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Tannemaat MR, Huijbers MG, Verschuuren JJGM. Myasthenia gravis-Pathophysiology, diagnosis, and treatment. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:283-305. [PMID: 38494283 DOI: 10.1016/b978-0-12-823912-4.00026-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Myasthenia gravis (MG) is an autoimmune disease characterized by dysfunction of the neuromuscular junction resulting in skeletal muscle weakness. It is equally prevalent in males and females, but debuts at a younger age in females and at an older age in males. Ptosis, diplopia, facial bulbar weakness, and limb weakness are the most common symptoms. MG can be classified based on the presence of serum autoantibodies. Acetylcholine receptor (AChR) antibodies are found in 80%-85% of patients, muscle-specific kinase (MuSK) antibodies in 5%-8%, and <1% may have low-density lipoprotein receptor-related protein 4 (Lrp4) antibodies. Approximately 10% of patients are seronegative for antibodies binding the known disease-related antigens. In patients with AChR MG, 10%-20% have a thymoma, which is usually detected at the onset of the disease. Important differences between clinical presentation, treatment responsiveness, and disease mechanisms have been observed between these different serologic MG classes. Besides the typical clinical features and serologic testing, the diagnosis can be established with additional tests, including repetitive nerve stimulation, single fiber EMG, and the ice pack test. Treatment options for MG consist of symptomatic treatment (such as pyridostigmine), immunosuppressive treatment, or thymectomy. Despite the treatment with symptomatic drugs, steroid-sparing immunosuppressants, intravenous immunoglobulins, plasmapheresis, and thymectomy, a large proportion of patients remain chronically dependent on corticosteroids (CS). In the past decade, the number of treatment options for MG has considerably increased. Advances in the understanding of the pathophysiology have led to new treatment options targeting B or T cells, the complement cascade, the neonatal Fc receptor or cytokines. In the future, these new treatments are likely to reduce the chronic use of CS, diminish side effects, and decrease the number of patients with refractory disease.
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Affiliation(s)
- Martijn R Tannemaat
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Maartje G Huijbers
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands; Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
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Zhen L, Zhao X, Li W, Wu J, Shang H, Chen S, Zhu X, Wang Y, Yu X, Hu G, Sun Z, Zhang Y, Zhang J, Fang H, Zhang Y, Zhang Q, Cui X, Lv J, Yang J, Gao F. Effectiveness of early glucocorticoids in myasthenia gravis: a retrospective cohort study. Front Neurol 2023; 14:1259484. [PMID: 38187148 PMCID: PMC10770254 DOI: 10.3389/fneur.2023.1259484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 11/23/2023] [Indexed: 01/09/2024] Open
Abstract
Purpose This study aimed to clarify the effect of early glucocorticoid (GC) application on achieving minimal manifestation (MM) status or better in the treatment of myasthenia gravis (MG) in the early clinical phase. Methods A retrospective analysis was performed using data from 336 patients with MG who received GC therapy from January 2015 to September 2022 in the Zhengzhou University Henan Institute of Medical and Pharmaceutical Sciences Myasthenia Gravis Biobank (ZMB). Patients were divided into two groups: the early mono-GC group (treated with GC within 6 months of MG onset) and the delayed mono-GC group. Results Kaplan-Meier analysis showed that the early mono-GC group achieved MM status earlier and more frequently than the delayed mono-GC group (log-rank test, p = 0.0082; hazard ratio [HR], 1.66; p = 0.011). The early mono-GC group had a lower maintenance oral GC dose than the delayed mono-GC group. In multivariate Cox regression analysis, early mono-GC (HR, 1.50; p = 0.043), early-onset MG (EOMG) (HR, 1.74; p = 0.034), and ocular MG (OMG) (HR, 1.90; p = 0.007) were associated with MM status or better. In conclusion, early mono-GC, EOMG, and OMG were positive predictors of treatment goals. In EOMG, OMG, and acetylcholine receptor antibody-positive MG (AChR-MG) subgroups, the maintenance oral GC doses in the early mono-GC group were significantly lower than the doses in the delayed mono-GC group (p < 0.05). Conclusion Early intervention with GC led to better long-term outcomes and reduced the necessary maintenance dose of oral GC for patients with MG. EOMG and OMG were positive predictors of MM status or better with mono-GC.
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Affiliation(s)
- Lulu Zhen
- Department of Neurology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Xue Zhao
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Wenbo Li
- Department of Neurology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Jinru Wu
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
- Basic Medical College, Zhengzhou University, Zhengzhou, China
| | - Haodong Shang
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
- BGI College, Zhengzhou University, Zhengzhou, China
| | - Shufan Chen
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
- BGI College, Zhengzhou University, Zhengzhou, China
| | - Xiaoyan Zhu
- Department of Neurology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Yiren Wang
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
- Basic Medical College, Zhengzhou University, Zhengzhou, China
| | - Xiaoxiao Yu
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
- BGI College, Zhengzhou University, Zhengzhou, China
| | - Guanlian Hu
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
- BGI College, Zhengzhou University, Zhengzhou, China
| | - Zhan Sun
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
- BGI College, Zhengzhou University, Zhengzhou, China
| | - Yingna Zhang
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Jing Zhang
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Hua Fang
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Yunke Zhang
- Department of Encephalopathy, First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, China
| | - Qingyong Zhang
- Myasthenia Gravis Comprehensive Diagnosis and Treatment Center, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Xinzheng Cui
- Myasthenia Gravis Comprehensive Diagnosis and Treatment Center, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Jie Lv
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Junhong Yang
- Department of Encephalopathy, First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, China
| | - Feng Gao
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
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Current management of myasthenia gravis in Belgium: a single-center experience. Acta Neurol Belg 2023; 123:375-384. [PMID: 36658451 PMCID: PMC9851893 DOI: 10.1007/s13760-023-02187-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 01/05/2023] [Indexed: 01/21/2023]
Abstract
INTRODUCTION As new treatments are becoming available for patients with myasthenia gravis (MG), it is worth reflecting on the actual status of MG treatment to determine which patients would most likely benefit from the new treatments. METHODS We reviewed the clinical files of all MG patients seen at the Department of Neurology of the Antwerp University Hospital during the years 2019, 2020 and 2021. RESULTS 163 patients were included. Age at diagnosis varied from the first to the eighth decades, with a peak of incidence from 60 to 70 years for both genders, and an additional peak from 20 to 30 years in women. Diplopia and ptosis were by far the most common onset symptom. At maximum disease severity, 24% of the patients still had purely ocular symptoms and 4% needed mechanical ventilation. 97% of the patients received a treatment with pyridostigmine and 68% with corticosteroids, often in combination with immunosuppressants. More than half reported side effects. At the latest visit, 50% of the patients were symptom-free. Also, half of the symptomatic patients were fulltime at work or retired with no or mild limitations in daily living. The remaining patients were working part-time, on sick leave, or retired with severe limitations. DISCUSSION AND CONCLUSION The majority of MG patients are doing well with currently available treatments, but often at the cost of side effects in the short and in the long term. A significant group is in need of better treatments.
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Zhang Y, Li F, Zhu H, Yu H, Wang T, Yan X. Less is not necessarily more: low-dose corticosteroid therapy and long-term prognosis in generalized myasthenia gravis after thymectomy. Neurol Sci 2022; 43:3949-3956. [DOI: 10.1007/s10072-022-05897-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 01/12/2022] [Indexed: 11/28/2022]
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Menon D, Bril V. Pharmacotherapy of Generalized Myasthenia Gravis with Special Emphasis on Newer Biologicals. Drugs 2022; 82:865-887. [PMID: 35639288 PMCID: PMC9152838 DOI: 10.1007/s40265-022-01726-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 11/20/2022]
Abstract
Myasthenia gravis (MG) is a chronic, fluctuating, antibody-mediated autoimmune disorder directed against the post-synaptic neuromuscular junctions of skeletal muscles, resulting in a wide spectrum of manifestations ranging from mild to potentially fatal. Given its unique natural course, designing an ideal trial design for MG has been wrought with difficulties and evidence in favour of several of the conventional agents is weak as per current standards. Despite this, acetylcholinesterases and corticosteroids have remained the cornerstones of treatment for several decades with intravenous immunoglobulins (IVIG) and therapeutic plasma exchange (PLEX) offering rapid treatment response, especially in crises. However, the treatment of MG entails long-term immunosuppression and conventional agents are viable options but take longer to act and have a number of class-specific adverse effects. Advances in immunology, translational medicine and drug development have seen the emergence of several newer biological agents which offer selective, target-specific immunotherapy with fewer side effects and rapid onset of action. Eculizumab is one of the newer agents that belong to the class of complement inhibitors and has been approved for the treatment of refractory general MG. Zilucoplan and ravulizumab are other agents in this group in clinical trials. Neisseria meningitis is a concern with all complement inhibitors, mandating vaccination. Neonatal Fc receptor (FcRn) inhibitors prevent immunoglobulin recycling and cause rapid reduction in antibody levels. Efgartigimod is an FcRn inhibitor recently approved for MG treatment, and rozanolixizumab, nipocalimab and batoclimab are other agents in clinical trial development. Although lacking high quality evidence from randomized clinical trials, clinical experience with the use of anti-CD20 rituximab has led to its use in refractory MG. Among novel targets, interleukin 6 (IL6) inhibitors such as satralizumab are promising and currently undergoing evaluation. Cutting-edge therapies include genetically modifying T cells to recognise chimeric antigen receptors (CAR) and chimeric autoantibody receptors (CAAR). These may offer sustained and long-term remissions, but are still in very early stages of evaluation. Hematopoietic stem cell transplantation (HSCT) allows immune resetting and offers sustained remission, but the induction regimens often involve serious systemic toxicity. While MG treatment is moving beyond conventional agents towards target-specific biologicals, lack of knowledge as to the initiation, maintenance, switching, tapering and long-term safety profile necessitates further research. These concerns and the high financial burden of novel agents may hamper widespread clinical use in the near future.
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Affiliation(s)
- Deepak Menon
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, 5EC-309, Toronto General Hospital, University of Toronto, 200 Elizabeth St, Toronto, M5G 2C4, Canada.
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Kaminski HJ, Denk J. Corticosteroid Treatment-Resistance in Myasthenia Gravis. Front Neurol 2022; 13:886625. [PMID: 35547366 PMCID: PMC9083070 DOI: 10.3389/fneur.2022.886625] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/21/2022] [Indexed: 12/25/2022] Open
Abstract
Chronic, high-dose, oral prednisone has been the mainstay of myasthenia gravis treatment for decades and has proven to be highly beneficial in many, toxic in some way to all, and not effective in a significant minority. No patient characteristics or biomarkers are predictive of treatment response leading to many patients suffering adverse effects with no benefit. Presently, measurements of treatment response, whether taken from clinician or patient perspective, are appreciated to be limited by lack of good correlation, which then complicates correlation to biological measures. Treatment response may be limited because disease mechanisms are not influenced by corticosteroids, limits on dosage because of adverse effects, or individual differences in corticosteroids. This review evaluates potential mechanisms that underlie lack of response to glucocorticoids in patients with myasthenia gravis.
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Affiliation(s)
- Henry J Kaminski
- Department of Neurology and Rehabilitation Medicine, George Washington University, Washington, DC, United States
| | - Jordan Denk
- Department of Neurology and Rehabilitation Medicine, George Washington University, Washington, DC, United States
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Wang L, Wang S, Yang H, Han J, Zhao X, Han S, Zhang Y, Lv J, Zhang J, Li M, Ji Y, Zhou S, He X, Fang H, Yang J, Zhang Y, Zhang Q, Gao P, Gao F. No correlation between acetylcholine receptor antibody concentration and individual clinical symptoms of myasthenia gravis: A systematic retrospective study involving 67 patients. Brain Behav 2021; 11:e02203. [PMID: 34075720 PMCID: PMC8323040 DOI: 10.1002/brb3.2203] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 04/06/2021] [Accepted: 05/11/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To investigate the correlation between acetylcholine receptor antibodies (AChR-Ab) concentration levels and individualized clinical symptoms in patients with AChR myasthenia gravis (AChR-MG) in China. METHODS ELISA was used to determine the concentration of AChR-Ab in patients with MG. The Myasthenia Gravis Foundation of America (MGFA) Clinical Classification, Quantitative Myasthenia Gravis (QMG) score, and MG-specific activities of daily living (MG-ADL) scoring systems were used to evaluate the clinical status of patients. Spearman correlation analysis was used to determine the correlation between the AChR-Ab concentration and clinical score. The changes in the antibody concentration and clinical score are shown in MGFA-antibody concentration-treatment plots. RESULTS Autoantibody detection tests were performed in 67 patients, and their clinical scores were recorded. Forty-nine patients received immunosuppressive therapy, 17 patients received pyridostigmine only, and 1 patient under thymectomy without any medication. The AChR-Ab concentration correlated with the MGFA Classification in 5 (29.4%) patients in the pyridostigmine-only group and 15 (30.6%) patients in the immunosuppressive drug group. The changes in the MGFA Classification preceded the changes in the AChR-Ab concentration in 4 (23.5%) patients treated with pyridostigmine and 10 (20.4%) patients on immunosuppressive drugs. In patients on oral non-steroidal immunosuppressants, the AChR-Ab concentration changed by more than 50%, whereas the MGFA Classification did not increase. The AChR-Ab concentration decreased in 17/32 (53.1%) patients after thymectomy, and then increased, whereas the AChR-Ab concentration increased in 15/32 (46.9%) patients and the MGFA Classification decreased in 27/32 (81.8%) patients after thymectomy. The AChR-Ab concentration presented a slight correlation with the corresponding MGFA, QMG, and MG-ADL in patients with thymoma. DISCUSSION In the Chinese AChR-MG population, the Changes in the AChR-Ab concentration in individuals with AChR-MG did not consistently correlate with the severity of clinical symptoms.
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Affiliation(s)
- Lulu Wang
- Department of NeurologyThe Second Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical SciencesZhengzhou UniversityZhengzhouChina
| | - Shumin Wang
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical SciencesZhengzhou UniversityZhengzhouChina
- Basic Medical CollegeZhengzhou UniversityZhengzhouChina
| | - Haonan Yang
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical SciencesZhengzhou UniversityZhengzhouChina
- BGI CollegeZhengzhou UniversityZhengzhouChina
| | - Jiaojiao Han
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical SciencesZhengzhou UniversityZhengzhouChina
- Basic Medical CollegeZhengzhou UniversityZhengzhouChina
| | - Xue Zhao
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical SciencesZhengzhou UniversityZhengzhouChina
| | - Sensen Han
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical SciencesZhengzhou UniversityZhengzhouChina
- BGI CollegeZhengzhou UniversityZhengzhouChina
| | - Yingna Zhang
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical SciencesZhengzhou UniversityZhengzhouChina
| | - Jie Lv
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical SciencesZhengzhou UniversityZhengzhouChina
| | - Jing Zhang
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical SciencesZhengzhou UniversityZhengzhouChina
| | - Mingqiang Li
- Department of NeurologyThe Second Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical SciencesZhengzhou UniversityZhengzhouChina
| | - Ying Ji
- Department of NeurologyThe Second Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical SciencesZhengzhou UniversityZhengzhouChina
| | - Shuxian Zhou
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical SciencesZhengzhou UniversityZhengzhouChina
- Basic Medical CollegeZhengzhou UniversityZhengzhouChina
| | - Xiaoxiao He
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical SciencesZhengzhou UniversityZhengzhouChina
- BGI CollegeZhengzhou UniversityZhengzhouChina
| | - Hua Fang
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical SciencesZhengzhou UniversityZhengzhouChina
| | - Junhong Yang
- Department of EncephalopathyFirst Affiliated Hospital of Henan University of TCMZhengzhouChina
| | - Yunke Zhang
- Department of EncephalopathyFirst Affiliated Hospital of Henan University of TCMZhengzhouChina
| | - Qingyong Zhang
- Myasthenia Gravis Comprehensive Diagnosis and Treatment CenterHenan Provincial People’s HospitalZhengzhouChina
| | - Peiyang Gao
- Department of Clinical MedicineXinxiang Medical University Sanquan Medical CollegeXinxiangChina
| | - Feng Gao
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical SciencesZhengzhou UniversityZhengzhouChina
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Ozawa Y, Uzawa A, Yasuda M, Kojima Y, Onishi Y, Oda F, Kanai T, Himuro K, Kawaguchi N, Kuwabara S. Long-term outcomes and prognostic factors in generalized myasthenia gravis. J Neurol 2021; 268:3781-3788. [PMID: 33774750 DOI: 10.1007/s00415-021-10520-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 03/07/2021] [Accepted: 03/10/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE This study aimed to investigate the timing of meeting the criteria for a status of "minimal manifestation (MM) or better" and the factors that influenced whether "MM or better status" or "MM or better status with an oral prednisolone (PSL) dose of 5 mg/day or less (5-mg MM)" was met in patients with acetylcholine receptor (AChR) antibody-positive generalized myasthenia gravis (MG). METHODS We performed a retrospective study in 93 patients with AChR antibody-positive generalized MG who were followed for 3 years after the start of immunotherapy. We reviewed clinical data, such as MG-related symptoms, the MG activities of daily living profile (MGADL) score, immunotherapy including the dose of PSL, and achievement of the status of MM or better at baseline and 3, 6, 12, 24, and 36 months after treatment. RESULTS An MM or better status was achieved in 60% of the patients 3 months and in 90% of the patients 2 years after initiating immunotherapy. At 2 years, 60% of the patients had achieved the treatment goal, which was an "5-mg MM". More frequent plasmapheresis and higher dose of PSL within 3 months after immunotherapy initiation were associated with difficulty in achieving the 5-mg MM status at 2 years. CONCLUSION Approximately 60% of the MG patients achieved the treatment goal within 2 years after treatment. PSL dose and the cumulative number of plasmapheresis procedures at 3 months after immunotherapy initiation may help identify treatment-resistant patients with MG.
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Affiliation(s)
- Yukiko Ozawa
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Akiyuki Uzawa
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan.
| | - Manato Yasuda
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Yuta Kojima
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan.,Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yosuke Onishi
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Fumiko Oda
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan.,Department of Neurology, National Hospital Organization Chiba Medical Center, Chiba, Japan
| | - Tetsuya Kanai
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan.,Kanai Medical Clinic, Chiba, Japan
| | - Keiichi Himuro
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan.,Department of Neurology, Matsudo Neurology Clinic, Chiba, Japan
| | - Naoki Kawaguchi
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan.,Department of Neurology, Neurology Clinic Chiba, Dowa Institute of Clinical Neuroscience, Chiba, Japan
| | - Satoshi Kuwabara
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
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Imai T, Suzuki S, Nagane Y, Uzawa A, Murai H, Utsugisawa K. Reappraisal of Oral Steroid Therapy for Myasthenia Gravis. Front Neurol 2020; 11:868. [PMID: 32982912 PMCID: PMC7477376 DOI: 10.3389/fneur.2020.00868] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/07/2020] [Indexed: 11/13/2022] Open
Abstract
Treatment with oral corticosteroids at high doses with an escalation and de-escalation schedule is effective against myasthena gravis (MG). In fact, the use of corticosteroids has led to a reduction in mortality to below 10% after the 1960s. However, long-term use of oral steroids above a certain dosage level is known to cause a number of problems. In 2014, the Japanese clinical guidelines for MG proposed that the first goal in MG treatment (treatment target) should be set at minimal manifestations (MM) with oral prednisolone (PSL) 5 mg/day or below, and that treatment strategies should strive to attain this level as rapidly as possible. In 2015, a multicenter, cross-sectional study revealed that higher PSL dose and longer PSL treatment do not ensure better outcome. In the absence of good response, the PSL dose should be decreased by combining with modalities such as plasma exchange/plasmapheresis and intravenous immunoglobulin (fast-acting treatments). In 2018, we conducted a multicenter, cross-sectional study in a large population of Japanese patients with generalized MG, aiming to elucidate the correlation between oral PSL regimens and achievement of treatment goals. The ORs for low vs. high dose to achieve treatment goals at 1, 2, and 3 years were 10.4, 2.75, and 1.86, respectively, whereas the corresponding ORs for low vs. medium dose were 13.4, 3.99, and 4.92. Early combination with fast-acting therapy (OR 2.19 at 2 years, 2.11 at 3 years) or combination with calcineurin inhibitors (OR 2.09 at 2 years, 2.36 at 3 years) were also positively associated with achieving treatment goals. These results indicate that early combination of low-dose PSL regimens with other therapies is the key for early achievement of treatment goals in generalized MG. However, even with this regimen, ~35% of patients did not achieve the treatment target after 3 years. These results suggest the limitation of the current oral corticosteroid therapy. We need to develop new treatment options to increase the rate of satisfactory outcome.
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Affiliation(s)
- Tomihiro Imai
- Department of Neurology, Sapporo Medical University Hospital, Sapporo, Japan
| | - Shigeaki Suzuki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Yuriko Nagane
- Department of Neurology, Hanamaki General Hospital, Hanamaki, Japan
| | - Akiyuki Uzawa
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hiroyuki Murai
- Department of Neurology, International University of Health and Welfare, Narita, Japan
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Maintenance immunosuppression in myasthenia gravis, an update. J Neurol Sci 2019; 410:116648. [PMID: 31901719 DOI: 10.1016/j.jns.2019.116648] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/25/2019] [Accepted: 12/24/2019] [Indexed: 01/08/2023]
Abstract
Therapies for myasthenia gravis (MG) include symptomatic and immunosuppressive/immunomodulatory treatment. Options for immunosuppression include corticosteroids, azathioprine, mycophenolate mofetil, cyclosporine, tacrolimus, methotrexate, rituximab, cyclophosphamide, eculizumab, intravenous immunoglobulin, subcutaneous immunoglobulin, plasmapheresis, and thymectomy. The practical aspects of long-term immunosuppressive therapy in MG are critically reviewed in this article. Application of one or more of these specific therapies is guided based on known efficacy, adverse effect profile, particular disease subtype and severity, and patient co-morbidities.
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Lee YG, Kim US. Efficacy and Safety of Low-to-Moderate Dose Oral Corticosteroid Treatment in Ocular Myasthenia Gravis. J Pediatr Ophthalmol Strabismus 2018; 55:339-342. [PMID: 30074608 DOI: 10.3928/01913913-20180620-01] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 04/18/2018] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate the response to corticosteroid therapy as a primary treatment for ocular myasthenia gravis. METHODS Patients diagnosed as having ocular myasthenia gravis by an acetylcholine receptor binding antibody test between January 2011 and September 2015 were included in the study and started receiving treatment with a corticosteroid. Patients with a blowout fracture, hyperthyroidism, diabetes mellitus, hypertension, cardiovascular disease, or history of strabismus surgery were excluded. Disappearance of diplopia and ptosis were considered a response to treatment. RESULTS Methylprednisolone therapy was administered to 29 patients (19 men and 10 women; average age: 49 ± 16.5 years) as an initial treatment. A total of 6 patients were lost to follow-up. Twenty-three of 29 patients (82.6%) were regarded as having presented a response to treatment. The average treatment duration was 3 weeks for patients responding to primary treatment. Eight patients complained of adverse effects from steroid therapy such as heartburn, insomnia, weight gain, and myalgia. CONCLUSIONS A corticosteroid could be considered as an initial treatment for patients diagnosed as having ocular myasthenia gravis by an acetylcholine receptor binding antibody test. [J Pediatr Ophthalmol Strabismus. 2018;55(5):339-342.].
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Wang S, Breskovska I, Gandhy S, Punga AR, Guptill JT, Kaminski HJ. Advances in autoimmune myasthenia gravis management. Expert Rev Neurother 2018; 18:573-588. [PMID: 29932785 PMCID: PMC6289049 DOI: 10.1080/14737175.2018.1491310] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Myasthenia gravis (MG) is an autoimmune neuromuscular disorder with no cure and conventional treatments limited by significant adverse effects and variable benefit. In the last decade, therapeutic development has expanded based on improved understanding of autoimmunity and financial incentives for drug development in rare disease. Clinical subtypes exist based on age, gender, thymic pathology, autoantibody profile, and other poorly defined factors, such as genetics, complicate development of specific therapies. Areas covered: Clinical presentation and pathology vary considerably among patients with some having weakness limited to the ocular muscles and others having profound generalized weakness leading to respiratory insufficiency. MG is an antibody-mediated disorder dependent on autoreactive B cells which require T-cell support. Treatments focus on elimination of circulating autoantibodies or inhibition of effector mechanisms by a broad spectrum of approaches from plasmapheresis to B-cell elimination to complement inhibition. Expert commentary: Standard therapies and those under development are disease modifying and not curative. As a rare disease, clinical trials are challenged in patient recruitment. The great interest in development of treatments specific for MG is welcome, but decisions will need to be made to focus on those that offer significant benefits to patients.
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Affiliation(s)
- Shuhui Wang
- Department of Neurology, George Washington University, Washington DC 20008
| | - Iva Breskovska
- Department of Neurology, George Washington University, Washington DC 20008
| | - Shreya Gandhy
- Department of Neurology, George Washington University, Washington DC 20008
| | - Anna Rostedt Punga
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Uppsala, Sweden
| | - Jeffery T. Guptill
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Henry J. Kaminski
- Department of Neurology, George Washington University, Washington DC 20008
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13
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Imai T, Utsugisawa K, Murai H, Tsuda E, Nagane Y, Suzuki Y, Minami N, Uzawa A, Kawaguchi N, Masuda M, Konno S, Suzuki H, Akaishi T, Aoki M. Oral corticosteroid dosing regimen and long-term prognosis in generalised myasthenia gravis: a multicentre cross-sectional study in Japan. J Neurol Neurosurg Psychiatry 2018; 89:513-517. [PMID: 29175893 PMCID: PMC5909754 DOI: 10.1136/jnnp-2017-316625] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 10/07/2017] [Accepted: 11/06/2017] [Indexed: 11/10/2022]
Abstract
OBJECTIVE We examined the correlation between the dosing regimen of oral prednisolone (PSL) and the achievement of minimal manifestation status or better on PSL ≤5 mg/day lasting >6 months (the treatment target) in patients with generalised myasthenia gravis (MG). METHODS We classified 590 patients with generalised MG into high-dose (n=237), intermediate-dose (n=187) and low-dose (n=166) groups based on the oral PSL dosing regimen, and compared the clinical characteristics, previous treatments other than PSL and prognosis between three groups. The effect of oral PSL dosing regimen on the achievement of the treatment target was followed for 3 years of treatment. RESULTS To achieve the treatment target, ORs for low-dose versus high-dose regimen were 10.4 (P<0.0001) after 1 year of treatment, 2.75 (P=0.007) after 2 years and 1.86 (P=0.15) after 3 years; and those for low-dose versus intermediate-dose regimen were 13.4 (P<0.0001) after 1 year, 3.99 (P=0.0003) after 2 years and 4.92 (P=0.0004) after 3 years. Early combined use of fast-acting treatment (OR: 2.19 after 2 years, P=0.02; OR: 2.11 after 3 years, P=0.04) or calcineurin inhibitors (OR: 2.09 after 2 years, P=0.03; OR: 2.36 after 3 years, P=0.02) was associated positively with achievement of treatment target. CONCLUSION A low-dose PSL regimen with early combination of other treatment options may ensure earlier achievement of the treatment target in generalised MG.
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Affiliation(s)
- Tomihiro Imai
- Department of Occupational Therapy, Sapporo Medical University School of Health Sciences, Sapporo, Japan.,Department of Neurology, Sapporo Medical University Hospital, Sapporo, Japan
| | | | - Hiroyuki Murai
- Department of Neurology, School of Medicine, International University of Health and Welfare, Narita, Japan
| | - Emiko Tsuda
- Department of Neurology, Sapporo Medical University Hospital, Sapporo, Japan
| | - Yuriko Nagane
- Department of Neurology, Hanamaki General Hospital, Hanamaki, Japan
| | - Yasushi Suzuki
- Department of Neurology, Sendai Medical Center, Sendai, Japan
| | - Naoya Minami
- Department of Neurology, Hokkaido Medical Center, Sapporo, Japan
| | - Akiyuki Uzawa
- Department of Neurology, Chiba University Graduate School of Medicine, Chiba, Japan
| | | | - Masayuki Masuda
- Department of Neurology, Tokyo Medical University, Tokyo, Japan
| | - Shingo Konno
- Department of Neurology, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Hidekazu Suzuki
- Department of Neurology, Kinki University School of Medicine, Osaka, Japan
| | - Tetsuya Akaishi
- Department of Neurology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masashi Aoki
- Department of Neurology, Tohoku University Graduate School of Medicine, Sendai, Japan
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Immature Exosomes Derived from MicroRNA-146a Overexpressing Dendritic Cells Act as Antigen-Specific Therapy for Myasthenia Gravis. Inflammation 2018; 40:1460-1473. [PMID: 28523463 DOI: 10.1007/s10753-017-0589-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Myasthenia gravis (MG) is a neurological autoimmune disease characterized by fluctuating weakness of certain voluntary muscles. Current treatments for MG are largely directed at suppressing the whole immune system by using immunosuppressants or glucocorticoids and often cause several side effects. The ideal therapeutic methods for MG should suppress aberrant immunoactivation specifically, while retaining normal function of the immune system. In this study, we first produced exosomes from microRNA-146a overexpressing dendritic cells (DCs). Then, we observed suppressive effects of those exosomes in experimental autoimmune myasthenia gravis (EAMG) mice. Results showed that exosomes from microRNA-146a overexpressing DCs expressed decreased levels of CD80 and CD86. In experimental autoimmune MG, exosomes from microRNA-146a overexpressing DCs suppressed ongoing clinical MG in mice and altered T helper cell profiles from Th1/Th17 to Th2/Treg both in serum and spleen, and the therapeutic effects of those exosomes were antigen-specific and partly dose dependent. All the findings provide experimental basis for antigen-specific therapy of MG.
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15
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Murai H, Utsugisawa K, Nagane Y, Suzuki S, Imai T, Motomura M. Rationale for the clinical guidelines for myasthenia gravis in Japan. Ann N Y Acad Sci 2018; 1413:35-40. [PMID: 29377151 DOI: 10.1111/nyas.13544] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 10/09/2017] [Accepted: 10/10/2017] [Indexed: 11/29/2022]
Abstract
According to the 2014 Japanese clinical guidelines for myasthenia gravis, the most important priority in treatment is maintaining patients' health-related quality of life. Therefore, the initial treatment goal is defined as maintaining a postintervention status of minimal manifestations or better (according to the Myasthenia Gravis Foundation of America classification) with an oral prednisolone dose of 5 mg/day or less. Every effort should be made to attain this level as rapidly as possible. To achieve this goal, the guidelines recommend minimizing the oral prednisolone dose, starting calcineurin inhibitors early in the course of treatment, using intravenous methylprednisolone infusion judiciously (often combined with plasma exchange/plasmapheresis or intravenous immunoglobulin), and effectively treating patients with an early, fast-acting treatment strategy. The early, fast-acting treatment strategy enables more frequent and earlier attainment of the initial goal than other strategies. Thymectomy is considered an option for treating nonthymomatous early-onset myasthenia gravis in patients with antiacetylcholine receptor antibodies and thymic hyperplasia in the early stages of the disease.
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Affiliation(s)
- Hiroyuki Murai
- Department of Neurology, School of Medicine, International University of Health and Welfare, Narita, Japan
| | | | - Yuriko Nagane
- Department of Neurology, Hanamaki General Hospital, Hanamaki, Japan
| | - Shigeaki Suzuki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Tomihiro Imai
- Department of Occupational Therapy, Sapporo Medical University School of Health Sciences, Sapporo, Japan
| | - Masakatsu Motomura
- Medical Engineering Course, Department of Engineering, The Faculty of Engineering, Nagasaki Institute of Applied Science, Nagasaki, Japan
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16
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Silvestri NJ, Wolfe GI. Start high, then go low: An effective strategy in the treatment of myasthenia gravis. Muscle Nerve 2017; 55:773-774. [DOI: 10.1002/mus.25654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 03/03/2017] [Accepted: 03/20/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Nicholas J. Silvestri
- Department of NeurologyUniversity at Buffalo Jacobs School of Medicine and Biomedical Sciences, State University of New York100 High StreetBuffalo New York14203 USA
| | - Gil I. Wolfe
- Department of NeurologyUniversity at Buffalo Jacobs School of Medicine and Biomedical Sciences, State University of New York100 High StreetBuffalo New York14203 USA
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Utsugisawa K, Nagane Y, Akaishi T, Suzuki Y, Imai T, Tsuda E, Minami N, Uzawa A, Kawaguchi N, Masuda M, Konno S, Suzuki H, Murai H, Aoki M. Early fast-acting treatment strategy against generalized myasthenia gravis. Muscle Nerve 2017; 55:794-801. [PMID: 27603432 PMCID: PMC5484288 DOI: 10.1002/mus.25397] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 08/31/2016] [Accepted: 09/05/2016] [Indexed: 11/10/2022]
Abstract
INTRODUCTION In this study we sought to clarify the effects of early fast-acting treatment (EFT) strategies on the time course for achieving the treatment target in generalized myasthenia gravis (MG). METHODS This retrospective study of 923 consecutive MG patients analyzed 688 generalized MG patients who had received immunotherapy during the disease course. The time to first achieve minimal manifestations (MM) or better while receiving prednisolone at ≤5 mg/day for ≥6 months (MM-or-better-5mg) up to 120 months after starting immunotherapy was compared between EFT and non-EFT patients. RESULTS Achievement of MM-or-better-5mg was more frequent and earlier in the EFT group (P = 0.0004, Wilcoxon test; P = 0.0001, log-rank test). Multivariate Cox regression analysis calculated a hazard ratio of 1.98 (P < 0.0001) for utilization of EFT. Dosing regimens of oral steroids in EFT produced no differences in the time course. CONCLUSIONS EFT strategies are advantageous for early achievement of MM-or-better-5mg. Muscle Nerve 55: 794-801, 2017.
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Affiliation(s)
- Kimiaki Utsugisawa
- Department of Neurology, Hanamaki General Hospital, 4-28, Kajoh-chou, Hanamaki, 025-0075, Japan
| | - Yuriko Nagane
- Department of Neurology, Hanamaki General Hospital, 4-28, Kajoh-chou, Hanamaki, 025-0075, Japan
| | - Tetsuya Akaishi
- Department of Neurology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasushi Suzuki
- Department of Neurology, Sendai Medical Center, Sendai, Japan
| | - Tomihiro Imai
- Department of Neurology, Sapporo Medical University Hospital, Sapporo, Japan
| | - Emiko Tsuda
- Department of Neurology, Sapporo Medical University Hospital, Sapporo, Japan
| | - Naoya Minami
- Department of Neurology, Hokkaido Medical Center, Sapporo, Japan
| | - Akiyuki Uzawa
- Department of Neurology, Chiba University School of Medicine, Chiba, Japan
| | | | - Masayuki Masuda
- Department of Neurology, Tokyo Medical University, Tokyo, Japan
| | - Shingo Konno
- Department of Neurology, Toho University Oh-hashi Medical Center, Tokyo, Japan
| | - Hidekazu Suzuki
- Department of Neurology, Kinki University School of Medicine, Osaka, Japan
| | - Hiroyuki Murai
- Department of Neurological therapeutics, Kyushu University Graduate School of Medicine, Fukuoka, Japan
| | - Masashi Aoki
- Department of Neurology, Tohoku University Graduate School of Medicine, Sendai, Japan
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18
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Maintenance immunosuppression in myasthenia gravis. J Neurol Sci 2016; 369:294-302. [DOI: 10.1016/j.jns.2016.08.057] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 07/20/2016] [Accepted: 08/26/2016] [Indexed: 11/17/2022]
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Manning E, Goldstein JM. Myasthenia Gravis in the Elderly: Differential Diagnosis and Management. CURRENT GERIATRICS REPORTS 2016. [DOI: 10.1007/s13670-016-0170-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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20
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Late-onset myasthenia gravis is predisposed to become generalized in the elderly. eNeurologicalSci 2016; 2:17-20. [PMID: 29473057 PMCID: PMC5818137 DOI: 10.1016/j.ensci.2016.02.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Revised: 02/08/2016] [Accepted: 02/10/2016] [Indexed: 11/23/2022] Open
Abstract
Objective The continuous increase in the number of patients presenting with late-onset myasthenia gravis (LOMG) underscores the need for a better understanding of the clinical course and the establishment of an optimal therapeutic strategy. We aimed to clarify factors associated with clinical outcomes in LOMG. Methods We retrospectively reviewed the clinical profiles of 40 patients with early-onset MG (EOMG) (onset age: 49 years or younger), 30 patients with non-elderly LOMG (onset age: 50–64 years), and 28 patients with elderly LOMG (onset age: 65 years or older) and compared the subgroups according to onset age and thymus status. The evaluated parameters were MGFA classification before treatment, MG-ADL score, complicating diseases, antibody titer, treatment, and MGFA post-intervention status. Results Elderly LOMG patients showed transition to generalized symptoms at a higher frequency and underwent thymectomy less frequently than EOMG and non-elderly LOMG patients (p < 0.001). The frequencies of crisis and plasmapheresis were significantly lower in thymectomized LOMG patients without thymoma than in thymectomized LOMG patients with thymoma or non-thymectomized LOMG patients (p < 0.01, P < 0.05, respectively). However, the outcome was not significantly different. All of the thymectomized LOMG patients without thymoma presenting with hyperplasia or thymic cyst had a favorable clinical course. Conclusions Our study showed that elderly LOMG patients are more prone to severity, suggesting that they require aggressive immunomodulatory therapy. Elderly LOMG patients showed transition to generalized symptoms at a higher frequency. Thymectomized LOMG patients without thymoma showed crisis less frequently. Our study showed that elderly LOMG patients are more prone to severity.
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Key Words
- AChR, acetylcholine receptor
- ChE-I, cholinesterase inhibitor
- Crisis
- DM, diabetes mellitus
- EOMG, early-onset myasthenia gravis
- Elderly
- Hyperplasia
- IVIg, intravenous immunoglobulin
- LOMG, late-onset myasthenia gravis
- Late-onset myasthenia gravis
- MG-ADL, myasthenia gravis activities of daily living score
- MGFA, Myasthenia Gravis Foundation of America
- PE, plasmapheresis
- PIS, MGFA post-intervention status
- PSL, prednisolone
- Steroid
- Thymectomy
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Utsugisawa K, Nagane Y, Imai T, Motomura M, Masuda M, Konno S, Suzuki S. Treatment of myasthenia gravis patients with calcineurin inhibitors in Japan: A retrospective analysis of outcomes. ACTA ACUST UNITED AC 2015. [DOI: 10.1111/cen3.12188] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | - Yuriko Nagane
- Department of Neurology; Hanamaki General Hospital; Hanamaki Japan
| | - Tomihiro Imai
- Sapporo Medical University School of Health Sciences; Sapporo Japan
| | - Masakatsu Motomura
- First Department of Internal Medicine; Graduate School of Biomedical Sciences; Nagasaki University; Nagasaki Japan
| | - Masayuki Masuda
- Department of Neurology; Tokyo Medical University; Tokyo Japan
| | - Shingo Konno
- Department of Neurology; Toho University Medical Center Oh-hashi Hospital; Tokyo Japan
| | - Shigeaki Suzuki
- Department of Neurology; Keio University School of Medicine; Tokyo Japan
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Abstract
Myasthenia gravis (MG) was first described in 17(th) century. It was after 1960s, when it became clear that MG was an autoimmune disease targeting AChR. Recently, anti-MuSK and anti-Lrp4 antibodies were found as novel antibodies in MG. In 1980s, in addition to cholinesterase inhibitors, high-dose corticosteroid treatment was introduced. This dramatically reduced the mortality rate of MG, but now we recognized that side effects of steroid have influenced patients significantly, and that high dose of steroid correlate with poor QOL. Since we have more means to treat MG at present, and also in the future, we should shift to the strategy in which steroid dose is kept low.
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Affiliation(s)
- Hiroyuki Murai
- Department of Neurology, Graduate School of Medical Sciences, Kyushu University
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