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Frisaldi E, Ferrero B, Di Liberto A, Barbiani D, Camerone EM, Piedimonte A, Vollert J, Cavallo R, Zibetti M, Lopiano L, Shaibani A, Benedetti F. The impact of patients' pre-treatment expectations on immunosuppressive treatment outcomes in myasthenia gravis: A pilot correlational study. Muscle Nerve 2024; 70:413-419. [PMID: 38940302 DOI: 10.1002/mus.28189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 06/05/2024] [Accepted: 06/11/2024] [Indexed: 06/29/2024]
Abstract
INTRODUCTION/AIMS The impact of treatment expectations on active treatment outcomes has not been specifically investigated in neuromuscular disorders. We thus explored in myasthenia gravis (MG) the contribution of patients' pre-treatment expectations combined with an immunosuppressant drug on treatment outcomes. METHODS This pilot correlational study involved 17 patients with generalized MG, scheduled to start immunosuppressant azathioprine. At baseline, a healthcare professional administered: (i) the Stanford Expectations of Treatment Scale; (ii) a structured checklist paper form asking patients which side-effects they expected to develop after starting azathioprine, coupled with a standardized framing of statements. Quantitative Myasthenia Gravis (QMG) score and daily dose of concomitant drugs were assessed by neurologists as clinical outcomes. Clinical outcomes and side-effects were re-assessed at 3 and 6 months, and clinical outcomes were monitored at 18 months. RESULTS Clinically significant improvement in the QMG scores was achieved at 3 or 6 months. The level of state anxiety appeared to act as moderator of pre-treatment negative expectations (strong, positive, indicative correlation, rs = .733, p = .001). The latter were, in turn, associated with the fulfillment of side-effects that patients expected to develop with the new treatment (moderate, positive, indicative correlation, rs = .699, p = .002). No significant correlation emerged between positive and negative expectations. DISCUSSION Our findings show a very quick clinical response and also suggest that patients' expectations and anxiety contributed to treatment outcomes, highlighting the importance of promoting safety messages and education strategies around newly introduced treatments. Future goals include evaluating a larger cohort that includes a matched control group.
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Affiliation(s)
- Elisa Frisaldi
- Rita Levi Montalcini Department of Neuroscience, University of Turin Medical School, Turin, Italy
- Clinical Neurosciences, Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Essen, Germany
| | - Bruno Ferrero
- Rita Levi Montalcini Department of Neuroscience, University of Turin Medical School, Turin, Italy
- Neurology 2 Unit, A.O.U. Città Della Salute e Della Scienza di Torino, Turin, Italy
| | - Alessandra Di Liberto
- Rita Levi Montalcini Department of Neuroscience, University of Turin Medical School, Turin, Italy
- Neurology 2 Unit, A.O.U. Città Della Salute e Della Scienza di Torino, Turin, Italy
- Neurology Unit, San Giovanni Bosco Hospital, Turin, Italy
| | - Diletta Barbiani
- Rita Levi Montalcini Department of Neuroscience, University of Turin Medical School, Turin, Italy
- Department of Psychology, Università Cattolica del Sacro Cuore, Milan, Italy
| | - Eleonora Maria Camerone
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Savona, Italy
- Department of Psychology, University of Milan-Bicocca, Milan, Italy
| | - Alessandro Piedimonte
- Rita Levi Montalcini Department of Neuroscience, University of Turin Medical School, Turin, Italy
- Istituto Auxologico Italiano, U.O. di Neurologia e Neuroriabilitazione, Ospedale San Giuseppe, Piancavallo (VCO), Italy
| | - Jan Vollert
- Department of Clinical and Biomedical Sciences, Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | | | - Maurizio Zibetti
- Rita Levi Montalcini Department of Neuroscience, University of Turin Medical School, Turin, Italy
- Neurology 2 Unit, A.O.U. Città Della Salute e Della Scienza di Torino, Turin, Italy
| | - Leonardo Lopiano
- Rita Levi Montalcini Department of Neuroscience, University of Turin Medical School, Turin, Italy
- Neurology 2 Unit, A.O.U. Città Della Salute e Della Scienza di Torino, Turin, Italy
| | - Aziz Shaibani
- Nerve and Muscle Center of Texas, Houston, Texas, USA
- Baylor College of Medicine, Houston, Texas, USA
| | - Fabrizio Benedetti
- Rita Levi Montalcini Department of Neuroscience, University of Turin Medical School, Turin, Italy
- Medicine and Physiology of Hypoxia, Plateau Rosà, Switzerland
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Li Y, Yang S, Dong X, Duan W, Jiang F, Chen K, Zhou Q, Cai H, Yang H. Diagnostic value of antibody concentration ratio for treatment-refractory myasthenia gravis. Neurol Sci 2024:10.1007/s10072-024-07601-w. [PMID: 38780854 DOI: 10.1007/s10072-024-07601-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 05/16/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE This study aimed to assess the diagnostic potential of the Antibody concentration ratio in identifying treatment-refractory myasthenia gravis (MG). METHODS A retrospective analysis was conducted on 116 MG patients who underwent antibody detection at least twice between June 1, 2015, and June 1, 2023. Demographic and clinical characteristics were collated to ascertain their association with refractory MG. The Antibody Concentration Ratio was applied to determine treatment response, using the International Consensus Guidance criteria as the reference standard. The area under nonparametric receiver operating characteristic curve (AUC), sensitivity, specificity, and accuracy were calculated to assess the diagnostic efficacy of the Antibody concentration ratio following consecutive immunotherapy relative to initial antibody concentrations for refractory MG. RESULTS 19 out of 116 patients were unequivocally diagnosed with refractory MG. A significant correlation was found between the Antibody Concentration Ratio and refractory MG status in treatment-refractory and treatment-responsive patients. Subsequently, the AUC demonstrated the robust diagnostic capability of the Antibody concentration ratio for refractory MG, with an AUC of 0.8709 (95% CI: 0.7995-0.9422, p < 0.0001). The optimal cut-off value stood at 0.8903, exhibiting a sensitivity of 94.74% (95% CI: 75.36%-99.73%), a specificity of 68.04% (95% CI: 58.23%-76.48%), and accuracy of 72.41% (95% CI: 64.28%-80.54%). CONCLUSION Elevated Antibody Concentration Ratio is intrinsically linked with refractory MG and exhibits potential as an diagnostic biomarker for the condition.
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Affiliation(s)
- Yi Li
- Department of Neurology, Research Center for Neuroimmune and Neuromuscular disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410000, Hunan, China
| | - Shumei Yang
- Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410000, Hunan, China
| | - Xiaohua Dong
- Department of Neurology, Research Center for Neuroimmune and Neuromuscular disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410000, Hunan, China
| | - Weiwei Duan
- Department of Neurology, Research Center for Neuroimmune and Neuromuscular disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410000, Hunan, China
| | - Fei Jiang
- Department of Neurology, Research Center for Neuroimmune and Neuromuscular disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410000, Hunan, China
| | - Kangzhi Chen
- Department of Neurology, Research Center for Neuroimmune and Neuromuscular disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410000, Hunan, China
| | - Qian Zhou
- Department of Neurology, Research Center for Neuroimmune and Neuromuscular disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410000, Hunan, China
| | - Haobin Cai
- Department of Neurology, Research Center for Neuroimmune and Neuromuscular disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410000, Hunan, China
| | - Huan Yang
- Department of Neurology, Research Center for Neuroimmune and Neuromuscular disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410000, Hunan, China.
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Howard JF, Bresch S, Farmakidis C, Freimer M, Genge A, Hewamadduma C, Hinton J, Hussain Y, Juntas-Morales R, Kaminski HJ, Maniaol A, Mantegazza R, Masuda M, Nowak RJ, Sivakumar K, Śmiłowski M, Utsugisawa K, Vu T, Weiss MD, Zajda M, Bloemers J, Boroojerdi B, Brock M, de la Borderie G, Duda PW, Vanderkelen M, Leite MI. Long-term safety and efficacy of zilucoplan in patients with generalized myasthenia gravis: interim analysis of the RAISE-XT open-label extension study. Ther Adv Neurol Disord 2024; 17:17562864241243186. [PMID: 38638673 PMCID: PMC11025429 DOI: 10.1177/17562864241243186] [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: 10/17/2023] [Accepted: 03/13/2024] [Indexed: 04/20/2024] Open
Abstract
Background Generalized myasthenia gravis (gMG) is a chronic, unpredictable disease associated with high treatment and disease burdens, with a need for more effective and well-tolerated treatments. Objectives To evaluate the long-term safety, tolerability, and efficacy of zilucoplan in a mild-to-severe, acetylcholine receptor autoantibody-positive (AChR+) gMG population. Design Ongoing, multicenter, phase III open-label extension (OLE) study. Methods Eligible patients had completed a qualifying randomized, placebo-controlled phase II or phase III zilucoplan study and received daily, self-administered subcutaneous 0.3 mg/kg zilucoplan. The primary endpoint was incidence of treatment-emergent adverse events (TEAEs). Secondary efficacy endpoints included change from baseline in Myasthenia Gravis Activities of Daily Living (MG-ADL) score. Results In total, 200 patients enrolled. At the cut-off date (8 September 2022), median (range) exposure to zilucoplan in RAISE-XT was 1.2 (0.11-4.45) years. Mean age at OLE baseline was 53.3 years. A total of 188 (94%) patients experienced a TEAE, with the most common being MG worsening (n = 52, 26%) and COVID-19 (n = 49, 25%). In patients who received zilucoplan 0.3 mg/kg in the parent study, further improvements in MG-ADL score continued through to Week 24 (least squares mean change [95% confidence interval] from double-blind baseline -6.06 [-7.09, -5.03]) and were sustained through to Week 60 (-6.04 [-7.21, -4.87]). In patients who switched from placebo in the parent study, rapid improvements in MG-ADL score were observed at the first week after switching to zilucoplan; further improvements were observed at Week 24, 12 weeks after switching (-6.46 [-8.19, -4.72]), and were sustained through to Week 60 (-6.51 [-8.37, -4.65]). Consistent results were observed in other efficacy endpoints. Conclusion Zilucoplan demonstrated a favorable long-term safety profile, good tolerability, and sustained efficacy through to Week 60 with consistent benefits in a broad AChR+ gMG population. Additional long-term data will be available in future analyses. Trial registration ClinicalTrials.gov identifier: NCT04225871 (https://clinicaltrials.gov/ct2/show/NCT04225871).
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Affiliation(s)
- James F. Howard
- Department of Neurology, UNC School of Medicine, The University College of North Carolina at Chapel Hill, 2200 Houpt Building, CB#7025, 170 Manning Drive, Chapel Hill, NC 27599-7025, USA
| | - Saskia Bresch
- Service de Neurologie, Hospital Pasteur, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Constantine Farmakidis
- Neuromuscular Division, Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Miriam Freimer
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Angela Genge
- Clinical Research Unit, Montreal Neurological Institute, Montreal, QC, Canada
| | - Channa Hewamadduma
- Academic Neuroscience Unit, Sheffield Teaching Hospitals Foundation Trust, Sheffield, UK
- Sheffield Institute for Translational Neurosciences (SITRAN), University of Sheffield, Sheffield, UK
| | - John Hinton
- Department of Neurology, Frederick P. Whiddon School of Medicine, University of South Alabama, Mobile, AL, USA
| | - Yessar Hussain
- Department of Neurology, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Raul Juntas-Morales
- Department of Neurology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Henry J. Kaminski
- Department of Neurology and Rehabilitation Medicine, George Washington University, Washington, DC, USA
| | | | - Renato Mantegazza
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale Neurologico Carlo Besta, Milan, Italy
| | - Masayuki Masuda
- Department of Neurology, Tokyo Medical University, Tokyo, Japan
| | - Richard J. Nowak
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | | | - Marek Śmiłowski
- Department of Hematology and Bone Marrow Transplantation, Medical University of Silesia, Katowice, Poland
| | | | - Tuan Vu
- Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Michael D. Weiss
- Department of Neurology, University of Washington Medical Center, Seattle, WA, USA
| | - Małgorzata Zajda
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warsaw, Poland
| | | | | | | | | | | | | | - M. Isabel Leite
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Skov M, Ruijs TQ, Grønnebæk TS, Skals M, Riisager A, Winther JB, Dybdahl KLT, Findsen A, Morgen JJ, Huus N, Broch-Lips M, Nielsen OB, de Cuba CMKE, Heuberger JAAC, de Kam ML, Tannemaat M, Verschuuren JJGM, Knutsen LJS, Kelly NM, Jensen KG, Arnold WD, Burghes AH, Olesen C, Bold J, Petersen TK, Quiroz JA, Hutchison J, Chin ER, Groeneveld GJ, Pedersen TH. The ClC-1 chloride channel inhibitor NMD670 improves skeletal muscle function in rat models and patients with myasthenia gravis. Sci Transl Med 2024; 16:eadk9109. [PMID: 38507469 DOI: 10.1126/scitranslmed.adk9109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 02/23/2024] [Indexed: 03/22/2024]
Abstract
Myasthenia gravis (MG) is a neuromuscular disease that results in compromised transmission of electrical signals at the neuromuscular junction (NMJ) from motor neurons to skeletal muscle fibers. As a result, patients with MG have reduced skeletal muscle function and present with symptoms of severe muscle weakness and fatigue. ClC-1 is a skeletal muscle specific chloride (Cl-) ion channel that plays important roles in regulating neuromuscular transmission and muscle fiber excitability during intense exercise. Here, we show that partial inhibition of ClC-1 with an orally bioavailable small molecule (NMD670) can restore muscle function in rat models of MG and in patients with MG. In severely affected MG rats, ClC-1 inhibition enhanced neuromuscular transmission, restored muscle function, and improved mobility after both single and prolonged administrations of NMD670. On this basis, NMD670 was progressed through nonclinical safety pharmacology and toxicology studies, leading to approval for testing in clinical studies. After successfully completing phase 1 single ascending dose in healthy volunteers, NMD670 was tested in patients with MG in a randomized, placebo-controlled, single-dose, three-way crossover clinical trial. The clinical trial evaluated safety, pharmacokinetics, and pharmacodynamics of NMD670 in 12 patients with mild MG. NMD670 had a favorable safety profile and led to clinically relevant improvements in the quantitative myasthenia gravis (QMG) total score. This translational study spanning from single muscle fiber recordings to patients provides proof of mechanism for ClC-1 inhibition as a potential therapeutic approach in MG and supports further development of NMD670.
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Affiliation(s)
- Martin Skov
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Titia Q Ruijs
- Centre for Human Drug Research, 2333 CL Leiden, Netherlands
- Leiden University Medical Centre, 2333 ZA Leiden, Netherlands
| | | | - Marianne Skals
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Anders Riisager
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | | | | | - Anders Findsen
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Jeanette J Morgen
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Nete Huus
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Martin Broch-Lips
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Ole B Nielsen
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
- Department of Biomedicine, Aarhus University, Ole Worms Alle 4, 8000 Aarhus C, Denmark
| | - Catherine M K E de Cuba
- Centre for Human Drug Research, 2333 CL Leiden, Netherlands
- Leiden University Medical Centre, 2333 ZA Leiden, Netherlands
| | | | | | | | | | - Lars J S Knutsen
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Nicholas M Kelly
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Klaus G Jensen
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - William D Arnold
- NextGen Precision Health, University of Missouri, 1030 Hitt St, Columbia, MO 65212, USA
| | - Arthur H Burghes
- Department of Biological Chemistry and Pharmacology, Ohio State University Wexner Medical Center, 1060 Carmack Road, Columbus, OH 43210, USA
- Department of Neurology, Neuromuscular Division, Ohio State University Wexner Medical Center, 395 W. 12(th) Ave, Columbus, OH 43210, USA
| | - Claus Olesen
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
- Department of Biomedicine, Aarhus University, Ole Worms Alle 4, 8000 Aarhus C, Denmark
| | - Jane Bold
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Thomas K Petersen
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Jorge A Quiroz
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - John Hutchison
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Eva R Chin
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Geert J Groeneveld
- Centre for Human Drug Research, 2333 CL Leiden, Netherlands
- Leiden University Medical Centre, 2333 ZA Leiden, Netherlands
| | - Thomas H Pedersen
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
- Department of Biomedicine, Aarhus University, Ole Worms Alle 4, 8000 Aarhus C, Denmark
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Zhang KY, Duan WW, Luo YB, Li Y, Hu J, Yang H. Comparative effectiveness and safety of intravenous methylprednisolone and tacrolimus monotherapy in ocular myasthenia gravis with unsatisfactory prednisone responses: a retrospective study. Orphanet J Rare Dis 2024; 19:19. [PMID: 38243274 PMCID: PMC10799357 DOI: 10.1186/s13023-024-03025-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 01/11/2024] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Oral prednisone has been recognized as the first-line therapy for the treatment of ocular myasthenia gravis (OMG). However, its long-term use is complicated by numerous adverse effects and is ineffective for some OMG patients in reaching remission. This study aimed to evaluate the effectiveness and safety of intravenous methylprednisolone (IVMP) and tacrolimus monotherapy for OMG patients with unsatisfactory responses to conventional prednisone therapy. METHODS We retrospectively reviewed 57 OMG patients who had not achieved satisfactory improvement after prednisone therapy and thereby received IVMP or tacrolimus monotherapy for at least 6 months. Ocular symptoms were evaluated by the ocular-quantitative MG (QMG) score at each time point. A ≥ 2-point fall in ocular QMG score was defined as the cut-off point to indicate clinical improvement. Logistic regression analysis was performed to identify factors associated with the efficacy of IVMP at discharge. Adverse events were recorded. RESULTS Both IVMP and tacrolimus monotherapy demonstrated significant clinical efficacy, with no statistical differences observed at the study endpoint. The proportions of patients who reached the cut-off point for efficacy evaluation were higher in the IVMP group than in the tacrolimus group (1, 3, and 6 months: 51.7% (15/29) vs 12.0% (3/25), p = 0.002; 69.0% (20/29) vs 40.0% (10/25), p = 0.033; 69.0% (20/29) vs 46.4% (13/28), p = 0.085, respectively). Multivariate logistics analysis showed that high ocular QMG scores at baseline indicated favourable responses to IVMP treatment (OR = 1.781; 95% CI 1.066-2.975; p = 0.028). All the adverse events were transient and tolerable. CONCLUSION Our findings suggest that both IVMP and tacrolimus monotherapy hold promise as viable treatment options for OMG patients with unsatisfactory responses to oral prednisone. The study supports the safety and effectiveness of both therapies, with IVMP exhibiting faster improvement and favourable efficacy in patients with high ocular QMG scores.
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Affiliation(s)
- Kai-Yue Zhang
- Department of Neurology, Xiangya Hospital, Central South University, Xiangya Road, Kaifu District, Changsha, 410008, China
| | - Wei-Wei Duan
- Department of Neurology, Xiangya Hospital, Central South University, Xiangya Road, Kaifu District, Changsha, 410008, China
| | - Yue-Bei Luo
- Department of Neurology, Xiangya Hospital, Central South University, Xiangya Road, Kaifu District, Changsha, 410008, China
| | - Yi Li
- Department of Neurology, Xiangya Hospital, Central South University, Xiangya Road, Kaifu District, Changsha, 410008, China
| | - Jue Hu
- Department of Neurology, Changsha Central Hospital, Changsha, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Xiangya Road, Kaifu District, Changsha, 410008, China.
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Bril V, Howard JF, Karam C, De Bleecker JL, Murai H, Utsugisawa K, Ulrichts P, Brauer E, Zhao S, Mantegazza R, Vu T. Effect of efgartigimod on muscle group subdomains in participants with generalized myasthenia gravis: post hoc analyses of the phase 3 pivotal ADAPT study. Eur J Neurol 2024; 31:e16098. [PMID: 37843174 PMCID: PMC11235734 DOI: 10.1111/ene.16098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/20/2023] [Accepted: 09/26/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND AND PURPOSE Generalized myasthenia gravis (gMG) is a rare, chronic, neuromuscular autoimmune disease mediated by pathogenic immunoglobulin G (IgG) autoantibodies. Patients with gMG experience debilitating muscle weakness, resulting in impaired mobility, speech, swallowing, vision and respiratory function. Efgartigimod is a human IgG1 antibody Fc fragment engineered for increased binding affinity to neonatal Fc receptor. The neonatal Fc receptor blockade by efgartigimod competitively inhibits endogenous IgG binding, leading to decreased IgG recycling and increased degradation resulting in lower IgG concentration. METHODS The safety and efficacy of efgartigimod were evaluated in the ADAPT study. Key efficacy outcome measures included Myasthenia Gravis Activities of Daily Living (MG-ADL) and Quantitative Myasthenia Gravis (QMG) scores. Efgartigimod demonstrated significant improvement in both the MG-ADL and QMG scores. This post hoc analysis aimed to determine whether all subdomains of MG-ADL and QMG improved with efgartigimod treatment. Individual items of MG-ADL and QMG were grouped into four subdomains: bulbar, ocular, limb/gross motor and respiratory. Change from baseline over 10 weeks in each subdomain was calculated for each group. RESULTS Greater improvements from baseline were seen across MG-ADL subdomains in participants treated with efgartigimod compared with placebo. These improvements were typically observed 1 to 2 weeks after the first infusion and correlated with reductions in IgG. Similar results were observed across most QMG subdomains. CONCLUSIONS These post hoc analyses of MG-ADL and QMG subdomain data from ADAPT suggest that efgartigimod is beneficial in improving muscle function and strength across all muscle groups, leading to the observed efficacy in participants with gMG.
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Affiliation(s)
- Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular DiseasesUniversity Health NetworkTorontoOntarioCanada
- University of TorontoTorontoOntarioCanada
| | - James F. Howard
- Department of NeurologyUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Chafic Karam
- Penn Neuroscience Center–NeurologyHospital of the University of PennsylvaniaPennsylvaniaPhiladelphiaUSA
| | | | - Hiroyuki Murai
- Department of Neurology, School of MedicineInternational University of Health and WelfareTokyoJapan
| | | | | | | | | | - Renato Mantegazza
- Department of Neuroimmunology and Neuromuscular DiseasesFondazione IRCCS Istituto Neurologico Carlo BestaMilanItaly
| | - Tuan Vu
- Department of NeurologyUniversity of South Florida Morsani College of MedicineTampaFloridaUSA
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Mihalache OA, Vilciu C, Petrescu DM, Petrescu C, Manea MC, Ciobanu AM, Ciobanu CA, Popa-Velea O, Riga S. Depression: A Contributing Factor to the Clinical Course in Myasthenia Gravis Patients. MEDICINA (KAUNAS, LITHUANIA) 2023; 60:56. [PMID: 38256317 PMCID: PMC10819146 DOI: 10.3390/medicina60010056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 12/22/2023] [Accepted: 12/26/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: The association between myasthenia gravis (MG) and depression is intricate and characterized by bidirectional causality. In this regard, MG can be a contributing factor to depression and, conversely, depression may worsen the symptoms of MG. This study aimed to identify any differences in the progression of the disease among patients with MG who were also diagnosed with depression as compared to those without depression. Our hypothesis focused on the theory that patients with more severe MG symptoms may have a higher likelihood of suffering depression at the same time. Materials and Methods: One hundred twenty-two male and female patients (N = 122) aged over 18 with a confirmed diagnosis of autoimmune MG who were admitted to the Neurology II department of Myasthenia Gravis, Clinical Institute Fundeni in Bucharest between January 2019 and December 2020, were included in the study. Patients were assessed at baseline and after six months. The psychiatric assessment of the patients included the Hamilton Depression Rating Scale-17 items (HAM-D), and neurological status was determined with two outcome measures: Quantitative Myasthenia Gravis (QMG) and Myasthenia Gravis Activities of Daily Life (MG-ADL). The patients were divided into two distinct groups as follows: group MG w/dep, which comprised 49 MG patients diagnosed with depressive disorder who were also currently receiving antidepressant medication, and group MG w/o dep, which consisted of 73 patients who did not have depression. Results: In our study, 40.16% of the myasthenia gravis (MG) patients exhibited a comorbid diagnosis of depression. Among the MG patients receiving antidepressant treatment, baseline assessments revealed a mean MG-ADL score of 7.73 (SD = 5.05), an average QMG score of 18.40 (SD = 8.61), and a mean Ham-D score of 21.53 (SD = 7.49). After a six-month period, a statistically significant decrease was observed in the MG-ADL (2.92, SD = 1.82), QMG (7.15, SD = 4.46), and Ham-D scores (11.16, SD = 7.49) (p < 0.0001). These results suggest a significant correlation between MG severity and elevated HAM-D depression scores. Regarding the MG treatment in the group with depression, at baseline, the mean dose of oral corticosteroids was 45.10 mg (SD = 16.60). Regarding the treatment with pyridostigmine, patients with depression and undergoing antidepressant treatment remained with an increased need for pyridostigmine, 144.49 mg (SD = 51.84), compared to those in the group without depression, 107.67 mg (SD = 55.64, p < 0.001). Conclusions: Our investigation confirms that the occurrence of depressive symptoms is significantly widespread among individuals diagnosed with MG. Disease severity, along with younger age and higher doses of cortisone, is a significant factor associated with depression in patients with MG. Substantial reductions in MG-ADL and QMG scores were observed within each group after six months, highlighting the effectiveness of MG management. The findings suggest that addressing depressive symptoms in MG patients, in addition to standard MG management, can lead to improved clinical outcomes.
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Affiliation(s)
- Oana Antonia Mihalache
- Department of Doctoral Studies, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Department of Neurology, “Fundeni” Clinical Institute, 022328 Bucharest, Romania;
| | - Crisanda Vilciu
- Department of Neurology, “Fundeni” Clinical Institute, 022328 Bucharest, Romania;
- Department of Neurology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Diana-Mihaela Petrescu
- Department of Neurology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Cristian Petrescu
- Department of Psychiatry, “Prof. Dr. Alexandru Obregia” Clinical Hospital of Psychiatry, 041914 Bucharest, Romania; (C.P.); (M.C.M.)
- Neuroscience Department, Discipline of Psychiatry, Faculty of Medicine, University of Medicine and Pharmacy “Carol Davila”, 020021 Bucharest, Romania
| | - Mihnea Costin Manea
- Department of Psychiatry, “Prof. Dr. Alexandru Obregia” Clinical Hospital of Psychiatry, 041914 Bucharest, Romania; (C.P.); (M.C.M.)
- Neuroscience Department, Discipline of Psychiatry, Faculty of Medicine, University of Medicine and Pharmacy “Carol Davila”, 020021 Bucharest, Romania
| | - Adela Magdalena Ciobanu
- Department of Psychiatry, “Prof. Dr. Alexandru Obregia” Clinical Hospital of Psychiatry, 041914 Bucharest, Romania; (C.P.); (M.C.M.)
- Neuroscience Department, Discipline of Psychiatry, Faculty of Medicine, University of Medicine and Pharmacy “Carol Davila”, 020021 Bucharest, Romania
| | | | - Ovidiu Popa-Velea
- Department of Medical Psychology, Faculty of Medicine, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania;
| | - Sorin Riga
- Department of Stress Research and Prophylaxis, “Prof. Dr. Alexandru Obregia” Clinical Hospital of Psychiatry, 041914 Bucharest, Romania;
- Romanian Academy of Medical Sciences, 927180 Bucharest, Romania
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Vu T, Wiendl H, Katsuno M, Reddel SW, Howard JF. Ravulizumab in Myasthenia Gravis: A Review of the Current Evidence. Neuropsychiatr Dis Treat 2023; 19:2639-2655. [PMID: 38059203 PMCID: PMC10697093 DOI: 10.2147/ndt.s374694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/17/2023] [Indexed: 12/08/2023] Open
Abstract
The terminal complement C5 inhibitor ravulizumab was engineered from the humanized monoclonal antibody eculizumab to have an extended half-life and duration of action. It binds to human terminal complement protein C5, inhibiting its cleavage into C5a and C5b, thus preventing the cascade of events that lead to architectural destruction of the postsynaptic neuromuscular junction membrane by the membrane attack complex, and consequent muscle weakness in patients with anti-acetylcholine receptor (AChR) antibody-positive generalized myasthenia gravis (gMG). The 26-week randomized, placebo-controlled period (RCP) of the phase 3 CHAMPION MG study demonstrated the rapid efficacy of ravulizumab in reducing MG symptoms. Weight-based dosing of ravulizumab every 8 weeks provided sustained efficacy, in terms of patient-reported (Myasthenia Gravis-Activities of Daily Living) and clinician-reported (Quantitative Myasthenia Gravis) endpoints in patients with anti-AChR antibody-positive gMG. Pharmacokinetic and pharmacodynamic analyses showed therapeutic serum ravulizumab concentrations (>175 µg/mL) were achieved immediately after the first dose and were maintained throughout 26 weeks, irrespective of patient body weight; inhibition of serum free C5 was immediate, complete (<0.5 μg/mL), and sustained in all patients. Interim results from the open-label extension (OLE) showed that after 60 weeks, efficacy was maintained in patients continuing on ravulizumab. Rapid and sustained improvements in efficacy, similar to those seen in patients initiating ravulizumab in the RCP, were observed after initiation of ravulizumab treatment in patients who switched from placebo in the RCP to ravulizumab in the OLE. The findings from the RCP and OLE support ravulizumab's favorable safety profile. In conclusion, ravulizumab has a simple weight-based administration and long dosing interval. Its targeted mechanism of action without generalized immunosuppression is reflected in its rapid onset of symptom improvement, sustained efficacy and good safety profile in the treatment of patients with anti-AChR antibody-positive gMG.
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Affiliation(s)
- Tuan Vu
- Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Stephen W Reddel
- Department of Neurology, Concord Hospital, University of Sydney, Sydney, NSW, Australia
| | - James F Howard
- Department of Neurology, The University of North Carolina, Chapel Hill, NC, USA
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Ruiter AM, Wang Z, Yin Z, Naber WC, Simons J, Blom JT, van Gemert JC, Verschuuren JJGM, Tannemaat MR. Assessing facial weakness in myasthenia gravis with facial recognition software and deep learning. Ann Clin Transl Neurol 2023; 10:1314-1325. [PMID: 37292032 PMCID: PMC10424649 DOI: 10.1002/acn3.51823] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 06/10/2023] Open
Abstract
OBJECTIVE Myasthenia gravis (MG) is an autoimmune disease leading to fatigable muscle weakness. Extra-ocular and bulbar muscles are most commonly affected. We aimed to investigate whether facial weakness can be quantified automatically and used for diagnosis and disease monitoring. METHODS In this cross-sectional study, we analyzed video recordings of 70 MG patients and 69 healthy controls (HC) with two different methods. Facial weakness was first quantified with facial expression recognition software. Subsequently, a deep learning (DL) computer model was trained for the classification of diagnosis and disease severity using multiple cross-validations on videos of 50 patients and 50 controls. Results were validated using unseen videos of 20 MG patients and 19 HC. RESULTS Expression of anger (p = 0.026), fear (p = 0.003), and happiness (p < 0.001) was significantly decreased in MG compared to HC. Specific patterns of decreased facial movement were detectable in each emotion. Results of the DL model for diagnosis were as follows: area under the curve (AUC) of the receiver operator curve 0.75 (95% CI 0.65-0.85), sensitivity 0.76, specificity 0.76, and accuracy 76%. For disease severity: AUC 0.75 (95% CI 0.60-0.90), sensitivity 0.93, specificity 0.63, and accuracy 80%. Results of validation, diagnosis: AUC 0.82 (95% CI: 0.67-0.97), sensitivity 1.0, specificity 0.74, and accuracy 87%. For disease severity: AUC 0.88 (95% CI: 0.67-1.0), sensitivity 1.0, specificity 0.86, and accuracy 94%. INTERPRETATION Patterns of facial weakness can be detected with facial recognition software. Second, this study delivers a 'proof of concept' for a DL model that can distinguish MG from HC and classifies disease severity.
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Affiliation(s)
- Annabel M. Ruiter
- Department of NeurologyLeiden University Medical CenterLeidenthe Netherlands
| | - Ziqi Wang
- Vision LabDelft University of TechnologyDelftthe Netherlands
| | - Zhao Yin
- Vision LabDelft University of TechnologyDelftthe Netherlands
| | - Willemijn C. Naber
- Department of NeurologyLeiden University Medical CenterLeidenthe Netherlands
| | - Jerrel Simons
- Department of NeurologyLeiden University Medical CenterLeidenthe Netherlands
| | - Jurre T. Blom
- Medical Illustrator at www.jurreblom.nlApeldoornthe Netherlands
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Mishra B, Sudheer P, Agarwal A, Srivastava MVP, Nilima, Vishnu VY. Minimal Clinically Important Difference (MCID) in Patient-Reported Outcome Measures for Neurological Conditions: Review of Concept and Methods. Ann Indian Acad Neurol 2023; 26:334-343. [PMID: 37970301 PMCID: PMC10645230 DOI: 10.4103/aian.aian_207_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/29/2023] [Accepted: 05/10/2023] [Indexed: 11/17/2023] Open
Abstract
The concept of the minimal clinically important difference (MCID) emerged from the recognition that statistical significance alone is not enough to determine the clinical relevance of treatment effects in clinical research. In many cases, statistically significant changes in outcomes may not be meaningful to patients or may not result in any tangible improvements in their health. This has led to a growing emphasis on the importance of measuring patient-reported outcome measures (PROMs) in clinical trials and other research studies, in order to capture the patient perspective on treatment effectiveness. MCID is defined as the smallest change in scores that is considered meaningful or important to patients. MCID is particularly important in fields such as neurology, where many of the outcomes of interest are subjective or based on patient-reported symptoms. This review discusses the challenges associated with interpreting outcomes of clinical trials based solely on statistical significance, highlighting the importance of considering clinical relevance and patient perception of change. There are two main approaches to estimating MCID: anchor-based and distribution-based. Anchor-based approaches compare change scores using an external anchor, while distribution-based approaches estimate MCID values based on statistical characteristics of scores within a sample. MCID is dynamic and context-specific, and there is no single 'gold standard' method for estimating it. A range of MCID thresholds should be defined using multiple methods for a disease under targeted intervention, rather than relying on a single absolute value. The use of MCID thresholds can be an important tool for researchers, neurophysicians and patients in evaluating the effectiveness of treatments and interventions, and in making informed decisions about care.
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Affiliation(s)
- Biswamohan Mishra
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Pachipala Sudheer
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ayush Agarwal
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Nilima
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
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11
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Howard JF, Bresch S, Genge A, Hewamadduma C, Hinton J, Hussain Y, Juntas-Morales R, Kaminski HJ, Maniaol A, Mantegazza R, Masuda M, Sivakumar K, Śmiłowski M, Utsugisawa K, Vu T, Weiss MD, Zajda M, Boroojerdi B, Brock M, de la Borderie G, Duda PW, Lowcock R, Vanderkelen M, Leite MI. Safety and efficacy of zilucoplan in patients with generalised myasthenia gravis (RAISE): a randomised, double-blind, placebo-controlled, phase 3 study. Lancet Neurol 2023; 22:395-406. [PMID: 37059508 DOI: 10.1016/s1474-4422(23)00080-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 02/08/2023] [Accepted: 02/14/2023] [Indexed: 04/16/2023]
Abstract
BACKGROUND Generalised myasthenia gravis is a chronic, unpredictable, and debilitating rare disease, often accompanied by high treatment burden and with an unmet need for more efficacious and well tolerated treatments. Zilucoplan is a subcutaneous, self-administered macrocyclic peptide complement C5 inhibitor. We aimed to assess safety, efficacy, and tolerability of zilucoplan in patients with acetylcholine receptor autoantibody (AChR)-positive generalised myasthenia gravis. METHODS RAISE was a randomised, double-blind, placebo-controlled, phase 3 trial that was done at 75 sites in Europe, Japan, and North America. We enrolled patients (aged 18-74 years) with AChR-positive generalised myasthenia gravis (Myasthenia Gravis Foundation of America disease class II-IV), a myasthenia gravis activities of daily living (MG-ADL) score of least 6, and a quantitative myasthenia gravis score of at least 12. Participants were randomly assigned (1:1) to receive subcutaneous zilucoplan 0·3 mg/kg once daily by self-injection, or matched placebo, for 12 weeks. The primary efficacy endpoint was change from baseline to week 12 in MG-ADL score in the modified intention-to-treat population (all randomly assigned patients who received at least one dose of study drug and had at least one post-dosing MG-ADL score). Safety was mainly assessed by the incidence of treatment-emergent adverse events (TEAEs) in all patients who had received at least one dose of zilucoplan or placebo. This trial is registered at ClinicalTrials.gov, NCT04115293. An open-label extension study is ongoing (NCT04225871). FINDINGS Between Sept 17, 2019, and Sept 10, 2021, 239 patients were screened for the study, of whom 174 (73%) were eligible. 86 (49%) patients were randomly assigned to zilucoplan 0·3 mg/kg and 88 (51%) were assigned to placebo. Patients assigned to zilucoplan showed a greater reduction in MG-ADL score from baseline to week 12, compared with those assigned to placebo (least squares mean change -4·39 [95% CI -5·28 to -3·50] vs -2·30 [-3·17 to -1·43]; least squares mean difference -2·09 [-3·24 to -0·95]; p=0·0004). TEAEs occurred in 66 (77%) patients in the zilucoplan group and in 62 (70%) patients in the placebo group. The most common TEAE was injection-site bruising (n=14 [16%] in the zilucoplan group and n=8 [9%] in the placebo group). Incidences of serious TEAEs and serious infections were similar in both groups. One patient died in each group; neither death (COVID-19 [zilucoplan] and cerebral haemorrhage [placebo]) was considered related to the study drug. INTERPRETATION Zilucoplan treatment showed rapid and clinically meaningful improvements in myasthenia gravis-specific efficacy outcomes, had a favourable safety profile, and was well tolerated, with no major safety findings. Zilucoplan is a new potential treatment option for a broad population of patients with AChR-positive generalised myasthenia gravis. The long-term safety and efficacy of zilucoplan is being assessed in an ongoing open-label extension study. FUNDING UCB Pharma.
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Affiliation(s)
- James F Howard
- Department of Neurology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Saskia Bresch
- Service de Neurologie, Hospital Pasteur, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Angela Genge
- Clinical Research Unit, The Montreal Neurological Institute, Montreal, QC, Canada
| | - Channa Hewamadduma
- Department of Neuroscience, Sheffield Institute for Translational Neurosciences (SITRAN), University of Sheffield and Sheffield Teaching Hospitals Foundation NHS Trust, Sheffield, UK
| | - John Hinton
- Diagnostic and Medical Clinic, Mobile, AL, USA
| | - Yessar Hussain
- Department of Neurology, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Raul Juntas-Morales
- Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, Barcelona, Spain
| | - Henry J Kaminski
- Department of Neurology & Rehabilitation Medicine, George Washington University, Washington, DC, USA
| | | | - Renato Mantegazza
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale Neurologico Carlo Besta, Milan, Italy
| | - Masayuki Masuda
- Department of Neurology, Tokyo Medical University, Tokyo, Japan
| | | | - Marek Śmiłowski
- Department of Hematology and Bone Marrow Transplantation, Medical University of Silesia, Katowice, Poland
| | | | - Tuan Vu
- Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Michael D Weiss
- Department of Neurology, University of Washington Medical Center, Seattle, WA, USA
| | | | | | | | | | | | | | | | - M Isabel Leite
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Meisel A, Annane D, Vu T, Mantegazza R, Katsuno M, Aguzzi R, Frick G, Gault L, Howard JF. Long-term efficacy and safety of ravulizumab in adults with anti-acetylcholine receptor antibody-positive generalized myasthenia gravis: results from the phase 3 CHAMPION MG open-label extension. J Neurol 2023:10.1007/s00415-023-11699-x. [PMID: 37103755 PMCID: PMC10134722 DOI: 10.1007/s00415-023-11699-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 04/28/2023]
Abstract
INTRODUCTION Ravulizumab demonstrated efficacy and an acceptable safety profile versus placebo in the randomized controlled period (RCP) of the phase 3 CHAMPION MG trial in patients with anti-acetylcholine receptor antibody-positive generalized myasthenia gravis. We report an interim analysis of the ongoing open-label extension (OLE) designed to evaluate long-term treatment effects. METHODS Following completion of the 26-week RCP, patients could enter the OLE; patients who received ravulizumab in the RCP continued the drug; patients who previously received placebo switched to ravulizumab. Patients receive body-weight-based maintenance dosing of ravulizumab every 8 weeks. Efficacy endpoints up to 60 weeks included Myasthenia Gravis-Activities of Daily Living (MG-ADL) and Quantitative Myasthenia Gravis (QMG) scores, with least-squares (LS) mean change and 95% confidence intervals (95% CI) reported. RESULTS Long-term efficacy and safety in the OLE were analyzed in 161 and 169 patients, respectively. Improvements in all scores were maintained through 60 weeks in patients who received ravulizumab during the RCP; LS mean change from RCP baseline in MG-ADL score was - 4.0 (95% CI: - 4.8, - 3.1; p < 0.0001). Rapid (within 2 weeks) and sustained improvements occurred in patients previously receiving placebo; LS mean change in MG-ADL score from OLE baseline to Week 60 was - 1.7 (95% CI: - 2.7, - 0.8; p = 0.0007). Similar trends were seen in QMG scores. Ravulizumab treatment was associated with a decreased rate of clinical deterioration events compared with placebo. Ravulizumab was well tolerated; no meningococcal infections were reported. CONCLUSION Findings support the sustained efficacy and long-term safety of ravulizumab, administered every 8 weeks, in adults with anti-acetylcholine receptor antibody-positive generalized myasthenia gravis. CLINICALTRIALS gov identifier: NCT03920293; EudraCT: 2018-003243-39.
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Affiliation(s)
| | | | - Tuan Vu
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | | | | | - Rasha Aguzzi
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
| | - Glen Frick
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
| | - Laura Gault
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
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Rituximab for myasthenia gravis. Cochrane Database Syst Rev 2023. [PMCID: PMC10075239 DOI: 10.1002/14651858.cd014574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/09/2023]
Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess: the safety and efficacy, as assessed by the effect on disease severity or functional ability and the burden of alternative treatment, of rituximab (including biosimilar variants) for the treatment of myasthenia gravis in adults; and outcomes and adverse effects between different patient subgroups, and treatment strategies, in order to aid treatment choice for individuals, and to inform policymakers about those most likely to benefit.
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Chen L, Li Y, Dong X, Tanzhu G, Chu X, Deng F, Li X, Zhang J, Long B, Jing D, Niu L, Peng H, Yang H, Zhou R. The Value of Postoperative Radiotherapy in Thymoma Patients with Myasthenia Gravis. Radiother Oncol 2023; 183:109644. [PMID: 36990391 DOI: 10.1016/j.radonc.2023.109644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 03/13/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023]
Abstract
INTRODUCTION Surgery is the first-line treatment for patients with thymoma associated with myasthenia gravis (MG); however, the value of radiotherapy among these patients remains debatable. Herein, we examined the impact of postoperative radiotherapy (PORT) on the efficacy and prognosis of patients with thymoma and MG. METHODS This retrospective cohort study included 126 patients with thymoma and MG who were enrolled in the Xiangya Hospital clinical database between 2011 and 2021. Demographic and clinical data were collected including sex, age, histologic subtype, Masaoka-Koga staging, primary tumor, lymph node, metastasis (TNM) staging, and therapeutic modalities. To evaluate short-term MG symptom improvement following PORT, we examined changes in the quantitative myasthenia gravis (QMG) scores within 3 months post-treatment. Minimal manifestation status (MMS) was the main endpoint for assessing long-term improvement in MG symptoms. Overall survival (OS) and disease-free survival (DFS) were primary endpoints to determine the impact of PORT on prognosis. RESULTS Effects of PORT on MG symptoms: QMG scores significantly differed between the non-PORT and PORT groups (χ2= 6.300, p = 0.012). The median time to achieve MMS was significantly shorter in the PORT group than that in the non-PORT group (2.0 years vs. 4.4 years; p = 0.031). Multivariate analysis revealed that radiotherapy was associated with a reduced time to achieve MMS (hazard ratio [HR] 1.971, 95% confidence interval [CI]:1.102-3.525, p = 0.022). Effects of PORT on DFS and OS: The 10-year OS rate of the entire cohort was 90.5%, whereas OS rates for the PORT and non-PORT groups were 94.4 and 85.1%, respectively. The 5-year DFS rates for the whole cohort, PORT group, and non-PORT group were 89.7, 95.8, and 81.5%, respectively. PORT was associated with improved DFS (HR 0.139, 95% CI: 0.037-0.533, p = 0.004). In the high-risk histologic subgroup (type B2, B3), patients who received PORT had better OS (p = 0.015) and DFS (p = 0.0053) than those who did not receive PORT. PORT was associated with improved DFS (HR 0.232, 95% CI: 0.069-0.782, p = 0.018) in Masaoka-Koga stages II, III, and IV disease. CONCLUSIONS Overall, our findings indicate that PORT positively impacts thymoma patients with MG, particularly those with a higher histologic subtype and Masaoka-Koga staging.
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Zhong H, Ruan Z, Yan C, Lv Z, Zheng X, Goh LY, Xi J, Song J, Luo L, Chu L, Tan S, Zhang C, Bu B, Da Y, Duan R, Yang H, Luo S, Chang T, Zhao C. Short-term outcome prediction for myasthenia gravis: an explainable machine learning model. Ther Adv Neurol Disord 2023; 16:17562864231154976. [PMID: 36860354 PMCID: PMC9969443 DOI: 10.1177/17562864231154976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 01/15/2023] [Indexed: 02/26/2023] Open
Abstract
Background Myasthenia gravis (MG) is an autoimmune disease characterized by muscle weakness and fatigability. The fluctuating nature of the disease course impedes the clinical management. Objective The purpose of the study was to establish and validate a machine learning (ML)-based model for predicting the short-term clinical outcome in MG patients with different antibody types. Methods We studied 890 MG patients who had regular follow-ups at 11 tertiary centers in China from 1 January 2015 to 31 July 2021 (653 patients for derivation and 237 for validation). The short-term outcome was the modified post-intervention status (PIS) at a 6-month visit. A two-step variable screening was used to determine the factors for model construction and 14 ML algorithms were used for model optimisation. Results The derivation cohort included 653 patients from Huashan hospital [age 44.24 (17.22) years, female 57.6%, generalized MG 73.5%], and the validation cohort included 237 patients from 10 independent centers [age 44.24 (17.22) years, female 55.0%, generalized MG 81.2%]. The ML model identified patients who were improved with an area under the receiver operating characteristic curve (AUC) of 0.91 [0.89-0.93], 'Unchanged' 0.89 [0.87-0.91], and 'Worse' 0.89 [0.85-0.92] in the derivation cohort, whereas identified patients who were improved with an AUC of 0.84 [0.79-0.89], 'Unchanged' 0.74 [0.67-0.82], and 'Worse' 0.79 [0.70-0.88] in the validation cohort. Both datasets presented a good calibration ability by fitting the expectation slopes. The model is finally explained by 25 simple predictors and transferred to a feasible web tool for an initial assessment. Conclusion The explainable, ML-based predictive model can aid in forecasting the short-term outcome for MG with good accuracy in clinical practice.
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Affiliation(s)
| | | | | | - Zhiguo Lv
- Department of Neurology, The Affiliated
Hospital of Changchun University of Chinese Medicine, Changchun, China
| | - Xueying Zheng
- Department of Biostatistics, School of Public
Health and Key Laboratory of Public Health Safety, Fudan University,
Shanghai, China
| | - Li-Ying Goh
- Shanghai Medical College, Fudan University,
Shanghai, China
| | - Jianying Xi
- Huashan Rare Disease Center, Department of
Neurology, Huashan Hospital, Fudan University, Shanghai, China,National Center for Neurological Disorders,
Shanghai, China
| | - Jie Song
- Huashan Rare Disease Center, Department of
Neurology, Huashan Hospital, Fudan University, Shanghai, China,National Center for Neurological Disorders,
Shanghai, China
| | - Lijun Luo
- Department of Neurology, Wuhan No.1 Hospital,
Wuhan, China
| | - Lan Chu
- Department of Neurology, The Affiliated
Hospital of Guizhou Medical University, Guiyang, China
| | - Song Tan
- Department of Neurology, Sichuan Provincial
People’s Hospital, University of Electronic Science and Technology of China,
Chengdu, China
| | - Chao Zhang
- Department of Neurology and Tianjin
Neurological Institute, Tianjin Medical University General Hospital,
Tianjin, China
| | - Bitao Bu
- Department of Neurology, Tongji Hospital,
Tongji Medical College, Huazhong University of Science and Technology,
Wuhan, China
| | - Yuwei Da
- Department of Neurology, Xuanwu Hospital,
Capital Medical University, Beijing, China
| | - Ruisheng Duan
- Department of Neurology, The First Affiliated
Hospital of Shandong First Medical University, Jinan, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital,
Central South University, Changsha, China
| | | | - Ting Chang
- Department of Neurology, Tangdu Hospital, The
Air Force Medical University, Xi’an 710000, China
| | - Chongbo Zhao
- Huashan Rare Disease Center, Department of
Neurology, Huashan Hospital, Fudan University, Shanghai 200040, China,National Center for Neurological Disorders,
Shanghai, China
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Bril V, Szczudlik A, Vaitkus A, Rozsa C, Kostera-Pruszczyk A, Hon P, Bednarik J, Tyblova M, Köhler W, Toomsoo T, Nowak RJ, Mozaffar T, Freimer ML, Nicolle MW, Magnus T, Pulley MT, Rivner M, Dimachkie MM, Distad BJ, Pascuzzi RM, Babiar D, Lin J, Querolt Coll M, Griffin R, Mondou E. Randomized Double-Blind Placebo-Controlled Trial of the Corticosteroid-Sparing Effects of Immunoglobulin in Myasthenia Gravis. Neurology 2023; 100:e671-e682. [PMID: 36270895 PMCID: PMC9969924 DOI: 10.1212/wnl.0000000000201501] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 09/16/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Myasthenia gravis (MG) is an autoimmune disease characterized by dysfunction at the neuromuscular junction. Treatment frequently includes corticosteroids (CSs) and IV immunoglobulin (IVIG). This study was conducted to determine whether immune globulin (human), 10% caprylate/chromatography purified (IGIV-C) could facilitate CS dose reduction in CS-dependent patients with MG. METHODS In this randomized double-blind placebo-controlled trial, CS-dependent patients with MG (Myasthenia Gravis Foundation of America Class II-Iva; AChR+) received a loading dose of 2 g/kg IGIV-C over 2 days (maximum 80 g/d) or placebo at week 0 (baseline). Maintenance doses (1 g/kg IGIV-C or placebo) were administered every 3 weeks through week 36. Tapering of CS was initiated at week 9 and continued through week 36 unless the patient worsened (quantitative MG score ≥4 points from baseline). CS doses were increased (based on the current CS dose) in patients who worsened. Patients were withdrawn if worsening failed to improve within 6 weeks or if a second CS increase was required. The primary efficacy end point (at week 39) was a ≥50% reduction in CS dose. Secondary and safety end points were assessed throughout the study and follow-up (weeks 42 and 45). The study results and full protocol are available at clinicaltrials.gov/ct2/show/NCT02473965. RESULTS The primary end point (≥50% reduction in CS dose) showed no significant difference between the IGIV-C treatment (60.0% of patients) and placebo (63.3%). There were no significant differences for secondary end points. Safety data indicated that IGIV-C was well tolerated. DISCUSSION In this study, IGIV-C was not more effective than placebo in reducing daily CS dose. These results suggest that the effects of IGIV-C and CS are not synergistic and may be mechanistically different. TRIAL REGISTRATION INFORMATION The trial was registered on clinicaltrialsregister.eu (EudraCT #: 2013-005099-17) and clinicaltrials.gov (identifier NCT02473965). CLASSIFICATION OF EVIDENCE This study provides Class II evidence that IVIG infusions in adult patients with MG do not increase the percentage of patients achieving a ≥50% reduction in corticosteroid dose compared with placebo.
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Affiliation(s)
- Vera Bril
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain.
| | - Andrzej Szczudlik
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Antanas Vaitkus
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Csilla Rozsa
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Anna Kostera-Pruszczyk
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Petr Hon
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Josef Bednarik
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Michaela Tyblova
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Wolfgang Köhler
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Toomas Toomsoo
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Richard J Nowak
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Tahseen Mozaffar
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Miriam L Freimer
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Michael W Nicolle
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Tim Magnus
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Michael T Pulley
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Michael Rivner
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Mazen M Dimachkie
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - B Jane Distad
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Robert M Pascuzzi
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Donna Babiar
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Jiang Lin
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Montse Querolt Coll
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Rhonda Griffin
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Elsa Mondou
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
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Xu P, Zhang Y, Chang T, Jiang L, Lv Z, Zhang Y, Xu H, Zhang D, Lan T, Cui Y, Hua Z, Gao C, Lu J, Huang Q, Tian J, Ma J, Wang J. Comparative the efficacy and acceptability of immunosuppressive agents for myasthenia gravis: A protocol for systematic review and network meta-analysis. Medicine (Baltimore) 2022; 101:e31454. [PMID: 36550882 PMCID: PMC9771229 DOI: 10.1097/md.0000000000031454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Immunosuppressive drugs are routinely used to treat myasthenia gravis (MG). However, current recommendations provide limited evidence to support treatment options, leading to considerable variation in practice among healthcare specialists. Hence, we present a protocol for a systematic review and network meta-analysis (NMA) to update the evidence by comparing the efficacy and acceptability of oral immunosuppressive drugs for the treatment of MG. METHODS We will conduct a systematic review and NMA of all randomized controlled trials evaluating the following oral immunosuppressive drugs for the treatment of MG. Published studies will be searched using the following databases from inception to November 23, 2021: CENTRAL, the CINAHL, MEDLINE, Embase, PsycINFO, Web of Science, and 3 Chinese databases (Chinese Biomedical Literatures Database, CNKI, and Wan Fang database). Assessment of study eligibility and data extraction will be conducted independently by 2 reviewers. The main outcome will be a quantitative MG scoring system. We will conduct Bayesian NMA to synthesize all evidence for each outcome and obtain a comprehensive ranking of all treatments. The quality of the evidence will be evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations framework. RESULTS The objective of this study was to assess the relative clinical efficacy and acceptability of first-line immunosuppressants for the treatment of MG, using a systematic review and NMA approach. CONCLUSION In the absence of head-to-head trials comparing therapies, evidence from this NMA of available clinical trials will inform clinicians, patients, and families the risk-benefit profiles of different treatment options.
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Affiliation(s)
- Peng Xu
- Department of Neurology, The Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Ying Zhang
- Department of Neurology, The Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Tianying Chang
- GCP Department, The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Li Jiang
- College of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Zhiguo Lv
- Department of Neurology, The Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Yibin Zhang
- College of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Hanying Xu
- College of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Dongmei Zhang
- Scientific Research Office, The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Tianye Lan
- Department of Neurology, The Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Yingzi Cui
- GCP Department, The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Zhen Hua
- Department of Cardiology, The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong Province, China
| | - Chengfei Gao
- Department of Physical Medicine and Rehabilitation, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong, China
| | - Jing Lu
- Research Center of Traditional Chinese Medicine, The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Qingxia Huang
- Research Center of Traditional Chinese Medicine, The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Jinhui Tian
- Evidence-Based Medicine Center, Lanzhou University, Lanzhou, Gansu Province, China
| | - Jihui Ma
- Department of Health Research, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Jian Wang
- Department of Neurology, The Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin Province, China
- * Correspondence:Jian Wang, Department of Neurology, The Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin Province, China (e-mail: )
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Li HY, Jiang P, Xie Y, Liang B, Li L, Zhao C, Yue YX, Li HF. Criteria for Treatment Response in Myasthenia Gravis: Comparison Between Absolute Change and Improvement Percentage in Severity Scores. Front Neurol 2022; 13:880040. [PMID: 35720071 PMCID: PMC9201395 DOI: 10.3389/fneur.2022.880040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 05/03/2022] [Indexed: 11/30/2022] Open
Abstract
Background The absolute change in the severity score between the baseline and pre-specified time frame (absolute criterion) was recommended as a criterion for myasthenia gravis (MG) treatment response. But heterogeneity of disease severity might dilute major changes in individual patients. The rationality of relative criterion (improvement percentage) had not been evaluated in treatment response in patients with MG. Objectives To investigate the consistency between an absolute criterion and a relative criterion in the evaluation of treatment response in patients with MG. Methods We retrospectively analyzed the treatment response to a 3-month standardized treatment protocol with only glucocorticoid in 257 MG patients native to immunological treatments. With the commonly used absolute criterion, cut-offs of relative criteria were generated with the receiver operating characteristic (ROC) curve in the whole cohort and in patients with different degrees of baseline severity stratified by pre-treatment quantitative myasthenia gravis score (QMGS). The consistency between absolute and relative criteria was examined with Cohen's Kappa test and Venn diagrams. Results The absolute and relative criteria had an overall substantial consistency (Kappa value, 0.639, p < 0.001) in the cohort. The Kappa values were substantial to almost perfect in mild and moderate groups and moderate in severe groups between the absolute and relative criteria (all p ≤ 0.001). More patients were classified as responsive with an absolute criterion while as unresponsive with a relative criterion in the moderate and severe groups. Conclusions The overall consistency between absolute and relative criteria was substantial in the whole cohort. The inconsistency between the two criteria was mainly from the moderate or severe patients at the baseline.
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Affiliation(s)
- Hong-Yan Li
- Department of Neurology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Ping Jiang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yanchen Xie
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Bing Liang
- Department of Neurology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Ling Li
- Department of Neurology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Cuiping Zhao
- Department of Neurology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Yao-Xian Yue
- Department of Neurology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
- *Correspondence: Yao-Xian Yue
| | - Hai-Feng Li
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- Hai-Feng Li
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19
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Alcantara M, Barnett C, Katzberg H, Bril V. An update on the use of immunoglobulins as treatment for myasthenia gravis. Expert Rev Clin Immunol 2022; 18:703-715. [PMID: 35639497 DOI: 10.1080/1744666x.2022.2084074] [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 Myasthenia gravis (MG) is an antibody mediated disease where pathogenic antibodies interact with the acetylcholine receptor or other proteins at the post-synaptic neuromuscular junction. There is growing evidence that immunoglobulin infusions are beneficial for clinical exacerbations and chronic refractory disease and may be an option for patients unresponsive to conventional immunosuppressive therapies. AREAS COVERED We performed an extensive literature review, looking for evidence on the use of immunoglobulins for the treatment of MG, by conducting a search in MEDLINE (1946 to present), EMBASE (1947 to present) and Clinicaltrials.gov. We have included studies on the use of intravenous immunoglobulins (IVIG) and subcutaneous immunoglobulins (SCIG) for acute deterioration and chronic disease. EXPERT OPINION The use of IVIG in MG provides an option for rapid improvement in critical deterioration, being preferred over more invasive and less available therapies such as plasmapheresis. For refractory MG, the addition of IVIG can improve a patient's status and reduce the dosage of immunosuppressive medications. The alternative of SCIG is also effective and has advantages of infusion time flexibility, fewer side-effects, and patient independence. The safety and efficacy of both interventions, patient preferences and quality of life may direct therapeutic choices in the future.
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Affiliation(s)
- Monica Alcantara
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Carolina Barnett
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto
| | - Hans Katzberg
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
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20
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Vu T, Meisel A, Mantegazza R, Annane D, Katsuno M, Aguzzi R, Enayetallah A, Beasley KN, Rampal N, Howard JF. Terminal Complement Inhibitor Ravulizumab in Generalized Myasthenia Gravis. NEJM EVIDENCE 2022; 1:EVIDoa2100066. [PMID: 38319212 DOI: 10.1056/evidoa2100066] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
BACKGROUND: Generalized myasthenia gravis (gMG) is a rare, chronic, and debilitating autoimmune disease. Activation of the complement system by autoantibodies against the postsynaptic acetylcholine receptor (AChR) leads to destruction of the postsynaptic membrane and disruption of neuromuscular transmission. This trial evaluated ravulizumab, a long-acting inhibitor of terminal complement protein C5, as a treatment for gMG. METHODS: In this randomized, double-blind, placebo-controlled, multinational trial, we randomly assigned (1:1) patients with anti-AChR antibody-positive gMG to intravenous ravulizumab or placebo for 26 weeks. Patients received a loading dose on day 1, followed by maintenance doses on day 15 and every 8 weeks thereafter. The primary end point and first secondary end point (change from baseline to week 26 in patient-reported Myasthenia Gravis–Activities of Daily Living [MG-ADL] scale and clinician-reported Quantitative Myasthenia Gravis [QMG] total scores, respectively) were compared between the ravulizumab- and placebo-treated groups. RESULTS: In total, 175 patients were enrolled. Ravulizumab significantly increased the magnitude of mean changes from baseline to week 26 versus placebo in MG-ADL (−3.1 vs. −1.4; P<0.001) and QMG (−2.8 vs. −0.8; P<0.001) total scores. Improvements in both measures occurred within 1 week of ravulizumab initiation and were sustained through week 26. QMG total scores improved by 5 points or more in a significantly greater proportion of ravulizumab-treated patients than of those receiving placebo (30.0% vs. 11.3%; P=0.005). No notable differences in adverse events were observed. CONCLUSIONS: Ravulizumab demonstrated rapid and sustained improvements in both patient- and clinician-reported outcomes and had a side effect and adverse-event profile that did not limit treatment in adults with anti-AChR antibody-positive gMG. (Funded by Alexion, AstraZeneca Rare Disease; ClinicalTrials.gov number, NCT03920293; EudraCT number, 2018-003243-39.)
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Affiliation(s)
- Tuan Vu
- University of South Florida Morsani College of Medicine, Tampa
| | | | - Renato Mantegazza
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milan
| | - Djillali Annane
- Hôpital Raymond Poincaré, University of Versailles, Garches, France
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21
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Nelke C, Stascheit F, Eckert C, Pawlitzki M, Schroeter CB, Huntemann N, Mergenthaler P, Arat E, Öztürk M, Foell D, Schreiber S, Vielhaber S, Gassa A, Stetefeld H, Schroeter M, Berger B, Totzeck A, Hagenacker T, Meuth SG, Meisel A, Wiendl H, Ruck T. Independent risk factors for myasthenic crisis and disease exacerbation in a retrospective cohort of myasthenia gravis patients. J Neuroinflammation 2022; 19:89. [PMID: 35413850 PMCID: PMC9005160 DOI: 10.1186/s12974-022-02448-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 03/29/2022] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Myasthenic crisis (MC) and disease exacerbation in myasthenia gravis (MG) are associated with significant lethality and continue to impose a high disease burden on affected patients. Therefore, we sought to determine potential predictors for MC and exacerbation as well as to identify factors affecting outcome. METHODS We examined a retrospective, observational cohort study of patients diagnosed with MG between 2000 and 2021 with a mean follow-up of 62.6 months after diagnosis from eight tertiary hospitals in Germany. A multivariate Cox regression model with follow-up duration as the time variable was used to determine independent risk factors for MC and disease exacerbation. RESULTS 815 patients diagnosed with MG according to national guidelines were included. Disease severity at diagnosis (quantitative MG score or Myasthenia Gravis Foundation of America class), the presence of thymoma and anti-muscle specific tyrosine kinase-antibodies were independent predictors of MC or disease exacerbation. Patients with minimal manifestation status 12 months after diagnosis had a lower risk of MC and disease exacerbation than those without. The timespan between diagnosis and the start of immunosuppressive therapy did not affect risk. Patients with a worse outcome of MC were older, had higher MGFA class before MC and at admission, and had lower vital capacity before and at admission. The number of comorbidities, requirement for intubation, prolonged mechanical ventilation, and MC triggered by infection were associated with worse outcome. No differences between outcomes were observed comparing treatments with IVIG (intravenous immunoglobulin) vs. plasma exchange vs. IVIG together with plasma exchange. CONCLUSIONS MC and disease exacerbations inflict a substantial burden of disease on MG patients. Disease severity at diagnosis and antibody status predicted the occurrence of MC and disease exacerbation. Intensified monitoring with emphasis on the prevention of infectious complications could be of value to prevent uncontrolled disease in MG patients.
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Affiliation(s)
- Christopher Nelke
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany.,Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, Munster, Germany
| | - Frauke Stascheit
- Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Department of Neurology With Experimental Neurology, Humboldt-Universität zu Berlin, Berlin, Germany.,Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, NeuroCure Clinical Research Center, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Carmen Eckert
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, Munster, Germany
| | - Marc Pawlitzki
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany.,Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital Münster, Munster, Germany
| | - Christina B Schroeter
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Niklas Huntemann
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Philipp Mergenthaler
- Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Department of Neurology With Experimental Neurology, Humboldt-Universität zu Berlin, Berlin, Germany.,Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, NeuroCure Clinical Research Center, Humboldt-Universität zu Berlin, Berlin, Germany.,Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ercan Arat
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Menekse Öztürk
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Dirk Foell
- Department for Pediatric Rheumatology and Immunology, University of Münster, Munster, Germany
| | - Stefanie Schreiber
- Department of Neurology, University of Magdeburg, Magdeburg, Germany.,German Center for Neurodegenerative Diseases, Bonn, Germany.,Center for Behavioral Brain Sciences, Magdeburg, Germany
| | - Stefan Vielhaber
- Department of Neurology, University of Magdeburg, Magdeburg, Germany.,German Center for Neurodegenerative Diseases, Bonn, Germany.,Center for Behavioral Brain Sciences, Magdeburg, Germany
| | - Asmae Gassa
- Department of Cardiothoracic Surgery, University of Cologne and University Hospital Cologne, Cologne, Germany
| | - Henning Stetefeld
- Department of Neurology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Michael Schroeter
- Department of Neurology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Benjamin Berger
- Clinic of Neurology and Neurophysiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Andreas Totzeck
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Tim Hagenacker
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Sven G Meuth
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Andreas Meisel
- Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Department of Neurology With Experimental Neurology, Humboldt-Universität zu Berlin, Berlin, Germany.,Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, NeuroCure Clinical Research Center, Humboldt-Universität zu Berlin, Berlin, Germany.,Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Center for Stroke Research Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,German Myasthenia Gravis Society, Berlin, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, Munster, Germany
| | - Tobias Ruck
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany. .,Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, Munster, Germany.
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22
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Li Y, Yang S, Dong X, Li Z, Peng Y, Jin W, Chen D, Zhou R, Jiang F, Yan C, Yang H. Factors affecting minimal manifestation status induction in myasthenia gravis. Ther Adv Neurol Disord 2022; 15:17562864221080520. [PMID: 35371293 PMCID: PMC8968991 DOI: 10.1177/17562864221080520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 01/25/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Minimal manifestation status (MMS) is an important landmark in the treatment of myasthenia gravis (MG), and predictors of MMS induction have rarely been identified in previous studies. Objective: The objective of this study is to evaluate the clinical factors associated with MMS induction among patients with MG. Design: This two-step retrospective cohort study with a single center investigated the factors that may be associated with MMS induction and retested these predictors in a test cohort. Methods: A total of 388 diagnosed MG patients who visited Xiangya Hospital between 1 July 2015 and 1 July 2019 were involved. We performed detailed chart reviews and recorded all cases achieving MMS. Demographics and clinical characteristics were also collected and their relationships to achieving MMS were investigated. Results: MMS was achieved in 124 patients (50.2%), and the median time to achieve MMS was 26 months. Several factors were found to be associated with MMS induction in exploring cohort, including muscle-specific tyrosine-protein kinase receptor (MuSK) antibody positivity (adjusted hazard ratio, HR = 4.333, 95% confidence interval, CI: 1.862–10.082), isolated ocular involvement (adjusted HR = 1.95, 95% CI: 1.284–2.961), and low baseline quantitative myasthenia gravis score (QMG score; adjusted HR = 2.022, 95% CI: 1.086–3.764). These factors were then retested in the test cohort. Isolated ocular involvement or low baseline QMG scores were factors found to be beneficial for MMS induction were confirmed. Conclusion: Isolated ocular involvement and low baseline QMG score are predictors of MMS induction in MG patients.
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Affiliation(s)
- Yi Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, P.R. China
| | - Shumei Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, P.R. China
| | - Xiaohua Dong
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, P.R. China
| | - Zhibin Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, P.R. China
| | - Yuyao Peng
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, P.R. China
| | - Wanlin Jin
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, P.R. China
| | - Di Chen
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, P.R. China
| | - Ran Zhou
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, P.R. China
| | - Fei Jiang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, P.R. China
| | - Chengkai Yan
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, P.R. China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, Hunan, P.R. China
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23
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Berger B, Schröter N. Changes in antibody titers and clinical course in myasthenia gravis retrospective study. PROGRESS IN NEUROLOGY AND PSYCHIATRY 2022. [DOI: 10.1002/pnp.738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Benjamin Berger
- Dr Berger is a Senior Physician and Dr Schröter is an Assistant Physician at the Clinic of Neurology and Neurophysiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Nils Schröter
- Dr Berger is a Senior Physician and Dr Schröter is an Assistant Physician at the Clinic of Neurology and Neurophysiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
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24
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Salari N, Fatahi B, Bartina Y, Kazeminia M, Fatahian R, Mohammadi P, Shohaimi S, Mohammadi M. Global prevalence of myasthenia gravis and the effectiveness of common drugs in its treatment: a systematic review and meta-analysis. J Transl Med 2021; 19:516. [PMID: 34930325 PMCID: PMC8686543 DOI: 10.1186/s12967-021-03185-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 12/06/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Myasthenia gravis is a neuromuscular autoimmune disorder characterized by weakness and disability in the voluntary muscles. There have been several preliminary studies on the epidemiology of myasthenia gravis in different parts of the world and the effectiveness of common drugs in its treatment, but there has been no comprehensive study of the efficacy of common drugs in the treatment of myasthenia gravis. Therefore, this study aimed to determine the epidemiology of myasthenia gravis globally and the effectiveness of common drugs in its treatment using systematic review and meta-analysis. METHODS Research studies were extracted from IranDoc, MagIran, IranMedex, SID, ScienceDirect, Web of Sciences (WoS), ProQuest, Medline (PubMed), Scopus and Google Scholar based on Cochran's seven-step guidelines using existing keywords extracted in MeSH browser. The I2 test was used to calculate the heterogeneity of studies, and Begg and Mazumdar rank correlation tests were used to assess publication bias. Data were analyzed using Comprehensive Meta-Analysis software (Version 2). RESULTS In the search for descriptive studies based on the research question, 7374 articles were found. After deleting articles unrelated to the research question, finally, 63 articles with a sample size of 1,206,961,907 people were included in the meta-analysis. The prevalence of MG worldwide was estimated to be 12.4 people (95% CI 10.6-14.5) per 100,000 population. For analytical studies on the effectiveness of common myasthenia gravis drugs, 4672 articles were found initially, and after removing articles unrelated to the research question, finally, 20 articles with a sample size of 643 people in the drug group and 619 people in the placebo group were included in the study. As a result of the combination of studies, the difference between the mean QMGS score index after taking Mycophenolate and Immunoglobulin or plasma exchange drugs in the group of patients showed a significant decrease of 1.4 ± 0.77 and 0.62 ± 0.28, respectively (P < 0.01). CONCLUSION The results of systematic review of drug evaluation in patients with myasthenia gravis showed that Mycophenolate and Immunoglobulin or plasma exchange drugs have positive effects in the treatment of MG. It also represents the positive effect of immunoglobulin or plasma exchange on reducing SFEMG index and QMGS index and the positive effect of Mycophenolate in reducing MG-ADL index, SFEMG and Anti-AChR antibodies index. In addition, based on a meta-analysis of the random-effect model, the overall prevalence of MG in the world is 12.4 people per 100,000 population, which indicates the urgent need for attention to this disease for prevention and treatment.
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Affiliation(s)
- Nader Salari
- Department of Biostatistics, School of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Behnaz Fatahi
- Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Yalda Bartina
- Department of Translation Studies, Faculty of Literature, Istanbul University, Istanbul, Turkey
| | - Mohsen Kazeminia
- Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Reza Fatahian
- Department of Neurosurgery, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Payam Mohammadi
- Department of Neurology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Shamarina Shohaimi
- Department of Biology, Faculty of Science, University Putra Malaysia, Serdang, Selangor Malaysia
| | - Masoud Mohammadi
- Cellular and Molecular Research Center, Gerash University of Medical Sciences, Gerash, Iran
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25
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Katzberg HD, Abraham A. Electrodiagnostic Assessment of Neuromuscular Junction Disorders. Neurol Clin 2021; 39:1051-1070. [PMID: 34602214 DOI: 10.1016/j.ncl.2021.06.013] [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: 10/20/2022]
Abstract
Please verify edits, "These techniques", or specify. This article reviews advanced electrodiagnostic techniques used to assess for neuromuscular junction disorders, including repetitive nerve stimulation, conventional or concentric-needle single-fiber electromyography (SFEMG), and stimulated SFEMG. These techniques have high sensitivity but limited specificity. Novel methods currently under investigation are discussed, including vestibular ocular myogenic potential and oculography analysis.
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Affiliation(s)
- Hans D Katzberg
- Division of Neurology, University Health Network, Toronto General Hospital, 200 Elizabeth Street, 5ES-306, Toronto, Ontario M5G 2C4, Canada.
| | - Alon Abraham
- Neuromuscular Diseases Unit, Department of Neurology, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, Tel Aviv 6423906, Israel
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26
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Howard JF, Karam C, Yountz M, O’Brien FL, Mozaffar T. Long-term efficacy of eculizumab in refractory generalized myasthenia gravis: responder analyses. Ann Clin Transl Neurol 2021; 8:1398-1407. [PMID: 34043280 PMCID: PMC8283175 DOI: 10.1002/acn3.51376] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 04/13/2021] [Accepted: 04/14/2021] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE Generalized myasthenia gravis (gMG) is an autoimmune disease that causes disabling weakness via damage to the neuromuscular junction. In most patients, the disease is mediated by autoantibodies to the acetylcholine receptor, which activate the complement cascade. Our objective was to analyze response profiles in adult patients with anti-acetylcholine receptor antibody-positive refractory gMG treated with eculizumab-a terminal complement inhibitor-in the REGAIN study or its open-label extension (OLE). METHODS We retrospectively analyzed Myasthenia Gravis-Activities of Daily Living (MG-ADL) and Quantitative Myasthenia Gravis (QMG) scores recorded during REGAIN and its OLE. Early/late responses were defined as improvement in MG-ADL score (≥3 points) or QMG score (≥5 points) at ≤12 or >12 weeks, respectively, after eculizumab initiation. RESULTS The analysis included 98 patients. By Week 12 and conclusion of the OLE, MG-ADL response had been achieved at some point by 67.3% and 84.7% of patients, respectively, and QMG response by 56.1% and 71.4%, respectively. Response was observed over multiple consecutive assessments for most patients. At Week 130, the least-squares mean percentage changes (95% CI) from baseline in MG-ADL score were -61.9% (-69.9%, -53.9%) and -47.5% (-59.0%, -36.0%) in early and late MG-ADL responders, respectively; the least-squares mean percentage changes from baseline in QMG score were -40.8% (-48.3%, -33.4%) and -55.5% (-68.4%, -42.7%) in early and late QMG responders, respectively. INTERPRETATION The findings suggest that, although most patients with refractory gMG will achieve clinical response by Week 12 of eculizumab treatment, first responses can be observed with longer-term treatment.
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Affiliation(s)
- James F. Howard
- Department of NeurologyThe University of North CarolinaChapel HillNorth CarolinaUSA
| | - Chafic Karam
- Department of NeurologyOregon Health & Science UniversityPortlandOregonUSA
- Present address:
Penn Neuroscience Center ‐ Neurology, Hospital of the University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | | | | | - Tahseen Mozaffar
- Department of NeurologyUniversity of CaliforniaIrvineCaliforniaUSA
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27
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Howard JF, Vissing J, Gilhus NE, Leite MI, Utsugisawa K, Duda PW, Farzaneh-Far R, Murai H, Wiendl H. Zilucoplan: An Investigational Complement C5 Inhibitor for the Treatment of Acetylcholine Receptor Autoantibody-Positive Generalized Myasthenia Gravis. Expert Opin Investig Drugs 2021; 30:483-493. [PMID: 33792453 DOI: 10.1080/13543784.2021.1897567] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Generalized myasthenia gravis (gMG) is an autoimmune disorder in which pathogenic autoantibodies damage the neuromuscular junction, causing disabling or life-threatening muscle weakness. Most treatments nonspecifically inhibit aspects of the immune system, do not directly address the causal mechanisms of tissue damage, and often have side-effect profiles that negatively impact patients. Understanding of the central pathogenic role of the complement cascade in gMG is advancing, and a new complement-targeting treatment is under investigation. AREAS COVERED We provide an overview of gMG etiology, the complement cascade, current treatments, and the investigational gMG therapy zilucoplan. Zilucoplan is a small, subcutaneously administered, macrocyclic peptide that inhibits cleavage of complement component C5 and the subsequent formation of the membrane attack complex. EXPERT OPINION In a randomized, double-blind, placebo-controlled, phase 2 clinical trial, zilucoplan demonstrated clinically meaningful complement inhibition in patients with acetylcholine receptor-positive gMG. Zilucoplan, a first-of-its-kind cyclic peptide targeting C5, appears to be a therapeutic option for the treatment of gMG based on available pharmacokinetic/pharmacodynamic data and phase 1 and 2 efficacy, safety, and tolerability data with limited long-term follow-up. Zilucoplan use earlier in the treatment paradigm would be suitable in this population should phase 3 efficacy and safety data be equally favorable.
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Affiliation(s)
- James F Howard
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - John Vissing
- Department of Clinical Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Nils E Gilhus
- Department of Clinical Medicine, University of Bergen and Haukeland University Hospital, Bergen, Norway
| | - M Isabel Leite
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kimiaki Utsugisawa
- Department of Neurology, Hanamaki General Hospital, Hanamaki, Iwate, Japan
| | | | | | - Hiroyuki Murai
- Department of Neurology, International University of Health and Welfare, Narita, Chiba, Japan
| | - Heinz Wiendl
- Department of Neurology, Institute of Translational Neurology, University of Münster, Münster, Germany
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Howard JF, Nowak RJ, Wolfe GI, Freimer ML, Vu TH, Hinton JL, Benatar M, Duda PW, MacDougall JE, Farzaneh-Far R, Kaminski HJ, Barohn R, Dimachkie M, Pasnoor M, Farmakidis C, Liu T, Colgan S, Benatar MG, Bertorini T, Pillai R, Henegar R, Bromberg M, Gibson S, Janecki T, Freimer M, Elsheikh B, Matisak P, Genge A, Guidon A, David W, Habib AA, Mathew V, Mozaffar T, Hinton JL, Hewitt W, Barnett D, Sullivan P, Ho D, Howard JF, Traub RE, Chopra M, Kaminski HJ, Aly R, Bayat E, Abu-Rub M, Khan S, Lange D, Holzberg S, Khatri B, Lindman E, Olapo T, Sershon LM, Lisak RP, Bernitsas E, Jia K, Malik R, Lewis-Collins TD, Nicolle M, Nowak RJ, Sharma A, Roy B, Nye J, Pulley M, Berger A, Shabbir Y, Sachdev A, Patterson K, Siddiqi Z, Sivak M, Bratton J, Small G, Kohli A, Fetter M, Vu T, Lam L, Harvey B, Wolfe GI, Silvestri N, Patrick K, Zakalik K, Duda PW, MacDougall J, Farzaneh-Far R, Pontius A, Hoarty M. Clinical Effects of the Self-administered Subcutaneous Complement Inhibitor Zilucoplan in Patients With Moderate to Severe Generalized Myasthenia Gravis: Results of a Phase 2 Randomized, Double-Blind, Placebo-Controlled, Multicenter Clinical Trial. JAMA Neurol 2021; 77:582-592. [PMID: 32065623 PMCID: PMC7042797 DOI: 10.1001/jamaneurol.2019.5125] [Citation(s) in RCA: 121] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Question What are the clinical effects of zilucoplan, a subcutaneously self-administered macrocyclic peptide inhibitor of complement component 5, in a broad population of patients with moderate to severe acetylcholine receptor autoantibody–positive generalized myasthenia gravis? Findings In a randomized, double-blind, placebo-controlled, multicenter phase 2 trial, zilucoplan yielded rapid, clinically meaningful, statistically significant, and sustained improvements in the primary and key secondary end points. Near-complete complement inhibition was associated with a faster onset and greater magnitude of benefit than submaximal complement inhibition, and favorable safety and tolerability were observed. Meaning The findings support a potential therapeutic role for zilucoplan in generalized myasthenia gravis and further evaluation in a phase 3 study. Importance Many patients with generalized myasthenia gravis (gMG) have substantial clinical disability, persistent disease burden, and adverse effects attributable to chronic immunosuppression. Therefore, there is a significant need for targeted, well-tolerated therapies with the potential to improve disease control and enhance quality of life. Objective To evaluate the clinical effects of zilucoplan, a subcutaneously (SC) self-administered macrocyclic peptide inhibitor of complement component 5, in a broad population of patients with moderate to severe gMG. Design, Setting, and Participants This randomized, double-blind, placebo-controlled phase 2 clinical trial at 25 study sites across North America recruited participants between December 2017 and August 2018. Fifty-seven patients were screened, of whom 12 did not meet inclusion criteria and 1 was lost to follow-up after randomization but before receiving study drug, resulting in a total of 44 acetylcholine receptor autoantibody (AChR-Ab)–positive patients with gMG with baseline Quantitative Myasthenia Gravis (QMG) scores of at least 12, regardless of treatment history. Interventions Patients were randomized 1:1:1 to a daily SC self-injection of placebo, 0.1-mg/kg zilucoplan, or 0.3-mg/kg zilucoplan for 12 weeks. Main Outcomes and Measures The primary and key secondary end points were the change from baseline to week 12 in QMG and MG Activities of Daily Living scores, respectively. Significance testing was prespecified at a 1-sided α of .10. Safety and tolerability were also assessed. Results The study of 44 patients was well balanced across the 3 treatment arms with respect to key demographic and disease-specific variables. The mean age of patients across all 3 treatment groups ranged from 45.5 to 54.6 years and most patients were white (average proportions across 3 treatment groups: 78.6%-86.7%). Clinically meaningful and statistically significant improvements in primary and key secondary efficacy end points were observed. Zilucoplan at a dose of 0.3 mg/kg SC daily resulted in a mean reduction from baseline of 6.0 points in the QMG score (placebo-corrected change, –2.8; P = .05) and 3.4 points in the MG Activities of Daily Living score (placebo-corrected change, –2.3; P = .04). Clinically meaningful and statistically significant improvements were also observed in other secondary end points, the MG Composite and MG Quality-of-Life scores. Outcomes for the 0.1-mg/kg SC daily dose were also statistically significant but slower in onset and less pronounced than with the 0.3-mg/kg dose. Rescue therapy (intravenous immunoglobulin or plasma exchange) was required in 3 of 15, 1 of 15, and 0 of 14 participants in the placebo, 0.1-mg/kg zilucoplan, and 0.3-mg/kg zilucoplan arms, respectively. Zilucoplan was observed to have a favorable safety and tolerability profile. Conclusions and Relevance Zilucoplan yielded rapid, meaningful, and sustained improvements over 12 weeks in a broad population of patients with moderate to severe AChR-Ab–positive gMG. Near-complete complement inhibition appeared superior to submaximal inhibition. The observed safety and tolerability profile of zilucoplan was favorable. Trial Registration ClinicalTrials.gov Identifier: NCT03315130.
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Affiliation(s)
| | | | | | | | | | | | | | - Petra W Duda
- Ra Pharmaceuticals Inc, Cambridge, Massachusetts
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Angela Genge
- Montreal Neurological Institute, Montreal, Quebec, Canada
| | | | | | | | | | | | | | | | | | | | - Doreen Ho
- Lahey Hospital, Burlington, Massachusetts
| | | | | | | | | | - Radwa Aly
- George Washington University, Washington, DC
| | - Elham Bayat
- George Washington University, Washington, DC
| | | | - Shaida Khan
- University of Texas Southwestern, Dallas, Irving
| | - Dale Lange
- Hospital for Special Surgery, New York, New York
| | | | - Bhupendra Khatri
- Center for Neurological Disorders, St Francis Hospital at Ascension, Milwaukee, Wisconsin
| | - Emily Lindman
- Center for Neurological Disorders, St Francis Hospital at Ascension, Milwaukee, Wisconsin
| | - Tayo Olapo
- Center for Neurological Disorders, St Francis Hospital at Ascension, Milwaukee, Wisconsin
| | - Lisa M Sershon
- Center for Neurological Disorders, St Francis Hospital at Ascension, Milwaukee, Wisconsin
| | | | | | - Kelly Jia
- Wayne State University, Detroit, Michigan
| | | | | | | | | | | | - Bhaskar Roy
- Yale School of Medicine, New Haven, Connecticut
| | - Joan Nye
- Yale School of Medicine, New Haven, Connecticut
| | | | | | | | | | | | | | - Mark Sivak
- Mount Sinai Hospital, New York, New York
| | | | - George Small
- Allegheny Neurological Associates, Pittsburgh, Pennsylvania
| | - Anem Kohli
- Allegheny Neurological Associates, Pittsburgh, Pennsylvania
| | - Mary Fetter
- Allegheny Neurological Associates, Pittsburgh, Pennsylvania
| | - Tuan Vu
- University of South Florida, Tampa
| | - Lucy Lam
- University of South Florida, Tampa
| | | | | | | | | | | | - Petra W Duda
- Ra Pharmaceuticals Inc, Cambridge, Massachusetts
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Peng Y, Jiang F, Zhou R, Jin W, Li Y, Duan W, Xu L, Yang H. Clinical Evaluation of the Efficacy and Safety of Co-Administration of Wuzhi Capsule and Tacrolimus in Adult Chinese Patients with Myasthenia Gravis. Neuropsychiatr Dis Treat 2021; 17:2281-2289. [PMID: 34285488 PMCID: PMC8286075 DOI: 10.2147/ndt.s319500] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 06/24/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Tacrolimus has been recommended as an effective immunosuppressant for patients with myasthenia gravis (MG), while the high price, variable bioavailability, and narrow therapeutic window restrict its clinical application. Wuzhi capsule (WZC) could improve tacrolimus blood concentration by inhibiting the metabolism of cytochrome P450 3A (CYP3A) and P-glycoprotein (P-gp). There are few studies focused on the coadministration of WZC and tacrolimus in autoimmune diseases. This study was aimed at quantifying the efficacy and safety of coadministration of WZC and tacrolimus in adult Chinese patients with MG. METHODS In this retrospective study, 122 patients with MG on tacrolimus were enrolled. The initial tacrolimus dose was 2 mg/d. Patients with standard initial tacrolimus concentration were classified into group A (standard-dose group). Those failed to reach target concentration were divided into group B (high-dose group) and group C (co-administering WZC group), according to treatment adjustment of increasing tacrolimus dose and co-administration of WZC, respectively. A logistic analysis was used to identify factors associated with clinical outcome. Adverse drug reactions (ADRs) were recorded for safety analysis. RESULTS The tacrolimus concentration after coadministration of WZC was remarkably increased. It was higher compared with simply increasing the tacrolimus dose (p<0.001). The multivariate logistic analysis indicated that the baseline quantitative MG score was a predictive factor for clinical outcomes (OR=0.189; 95% CI 0.082-0.436; p<0.001). Fourteen patients (11.5%) reported ADRs after tacrolimus therapy. ADRs incidence was not related to WZC coadministration. CONCLUSION The coadministration of WZC and tacrolimus can substantially elevate the tacrolimus concentration. It is a safe and economic treatment for adult Chinese patients with MG. Patients with a worse disease condition tend to present a better clinical outcome after tacrolimus therapy.
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Affiliation(s)
- Yuyao Peng
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, 410008, People's Republic of China
| | - Fei Jiang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, 410008, People's Republic of China
| | - Ran Zhou
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, 410008, People's Republic of China
| | - Wanlin Jin
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, 410008, People's Republic of China
| | - Yi Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, 410008, People's Republic of China
| | - Weiwei Duan
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, 410008, People's Republic of China
| | - Liqun Xu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, 410008, People's Republic of China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, 410008, People's Republic of China
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Díez-Porras L, Homedes C, Alberti MA, Vélez-Santamaría V, Casasnovas C. Intravenous immunoglobulins may prevent prednisone-exacerbation in myasthenia gravis. Sci Rep 2020; 10:13497. [PMID: 32782330 PMCID: PMC7421901 DOI: 10.1038/s41598-020-70539-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 07/31/2020] [Indexed: 01/09/2023] Open
Abstract
Corticosteroids may produce a paradoxical worsening of myasthenia gravis (MG) symptoms within the first weeks of treatment. We therefore wanted to assess the hypothesis that a prior infusion of intravenous immunoglobulin (IVIG) may have a protective effect. Our primary objectives were to show that the coadministration of immunoglobulins and glucocorticoids is safe and effective for controlling myasthenic symptoms, and to compare the exacerbation rate with this approach and historical practice without IVIG. We recruited 45 patients with generalized MG who required corticosteroids for the first time and we gave all IVIG before starting the full doses of prednisone. Monitoring was performed with validated scales, questionnaires, and blood tests over a 6-week period. Only 4.4% had severe adverse effects related to IVIG and 86.7% improved clinically. Notably, only 2.2% had a paradoxical symptom exacerbation in the first weeks of starting prednisone, which was statistically lower than the 42% reported in a historical series. We conclude that adjuvant therapy with IVIG when starting prednisone for the first time in patients with generalized MG is safe and effective. Given that the rate of paradoxical worsening was lower than that previously reported, the addition of IVIG may have a protective effect against such exacerbations.
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Affiliation(s)
- Laura Díez-Porras
- Neuromuscular Unit. Department of Neurology, Bellvitge University Hospital, Feixa Llarga Street s/n, L'Hospitalet del Llobregat, 08907, Barcelona, Spain
| | - Christian Homedes
- Neuromuscular Unit. Department of Neurology, Bellvitge University Hospital, Feixa Llarga Street s/n, L'Hospitalet del Llobregat, 08907, Barcelona, Spain
| | - Maria Antonia Alberti
- Neuromuscular Unit. Department of Neurology, Bellvitge University Hospital, Feixa Llarga Street s/n, L'Hospitalet del Llobregat, 08907, Barcelona, Spain
| | - Valentina Vélez-Santamaría
- Neuromuscular Unit. Department of Neurology, Bellvitge University Hospital, Feixa Llarga Street s/n, L'Hospitalet del Llobregat, 08907, Barcelona, Spain.,Neurometabolic Diseases Group, Bellvitge Biomedical Research Institute (IDIBELL), 199 Granvia de l'Hospitalet, L'Hospitalet de Llobregat, 08908, Barcelona, Spain
| | - Carlos Casasnovas
- Neuromuscular Unit. Department of Neurology, Bellvitge University Hospital, Feixa Llarga Street s/n, L'Hospitalet del Llobregat, 08907, Barcelona, Spain. .,Neurometabolic Diseases Group, Bellvitge Biomedical Research Institute (IDIBELL), 199 Granvia de l'Hospitalet, L'Hospitalet de Llobregat, 08908, Barcelona, Spain. .,Center for Biomedical Research on Rare Diseases (CIBERER), ISCIII, 3-5 Monforte de Lemos, Pabellón 121, 28029, Madrid, Spain.
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Vemuri D, Garuda BR, Gopi S, Kumar TS, Kumari UA. Disease Severity Assessment and Short-Term Outcome in Patients with Myasthenia Gravis. Ann Indian Acad Neurol 2020; 23:215-219. [PMID: 32189865 PMCID: PMC7061515 DOI: 10.4103/aian.aian_243_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 06/19/2019] [Accepted: 06/26/2019] [Indexed: 11/04/2022] Open
Abstract
Background Myasthenia gravis (MG) is an autoimmune disorder with a chronic fluctuating course. The outcome measures encapsulate disease severity, functional impact at diagnosis, and objective evaluation of clinical benefit from therapeutic interventions. Aims and Objective To assess the disease severity, correlation between various outcome measures, and to evaluate the short-term outcome at 3 months and 6 months in a cohort of MG patients. Materials and Methods Quantitative myasthenia gravis (QMG) score, myasthenia gravis composite (MGC) score, and myasthenia gravis quality of life-15 (MG-QoL-15) score were applied to 54 patients at first visit, 3 months and 6 months follow-up. Results Mean quality of life-15 (QoL-15) score at base line was 15.241. Mean QMG and MGC scores at baseline were 14.63 ± 8.37 and 15.87 ± 9.14, respectively. QMG score showed a strong positive correlation with both MGC and MG-QoL-15 scores. QMG and MGC scores showed a moderate correlation with acetylcholine receptor antibody (AChR Ab) titers. Mean QMG at follow-up was 9.95 ± 5.49 at 3 months and 6.74 ± 4.74 at 6 months. Mean MGC at follow-up was 10.75 ± 5.58 at 3 months and 6.51 ± 4.36 at 6 months. Conclusion The combination of physician-evaluated and patient-reported outcome measures provided a more discerning picture of patient status and response to treatment. Incorporating MG outcome measures into clinical practice would aid in modulating therapies.
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Affiliation(s)
- Deepthi Vemuri
- Department of Neurology, Andhra Medical College/King George Hospital, Visakhapatnam, Andhra Pradesh, India
| | - Butchi Raju Garuda
- Department of Neurology, Andhra Medical College/King George Hospital, Visakhapatnam, Andhra Pradesh, India
| | - S Gopi
- Department of Neurology, Andhra Medical College/King George Hospital, Visakhapatnam, Andhra Pradesh, India
| | - T Sateesh Kumar
- Department of Neurology, Andhra Medical College/King George Hospital, Visakhapatnam, Andhra Pradesh, India
| | - U Aruna Kumari
- Department of Neurology, Andhra Medical College/King George Hospital, Visakhapatnam, Andhra Pradesh, India
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Husain Q, Hoehle L, Phillips K, Caradonna DS, Gray ST, Sedaghat AR. The 22-Item Sinonasal Outcome Test as a Tool for the Assessment of Quality of Life and Symptom Control in Allergic Rhinitis. Am J Rhinol Allergy 2019; 34:209-216. [DOI: 10.1177/1945892419884789] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background The 22-item Sinonasal Outcome Test (SNOT-22) is a validated patient-reported outcome measure for chronic rhinosinusitis and in many circumstances is used in rhinology/otolaryngology clinics to assess sinonasal symptoms in general when a formal diagnosis is not established, although with little support for such usage. Objective To assess the utility of the SNOT-22 as a reflection of quality of life (QOL) and symptom control for patients with allergic rhinitis (AR). Methods Retrospective review of 353 patients with persistent AR. Each patient completed a SNOT-22, 5-item EuroQol general health-related QOL (EQ-5D) questionnaire (from which the visual analog scale [VAS] was used), and Rhinitis Control Assessment Test (RCAT). In addition, 95 patients also completed these questionnaires 1 to 12 months later. Results The SNOT-22 was negatively correlated with the EuroQol 5-dimensional visual analog scale (EQ-5D VAS; r = −.45, 95% confidence interval [CI]: −0.53 to −0.36, P < .001) and RCAT ( r = −.62, 95% CI: −0.68 to −0.55, P < .001), with excellent internal consistency. The SNOT-22 demonstrated responsiveness, with mean change of −5.8 (95% CI: −8.9 to −2.6, P < .001) from pre- to posttreatment. The change in SNOT-22 over the treatment period was correlated with change in EQ-5D VAS ( r = −.28, 95% CI: −0.46 to −0.07, P = .008) and RCAT ( r = −.56, 95% CI: −0.69 to −0.41, P < .001). The minimal clinically important difference was calculated to be between 6 and 11. Conclusion The SNOT-22 has utility to assess QOL and symptom control in AR, and it is both reliable and responsive in its application to patients with AR. The SNOT-22 may therefore be a convenient and versatile tool in the clinical assessment of patients with AR.
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Affiliation(s)
- Qasim Husain
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - Lloyd Hoehle
- Edward Via College of Osteopathic Medicine—Carolinas, Spartanburg, South Carolina
| | - Katie Phillips
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - David S. Caradonna
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
- Division of Otolaryngology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Stacey T. Gray
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - Ahmad R. Sedaghat
- Department of Otolaryngology—Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Barnett C, Herbelin L, Dimachkie MM, Barohn RJ. Measuring Clinical Treatment Response in Myasthenia Gravis. Neurol Clin 2019; 36:339-353. [PMID: 29655453 DOI: 10.1016/j.ncl.2018.01.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
In this article we provide an overview of health-related outcome measurement-to better understand what different outcomes used in myasthenia actually measure-and to provide some guidance when choosing measures based on the clinical context and question. In myasthenia, the most commonly used outcome measures are aimed at assessing the signs and symptoms. In this review, we provide a summary of the most commonly used outcome measures. We discuss instruments that gauge disease overall health impact, such as on disability and quality of life. Finally, we discuss other relevant outcomes such as steroid-sparing effects and the role of surrogate markers.
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Affiliation(s)
- Carolina Barnett
- Neurology (Medicine), University of Toronto, University Health Network, Toronto, Ontario, Canada.
| | - Laura Herbelin
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Mazen M Dimachkie
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Richard J Barohn
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
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Sedaghat AR. Understanding the Minimal Clinically Important Difference (MCID) of Patient-Reported Outcome Measures. Otolaryngol Head Neck Surg 2019; 161:551-560. [PMID: 31159641 DOI: 10.1177/0194599819852604] [Citation(s) in RCA: 166] [Impact Index Per Article: 33.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE The minimal clinically important difference (MCID) of a patient-reported outcome measure (PROM) represents a threshold value of change in PROM score deemed to have an implication in clinical management. The MCID is frequently used to interpret the significance of results from clinical studies that use PROMs. However, an understanding of the many caveats of the MCID, as well as its strengths and limitations, is necessary. The objective of this article is to provide a review of the calculation, interpretation, and caveats of MCID. DATA SOURCES MEDLINE and PubMed Central. REVIEW METHODS Literature search-including primary studies, review articles, and consensus statements-pertinent to the objectives of this review using PubMed. CONCLUSIONS The MCID of a PROM may vary depending on the patients and clinical context in which the PROM is given. The primary approaches for calculating MCID are distribution-based and anchor-based methods. Each methodology has strengths and limitations, and the ideal determination of a PROM MCID includes synthesis of results from both approaches. The MCID of a PROM is also not perfect in detecting patients experiencing a clinically important improvement, and this is reflected in its accuracy (eg, sensitivity and specificity). IMPLICATIONS FOR PRACTICE Interpretation or application of MCID requires consideration of all caveats underlying the MCID, including the patients in whom it was derived, the limitations of the methodologies used to calculate it, and its accuracy for identifying patients who have experienced clinically significant improvement.
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Affiliation(s)
- Ahmad R Sedaghat
- Department of Otolaryngology-Head & Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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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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36
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Frisaldi E, Shaibani A, Vollert J, Ferrero B, Carrino R, Ibraheem HD, Vase L, Benedetti F. The placebo response in myasthenia gravis assessed by quantitative myasthenia gravis score: A meta-analysis. Muscle Nerve 2019; 59:671-678. [PMID: 30883809 DOI: 10.1002/mus.26469] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 03/11/2019] [Accepted: 03/12/2019] [Indexed: 12/17/2022]
Abstract
INTRODUCTION This meta-analysis investigates the placebo response in generalized myasthenia gravis (MG) trials by means of Quantitative Myasthenia Gravis (QMG) scores. METHODS PubMed, Scopus, Web of Science, Cochrane Controlled Trial Register, and EMBASE were searched. QMG score, dropouts rate, adverse events (AEs), and AEs responsible for dropouts were examined, together with treatment moderators. RESULTS The magnitude of placebo response showed an effect size of 0.24, which was significantly lower than 0.67 of the drug response (P = 0.019). Furthermore, the forest plot revealed that, overall, active treatments showed a significantly higher impact on QMG scores than placebos. CONCLUSIONS Placebo and drug responses in MG trials are small and moderate, respectively. The lack of MG trials with a pure placebo arm or a no-treatment control arm made it impossible to disentangle improvements due to the placebo psychological effect from other effects such as natural history and/or regression to the mean. Muscle Nerve 59:671-678, 2019.
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Affiliation(s)
- Elisa Frisaldi
- Department of Neuroscience, University of Turin Medical School, Corso Raffaello 30, 10125 Turin, Italy
| | | | - Jan Vollert
- Pain Research, Faculty of Medicine, Department of Surgery & Cancer, Imperial College London, London, United Kingdom.,Center of Biomedicine and Medical Technology Mannheim CBTM, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Bruno Ferrero
- Department of Neuroscience, University of Turin Medical School, Corso Raffaello 30, 10125 Turin, Italy
| | - Roberta Carrino
- Department of Neuroscience, University of Turin Medical School, Corso Raffaello 30, 10125 Turin, Italy
| | | | - Lene Vase
- Department of Psychology and Behavioural Sciences, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark
| | - Fabrizio Benedetti
- Department of Neuroscience, University of Turin Medical School, Corso Raffaello 30, 10125 Turin, Italy.,Plateau Rosà Laboratories, Plateau Rosà, Italy/Switzerland
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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: 108] [Impact Index Per Article: 21.6] [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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Wolfe GI, Kaminski HJ, Aban IB, Minisman G, Kuo HC, Marx A, Ströbel P, Mazia C, Oger J, Cea JG, Heckmann JM, Evoli A, Nix W, Ciafaloni E, Antonini G, Witoonpanich R, King JO, Beydoun SR, Chalk CH, Barboi AC, Amato AA, Shaibani AI, Katirji B, Lecky BRF, Buckley C, Vincent A, Dias-Tosta E, Yoshikawa H, Waddington-Cruz M, Pulley MT, Rivner MH, Kostera-Pruszczyk A, Pascuzzi RM, Jackson CE, Verschuuren JJGM, Massey JM, Kissel JT, Werneck LC, Benatar M, Barohn RJ, Tandan R, Mozaffar T, Silvestri NJ, Conwit R, Sonett JR, Jaretzki A, Newsom-Davis J, Cutter GR. Long-term effect of thymectomy plus prednisone versus prednisone alone in patients with non-thymomatous myasthenia gravis: 2-year extension of the MGTX randomised trial. Lancet Neurol 2019; 18:259-268. [PMID: 30692052 PMCID: PMC6774753 DOI: 10.1016/s1474-4422(18)30392-2] [Citation(s) in RCA: 121] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 10/11/2018] [Accepted: 10/15/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND The Thymectomy Trial in Non-Thymomatous Myasthenia Gravis Patients Receiving Prednisone (MGTX) showed that thymectomy combined with prednisone was superior to prednisone alone in improving clinical status as measured by the Quantitative Myasthenia Gravis (QMG) score in patients with generalised non-thymomatous myasthenia gravis at 3 years. We investigated the long-term effects of thymectomy up to 5 years on clinical status, medication requirements, and adverse events. METHODS We did a rater-blinded 2-year extension study at 36 centres in 15 countries for all patients who completed the randomised controlled MGTX and were willing to participate. MGTX patients were aged 18 to 65 years at enrolment, had generalised non-thymomatous myasthenia gravis of less than 5 years' duration, had acetylcholine receptor antibody titres of 1·00 nmol/L or higher (or concentrations of 0·50-0·99 nmol/L if diagnosis was confirmed by positive edrophonium or abnormal repetitive nerve stimulation, or abnormal single fibre electromyography), had Myasthenia Gravis Foundation of America Clinical Classification Class II-IV disease, and were on optimal anticholinesterase therapy with or without oral corticosteroids. In MGTX, patients were randomly assigned (1:1) to either thymectomy plus prednisone or prednisone alone. All patients in both groups received oral prednisone at doses titrated up to 100 mg on alternate days until they achieved minimal manifestation status. The primary endpoints of the extension phase were the time-weighted means of the QMG score and alternate-day prednisone dose from month 0 to month 60. Analyses were by intention to treat. The trial is registered with ClinicalTrials.gov, number NCT00294658. It is closed to new participants, with follow-up completed. FINDINGS Of the 111 patients who completed the 3-year MGTX, 68 (61%) entered the extension study between Sept 1, 2009, and Aug 26, 2015 (33 in the prednisone alone group and 35 in the prednisone plus thymectomy group). 50 (74%) patients completed the 60-month assessment, 24 in the prednisone alone group and 26 in the prednisone plus thymectomy group. At 5 years, patients in the thymectomy plus prednisone group had significantly lower time-weighted mean QMG scores (5·47 [SD 3·87] vs 9·34 [5·08]; p=0·0007) and mean alternate-day prednisone doses (24 mg [SD 21] vs 48 mg [29]; p=0·0002) than did those in the prednisone alone group. 14 (42%) of 33 patients in the prednisone group, and 12 (34%) of 35 in the thymectomy plus prednisone group, had at least one adverse event by month 60. No treatment-related deaths were reported during the extension phase. INTERPRETATION At 5 years, thymectomy plus prednisone continues to confer benefits in patients with generalised non-thymomatous myasthenia gravis compared with prednisone alone. Although caution is appropriate when generalising our findings because of the small sample size of our study, they nevertheless provide further support for the benefits of thymectomy in patients with generalised non-thymomatous myasthenia gravis. FUNDING National Institutes of Health, National Institute of Neurological Disorders and Stroke.
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Affiliation(s)
- Gil I Wolfe
- Department of Neurology, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA.
| | - Henry J Kaminski
- Department of Neurology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Inmaculada B Aban
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Greg Minisman
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hui-Chien Kuo
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alexander Marx
- Institute of Pathology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Philipp Ströbel
- Institute of Pathology, University of Göttingen, Göttingen, Germany
| | - Claudio Mazia
- Department of Neurology, University of Buenos Aires, Buenos Aires, Argentina
| | - Joel Oger
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - J Gabriel Cea
- Department of Neurology, University of Chile, Santiago, Chile
| | - Jeannine M Heckmann
- Division of Neurology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Amelia Evoli
- Department of Neurology, Catholic University, Rome, Italy
| | - Wilfred Nix
- Department of Neurology, Johanes Gutenberg University, Mainz, Germany
| | - Emma Ciafaloni
- Department of Neurology, University of Rochester Medical Centre, Rochester, NY, USA
| | - Giovanni Antonini
- Department of Neurology, Mental Health and Sensory Organs, University of Rome Sapienza, Rome, Italy
| | | | - John O King
- Department of Neurology, University of Melbourne, Melbourne, VIC, Australia
| | - Said R Beydoun
- Department of Neurology, University of Southern California, Los Angeles, CA, USA
| | - Colin H Chalk
- Department of Neurology, McGill University, Montreal, QC, Canada
| | - Alexandru C Barboi
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Anthony A Amato
- Department of Neurology, Harvard Medical School, Boston, MA, USA
| | | | - Bashar Katirji
- Department of Neurology, Case Western Reserve University, Cleveland, OH, USA
| | | | - Camilla Buckley
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK
| | - Elza Dias-Tosta
- Unit of Neurology, Hospital de Base do Distrito Federal, Brasília, Brazil
| | | | | | - Michael T Pulley
- Department of Neurology, University of Florida, Jacksonville, FL, USA
| | - Michael H Rivner
- Department of Neurology, Georgia Regents University, Augusta, GA, USA
| | | | - Robert M Pascuzzi
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Carlayne E Jackson
- Department of Neurology, University of Texas Health Science Centre, San Antonio, TX, USA
| | | | - Janice M Massey
- Department of Neurology, Duke University Medical Centre, Durham, NC, USA
| | - John T Kissel
- Department of Neurology, Ohio State University Wexner Medical Centre, Columbus, OH, USA
| | - Lineu C Werneck
- Department of Neurology, Universidade Federal do Parana, Curitiba, Brazil
| | - Michael Benatar
- Department of Neurology, University of Miami, Miami, FL, USA
| | - Richard J Barohn
- Department of Neurology, University of Kansas Medical Centre, Kansas City, KS, USA
| | - Rup Tandan
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, VT, USA
| | - Tahseen Mozaffar
- Department of Neurology, University of California, Irvine, Orange, CA, USA
| | - Nicholas J Silvestri
- Department of Neurology, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Robin Conwit
- Division of Extramural Research, National Institutes of Health/National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Joshua R Sonett
- Section of General Thoracic Surgery, Columbia University Medical Centre, New York, NY, USA
| | - Alfred Jaretzki
- Section of General Thoracic Surgery, Columbia University Medical Centre, New York, NY, USA
| | - John Newsom-Davis
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK
| | - Gary R Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
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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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Phillips KM, Hoehle LP, Caradonna DS, Gray ST, Sedaghat AR. Minimal clinically important difference for the 22-item Sinonasal Outcome Test in medically managed patients with chronic rhinosinusitis. Clin Otolaryngol 2018; 43:1328-1334. [DOI: 10.1111/coa.13177] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 06/22/2018] [Indexed: 12/16/2022]
Affiliation(s)
- Katie M. Phillips
- Department of Otolaryngology; Harvard Medical School; Boston Massachusetts
- Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
| | - Lloyd P. Hoehle
- Department of Otolaryngology; Harvard Medical School; Boston Massachusetts
- Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
| | - David S. Caradonna
- Department of Otolaryngology; Harvard Medical School; Boston Massachusetts
- Division of Otolaryngology; Beth Israel Deaconess Medical Center; Boston Massachusetts
| | - Stacey T. Gray
- Department of Otolaryngology; Harvard Medical School; Boston Massachusetts
- Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
| | - Ahmad R. Sedaghat
- Department of Otolaryngology; Harvard Medical School; Boston Massachusetts
- Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts
- Division of Otolaryngology; Beth Israel Deaconess Medical Center; Boston Massachusetts
- Department of Otolaryngology and Communications Enhancement; Boston Children's Hospital; Boston Massachusetts
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Howard JF, Utsugisawa K, Benatar M, Murai H, Barohn RJ, Illa I, Jacob S, Vissing J, Burns TM, Kissel JT, Muppidi S, Nowak RJ, O'Brien F, Wang JJ, Mantegazza R. Safety and efficacy of eculizumab in anti-acetylcholine receptor antibody-positive refractory generalised myasthenia gravis (REGAIN): a phase 3, randomised, double-blind, placebo-controlled, multicentre study. Lancet Neurol 2017; 16:976-986. [PMID: 29066163 DOI: 10.1016/s1474-4422(17)30369-1] [Citation(s) in RCA: 422] [Impact Index Per Article: 60.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/20/2017] [Accepted: 09/21/2017] [Indexed: 01/30/2023]
Abstract
BACKGROUND Complement is likely to have a role in refractory generalised myasthenia gravis, but no approved therapies specifically target this system. Results from a phase 2 study suggested that eculizumab, a terminal complement inhibitor, produced clinically meaningful improvements in patients with anti-acetylcholine receptor antibody-positive refractory generalised myasthenia gravis. We further assessed the efficacy and safety of eculizumab in this patient population in a phase 3 trial. METHODS We did a phase 3, randomised, double-blind, placebo-controlled, multicentre study (REGAIN) in 76 hospitals and specialised clinics in 17 countries across North America, Latin America, Europe, and Asia. Eligible patients were aged at least 18 years, with a Myasthenia Gravis-Activities of Daily Living (MG-ADL) score of 6 or more, Myasthenia Gravis Foundation of America (MGFA) class II-IV disease, vaccination against Neisseria meningitides, and previous treatment with at least two immunosuppressive therapies or one immunosuppressive therapy and chronic intravenous immunoglobulin or plasma exchange for 12 months without symptom control. Patients with a history of thymoma or thymic neoplasms, thymectomy within 12 months before screening, or use of intravenous immunoglobulin or plasma exchange within 4 weeks before randomisation, or rituximab within 6 months before screening, were excluded. We randomly assigned participants (1:1) to either intravenous eculizumab or intravenous matched placebo for 26 weeks. Dosing for eculizumab was 900 mg on day 1 and at weeks 1, 2, and 3; 1200 mg at week 4; and 1200 mg given every second week thereafter as maintenance dosing. Randomisation was done centrally with an interactive voice or web-response system with patients stratified to one of four groups based on MGFA disease classification. Where possible, patients were maintained on existing myasthenia gravis therapies and rescue medication was allowed at the study physician's discretion. Patients, investigators, staff, and outcome assessors were masked to treatment assignment. The primary efficacy endpoint was the change from baseline to week 26 in MG-ADL total score measured by worst-rank ANCOVA. The efficacy population set was defined as all patients randomly assigned to treatment groups who received at least one dose of study drug, had a valid baseline MG-ADL assessment, and at least one post-baseline MG-ADL assessment. The safety analyses included all randomly assigned patients who received eculizumab or placebo. This trial is registered with ClinicalTrials.gov, number NCT01997229. FINDINGS Between April 30, 2014, and Feb 19, 2016, we randomly assigned and treated 125 patients, 62 with eculizumab and 63 with placebo. The primary analysis showed no significant difference between eculizumab and placebo (least-squares mean rank 56·6 [SEM 4·5] vs 68·3 [4·5]; rank-based treatment difference -11·7, 95% CI -24·3 to 0·96; p=0·0698). No deaths or cases of meningococcal infection occurred during the study. The most common adverse events in both groups were headache and upper respiratory tract infection (ten [16%] for both events in the eculizumab group and 12 [19%] for both in the placebo group). Myasthenia gravis exacerbations were reported by six (10%) patients in the eculizumab group and 15 (24%) in the placebo group. Six (10%) patients in the eculizumab group and 12 (19%) in the placebo group required rescue therapy. INTERPRETATION The change in the MG-ADL score was not statistically significant between eculizumab and placebo, as measured by the worst-rank analysis. Eculizumab was well tolerated. The use of a worst-rank analytical approach proved to be an important limitation of this study since the secondary and sensitivity analyses results were inconsistent with the primary endpoint result; further research into the role of complement is needed. FUNDING Alexion Pharmaceuticals.
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Affiliation(s)
- James F Howard
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA.
| | | | - Michael Benatar
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, 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, KA, USA
| | - Isabel Illa
- Neurology Department, Hospital Sant Pau, Universitat Autònoma Barcelona, Barcelona, Spain
| | - Saiju Jacob
- Queen Elizabeth Neuroscience Centre, Wellcome Trust Clinical Research Facility, University Hospitals of Birmingham, Birmingham, UK
| | - John Vissing
- Rigshospitalet, Department of Neurology, University of Copenhagen, Copenhagen, Denmark
| | - Ted M Burns
- Department of Neurology, University of Virginia Health System, Charlottesville, VA, USA
| | - John T Kissel
- Department of Neurology, Ohio State University, Columbus, OH, USA
| | - Srikanth Muppidi
- Department of Neurology and Neurosciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Richard J Nowak
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
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Luo M, Liu X, Meng H, Xu L, Li Y, Li Z, Liu C, Luo YB, Hu B, Xue Y, Liu Y, Luo Z, Yang H. IFNA-AS1 regulates CD4 + T cell activation in myasthenia gravis though HLA-DRB1. Clin Immunol 2017; 183:121-131. [PMID: 28822831 DOI: 10.1016/j.clim.2017.08.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 08/04/2017] [Accepted: 08/10/2017] [Indexed: 12/17/2022]
Abstract
Abnormal CD4+T cell activation is known to play roles in the pathogenesis of myasthenia gravis (MG). However, little is known about the mechanisms underlying the roles of lncRNAs in regulating CD4+ T cell. In this study, we discovered that the lncRNA IFNG-AS1 is abnormally expressed in MG patients associated with quantitative myasthenia gravis (QMG) and the positive anti-AchR Ab levels patients. IFNG-AS1 influenced Th1/Treg cell proliferation and regulated the expression levels of their transcription factors in an experimental autoimmune myasthenia gravis (EAMG)model. IFNG-AS1 could reduce the expression of HLA-DRB and HLA-DOB and they had a negative correlation in MG. Furthermore IFNG-AS1 influenced the expression levels of CD40L and CD4+ T cells activation in MG patient partly depend on effecting the HLA-DRB1 expression. It suggests that IFNG-AS1 may be involved in CD4+T cell-mediated immune responses in MG.
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Affiliation(s)
- Mengchuan Luo
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China; Neurology Institute of Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Xiaofang Liu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China; Neurology Institute of Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Huanyu Meng
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China; Neurology Institute of Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Liqun Xu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China; Neurology Institute of Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Yi Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China; Neurology Institute of Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Zhibin Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China; Neurology Institute of Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Chang Liu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China; Neurology Institute of Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Yue-Bei Luo
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China; Neurology Institute of Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Bo Hu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China; Neurology Institute of Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Yuanyuan Xue
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China; Neurology Institute of Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Yu Liu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China; Neurology Institute of Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Zhaohui Luo
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China; Neurology Institute of Xiangya Hospital, Central South University, Changsha, Hunan 410008, China.
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China; Neurology Institute of Xiangya Hospital, Central South University, Changsha, Hunan 410008, China.
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Lipka AF, Vrinten C, van Zwet EW, Schimmel KJ, Cornel MC, Kuijpers MR, Hekster YA, Weinreich SS, Verschuuren JJ. Ephedrine treatment for autoimmune myasthenia gravis. Neuromuscul Disord 2017; 27:259-265. [DOI: 10.1016/j.nmd.2016.11.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 11/09/2016] [Accepted: 11/14/2016] [Indexed: 11/27/2022]
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Abstract
The development of validated assessment tools for evaluating disease status and response to interventions in patients with myasthenia gravis (MG) has been driven by clinical studies of emerging MG therapies. However, only a small proportion of MG-focused neurology practices have adopted these assessment tools for routine clinical use. This article reviews the suitability of 5 assessment instruments for incorporation into clinical practice, which should be driven by their ability to contribute to improved patient outcomes, and to be implemented within practice personnel and resource constraints. It is recommended that assessments based on both physician-evaluated and patient-reported outcomes be selected, to adequately evaluate both point-in-time symptom load and functional impact of MG symptoms over time. Provider resource allocation and reimbursement issues may be the most significant roadblocks to successful ongoing use of these tools; to that end, the addition of regular assessments to MG standards of care is recommended.
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Affiliation(s)
- Srikanth Muppidi
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA
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Karim MR, Zhang HY, Yuan J, Sun Q, Wang YF. Regulatory B Cells in Seropositive Myasthenia Gravis versus Healthy Controls. Front Neurol 2017; 8:43. [PMID: 28265257 PMCID: PMC5317198 DOI: 10.3389/fneur.2017.00043] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 01/31/2017] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To find out if the failure in immunotolerance of myasthenia gravis (MG) is a possible aspect of deduction in Breg cells and to characterize B cell subsets in MG. METHODS Flow cytometry detection and enzyme-linked immunosorbent assays in peripheral blood films of 10 MG patients and 10 healthy controls (HCs) were performed after isolation of B cells. The CD19+CD5+CD1d+ Breg cells percentages were measured to complement a B cell phenotype assay and frequencies of B cell subsets. The clinical outcome measures and immunological variables of patients with MG were compared with HCs. RESULTS Patients with MG had relatively lowered percentages of CD19+CD5+CD1d+ Breg cells as compared to HCs. The production of interleukin (IL)-10 and transforming growth factor (TGF)-β1 was relatively lesser in patients with MG than HCs, which were linked with more severe of MG disease status according to Myasthenia Gravis Foundation of America (MGFA) clinical classification. The reduction of cytokine production was more significant for IL-10 than TGF-β1 when compared to HCs. CONCLUSION It has been observed that the reduced number of B cells is able to produce IL-10 in MG patients but lesser than compared to HCs. The Bregs reduction mainly was regarded by the severity of disease status, which was highly significant and also by disease duration which was statistically significant as well. The findings of the measurement of B cell phenotype assay and frequencies of B cell subsets between MGs and HCs give us new ideas to develop B cell-mediated therapies of MG such as (1) isolated B cells of MGs could be cultured with steroids, e.g., dexamethasone in vitro to see if it induces the CD19+CD5+CD1d+ Breg cells, (2) it may observe whether induced CD19+CD5+CD1d+ Bregs have higher production of IL-10 and TGF-β1, as both are linked with disease severity, and (3) after completion in vitro steps, through further research in vivo to observe whether it improves the function of MG disease status.
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Affiliation(s)
- Md Rezaul Karim
- Department of Neurology, Taihe Hospital of Hubei University of Medicine , Shiyan , China
| | - Hong-Yan Zhang
- Department of Neurology, Taihe Hospital of Hubei University of Medicine , Shiyan , China
| | - Jiang Yuan
- Department of Neurology, Taihe Hospital of Hubei University of Medicine , Shiyan , China
| | - Qiang Sun
- Department of Neurology, Taihe Hospital of Hubei University of Medicine , Shiyan , China
| | - Yun-Fu Wang
- Department of Neurology, Taihe Hospital of Hubei University of Medicine , Shiyan , China
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Verschuuren J, Strijbos E, Vincent A. Neuromuscular junction disorders. HANDBOOK OF CLINICAL NEUROLOGY 2017; 133:447-66. [PMID: 27112691 DOI: 10.1016/b978-0-444-63432-0.00024-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Diseases of the neuromuscular junction comprise a wide range of disorders. Antibodies, genetic mutations, specific drugs or toxins interfere with the number or function of one of the essential proteins that control signaling between the presynaptic nerve ending and the postsynaptic muscle membrane. Acquired autoimmune disorders of the neuromuscular junction are the most common and are described here. In myasthenia gravis, antibodies to acetylcholine receptors or to proteins involved in receptor clustering, particularly muscle-specific kinase, cause direct loss of acetylcholine receptors or interfere with the agrin-induced acetylcholine receptor clustering necessary for efficient neurotransmission. In the Lambert-Eaton myasthenic syndrome (LEMS), loss of the presynaptic voltage-gated calcium channels results in reduced release of the acetylcholine transmitter. The conditions are generally recognizable clinically and the diagnosis confirmed by serologic testing and electromyography. Screening for thymomas in myasthenia or small cell cancer in LEMS is important. Fortunately, a wide range of symptomatic treatments, immunosuppressive drugs, or other immunomodulating therapies is available. Future research is directed to understanding the pathogenesis, discovering new antigens, and trying to develop disease-specific treatments.
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Affiliation(s)
- Jan Verschuuren
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands.
| | - Ellen Strijbos
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
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Li HF, Hong Y, Xie Y, Hao HJ, Sun RC. Precision medicine in myasthenia graves: begin from the data precision. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:106. [PMID: 27127759 DOI: 10.21037/atm.2016.02.16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Myasthenia gravis (MG) is a prototypic autoimmune disease with overt clinical and immunological heterogeneity. The data of MG is far from individually precise now, partially due to the rarity and heterogeneity of this disease. In this review, we provide the basic insights of MG data precision, including onset age, presenting symptoms, generalization, thymus status, pathogenic autoantibodies, muscle involvement, severity and response to treatment based on references and our previous studies. Subgroups and quantitative traits of MG are discussed in the sense of data precision. The role of disease registries and scientific bases of precise analysis are also discussed to ensure better collection and analysis of MG data.
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Affiliation(s)
- Hai-Feng Li
- 1 Department of Neurology, Qilu Hospital of Shandong University, Jinan 250012, China ; 2 Department of Clinical Medicine, University of Bergen, Bergen, Norway ; 3 Department of Neurology, The George Washington University, Washington, DC, USA ; 4 Department of Neurology, Peking University First Hospital, Beijing 100034, China ; 5 College of Information and Engineering, Qingdao University, Qingdao 266071, China
| | - Yu Hong
- 1 Department of Neurology, Qilu Hospital of Shandong University, Jinan 250012, China ; 2 Department of Clinical Medicine, University of Bergen, Bergen, Norway ; 3 Department of Neurology, The George Washington University, Washington, DC, USA ; 4 Department of Neurology, Peking University First Hospital, Beijing 100034, China ; 5 College of Information and Engineering, Qingdao University, Qingdao 266071, China
| | - Yanchen Xie
- 1 Department of Neurology, Qilu Hospital of Shandong University, Jinan 250012, China ; 2 Department of Clinical Medicine, University of Bergen, Bergen, Norway ; 3 Department of Neurology, The George Washington University, Washington, DC, USA ; 4 Department of Neurology, Peking University First Hospital, Beijing 100034, China ; 5 College of Information and Engineering, Qingdao University, Qingdao 266071, China
| | - Hong-Jun Hao
- 1 Department of Neurology, Qilu Hospital of Shandong University, Jinan 250012, China ; 2 Department of Clinical Medicine, University of Bergen, Bergen, Norway ; 3 Department of Neurology, The George Washington University, Washington, DC, USA ; 4 Department of Neurology, Peking University First Hospital, Beijing 100034, China ; 5 College of Information and Engineering, Qingdao University, Qingdao 266071, China
| | - Ren-Cheng Sun
- 1 Department of Neurology, Qilu Hospital of Shandong University, Jinan 250012, China ; 2 Department of Clinical Medicine, University of Bergen, Bergen, Norway ; 3 Department of Neurology, The George Washington University, Washington, DC, USA ; 4 Department of Neurology, Peking University First Hospital, Beijing 100034, China ; 5 College of Information and Engineering, Qingdao University, Qingdao 266071, China
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Barnett C, Merkies ISJ, Katzberg H, Bril V. Psychometric Properties of the Quantitative Myasthenia Gravis Score and the Myasthenia Gravis Composite Scale. J Neuromuscul Dis 2015; 2:301-311. [PMID: 27858737 PMCID: PMC5240569 DOI: 10.3233/jnd-150082] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background: The Quantitative Myasthenia Gravis Score and the Myasthenia Gravis Composite are two commonly used outcome measures in Myasthenia Gravis. So far, their measurement properties have not been compared, so we aimed to study their psychometric properties using the Rasch model. Methods: 251 patients with stable myasthenia gravis were assessed with both scales, and 211 patients returned for a second assessment. We studied fit to the Rasch model at the first visit, and compared item fit, thresholds, differential item functioning, local dependence, person separation index, and tests for unidimensionality. We also assessed test-retest reliability and estimated the Minimal Detectable Change. Results: Neither scale fit the Rasch model (X2p < 0.05). The Myasthenia Gravis Composite had lower discrimination properties than the Quantitative Myasthenia Gravis Scale (Person Separation Index: 0.14 and 0.7). There was local dependence in both scales, as well as differential item functioning for ocular and generalized disease. Disordered thresholds were found in 6(60%) items of the Myasthenia Gravis Composite and in 4(31%) of the Quantitative Myasthenia Gravis Score. Both tools had adequate test-retest reliability (ICCs >0.8). The minimally detectable change was 4.9 points for the Myasthenia Gravis Composite and 4.3 points for the Quantitative Myasthenia Gravis Score. Conclusions: Neither scale fulfilled Rasch model expectations. The Quantitative Myasthenia Gravis Score has higher discrimination than the Myasthenia Gravis Composite. Both tools have items with disordered thresholds, differential item functioning and local dependency. There was evidence of multidimensionality in the QMGS. The minimal detectable change values are higher than previous studies on the minimal significant change. These findings might inform future modifications of these tools.
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Affiliation(s)
- Carolina Barnett
- Division of Neurology - Department of Medicine. University Health Network, Toronto General Hospital, Toronto, Canada
| | - Ingemar S J Merkies
- Department of Neurology, Maastricht University Medical Centre, Maastricht, The Netherlands.,Spaarne Hospital, Hoofddorp, The Netherlands
| | - Hans Katzberg
- Division of Neurology - Department of Medicine. University Health Network, Toronto General Hospital, Toronto, Canada
| | - Vera Bril
- Division of Neurology - Department of Medicine. University Health Network, Toronto General Hospital, Toronto, Canada
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Stunnenberg BC, Woertman W, Raaphorst J, Statland JM, Griggs RC, Timmermans J, Saris CG, Schouwenberg BJ, Groenewoud HM, Stegeman DF, van Engelen BGM, Drost G, van der Wilt GJ. Combined N-of-1 trials to investigate mexiletine in non-dystrophic myotonia using a Bayesian approach; study rationale and protocol. BMC Neurol 2015; 15:43. [PMID: 25880166 PMCID: PMC4407841 DOI: 10.1186/s12883-015-0294-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 02/27/2015] [Indexed: 01/22/2023] Open
Abstract
Background To obtain evidence for the clinical and cost-effectiveness of treatments for patients with rare diseases is a challenge. Non-dystrophic myotonia (NDM) is a group of inherited, rare muscle diseases characterized by muscle stiffness. The reimbursement of mexiletine, the expert opinion drug for NDM, has been discontinued in some countries due to a lack of independent randomized controlled trials (RCTs). It remains unclear however, which concessions can be accepted towards the level 1 evidence needed for coverage decisions, in rare diseases. Considering the large number of rare diseases with a lack of treatment evidence, more experience with innovative trial designs is needed. Both NDM and mexiletine are well suited for an N-of-1 trial design. A Bayesian approach allows for the combination of N-of-1 trials, which enables the assessment of outcomes on the patient and group level simultaneously. Methods/Design We will combine 30 individual, double-blind, randomized, placebo-controlled N-of-1 trials of mexiletine (600 mg daily) vs. placebo in genetically confirmed NDM patients using hierarchical Bayesian modeling. Our results will be compared and combined with the main results of an international cross-over RCT (mexiletine vs. placebo in NDM) published in 2012 that will be used as an informative prior. Similar criteria of eligibility, treatment regimen, end-points and measurement instruments are employed as used in the international cross-over RCT. Discussion The treatment of patients with NDM with mexiletine offers a unique opportunity to compare outcomes and efficiency of novel N-of-1 trial-based designs and conventional approaches in producing evidence of clinical and cost-effectiveness of treatments for patients with rare diseases. Trial registration ClinicalTrials.gov Identifier: NCT02045667
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Affiliation(s)
- Bas C Stunnenberg
- Department of Neurology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Willem Woertman
- Department of Health Evidence, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Joost Raaphorst
- Department of Neurology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Jeffrey M Statland
- Department of Neurology, University of Kansas Medical Center, PO Box 2012, KS 66160, Kansas City, USA.
| | - Robert C Griggs
- Department of Neurology, University of Rochester Medical Center, PO Box 420669, Rochester, NY, 14642, USA.
| | - Janneke Timmermans
- Department of Cardiology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Christiaan G Saris
- Department of Neurology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Bas J Schouwenberg
- Department of Pharmacology-Toxicology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Hans M Groenewoud
- Department of Health Evidence, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Dick F Stegeman
- Department of Neurology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Baziel G M van Engelen
- Department of Neurology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Gea Drost
- Department of Neurology and Neurosurgery, University Medical Center Groningen, PO Box 30001, 9700 RB, Groningen, The Netherlands.
| | - Gert Jan van der Wilt
- Department of Health Evidence, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
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50
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Alabdali M, Barnett C, Katzberg H, Breiner A, Bril V. Intravenous immunoglobulin as treatment for myasthenia gravis: current evidence and outcomes. Expert Rev Clin Immunol 2014; 10:1659-65. [PMID: 25331319 DOI: 10.1586/1744666x.2014.971757] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
We examined the current evidence for the efficacy of IV immunoglobulin (IVIG) in myasthenia gravis (MG) and the outcomes used to demonstrate this efficacy. There is class 1 evidence for the use of short-term IVIG in MG patients worsening MG and also good evidence for IVIG use in myasthenic crisis. For long-term maintenance therapy, controlled studies are lacking and the evidence is limited to class III retrospective studies. The clinical scales, serological, electrophysiological, and patient-reported quality of life outcomes with IVIG have been assessed. At this time, the quantitative myasthenia gravis score, a functional scale, remains the preferable outcome measure as it has demonstrated responsiveness in the clinical trial setting, but a scale incorporating patient-reported outcomes and the patients complaint of fatigue is likely to be preferable. The MG-composite is such a scale, but has measurement limitations that may reduce its sensitivity. Across trials, IVIG has generally been well tolerated.
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Affiliation(s)
- Majed Alabdali
- Division of Neurology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth St, Toronto, Ontario, M5A 4H9, Canada
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