attacks is expected to prevent disability accrual. Until recently, no regulator-approved therapies were available for NMOSD. Traditional immunosuppressant therapies, including mycophenolate mofetil, azathioprine and rituximab, were widely used but their benefits have not been assessed in controlled studies. In 2019 and 2020, five phase II and III randomized placebo-controlled trials of four mechanism-based therapies for NMOSD were published and demonstrated that all four effectively prolonged the time to first relapse. All four drugs were monoclonal antibodies: the complement C5 antibody eculizumab, the IL-6 receptor antibody satralizumab, the B cell-depleting antibody inebilizumab, which targets CD19, and rituximab, which targets CD20. We review the pathophysiology of NMOSD, the rationale for the development of these mechanism-based drugs, the methodology and outcomes of the five trials, and the implications of these findings for the treatment of NMOSD.
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Affiliation(s)
- Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, MN, USA. .,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA. .,Center of Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA.
| | - Anastasia Zekeridou
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.,Center of Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA
| | - Brian G Weinshenker
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.,Center of Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA
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