1
|
Wang Z, Zhang Z, Luo T, Du X, Yang M, Yao Q, Su L, Li Y, Chen X, Huang X, Zhang Y. Increased serum interleukin-41 correlates with disease severity in myasthenia gravis. Int Immunopharmacol 2024; 134:112275. [PMID: 38759373 DOI: 10.1016/j.intimp.2024.112275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 05/12/2024] [Accepted: 05/13/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Myasthenia gravis (MG) is an autoimmune disease mediated by pathogenic antibodies produced by abnormally activated B cells, resulting in neuromuscular junction transmission dysfunction. Interleukin-41 (IL-41) is a novel immunomodulatory cytokine that has been implicated in various metabolic, inflammatory, and autoimmune diseases. The role of IL-41 in MG is still unclear up to now, our study aimed to investigate the level of IL-41 in MG patients and its correlation with clinical features and inflammatory indicators. METHODS Totally, 60 MG patients and 30 healthy controls (HC) were recruited. Baseline data and laboratory parameters were routinely recorded through electronic medical systems. IL-41 levels were measured by enzyme-linked immunosorbent assay. Proportions of T-cell and B-cell subsets and natural killer cells were analyzed by flow cytometry. The correlation between serum IL-41 and MG related parameters was investigated, and the clinical value of IL-41 in the diagnosis of MG was evaluated by receiver operator characteristic curve (ROC) analysis. RESULTS Serum IL-41 levels in MG patients were higher than in HC, and were higher in Myasthenia Gravis Foundation of America (MGFA) III + IV group than that in MGFA I + II group. Serum IL-41 was positively correlated with MG-specific activities of daily living scale (MG-ADL), MGFA classification, platelet to lymphocyte ratio (PLR), and proportion of CD19+ B cells, while it was negatively correlated with high-sensitive C-reactive protein (hs-CRP) and circulatory plasma cells in MG patients. Serum IL-41 levels increased in patients who were treated with efgartigimod during the first cycle of therapy. However, compared to disease initiation, serum IL-41 levels decreased when clinical features steadily improved. ROC analysis showed that IL-41 had a diagnostic value for MG. CONCLUSION The present findings suggested that serum IL-41 was increased in MG patients and was positively associated with the severity of the disease. IL-41 may be essential to the immunopathological mechanism of MG and a potential biomarker for MG.
Collapse
Affiliation(s)
- Zhouyi Wang
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, No. 99 Huaihai West Road, Quanshan District, Xuzhou, Jiangsu, China; Central Laboratory, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Zhouao Zhang
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, No. 99 Huaihai West Road, Quanshan District, Xuzhou, Jiangsu, China; Central Laboratory, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Tiancheng Luo
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, No. 99 Huaihai West Road, Quanshan District, Xuzhou, Jiangsu, China; Central Laboratory, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Xue Du
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, No. 99 Huaihai West Road, Quanshan District, Xuzhou, Jiangsu, China
| | - Mingjin Yang
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, No. 99 Huaihai West Road, Quanshan District, Xuzhou, Jiangsu, China
| | - Qian Yao
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, No. 99 Huaihai West Road, Quanshan District, Xuzhou, Jiangsu, China
| | - Luyao Su
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, No. 99 Huaihai West Road, Quanshan District, Xuzhou, Jiangsu, China
| | - Yuting Li
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, No. 99 Huaihai West Road, Quanshan District, Xuzhou, Jiangsu, China
| | - Xiao Chen
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, No. 99 Huaihai West Road, Quanshan District, Xuzhou, Jiangsu, China
| | - Xiaoyu Huang
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, No. 99 Huaihai West Road, Quanshan District, Xuzhou, Jiangsu, China; Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China.
| | - Yong Zhang
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, No. 99 Huaihai West Road, Quanshan District, Xuzhou, Jiangsu, China.
| |
Collapse
|
2
|
Ohnari K, Hashimoto T, Iwanaka Y, Ohnari K, Adachi H, Okada K. Dramatic improvement in refractory myasthenia gravis with eculizumab treatment: a case report. J Neurol 2024; 271:2902-2905. [PMID: 38393426 DOI: 10.1007/s00415-024-12245-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/03/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024]
Affiliation(s)
- Kana Ohnari
- Department of Neurology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Tomoyo Hashimoto
- Department of Neurology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan.
| | - Yukio Iwanaka
- Department of Neurology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Keiko Ohnari
- Department of Neurology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Hiroaki Adachi
- Department of Neurology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kazumasa Okada
- Department of Neurology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| |
Collapse
|
3
|
Lu Y, Ma Q, Yu L, Huang H, Liu X, Chen P, Ran H, Liu W. JAK2 inhibitor ameliorates the progression of experimental autoimmune myasthenia gravis and balances Th17/Treg cells via regulating the JAK2/STAT3-AKT/mTOR signaling pathway. Int Immunopharmacol 2023; 115:109693. [PMID: 36638660 DOI: 10.1016/j.intimp.2023.109693] [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: 10/02/2022] [Revised: 12/12/2022] [Accepted: 01/02/2023] [Indexed: 01/12/2023]
Abstract
BACKGROUND An imbalance in Th17/regulatory T (Treg) cells is the major pathogenic mechanism underlying myasthenia gravis (MG). JAK2 inhibitors selectively inhibit JAK2 and reduce inflammatory responses. However, there have been no studies examining the therapeutic effects of JAK2 inhibitors in the context of MG. METHODS Here, an experimental autoimmune MG (EAMG) rat model was established to explore the therapeutic effect of JAK2 inhibitors on EAMG rats immunized with the AChR α-subunit (97-116 peptide). A JAK2 inhibitor was administered to EAMG rats both in vivo and in vitro. The following experimental methods were used to evaluate the effects of JAK2 inhibitors. The behavioral scores and body weights of the rats were assessed on alternate days. Serum anti-AChR (97-116) IgG and cytokine levels were detected using ELISA. CD4+ T cell subsets and related transcription factors in mononuclear cells were detected using flow cytometry and qPCR, respectively. The expression levels of protein molecules in the signaling pathway were detected by western blotting, and the neuromuscular junctions were observed using immunofluorescence. RESULTS The results revealed that JAK2 inhibitors could regulate Th17/Treg balance in vivo and in vitro. JAK2 inhibitors reduced the immune response in EAMG rats (including reducing pro-inflammatory cytokines and postsynaptic membrane complement deposition), improved clinical symptoms, and increased AChR aggregation in the postsynaptic membrane. Meanwhile, this study demonstrated that JAK2 inhibitor treatment suppressed the phosphorylation of JAK2/STAT3 and AKT/mTOR pathways and decreased the expression level of the IL-23 receptor. CONCLUSIONS This study reveals that there is crosstalk between the JAK2/STAT3 and AKT/mTOR pathways in EAMG rats. JAK2 inhibitors can ameliorate EAMG by regulating Th17/Treg balance by inhibiting both signaling pathways. Our study provides new potential therapeutic targets for MG immunotherapy.
Collapse
Affiliation(s)
- Yaru Lu
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, No.58 Zhongshan Road 2, Guangzhou 510080, China
| | - Qian Ma
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, No.58 Zhongshan Road 2, Guangzhou 510080, China
| | - Lu Yu
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, No.58 Zhongshan Road 2, Guangzhou 510080, China
| | - Huan Huang
- Department of Neurology and Psychiatry, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Xiaoxi Liu
- Department of Neurology, Nanfang Hospital, Southern Medical University, No. 1383 North Guangzhou Avenue, Guangzhou 510510, China
| | - Pei Chen
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, No.58 Zhongshan Road 2, Guangzhou 510080, China
| | - Hao Ran
- School of Pharmaceutical Sciences, Sun Yat-Sen University, No.135 West Newport Road, Guangzhou 510006, China
| | - Weibin Liu
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, No.58 Zhongshan Road 2, Guangzhou 510080, China.
| |
Collapse
|
4
|
Huda R. Inflammation and autoimmune myasthenia gravis. Front Immunol 2023; 14:1110499. [PMID: 36793733 PMCID: PMC9923104 DOI: 10.3389/fimmu.2023.1110499] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/13/2023] [Indexed: 02/03/2023] Open
Abstract
Myasthenia gravis (MG) is a neuromuscular autoimmune disorder characterized by chronic but intermittent fatigue of the eye- and general body muscles. Muscle weakness is caused primarily by the binding of an autoantibody to the acetylcholine receptors, resulting in blockage of normal neuromuscular signal transmission. Studies revealed substantial contributions of different proinflammatory or inflammatory mediators in the pathogenesis of MG. Despite these findings, compared to therapeutic approaches that target autoantibody and complements, only a few therapeutics against key inflammatory molecules have been designed or tested in MG clinical trials. Recent research focuses largely on identifying unknown molecular pathways and novel targets involved in inflammation associated with MG. A well-designed combination or adjunct treatment utilizing one or more selective and validated promising biomarkers of inflammation as a component of targeted therapy may yield better treatment outcomes. This review briefly discusses some preclinical and clinical findings of inflammation associated with MG and current therapy approaches and suggest the potential of targeting important inflammatory marker(s) along with current monoclonal antibody or antibody fragment based targeted therapies directed to a variety of cell surface receptors.
Collapse
|
5
|
Iwasa K, Furukawa Y, Yoshikawa H, Yamada M, Ono K. CD59 Expression in Skeletal Muscles and Its Role in Myasthenia Gravis. NEUROLOGY - NEUROIMMUNOLOGY NEUROINFLAMMATION 2023; 10:10/1/e200057. [DOI: 10.1212/nxi.0000000000200057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/19/2022] [Indexed: 11/18/2022]
Abstract
Background and ObjectivesComplement regulatory proteins at the neuromuscular junction (NMJ) could offer protection against complement-mediated damage in myasthenia gravis (MG). However, there is limited information on their expression at the human NMJ. Thus, this study aimed at investigating the expression of the cluster of differentiation 59 (CD59) at the NMJ of human muscle specimens and demonstrating the overexpression ofCD59mRNA and protein in the muscles of patients with MG.MethodsIn this observational study, muscle specimens from 16 patients with MG (9 and 7 patients with and without thymoma, respectively) and 6 nonmyopathy control patients were examined. Immunohistochemical stains, Western blot analysis, and quantitative real-time reverse transcription PCR were used to evaluate the CD59 expression.ResultsA strong localized expression of CD59 was observed at the NMJ in both patients with and without MG. Moreover, the CD59/glyceraldehyde-3-phosphate dehydrogenase protein ratio in patients with MG was significantly higher than that in the nonmyopathy controls (MG; n = 16, median 0.16, interquartile range (IQR) 0.08–0.26 and nonmyopathy controls; n = 6, median 0.03, IQR 0.02–0.11,p= 0.01). The proportion ofCD59mRNA expression relative toAChRmRNA expression (ΔCtCD59/AChR) was associated with the quantitative MG score, MG activities of daily living score, and MG of Foundation of America Clinical Classification (r= 0.663,p= 0.01;r= 0.638,p= 0.014; andr= 0.715,p= 0.003, respectively).DiscussionCD59, which acts as a complement regulator, may protect the NMJ from complement attack. Our findings could provide a basis for further research that investigates the underlying pathogenesis in MG and the immunomodulating interactions of the muscle cells.
Collapse
|
6
|
Huang X, Xu M, Wang Y, Zhang Z, Li F, Chen X, Zhang Y. The systemic inflammation markers as possible indices for predicting respiratory failure and outcome in patients with myasthenia gravis. Ann Clin Transl Neurol 2022; 10:98-110. [PMID: 36453129 PMCID: PMC9852395 DOI: 10.1002/acn3.51706] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/08/2022] [Accepted: 11/10/2022] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE This study aimed to explore the relationship between systemic inflammation markers and clinical activity, respiratory failure, and prognosis in patients with myasthenia gravis (MG). METHODS One hundred and seventeen MG patients and 120 controls were enrolled in this study. Differences in the four immune-related markers of two groups based on blood cell counts: neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), lymphocyte to monocyte ratio (LMR), and systemic immune-inflammation index (SII) were measured. The stability of the associations between systemic inflammation markers and respiratory failure in MG patients was confirmed by adjusted logistic regression analysis. Moreover, Kaplan-Meier curve and multivariate COX regression models were applied to assess the factors affecting the outcome of MG. RESULTS NLR, PLR, and SII were higher in MG patients than those in controls and were positively associated with MGFA classification, but not LMR. Adjusted logistic regression analysis showed that PLR was an independent predictor of MG with respiratory failure. The ROC curve demonstrated that PLR showed good sensitivity and specificity for the diagnosis of MG with respiratory failure. Kaplan-Meier curve showed that GMG, positive AchR-Ab, respiratory failure, high NLR, PLR, SII, and IVIg exposure correlated with the risk for poor outcomes in MG patients. The multivariate COX regression models indicated that GMG and high SII was a risk factor for poor outcome of MG. INTERPRETATION The systemic inflammation markers expressed abnormally in MG patients, in which PLR may be an independent predictor of respiratory failure, and high SII and GMG were predictive risk factors for poor outcomes in MG patients.
Collapse
Affiliation(s)
- Xiaoyu Huang
- Department of NeurologyAffiliated Hospital of Xuzhou Medical UniversityNo. 99 Huaihai West Road, Quanshan DistrictXuzhouJiangsuChina,Department of NeurologyTianjin Neurological Institute, Tianjin Medical University General HospitalTianjinChina
| | - Mingming Xu
- Department of NeurologyAffiliated Hospital of Xuzhou Medical UniversityNo. 99 Huaihai West Road, Quanshan DistrictXuzhouJiangsuChina
| | - Yingying Wang
- Department of NeurologyAffiliated Hospital of Xuzhou Medical UniversityNo. 99 Huaihai West Road, Quanshan DistrictXuzhouJiangsuChina
| | - Zhouao Zhang
- Department of NeurologyAffiliated Hospital of Xuzhou Medical UniversityNo. 99 Huaihai West Road, Quanshan DistrictXuzhouJiangsuChina
| | - Fengzhan Li
- Department of NeurologyAffiliated Hospital of Xuzhou Medical UniversityNo. 99 Huaihai West Road, Quanshan DistrictXuzhouJiangsuChina
| | - Xiao Chen
- Department of NeurologyAffiliated Hospital of Xuzhou Medical UniversityNo. 99 Huaihai West Road, Quanshan DistrictXuzhouJiangsuChina
| | - Yong Zhang
- Department of NeurologyAffiliated Hospital of Xuzhou Medical UniversityNo. 99 Huaihai West Road, Quanshan DistrictXuzhouJiangsuChina
| |
Collapse
|
7
|
Duan W, Zhou H, Dong X, Li B, Li Y, Cai H, Zhou Q, Ouyang S, Yin W, Yang H. Application of lymphoplasmapheresis in the treatment of severe myasthenia gravis. Front Neurol 2022; 13:1018509. [PMID: 36303555 PMCID: PMC9595276 DOI: 10.3389/fneur.2022.1018509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 09/26/2022] [Indexed: 11/13/2022] Open
Abstract
Background Lymphoplasmapheresis (LPE) is a treatment that combines traditional plasma exchange and lymphocyte removal technique. It has been applied to treat a variety of autoimmune diseases, but its application value in the treatment of severe myasthenia gravis (MG) is not yet clear. Therefore, the aim of this study was to investigate the efficacy and safety of LPE in severe MG. Methods Clinical data of 123 severe patients with MG (Myasthenia Gravis Foundation of America Clinical Classification, Class IV) who received LPE treatment were included in a retrospective analysis. Efficacy was evaluated by the change of Quantitative Myasthenia Gravis score (QMGS) before and after treatment. Univariate and multivariate logistic regression analysis was used to explore clinical factors affecting efficacy. Results A total of 220 replacements were performed in 123 patients, with an average of 1.79 replacements per patient. The overall safety of LPE was good, and no serious adverse reactions occurred. After treatment, the mean QMGS of patients decreased significantly, from 23.40 ± 4.25 points before treatment to 17.93 ± 5.61 points after treatment, a decrease of 5.47 ± 4.16 points. 75.6% of patients experienced remission of clinical symptoms. During a 2-month follow-up of 64 patients, a progressive improvement in QMGS was found. Each muscle group involved in MG responded well to LPE treatment. In addition, LPE significantly reduced the levels of AChR-Ab and inflammatory cytokines in patients. Age ≥ 50 years and co-infection were unfavorable factors affecting the efficacy. Conclusions In this study cohort, LPE is safe for the treatment of severe MG and achieves good treatment outcome with fewer replacements. In patients with MG, the avoidance and timely control of infection are necessary. Our study provides a potential new treatment option for severe MG.
Collapse
Affiliation(s)
- Weiwei Duan
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Hao Zhou
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Xiaohua Dong
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Bijuan Li
- Department of Blood Transfusion, Xiangya Hospital, Central South University, Changsha, China
| | - Yi Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Haobing Cai
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Qian Zhou
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Song Ouyang
- Department of Neurology, The Affiliated Changsha Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Weifan Yin
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Huan Yang
| |
Collapse
|
8
|
Exploring the Gut Microbiome in Myasthenia Gravis. Nutrients 2022; 14:nu14081647. [PMID: 35458209 PMCID: PMC9027283 DOI: 10.3390/nu14081647] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/10/2022] [Accepted: 04/12/2022] [Indexed: 12/13/2022] Open
Abstract
The human gut microbiota is vital for maintaining human health in terms of immune system homeostasis. Perturbations in the composition and function of microbiota have been associated with several autoimmune disorders, including myasthenia gravis (MG), a neuromuscular condition associated with varying weakness and rapid fatigue of the skeletal muscles triggered by the host’s antibodies against the acetylcholine receptor (AChR) in the postsynaptic muscle membrane at the neuromuscular junction (NMJ). It is hypothesized that perturbation of the gut microbiota is associated with the pathogenesis of MG. The gut microbiota community profiles are usually generated using 16S rRNA gene sequencing. Compared to healthy individuals, MG participants had an altered gut microbiota’s relative abundance of bacterial taxa, particularly with a drop in Clostridium. The microbial diversity related to MG severity and the overall fecal short-chain fatty acids (SCFAs) were lower in MG subjects. Changes were also found in terms of serum biomarkers and fecal metabolites. A link was found between the bacterial Operational Taxonomic Unit (OTU), some metabolite biomarkers, and MG’s clinical symptoms. There were also variations in microbial and metabolic markers, which, in combination, could be used as an MG diagnostic tool, and interventions via fecal microbiota transplant (FMT) could affect MG development. Probiotics may influence MG by restoring the gut microbiome imbalance, aiding the prevention of MG, and lowering the risk of gut inflammation by normalizing serum biomarkers. Hence, this review will discuss how alterations of gut microbiome composition and function relate to MG and the benefits of gut modulation.
Collapse
|
9
|
Bahauddin A, Ivannikov M, Wang Z, Jamaluddin M, Curtis K, Ibtehaj N, Yeager L, Soong L, Fang X, Huda R. Histone Deacetylase Isoforms Differentially Modulate Inflammatory and Autoantibody Responses in a Mouse Model of Myasthenia Gravis. Front Neurol 2022; 12:804113. [PMID: 35222229 PMCID: PMC8866970 DOI: 10.3389/fneur.2021.804113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 12/24/2021] [Indexed: 11/13/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disease characterized by chronic muscle fatigue and weakness caused by autoantibodies and complement-mediated damage at neuromuscular junctions. Histone deacetylases (HDACs) are crucial epigenetic regulators of proinflammatory gene expression; however, it is unclear whether HDACs modulate chronic inflammation or autoantibody production associated with MG pathogenesis. We examined expression profiles and serum levels of key inflammatory cytokines (IL-6 and IL-21) and acetylcholine receptor (AChR)-specific autoantibodies following pharmacological inhibition of key HDAC isoforms in a mouse model of MG. We found that HDAC inhibition significantly reduced the production of IL-6, but not IL-21, in AChR-stimulated PBMCs and splenocytes (n = 5 per group). Trichostatin (pan-HDAC inhibitor) treatment of MG-PBMCs (n = 2) also exhibited reduced production of induced IL-6. Although HDAC1 inhibition lowered IL-6 levels the most, HDAC2 inhibition depleted intracellular IL-6 and markedly reduced serum anti-AChR IgG2b in EAMG mice. The transcriptomic profiling and pathway mapping also revealed that autoimmunity-linked, major cell signaling pathways were differentially altered by HDAC1/2 inhibition. HDAC inhibition-mediated reduction in IL-6 and autoantibody levels also correlated with milder disease and preservation of muscle AChR in the treated mice. Overall, our findings revealed isoform-specific functional variance of HDACs in reducing inflammation and identified HDAC-regulated many genes underlying specific inflammatory and autoantibody pathways in EAMG. Thus, the study provides a rationale for further research to evaluate the HDACs or their gene targets as a potential adjunct treatment for MG.
Collapse
Affiliation(s)
- Afrin Bahauddin
- Department of Microbiology and Immunology, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | - Maxim Ivannikov
- Optical Microscopy Core, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | - Zhongying Wang
- Department of Microbiology and Immunology, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | - Mohammad Jamaluddin
- Department of Pediatrics, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | - Kyra Curtis
- School of Medicine, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | - Naazneen Ibtehaj
- Department of Microbiology and Immunology, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | - Linsey Yeager
- Department of Microbiology and Immunology, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | - Lynn Soong
- Department of Microbiology and Immunology, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | - Xiang Fang
- Department of Neurology, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | - Ruksana Huda
- Department of Microbiology and Immunology, University of Texas Medical Branch at Galveston, Galveston, TX, United States
- *Correspondence: Ruksana Huda
| |
Collapse
|
10
|
Gomathy SB, Agarwal A, Vishnu VY. Molecular Therapy in Myasthenia Gravis. Neurology 2022. [DOI: 10.17925/usn.2022.18.1.49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disorder caused by antibodies that act against the myoneural junction. Conventional immunosuppressants such as corticosteroids, azathioprine and mycophenolate are associated with long-term side effects and many patients do not achieve remission and may become refractory. Thus, there is an unmet need for target-specific therapies that act faster, have fewer side effects and lead to stable disease remission. However, many of the novel therapeutic agents being described are not meeting their primary endpoints. We reviewed the current status of novel immunotherapies for MG, their mechanisms of action, along with the side effect profiles. Fast onset of action, sustained disease remission and relatively low frequency of side effects of the new agents are attractive. However, the unknown long-term safety and high cost are precluding factors. Better preclinical studies and more randomized trials are needed before novel agents are routinely employed.
Collapse
|
11
|
Feng X, Song Z, Wu M, Liu Y, Luo S, Zhao C, Zhang W. Efficacy and Safety of Immunotherapies in Refractory Myasthenia Gravis: A Systematic Review and Meta-Analysis. Front Neurol 2021; 12:725700. [PMID: 34925206 PMCID: PMC8672452 DOI: 10.3389/fneur.2021.725700] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 10/25/2021] [Indexed: 01/21/2023] Open
Abstract
Introduction: Approximately 10–20% of patients WITH myasthenia gravis (MG) are refractory to conventional immunotherapies. The purpose of this study was to conduct a systematic review and meta-analysis to explore the optimal therapies for refractory MG. Method: Correlative studies were performed through a search in PubMed, Cochrane Library, and Embase databases. The primary outcome was defined by changes in the quantitative myasthenia gravis score (QMG). Secondary outcomes were defined by the Myasthenia Gravis Activities of Daily Living Scale (MG-ADL), Myasthenia Gravis Foundation of America (MGFA) post intervention status, adverse events, and disease exacerbation after treatment. Result: A total of 16 studies were included with 403 patients with refractory MG on therapies with rituximab, eculizumab, tacrolimus, and cladribine. Therapeutic efficacy of rituximab and eculizumab was identified with an estimated reduction in QMG score (4.158 vs. 6.928) and MG-ADL (4.400 vs. 4.344), respectively. No significant changes were revealed in efficacy or exacerbation density between the two independent therapeutic cohorts. The estimated adverse event density of eculizumab was more significant than that in the rituximab group (1.195 vs. 0.134 per patient-year), while the estimated serious event density was similar. Conclusion: The efficacy and safety of rituximab and eculizumab have been approved in patients with refractory MG. Rituximab had a superior safety profile than eculizumab with a lower incidence of adverse events. Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021236818, identifier CRD42021236818.
Collapse
Affiliation(s)
- Xuelin Feng
- Department of Neurology, East Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zubiao Song
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Mengli Wu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yanmei Liu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Sushan Luo
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Chongbo Zhao
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Weixi Zhang
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| |
Collapse
|
12
|
Beladakere Ramaswamy S, Singh S, Hooshmand S, Junsang C, Sweeney M, Govindarajan R. Current and Upcoming Treatment Modalities in Myasthenia Gravis. J Clin Neuromuscul Dis 2021; 23:75-99. [PMID: 34808650 DOI: 10.1097/cnd.0000000000000377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
ABSTRACT Myasthenia gravis (MG) is one of the extensively studied autoimmune disorder. There has been a dramatic increase in research to further understand molecular pathogenesis of MG and clinical trials for new drugs in MG treatment in the past decade. This review article is to consolidate the available information in simple terms with students, residents, and fellows as target audience for easy learning and help application of this knowledge to clinical practice.
Collapse
|
13
|
Xiao H, Wu K, Liang X, Li R, Lai KP. Clinical Efficacy and Safety of Eculizumab for Treating Myasthenia Gravis. Front Immunol 2021; 12:715036. [PMID: 34456922 PMCID: PMC8384962 DOI: 10.3389/fimmu.2021.715036] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/26/2021] [Indexed: 12/18/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disease primarily mediated by acetylcholine receptor antibodies (AChR-Ab), cellular immune dependence, and complement system involvement. Since the AChR on the postsynaptic membrane is destroyed by an immune attack, sufficient endplate potential cannot be generated, resulting in the development of a synaptic transmission disorder at the neuromuscular junction and in muscle weakness. The role of the complement system in MG has been demonstrated in animal models and clinical tests, and it has been determined that complement inhibition in patients with MG can prevent disease induction and reverse its progression. Eculizumab is a humanized monoclonal antibody that inhibits the cleavage of complement protein C5 and prevents autoimmune damage; additionally, it has received subsequent approval by the Federal Drug Administration of the United States for MG treatment. However, various concerns regarding the use of eculizumab persist. In this review, we have discussed the treatment time, cost effectiveness, long-term efficacy, and tolerability of eculizumab for MG treatment. We have also summarized historical information and have presented perspectives on this new therapeutic modality.
Collapse
Affiliation(s)
- Hai Xiao
- Department of Neurology, Guigang City People’s Hospital, The Eighth Affiliated Hospital of Guangxi Medical University, Guigang, China
| | - Ka Wu
- Department of Pharmacy, The Second People’s Hospital of Nanning City, The Third Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xiaoliu Liang
- College of Pharmacy, Guangxi Medical University, Nanning, China
| | - Rong Li
- Laboratory of Environmental Pollution and Integrative Omics, Guilin Medical University, Guilin, China
| | - Keng Po Lai
- Laboratory of Environmental Pollution and Integrative Omics, Guilin Medical University, Guilin, China
| |
Collapse
|
14
|
Rodolico C, Nicocia G, Damato V, Antonini G, Liguori R, Evoli A. Benefit and danger from immunotherapy in myasthenia gravis. Neurol Sci 2021; 42:1367-1375. [PMID: 33543421 PMCID: PMC7861968 DOI: 10.1007/s10072-021-05077-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/18/2021] [Indexed: 12/27/2022]
Abstract
In the last years, significant advances have improved the knowledge of myasthenia gravis (MG) immunopathogenesis and have enabled to realize new molecules with a selective action targeting compounds of the immunological system. This review discusses emerging treatments for MG, including complement inhibitors, neonatal Fc receptor targeting agents, and B cell interfering drugs, focusing on benefit and danger. In the second section of the review, several related adverse events of immunotherapy, including MGonset, are debated.
Collapse
Affiliation(s)
- Carmelo Rodolico
- Department of Clinical and Experimental Medicine, Unit of Neurology and Neuromuscular Diseases, University of Messina, Messina, Italy.
| | - Giulia Nicocia
- Department of Clinical and Experimental Medicine, Unit of Neurology and Neuromuscular Diseases, University of Messina, Messina, Italy
| | | | - Giovanni Antonini
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Rocco Liguori
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
- IRCCS, Institute of Neurological Sciences, Bologna, Italy
| | - Amelia Evoli
- Department of Neurosciences, Catholic University, Rome, Italy
| |
Collapse
|
15
|
Howard JF, Vissing J, Gilhus NE, Leite MI, Utsugisawa K, Duda PW, Farzaneh-Far R, Murai H, Wiendl H. Zilucoplan: An Investigational Complement C5 Inhibitor for the Treatment of Acetylcholine Receptor Autoantibody-Positive Generalized Myasthenia Gravis. Expert Opin Investig Drugs 2021; 30:483-493. [PMID: 33792453 DOI: 10.1080/13543784.2021.1897567] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Generalized myasthenia gravis (gMG) is an autoimmune disorder in which pathogenic autoantibodies damage the neuromuscular junction, causing disabling or life-threatening muscle weakness. Most treatments nonspecifically inhibit aspects of the immune system, do not directly address the causal mechanisms of tissue damage, and often have side-effect profiles that negatively impact patients. Understanding of the central pathogenic role of the complement cascade in gMG is advancing, and a new complement-targeting treatment is under investigation. AREAS COVERED We provide an overview of gMG etiology, the complement cascade, current treatments, and the investigational gMG therapy zilucoplan. Zilucoplan is a small, subcutaneously administered, macrocyclic peptide that inhibits cleavage of complement component C5 and the subsequent formation of the membrane attack complex. EXPERT OPINION In a randomized, double-blind, placebo-controlled, phase 2 clinical trial, zilucoplan demonstrated clinically meaningful complement inhibition in patients with acetylcholine receptor-positive gMG. Zilucoplan, a first-of-its-kind cyclic peptide targeting C5, appears to be a therapeutic option for the treatment of gMG based on available pharmacokinetic/pharmacodynamic data and phase 1 and 2 efficacy, safety, and tolerability data with limited long-term follow-up. Zilucoplan use earlier in the treatment paradigm would be suitable in this population should phase 3 efficacy and safety data be equally favorable.
Collapse
Affiliation(s)
- James F Howard
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - John Vissing
- Department of Clinical Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Nils E Gilhus
- Department of Clinical Medicine, University of Bergen and Haukeland University Hospital, Bergen, Norway
| | - M Isabel Leite
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kimiaki Utsugisawa
- Department of Neurology, Hanamaki General Hospital, Hanamaki, Iwate, Japan
| | | | | | - Hiroyuki Murai
- Department of Neurology, International University of Health and Welfare, Narita, Chiba, Japan
| | - Heinz Wiendl
- Department of Neurology, Institute of Translational Neurology, University of Münster, Münster, Germany
| |
Collapse
|
16
|
Wymann S, Dai Y, Nair AG, Cao H, Powers GA, Schnell A, Martin-Roussety G, Leong D, Simmonds J, Lieu KG, de Souza MJ, Mischnik M, Taylor S, Ow SY, Spycher M, Butcher RE, Pearse M, Zuercher AW, Baz Morelli A, Panousis C, Wilson MJ, Rowe T, Hardy MP. A novel soluble complement receptor 1 fragment with enhanced therapeutic potential. J Biol Chem 2020; 296:100200. [PMID: 33334893 PMCID: PMC7948397 DOI: 10.1074/jbc.ra120.016127] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/14/2020] [Accepted: 12/16/2020] [Indexed: 12/13/2022] Open
Abstract
Human complement receptor 1 (HuCR1) is a pivotal regulator of complement activity, acting on all three complement pathways as a membrane-bound receptor of C3b/C4b, C3/C5 convertase decay accelerator, and cofactor for factor I-mediated cleavage of C3b and C4b. In this study, we sought to identify a minimal soluble fragment of HuCR1, which retains the complement regulatory activity of the wildtype protein. To this end, we generated recombinant, soluble, and truncated versions of HuCR1 and compared their ability to inhibit complement activation in vitro using multiple assays. A soluble form of HuCR1, truncated at amino acid 1392 and designated CSL040, was found to be a more potent inhibitor than all other truncation variants tested. CSL040 retained its affinity to both C3b and C4b as well as its cleavage and decay acceleration activity and was found to be stable under a range of buffer conditions. Pharmacokinetic studies in mice demonstrated that the level of sialylation is a major determinant of CSL040 clearance in vivo. CSL040 also showed an improved pharmacokinetic profile compared with the full extracellular domain of HuCR1. The in vivo effects of CSL040 on acute complement-mediated kidney damage were tested in an attenuated passive antiglomerular basement membrane antibody-induced glomerulonephritis model. In this model, CSL040 at 20 and 60 mg/kg significantly attenuated kidney damage at 24 h, with significant reductions in cellular infiltrates and urine albumin, consistent with protection from kidney damage. CSL040 thus represents a potential therapeutic candidate for the treatment of complement-mediated disorders.
Collapse
Affiliation(s)
- Sandra Wymann
- Research and Development, CSL Behring AG, Bern, Switzerland
| | - Yun Dai
- CSL Ltd, Bio21 Institute, Victoria, Australia
| | - Anup G Nair
- CSL Ltd, Bio21 Institute, Victoria, Australia
| | - Helen Cao
- CSL Ltd, Bio21 Institute, Victoria, Australia
| | | | - Anna Schnell
- Research and Development, CSL Behring AG, Bern, Switzerland
| | | | - David Leong
- CSL Ltd, Bio21 Institute, Victoria, Australia
| | | | - Kim G Lieu
- CSL Ltd, Bio21 Institute, Victoria, Australia
| | | | - Marcel Mischnik
- Research and Development, CSL Behring GmbH, Marburg, Germany
| | | | - Saw Yen Ow
- CSL Ltd, Bio21 Institute, Victoria, Australia
| | - Martin Spycher
- Research and Development, CSL Behring AG, Bern, Switzerland
| | | | | | | | | | | | | | - Tony Rowe
- CSL Ltd, Bio21 Institute, Victoria, Australia
| | | |
Collapse
|
17
|
Bennani HN, Lagrange E, Noble J, Malvezzi P, Motte L, Chevallier E, Rostaing L, Jouve T. Treatment of refractory myasthenia gravis by double-filtration plasmapheresis and rituximab: A case series of nine patients and literature review. J Clin Apher 2020; 36:348-363. [PMID: 33349954 DOI: 10.1002/jca.21868] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 12/03/2020] [Accepted: 12/08/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Myasthenia gravis (MG) is an autoimmune disease mediated by circulating autoantibodies (anti-AchR, anti-MuSK, etc.). More than 20% of myasthenic patients are refractory to conventional treatments (plasma exchange, IVIg, steroids, azathioprine, mycophenolate mofetil). Rituximab (B-lymphocyte-depleting anti-CD20) and apheresis (double-filtration plasmapheresis [DFPP] and immunoadsorption [IA]) are interesting therapeutic alternatives. METHODS This monocentric pilot study included nine refractory myasthenic patients (March 2018 to May 2020) treated by DFPP and/or IA associated with rituximab (375 mg/m2 ). Clinical responses were assessed using the Myasthenia Gravis Foundation of America (MGFA) score. RESULTS Average age of patients was 53 ± 17 years. Gender ratio (M/F) was 3:6. The combination of apheresis and rituximab reduced median MGFA score from IV to II after 12 months of follow-up. Clinical improvement assessed by MGFA score was sustained in the long-term for all patients, during an average follow-up of 14 ± 9 months, allowing them to be self-sufficient and out sick-leave. The median number of apheresis sessions was 7 (5-30). The dose of prednisolone was reduced in two patients from 40 mg/d and 30 mg/d to 7.5 mg/d and 10 mg/d, respectively. It was stopped in a patient who was taking 30 mg/d. No infectious, bleeding, or thrombosis complications were noted. CONCLUSION The combination of rituximab and DFPP was effective to treat refractory MG.
Collapse
Affiliation(s)
- Hamza N Bennani
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble, La Tronche, France
| | - Emmeline Lagrange
- Exploration Fonctionnelle du Système Nerveux instead of Service de Neurologie, CHU Grenoble, La Tronche, France
| | - Johan Noble
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble, La Tronche, France
| | - Paolo Malvezzi
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble, La Tronche, France
| | - Lionel Motte
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble, La Tronche, France
| | - Eloi Chevallier
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble, La Tronche, France
| | - Lionel Rostaing
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble, La Tronche, France.,Université Grenoble-Alpes, La Tronche, France
| | - Thomas Jouve
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble, La Tronche, France.,Université Grenoble-Alpes, La Tronche, France
| |
Collapse
|
18
|
Menon D, Barnett C, Bril V. Novel Treatments in Myasthenia Gravis. Front Neurol 2020; 11:538. [PMID: 32714266 PMCID: PMC7344308 DOI: 10.3389/fneur.2020.00538] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 05/14/2020] [Indexed: 01/08/2023] Open
Abstract
Myasthenia gravis (MG) is the prototypical autoimmune disorder caused by specific autoantibodies at the neuromuscular junction. Broad-based immunotherapies, such as corticosteroids, azathioprine, mycophenolate, tacrolimus, and cyclosporine, have been effective in controlling symptoms of myasthenia. While being effective in a majority of MG patients many of these immunosuppressive agents are associated with long-term side effects, often intolerable for patients, and take several months to be effective. With advances in translational research and drug development capabilities, more directed therapeutic agents that can alter the future of MG treatment have been developed. This review focuses on the aberrant immunological processes in MG, the novel agents that target them along with the clinical evidence for efficacy and safety. These agents include terminal complement C5 inhibitors, Fc receptor inhibitors, B cell depleting agents (anti CD 19 and 20 and B cell activating factor [BAFF)]inhibitors), proteosome inhibitors, T cells and cytokine based therapies (chimeric antigen receptor T [CART-T] cell therapy), autologous stem cell transplantation, and subcutaneous immunoglobulin (SCIG). Most of these new agents have advantages over conventional immunosuppressive treatment (IST) for MG therapy in terms of faster onset of action, favourable side effect profile and the potential for a sustained and long-term remission.
Collapse
Affiliation(s)
| | | | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
19
|
Habib AA, Ahmadi Jazi G, Mozaffar T. Update on immune-mediated therapies for myasthenia gravis. Muscle Nerve 2020; 62:579-592. [PMID: 32462710 DOI: 10.1002/mus.26919] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 05/04/2020] [Accepted: 05/07/2020] [Indexed: 11/05/2022]
Abstract
With the exception of thymectomy, immune modulatory treatment strategies and clinical trials in myasthenia gravis over the past 50 y were mainly borrowed from experience in other nonneurologic autoimmune disorders. The current experimental therapy paradigm has significantly changed such that treatments directed against the pathological mechanisms specific to myasthenia gravis are being tested, in some cases as the initial disease indication. Key advances have been made in three areas: (i) the expanded role and long-term benefits of thymectomy, (ii) complement inhibition to prevent antibody-mediated postsynaptic membrane damage, and (iii) neonatal Fc receptor (FcRn) inhibition as in vivo apheresis, removing pathogenic antibodies. Herein, we discuss these advances and the potential for these newer therapies to significantly influence the current treatment paradigms. While these therapies provide exciting new options with rapid efficacy, there are anticipated challenges to their use, especially in terms of a dramatic increase in cost of care for some patients with myasthenia gravis.
Collapse
Affiliation(s)
- Ali Aamer Habib
- Department of Neurology, University of California, Irvine, California
| | | | - Tahseen Mozaffar
- Department of Neurology, University of California, Irvine, California.,Department of Orthopedic Surgery, University of California, Irvine, California.,Departments of Pathology and Laboratory Medicine, University of California, Irvine, California
| |
Collapse
|
20
|
Huda R. New Approaches to Targeting B Cells for Myasthenia Gravis Therapy. Front Immunol 2020; 11:240. [PMID: 32153573 PMCID: PMC7047318 DOI: 10.3389/fimmu.2020.00240] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 01/29/2020] [Indexed: 01/06/2023] Open
Abstract
Current therapies for myasthenia gravis (MG) are limited, and many investigations have recently focused on target-specific therapies. B cell-targeting monoclonal antibody (mAb) therapies for MG are increasingly attractive due to their specificity and efficacy. The targeted B cell biomarkers are mainly the cluster of differentiation (CD) proteins that mediate maturation, differentiation, or survival of pathogenic B cells. Additional B cell-directed therapies include non-specific peptide inhibitors that preferentially target specific B cell subsets. The primary goals of such therapies are to intercept autoantibodies and prevent the generation of an inflammatory response that contributes to the pathogenesis of MG. Treatment of patients with MG using B cell-directed mAbs, antibody fragments, or selective inhibitors have exhibited moderate to high efficacy in early studies, and some of these therapies appear to be highly promising for further drug development. Numerous other biologics targeting various B cell surface molecules have been approved for the treatment of other conditions or are either in clinical trials or preclinical development stages. These approaches remain to be tested in patients with MG or animal models of the disease. This review article provides an overview of B cell-targeted treatments for MG, including those already available and those still in preclinical and clinical development. We also discuss the potential benefits as well as the shortcomings of these approaches to development of new therapies for MG and future directions in the field.
Collapse
Affiliation(s)
- Ruksana Huda
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, United States
| |
Collapse
|
21
|
Nicocia G, Bonanno C, Lupica A, Toscano A, Rodolico C. Myasthenia gravis after etanercept and ustekinumab treatment for psoriatic arthritis: A case report. Neuromuscul Disord 2020; 30:246-249. [PMID: 32057636 DOI: 10.1016/j.nmd.2020.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/02/2020] [Accepted: 01/06/2020] [Indexed: 01/18/2023]
Abstract
A 35-year-old man was diagnosed with psoriatic arthritis treated with methotrexate and cyclosporine, the latter was then interrupted. Subsequently, etanercept was introduced, administered for 10 years and then replaced with ustekinumab. Six months after treatment with ustekinumab, patient underwent a chest CT scan for pneumonia, showing an anterior mediastinal mass which turned out to be a thymoma. He was referred to our department with fatigue, difficulty in raising arms and transient episodes of diplopia after exertion. Clinical history revealed that these symptoms had begun about 7 years previously but were ascribed to psoriatic arthritis. A diagnosis of anti-acetylcholine receptor antibodies positive myasthenia gravis was made; a higher dosage of methotrexate and prednisone were started with regression of symptoms. Our case increases the number of clinical reports of myasthenia gravis onset in patients with a history of rheumatic disease treated with anti-TNFα drugs. We speculate that ustekinumab could contribute to clinical worsening.
Collapse
Affiliation(s)
- Giulia Nicocia
- Department of Clinical and Experimental Medicine, Unit of Neurology and Neuromuscular Diseases, University of Messina, Messina, Italy
| | - Carmen Bonanno
- Department of Clinical and Experimental Medicine, Unit of Neurology and Neuromuscular Diseases, University of Messina, Messina, Italy
| | - Antonino Lupica
- Department of Clinical and Experimental Medicine, Unit of Neurology and Neuromuscular Diseases, University of Messina, Messina, Italy
| | - Antonio Toscano
- Department of Clinical and Experimental Medicine, Unit of Neurology and Neuromuscular Diseases, University of Messina, Messina, Italy
| | - Carmelo Rodolico
- Department of Clinical and Experimental Medicine, Unit of Neurology and Neuromuscular Diseases, University of Messina, Messina, Italy.
| |
Collapse
|
22
|
Abstract
No consensus has been reached on the ideal therapeutic algorithm for myasthenia gravis (MG). Most patients with MG require induction therapy with high doses of corticosteroids and maintenance with an immunosuppressant. Severe cases and acute worsening require intravenous immunoglobulin or plasmapheresis before oral immunosuppressants start having an effect. However, biologics are emerging as important therapeutic tools that promise to provide better corticosteroid sparing effects than standard treatments and can even induce remission. In particular, eculizumab, a monoclonal antibody against complement C5, has been approved by the FDA for refractory MG on the basis of a phase III trial. Rituximab, an anti-CD20 monoclonal antibody that depletes peripheral B cells, has also been effective in many large uncontrolled series, although was not in a small phase III trial. Whether the newer anti-CD20 agents ocrelizumab, ofatumumab, obinutuzumab, ublituximab or inebilizumab will be more effective remains unclear. Belimumab, an antibody against the B cell trophic factor BAFF, was ineffective in phase III trials, and efgartigimod, which depletes antibodies, was effective in a phase II study. Some anti-cytokine agents relevant to MG immunopathogenesis also seem promising. Checkpoint inhibitors can trigger MG in some patients, necessitating early intervention. Increased availability of new biologics provides targeted immunotherapies and the opportunities to develop more specific therapies.
Collapse
|
23
|
Zheng P, Li Y, Wu J, Zhang H, Huang Y, Tan X, Pan J, Duan J, Liang W, Yin B, Deng F, Perry SW, Wong M, Licinio J, Wei H, Yu G, Xie P. Perturbed Microbial Ecology in Myasthenia Gravis: Evidence from the Gut Microbiome and Fecal Metabolome. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2019; 6:1901441. [PMID: 31559142 PMCID: PMC6755540 DOI: 10.1002/advs.201901441] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Indexed: 05/27/2023]
Abstract
Myasthenia gravis (MG) is a devastating acquired autoimmune disease. Emerging evidence indicates that the gut microbiome plays a key role in maintaining immune system homeostasis. This work reports that MG is characterized by decreased α-phylogenetic diversity, and significantly disturbed gut microbiome and fecal metabolome. The altered gut microbial composition is associated with fecal metabolome changes, with 38.75% of altered bacterial operational taxonomic units showing significant correlations with a range of metabolite biomarkers. Some microbes are particularly linked with MG severity. Moreover, a combination of microbial makers and their correlated metabolites enable discriminating MG from healthy controls (HCs) with 100% accuracy. To investigate whether disturbed gut mcirobiome might contribute to the onset of MG, germ-free (GF) mice are initially colonized with MG microbiota (MMb) or healthy microbiota (HMb), and then immunized in a classic mouse model of MG. The MMb mice demonstrate substantially impaired locomotion ability compared with the HMb mice. This effect could be reversed by cocolonizing GF mice with both MMb and HMb. The MMb mice also exhibit similar disturbances of fecal metabolic pathways as found in MG. Together these data demonstrate disturbances in microbiome composition and activity that are likely to be relevant to the pathogenesis of MG.
Collapse
Affiliation(s)
- Peng Zheng
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqing400016China
- Institute of Neuroscience and the Collaborative Innovation Center for Brain ScienceChongqing Medical UniversityChongqing400016China
- NHC Key Laboratory of Diagnosis and Treatment on Brain Function and DiseaseChongqing400016China
| | - Yifan Li
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqing400016China
- Institute of Neuroscience and the Collaborative Innovation Center for Brain ScienceChongqing Medical UniversityChongqing400016China
- NHC Key Laboratory of Diagnosis and Treatment on Brain Function and DiseaseChongqing400016China
| | - Jing Wu
- The M.O.E. Key Laboratory of Laboratory Medical Diagnosticsthe College of Laboratory MedicineChongqing Medical UniversityChongqing400016China
| | - Hanping Zhang
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqing400016China
- Institute of Neuroscience and the Collaborative Innovation Center for Brain ScienceChongqing Medical UniversityChongqing400016China
- NHC Key Laboratory of Diagnosis and Treatment on Brain Function and DiseaseChongqing400016China
| | - Yu Huang
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqing400016China
- Institute of Neuroscience and the Collaborative Innovation Center for Brain ScienceChongqing Medical UniversityChongqing400016China
- NHC Key Laboratory of Diagnosis and Treatment on Brain Function and DiseaseChongqing400016China
| | - Xunmin Tan
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqing400016China
- Institute of Neuroscience and the Collaborative Innovation Center for Brain ScienceChongqing Medical UniversityChongqing400016China
- NHC Key Laboratory of Diagnosis and Treatment on Brain Function and DiseaseChongqing400016China
| | - Junxi Pan
- The M.O.E. Key Laboratory of Laboratory Medical Diagnosticsthe College of Laboratory MedicineChongqing Medical UniversityChongqing400016China
| | - Jiajia Duan
- The M.O.E. Key Laboratory of Laboratory Medical Diagnosticsthe College of Laboratory MedicineChongqing Medical UniversityChongqing400016China
| | - Weiwei Liang
- The M.O.E. Key Laboratory of Laboratory Medical Diagnosticsthe College of Laboratory MedicineChongqing Medical UniversityChongqing400016China
| | - Bangmin Yin
- The M.O.E. Key Laboratory of Laboratory Medical Diagnosticsthe College of Laboratory MedicineChongqing Medical UniversityChongqing400016China
| | - Fengli Deng
- Social Medicine and Health ManagementChongqing Medical UniversityChongqing400016China
| | - Seth W. Perry
- Department of PsychiatryCollege of MedicineSUNY Upstate Medical UniversitySyracuseNY13210USA
| | - Ma‐Li Wong
- Department of PsychiatryCollege of MedicineSUNY Upstate Medical UniversitySyracuseNY13210USA
| | - Julio Licinio
- Department of PsychiatryCollege of MedicineSUNY Upstate Medical UniversitySyracuseNY13210USA
| | - Hong Wei
- Precision Medicine InstituteThe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouGuangdong510080China
| | - Gang Yu
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqing400016China
| | - Peng Xie
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqing400016China
- Institute of Neuroscience and the Collaborative Innovation Center for Brain ScienceChongqing Medical UniversityChongqing400016China
- NHC Key Laboratory of Diagnosis and Treatment on Brain Function and DiseaseChongqing400016China
| |
Collapse
|
24
|
Cai X, Li Z, Xi J, Song H, Liu J, Zhu W, Guo Y, Jiao Z. Myasthenia gravis and specific immunotherapy: monoclonal antibodies. Ann N Y Acad Sci 2019; 1452:18-33. [PMID: 31393614 DOI: 10.1111/nyas.14195] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/23/2019] [Accepted: 06/25/2019] [Indexed: 01/21/2023]
Affiliation(s)
- Xiao‐Jun Cai
- Department of Clinical Pharmacy, Huashan HospitalFudan University Shanghai P. R. China
- Department of Pharmacythe Affiliated Wuxi People's Hospital of Nanjing Medical University Wuxi P. R. China
| | - Zai‐Wang Li
- Department of Neurology, Shenzhen People's Hospital, the Second Clinical Medical College of Jinan Universitythe First Affiliated Hospital of Southern University of Science and Technology Shenzhen P. R. China
- Department of Neurologythe Affiliated Wuxi People's Hospital of Nanjing Medical University Wuxi P. R. China
| | - Jian‐Ying Xi
- Department of Neurology, Huashan HospitalFudan University Shanghai P. R. China
| | - Hui‐Zhu Song
- Department of Pharmacythe Affiliated Wuxi People's Hospital of Nanjing Medical University Wuxi P. R. China
| | - Jue Liu
- Department of Clinical Pharmacy, Huashan HospitalFudan University Shanghai P. R. China
| | - Wen‐Hua Zhu
- Department of Neurology, Huashan HospitalFudan University Shanghai P. R. China
| | - Yi Guo
- Department of Neurology, Shenzhen People's Hospital, the Second Clinical Medical College of Jinan Universitythe First Affiliated Hospital of Southern University of Science and Technology Shenzhen P. R. China
| | - Zheng Jiao
- Department of Clinical Pharmacy, Huashan HospitalFudan University Shanghai P. R. China
| |
Collapse
|
25
|
Long-term efficacy and safety of eculizumab in Japanese patients with generalized myasthenia gravis: A subgroup analysis of the REGAIN open-label extension study. J Neurol Sci 2019; 407:116419. [PMID: 31698177 DOI: 10.1016/j.jns.2019.08.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 08/01/2019] [Accepted: 08/02/2019] [Indexed: 12/31/2022]
Abstract
The terminal complement inhibitor eculizumab was shown to improve myasthenia gravis-related symptoms in the 26-week, phase 3, randomized, double-blind, placebo-controlled REGAIN study (NCT01997229). In this 52-week sub-analysis of the open-label extension of REGAIN (NCT02301624), eculizumab's efficacy and safety were assessed in 11 Japanese and 88 Caucasian patients with anti-acetylcholine receptor antibody-positive refractory generalized myasthenia gravis. For patients who had received placebo during REGAIN, treatment with open-label eculizumab resulted in generally similar outcomes in the Japanese and Caucasian populations. Rapid improvements were maintained for 52 weeks, assessed by change in score from open-label extension baseline to week 52 (mean [standard error]) using the following scales (in Japanese and Caucasian patients, respectively): Myasthenia Gravis Activities of Daily Living (-2.4 [1.34] and - 3.3 [0.65]); Quantitative Myasthenia Gravis (-2.9 [1.98] and - 4.3 [0.79]); Myasthenia Gravis Composite (-4.5 [2.63] and - 4.9 [1.19]); and Myasthenia Gravis Quality of Life 15-item questionnaire (-8.6 [5.68] and - 6.5 [1.93]). Overall, the safety of eculizumab was consistent with its known safety profile. In this interim sub-analysis, the efficacy and safety of eculizumab in Japanese and Caucasian patients were generally similar, and consistent with the overall REGAIN population.
Collapse
|
26
|
Edmundson C, Guidon AC. Eculizumab: A Complementary addition to existing long-term therapies for myasthenia gravis. Muscle Nerve 2019; 60:7-9. [PMID: 31074870 DOI: 10.1002/mus.26512] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Christyn Edmundson
- Division of Neuromuscular Medicine, Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amanda C Guidon
- Division of Neuromuscular Medicine, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 820, Boston, Massachusetts, 02114, USA
| |
Collapse
|
27
|
Abstract
The humanized monoclonal antibody eculizumab (Soliris®) is a complement inhibitor indicated for use in anti-acetylcholine receptor (AChR) antibody-positive adults with generalized myasthenia gravis (gMG) in the USA, refractory gMG in the EU, or gMG with symptoms that are difficult to control with high-dose IVIg therapy or PLEX in Japan. It is the first complement inhibitor to be approved for use in these patients. In the well-designed, 26-week REGAIN study in patients with anti-AChR-positive refractory gMG, although a statistically significant benefit of eculizumab over placebo in the prespecified primary endpoint analysis (change from baseline in MG-activities of daily living (ADL) score assessed by worst-rank ANCOVA) was not formally demonstrated, preplanned and post hoc sensitivity analyses of this outcome, as well as other secondary outcomes supported the efficacy of eculizumab. Overall, patients receiving eculizumab experienced significant improvements in the ADL, muscle strength and health-related quality of life (HR-QOL) parameters relative to patients receiving placebo. Moreover, an ongoing extension of REGAIN showed that treatment benefits with eculizumab were sustained during continued therapy for at least 52 weeks. Eculizumab was generally well tolerated in these studies, with a tolerability profile similar to that reported previously in other indications. Although several questions remain, such as duration of treatment, cost effectiveness and long-term efficacy and tolerability, current evidence indicates that eculizumab is a valuable emerging therapy for patients with refractory gMG.
Collapse
Affiliation(s)
- Sohita Dhillon
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
| |
Collapse
|
28
|
Abstract
Acquired Myasthenia Gravis (MG) is a neuromuscular disease caused by autoantibodies against components of the neuromuscular junction. It is a prototype organ-specific autoimmune disease with well-defined antigenic targets mainly the nicotinic acetylcholine receptor (AChR). Patients suffer from fluctuating, fatigable muscle weakness that worsens with activity and improves with rest. Various therapeutic strategies have been used over the years to alleviate MG symptoms. These strategies aim at improving the transmission of the nerve impulse to muscle or at lowering the immune system with steroids or immunosuppressant drugs. Nevertheless, MG remains a chronic disease and symptoms tend to persist in many patients, some being or becoming refractory over time. In this review, based on recent experimental data on MG or based on results from clinical trials for other autoimmune diseases, we explore new potential therapeutic approaches for MG patients, going from non-specific approaches with the use of stem cells with their anti-inflammatory and immunosuppressive properties to targeted therapies using monoclonal antibodies specific for cell-surface antigens or circulating molecules.
Collapse
Affiliation(s)
- Anthony Behin
- APHP, Centre de Référence des Maladies Neuromusculaires Nord/Est/Ile-de-France, Institut de Myologie, GH Pitié-Salpêtrière, Paris, France.,AIM, Institut de Myologie, Paris, France
| | - Rozen Le Panse
- INSERM U974, Paris, France.,UPMC Sorbonne Université, Paris, France.,AIM, Institut de Myologie, Paris, France
| |
Collapse
|
29
|
Mo C, Zeng Z, Deng Q, Ding Y, Xiao R. Imbalance between T helper 17 and regulatory T cell subsets plays a significant role in the pathogenesis of systemic sclerosis. Biomed Pharmacother 2018; 108:177-183. [PMID: 30219674 DOI: 10.1016/j.biopha.2018.09.037] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 09/06/2018] [Accepted: 09/07/2018] [Indexed: 02/06/2023] Open
Abstract
Systemic sclerosis (SSc) is a rare autoimmune disease that is characterized by fibrosis, inflammation, and vasculopathy of the skin and internal organs. The etiopathogenesis of SSc remains unclear. However, the pivotal role of T lymphocytes with an aberrant immune response in SSc is well established. Among T cells, IL-17-producing helper T (Th17) cell and regulatory T (Treg) cell subsets have recently been found to play crucial roles in SSc pathogenesis. Generally speaking, Th17 cell subsets up-regulate inflammation, fibrosis, and autoimmunity, which are present in SSc, while Treg cell subsets have an immunosuppressive function and resist the immunological performance of Th17 cells. Up-to-date evidence has pointed out that the imbalance and abnormal functions of Th17/Treg cells may contribute to SSc. Therefore, this review aims to summarize the current understanding of the vital cytokines and signaling pathways that are involved in Th17/Treg differentiation and functions, and their roles in the pathogenesis of SSc, thus providing novel insights about targeting the Th17/Treg balance as a potential therapy for SSc treatment in the near future.
Collapse
Affiliation(s)
- Cuiling Mo
- Department of Dermatology, Second Xiangya Hospital, Central South University, 139 Ren-Min Road, Changsha 410011, China; Department of Ophthalmology, Xiangya Hospital, Central South University, Changsha, 410078, China.
| | - Zhuotong Zeng
- Department of Dermatology, Second Xiangya Hospital, Central South University, 139 Ren-Min Road, Changsha 410011, China.
| | - Qiancheng Deng
- Department of Dermatology, Second Xiangya Hospital, Central South University, 139 Ren-Min Road, Changsha 410011, China.
| | - Yan Ding
- Department of Dermatology, Hainan Provincial Dermatology Disease Hospital, 15 LongKun-Nan Road, Haikou 570206, China.
| | - Rong Xiao
- Department of Dermatology, Second Xiangya Hospital, Central South University, 139 Ren-Min Road, Changsha 410011, China.
| |
Collapse
|
30
|
Howard JF, Utsugisawa K, Benatar M, Murai H, Barohn RJ, Illa I, Jacob S, Vissing J, Burns TM, Kissel JT, Muppidi S, Nowak RJ, O'Brien F, Wang JJ, Mantegazza R. Safety and efficacy of eculizumab in anti-acetylcholine receptor antibody-positive refractory generalised myasthenia gravis (REGAIN): a phase 3, randomised, double-blind, placebo-controlled, multicentre study. Lancet Neurol 2017; 16:976-986. [PMID: 29066163 DOI: 10.1016/s1474-4422(17)30369-1] [Citation(s) in RCA: 426] [Impact Index Per Article: 60.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/20/2017] [Accepted: 09/21/2017] [Indexed: 01/30/2023]
Abstract
BACKGROUND Complement is likely to have a role in refractory generalised myasthenia gravis, but no approved therapies specifically target this system. Results from a phase 2 study suggested that eculizumab, a terminal complement inhibitor, produced clinically meaningful improvements in patients with anti-acetylcholine receptor antibody-positive refractory generalised myasthenia gravis. We further assessed the efficacy and safety of eculizumab in this patient population in a phase 3 trial. METHODS We did a phase 3, randomised, double-blind, placebo-controlled, multicentre study (REGAIN) in 76 hospitals and specialised clinics in 17 countries across North America, Latin America, Europe, and Asia. Eligible patients were aged at least 18 years, with a Myasthenia Gravis-Activities of Daily Living (MG-ADL) score of 6 or more, Myasthenia Gravis Foundation of America (MGFA) class II-IV disease, vaccination against Neisseria meningitides, and previous treatment with at least two immunosuppressive therapies or one immunosuppressive therapy and chronic intravenous immunoglobulin or plasma exchange for 12 months without symptom control. Patients with a history of thymoma or thymic neoplasms, thymectomy within 12 months before screening, or use of intravenous immunoglobulin or plasma exchange within 4 weeks before randomisation, or rituximab within 6 months before screening, were excluded. We randomly assigned participants (1:1) to either intravenous eculizumab or intravenous matched placebo for 26 weeks. Dosing for eculizumab was 900 mg on day 1 and at weeks 1, 2, and 3; 1200 mg at week 4; and 1200 mg given every second week thereafter as maintenance dosing. Randomisation was done centrally with an interactive voice or web-response system with patients stratified to one of four groups based on MGFA disease classification. Where possible, patients were maintained on existing myasthenia gravis therapies and rescue medication was allowed at the study physician's discretion. Patients, investigators, staff, and outcome assessors were masked to treatment assignment. The primary efficacy endpoint was the change from baseline to week 26 in MG-ADL total score measured by worst-rank ANCOVA. The efficacy population set was defined as all patients randomly assigned to treatment groups who received at least one dose of study drug, had a valid baseline MG-ADL assessment, and at least one post-baseline MG-ADL assessment. The safety analyses included all randomly assigned patients who received eculizumab or placebo. This trial is registered with ClinicalTrials.gov, number NCT01997229. FINDINGS Between April 30, 2014, and Feb 19, 2016, we randomly assigned and treated 125 patients, 62 with eculizumab and 63 with placebo. The primary analysis showed no significant difference between eculizumab and placebo (least-squares mean rank 56·6 [SEM 4·5] vs 68·3 [4·5]; rank-based treatment difference -11·7, 95% CI -24·3 to 0·96; p=0·0698). No deaths or cases of meningococcal infection occurred during the study. The most common adverse events in both groups were headache and upper respiratory tract infection (ten [16%] for both events in the eculizumab group and 12 [19%] for both in the placebo group). Myasthenia gravis exacerbations were reported by six (10%) patients in the eculizumab group and 15 (24%) in the placebo group. Six (10%) patients in the eculizumab group and 12 (19%) in the placebo group required rescue therapy. INTERPRETATION The change in the MG-ADL score was not statistically significant between eculizumab and placebo, as measured by the worst-rank analysis. Eculizumab was well tolerated. The use of a worst-rank analytical approach proved to be an important limitation of this study since the secondary and sensitivity analyses results were inconsistent with the primary endpoint result; further research into the role of complement is needed. FUNDING Alexion Pharmaceuticals.
Collapse
Affiliation(s)
- James F Howard
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA.
| | | | - Michael Benatar
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Hiroyuki Murai
- Department of Neurology, International University of Health and Welfare, Narita, Japan
| | - Richard J Barohn
- Department of Neurology, University of Kansas Medical Center, Kansas City, KA, USA
| | - Isabel Illa
- Neurology Department, Hospital Sant Pau, Universitat Autònoma Barcelona, Barcelona, Spain
| | - Saiju Jacob
- Queen Elizabeth Neuroscience Centre, Wellcome Trust Clinical Research Facility, University Hospitals of Birmingham, Birmingham, UK
| | - John Vissing
- Rigshospitalet, Department of Neurology, University of Copenhagen, Copenhagen, Denmark
| | - Ted M Burns
- Department of Neurology, University of Virginia Health System, Charlottesville, VA, USA
| | - John T Kissel
- Department of Neurology, Ohio State University, Columbus, OH, USA
| | - Srikanth Muppidi
- Department of Neurology and Neurosciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Richard J Nowak
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | | | | | | | | |
Collapse
|
31
|
Chae CS, Kim GC, Park ES, Lee CG, Verma R, Cho HL, Jun CD, Yoo YJ, Im SH. NFAT1 Regulates Systemic Autoimmunity through the Modulation of a Dendritic Cell Property. THE JOURNAL OF IMMUNOLOGY 2017; 199:3051-3062. [PMID: 28972088 DOI: 10.4049/jimmunol.1700882] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 08/28/2017] [Indexed: 01/10/2023]
Abstract
The transcription factor NFAT1 plays a pivotal role in the homeostasis of T lymphocytes. However, its functional importance in non-CD4+ T cells, especially in systemic immune disorders, is largely unknown. In this study, we report that NFAT1 regulates dendritic cell (DC) tolerance and suppresses systemic autoimmunity using the experimental autoimmune myasthenia gravis (EAMG) as a model. Myasthenia gravis and EAMG are T cell-dependent, Ab-mediated autoimmune disorders in which the acetylcholine receptor is the major autoantigen. NFAT1-knockout mice showed higher susceptibility to EAMG development with enhanced Th1/Th17 cell responses. NFAT1 deficiency led to a phenotypic alteration of DCs that show hyperactivation of NF-κB-mediated signaling pathways and enhanced binding of NF-κB (p50) to the promoters of IL-6 and IL-12. As a result, NFAT1-knockout DCs produced much higher levels of proinflammatory cytokines such as IL-1β, IL-6, IL-12, and TNF-α, which preferentially induce Th1/Th17 cell differentiation. Our data suggest that NFAT1 may limit the hyperactivation of the NF-κB-mediated proinflammatory response in DCs and suppress autoimmunity by serving as a key regulator of DC tolerance.
Collapse
Affiliation(s)
- Chang-Suk Chae
- Academy of Immunology and Microbiology, Institute for Basic Science, Pohang 37673, Republic of Korea
| | - Gi-Cheon Kim
- Academy of Immunology and Microbiology, Institute for Basic Science, Pohang 37673, Republic of Korea
| | - Eun Sil Park
- School of Life Sciences, Gwangju Institute of Science and Technology, Gwangju 61005, Republic of Korea; and
| | - Choong-Gu Lee
- Academy of Immunology and Microbiology, Institute for Basic Science, Pohang 37673, Republic of Korea
| | - Ravi Verma
- Academy of Immunology and Microbiology, Institute for Basic Science, Pohang 37673, Republic of Korea
| | - Haag-Lim Cho
- School of Life Sciences, Gwangju Institute of Science and Technology, Gwangju 61005, Republic of Korea; and
| | - Chang-Duk Jun
- School of Life Sciences, Gwangju Institute of Science and Technology, Gwangju 61005, Republic of Korea; and
| | - Yung Joon Yoo
- School of Life Sciences, Gwangju Institute of Science and Technology, Gwangju 61005, Republic of Korea; and
| | - Sin-Hyeog Im
- Academy of Immunology and Microbiology, Institute for Basic Science, Pohang 37673, Republic of Korea; .,Division of Integrative Biosciences and Biotechnology, Pohang University of Science and Technology, Pohang 37673, Republic of Korea
| |
Collapse
|
32
|
Guoyan Q, Peng L, Shanshan G, Hongxia Y, Huimin D, Yinping X. Effect of Jianpiyiqi granule on ocular myasthenia gravis in children prepared with a formula from Traditional Chinese Medicine. J TRADIT CHIN MED 2017. [DOI: 10.1016/s0254-6272(17)30162-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
33
|
High-dose BAFF receptor specific mAb-siRNA conjugate generates Fas-expressing B cells in lymph nodes and high-affinity serum autoantibody in a myasthenia mouse model. Clin Immunol 2017; 176:122-130. [DOI: 10.1016/j.clim.2017.01.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 01/11/2017] [Indexed: 01/04/2023]
|
34
|
Wu X, Tüzün E. Are linear AChR epitopes the real culprit in ocular myasthenia gravis? Med Hypotheses 2017; 99:26-28. [DOI: 10.1016/j.mehy.2016.11.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 11/23/2016] [Indexed: 10/20/2022]
|
35
|
Dalakas MC. Future perspectives in target-specific immunotherapies of myasthenia gravis. Ther Adv Neurol Disord 2015; 8:316-27. [PMID: 26600875 PMCID: PMC4643871 DOI: 10.1177/1756285615605700] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disease caused by complement-fixing antibodies against acetylcholine receptors (AChR); antigen-specific CD4+ T cells, regulatory T cells (Tregs) and T helper (Th) 17+ cells are essential in antibody production. Target-specific therapeutic interventions should therefore be directed against antibodies, B cells, complement and molecules associated with T cell signaling. Even though the progress in the immunopathogenesis of the disease probably exceeds any other autoimmune disorder, MG is still treated with traditional drugs or procedures that exert a non-antigen specific immunosuppression or immunomodulation. Novel biological agents currently on the market, directed against the following molecular pathways, are relevant and specific therapeutic targets that can be tested in MG: (a) T cell intracellular signaling molecules, such as anti-CD52, anti-interleukin (IL) 2 receptors, anti- costimulatory molecules, and anti-Janus tyrosine kinases (JAK1, JAK3) that block the intracellular cascade associated with T-cell activation; (b) B cells and their trophic factors, directed against key B-cell molecules; (c) complement C3 or C5, intercepting the destructive effect of complement-fixing antibodies; (d) cytokines and cytokine receptors, such as those targeting IL-6 which promotes antibody production and IL-17, or the p40 subunit of IL-12/1L-23 that affect regulatory T cells; and (e) T and B cell transmigration molecules associated with lymphocyte egress from the lymphoid organs. All drugs against these molecular pathways require testing in controlled trials, although some have already been tried in small case series. Construction of recombinant AChR antibodies that block binding of the pathogenic antibodies, thereby eliminating complement and antibody-depended-cell-mediated cytotoxicity, are additional novel molecular tools that require exploration in experimental MG.
Collapse
Affiliation(s)
- Marinos C. Dalakas
- Neuroimmunology Unit, University of Athens Medical School, Athens, Greece and Director, Neuromuscular Division, Thomas Jefferson University, 900 Walnut Street, Philadelphia, PA 19107, USA
| |
Collapse
|
36
|
Abstract
Hypersensitivity reactions to corticosteroids (CS) are rare in the general population, but they are not uncommon in high-risk groups such as patients who receive repeated doses of CS. Hypersensitivity reactions to steroids are broadly divided into two categories: immediate reactions, typically occurring within 1 h of drug administration, and non-immediate reactions, which manifest more than an hour after drug administration. The latter group is more common. We reviewed the literature using the search terms "hypersensitivity to steroids, adverse effects of steroids, steroid allergy, allergic contact dermatitis, corticosteroid side effects, and type I hypersensitivity" to identify studies or clinical reports of steroid hypersensitivity. We discuss the prevalence, mechanism, presentation, evaluation, and therapeutic options in corticosteroid hypersensitivity reactions. There is a paucity of literature on corticosteroid allergy, with most reports being case reports. Most reports involve non-systemic application of corticosteroids. Steroid hypersensitivity has been associated with type I IgE-mediated allergy including anaphylaxis. The overall prevalence of type I steroid hypersensitivity is estimated to be 0.3-0.5%. Allergic contact dermatitis (ACD) is the most commonly reported non-immediate hypersensitivity reaction and usually follows topical CS application. Atopic dermatitis and stasis dermatitis of the lower extremities are risk factors for the development of ACD from topical CS. Patients can also develop hypersensitivity reactions to nasal, inhaled, oral, and parenteral CS. A close and detailed evaluation is required for the clinician to confirm the presence of a true hypersensitivity reaction to the suspected drug and choose the safest alternative. Choosing an alternative CS is not only paramount to the patient's safety but also ameliorates the worry of developing an allergic, and potentially fatal, steroid hypersensitivity reaction. This evaluation becomes especially important in high-risk groups where steroids are a life-saving treatment. The assessment should be done when the patient's underlying condition is in a quiescent state.
Collapse
|
37
|
Guidelines for standard preclinical experiments in the mouse model of myasthenia gravis induced by acetylcholine receptor immunization. Exp Neurol 2015; 270:11-7. [DOI: 10.1016/j.expneurol.2015.02.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 01/13/2015] [Accepted: 02/04/2015] [Indexed: 01/25/2023]
|
38
|
Differential Cytokine Changes in Patients with Myasthenia Gravis with Antibodies against AChR and MuSK. PLoS One 2015; 10:e0123546. [PMID: 25893403 PMCID: PMC4403992 DOI: 10.1371/journal.pone.0123546] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 03/04/2015] [Indexed: 12/16/2022] Open
Abstract
Neuromuscular transmission failure in myasthenia gravis (MG) is most commonly elicited by autoantibodies (ab) to the acetylcholine receptor or the muscle-specific kinase, constituting AChR-MG and MuSK-MG. It is controversial whether these MG subtypes arise through different T helper (Th) 1, Th2 or Th17 polarized immune reactions and how these reactions are blunted by immunosuppression. To address these questions, plasma levels of cytokines related to various Th subtypes were determined in patients with AChR-MG, MuSK-MG and healthy controls (CON). Peripheral blood mononuclear cells (PBMC) were activated in vitro by anti-CD3, and cytokines were quantified in supernatants. In purified blood CD4+ T cells, RNA of various cytokines, Th subtype specific transcription factors and the co-stimulatory molecule, CD40L, were quantified by qRT-PCR. Plasma levels of Th1, Th2 and Th17 related cytokines were overall not significantly different between MG subtypes and CON. By contrast, in vitro stimulated PBMC from MuSK-MG but not AChR-MG patients showed significantly increased secretion of the Th1, Th17 and T follicular helper cell related cytokines, IFN-γ, IL-17A and IL-21. Stimulated expression of IL-4, IL-6, IL-10 and IL-13 was not significantly different. At the RNA level, expression of CD40L by CD4+ T cells was reduced in both AChR-MG and MuSK-MG patients while expression of Th subset related cytokines and transcription factors were normal. Immunosuppression treatment had two effects: First, it reduced levels of IL12p40 in the plasma of AChR-MG and MuSK-MG patients, leaving other cytokine levels unchanged; second, it reduced spontaneous secretion of IFN-γ and increased secretion of IL-6 and IL-10 by cultured PBMC from AChR-MG, but not MuSK-MG patients. We conclude that Th1 and Th17 immune reactions play a role in MuSK-MG. Immunosuppression attenuates the Th1 response in AChR-MG and MuSK-MG, but otherwise modulates immune responses in AChR-MG and MuSK-MG patients differentially.
Collapse
|
39
|
Yang ZX, Xu KL, Xiong H. Clinical characteristics and therapeutic evaluation of childhood myasthenia gravis. Exp Ther Med 2015; 9:1363-1368. [PMID: 25780436 PMCID: PMC4353784 DOI: 10.3892/etm.2015.2256] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 12/05/2014] [Indexed: 11/28/2022] Open
Abstract
This study aimed to analyze the clinical characteristics, classification and treatment of childhood myasthenia gravis (MG) and address the prognosis through follow-up. The clinical data of 135 children with MG were grouped according to clinical type and therapeutic drugs, retrospectively analyzed and prospectively monitored. Of the 135 MG patients, 85.2% had type I (ocular type), with only 4.2% progressing to systemic MG; 13.4% had type II (general type); and 1.5% had type III (fulminating type). Relapse occurred in 46.1% of the 102 patients that were followed up. The positive rate for the primary acetylcholine receptor antibody was 40.19%, without significant differences among clinical subtypes. The positive rate of the repetitive nerve stimulation frequency test by electromyography was 37.97%. Decreased expression of CD4+, CD8+, or CD3+ was present in 71% of the patients. Thymic hyperplasia was present in 5.93% of the patients, while 1.48% had thymoma. Steroid treatment was effective in the majority of the patients. Ocular type MG was common in this cohort of patients. The incidence and mortality of myasthenia crisis were low, the presence of concurrent thymoma was rare and only a limited number of children developed neurological sequelae.
Collapse
Affiliation(s)
- Zhi-Xiao Yang
- Department of Neurology, Children's Hospital of Zhengzhou, Zhengzhou, Henan 450053, P.R. China
| | - Kai-Li Xu
- Department of Neurology, Children's Hospital of Zhengzhou, Zhengzhou, Henan 450053, P.R. China
| | - Hui Xiong
- Department of Paediatrics, Peking University First Hospital, Beijing 100034, P.R. China
| |
Collapse
|
40
|
Luo J, Lindstrom J. Antigen-specific immunotherapeutic vaccine for experimental autoimmune myasthenia gravis. THE JOURNAL OF IMMUNOLOGY 2014; 193:5044-55. [PMID: 25288571 DOI: 10.4049/jimmunol.1401392] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Myasthenia gravis (MG) and experimental autoimmune myasthenia gravis (EAMG) are caused by Ab-mediated autoimmune responses to muscle nicotinic acetylcholine receptors (AChRs) that impair neuromuscular transmission, thereby causing muscle weakness. Previously, we discovered that i.p. injection of a therapeutic vaccine consisting of bacterially expressed cytoplasmic domains of human AChR subunits reduced the development of chronic EAMG in rats. In this article, we show that immunization with the therapeutic vaccine in adjuvants does not induce EAMG and, thus, is safe. The potency and efficacy of the therapeutic vaccine were greatly increased by s.c. administration of repeated low doses in IFA. Onset of chronic EAMG could be prevented. Established chronic EAMG could be rapidly reversed, modeling therapy of chronic MG. Therapy reduced pathological Abs assayed by immune precipitation of a main immunogenic region chimera. Successfully treated rats exhibited long-term resistance to reinduction of EAMG, suggesting a lasting cure of MG. A long-term effect of therapy was to change the isotype of the pathogenic Ab response from IgG2b, which fixes complement, to IgG1, which does not. Prevention and reversal of chronic EAMG was not caused by the isotype switch, but the isotype switch may contribute to resistance to reinduction of EAMG. Immunization with AChR cytoplasmic domains in adjuvant is promising as a safe, Ag-specific, potent, effective, rapidly acting, and long-lasting therapeutic approach to MG.
Collapse
Affiliation(s)
- Jie Luo
- Department of Neuroscience, University of Pennsylvania Medical School, Philadelphia, PA 19104
| | - Jon Lindstrom
- Department of Neuroscience, University of Pennsylvania Medical School, Philadelphia, PA 19104
| |
Collapse
|
41
|
Zhang L, Liu J, Wang H, Zhao C, Lu J, Xue J, Gu Y, Hao C, Lin S, Lv C. Double filtration plasmapheresis benefits myasthenia gravis patients through an immunomodulatory action. J Clin Neurosci 2014; 21:1570-4. [DOI: 10.1016/j.jocn.2013.11.046] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 11/05/2013] [Indexed: 01/06/2023]
|
42
|
Kusner LL, Satija N, Cheng G, Kaminski HJ. Targeting therapy to the neuromuscular junction: proof of concept. Muscle Nerve 2014; 49:749-56. [PMID: 24037951 PMCID: PMC4296224 DOI: 10.1002/mus.24057] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 08/10/2013] [Accepted: 08/13/2013] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The site of pathology in myasthenia gravis (MG) is the neuromuscular junction (NMJ). Our goal was to determine the ability to direct complement inhibition to the NMJ. METHODS A single-chain antibody directed against the alpha subunit of the acetylcholine receptor was synthesized (scFv-35) and coupled to decay-accelerating factor (DAF, scFv-35-DAF). scFv-35-DAF was tested in a passive model of experimentally acquired MG. RESULTS Administration of scFv-35-DAF to mice deficient in intrinsic complement inhibitors produced no weakness despite confirmation of its localization to the NMJ and no evidence of tissue destruction related to complement activation. Rats with experimentally acquired MG treated with scFV-35-DAF showed less weakness and a reduction of complement deposition. CONCLUSIONS We demonstrate a method to effectively target a therapeutic agent to the NMJ.
Collapse
Affiliation(s)
- Linda L Kusner
- Department of Pharmacology and Physiology, George Washington University, Washington, DC, USA
| | | | | | | |
Collapse
|
43
|
Ulusoy C, Kim E, Tüzün E, Huda R, Yılmaz V, Poulas K, Trakas N, Skriapa L, Niarchos A, Strait RT, Finkelman FD, Turan S, Zisimopoulou P, Tzartos S, Saruhan-Direskeneli G, Christadoss P. Preferential production of IgG1, IL-4 and IL-10 in MuSK-immunized mice. Clin Immunol 2014; 151:155-63. [DOI: 10.1016/j.clim.2014.02.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 02/06/2014] [Accepted: 02/20/2014] [Indexed: 01/09/2023]
|
44
|
Clinical Study of Effects of Jian Ji Ning, a Chinese Herbal Medicine Compound Preparation, in Treating Patients with Myasthenia Gravis via the Regulation of Differential MicroRNAs Expression in Serum. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2014; 2014:518942. [PMID: 24734107 PMCID: PMC3956408 DOI: 10.1155/2014/518942] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 10/09/2013] [Accepted: 10/22/2013] [Indexed: 02/07/2023]
Abstract
Myasthenia gravis (MG) is an autoimmune disease, of which the pathogenesis has remained unclear. At present, MG does not have any effective treatment with minor side effects. Jian Ji Ning (JJN), a traditional Chinese medicine formula consisting of 11 medicinal plants, has been used in the treatment of MG for many years. The present study aims to determine if the Chinese herbal medicine JJN could lighten the clinical symptoms of patients with MG via the regulation of differential microRNAs (miRNAs) expression in serum. JJN should be orally administered twice a day for 6 months. In the efficacy evaluation adopting the Quantitative Myasthenia Gravis Score (QMG), we found that JJN could improve the clinical symptoms of patients with MG more effectively. Besides, we found that JJN could regulate differential miRNAs expression in serum of patients with MG. Accordingly, we speculate that the effects of JJN on improving clinical symptoms and blood test indicators of patients with MG may be due to its inhibition of apoptotic pathways of some immune cells and its connection with the regulation of serum miRNAs of some patients. In conclusion, we believe that JJN has a reliable curative effect on patients with MG-induced neuropathologic changes.
Collapse
|
45
|
Howard JF, Barohn RJ, Cutter GR, Freimer M, Juel VC, Mozaffar T, Mellion ML, Benatar MG, Farrugia ME, Wang JJ, Malhotra SS, Kissel JT. A randomized, double-blind, placebo-controlled phase II study of eculizumab in patients with refractory generalized myasthenia gravis. Muscle Nerve 2013; 48:76-84. [PMID: 23512355 DOI: 10.1002/mus.23839] [Citation(s) in RCA: 153] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2013] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Complement activation at the neuromuscular junction is a primary cause of acetylcholine receptor loss and failure of neuromuscular transmission in myasthenia gravis (MG). Eculizumab, a humanized monoclonal antibody, blocks the formation of terminal complement complex by specifically preventing the enzymatic cleavage of complement 5 (C5). METHODS This study was a randomized, double-blind, placebo-controlled, crossover trial involving 14 patients with severe, refractory generalized MG (gMG). RESULTS Six of 7 patients treated with eculizumab for 16 weeks (86%) achieved the primary endpoint of a 3-point reduction in the quantitative myasthenia gravis (QMG) score. Examining both treatment periods, the overall change in mean QMG total score was significantly different between eculizumab and placebo (P = 0.0144). After assessing data obtained from all visits, the overall change in mean QMG total score from baseline was found to be significantly different between eculizumab and placebo (P < 0.0001). Eculizumab was well tolerated. CONCLUSION The data suggest that eculizumab may have a role in treating severe, refractory MG.
Collapse
Affiliation(s)
- James F Howard
- Department of Neurology, University of North Carolina, 2200 Physicians Office Building, CB 7025, 170 Manning Drive, Chapel Hill, North Carolina, 27599-7025, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Abstract
BACKGROUND Myasthenia Gravis (MG) is an autoimmune disease caused by complement-fixing antibodies against the acetylcholine receptors (AChR). Antigen-specific CD4+ T cells, Tregs and Th17+ are also necessary. Consequently, antibodies, B cells, molecules associated with signalling pathways on T helper cells, cytokines and complement are targets for more specific treatment options. OBJECTIVES Because available immunosuppressive therapies cause unacceptable side effects after long-term use or are not always effective in inducing remission, novel biological agents directed against the following targets might be options for future therapies in MG: 1) T cell Intracellular Signaling Pathways associated with T cell activation, such as monoclonal antibodies against CD52, Interleukin 2-receptor (IL-2 R), co-stimulatory molecules or compounds inhibiting Janus tyrosine kinases JAK1, JAK3; 2) B cells, against key B cell-surface molecules or trophic factors B cell activation factor (BAFF) and a proliferating inducing ligand (APRIL); 3) Complement, against C3 or C5 that intercept membranolytic attack complex formation; 4) Cytokines and cytokine receptors, including IL-6, IL-17, the p40 subunit of IL12/1L-23, and GM-CSF; and 5) Lymphocyte migration molecules. Construction of recombinant AChR antibodies that block the binding of the pathogenic antibodies, can be a future molecular tool. CONCLUSION New biological agents are in the offing for future therapies in MG. Their efficacy needs to be secured with vigorously controlled clinical trials and weighted against excessive cost and rare complications.
Collapse
|
47
|
Kaminski HJ, Kusner LL, Wolfe GI, Aban I, Minisman G, Conwit R, Cutter G. Biomarker development for myasthenia gravis. Ann N Y Acad Sci 2013; 1275:101-6. [PMID: 23278584 DOI: 10.1111/j.1749-6632.2012.06787.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Biomarkers are defined as characteristics (e.g., proteins, RNA, single nucleotide polymorphisms, imaging) that are objectively measured and evaluated as indicators of pathogenic processes or pharmacologic responses to therapeutic intervention. Biomarkers are important in clinical trials where the robust biomarker reflects the underlying disease process in a sensitive and reliable manner. For myasthenia gravis (MG), acetylcholine receptor and muscle-specific kinase antibodies, as well as single-fiber electromyography, serve as excellent biomarkers for diagnosis but do not adequately substitute for clinical evaluations to predict treatment response. New technologies are emerging that enable broad biomarker discovery in biological fluids. Biomarker evaluation is ideally done in the context of longitudinal clinical trials. The MGTX trial has collected plasma and serum for RNA and protein analysis and thymus, which will allow robust biomarker discovery. The ultimate goal will be to identify candidates for a reliable substitute for a clinically meaningful end point that is a direct measure of the effectiveness of a therapy in the context of a continuum of disease natural history and a patient's overall well-being.
Collapse
Affiliation(s)
- Henry J Kaminski
- Neurology Pharmacology and Physiology, George Washington University, Washington, DC, USA.
| | | | | | | | | | | | | |
Collapse
|
48
|
Huda R, Tüzün E, Christadoss P. Complement C2 siRNA mediated therapy of myasthenia gravis in mice. J Autoimmun 2013; 42:94-104. [PMID: 23410585 DOI: 10.1016/j.jaut.2013.01.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Revised: 12/17/2012] [Accepted: 01/02/2013] [Indexed: 01/17/2023]
Abstract
Activation of complement components is crucial in the progression and severity of myasthenia gravis and experimental autoimmune myasthenia gravis (EAMG). Mice deficient in complement component C4 or treated with monoclonal antibody to C1q are resistant to EAMG. In this study, we show that inhibition of complement cascade activation by suppressing the expression of a critical low-abundant protein, C2, in the classical complement pathway, significantly improved clinical and immunopathological manifestations of EAMG. Two weeks after a second booster immunization with acetylcholine receptor, when mice exhibit muscle weakness, i.p. injection of C2 siRNA significantly suppressed C2 mRNA in the blood cells and liver of EAMG mice. Treatment of EAMG mice with C2 siRNA, once a week for 5 weeks, significantly improved muscle strength, which was further evidenced by functional AChR preservation in muscle, reduction in number of C3 and membrane-attack complexes at neuro-muscular junctions in forelimb muscle sections, and a transient decrease in serum IgG2b levels. Our study shows for the first time that siRNA-mediated suppression of C2, a component of the classical complement system, following established disease, can effectively contribute to the remission of EAMG. Therefore, C2 siRNA mediated therapy can be applied in all complement mediated autoimmune diseases.
Collapse
Affiliation(s)
- Ruksana Huda
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX 77555-1070, USA
| | | | | |
Collapse
|
49
|
Abstract
The mechanisms leading to the onset and perpetuation of systemic and tissue-specific autoimmune diseases are complex, and numerous hypotheses have been proposed or confirmed over the past 12 months. It is particularly of note that the number of articles published during 2011 in the major immunology and autoimmunity journals increased by 3 % compared to the previous year. The present article is dedicated to a brief review of the reported data and, albeit not comprehensive of all articles, is aimed at identifying common and future themes. First, clinical researchers were particularly dedicated to defining refractory forms of diseases and to discuss the use and switch of therapeutic monoclonal antibodies in everyday practice. Second, following the plethora of genome-wide association studies reported in most multifactorial diseases, it became clear that genomics cannot fully explain the individual susceptibility and additional environmental or epigenetic factors are necessary. Both these components were widely investigated, both in organ-specific (i.e., type 1 diabetes) and systemic (i.e., systemic lupus erythematosus) diseases. Third, a large number of 2011 works published in the autoimmunity area are dedicated to dissect pathogenetic mechanisms of tolerance breakdown in general or in specific conditions. While our understanding of T regulatory and Th17 cells has significantly increased in 2011, it is of note that most of the proposed lines of evidence identify potential targets for future treatments and should not be overlooked.
Collapse
|
50
|
The increased expression of CD21 on AchR specified B cells in patients with myasthenia gravis. J Neuroimmunol 2012; 256:49-54. [PMID: 23266128 DOI: 10.1016/j.jneuroim.2012.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Revised: 11/28/2012] [Accepted: 11/30/2012] [Indexed: 12/15/2022]
Abstract
CD21, a major complement receptor expressed on B cells, is associated with autoimmune disorders. In the present study, we investigated the role of CD21 in pathogenesis of myasthenia gravis (MG) in relationship to anti-acetylcholine receptor (AchR) IgG (anti-AchR IgG) secretion. We detected increased surface expression of CD21 on AchR specified B cells as well as decreased surface expression of CD21 on total B cells in peripheral blood of patients with generalized MG (gMG). In addition, the serum concentrations of soluble secreted CD21 (sCD21) were decreased in patients with gMG. We also found that the level of CD21(+) AchR specified B cells correlated positively with serum anti-AchR IgG level, while the serum concentration of soluble CD21 correlated negatively with serum anti-AchR IgG level. Our data suggests that CD21 might facilitate its function on AchR specified B cell activation, resulting in the secretion of anti-AchR IgG.
Collapse
|