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Doneddu PE, Cocito D, Fazio R, Benedetti L, Peci E, Liberatore G, Falzone YM, Germano F, Gallia F, Giannotta C, Lleixà C, Bianchi E, Nobile-Orazio E. Prospective open-label trial with rituximab in patients with chronic inflammatory demyelinating polyradiculoneuropathy not responding to conventional immune therapies. J Neurol Neurosurg Psychiatry 2024:jnnp-2023-332844. [PMID: 38729746 DOI: 10.1136/jnnp-2023-332844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 02/13/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND To evaluate the efficacy of rituximab in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) patients not responding to conventional immune therapies. METHODS An open-label, prospective exploratory study was conducted with intravenous rituximab on 17 CIDP patients who had not responded to at least two first-line therapies. The primary endpoint was to determine the proportion of patients who showed improvement 6 months after rituximab therapy. The percentage of responders to rituximab, along with a 95% CI, was reported and compared with the 30% response rate after other immunosuppressive drugs previously documented in the literature. RESULTS 13 of the 17 treated patients (76.5%) showed improvement at 6 months (95% CI 50.1 to 93.2). Among the 14 patients who completed the 12-month follow-up (2 were lost to follow-up after showing improvement at months 8 and 10, and 1 deteriorated at 6 months), 13 (92.9%) demonstrated improvement at 12 months (95% CI 66.1 to 99.8). Nerve conduction parameters improved by at least 20% in two nerves in 6 out of 15 (40%) patients at 6 months and in 7 out of 13 (53.9%) at 12 months. None of the treated patients withdrew from the study due to side effects. There was a significant reduction of circulating CD19+ cells 15 days, 2, 6 and 12 months after treatment. CONCLUSION Rituximab seems to be a safe therapy in most patients with CIDP not responding to conventional immune therapies. The high percentage of patients who improved in this study suggests a possible positive effect of rituximab which is worth investigating in future randomised controlled clinical trials. TRIAL REGISTRATION NUMBER NCT05877040.
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Affiliation(s)
- Pietro Emiliano Doneddu
- Neuromuscular and Neuroimmunology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Dario Cocito
- Dipartimento Scienze Cliniche e Biologiche, Università di Torino, Torino, Italy
| | - Raffaella Fazio
- Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology (INSPE), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Erdita Peci
- Presidio Sanitario Major, Istituti Clinici Scientifici Maugeri, Torino, Italy
| | - Giuseppe Liberatore
- Neuromuscular and Neuroimmunology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Yuri Matteo Falzone
- Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology (INSPE), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Germano
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal Infantile Science (DINOGMI), Genoa University, Genova, Italy
| | - Francesca Gallia
- Neuromuscular and Neuroimmunology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Claudia Giannotta
- Neuromuscular and Neuroimmunology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Cinta Lleixà
- Department of Neurology, Neuromuscular Diseases Unit, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Elisa Bianchi
- Laboratorio di Malattie Neurologiche, Istituto di ricerche farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milano, Italy
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Zheng Y, Hu J, Sun C, Qiao K, Zhao Y, Liu B, Sun J, Xi J, Luo S, Lu J, Zhao C, Lin J. Insights into refractory chronic inflammatory demyelinating polyneuropathy: a comprehensive real-world study. Front Neurol 2024; 15:1326874. [PMID: 38356878 PMCID: PMC10865491 DOI: 10.3389/fneur.2024.1326874] [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: 11/24/2023] [Accepted: 01/15/2024] [Indexed: 02/16/2024] Open
Abstract
Background Refractory chronic inflammatory demyelinating polyneuropathy (CIDP) is a challenging subset of CIDP. It does not respond well to immune therapy and causes substantial disability. A comprehensive understanding of its clinical profile, electrophysiological characteristics and potential risk factors associated with refractoriness remains to be further elucidated. Methods Data in this cross-sectional study was collected and reviewed from the Huashan Peripheral Neuropathy Database (HSPN). Included patients were categorized into refractory CIDP and non-refractory CIDP groups based on treatment response. The clinical and electrophysiological characteristics were compared between refractory and non-refractory CIDP groups. Potential risk factors associated with refractory CIDP were explored with a multivariate logistic regression model. Results Fifty-eight patients with CIDP were included. Four disease course patterns of refractory CIDP are described: a relapsing-remitting form, a stable form, a secondary progressive form and a primary progressive form. Compared to non-refractory CIDP patients, refractory CIDP exhibited a longer disease duration (48.96 ± 33.72 vs. 28.33 ± 13.72 months, p = 0.038) and worse functional impairment (MRC sum score, 46.08 ± 12.69 vs. 52.81 ± 7.34, p = 0.018; mRS, 2.76 ± 0.93 vs. 2.33 ± 0.99, p = 0.082; INCAT, 3.68 ± 1.76 vs. 3.03 ± 2.28, p = 0.056, respectively). Electrophysiological studies further revealed greater axonal impairment (4.15 ± 2.0 vs. 5.94 ± 2.77 mv, p = 0.011, ulnar CMAP) and more severe demyelination (5.56 ± 2.86 vs. 4.18 ± 3.71 ms, p = 0.008, ulnar distal latency, 7.94 ± 5.62 vs. 6.52 ± 6.64 ms, p = 0.035, median distal latency; 30.21 ± 12.59 vs. 37.48 ± 12.44 m/s, p = 0.035, median conduction velocity; 58.66 ± 25.73 vs. 42.30 ± 13.77 ms, p = 0.033, median F-wave latency), compared to non-refractory CIDP. Disease duration was shown to be an independent risk factor for refractory CIDP (p < 0.05, 95%CI [0.007, 0.076]). Conclusion This study provided a comprehensive description of refractory CIDP, addressing its clinical features, classification of clinical course, electrophysiological characteristics, and prognostic factors, effectively elucidating its various aspects. These findings contribute to a better understanding of this challenging subset of CIDP and might be informative for management and treatment strategies.
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Affiliation(s)
- Yongsheng Zheng
- Department of Neurology, Huashan Hospital of Fudan University, Shanghai, China
- National Center for Neurological Disorders (NCND), Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital Fudan University, Shanghai, China
| | - Jianian Hu
- Department of Neurology, Huashan Hospital of Fudan University, Shanghai, China
- National Center for Neurological Disorders (NCND), Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital Fudan University, Shanghai, China
| | - Chong Sun
- Department of Neurology, Huashan Hospital of Fudan University, Shanghai, China
- National Center for Neurological Disorders (NCND), Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital Fudan University, Shanghai, China
| | - Kai Qiao
- Department of Neurology, Huashan Hospital of Fudan University, Shanghai, China
| | - Yanyin Zhao
- Department of Neurology, Huashan Hospital of Fudan University, Shanghai, China
- National Center for Neurological Disorders (NCND), Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital Fudan University, Shanghai, China
| | - Bingyou Liu
- Department of Neurology, Huashan Hospital of Fudan University, Shanghai, China
| | - Jian Sun
- Department of Neurology, Huashan Hospital of Fudan University, Shanghai, China
| | - Jianying Xi
- Department of Neurology, Huashan Hospital of Fudan University, Shanghai, China
- National Center for Neurological Disorders (NCND), Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital Fudan University, Shanghai, China
| | - Sushan Luo
- Department of Neurology, Huashan Hospital of Fudan University, Shanghai, China
- National Center for Neurological Disorders (NCND), Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital Fudan University, Shanghai, China
| | - Jiahong Lu
- Department of Neurology, Huashan Hospital of Fudan University, Shanghai, China
| | - Chongbo Zhao
- Department of Neurology, Huashan Hospital of Fudan University, Shanghai, China
- National Center for Neurological Disorders (NCND), Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital Fudan University, Shanghai, China
| | - Jie Lin
- Department of Neurology, Huashan Hospital of Fudan University, Shanghai, China
- National Center for Neurological Disorders (NCND), Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital Fudan University, Shanghai, China
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Liu B, Hu J, Sun C, Qiao K, Xi J, Zheng Y, Sun J, Luo S, Zhao Y, Lu J, Lin J, Zhao C. Effectiveness and safety of rituximab in autoimmune nodopathy: a single-center cohort study. J Neurol 2023; 270:4288-4295. [PMID: 37195346 DOI: 10.1007/s00415-023-11759-2] [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: 03/02/2023] [Revised: 04/29/2023] [Accepted: 05/02/2023] [Indexed: 05/18/2023]
Abstract
Autoimmune nodopathy is a peripheral neuropathy characterized by acquired motor and sensory deficit with autoantibodies against the node of Ranvier or paranodal region in the peripheral nervous system. The clinical and pathological characteristics of the disease are distinct from that of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), and the standard treatment for CIDP is partially effective. Rituximab is a chimeric monoclonal antibody which binds and depletes B cells in peripheral blood. This prospective observational study included 19 patients with autoimmune nodopathy. Participants received intravenous rituximab treatment 100 mg the first day and 500 mg the next day and given every 6 months. The Inflammatory Neuropathy Cause and Treatment (INCAT) disability score, Inflammatory Rasch-Built Overall Disability Scale (I-RODS), Medical Research Council (MRC) sum score, and Neuropathy Impairment Score (NIS) were collected at entry and before the rituximab infusion every 6 months. At the last visit, 94.7% (18/19) of the patients showed clinical improvement on either the INCAT, I-RODS, MRC, or NIS scale. After the first infusion, 9 patients (47.7%) showed improvement on the INCAT score, and 11 patients (57.9%) on cI-RODS. In patients who received more than one rituximab infusion, the improvement of INCAT score and cI-RODS at the last assessment was higher than that after the first infusion. We also observed tapered or withdrawn concomitant oral medications in these patients.
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Affiliation(s)
- Bingyou Liu
- Department of Neuology, Huashan Hospital, Fudan University, Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Jianian Hu
- Department of Neuology, Huashan Hospital, Fudan University, Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Chong Sun
- Department of Neuology, Huashan Hospital, Fudan University, Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Kai Qiao
- Department of Neuology, Huashan Hospital, Fudan University, Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Jianying Xi
- Department of Neuology, Huashan Hospital, Fudan University, Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Yongsheng Zheng
- Department of Neuology, Huashan Hospital, Fudan University, Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Jian Sun
- Department of Neuology, Huashan Hospital, Fudan University, Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Sushan Luo
- Department of Neuology, Huashan Hospital, Fudan University, Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Yanyin Zhao
- Department of Neuology, Huashan Hospital, Fudan University, Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Jiahong Lu
- Department of Neuology, Huashan Hospital, Fudan University, Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Jie Lin
- Department of Neuology, Huashan Hospital, Fudan University, Shanghai, China.
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China.
- National Center for Neurological Disorders, Shanghai, China.
| | - Chongbo Zhao
- Department of Neuology, Huashan Hospital, Fudan University, Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
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Briani C, Cocito D, Campagnolo M, Doneddu PE, Nobile-Orazio E. Update on therapy of chronic immune-mediated neuropathies. Neurol Sci 2022; 43:605-614. [PMID: 33452933 DOI: 10.1007/s10072-020-04998-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/12/2020] [Indexed: 12/27/2022]
Abstract
Chronic immune-mediated neuropathies, including chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), neuropathies associated with monoclonal gammopathy, and multifocal motor neuropathy (MMN), are a group of disorders deemed to be caused by an immune response against peripheral nerve antigens. Several immune therapies have been reported to be variably effective in these neuropathies including steroids, plasma exchange, and high-dose intravenous (IVIg) or subcutaneous (SCIg) immunoglobulins. These therapies are however far from being invariably effective and may be associated with a number of side effects leading to the use of immunosuppressive agents whose efficacy has not been so far confirmed in randomized trials. More recently, new biological agents, such as rituximab, have proved to be effective in patients with neuropathy associated with IgM monoclonal gammopathy and are currently tested in CIDP.
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Affiliation(s)
- Chiara Briani
- Neurology Unit, Department of Neuroscience, University of Padova, Via Giustiniani, 5, 35128, Padova, Italy.
| | - Dario Cocito
- Istituti Clinici Scientifici Maugeri, Torino, Italy
| | - Marta Campagnolo
- Neurology Unit, Department of Neuroscience, University of Padova, Via Giustiniani, 5, 35128, Padova, Italy
| | - Pietro Emiliano Doneddu
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical and Research Institute, Rozzano, Milan, Italy
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical and Research Institute, Rozzano, Milan, Italy.,Department of Medical Biotechnology and Translational Medicine, Milan University, Milan, Italy
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5
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Van den Bergh PYK, van Doorn PA, Hadden RDM, Avau B, Vankrunkelsven P, Allen JA, Attarian S, Blomkwist-Markens PH, Cornblath DR, Eftimov F, Goedee HS, Harbo T, Kuwabara S, Lewis RA, Lunn MP, Nobile-Orazio E, Querol L, Rajabally YA, Sommer C, Topaloglu HA. European Academy of Neurology/Peripheral Nerve Society guideline on diagnosis and treatment of chronic inflammatory demyelinating polyradiculoneuropathy: Report of a joint Task Force-Second revision. Eur J Neurol 2021; 28:3556-3583. [PMID: 34327760 DOI: 10.1111/ene.14959] [Citation(s) in RCA: 164] [Impact Index Per Article: 54.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To revise the 2010 consensus guideline on chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). METHODS Seventeen disease experts, a patient representative, and two Cochrane methodologists constructed 12 Population/Intervention/Comparison/Outcome (PICO) questions regarding diagnosis and treatment to guide the literature search. Data were extracted and summarized in GRADE summary of findings (for treatment PICOs) or evidence tables (for diagnostic PICOs). RESULTS Statements were prepared according to the GRADE Evidence-to-Decision frameworks. Typical CIDP and CIDP variants were distinguished. The previous term "atypical CIDP" was replaced by "CIDP variants" because these are well characterized entities (multifocal, focal, distal, motor, or sensory CIDP). The levels of diagnostic certainty were reduced from three (definite, probable, possible CIDP) to only two (CIDP and possible CIDP), because the diagnostic accuracy of criteria for probable and definite CIDP did not significantly differ. Good Practice Points were formulated for supportive criteria and investigations to be considered to diagnose CIDP. The principal treatment recommendations were: (a) intravenous immunoglobulin (IVIg) or corticosteroids are strongly recommended as initial treatment in typical CIDP and CIDP variants; (b) plasma exchange is strongly recommended if IVIg and corticosteroids are ineffective; (c) IVIg should be considered as first-line treatment in motor CIDP (Good Practice Point); (d) for maintenance treatment, IVIg, subcutaneous immunoglobulin or corticosteroids are recommended; (e) if the maintenance dose of any of these is high, consider either combination treatments or adding an immunosuppressant or immunomodulatory drug (Good Practice Point); and (f) if pain is present, consider drugs against neuropathic pain and multidisciplinary management (Good Practice Point).
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Affiliation(s)
- Peter Y K Van den Bergh
- Neuromuscular Reference Centre, Department of Neurology, University Hospital Saint-Luc, Brussels, Belgium
| | - Pieter A van Doorn
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | - Bert Avau
- Cochrane Belgium, CEBAM, Leuven, Belgium and CEBaP, Belgian Red Cross, Mechelen, Belgium
| | | | - Jeffrey A Allen
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shahram Attarian
- Centre de Référence des Maladies Neuromusculaires et de la SLA, APHM, CHU Timone, Marseille, France
| | | | - David R Cornblath
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Filip Eftimov
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - H Stephan Goedee
- Department of Neuromuscular Disorders, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Thomas Harbo
- Department of Neurology, Århus University Hospital, Århus, Denmark
| | - Satoshi Kuwabara
- Department of Neurology, Chiba University Hospital, Chiba, Japan
| | - Richard A Lewis
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michael P Lunn
- Department of Neurology and MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical and Research Center, Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Luis Querol
- Neuromuscular Diseases Unit-Neurology Department, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
| | - Yusuf A Rajabally
- Regional Neuromuscular Service, Neurology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Claudia Sommer
- Neurology Clinic, University Hospital Würzburg, Würzburg, Germany
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6
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Hu J, Sun C, Lu J, Zhao C, Lin J. Efficacy of rituximab treatment in chronic inflammatory demyelinating polyradiculoneuropathy: a systematic review and meta-analysis. J Neurol 2021; 269:1250-1263. [PMID: 34120208 DOI: 10.1007/s00415-021-10646-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/01/2021] [Accepted: 06/03/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Current standard treatment in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) has been proved effective, but it is poorly effective in refractory patients and unclear for anti-IgG4 antibody-associated CIDP. Rituximab is a B cell-depleting monoclonal antibody. It has been applied as one of the management strategies in CIDP, but its efficacy is unknown. OBJECTIVE To perform a systematic review and a meta-analysis of the efficacy of rituximab treatment in CIDP patients. METHODS Through searches in MEDLINE, PubMed, EMBASE, BIOSOS, Web of Science, and Cochrane library on March 31st, 2021, 15 studies were identified. Patients' characteristics, treatment regime and outcome measure were extracted. RESULTS Ninety-six patients in 15 studies were included. The pooled estimate of responsiveness was 75% (95% CI 72-78%). The standard mean difference (SMD) of Inflammatory Neuropathy Cause and Treatment (INCAT) disability score improvement was 1.7 (95% CI 1.0-2.3, p value < 0.0001) and the Medical Research Council (MRC) score for muscle power is 1.3 (95% CI - 2.6 to - 0.1, p value 0.04). All of the anti-IgG4 antibody-positive patients showed excellent responses to rituximab treatment. CONCLUSION Rituximab was effective in the treatment in CIDP patients, especially in anti-IgG4 antibody-positive patients. Randomized clinical trials are needed to determine the effectiveness and safety of rituximab in CIDP patients.
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Affiliation(s)
- Jianian Hu
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Middle Wulumuqi Road, Shanghai, 200040, China
| | - Chong Sun
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Middle Wulumuqi Road, Shanghai, 200040, China
| | - Jiahong Lu
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Middle Wulumuqi Road, Shanghai, 200040, China
| | - Chongbo Zhao
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Middle Wulumuqi Road, Shanghai, 200040, China
| | - Jie Lin
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Middle Wulumuqi Road, Shanghai, 200040, China.
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7
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Van den Bergh PYK, van Doorn PA, Hadden RDM, Avau B, Vankrunkelsven P, Allen JA, Attarian S, Blomkwist-Markens PH, Cornblath DR, Eftimov F, Goedee HS, Harbo T, Kuwabara S, Lewis RA, Lunn MP, Nobile-Orazio E, Querol L, Rajabally YA, Sommer C, Topaloglu HA. European Academy of Neurology/Peripheral Nerve Society guideline on diagnosis and treatment of chronic inflammatory demyelinating polyradiculoneuropathy: Report of a joint Task Force-Second revision. J Peripher Nerv Syst 2021; 26:242-268. [PMID: 34085743 DOI: 10.1111/jns.12455] [Citation(s) in RCA: 159] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 12/14/2022]
Abstract
To revise the 2010 consensus guideline on chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Seventeen disease experts, a patient representative, and two Cochrane methodologists constructed 12 Population/Intervention/Comparison/Outcome (PICO) questions regarding diagnosis and treatment to guide the literature search. Data were extracted and summarized in GRADE summary of findings (for treatment PICOs) or evidence tables (for diagnostic PICOs). Statements were prepared according to the GRADE Evidence-to-Decision frameworks. Typical CIDP and CIDP variants were distinguished. The previous term "atypical CIDP" was replaced by "CIDP variants" because these are well characterized entities (multifocal, focal, distal, motor, or sensory CIDP). The levels of diagnostic certainty were reduced from three (definite, probable, possible CIDP) to only two (CIDP and possible CIDP), because the diagnostic accuracy of criteria for probable and definite CIDP did not significantly differ. Good Practice Points were formulated for supportive criteria and investigations to be considered to diagnose CIDP. The principal treatment recommendations were: (a) intravenous immunoglobulin (IVIg) or corticosteroids are strongly recommended as initial treatment in typical CIDP and CIDP variants; (b) plasma exchange is strongly recommended if IVIg and corticosteroids are ineffective; (c) IVIg should be considered as first-line treatment in motor CIDP (Good Practice Point); (d) for maintenance treatment, IVIg, subcutaneous immunoglobulin or corticosteroids are recommended; (e) if the maintenance dose of any of these is high, consider either combination treatments or adding an immunosuppressant or immunomodulatory drug (Good Practice Point); and (f) if pain is present, consider drugs against neuropathic pain and multidisciplinary management (Good Practice Point).
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Affiliation(s)
- Peter Y K Van den Bergh
- Neuromuscular Reference Centre, Department of Neurology, University Hospital Saint-Luc, Brussels, Belgium
| | - Pieter A van Doorn
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | - Bert Avau
- Cochrane Belgium, CEBAM, Leuven, Belgium and CEBaP, Belgian Red Cross, Mechelen, Belgium
| | | | - Jeffrey A Allen
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shahram Attarian
- Centre de Référence des Maladies Neuromusculaires et de la SLA, APHM, CHU Timone, Marseille, France
| | | | - David R Cornblath
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Filip Eftimov
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - H Stephan Goedee
- Department of Neuromuscular Disorders, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Thomas Harbo
- Department of Neurology, Århus University Hospital, Århus, Denmark
| | - Satoshi Kuwabara
- Department of Neurology, Chiba University Hospital, Chiba, Japan
| | - Richard A Lewis
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michael P Lunn
- Department of Neurology and MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical and Research Center, Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Luis Querol
- Neuromuscular Diseases Unit-Neurology Department, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
| | - Yusuf A Rajabally
- Regional Neuromuscular Service, Neurology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Claudia Sommer
- Neurology Clinic, University Hospital Würzburg, Würzburg, Germany
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8
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Rituximab Treatment for Chronic Idiopathic Axonal Polyneuropathy. J Clin Neuromuscul Dis 2021; 22:214-219. [PMID: 34019006 DOI: 10.1097/cnd.0000000000000328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Chronic idiopathic axonal polyneuropathy is a disorder of unknown etiology resulting in progressive weakness and sensory disturbances predominantly in the hands and feet. Nerve conduction studies and electromyography confirm axonal damage in the nerves of the upper and lower extremities. The pathology is symmetrical with a distal predilection. Patients usually do not respond to the classical treatment with steroids, intravenous immunoglobulin, plasmapheresis, or immunosuppressant drugs. We describe 2 cases of chronic idiopathic axonal polyneuropathy who received intravenous rituximab as a last resort because of the severity of their symptoms. Both patients showed dramatic improvement in their weakness, muscle atrophy, numbness, and paresthesias only few weeks after the induction dose. Their daily functional activities improved to self-independence.
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Motte J, Fisse AL, Köse N, Grüter T, Mork H, Athanasopoulos D, Fels M, Otto S, Siglienti I, Schneider-Gold C, Hellwig K, Yoon MS, Gold R, Pitarokoili K. Treatment response to cyclophosphamide, rituximab, and bortezomib in chronic immune-mediated sensorimotor neuropathies: a retrospective cohort study. Ther Adv Neurol Disord 2021; 14:1756286421999631. [PMID: 33747132 PMCID: PMC7940507 DOI: 10.1177/1756286421999631] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 02/10/2021] [Indexed: 12/13/2022] Open
Abstract
Background: Up to 20% of patients with chronic immune-mediated sensorimotor neuropathies (CIN) do not respond adequately to first-line therapies. However, studies on further treatment are scarce. Methods: We analyzed retrospectively 200 CIN patients regarding disease characteristics and response to therapy with cyclophosphamide (CYP), rituximab (RTX), and bortezomib (BTZ). Treatment response was defined as improvement or stabilization of inflammatory neuropathy cause and treatment overall disability score (INCAT-ODSS). Results: A total of 48 of 181 patients (26.5%) received therapy with CYP, RTX, or BTZ. The most frequently and first used therapy was CYP (69%). More than 40% of patients needed a second or third treatment. Overall, 71 treatments were applied in 48 patients. The combination of up to all three treatments enhanced the response-rate to 90%. Treatment within 24 months after initial diagnosis resulted in significantly higher response rate than late treatment (79% versus 50 %, p = 0.04, χ2-test, n = 46) and in lower disability in long-term follow up (INCAT-ODSS 3.8 versus 5.8, p = 0.02, t-test, n = 48). Patients with Lewis-Sumner syndrome (n = 9) and autoantibody mediated neuropathies (n = 13) had excellent response rates after treatment with RTX (90–100%). In contrast, typical chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) showed a response rate of 64% in CYP, 64% in RTX, and 75% in BTZ. Conclusion: Treatment with CYP, RTX, or BTZ was effective in this cohort of CIN refractory to first-line treatment. Our data increase evidence for an early use of these therapies. High efficacy of RTX in Lewis-Sumner syndrome in contrast to typical CIDP suggests a distinct pathophysiology.
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Affiliation(s)
- Jeremias Motte
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, Bochum, 44791, Germany
| | - Anna Lena Fisse
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Nuray Köse
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Thomas Grüter
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Hannah Mork
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | | | - Miriam Fels
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Susanne Otto
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Ines Siglienti
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | | | - Kerstin Hellwig
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Min-Suk Yoon
- Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Kalliopi Pitarokoili
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
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10
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Fisse AL, Motte J, Grüter T, Sgodzai M, Pitarokoili K, Gold R. Comprehensive approaches for diagnosis, monitoring and treatment of chronic inflammatory demyelinating polyneuropathy. Neurol Res Pract 2020; 2:42. [PMID: 33324942 PMCID: PMC7722337 DOI: 10.1186/s42466-020-00088-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 09/04/2020] [Indexed: 02/08/2023] Open
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is the most common chronic inflammatory neuropathy. CIDP is diagnosed according to the European Federation of Neurological Societies/Peripheral Nerve Society (EFNS/PNS) criteria, which combine clinical features with the electrophysiological evidence of demyelination. However, firstly, diagnosis is challenging, as some patients e.g. with severe early axonal damage do not fulfil the criteria. Secondly, objective and reliable tools to monitor the disease course are lacking. Thirdly, about 25% of CIDP patients do not respond to evidence-based first-line therapy. Recognition of these patients is difficult and treatment beyond first-line therapy is based on observational studies and case series only. Individualized immunomodulatory treatment does not exist due to the lack of understanding of essential aspects of the underlying pathophysiology. Novel diagnostic imaging techniques and molecular approaches can help to solve these problems but do not find enough implementation. This review gives a comprehensive overview of novel diagnostic techniques and monitoring approaches for CIDP and how these can lead to individualized treatment and better understanding of pathophysiology.
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Affiliation(s)
- Anna Lena Fisse
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Jeremias Motte
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Thomas Grüter
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Melissa Sgodzai
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Kalliopi Pitarokoili
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
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11
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Dalakas MC, Alexopoulos H, Spaeth PJ. Complement in neurological disorders and emerging complement-targeted therapeutics. Nat Rev Neurol 2020; 16:601-617. [PMID: 33005040 PMCID: PMC7528717 DOI: 10.1038/s41582-020-0400-0] [Citation(s) in RCA: 134] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2020] [Indexed: 12/30/2022]
Abstract
The complement system consists of a network of plasma and membrane proteins that modulate tissue homeostasis and contribute to immune surveillance by interacting with the innate and adaptive immune systems. Dysregulation, impairment or inadvertent activation of complement components contribute to the pathogenesis of some autoimmune neurological disorders and could even contribute to neurodegenerative diseases. In this Review, we summarize current knowledge about the main functions of the complement pathways and the involvement of complement in neurological disorders. We describe the complex network of complement proteins that target muscle, the neuromuscular junction, peripheral nerves, the spinal cord or the brain and discuss the autoimmune mechanisms of complement-mediated myopathies, myasthenia, peripheral neuropathies, neuromyelitis and other CNS disorders. We also consider the emerging role of complement in some neurodegenerative diseases, such as Alzheimer disease, amyotrophic lateral sclerosis and even schizophrenia. Finally, we provide an overview of the latest complement-targeted immunotherapies including monoclonal antibodies, fusion proteins and peptidomimetics that have been approved, that are undergoing phase I–III clinical trials or that show promise for the treatment of neurological conditions that respond poorly to existing immunotherapies. In this Review, Dalakas et al. discuss the complement system, the role it plays in autoimmune neurological disease and neurodegenerative disease, and provide an overview of the latest therapeutics that target complement and that can be used for or have potential in neurological disorders. Complement has an important physiological role in host immune defences and tissue remodelling. The physiological role of complement extends to the regulation of synaptic development. Complement has a key pathophysiological role in autoimmune neurological diseases and mediates the actions of pathogenic autoantibodies, such as acetylcholine receptor antibodies and aquaporin 4 antibodies. For some autoimmune neurological diseases, such as myasthenia gravis and neuromyelitis optica spectrum disorders, approved complement-targeted treatments are now available. Complement also seems to be of pathogenic relevance in neurodegenerative diseases such as Alzheimer disease, in which innate immune-driven inflammation is receiving increasing attention. The field of complement-targeted therapeutics is rapidly expanding, with several FDA-approved agents and others currently in phase II and phase III clinical trials.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA. .,Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
| | - Harry Alexopoulos
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Peter J Spaeth
- Institute of Pharmacology, University of Bern, Bern, Switzerland
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12
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Shimizu S, Iijima M, Fukami Y, Tamura N, Nakatochi M, Ando M, Nishi R, Koike H, Kaida K, Koga M, Kanda T, Ogata H, Kira JI, Mori M, Kuwabara S, Katsuno M. Efficacy and Safety of Rituximab in Refractory CIDP With or Without IgG4 Autoantibodies (RECIPE): Protocol for a Double-Blind, Randomized, Placebo-Controlled Clinical Trial. JMIR Res Protoc 2020; 9:e17117. [PMID: 32234705 PMCID: PMC7160709 DOI: 10.2196/17117] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 01/27/2020] [Accepted: 01/27/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an immune-mediated peripheral neuropathy that is currently classified into several clinical subtypes, which are presumed to have different pathogenic mechanisms. Recently, studies identified a subgroup of patients with CIDP who were positive for IgG4 autoantibodies against paranodal proteins, such as neurofascin-155 and contactin-1, who respond poorly to first-line therapies for typical CIDP, including intravenous immunoglobulin therapy. OBJECTIVE This study aims to evaluate the efficacy and safety of intravenous rituximab according to IgG4 autoantibody status in patients with refractory CIDP. METHODS The Evaluation of the Efficacy and Safety of Rituximab in Refractory CIDP Patients with IgG4 Autoantibodies in the Exploratory Clinical (RECIPE) trial consists of 2 cohorts: a multicenter, placebo-controlled, randomized study cohort of 15 patients with IgG4 autoantibody-positive CIDP (rituximab:placebo = 2:1) and an open-label trial cohort of 10 patients with antibody-negative CIDP. The primary endpoint is improvement in functional outcome assessed using the adjusted Inflammatory Neuropathy Cause and Treatment Disability Scale score at 26, 38, or 52 weeks after the start of treatment with rituximab in patients with CIDP and anti-paranodal protein antibodies. Secondary outcome measures include grip strength, manual muscle testing sum scores, results of nerve conduction studies, and other functional scales. RESULTS We plan to enroll 25 cases for the full analysis set. Recruitment is ongoing, with 14 patients enrolled as of January 2020. Enrollment will close in September 2020, and the study is planned to end in December 2021. CONCLUSIONS This randomized controlled trial will determine if rituximab is safe and effective in patients with anti-paranodal antibodies. An open-label study will provide additional data on the effects of rituximab in patients with antibody-negative CIDP. The results of the RECIPE trial are expected to provide evidence for the positioning of rituximab as a pathogenesis-based therapeutic for refractory CIDP. TRIAL REGISTRATION ClinicalTrials.gov NCT03864185, https://clinicaltrials.gov/ct2/show/NCT03864185 ; The Japan Registry of Clinical Trials jRCT2041180037, https://jrct.niph.go.jp/en-latest-detail/jRCT2041180037. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/17117.
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Affiliation(s)
- Shinobu Shimizu
- Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Masahiro Iijima
- Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan.,Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuki Fukami
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Natsuko Tamura
- Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan.,Center for Integrated Medical Research, Hiroshima University Hospital, Hiroshima, Japan
| | - Masahiro Nakatochi
- Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan.,Department of Nursing, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahiko Ando
- Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Ryoji Nishi
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kenichi Kaida
- Department of Neurology, Anti-aging and Vascular Medicine, National Defense Medical College, Tokorozawa, Japan
| | - Michiaki Koga
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Takashi Kanda
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Hidenori Ogata
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Jun-Ichi Kira
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masahiro Mori
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Satoshi Kuwabara
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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13
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Di Stefano V, Barbone F, Ferrante C, Telese R, Vitale M, Onofrj M, Di Muzio A. Inflammatory polyradiculoneuropathies: Clinical and immunological aspects, current therapies, and future perspectives. EUR J INFLAMM 2020. [DOI: 10.1177/2058739220942340] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Inflammatory polyradiculoneuropathies are heterogeneous disorders characterized by immune-mediated leukocyte infiltration of peripheral nerves and nerve roots leading to demyelination or axonal degeneration or both. Inflammatory polyradiculoneuropathies can be divided into acute and chronic: Guillain–Barré syndrome and chronic inflammatory demyelinating polyneuropathy and their variants. Despite major advances in immunology and molecular biology have been made in the last years, the pathogenesis of these disorders is not completely understood. This review summarizes the current literature of the clinical features and pathogenic mechanisms of inflammatory polyradiculoneuropathies and focuses on current therapies and new potential treatment for the future.
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Affiliation(s)
- Vincenzo Di Stefano
- Department of Neurosciences, Imaging and Clinical Sciences, “G. d’Annunzio” University, Chieti, Italy
| | - Filomena Barbone
- Department of Neurosciences, Imaging and Clinical Sciences, “G. d’Annunzio” University, Chieti, Italy
| | - Camilla Ferrante
- Department of Neurosciences, Imaging and Clinical Sciences, “G. d’Annunzio” University, Chieti, Italy
| | - Roberta Telese
- Department of Neurosciences, Imaging and Clinical Sciences, “G. d’Annunzio” University, Chieti, Italy
| | - Michela Vitale
- Department of Neurosciences, Imaging and Clinical Sciences, “G. d’Annunzio” University, Chieti, Italy
| | - Marco Onofrj
- Department of Neurosciences, Imaging and Clinical Sciences, “G. d’Annunzio” University, Chieti, Italy
| | - Antonio Di Muzio
- Department of Neurology, “SS. Annunziata” Hospital, Chieti, Italy
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14
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Koike H, Nishi R, Ikeda S, Kawagashira Y, Iijima M, Katsuno M, Sobue G. Ultrastructural mechanisms of macrophage-induced demyelination in CIDP. Neurology 2018; 91:1051-1060. [PMID: 30429275 DOI: 10.1212/wnl.0000000000006625] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 07/18/2018] [Indexed: 11/15/2022] Open
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is a form of chronic neuropathy that is presumably caused by heterogeneous immune-mediated processes. Recent advances in the search for autoantibodies against components expressed at nodal regions, such as the nodes of Ranvier and paranodes, have substantially contributed to clarifying the pathogenesis of CIDP in a subpopulation of patients. In particular, immunoglobulin G4 (IgG4) antibodies to paranodal junction proteins, including neurofascin-155 and contactin-1, have attracted the attention of researchers. Paranodal dissection resulting from the attachment of IgG4 at paranodal junctions and the absence of macrophage-induced demyelination are characteristic pathologic features in patients who have these antibodies. By contrast, the mechanisms of neuropathy in cases with classical macrophage-induced demyelination remain unclear despite the long-standing recognition of this process in CIDP. In addition to complement-dependent damage provoked by autoantibodies, recent studies have shed light on antibody-dependent phagocytosis by macrophages without participation of complements. However, a direct association between specific autoantibodies and macrophage-induced demyelination has not been reported. Electron microscopic examination of longitudinal sections of sural nerve biopsy specimens suggested that macrophages recognize specific sites of myelinated fibers as the initial target of demyelination. The site that macrophages select to initiate myelin breakdown is located around the nodal regions in some patients and internode in others. Hence, it seems that the components that distinguish between the nodal regions and internode play a pivotal role in the behavior of macrophages that initiate phagocytosis of myelin. Further studies are needed to elucidate the mechanisms underlying macrophage-induced demyelination from this perspective.
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Affiliation(s)
- Haruki Koike
- From the Department of Neurology (H.K., R.N., S.I., Y.K., M.I., M.K., G.S.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan.
| | - Ryoji Nishi
- From the Department of Neurology (H.K., R.N., S.I., Y.K., M.I., M.K., G.S.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Shohei Ikeda
- From the Department of Neurology (H.K., R.N., S.I., Y.K., M.I., M.K., G.S.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Yuichi Kawagashira
- From the Department of Neurology (H.K., R.N., S.I., Y.K., M.I., M.K., G.S.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Masahiro Iijima
- From the Department of Neurology (H.K., R.N., S.I., Y.K., M.I., M.K., G.S.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Masahisa Katsuno
- From the Department of Neurology (H.K., R.N., S.I., Y.K., M.I., M.K., G.S.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Gen Sobue
- From the Department of Neurology (H.K., R.N., S.I., Y.K., M.I., M.K., G.S.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
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15
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Russo F, Vispi M, Bocci S, Mancini V, Sirna R, Giannini F, Pellegrino M. New onset psoriasis in a patient with chronic inflammatory demyelinating polyneuropathy treated with Rituximab. GIORN ITAL DERMAT V 2018; 155:802-803. [PMID: 30350559 DOI: 10.23736/s0392-0488.18.06180-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Filomena Russo
- Section of Dermatology, Department of Clinical Medicine and Immunological Science, University of Siena, Siena, Italy -
| | - Martina Vispi
- Section of Dermatology, Department of Dermatology, Misericordia Hospital, Grosseto, Italy
| | - Silvia Bocci
- Unit of Neurology and Clinical Neurophysiology, Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy
| | - Virginia Mancini
- Section of Pathology, Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - Riccardo Sirna
- Section of Dermatology, Department of Dermatology, Misericordia Hospital, Grosseto, Italy
| | - Fabio Giannini
- Unit of Neurology and Clinical Neurophysiology, Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy
| | - Michele Pellegrino
- Section of Dermatology, Department of Clinical Medicine and Immunological Science, University of Siena, Siena, Italy
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16
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Roux T, Debs R, Maisonobe T, Lenglet T, Delorme C, Louapre C, Leblond V, Viala K. Rituximab in chronic inflammatory demyelinating polyradiculoneuropathy with associated diseases. J Peripher Nerv Syst 2018; 23:235-240. [PMID: 30203907 DOI: 10.1111/jns.12287] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 09/03/2018] [Accepted: 09/06/2018] [Indexed: 11/29/2022]
Abstract
We aimed to analyse the response to rituximab in a cohort of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) patients with associated disorders. We conducted a clinical and electrophysiological retrospective monocentric study in 28 CIDP patients. Response to rituximab was defined as (a) a five-point increase in the Medical Research Council sum score or a one-point decrease in the Overall Neuropathy Limitations Scale score, compared to the score at the first rituximab infusion, or (b) the discontinuation of, or reduced need for, the last treatments before rituximab initiation. Twenty-one patients (75%) were responders to rituximab. The median time before response was 6 months (1-10 months). Only two patients needed to be treated again during a median follow-up of 2.0 years (0.75-9 years). Interestingly, the response rate was good in patients with associated autoimmune disease (5/8) and similar to the response rate observed in patients with a haematological disease (16/20) (P = 0.63). A shorter disease duration was associated with a better clinical response to rituximab (odds ratio 0.81, P = 0.025) and the response rate was better (P = 0.05) in common forms (83.3%) than in sensory forms (42.9%). No major adverse events were recorded. Rituximab is efficacious in CIDP patients with haematological or autoimmune disease. It improves clinical response and decreases dependence on first-line treatments.
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Affiliation(s)
- Thomas Roux
- Department of Clinical Neurophysiology, APHP, Pitié-Salpêtrière Hospital, Paris, France
| | - Rabab Debs
- Department of Clinical Neurophysiology, APHP, Pitié-Salpêtrière Hospital, Paris, France.,Medical School, Pierre et Marie Curie University-Paris VI, Paris, France
| | - Thierry Maisonobe
- Department of Clinical Neurophysiology, APHP, Pitié-Salpêtrière Hospital, Paris, France.,Medical School, Pierre et Marie Curie University-Paris VI, Paris, France
| | - Timothée Lenglet
- Department of Clinical Neurophysiology, APHP, Pitié-Salpêtrière Hospital, Paris, France.,Medical School, Pierre et Marie Curie University-Paris VI, Paris, France
| | - Cécile Delorme
- Department of Clinical Neurophysiology, APHP, Pitié-Salpêtrière Hospital, Paris, France.,Medical School, Pierre et Marie Curie University-Paris VI, Paris, France
| | - Céline Louapre
- Department of Neurology, APHP, Pitié-Salpêtrière Hospital, Paris, France
| | - Véronique Leblond
- Department of Haematology, APHP, Pitié-Salpêtrière Hospital, Paris, France
| | - Karine Viala
- Department of Clinical Neurophysiology, APHP, Pitié-Salpêtrière Hospital, Paris, France.,Medical School, Pierre et Marie Curie University-Paris VI, Paris, France
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17
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Huehnchen P, Boehmerle W, Endres M. Fingolimod therapy is not effective in a mouse model of spontaneous autoimmune peripheral polyneuropathy. Sci Rep 2018; 8:5648. [PMID: 29618748 PMCID: PMC5884804 DOI: 10.1038/s41598-018-23949-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 03/21/2018] [Indexed: 12/11/2022] Open
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an autoimmune disorder, which causes progressive sensory and motor deficits and often results in severe disability. Knockout of the co-stimulatory protein CD86 in mice of the non-obese diabetic background (NoD.129S4-Cd86tm1Shr/JbsJ) results in the development of a spontaneous autoimmune peripheral polyneuropathy (SAPP). We used this previously described transgenic model to study the effects of the sphingosine-1-phosphate receptor agonist fingolimod on SAPP symptoms, functional and electrophysiological characteristics. Compared to two control strains, knockout of CD86 in NOD mice (CD86−/− NOD) resulted in progressive paralysis with distinct locomotor deficits due to a severe sensory-motor axonal-demyelinating polyneuropathy as assessed by electrophysiological measurements. We started fingolimod treatment when CD86−/− NOD mice showed signs of unilateral hind limb weakness and continued at a dose of 1 mg/kg/day for eight weeks. We did not observe any beneficial effects of fingolimod regarding disease progression. In addition, fingolimod did not influence the functional outcome of CD86−/− NOD mice compared to vehicle treatment nor any of the electrophysiological characteristics. In summary, we show that fingolimod treatment has no beneficial effects in autoimmune polyneuropathy, which is in line with recent clinical data obtained in CIDP patients.
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Affiliation(s)
- Petra Huehnchen
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Klinik und Hochschulambulanz für Neurologie, Berlin, Germany. .,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Cluster of Excellence NeuroCure, Berlin, Germany. .,Berlin Institute of Health, 10178, Berlin, Germany.
| | - Wolfgang Boehmerle
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Klinik und Hochschulambulanz für Neurologie, Berlin, Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Cluster of Excellence NeuroCure, Berlin, Germany
| | - Matthias Endres
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Klinik und Hochschulambulanz für Neurologie, Berlin, Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Cluster of Excellence NeuroCure, Berlin, Germany.,Berlin Institute of Health, 10178, Berlin, Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Stroke Research Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany.,DZHK (German Center for Cardiovascular Research), partner site Berlin, Berlin, Germany
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Illa I. ARTHUR ASBURY LECTURE: Chronic inflammatory demyelinating polyradiculoneuropathy: clinical aspects and new animal models of auto-immunity to nodal components. J Peripher Nerv Syst 2017; 22:418-424. [DOI: 10.1111/jns.12237] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 10/20/2017] [Accepted: 10/20/2017] [Indexed: 12/28/2022]
Affiliation(s)
- Isabel Illa
- Unitat Neuromuscular Servei Neurología; Hospital Santa Creu i Sant Pau, Universitat Autònoma Barcelona, CIBERER; Barcelona Spain
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Rajabally YA. Unconventional treatments for chronic inflammatory demyelinating polyneuropathy. Neurodegener Dis Manag 2017; 7:331-342. [PMID: 29043889 DOI: 10.2217/nmt-2017-0017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
This article focuses on the unconventional treatments used in chronic inflammatory demyelinating polyneuropathy (CIDP). First line, evidence-based treatments for CIDP include corticosteroids, immunoglobulins and plasma exchanges. Several unproven treatments are however given in treatment-refractory disease or to reduce requirements in validated therapies for reasons of side effects/practical delivery/cost. Despite methodological issues, IFN-α, azathioprine and methotrexate have not been shown to be useful in randomized controlled trials. Cyclophosphamide, rituximab and, as final resort in highly selected cases, hematopoietic stem cell transplant may be options considered in severely disabled refractory patients. Debatably, azathioprine, methotrexate, cyclosporine and mycophenolate mofetil are still occasionally used, among others, in milder disease. Physical therapy may be of benefit in CIDP but is not systematically considered as an integral part of management strategies. Current literature relating to unconventional therapies in CIDP is reviewed here and the possible avenues that require consideration in severe refractory disease and less disabling forms are discussed.
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Affiliation(s)
- Yusuf A Rajabally
- School of Life & Health Sciences, Aston Brain Centre, Aston University, Birmingham, UK.,Regional Neuromuscular Clinic, University Hospitals Birmingham, Birmingham, UK
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Rajabally YA, Stettner M, Kieseier BC, Hartung HP, Malik RA. CIDP and other inflammatory neuropathies in diabetes — diagnosis and management. Nat Rev Neurol 2017; 13:599-611. [DOI: 10.1038/nrneurol.2017.123] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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