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Zhdanava M, Pesa J, Boonmak P, Cai Q, Pilon D, Choudhry Z, Souayah N. Economic burden of generalized myasthenia gravis (MG) in the United States and the impact of common comorbidities and acute MG-events. Curr Med Res Opin 2024; 40:1145-1153. [PMID: 38745448 DOI: 10.1080/03007995.2024.2353381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/05/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND This study assessed the incremental healthcare costs and resource utilization (HRU) associated with generalized myasthenia gravis (gMG), as well as variability in these outcomes among patients with gMG and common comorbidities and acute MG-related events. METHODS Adults with gMG and without MG were identified from a large US database (2017-2021). The index date was the first MG diagnosis (gMG cohort) or random date (non-MG cohort). Cohorts were propensity score matched 1:1. The gMG cohort included subgroups of patients with a 12-month pre-index (baseline) cardiometabolic or psychiatric comorbidity, or a post-index MG exacerbation/crisis. Monthly healthcare costs (2021 USD) and HRU were compared post-index between gMG and non-MG cohorts. RESULTS The gMG and matched non-MG cohorts each contained 2,739 patients. Mean incremental healthcare costs associated with MG were $4,155 (gMG: $5,567; non-MG: $1,411), with differences driven by incremental inpatient costs of $2,166 (gMG: $2,617; non-MG: $452); all p < 0.001. The gMG versus non-MG cohort had 4.36 times more inpatient admissions and 2.26 times more outpatient visits; all p < 0.001. Among patients with gMG in cardiometabolic (n = 1,859), psychiatric (n = 1,308), and exacerbation/crisis (n = 419) subgroups, mean monthly healthcare costs were $6,660, $7,443, and $17,330, respectively. CONCLUSIONS gMG is associated with substantial incremental costs and HRU, with inpatient costs driving the total incremental costs. Costs increased by 20% and 34% among patients with cardiometabolic and psychiatric conditions, respectively, and over three times among those with acute MG-related events. gMG is a complex disease requiring management of comorbidities and treatment options that can prevent acute symptomatic events.
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Affiliation(s)
| | - Jacqueline Pesa
- Janssen Scientific Affairs, LLC, a Johnson & Johnson Company, Titusville, NJ, USA
| | | | - Qian Cai
- Janssen Scientific Affairs, LLC, a Johnson & Johnson Company, Titusville, NJ, USA
| | | | - Zia Choudhry
- Janssen Scientific Affairs, LLC, a Johnson & Johnson Company, Titusville, NJ, USA
| | - Nizar Souayah
- Department of Neurology & Neurosciences, Rutgers-New Jersey Medical School, Newark, NJ, USA
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Di Stefano V, Iacono S, Militello M, Leone O, Rispoli MG, Ferri L, Ajdinaj P, Lanza P, Lupica A, Crescimanno G, Monastero R, Di Muzio A, Brighina F. Comorbidity in myasthenia gravis: multicentric, hospital-based, and controlled study of 178 Italian patients. Neurol Sci 2024; 45:3481-3494. [PMID: 38383750 PMCID: PMC11176220 DOI: 10.1007/s10072-024-07368-0] [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: 09/30/2023] [Accepted: 01/27/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Myasthenia gravis (MG) is an autoimmune disorder with fluctuating weakness that causes significant disability and morbidity. Comorbidities may influence the course of MG, particularly in specific subgroups. The aim of this study is to investigate the frequency of comorbidities in MG patients compared to healthy controls (HC) and to evaluate their distribution according to age at disease onset, sex, and disease severity. METHODS MG patients attending the University Hospital "Paolo Giaccone" in Palermo and "SS Annunziata" Hospital in Chieti were enrolled; HC were enrolled from the general population. Non-parametric statistics and logistic regression were used to assess the association of specific comorbidities according to age at disease onset, sex, disease subtypes, and severity of the disease. RESULTS A total of 356 subjects were included in the study: 178 MG patients (46% F; median age 60 years [51-71]) and 178 sex- and age-matched HC (46% F, median age 59 years [50-66]). Overall, 86% of MG patients and 76% of HC suffered from comorbidities, and MG patients had a higher number of comorbidities compared to HC. Patients with late-onset suffered from more comorbidities than those with early-onset MG. Hypertension was more common in male patients with MG, while thymic hyperplasia, osteoporosis, and autoimmune diseases were more common in females. Respiratory disorders and thymoma were more common in patients with more severe disease (p < 0.05 for all comparisons). CONCLUSION MG patients, particularly those with late onset, showed a higher prevalence of comorbidities than HC. Assessment of comorbidities in MG is an essential issue to identify the appropriate treatment and achieve the best management.
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Affiliation(s)
- Vincenzo Di Stefano
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy
| | - Salvatore Iacono
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy
| | - Massimiliano Militello
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy
| | - Olga Leone
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy
| | | | - Laura Ferri
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Paola Ajdinaj
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Placido Lanza
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy
| | - Antonino Lupica
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy
| | - Grazia Crescimanno
- Institute for Biomedical Research and Innovation, National Research Council of Italy, Palermo, Italy
| | - Roberto Monastero
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy.
| | - Antonio Di Muzio
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Filippo Brighina
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy
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Croitoru CG, Pavel-Tanasa M, Cuciureanu DI, Hodorog DN, Cianga P. Autoimmune and Non-Autoimmune Comorbidities in Myasthenic Patients of East-European Descent: A Case-Control Study. J Clin Med 2024; 13:2273. [PMID: 38673546 PMCID: PMC11051044 DOI: 10.3390/jcm13082273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 04/08/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024] Open
Abstract
Background: As the life expectancy of patients with myasthenia gravis (MG) is improving, so the number of comorbidities continues to rise, with a potentially significant impact on the overall morbidity and mortality. The main aim of the study was to assess comorbidities of MG in a group of patients of East-European descent. Methods: We retrospectively compared 185 adult myasthenic patients with 895 sex- and age-matched controls, admitted from January 2013 to December 2021. Results: Of these patients, 60% had late-onset MG (LOMG), with a clear predominance of women in both the LOMG and early-onset (EOMG) types; and 23.8% of the patients had a radiological description consistent with thymoma. All myasthenic patients had at least one comorbidity; 20 (10.8%) of the patients associated at least one autoimmune comorbidity. Obesity (p < 0.01), type 2 diabetes (p < 0.0001), cerebrovascular diseases (p < 0.0001), essential hypertension (p < 0.01), and cardiac arrythmias (p < 0.0001) were more frequent in patients than in the control group. The granulocyte-to-lymphocyte ratio was higher in the myasthenic patients compared to the controls (p < 0.01 for LOMG). Discussion: We, thus, suggest a common chronic low-grade inflammatory background as a possible connection between MG subtypes and some of these apparently unconnected comorbidities. Conclusions: The East-European origin of the patients offered a different social and cultural angle of a disease studied mainly on populations of West-European and Asian descent.
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Affiliation(s)
- Cristina Georgiana Croitoru
- I Neurology Clinic, “Prof. Dr. Nicolae Oblu” Emergency Clinical Hospital, 700309 Iași, Romania
- Department of Immunology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania;
| | - Mariana Pavel-Tanasa
- Department of Immunology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania;
| | - Dan Iulian Cuciureanu
- I Neurology Clinic, “Prof. Dr. Nicolae Oblu” Emergency Clinical Hospital, 700309 Iași, Romania
- Department Medical III, Discipline of Neurology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Diana Nicoleta Hodorog
- I Neurology Clinic, “Prof. Dr. Nicolae Oblu” Emergency Clinical Hospital, 700309 Iași, Romania
- Department Medical III, Discipline of Neurology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Petru Cianga
- Department of Immunology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania;
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Moura J, Fernandes J, Lima MJ, Sousa AP, Samões R, Martins Silva A, Santos E. Treatment strategies and treatment-related adverse events in MG according to the age of onset. Front Neurol 2024; 15:1277420. [PMID: 38529037 PMCID: PMC10961456 DOI: 10.3389/fneur.2024.1277420] [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: 08/14/2023] [Accepted: 02/26/2024] [Indexed: 03/27/2024] Open
Abstract
Introduction Early-onset (EOMG) and late-onset (LOMG) are distinct groups of MG patients. It is unclear if treatment strategies and treatment-related adverse events may differ according to the age of MG onset. Methods This single-center retrospective study includes all MG patients followed at a tertiary center since 2007. We reviewed the electronic clinical records. Results In total, 212 patients were identified, 142 (67.0%) females, with a median disease duration of 10 years. The median age of symptom onset was 42.0 (26.0-64.5) years, with 130 (61.3%) EOMG cases and 82 (38.7%) LOMG. EOMG were more frequently female, had longer disease duration and often more generalized MG (p < 0.001). Comorbidities were significantly more frequent in LOMG (67.1%) compared to EOMG (53.1%) (p = 0.002). Steroid-related adverse effects motivating the switch to steroid-sparing agents (82.0%) were different between groups, with hypertension, hypercholesterolemia, diabetes mellitus and malignancies being more common in LOMG. At the same time, osteoporosis and dyspepsia were more frequent in EOMG (p < 0.001). The most common first-line choice was azathioprine (45.8%), and rituximab was used in 4 patients (1.9%). Conclusion Our study shows that treatment modalities are similar between EOMG and LOMG, while steroid-related adverse events appear to be distinct.
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Affiliation(s)
- João Moura
- Department of Neurology, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Unit of Multidisciplinary Research in Biomedicine (UMIB), Instituto de Ciências Biomédicas Abel Salazar (ICBAS), University of Porto, Porto, Portugal
| | - Joana Fernandes
- Department of Neurology, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Maria João Lima
- Department of Neurology, Unidade Local de Saúde de Matosinhos, Porto, Portugal
| | - Ana Paula Sousa
- Department of Neurophysiology, Hospital de Santo António, Centro Hospitalar Universitário Do Porto, Porto, Portugal
| | - Raquel Samões
- Department of Neurology, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Unit of Multidisciplinary Research in Biomedicine (UMIB), Instituto de Ciências Biomédicas Abel Salazar (ICBAS), University of Porto, Porto, Portugal
- Laboratory for Integrative and Translational Research in Population Health (ITR), Porto, Portugal
| | - Ana Martins Silva
- Department of Neurology, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Unit of Multidisciplinary Research in Biomedicine (UMIB), Instituto de Ciências Biomédicas Abel Salazar (ICBAS), University of Porto, Porto, Portugal
- Laboratory for Integrative and Translational Research in Population Health (ITR), Porto, Portugal
| | - Ernestina Santos
- Department of Neurology, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Unit of Multidisciplinary Research in Biomedicine (UMIB), Instituto de Ciências Biomédicas Abel Salazar (ICBAS), University of Porto, Porto, Portugal
- Laboratory for Integrative and Translational Research in Population Health (ITR), Porto, Portugal
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Salort-Campana E, Laforet P, de Pouvourville G, Crochard A, Chollet G, Nevoret C, Emery C, Bouée S, Tard C. Epidemiology of myasthenia gravis in France: A retrospective claims database study (STAMINA). Rev Neurol (Paris) 2024; 180:202-210. [PMID: 37945494 DOI: 10.1016/j.neurol.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 08/04/2023] [Accepted: 09/21/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND The objectives of this observational study were to report the incidence and prevalence of myasthenia gravis (MG) in France, describe patients' characteristics and treatment patterns, and estimate mortality. METHODS A historical cohort analysis was performed using the French National Health Data System (SNDS) database between 2008 and 2020. Patients with MG were identified based on ICD-10 codes during hospitalization and/or long-term disease (ALD) status, which leads to a 100% reimbursement for healthcare expenses related to MG. The study population was matched to a control group based on age, sex and region of residence. RESULTS The overall incidence of MG was estimated at 2.5/100,000 in 2019 and the overall prevalence at 34.2/100,000. The mean age was 58.3 years for incident patients and 58.6 for prevalent patients. Among patients with MG, 57.1% were women. In the first year after identification of MG, acetylcholinesterase inhibitors were the most commonly used treatments (87.0%). Corticosteroids were delivered to 58.3% of patients, intravenous immunoglobulin to 34.4%, and azathioprine to 29.9%. Additionally, 8% of patients underwent thymectomy. The proportions of patients with exacerbations and crises were 59.7% and 13.5% respectively in the first year after MG identification. All-cause mortality was significantly higher in patients with MG compared to matched controls (HR=1.82 (95% CI [1.74;1.90], P<0.0001)). CONCLUSION In this study, the incidence and prevalence of MG estimated in France were found to be higher than previously reported. Most exacerbations and crises occurred within the first year after MG identification. MG was associated with increased mortality compared to a control population matched on age, gender, and geographical region.
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Affiliation(s)
- E Salort-Campana
- Service du Pr Attarian, Centre de référence des maladies neuromusculaires PACA Réunion Rhône Alpes, AP-HM, Marseille, France
| | - P Laforet
- Service de Neurologie, Hôpital Raymond Poincaré, Centre de référence des maladies neuromusculaires Nord-Est-Ile de France, FHU Phenix, Garches, France
| | | | | | | | | | - C Emery
- CEMKA, Bourg-La-Reine, France
| | - S Bouée
- CEMKA, Bourg-La-Reine, France
| | - C Tard
- Service de neurologie, U1172, Centre de référence des maladies neuromusculaires Nord/Est/Ile-de-France, CHU de Lille, Lille, France
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6
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Panda PK, Sharawat IK. Myasthenia gravis and economic burden: Exploring the impact of family dynamics on financial strain. J Clin Neurosci 2024; 120:92-93. [PMID: 38237492 DOI: 10.1016/j.jocn.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 01/10/2024] [Indexed: 02/12/2024]
Affiliation(s)
- Prateek Kumar Panda
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand 249203, India
| | - Indar Kumar Sharawat
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand 249203, India.
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Sun C, Ruan Z, Zhang Y, Guo R, Li H, Wang T, Gao T, Tang Y, Song N, Hao S, Huang X, Li S, Ning F, Su Y, Lu Q, Wang Q, Cao X, Li Z, Chang T. High indirect bilirubin levels as an independent predictor of postoperative myasthenic crisis: a single-center, retrospective study. Front Neurol 2024; 14:1336823. [PMID: 38283685 PMCID: PMC10811789 DOI: 10.3389/fneur.2023.1336823] [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: 11/15/2023] [Accepted: 12/28/2023] [Indexed: 01/30/2024] Open
Abstract
Background Thymectomy is an efficient and standard treatment strategy for patients with myasthenia gravis (MG), postoperative myasthenic crisis (POMC) is the major complication related to thymectomy and has a strongly life-threatening effect. As a biomarker, whether the bilirubin level is a risk factor for MG progression remains unclear. This study aimed to investigate the association between the preoperative bilirubin level and postoperative myasthenic crisis (POMC). Methods We analyzed 375 patients with MG who underwent thymectomy at Tangdu Hospital between January 2012 and September 2021. The primary outcome measurement was POMC. The association between POMC and bilirubin level was analyzed by restricted cubic spline (RCS). Indirect bilirubin (IBIL) was divided into two subgroups based on the normal upper limit of IBIL, 14 μmol/L. Results Compared with non-POMC group, IBIL levels were significantly higher in patients with POMC. Elevated IBIL levels were closely associated with an increased risk of POMC (p for trend = 0.002). There was a dose-response curve relationship between IBIL levels and POMC incidence (p for non-linearity = 0.93). However, DBIL levels showed a U-shaped association with POMC incidence. High IBIL level (≥14 μmol/L) was an independent predictive factor for POMC [odds ratio = 3.47, 95% confidence interval (CI): 1.56-7.8, p = 0.002]. The addition of high IBIL levels improved the prediction model performance (net reclassification index = 0.186, 95% CI: 0.039-0.334; integrated discrimination improvement = 0.0345, 95% CI: 0.005-0.065). Conclusion High preoperative IBIL levels, especially those exceeding the normal upper limit, could independently predict the incidence of POMC.
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Affiliation(s)
- Chao Sun
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Zhe Ruan
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yu Zhang
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Rongjing Guo
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Huanhuan Li
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Tantan Wang
- School of Pharmaceutical Sciences, Peking-Tsinghua Center for Life Sciences, Key Laboratory of Bioorganic Phosphorus Chemistry & Chemical Biology (Ministry of Education), Tsinghua University, Beijing, China
| | - Ting Gao
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yonglan Tang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Na Song
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Sijia Hao
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xiaoxi Huang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Shuang Li
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Fan Ning
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yue Su
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Qiang Lu
- Department of Thoracic Surgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Qingqing Wang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xiangqi Cao
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Zhuyi Li
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Ting Chang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
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Pisc J, Ting A, Skornicki M, Sinno O, Lee E. Healthcare resource utilization, costs and treatment associated with myasthenia gravis exacerbations among patients with myasthenia gravis in the USA: a retrospective analysis of claims data. J Comp Eff Res 2024; 13:e230108. [PMID: 38099519 PMCID: PMC10842297 DOI: 10.57264/cer-2023-0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 11/27/2023] [Indexed: 01/06/2024] Open
Abstract
Aim: There are limited data on the clinical and economic burden of exacerbations in patients with myasthenia gravis (MG). We assessed patient clinical characteristics, treatments and healthcare resource utilization (HCRU) associated with MG exacerbation. Patients & methods: This was a retrospective analysis of adult patients with MG identified by commercial, Medicare or Medicaid insurance claims from the IBM® MarketScan® database. Eligible patients had two or more MG diagnosis codes, without evidence of exacerbation or crisis in the baseline period (12 months prior to index [first eligible MG diagnosis]). Clinical characteristics were evaluated at baseline and 12 weeks before each exacerbation. Number of exacerbations, MG treatments and HCRU costs associated with exacerbation were described during a 2-year follow-up period. Results: Among 9352 prevalent MG patients, 34.4% (n = 3218) experienced ≥1 exacerbation after index: commercial, 53.0% (n = 1706); Medicare, 39.4% (n = 1269); and Medicaid, 7.6% (n = 243). During follow-up, the mean (standard deviation) number of exacerbations per commercial and Medicare patient was 3.7 (7.0) and 2.7 (4.1), respectively. At least two exacerbations were experienced by approximately half of commercial and Medicare patients with ≥1 exacerbation. Mean total MG-related healthcare costs per exacerbation ranged from $26,078 to $51,120, and from $19,903 to $49,967 for commercial and Medicare patients, respectively. AChEI use decreased in patients with multiple exacerbations, while intravenous immunoglobulin use increased with multiple exacerbations. Conclusion: Despite utilization of current treatments for MG, MG exacerbations are associated with a high clinical and economic burden in both commercial and Medicare patients. Additional treatment options and improved disease management may help to reduce exacerbations and disease burden.
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Zhu Y, Wang B, Hao Y, Zhu R. Clinical features of myasthenia gravis with neurological and systemic autoimmune diseases. Front Immunol 2023; 14:1223322. [PMID: 37781409 PMCID: PMC10538566 DOI: 10.3389/fimmu.2023.1223322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/23/2023] [Indexed: 10/03/2023] Open
Abstract
Multiple reports on the co-existence of autoimmune diseases and myasthenia gravis (MG) have raised considerable concern. Therefore, we reviewed autoimmune diseases in MG to explore their clinical presentations and determine whether the presence of autoimmune diseases affects the disease severity and treatment strategies for MG. We reviewed all the major immune-mediated coexisting autoimmune conditions associated with MG. PubMed, Embase and Web of Science were searched for relevant studies from their inception to January 2023. There is a higher frequency of concomitant autoimmune diseases in patients with MG than in the general population with a marked risk in women. Most autoimmune comorbidities are linked to AChR-MG; however, there are few reports of MuSK-MG. Thyroid disorders, systemic lupus erythematosus, and vitiligo are the most common system autoimmune diseases associated with MG. In addition, MG can coexist with neurological autoimmune diseases, such as neuromyelitis optica (NMO), inflammatory myopathy (IM), multiple sclerosis (MS), and autoimmune encephalitis (AE), with NMO being the most common. Autoimmune diseases appear to develop more often in early-onset MG (EOMG). MS coexists more commonly with EOMG, while IM coexists with LOMG. In addition, MG complicated by autoimmune diseases tends to have mild clinical manifestations, and the coexistence of autoimmune diseases does not influence the clinical course of MG. The clinical course of neurological autoimmune diseases is typically severe. Autoimmune diseases occur most often after MG or as a combined abnormality; therefore, timely thymectomy followed by immunotherapy could be effective. In addition, thymoma-associated AChR MG is associated with an increased risk of AE and IM, whereas NMO and MS are associated with thymic hyperplasia. The co-occurrence of MG and autoimmune diseases could be attributed to similar immunological mechanisms with different targets and common genetic factor predisposition. This review provides evidence of the association between MG and several comorbid autoimmune diseases.
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Affiliation(s)
| | | | | | - Ruixia Zhu
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China
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10
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Hughes T, Howard JF, Silvestri NJ, Anderson AEL, Sato M, Suchotliff S, Guptill JT, Phillips G. The economic burden of individuals living with generalized myasthenia gravis and facing social determinants of health challenges. Front Public Health 2023; 11:1247931. [PMID: 37766748 PMCID: PMC10520715 DOI: 10.3389/fpubh.2023.1247931] [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: 06/26/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023] Open
Abstract
Objective Better understanding the impact of social determinants of health (SDOH) barriers from the patient perspective is crucial to improve holistic patient support in generalized myasthenia gravis (gMG), a rare autoimmune disorder with high disease and treatment burden. The objective of this study was to identify economic challenges experienced by individuals living with gMG and SDOH barriers to better address current unmet needs. Methods Adults (18-75 years) living with gMG and experiencing SDOH barriers in the United States were recruited to a mixed-methods study including qualitative interviews and a web-based quantitative survey. Quotas were implemented to include a balanced spread of baseline demographic categories including insurance type, living environment, and employment status among the study sample. Direct and indirect economic challenges were identified by degree of concern. Results The survey was completed by 38 individuals living with gMG, the majority of whom were enrolled in public insurance and not employed. The most commonly reported major economic concerns were managing funds for emergency care (66%), loss of income (61%), and non-medical expenses (58%), highlighting the diversity of economic challenges. Individuals who were using public insurance plans, living in non-urban environments, and unemployed experienced pronounced challenges around managing non-medical costs and accessing government assistance. Conclusion Both direct and indirect costs were emphasized as major concerns among individuals living with gMG and SDOH barriers. Increasing access to relevant, personalized, and holistic resources, including care management, should be prioritized to improve disease management and outcomes for individuals living with gMG.
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Affiliation(s)
- Tom Hughes
- Argenx US Inc., Boston, MA, United States
| | - James F. Howard
- Department of Neurology, University of North Carolina, Chapel Hill, NC, United States
| | | | | | - Mai Sato
- ZS Associates, New York, NY, United States
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Hughes T, Anderson AEL, Habib AA, Perez K, Bergin C, Suchotliff S, Zvosec C, McDaniel D, Sato M, Whangbo A, Phillips G. Impact of social determinants of health on individuals living with generalized myasthenia gravis and implications for patient support programs. Front Public Health 2023; 11:1147489. [PMID: 37275500 PMCID: PMC10235801 DOI: 10.3389/fpubh.2023.1147489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 05/05/2023] [Indexed: 06/07/2023] Open
Abstract
Introduction Social determinants of health (SDOH) are important contributors to health outcomes, and better understanding their impact on individuals diagnosed with rare, chronic diseases with high burden and unmet need is critical. Characterizing SDOH burden can help improve the design of patient support programs (PSPs), using targeted approaches to remove barriers to access. Methods This study used a mixed-methods strategy employing a quantitative survey, which was designed based on qualitative interviews, to understand the unmet needs and awareness/utilization of PSPs among individuals living with generalized myasthenia gravis (gMG) and experiencing SDOH barriers. The survey was completed by 38 individuals living with gMG, of which the majority were non-White/Caucasian, unemployed, low income, and enrolled in public insurance. Common SDOH challenges, awareness/utilization of available PSPs, and unmet needs were identified. Results Financial and mental health concerns were the most common among individuals living with gMG and experiencing SDOH barriers throughout diagnosis, accessing treatment, initiating treatment, and continuing treatment. Awareness and utilization of existing support services were low, especially when accessing treatment. Educational, financial, and personalized support with high "human touch" were commonly perceived as the most valuable resources. Implications To better serve the needs of individuals with gMG experiencing SDOH barriers, PSPs should use a targeted approach to offer services tailored to harder-to-reach populations. Further, providers, advocacy groups, manufacturers, and public organizations in the gMG ecosystem should strengthen collaborations with PSPs to enable individuals living with gMG to access the services they need to improve their health outcomes.
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Affiliation(s)
- Tom Hughes
- argenx US Inc., Boston, MA, United States
| | | | - Ali A. Habib
- UCI Health ALS & Neuromuscular Center, University of California Irvine, Orange, CA, United States
| | | | | | | | | | | | - Mai Sato
- ZS Associates, New York, NY, United States
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Lim JL, Augustinus R, Plomp JJ, Roya-Kouchaki K, Vergoossen DLE, Fillié-Grijpma Y, Struijk J, Thomas R, Salvatori D, Steyaert C, Blanchetot C, Vanhauwaert R, Silence K, van der Maarel SM, Verschuuren JJ, Huijbers MG. Development and characterization of agonistic antibodies targeting the Ig-like 1 domain of MuSK. Sci Rep 2023; 13:7478. [PMID: 37156800 PMCID: PMC10167245 DOI: 10.1038/s41598-023-32641-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/30/2023] [Indexed: 05/10/2023] Open
Abstract
Muscle-specific kinase (MuSK) is crucial for acetylcholine receptor (AChR) clustering and thereby neuromuscular junction (NMJ) function. NMJ dysfunction is a hallmark of several neuromuscular diseases, including MuSK myasthenia gravis. Aiming to restore NMJ function, we generated several agonist monoclonal antibodies targeting the MuSK Ig-like 1 domain. These activated MuSK and induced AChR clustering in cultured myotubes. The most potent agonists partially rescued myasthenic effects of MuSK myasthenia gravis patient IgG autoantibodies in vitro. In an IgG4 passive transfer MuSK myasthenia model in NOD/SCID mice, MuSK agonists caused accelerated weight loss and no rescue of myasthenic features. The MuSK Ig-like 1 domain agonists unexpectedly caused sudden death in a large proportion of male C57BL/6 mice (but not female or NOD/SCID mice), likely caused by a urologic syndrome. In conclusion, these agonists rescued pathogenic effects in myasthenia models in vitro, but not in vivo. The sudden death in male mice of one of the tested mouse strains revealed an unexpected and unexplained role for MuSK outside skeletal muscle, thereby hampering further (pre-) clinical development of these clones. Future research should investigate whether other Ig-like 1 domain MuSK antibodies, binding different epitopes, do hold a safe therapeutic promise.
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Affiliation(s)
- Jamie L Lim
- Department of Human Genetics, Leiden University Medical Center, Einthovenweg 20, 2300 RC, Leiden, The Netherlands
| | - Roy Augustinus
- Department of Human Genetics, Leiden University Medical Center, Einthovenweg 20, 2300 RC, Leiden, The Netherlands
| | - Jaap J Plomp
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Kasra Roya-Kouchaki
- Department of Human Genetics, Leiden University Medical Center, Einthovenweg 20, 2300 RC, Leiden, The Netherlands
| | - Dana L E Vergoossen
- Department of Human Genetics, Leiden University Medical Center, Einthovenweg 20, 2300 RC, Leiden, The Netherlands
| | - Yvonne Fillié-Grijpma
- Department of Human Genetics, Leiden University Medical Center, Einthovenweg 20, 2300 RC, Leiden, The Netherlands
| | - Josephine Struijk
- Department of Human Genetics, Leiden University Medical Center, Einthovenweg 20, 2300 RC, Leiden, The Netherlands
| | - Rachel Thomas
- Department PDC-Pathologie, Leiden University Medical Center, Leiden, The Netherlands
| | - Daniela Salvatori
- Veterinary Faculty, Department Clinical Sciences, Universiteit Utrecht, Utrecht, The Netherlands
| | | | | | | | | | - Silvère M van der Maarel
- Department of Human Genetics, Leiden University Medical Center, Einthovenweg 20, 2300 RC, Leiden, The Netherlands
| | - Jan J Verschuuren
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Maartje G Huijbers
- Department of Human Genetics, Leiden University Medical Center, Einthovenweg 20, 2300 RC, Leiden, The Netherlands.
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.
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13
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Ozdemir HN, Karasoy H, Yuceyar AN, Ekmekci O. Effects of comorbid diseases on clinical outcomes in patients with myasthenia gravis. Neurol Sci 2023:10.1007/s10072-023-06750-8. [PMID: 36943588 DOI: 10.1007/s10072-023-06750-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 03/13/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND This cross-sectional study was undertaken to evaluate the existence and distribution of comorbid disorders among myasthenia gravis (MG) patients according to subgroups and to identify the effects of the comorbid diseases of MG patients on clinical outcomes. METHODS The patients were divided into six subgroups according to serum antibodies, age at onset, and thymoma presence. All patients were treated in line with the International Consensus Guidance for Management of Myasthenia Gravis. To assess the clinical outcome after treatment for MG, we used the MGFA Post-intervention Status. In generalized MG patients, the good prognosis group included patients who were classified as having minimal-manifestation status or better. In ocular MG patients, the remission subgroup included patients who were classified as having complete stable remission or pharmacological remission status. RESULTS Our study included 168 MG patients, 85 were female while 83 were male. Comorbid diseases were present in 124 (73.8%) MG cases. After at least 1 year of follow-up, 106 (86.8%) of the generalized MG patients were in the good prognosis group and 16 (13.2%) generalized MG patients were in the poor prognosis group. 27 (58.6%) ocular MG patients were in the remission group and 19 (41.3%) ocular MG patients were in the non-remission group. Hypertension increased the risk of poor prognosis by 3.55-fold among patients with generalized MG and type 2 DM increased the risk of not achieving remission by 9.32-fold among patients with ocular MG. CONCLUSION Hypertension and type 2 DM had negative effects on the clinical outcomes of MG.
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Affiliation(s)
| | - Hatice Karasoy
- Department of Neurology, Ege University Medical School, 35100, Izmir, Turkey
| | - Ayse Nur Yuceyar
- Department of Neurology, Ege University Medical School, 35100, Izmir, Turkey
| | - Ozgul Ekmekci
- Department of Neurology, Ege University Medical School, 35100, Izmir, Turkey.
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Schirò G, Iacono S, Balistreri CR. The Role of Human Microbiota in Myasthenia Gravis: A Narrative Review. Neurol Int 2023; 15:392-404. [PMID: 36976669 PMCID: PMC10053295 DOI: 10.3390/neurolint15010026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/05/2023] [Accepted: 03/07/2023] [Indexed: 03/15/2023] Open
Abstract
Myasthenia gravis (MG) is an autoimmune neuromuscular disease characterized by fluctuating weakness of the skeletal muscles. Although antibodies against the neuromuscular junction components are recognized, the MG pathogenesis remains unclear, even if with a well-known multifactorial character. However, the perturbations of human microbiota have been recently suggested to contribute to MG pathogenesis and clinical course. Accordingly, some products derived from commensal flora have been demonstrated to have anti-inflammatory effects, while other have been shown to possess pro-inflammatory properties. In addition, patients with MG when compared with age-matched controls showed a distinctive composition in the oral and gut microbiota, with a typical increase in Streptococcus and Bacteroides and a reduction in Clostridia as well as short-chain fatty acid reduction. Moreover, restoring the gut microbiota perturbation has been evidenced after the administration of probiotics followed by an improvement of symptoms in MG cases. To highlight the role of the oral and gut microbiota in MG pathogenesis and clinical course, here, the current evidence has been summarized and reviewed.
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Affiliation(s)
- Giuseppe Schirò
- Neurology Unit, Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, 90127 Palermo, Italy
| | - Salvatore Iacono
- Neurology Unit, Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, 90127 Palermo, Italy
- Correspondence:
| | - Carmela Rita Balistreri
- Cellular and Molecular Laboratory, Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, 90127 Palermo, Italy
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15
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Frequency and Correlates of Mild Cognitive Impairment in Myasthenia Gravis. Brain Sci 2023; 13:brainsci13020170. [PMID: 36831713 PMCID: PMC9953757 DOI: 10.3390/brainsci13020170] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/14/2023] [Accepted: 01/17/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Antibodies against acetylcholine receptors (AChRs) can also target nicotinic AChRs that are present throughout the central nervous system, thus leading to cognitive dysfunctions in patients with myasthenia gravis (MG). However, the presence of cognitive impairment in MG is controversial, and the factors that may influence this risk are almost completely unknown. In this study, the frequency of mild cognitive impairment (MCI) in MG, as well as the clinical, immunological, and behavioral correlates of MCI in MG were evaluated. METHODS A total of 52 patients with MG underwent a comprehensive assessment including motor and functional scales, serological testing, and neuropsychological and behavioral evaluation. RESULTS The frequency of MCI was 53.8%, and the most impaired cognitive domains were, in order, visuoconstructive/visuospatial skills, memory, and attention. After multivariate analysis, only pyridostigmine use was inversely associated with the presence of MCI, while a trend toward a positive association between MCI and disease severity and arms/legs hyposthenia was found. Correlation analyses showed that daily doses of prednisone and azathioprine significantly correlated with depressive symptomatology, while disease severity significantly correlated with depressive symptomatology and sleep disturbance. CONCLUSIONS The presence of MCI is rather frequent in MG and is characterized by multidomain amnestic impairment. Such preliminary data need further confirmation on larger case series.
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Alkhotani A, Alrishi N. Severity and antibodies profile of seropositive myasthenia gravis. SAUDI JOURNAL FOR HEALTH SCIENCES 2023. [DOI: 10.4103/sjhs.sjhs_153_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
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Real-world utilization patterns of intravenous immunoglobulin in adults with generalized myasthenia gravis in the United States. J Neurol Sci 2022; 443:120480. [PMID: 36347174 DOI: 10.1016/j.jns.2022.120480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 09/14/2022] [Accepted: 10/23/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To evaluate real-world utilization patterns of intravenous immunoglobulin (IVIg) among patients with generalized myasthenia gravis (gMG) over 3 years post-IVIg initiation. METHODS Patients with gMG who initiated IVIg treatment were identified from a United States claims database (Symphony Health's Integrated Dataverse [IDV]®, January 1, 2014 - December 31, 2019). The frequency of subsequent IVIg treatment and associated cost during the year post-IVIg initiation were analyzed. Usage patterns of IVIg and concomitant gMG treatments during the year preceding and 3 years post-IVIg initiation were compared. RESULTS Among 1225 patients with gMG who initiated IVIg treatment, 706 patients (57.6%) received 1 to 5 IVIg treatment courses (intermittent IVIg users), and 519 patients (42.4%) received ≥6 IVIg treatment courses (chronic IVIg users) within the subsequent year. Mean annual medical cost per patient was nearly 2.5-fold higher for chronic vs. intermittent IVIg users ($161,478 vs. $64,888, p < 0.001). The proportion of patients using corticosteroids and nonsteroidal immunosuppressive treatments (NSISTs) was not reduced over the 3-year follow-up period following IVIg initiation, even for patients who continued annual chronic IVIg for 3 consecutive years post-initiation. CONCLUSIONS Nearly half of patients with gMG received chronic and multiple IVIg treatment courses within the first year once initiating IVIg treatment, indicating higher usage than expected. For all IVIg initiators, the proportion of patients using corticosteroids and NSISTs did not decrease over 3 years despite IVIg initiation.
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Chen K, Li Y, Yang H. Poor responses and adverse outcomes of myasthenia gravis after thymectomy: Predicting factors and immunological implications. J Autoimmun 2022; 132:102895. [PMID: 36041292 DOI: 10.1016/j.jaut.2022.102895] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 08/09/2022] [Accepted: 08/11/2022] [Indexed: 10/15/2022]
Abstract
Myasthenia gravis (MG) has been recognized as a series of heterogeneous but treatable autoimmune conditions. As one of the indispensable therapies, thymectomy can achieve favorable prognosis especially in early-onset generalized MG patients with seropositive acetylcholine receptor antibody. However, poor outcomes, including worsening or relapse of MG, postoperative myasthenic crisis and even post-thymectomy MG, are also observed in certain scenarios. The responses to thymectomy may be associated with the general characteristics of patients, disease conditions of MG, autoantibody profiles, native or ectopic thymic pathologies, surgical-related factors, pharmacotherapy and other adjuvant modalities, and the presence of comorbidities and complications. However, in addition to these variations among individuals, pathological remnants and the abnormal immunological milieu and responses potentially represent major mechanisms that underlie the detrimental neurological outcomes after thymectomy. We underscore these plausible risk factors and discuss the immunological implications therein, which may be conducive to better managing the indications for thymectomy, to avoiding modifiable risk factors of poor responses and adverse outcomes, and to developing post-thymectomy preventive and therapeutic strategies for MG.
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Affiliation(s)
- Kangzhi Chen
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Yi Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China.
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19
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Li F, Zhang H, Tao Y, Stascheit F, Han J, Gao F, Liu H, Carmona-Bayonas A, Li Z, Rueckert JC, Meisel A, Zhao S. Prediction of the generalization of myasthenia gravis with purely ocular symptoms at onset: a multivariable model development and validation. Ther Adv Neurol Disord 2022; 15:17562864221104508. [PMID: 35755967 PMCID: PMC9218496 DOI: 10.1177/17562864221104508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 05/05/2022] [Indexed: 11/16/2022] Open
Abstract
Background About half of myasthenia gravis (MG) patients with purely ocular symptoms at onset progress to generalized myasthenia gravis (gMG). Objectives To develop and validate a model to predict the generalization of MG at 6 months after disease onset in patients with ocular-onset myasthenia gravis (OoMG). Methods Data of patients with OoMG were retrospectively collected from two tertiary hospitals in Germany and China. An accelerated failure time model was developed using the backward elimination method based on the German cohort to predict the generalization of OoMG. The model was then externally validated in the Chinese cohort, and its performance was assessed using Harrell's C-index and calibration plots. Results Four hundred and seventy-seven patients (275 from Germany and 202 from China) were eligible for inclusion. One hundred and three (37.5%) patients in the German cohort progressed from OoMG to gMG with a median follow-up time of 69 (32-116) months. The median time to generalization was 29 (16-71) months. The estimated cumulative probability of generalization was 30.5% [95% CI (confidence interval), 24.3-36.2%) at 5 years after disease onset. The final model, which was represented as a nomogram, included five clinical variables: sex, titer of anti-AChR antibody, status of anti-MuSK antibody, age at disease onset and the presence of other autoimmune disease. External validation of the model using the bootstrap showed a C-index of 0.670 (95% CI, 0.602-0.738). Calibration curves revealed moderate agreement of predicted and observed outcomes. Conclusion The nomogram is a good predictor for generalization in patients with OoMG that can be used to inform of the individual generalization risk, which might improve the clinical decision-making.
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Affiliation(s)
- Feng Li
- Department of Thoracic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hongbin Zhang
- Department of Surgery, Competence Center of Thoracic Surgery, Charite University Hospital Berlin, Berlin, Germany
| | - Ya Tao
- Department of Obstetrics, The First Affiliated Hospital of Zhengzhou University, Obstetric Emergency and Critical Care Medicine of Henan Province, Zhengzhou, China
| | - Frauke Stascheit
- Department of Neurology, Integrated Center for Myasthenia Gravis, NeuroCure Clinical Research Center, Center for Stroke Research Berlin, Charité - University Medicine Berlin, Berlin, Germany
| | - Jiaojiao Han
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Feng Gao
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Hongbo Liu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Alberto Carmona-Bayonas
- Hospital Universitario Morales Meseguer, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria, Murcia, Spain
| | - Zhongmin Li
- Department of Surgery, Competence Center of Thoracic Surgery, Charite University Hospital Berlin, Berlin, Germany
| | - Jens-C Rueckert
- Department of Surgery, Competence Center of Thoracic Surgery, Charite University Hospital Berlin, 10117, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology, Integrated Center for Myasthenia Gravis, NeuroCure Clinical Research Center, Center for Stroke Research Berlin, Charité - University Medicine Berlin, Berlin, Germany
| | - Song Zhao
- Department of Thoracic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
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Galassi G. Comment on comorbidities in older patients with myasthenia gravis. Acta Neurol Scand 2022; 145:789-790. [PMID: 35307817 DOI: 10.1111/ane.13606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 02/26/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Giuliana Galassi
- Department of Biomedical Metabolic Neural Sciences University of Modena Modena Italy
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21
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Kim Y, Li X, Huang Y, Kim M, Shaibani A, Sheikh K, Zhang GQ, Nguyen TP. COVID-19 Outcomes in Myasthenia Gravis Patients: Analysis From Electronic Health Records in the United States. Front Neurol 2022; 13:802559. [PMID: 35418937 PMCID: PMC8996116 DOI: 10.3389/fneur.2022.802559] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/28/2022] [Indexed: 02/03/2023] Open
Abstract
Background Myasthenia gravis (MG) is an autoimmune, neuromuscular condition and patients with MG are vulnerable due to immunosuppressant use and disease manifestations of dyspnea and dysphagia during the coronavirus disease 2019 (COVID-19) pandemic. Methods We conducted a retrospective cohort study using the Optum® de-identified COVID-19 Electronic Health Record (EHR) dataset. Primary outcomes, such as hospitalization, ventilator use, intensive care unit (ICU) admission, and death in COVID-19 patients with MG, were compared with those of COVID-19 patients without MG: the subgroups of non-MG included those with rheumatoid arthritis (RA), systemic lupus (SLE), and multiple sclerosis (MS). We further analyzed factors affecting mortality, such as age, race/ethnicity, comorbidities, and MG treatments. Results Among 421,086 individuals with COVID-19, there were 377 patients with MG, 7,362 patients with RA, 1,323 patients with SLE, 1,518 patients with MS, and 410,506 patients without MG. Patients with MG were older and had more comorbidities compared with non-MG patients and had the highest rates of hospitalization (38.5%), ICU admission (12.7%), ventilator use (3.7%), and mortality (10.6%) compared with all other groups. After adjusting for risk factors, patients with MG had increased risks for hospitalization and ICU compared with patients with non-MG and with RA but had risks similar to patients with SLE and with MS. The adjusted risk for ventilator use was similar across all groups, but the risk for mortality in patients with MG was lower compared with the SLE and MS groups. Among patients with MG, age over 75 years and dysphagia were predictors for increased COVID-19 mortality, but the recent MG treatment was not associated with COVID-19 mortality. Conclusions COVID-19 patients with MG are more likely to be admitted to the hospital and require ICU care. Older age and patients with dysphagia had an increased risk of mortality.
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Affiliation(s)
- Youngran Kim
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Xiaojin Li
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Yan Huang
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Minseon Kim
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Aziz Shaibani
- Nerve and Muscle Center of Texas, Houston, TX, United States
| | - Kazim Sheikh
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Guo-Qiang Zhang
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Thy Phuong Nguyen
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
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22
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Iori E, Ariatti A, Mazzoli M, Bastia E, Gozzi M, Agnoletto V, Marchioni A, Galassi G. Cardiac disorders worsen the final outcome in myasthenic crisis undergoing non-invasive mechanical ventilation: a retrospective 20-year study from a single center. ACTA MYOLOGICA : MYOPATHIES AND CARDIOMYOPATHIES : OFFICIAL JOURNAL OF THE MEDITERRANEAN SOCIETY OF MYOLOGY 2022; 41:15-23. [PMID: 35465341 PMCID: PMC9004337 DOI: 10.36185/2532-1900-064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 03/07/2022] [Indexed: 01/24/2023]
Abstract
The study was performed to evaluate the impact of cardiological disorders on the outcome of myasthenic crisis (MC) requiring ventilation. The study includes 90 cases admitted to the Neurology Unit of Modena, Italy (January 2000 - September 2020). All patients were eligible for a non-invasive ventilation (NIV) trial. We analyzed the effect of cardiac comorbidities on the outcomes, which were the need of invasive ventilation, the risk tracheostomy for weaning failure and the duration of intensive care unit (ICU) stay Females were 58.9% and males 41.1%. Median age at diagnosis was 59 and at MC was 65. Patients were classified as early (EOMG) or late (LOMG), 34.4 and 65.6% respectively, according to age above or below 50; 85% of patients were anti- AChR antibody positive. Hypertension and cardiac diseases occurred at the diagnosis in 61 and 44.4%, respectively. Invasive mechanical ventilation (MV) was needed in 34% of cases. Nine subjects (10%) underwent tracheostomy because of weaning failure. Independent predictors of NIV failure were atrial fibrillation (AF), either parossistic or persistent (OR 3.05, p < 0.01), hypertensive cardiopathy (HHD) (OR 2.52, p < 0.01) and ischaemic heart disease (IHD) (OR 3.08, p < 0.01). Hypertension (HT) had no statistical effect on the outcomes. HHD was a predictor of weaning failure (OR 4.01, p = 0.017). Our study shows that HHD, AF and IHD increase the risk of NIV failure in MC receiving ventilation.
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Affiliation(s)
- Erika Iori
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena, Italy
| | - Alessandra Ariatti
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena, Italy
| | - Marco Mazzoli
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena, Italy
| | - Elisabetta Bastia
- Division of Cardiology, Baggiovara Hospital, Azienda Ospedaliera Universitaria, Modena, Italy
| | - Manuela Gozzi
- Radiology, Azienda Ospedaliera Universitaria, Modena, Italy
| | - Virginia Agnoletto
- Division of Cardiology, Baggiovara Hospital, Azienda Ospedaliera Universitaria, Modena, Italy
| | | | - Giuliana Galassi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena, Italy,Correspondence Giuliana Galassi Department of Biomedical, Metabolic and Neural Sciences, University of Modena, via P. Giardini 454, 41124 Modena, Italy. Tel: + 39 059 3497325801. Fax. + 39 059 367961. E-mail:
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Zheng Y, Yuan X, Zhang C, Liu R, Jin H, Hao H, Li F, Zhao Y, Yuan Y, Wang Z, Gao F. Efficacy and Safety of Tacrolimus Therapy for a Single Chinese Cohort With Very-Late-Onset Myasthenia Gravis. Front Neurol 2022; 13:843523. [PMID: 35432159 PMCID: PMC9007732 DOI: 10.3389/fneur.2022.843523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 02/15/2022] [Indexed: 11/28/2022] Open
Abstract
Background and Purpose Previous studies have found tacrolimus to be a favorable drug for treating different types of myasthenia gravis (MG), but few have focused on very-late-onset MG (VLOMG). This study evaluated the efficacy and safety of tacrolimus for VLOMG therapy. Methods This was a retrospective single-center cohort study of 70 patients with VLOMG (onset ≥65 years) who visited Peking University First Hospital in 2019. Participants were divided into the tacrolimus (Tac) group and the control group based on tacrolimus usage. We further divided the Tac group into patients treated without corticosteroids and with corticosteroids. Sociodemographic features, clinical profiles, and outcomes were compared between different therapies and further analyzed by multivariate regression. Details of tacrolimus treatment, comorbidities, and adverse drug reactions (ADRs) were described. Results Among 70 patients, the median (interquartile range) age at onset was 71 (68–77) years, and the follow-up duration was 27 (27-29) months. Most patients were types I (28%) and III (40%) according to the MG Foundation of America (MGFA) classification. In the Tac group, tacrolimus treatment was maintained for 36 (27-38) months. The dosage at the final evaluation was 1.0 (1.0–1.75) mg/day, and the last blood concentration test was 4.25 (2.85–5.7) ng/ml. A total of 43% reached remission, and 37% improved based on MGFA postintervention status (MGFA-PIS). For the 9 patients, newly diagnosed at enrollment within this group, MG activities of daily living (MG-ADL) decreased significantly from 3 (2-5) to 2 (1-2) (p = 0.041). Regarding the 13 patients, coadministering Wuzhi capsules the tacrolimus concentration increased from 2.75 (1.4–3.8) ng/ml to 5.95 (5.1–7.0) ng/ml (p = 0.012). No significant differences in outcomes were observed between tacrolimus treatment without and with corticosteroids or between the Tac group and the control group. A total of 93% had at least one comorbidity. ADRs related to tacrolimus emerged in 25% (9/36) of patients, most of which were not serious and reversible. Conclusions Tacrolimus is effective and safe in treating VLOMG. Tacrolimus monotherapy without corticosteroids can be used as an initial and maintenance treatment for VLOMG. Wuzhi capsules work well in elevating tacrolimus concentrations in this population.
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Affiliation(s)
- Yiming Zheng
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Xiaoqiu Yuan
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Caifeng Zhang
- Department of Neurology, Peking University First Hospital, Beijing, China
- North China University of Science and Technology Affiliated Hospital, Qinhuangdao, China
| | - Ran Liu
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Haiqiang Jin
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Hongjun Hao
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Fan Li
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Yawen Zhao
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Yun Yuan
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Zhaoxia Wang
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Feng Gao
- Department of Neurology, Peking University First Hospital, Beijing, China
- *Correspondence: Feng Gao
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Klimiec‐Moskal E, Quirke M, Leite MI. Comorbidities in older patients with myasthenia gravis - Comparison between early- and late-onset disease. Acta Neurol Scand 2022; 145:371-374. [PMID: 34750811 DOI: 10.1111/ane.13549] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/24/2021] [Accepted: 10/31/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND Multimorbidity is an emerging challenge in older myasthenia gravis patients, which can have even greater impact on quality of life and outcome than symptoms of myasthenia. AIMS OF THE STUDY We aimed to investigate comorbidities in older population and compare early-onset (EOMG) and late-onset (LOMG) myasthenia patients. METHODS We investigated clinical information of patients from Oxford Myasthenia Centre age 50 or older. Data on 60 chronic disorders were extracted. RESULTS We included 327 myasthenia patients (30.9% EOMG and 69.1% LOMG) with a median age of 70 years. Comorbidities were present in 94.5% of patients and accumulated with age. Hypertension (58.4% vs. 31.7%), hypercholesterolemia (41.2% vs. 23.8%), diabetes (24.8% vs. 11.9%), cataract (15.5% vs. 5.0%) and prostate disorders (15.0% vs. 2.0%) were more common in LOMG than EOMG, but there were no differences between 70 EOMG and 70 LOMG patients matched according to age and sex. CONCLUSIONS Comorbidities in older patients with myasthenia are very common, increase with age, and do not differ between early- and late-onset disease.
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Affiliation(s)
| | - Mary Quirke
- Nuffield Department of Clinical Neurosciences John Radcliffe Hospital Oxford University Hospitals Oxford UK
| | - Maria Isabel Leite
- Nuffield Department of Clinical Neurosciences John Radcliffe Hospital Oxford University Hospitals Oxford UK
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25
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Bixio R, Bertelle D, Pistillo F, Pedrollo E, Carletto A, Rossini M, Viapiana O. Rheumatoid arthritis and myasthenia gravis: a case-based review of the therapeutic options. Clin Rheumatol 2022; 41:1247-1254. [PMID: 35031874 PMCID: PMC8913445 DOI: 10.1007/s10067-022-06062-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/08/2022] [Accepted: 01/10/2022] [Indexed: 11/30/2022]
Abstract
Introduction Myasthenia gravis is an autoimmune disease affecting the neuromuscular junction, often associated with other autoimmune diseases, including rheumatoid arthritis. Patients with rheumatoid arthritis present an increased prevalence of myasthenia gravis compared to the general population. While these two diseases share some therapeutic options, such as glucocorticoids, methotrexate, and rituximab, there are no guidelines for treating concomitant disease. We aim to review the available evidence and to discuss the efficacy and safety of the therapeutic options in patients with rheumatoid arthritis associated with myasthenia gravis. Method We described three patients with rheumatoid arthritis associated with myasthenia gravis and we performed a systematic review of the associated literature. Results A 48-year-old man and two women (48 and 55 years old) with concomitant diagnoses of active rheumatoid arthritis and well-controlled myasthenia gravis are described. They were treated with methotrexate, leflunomide, upadacitinib, and adalimumab. None of them experienced changes in their myasthenic symptoms. We found 9 additional cases from our literature review. Methotrexate, rituximab, upadacitinib, diphenyl sulfone, auranofin, and loxoprofen sodium did not show an impact on the seven patients with previously well-controlled myasthenia. Glucocorticoids, methotrexate, and rituximab proved effective in active myasthenia gravis and arthritis. Conflicting data emerged for Tumor-necrosis factor inhibitors. Conclusions Although the available evidence remains scarce, we consider glucocorticoids, methotrexate, and rituximab as safe and effective options. The role of tumor-necrosis factor inhibitors remains uncertain. Eventually, Janus Kinase inhibitors are a novel interesting option for these patients.Key Points • To date, the only evidence on the treatment of patients with rheumatoid arthritis and concomitant myasthenia gravis derives from case reports. • Based on the review of the available case reports and on the cases we described, we consider glucocorticoids, methotrexate, and rituximab as safe and effective options, while the role of Tumor-necrosis factor inhibitors remains uncertain. • Based on the cases we described, Janus Kinase inhibitors are a novel interesting option for patients with concomitant rheumatoid arthritis and myasthenia gravis. |
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Affiliation(s)
- Riccardo Bixio
- Rheumatology Section, Department of Medicine, University of Verona Hospital Trust, 37134 Verona, Italy
| | - Davide Bertelle
- Rheumatology Section, Department of Medicine, University of Verona Hospital Trust, 37134 Verona, Italy
| | - Francesca Pistillo
- Rheumatology Section, Department of Medicine, University of Verona Hospital Trust, 37134 Verona, Italy
| | - Elisa Pedrollo
- Rheumatology Section, Department of Medicine, University of Verona Hospital Trust, 37134 Verona, Italy
| | - Antonio Carletto
- Rheumatology Section, Department of Medicine, University of Verona Hospital Trust, 37134 Verona, Italy
| | - Maurizio Rossini
- Rheumatology Section, Department of Medicine, University of Verona Hospital Trust, 37134 Verona, Italy
| | - Ombretta Viapiana
- Rheumatology Section, Department of Medicine, University of Verona Hospital Trust, 37134 Verona, Italy
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Wang Q, Liu Y, Kuang S, Li R, Weng N, Zhou Z. miR-181a Ameliorates the Progression of Myasthenia Gravis by Regulating TRIM9. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2021; 2021:1303375. [PMID: 34925522 PMCID: PMC8677396 DOI: 10.1155/2021/1303375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 09/30/2021] [Indexed: 11/29/2022]
Abstract
Abnormally activated CD4+ T cells are considered to be an important factor in the pathogenesis of myasthenia gravis (MG). In the pathogenesis of MG, the imbalance of proinflammatory cytokines and immune cells maintains the imbalance of immune response and inflammatory microenvironment. Studies have shown that miRNA is involved in the pathogenesis of MG. In our experiment, we extracted peripheral blood mononuclear cells (PBMCs) from MG patients and detected the expression of miR-181a and TRIM9 in PBMCs by qRT-PCR. In vitro experiments were conducted to explore the regulatory mechanism of miR-181a on target genes and its influence on inflammatory factors related to MG disease. Experimental autoimmune myasthenia gravis (EAMG) model mice are established, and the effects of miR-181a on EAMG symptoms and inflammatory factors are explored through in vivo experiments. According to a total of 40 EAMG mice that were successfully modeled, all EAMG mice showed symptoms of muscle weakness; their diet was reduced; their weight gain was slow; and even weight loss occurred. In MG patients and EAMG mice, the expression of miR-181a was low and TRIM9 was highly expressed. Bioinformatics website and dual-luciferase report analysis of miR-181a had a targeting relationship with TRIM9, and miR-181a could target the expression of TRIM9. After upregulating miR-181a or interfering with TRIM9, serum miR-181a in EAMG mice was significantly upregulated; TRIM9 was significantly downregulated; its clinical symptoms were reduced; and the expression of inflammatory factors was reduced. The study finally learned that miR-181a can reduce the level of MG inflammatory factors by targeting the expression of TRIM9 and has the effect of improving the symptoms of MG.
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Affiliation(s)
- Qiang Wang
- The Second Clinical Medical College of Guizhou University of Traditional Chinese Medicine, Guiyang 550002, Guizhou, China
| | - Yunquan Liu
- The Second Clinical Medical College of Guizhou University of Traditional Chinese Medicine, Guiyang 550002, Guizhou, China
| | - Shixiang Kuang
- The Second Clinical Medical College of Guizhou University of Traditional Chinese Medicine, Guiyang 550002, Guizhou, China
| | - Ruozhao Li
- The Second Clinical Medical College of Guizhou University of Traditional Chinese Medicine, Guiyang 550002, Guizhou, China
| | - Ning Weng
- The Second Clinical Medical College of Guizhou University of Traditional Chinese Medicine, Guiyang 550002, Guizhou, China
| | - Zhichao Zhou
- Department of Neurology, Zhuji Affiliated Hospital of Shaoxing University, Zhuji 311800, Zhejiang, China
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27
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Rispoli MG, Ferri L, Ajdinaj P, Falzano V, Di Muzio A. Guillain-Barré syndrome and myasthenia gravis in the context of autoimmune polyendocrine syndrome type III. Neurol Sci 2021; 42:4789-4792. [PMID: 34331156 DOI: 10.1007/s10072-021-05517-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 07/18/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Marianna Gabriella Rispoli
- Department of Neuroscience, Imaging and Clinical Sciences, G. D'Annunzio University, SS Annunziata Hospital, Via dei Vestini, 66100, Chieti, Abruzzo, Italy. .,Center for Neuromuscular Diseases, "SS Annunziata" Hospital, Chieti, Abruzzo, Italy.
| | - Laura Ferri
- Department of Neuroscience, Imaging and Clinical Sciences, G. D'Annunzio University, SS Annunziata Hospital, Via dei Vestini, 66100, Chieti, Abruzzo, Italy.,Center for Neuromuscular Diseases, "SS Annunziata" Hospital, Chieti, Abruzzo, Italy
| | - Paola Ajdinaj
- Department of Neuroscience, Imaging and Clinical Sciences, G. D'Annunzio University, SS Annunziata Hospital, Via dei Vestini, 66100, Chieti, Abruzzo, Italy.,Center for Neuromuscular Diseases, "SS Annunziata" Hospital, Chieti, Abruzzo, Italy
| | - Valeriana Falzano
- Endocrinology Unit, "SS Annunziata" Hospital, Chieti, Abruzzo, Italy
| | - Antonio Di Muzio
- Center for Neuromuscular Diseases, "SS Annunziata" Hospital, Chieti, Abruzzo, Italy.,Department of Neurology, SS Annunziata Hospital, Chieti, Italy
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28
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Vijayan J, Menon D, Barnett C, Katzberg H, Lovblom LE, Bril V. Clinical profile and impact of comorbidities in patients with very-late-onset myasthenia gravis. Muscle Nerve 2021; 64:462-466. [PMID: 34235762 DOI: 10.1002/mus.27369] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 06/30/2021] [Accepted: 07/04/2021] [Indexed: 11/11/2022]
Abstract
INTRODUCTION/AIMS The purpose of this study was to evaluate the clinical profile of myasthenia gravis (MG) in older patients and determine the impact of medical comorbidities on their MG status and outcome. METHODS This was a retrospective chart review of patients with a symptom onset of MG at or after 65 years of age. Correlations were made between demographics, clinical characteristics, the Myasthenia Gravis Foundation of America (MGFA) severity scale scores, and Myasthenia Gravis Impairment Index (MGII) scores with two outcome measures: MGFA Post-Intervention Status (MGFA-PIS) and Simple Single Question (SSQ). RESULTS The study population included 109 patients, with 90 of them having more than one follow-up visit. Their mean age was 75.3 ± 6.9 years and sex distribution was even. Of these patients, 67.7% had generalized MG. Nine-one percent of patients had one comorbidity. None of the demographic factors or comorbidities showed an association with MGFA-PIS, SSQ, or MGII after correction for multiple comparisons. Seventy-one percent of the patients improved with treatment, 12.4% remained unchanged, and 16.6% showed worsening at their last follow-up visit. DISCUSSION Our study shows that patients with very-late-onset MG had a good prognosis and treatment response. None of the comorbidities had an impact on the severity of myasthenic symptoms or on outcome in these patients.
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Affiliation(s)
- Joy Vijayan
- Ellen and Martin Prosserman Center for Neuromuscular Diseases, Toronto, Ontario, Canada.,Division of Neurology, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Deepak Menon
- Ellen and Martin Prosserman Center for Neuromuscular Diseases, Toronto, Ontario, Canada.,Division of Neurology, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Carolina Barnett
- Ellen and Martin Prosserman Center for Neuromuscular Diseases, Toronto, Ontario, Canada.,Division of Neurology, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Hans Katzberg
- Ellen and Martin Prosserman Center for Neuromuscular Diseases, Toronto, Ontario, Canada.,Division of Neurology, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Leif Erik Lovblom
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Vera Bril
- Ellen and Martin Prosserman Center for Neuromuscular Diseases, Toronto, Ontario, Canada.,Division of Neurology, University Health Network and University of Toronto, Toronto, Ontario, Canada
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Comorbidities worsen the prognosis of generalized myasthenia gravis post-thymectomy. J Neurol Sci 2021; 427:117549. [PMID: 34167051 DOI: 10.1016/j.jns.2021.117549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The effect of comorbidities on the prognosis of myasthenia gravis (MG) remains unclear. In particular, the role of other autoimmune diseases (AD) is controversial. METHODS In this retrospective single-center cohort study, we investigated 154 consecutive generalized thymectomized MG patients, with a mean follow-up time of 8.6 (±5.0) years post-thymectomy. Comorbidities diagnosed at any timepoint were retrieved from medical records and Charlson comorbidity index (CCI) scores were calculated. Patients were categorized into subgroups MG alone (n = 45) and MG with any comorbidity (n = 109); the latter was further categorized into MG with other ADs (n = 33) and MG with non-AD comorbidities (n = 76). The endpoints analyzed were complete stable remission (CSR), minimal need for medications, and need for in-hospital treatments. RESULTS CSR was more frequent in MG alone than in MG with any comorbidity group (26.7% vs 8.3%, p = 0.004). Minimal need for medication was reached more often in the MG alone than in the MG with non-AD comorbidities group (p = 0.047). Need for in-hospital treatments was lower in the MG alone group than in MG patients with any comorbidity (p = 0.046). Logistic regression analysis revealed that lower CCI scores increased the likelihood of CSR (p = 0.033). Lower CCI scores were more prevalent both in patients with minimal need for medication and in patients who did not need in-hospital treatments (p < 0.001). CONCLUSIONS Patients with generalized MG and comorbidities have a poorer prognosis than patients with MG alone during almost 9 years follow-up after thymectomy. AD comorbidities appeared not to translate into a higher risk compared to other comorbidities.
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30
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Sherman WF, Wu VJ, Ofa SA, Ross BJ, Savage-Elliott ID, Sanchez FL. Increased rate of complications in myasthenia gravis patients following hip and knee arthroplasty: a nationwide database study in the PearlDiver Database on 257,707 patients. Acta Orthop 2021; 92:176-181. [PMID: 33390062 PMCID: PMC8158199 DOI: 10.1080/17453674.2020.1865031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - The increasing prevalence of total hip arthroplasty (THA) and total knee arthroplasty (TKA) within the growing elderly population is translating into a larger number of patients with neuromuscular conditions such as myasthenia gravis (MG) receiving arthroplasty. We compared systemic and joint complications following a THA or TKA between patients with MG and patients without MG.Patients and methods - Patient records were queried from PearlDiver (Pearl Diver Inc, Fort Wayne, IN, USA), an administrative claims database, using ICD-9/ICD-10 and Current Procedural Terminology codes. In-hospital and 90-day post-discharge rates of systemic and joint complications were compared between the 2 cohorts.Results - 372 patients with MG and 249,428 patients without MG who received a THA or TKA were included in the study. At 90 days post-discharge, MG patients exhibited exhibited between 1.6 and 15% higher rates of systemic complications, including cerebrovascular event, pneumonia, respiratory failure, sepsis, myocardial infarction, acute renal failure, anemia, and deep vein thrombosis (all p < 0.001). The same results were also found during the in-hospital time period. 90-day incidence of aseptic loosening was the only joint complication with significantly increased odds risk for the MG cohort (OR 5; 95% CI 2-12).Interpretation - Patients with MG exhibited significantly higher risk for multiple systemic complications during the index hospital stay and in the acute post-discharge setting.
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Affiliation(s)
- William F Sherman
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA, USA,Correspondence:
| | - Victor J Wu
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Sione A Ofa
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Bailey J Ross
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Ian D Savage-Elliott
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Fernando L Sanchez
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA, USA
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Kalita J, Tripathi A, Dongre N, Misra UK. Impact of COVID-19 pandemic and lockdown in a cohort of myasthenia gravis patients in India. Clin Neurol Neurosurg 2021; 202:106488. [PMID: 33460984 PMCID: PMC7803624 DOI: 10.1016/j.clineuro.2021.106488] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/02/2021] [Accepted: 01/08/2021] [Indexed: 12/15/2022]
Abstract
Objective Myasthenia gravis (MG) is characterized by fluctuating muscle weakness due to immune mediated damage of acetylcholine receptor (AchR). COVID-19 infection, mental stress and non-availability of drugs following lockdown may worsen myasthenic symptoms. We report the impact of COVID 19, and lockdown on the physical and mental health, and quality of sleep in a cohort of MG. Methods Thirty-eight MG patients were telephonically interviewed 2months after the declaration of lockdown in India. The difficulty in procuring drugs, complications, and worsening in the MG Foundation of America (MGFA) stage were noted. The patients were enquired about MG Quality of Life 15 (MGQOL15), MG Activity of Daily Living (MGADL), Hospital Anxiety and Depression Scale (HADS) and Pittsburgh Sleep Quality Index (PSQI) using a prefixed questionnaire. Their pre-COVID parameters were retrieved from our earlier trial data, which was completed 4months back. The scores of the above mentioned parameters before and after COVID were compared. Results Their median age was 45 years, and the median duration of treatment for MG was 4.5years. Eleven (28.9 %) patients were hypertensive and 3(7.9 %) diabetic. All were on prednisolone and 18(47.4 %) received azathioprine. None developed COVID, but three had other infections. Two patients needed hospitalization because of wrong medication in one and severe anxiety-insomnia in another. Following COVID19 and lockdown, MG patients had worsening in MGQOL15, MGADL, HADS and PSQI scores. Pittsburgh Sleep Quality Index score correlated with MGQOL15 and dose of acetylcholine esterase inhibitors. Conclusion COVID-19 and lockdown were associated with anxiety, depression, poor MGQOL and sleep especially in severe MG patients.
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Affiliation(s)
- Jayantee Kalita
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, 226014, India.
| | - Abhilasha Tripathi
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, 226014, India
| | - Nikhil Dongre
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, 226014, India
| | - Usha K Misra
- Department of Neurology, Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226007, India
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Incidence, mortality, and economic burden of myasthenia gravis in China: A nationwide population-based study. LANCET REGIONAL HEALTH-WESTERN PACIFIC 2020; 5:100063. [PMID: 34327399 PMCID: PMC8315547 DOI: 10.1016/j.lanwpc.2020.100063] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/11/2020] [Accepted: 11/16/2020] [Indexed: 02/06/2023]
Abstract
Background Myasthenia gravis (MG) is the most common primary disorder of neuromuscular transmission, but the incidence of MG in China is unknown. We conducted the first nationwide study to determine the incidence and mortality rates of MG in all age groups at the national level in China. Methods This national population-based registry study is based on the database of the Hospital Quality Monitoring System of National Health Commission, which covers 1665 hospitals providing myasthenia gravis care in 31 provinces and municipalities across China. 94,638 hospital admissions for 59,243 myasthenia gravis patients were identified from January 1st, 2016 to December 31st, 2018. Myasthenia gravis was identified by ICD-10 codes (G70). Incidence of myasthenia gravis was stratified by age, sex, and province. Findings Of 59,243 patients, 30,503 individuals with myasthenia gravis were newly diagnosed. Age and sex adjusted incidence of myasthenia gravis was 0.68 per 100,000 person-years, with highest in the age group of 70–74 years. The incidence in females was 0.76 per 100,000 and 0.60 per 100,000 in males. The admission mortality rate was 14.69‰. Respiratory failure was the leading cause of death in patients with myasthenic crisis. There were 14,840 patients with thymomas, encompassing 14,636 (26.5%) adults and 204 (7.1%) juveniles. 9453 (63.7%) patients with thymomas underwent thymomectomy. The median length of hospital stay was 8 days (interquartile range (IQR) 4 to 15 days) with median hospitalization cost $1037 (IQR $493 to $2925). The Basic Medical Insurance was the most common payment method, covering 67.4% of patients. Interpretation The age and sex adjusted incidence of MG was 0.68 per 100,000 person-years in China. The admission mortality rate was 14.69‰. Most cases of new onset MG occurred in the seventh decade of life. Funding National Science Foundation of China (91642205, and 81830038); Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing
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Dong D, Chong MKC, Wu Y, Kaminski H, Cutter G, Xu X, Li H, Zhao C, Yin J, Yu S, Zhu J. Gender differences in quality of life among patients with myasthenia gravis in China. Health Qual Life Outcomes 2020; 18:296. [PMID: 32883289 PMCID: PMC7470440 DOI: 10.1186/s12955-020-01549-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 08/28/2020] [Indexed: 11/10/2022] Open
Abstract
Background Myasthenia gravis (MG), a chronic neuromuscular disorder, can adversely affect patients’ health-related quality of life (HRQoL), especially in women. The study aimed to evaluate the difference in HRQoL of women and men MG patients and explore the factors that mediate the relationship between gender and HRQoL. Methods A cross-sectional study was conducted among 1815 patients with MG in China. The revised 15-item MG quality of life scale (MG-QOL15r) was used to access patients’ HRQoL in overall, physical, social and emotional domains. Socio-demographic information, diagnosis and treatment history, comorbidities, social support, active lifestyle and the MG activities of daily living scale (MG-ADL) were recorded and compared between women and men using the Student’s t-test and Pearson’s Chi-square test. Multivariable regression analyses were conducted to identify independent contributors to HRQoL, especially those affecting different gender. Results On average, female patients with MG reported a lower MG-QOL15r score than the males (44.49 ± 29.10 vs 49.32 ± 29.18). The association between gender and patients’ HRQoL interacted with the number of comorbidities across the overall, physical and social domains of patients. As the number of comorbidities increased, the scores of HRQoL decreased and it was faster among females than the males (p < 0.05). Moreover, unemployment, exacerbation of the disease, and active lifestyle contributed to the patients’ HRQoL across all domains. Unemployment (β = − 4.99 [95%CI, − 7.80 to − 2.18], p < 0.001) and exacerbations (β = − 8.49 [95%CI, − 11.43 to − 5.54], p < 0.001) were correlated with poorer HRQoL; while an active lifestyle had a positive impact on HRQoL (β = 0.28 [95%CI, 0.16 to 0.40], p < 0.001). Conclusions The results indicate that the HRQoL of women MG patients was lower than that of men. The relationship between gender and HRQoL is modulated by the number of comorbidities. Thus, to improve the HRQoL of women MG patients, symptomatic treatments might not be enough, their comorbid conditions should be considered as well. Additionally, employment status, MG exacerbations, and an active lifestyle have been found as determining factors of the patients’ HRQoL, which suggests future interventions should cope with these factors to improve their quality of life.
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Affiliation(s)
- Dong Dong
- JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, SAR, China
| | - Marc Ka-Chun Chong
- JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, SAR, China
| | - Yushan Wu
- JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, SAR, China
| | - Henry Kaminski
- Department of Neurology, The George Washington University, Washington, DC, USA
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Xianhao Xu
- Department of Neurology, Beijing Hospital, Beijing, China
| | - Haifeng Li
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chongbo Zhao
- Department of Neurology, Huashan hospital, Fudan University, Shanghai, China
| | - Jian Yin
- Department of Neurology, Beijing Hospital, Beijing, China.,National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Siyue Yu
- JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, SAR, China.
| | - Jianfeng Zhu
- School of Social Development and Public Policy, Fudan University, Shanghai, China.
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Chou C, Huang M, Lan W, Kong S, Kuo C, Chou I. Prevalence and risk of thyroid diseases in myasthenia gravis. Acta Neurol Scand 2020; 142:239-247. [PMID: 32329050 DOI: 10.1111/ane.13254] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/17/2020] [Accepted: 04/20/2020] [Indexed: 01/05/2023]
Abstract
OBJECTIVES To estimate the prevalence of thyroid diseases and the cumulative risk of thyroid diseases during a follow-up period after myasthenia gravis (MG) diagnosis compared with non-MG controls. MATERIALS AND METHODS We used the Taiwan National Health Insurance Database linked to Registry of Catastrophic Illness database to identify patients with MG. The controls were composed of those who did not have MG and were matched with the MG patients by sex, age, and the index date. We recorded thyroid disease histories before and after the index date. RESULTS Our study included 5813 MG patients and 29 065 controls. The prevalence of thyroid diseases in the MG patients at diagnosis was 18.4%, which was nearly 3.9-fold greater than that in the control group. (Odds ratio [OR] 3.895, 95% Confidence interval [CI] 3.574-4.246) After excluding pre-existing thyroid diseases, the incidence of comorbid thyroid diseases was 8.7% in the MG patients and 4% in the control group. The MG patients had a 2.36-fold increased risk of developing thyroid diseases compared to the control group. (crude hazard ratio [HR] 2.360, 95% CI 2.095-2.659) The cumulative probabilities of developing thyroid diseases at 1, 5, and 10 years after the index date were 21.6%, 24.9%, and 28.7%, respectively, in the MG patients, while the cumulative probabilities were 6.5%, 8.8%, and 11.8%, respectively, in control group (log-rank test <0.0001). CONCLUSIONS The current population-based study showed a higher prevalence of pre-existing thyroid diseases and a higher cumulative probability of thyroid diseases during follow-up after MG diagnosis than in the general population.
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Affiliation(s)
- Cheng‐Che Chou
- Division of Paediatric Neurology Taipei Medical University Shuang Ho Hospital New Taipei City Taiwan
| | - Man‐Hsu Huang
- Division of Pathology Taipei Medical University Shuang Ho Hospital New Taipei City Taiwan
| | - Wen‐Ching Lan
- Division of Big Data Analytics and Statistics Chang Gung Memorial Hospital, Linko Branch Taoyuan Taiwan
| | - Shu‐Sing Kong
- Division of Paediatric Neurology Taipei Medical University Shuang Ho Hospital New Taipei City Taiwan
| | - Chang‐Fu Kuo
- Division of Rheumatology Chang Gung Memorial Hospital, Linko Branch Taoyuan Taiwan
| | - I‐Jun Chou
- Division of Paediatric Neurology Chang Gung Memorial Hospital and Chang Gung Children’s Hospital, Linko Branch Taoyuan Taiwan
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Social, professional and neuropsychiatric outcomes in patients with myasthenia gravis. Neurol Sci 2020; 42:167-173. [PMID: 32592102 DOI: 10.1007/s10072-020-04528-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 06/21/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Recent medical advances have enabled the control of neurological symptoms and increased survival of patients with myasthenia gravis (MG). However, MG has many veiled consequences that may be underestimated by neurologists. Our aim was to clarify the social, professional, and neuropsychiatric issues of MG patients. METHODS We carried out a cross-sectional cohort study with MG patients from a university-affiliated referral hospital. We registered clinical and sociodemographic data, and patients were classified according the MGFA classification. Clinical severity was assessed with Myasthenia Gravis Composite (MGC) scale. Trained and blind investigators analyzed social and professional outcomes. Neuropsychiatric symptoms were evaluated with the Hospital Anxiety and Depression Scale (HADS) and the social support with the Multidimensional Scale of Perceived Social Support (MSPSS). RESULTS We enrolled 49 patients with MG. The mean age was 45.3 ± 18.1 years and 39 (79.6%) were women. There were 19 (38.8%) patients who become unemployed, 23 (46.9%) who had to retire prematurely, 31 (63.3%) that reported a significant reduction in work performance, and 23 (46.9%) who had a reduction in monthly income after the diagnosis of MG. Only 16 (32.6%) received any financial support and 24 (48.9%) patients had the perception of receiving a satisfactory social support. The practice of physical activity is a habit in only 10 patients (20.4%). Neuropsychiatric symptoms were present in 26 (53.1%) patients. CONCLUSION Patients with MG are vulnerable to social, professional, and mental disadvantages. Therapeutic success in MG goes beyond symptom relief and inevitably depends on a personalized approach to the patient.
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Vitturi BK, Pellegrinelli A, Valerio BCO. Medication adherence in patients with myasthenia gravis in Brazil: a cross-sectional study. Acta Neurol Belg 2020; 120:83-89. [PMID: 31555980 DOI: 10.1007/s13760-019-01209-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 09/16/2019] [Indexed: 10/25/2022]
Abstract
Advances in the treatment of MG have allowed most patients to effectively treat their disorder with oral medications. In parallel, non-adherence to medication treatment regimens is a worldwide health problem. Other chronic neurological disorders have already been associated with low adherence to treatment. However, the literature regarding adherence among patients with MG is definitely poor. The purpose of this study was to capture the prevalence and the associated factors of non-adherence to pharmacological treatment in patients with MG. We carried out a cross-sectional cohort study with 58 consecutive patients with MG from a university-affiliated referral hospital in São Paulo, Brazil. We registered clinical and sociodemographic data and patients were classified according to the MGFA classification. Clinical severity was assessed with myasthenia gravis composite (MGC) scale. Neuropsychiatric symptoms were evaluated with the Hospital Anxiety and Depression Scale (HADS) and quality of life with the 15-Item Quality Of Life Instrument for myasthenia gravis scale (MG-QOL15). Adherence to pharmacological treatment was evaluated using the 8-item Morisky Medication Adherence Scale (MMAS-8). There were 26 (44.8%) patients adherent to treatment. Low adherence was associated with poor educational attainment, longer time of disease and greater daily number of pills (p < 0.05). Patients with poor compliance to treatment presented worse quality of life and increased neuropsychiatric symptoms (p < 0.05). Adherence can be relatively challenging in patients with MG. Medical approach should recognize that therapeutic success in the treatment of MG goes through adherence to treatment.
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