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Ohara H, Kikutsuji N, Iguchi N, Kinoshita M. Efgartigimod combined with steroids as a fast-acting therapy for myasthenic crisis: a case report. BMC Neurol 2024; 24:292. [PMID: 39174898 PMCID: PMC11340165 DOI: 10.1186/s12883-024-03804-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 08/14/2024] [Indexed: 08/24/2024] Open
Abstract
BACKGROUND Generalized myasthenia gravis (gMG) can be managed with acetylcholinesterase inhibitors (AChEis; e.g., pyridostigmine), corticosteroids, other immunosuppressive drugs (e.g., tacrolimus), and their combinations. Intravenous immunoglobulin (IVIg) or plasmapheresis (PLEX) may be administered if symptoms persist. PLEX and IVIg are also mainstays of treatment for myasthenic crisis. Recently, efgartigimod was approved in Japan for treating adults with gMG (irrespective of the antibody status) who do not have a sufficient response to corticosteroids and nonsteroidal immunosuppressive therapies. Efgartigimod is generally safe and well tolerated. However, since phase III trials of efgartigimod excluded those with myasthenic crisis, the efficacy of efgartigimod in treating myasthenic crisis is still unclear. Moreover, there are no reports that efgartigimod therapy can reduce the dose of corticosteroids needed to achieve a minimal manifestation status. CASE PRESENTATION We report the case of a 70-yeat-old woman with gMG who developed a myasthenic crisis. After she was diagnosed with gMG, the patient had been treated with oral corticosteroids and tacrolimus for 1 year. However, she refused to continue taking the medication, and two weeks later, she developed ptosis, dysphagia and dyspnea. The patient was intubated and treated with efgartigimod in combination with steroid therapy, and she recovered without PLEX or IVIg. Afterward, when she experienced worsening of fatigue and increased levels of anti-acetylcholine receptor antibodies, efgartigimod therapy was effective. The patient achieved minimal manifestation status even after the reduction of corticosteroids and showed improvements in the Myasthenia Gravis Activities of Daily Living scales after 4 cycles of efgartigimod infusion. CONCLUSIONS Our case suggests that efgartigimod can be an alternative drug for achieving minimal manifestation status in patients with myasthenic crisis. Considering its strong efficacy and safety, efgartigimod could be expanded to use as bridging therapy in the acute and chronic phases of gMG.
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Affiliation(s)
- Hiroya Ohara
- Department of Neurology, Minaminara General Medical Center, Yoshino, Nara, Japan
| | - Naoya Kikutsuji
- Department of Neurology, Minaminara General Medical Center, Yoshino, Nara, Japan
| | - Naohiko Iguchi
- Department of Neurology, Nara Medical University, Kashihara, Nara, Japan
| | - Masako Kinoshita
- Department of Neurology, National Hospital Organization Utano National Hospital, Ondoyama-Cho, Narutaki, Ukyoku, Kyoto, 616-8255, Japan.
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Gazzola M, Martinat C. Unlocking the Complexity of Neuromuscular Diseases: Insights from Human Pluripotent Stem Cell-Derived Neuromuscular Junctions. Int J Mol Sci 2023; 24:15291. [PMID: 37894969 PMCID: PMC10607237 DOI: 10.3390/ijms242015291] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 09/26/2023] [Accepted: 10/16/2023] [Indexed: 10/29/2023] Open
Abstract
Over the past 20 years, the use of pluripotent stem cells to mimic the complexities of the human neuromuscular junction has received much attention. Deciphering the key mechanisms underlying the establishment and maturation of this complex synapse has been driven by the dual goals of addressing developmental questions and gaining insight into neuromuscular disorders. This review aims to summarise the evolution and sophistication of in vitro neuromuscular junction models developed from the first differentiation of human embryonic stem cells into motor neurons to recent neuromuscular organoids. We also discuss the potential offered by these models to decipher different neuromuscular diseases characterised by defects in the presynaptic compartment, the neuromuscular junction, and the postsynaptic compartment. Finally, we discuss the emerging field that considers the use of these techniques in drug screening assay and the challenges they will face in the future.
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Affiliation(s)
- Morgan Gazzola
- INSERM U861, Institute for Stem Cell Therapy and Exploration of Monogenic Diseases, 91100 Corbeil-Essonnes, France;
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Fan Z, Lei L, Su S, Zhang S, Xie N, Li L, Lu Y, Di L, Wang M, Xu M, Shen X, Da Y. Comparison between mono-tacrolimus and mono-glucocorticoid in the treatment of myasthenia gravis. Ann Clin Transl Neurol 2023; 10:589-598. [PMID: 36808840 PMCID: PMC10109324 DOI: 10.1002/acn3.51746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 02/04/2023] [Accepted: 02/07/2023] [Indexed: 02/23/2023] Open
Abstract
OBJECTIVE Use of tacrolimus in mild to moderate myasthenia gravis (MG) is generally limited to glucocorticoid-refractory cases; the advantage of mono-tacrolimus over mono-glucocorticoids is unknown. METHODS We included mild to moderate MG patients treated with mono-tacrolimus (mono-TAC) or mono-glucocorticoids (mono-GC). The correlation between the immunotherapy options and the treatment efficacy and side effects were examined in 1:1 propensity-score matching. The main outcome was time to minimal manifestations status or better (MMS or better). Secondary outcomes include time to relapse, the mean changes in Myasthenia Gravis-specific Activities of Daily Living (MG-ADL) scores and the rate of adverse events. RESULTS Baseline characteristics showed no difference between matched groups (49 matched pairs). There were no differences in median time to MMS or better between the mono-TAC group and mono-GC group (5.1 vs. 2.8 months: unadjusted hazard ratio [HR], 0.73; 95% CI, 0.46-1.16; p = 0.180), as well as in median time to relapse (data unavailable for the mono-TAC group since 44 of 49 [89.8%] participants remained in MMS or better; 39.7 months in mono-GC group: unadjusted HR, 0.67; 95% CI, 0.23-1.97; p = 0.464). Changes in MG-ADL scores between the two groups were similar (mean differences, 0.3; 95% CI, -0.4 to 1.0; p = 0.462). The rate of adverse events was lower in the mono-TAC group compared to the mono-GC group (24.5% vs. 55.1%, p = 0.002). INTERPRETATION Mono-tacrolimus performs superior tolerability with non-inferior efficacy compared to mono-glucocorticoids in mild to moderate myasthenia gravis patients who refuse or have a contraindication to glucocorticoids.
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Affiliation(s)
- Zhirong Fan
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
- Department of NeurologyXijing Hospital, Fourth Military Medical UniversityXi'anChina
| | - Lin Lei
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
- Department of NeurologyBeijing Jishuitan HospitalBeijingChina
| | - Shengyao Su
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Shu Zhang
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Nairong Xie
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Ling Li
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
- Department of NeurologyTianjin 4th Centre HospitalTianjinChina
| | - Yan Lu
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Li Di
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Min Wang
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Min Xu
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Xin‐Ming Shen
- Department of Neurology and Neuromuscular Research LaboratoryMayo ClinicRochesterMinnesotaUSA
| | - Yuwei Da
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
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Different monoclonal antibodies and immunosuppressants administration in patients with neuromyelitis optica spectrum disorder: a Bayesian network meta-analysis. J Neurol 2023; 270:2950-2963. [PMID: 36884069 DOI: 10.1007/s00415-023-11641-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/19/2023] [Accepted: 02/20/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND A variety of novel monoclonal antibodies and immunosuppressant have been proved effective in treating Neuromyelitis Optica Spectrum Disorder (NMOSD). This network meta-analysis compared and ranked the efficacy and tolerability of currently used monoclonal antibodies and immunosuppressive agents in NMOSD. METHODS Electronic database including PubMed, Embase and Cochrane Library were searched for relevant studies evaluating monoclonal antibodies and immunosuppressants in patients with NMOSD. The primary outcome measures were annualized relapse rate (ARR), relapse rate, the Expanded Disability Status Scale (EDSS) score, and total adverse events (AEs). RESULTS We identified 25 studies with 2919 patients in our meta-analysis. For the primary outcome, rituximab (RTX) (SUCRA: 0.02) ranked first in reduction ARR with a significant difference compared with azathioprine (AZA) (MD - 0.34, 95% CrI - 0.55 to - 0.12) and mycophenolate mofetil (MMF) (MD -0.38, 95% CrI - 0.63 to - 0.14). Tocilizumab (SUCRA: 0.05) ranked first in relapse rate, which was superior to satralizumab (lnOR - 25.4, 95% CrI - 74.4 to - 2.49) and inebilizumab (lnOR - 24.86, 95% CrI - 73.75 to - 1.93). MMF (SUCRA: 0.27) had the fewest AEs followed by RTX (SUCRA: 0.35), both of which showed a significant difference compared with AZA and corticosteroids (MMF vs AZA: lnOR - 1.58, 95% CrI - 2.48 to - 0.68; MMF vs corticosteroids: lnOR - 1.34, 95% CrI - 2.3 to - 0.37) (RTX vs AZA: lnOR - 1.34, 95% CrI - 0.37 to - 2.3; RTX vs corticosteroids: lnOR - 2.52, 95% CrI - 0.32 to - 4.86). In EDSS score, no statistical difference was found between different interventions. CONCLUSION RTX and tocilizumab showed better efficacy than traditional immunosuppressants in reducing relapse. For safety, MMF and RTX had fewer AEs. However, studies with larger sample size on newly developed monoclonal antibodies are warranted in the future.
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Huang X, Qiu L, Lu Y, Chen J, Yang W, Ou C, Ran H, Liu W. Clinical evaluation of efficacy of leflunomide combined with low-dose prednisone for treatment of myasthenia gravis. Acta Neurol Belg 2023; 123:153-160. [PMID: 34410678 DOI: 10.1007/s13760-021-01769-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 07/28/2021] [Indexed: 11/25/2022]
Abstract
This study evaluated the clinical efficacy of leflunomide combined with low-dose prednisone (0.25 mg/kg/day) for treatment of myasthenia gravis (MG). We enrolled 32 MG patients treated with leflunomide combined with low-dose prednisone. In the control group, 14 patients were treated with low-dose prednisone. Improvement in MG composite (MGC) score of ≥ 3 points from enrollment to 12-week follow-up indicated that the treatment was effective. In the leflunomide combined low-dose prednisone group, the median of MGC score at the time of enrollment was 8.5 points. After 12 weeks, the MGC score dropped to four points. There was statistically significant difference in MGC score before and after treatment (p < 0.001). In the low-dose prednisone group also followed up for 12 weeks, the median of MGC score of the patients decreased from 7 to 4 points, and the change was not statistically significant (p = 0.05). In the leflunomide combined low-dose prednisone group, the improvement of clinical symptoms occurred mainly in the first 4 weeks and the last 4 weeks. Relatively, the decline of the score was mostly seen during the first 8 weeks in the low-dose prednisone group. In leflunomide combined with low-dose prednisone group, the effective rate of generalized MG(gMG) was significantly higher than ocular MG(oMG) (χ2 test, p = 0.036). However, there is no significant difference in the effective rate between AChR-Ab-positive and -negative groups (Fisher's Exact Test, p = 0.625). No serious side effects were observed in any of the subjects. Leflunomide combined with low-dose prednisone rapidly improved the clinical symptoms of patients with MG. It may be a promising treatment for gMG.
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Affiliation(s)
- Xin Huang
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road 2, Guangzhou, 510080, China
| | | | | | | | | | | | - Hao Ran
- School of Pharmaceutical Sciences, Sun Yat-Sen University, No. 135 West Xingang Road, Guangzhou, 510275, China.
| | - Weibin Liu
- Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road 2, Guangzhou, 510080, China.
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Xu P, Zhang Y, Chang T, Jiang L, Lv Z, Zhang Y, Xu H, Zhang D, Lan T, Cui Y, Hua Z, Gao C, Lu J, Huang Q, Tian J, Ma J, Wang J. Comparative the efficacy and acceptability of immunosuppressive agents for myasthenia gravis: A protocol for systematic review and network meta-analysis. Medicine (Baltimore) 2022; 101:e31454. [PMID: 36550882 PMCID: PMC9771229 DOI: 10.1097/md.0000000000031454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Immunosuppressive drugs are routinely used to treat myasthenia gravis (MG). However, current recommendations provide limited evidence to support treatment options, leading to considerable variation in practice among healthcare specialists. Hence, we present a protocol for a systematic review and network meta-analysis (NMA) to update the evidence by comparing the efficacy and acceptability of oral immunosuppressive drugs for the treatment of MG. METHODS We will conduct a systematic review and NMA of all randomized controlled trials evaluating the following oral immunosuppressive drugs for the treatment of MG. Published studies will be searched using the following databases from inception to November 23, 2021: CENTRAL, the CINAHL, MEDLINE, Embase, PsycINFO, Web of Science, and 3 Chinese databases (Chinese Biomedical Literatures Database, CNKI, and Wan Fang database). Assessment of study eligibility and data extraction will be conducted independently by 2 reviewers. The main outcome will be a quantitative MG scoring system. We will conduct Bayesian NMA to synthesize all evidence for each outcome and obtain a comprehensive ranking of all treatments. The quality of the evidence will be evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations framework. RESULTS The objective of this study was to assess the relative clinical efficacy and acceptability of first-line immunosuppressants for the treatment of MG, using a systematic review and NMA approach. CONCLUSION In the absence of head-to-head trials comparing therapies, evidence from this NMA of available clinical trials will inform clinicians, patients, and families the risk-benefit profiles of different treatment options.
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Affiliation(s)
- Peng Xu
- Department of Neurology, The Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Ying Zhang
- Department of Neurology, The Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Tianying Chang
- GCP Department, The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Li Jiang
- College of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Zhiguo Lv
- Department of Neurology, The Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Yibin Zhang
- College of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Hanying Xu
- College of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Dongmei Zhang
- Scientific Research Office, The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Tianye Lan
- Department of Neurology, The Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Yingzi Cui
- GCP Department, The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Zhen Hua
- Department of Cardiology, The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong Province, China
| | - Chengfei Gao
- Department of Physical Medicine and Rehabilitation, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong, China
| | - Jing Lu
- Research Center of Traditional Chinese Medicine, The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Qingxia Huang
- Research Center of Traditional Chinese Medicine, The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Jinhui Tian
- Evidence-Based Medicine Center, Lanzhou University, Lanzhou, Gansu Province, China
| | - Jihui Ma
- Department of Health Research, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Jian Wang
- Department of Neurology, The Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin Province, China
- * Correspondence:Jian Wang, Department of Neurology, The Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin Province, China (e-mail: )
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Alhaidar MK, Abumurad S, Soliven B, Rezania K. Current Treatment of Myasthenia Gravis. J Clin Med 2022; 11:jcm11061597. [PMID: 35329925 PMCID: PMC8950430 DOI: 10.3390/jcm11061597] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 02/04/2023] Open
Abstract
Myasthenia gravis (MG) is the most extensively studied antibody-mediated disease in humans. Substantial progress has been made in the treatment of MG in the last century, resulting in a change of its natural course from a disease with poor prognosis with a high mortality rate in the early 20th century to a treatable condition with a large proportion of patients attaining very good disease control. This review summarizes the current treatment options for MG, including non-immunosuppressive and immunosuppressive treatments, as well as thymectomy and targeted immunomodulatory drugs.
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Chen R, Zhang N, Gao L, Zhong Y, Xu L, Liu H, Zheng Q, Li L. Quantitative evaluation of drug efficacy in the treatment of myasthenia gravis. Expert Opin Investig Drugs 2021; 30:1231-1240. [PMID: 34821184 DOI: 10.1080/13543784.2021.2010704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES This study aimed to quantitatively evaluate placebo effect and drug efficacy characteristics and identify associated factors that affect quantitative myasthenia gravis (MG) score (QMGs) and MG activities of daily living score (MG-ADLs) in patients with MG. METHODS Randomized placebo-controlled clinical trials were comprehensively searched in public databases (PubMed, EMBASE, and Cochrane Library databases).A model-based meta-analysis was developed to describe time-course about drug efficacy and placebo effect. RESULTS Twelve articles including 13 trials (673 participants) that were eligible for this study evaluated four immunosuppressants (tacrolimus, cyclosporine, prednisone, and mycophenolate mofetil) and five targeted therapy drugs (eculizumab, belimumab, zilucoplan, efgartigimod, and iscalimab). The pharmacodynamic model showed that eculizumab had the highest efficacy in reducing QMGs scores (3.66 points), and efgartigimod had the highest efficacy in reducing MG-ADLs scores (1.97 points). The placebo effect of QMGs and MG-ADLs increased apparently with time and reached 52% and 90% of their maximum effect in 12 weeks, respectively. In addition, this study found that the activities of daily living ability increased with the increase of the proportion of patients undergoing thymectomy. CONCLUSION This study analyzed the efficacy characteristics of nine drugs. The present findings provide necessary quantitative information for drug development of MG.
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Affiliation(s)
- Rui Chen
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ningyuan Zhang
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Lili Gao
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ying Zhong
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ling Xu
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Hongxia Liu
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Qingshan Zheng
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Lujin Li
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Duan W, Peng Y, Jin W, Ouyang S, Yang H. Tacrolimus as Single-Agent Immunotherapy and Minimal Manifestation Status in Nonthymoma Myasthenia Gravis. J Immunol Res 2021; 2021:9138548. [PMID: 34845439 PMCID: PMC8627335 DOI: 10.1155/2021/9138548] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 10/10/2021] [Accepted: 11/02/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Tacrolimus is a second-line immunosuppressant in myasthenia gravis (MG) therapy, which is mainly used in combination with corticosteroids to reduce steroid dose and maintain the effect of immunotherapy. However, few studies have focused on the effect of tacrolimus as single-agent immunotherapy on achieving minimal manifestation status (MMS). Thus, this study is aimed at exploring the efficacy and influencing factors of tacrolimus as single-agent immunotherapy in MG. METHODS Clinical data of 75 nonthymoma MG patients treated with tacrolimus single-agent as initial immunotherapy were retrospectively analyzed. The therapeutic effect was evaluated by Myasthenia Gravis Foundation of America postintervention status. Clinical factors affecting the achievement of MMS and treatment reactivity of different MG subtypes were determined by Cox regression analysis. RESULTS Tacrolimus was generally safe, with only two patients (2.7%) switching medications due to side effects. 32% of patients had improved symptoms after 1 month of treatment. 69.2% of patients achieved MMS or better after one year. The age < 39 years old, QMG score < 11 points, and AChR - Ab titer < 8.07 nmol/L were indicative of a favorable response, which was independent of gender, course of the disease. As for MG subtypes, ocular and seronegative MG showed better treatment sensitivity. CONCLUSIONS Tacrolimus as single-agent immunotherapy takes effect quickly and can effectively enable nonthymoma MG patients to achieve MMS. Tacrolimus can be used alone for the initial immunotherapy of MG patients, especially for young, mild, and low antibody titer patients.
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Affiliation(s)
- Weiwei Duan
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, 410008 Hunan, China
| | - Yuyao Peng
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, 410008 Hunan, China
| | - Wanlin Jin
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, 410008 Hunan, China
| | - Song Ouyang
- Department of Neurology, The First Hospital of Changsha, University of South China, Changsha, 410005 Hunan, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, 410008 Hunan, China
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Yoo WH, Lee SI, Kim TH, Sung JJ, Kim SM, Hua F, Sumarsono B, Park SH. Safety of Tacrolimus in Autoimmune Disease: Results From Post-marketing Surveillance in South Korea. JOURNAL OF RHEUMATIC DISEASES 2021; 28:202-215. [PMID: 37476363 PMCID: PMC10324909 DOI: 10.4078/jrd.2021.28.4.202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 07/05/2021] [Accepted: 07/09/2021] [Indexed: 07/22/2023]
Abstract
Objective Tacrolimus, a macrolide immunosuppressant, is approved in Korea for the treatment of rheumatoid arthritis (RA), lupus nephritis (LN) and myasthenia gravis (MG) We report three prospective post-marketing surveillance studies of tacrolimus conducted in South Korea in these indications. Methods Studies were conducted according to South Korean Ministry of Food and Drug Safety requirements Patients were followed up for the duration of the study (up to 4 years) or until treatment discontinuation Occurrence and likely relationship with tacrolimus of adverse events (AEs), adverse drug reactions (ADRs; defined as AEs where causal relationship to tacrolimus could not be excluded) and serious AEs were recorded Association of AEs with demographic and medical factors was evaluated by multivariable analysis. Results The studies included 740 (RA), 307 (LN) and 104 (MG) patients The incidence of AEs was 127% in RA (642% of AEs potentially related to tacrolimus), 209% (378% potentially related) in LN and 298% (568% potentially related) in MG The incidence of ADRs was 84%, 98% and 202%, respectively Serious AEs were reported in 07%, 72% and 87%, respectively The most common AEs were abdominal pain (RA), pharyngitis (LN) and diarrhea (MG) Unexpected AEs occurred in 35% of patients with RA, 29% in LN and 87% in MG; no pattern of unexpected AEs was apparent Multivariable analysis demonstrated that patients with comorbidity had higher probability of experiencing an AE in RA and MG studies. Conclusion The incidence of AEs and the safety profile of tacrolimus in each indication was consistent with previous reports.
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Affiliation(s)
- Wan-Hee Yoo
- Division of Rheumatology, Department of Internal Medicine, Jeonbuk National University Medical School, Jeonju, Korea
| | - Sang-Il Lee
- Department of Internal Medicine, Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Tae-Hwan Kim
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - Jung-Joon Sung
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seung Min Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Fan Hua
- Astellas Pharma Singapore Pte Ltd., Singapore, Korea
| | | | - Sung Hwan Park
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Ke L, Li Q, Song J, Jiao W, Ji A, Chen T, Pan H, Song Y. The mitochondrial biogenesis signaling pathway is a potential therapeutic target for myasthenia gravis via energy metabolism (Review). Exp Ther Med 2021; 22:702. [PMID: 34007311 PMCID: PMC8120506 DOI: 10.3892/etm.2021.10134] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 07/21/2020] [Indexed: 02/06/2023] Open
Abstract
Myasthenia gravis (MG) is an autoantibody-mediated autoimmune disease that is characterized by muscle weakness and fatigue. Traditional treatments for MG target the neuromuscular junction (NMJ) or the immune system. However, the efficacy of such treatments is limited, and novel therapeutic options for MG are urgently required. In the current review, a new therapeutic strategy is proposed based on the mitochondrial biogenesis and energy metabolism pathway, as stimulating mitochondrial biogenesis and the energy metabolism might alleviate myasthenia gravis. A number of cellular sensors of the energy metabolism were investigated, including AMP-activated protein kinase (AMPK) and sirtuin 1 (SIRT1). AMPK and SIRT1 are sensors that regulate cellular energy homeostasis and maintain energy metabolism by balancing anabolism and catabolism. Peroxisome proliferator-activated receptor γ coactivator 1α and its downstream transcription factors nuclear respiratory factors 1, nuclear respiratory factors 2, and transcription factor A are key sensors of mitochondrial biogenesis, which can restore mitochondrial DNA and produce new mitochondria. These processes help to control muscle contraction and relieve the symptoms of MG, including muscle weakness caused by dysfunctional NMJ transmission. Therefore, the present review provides evidence for the therapeutic potential of targeting mitochondrial biogenesis for the treatment of MG.
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Affiliation(s)
- Lingling Ke
- Science and Technology Innovation Center, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, P.R. China.,Institute of Pi-Wei, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, P.R. China
| | - Qing Li
- Science and Technology Innovation Center, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, P.R. China.,Institute of Pi-Wei, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, P.R. China
| | - Jingwei Song
- Science and Technology Innovation Center, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, P.R. China.,Institute of Pi-Wei, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, P.R. China
| | - Wei Jiao
- Science and Technology Innovation Center, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, P.R. China.,Institute of Pi-Wei, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, P.R. China
| | - Aidong Ji
- Clinical Medical College of Acupuncture, Moxibustion and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510006, P.R. China
| | - Tongkai Chen
- Science and Technology Innovation Center, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, P.R. China.,Institute of Clinical Pharmacology, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, P.R. China
| | - Huafeng Pan
- Science and Technology Innovation Center, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, P.R. China
| | - Yafang Song
- Science and Technology Innovation Center, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, P.R. China.,Institute of Pi-Wei, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, P.R. China
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12
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What's in the Neuromuscular Junction Literature? J Clin Neuromuscul Dis 2021; 21:195-204. [PMID: 32453095 DOI: 10.1097/cnd.0000000000000285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Four retrospective studies from the United States, Europe, and Asia address outcomes in juvenile myasthenia gravis. Common features include earlier onset with ocular myasthenia gravis (MG) and generally good outcomes overall. Patients who were seronegative, had equivocal acetylcholine receptor (AChR) antibodies, or had only clustered AChR antibodies had better outcomes. An article highlighting the utility of median nerve slow-repetitive stimulation is reviewed and another showing the high sensitivity of repetitive nerve stimulation in myasthenic crisis is covered. Two articles address the thymus and thymectomy in non-AChR antibody-positive autoimmune MG. Longer term data on eculizumab as well as studies of cyclophosphamide, rituximab, and tacrolimus are summarized. Other topics include the possible role of statins in MG and central nervous system autoimmune comorbidities.
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Wang L, Tan H, Huang W, ZhangBao J, Chang X, Zhou L, Lu C, Wang M, Lu J, Zhao C, Quan C. Low-dose tacrolimus in treating neuromyelitis optica spectrum disorder. Mult Scler Relat Disord 2020; 48:102707. [PMID: 33383362 DOI: 10.1016/j.msard.2020.102707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 11/22/2020] [Accepted: 12/17/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND The value of tacrolimus (TAC) in neuromyelitis optica spectrum disorder (NMOSD) has not been fully demonstrated. In this study, we aimed to explore the effectiveness and safety of low-dose TAC in treating NMOSD. METHODS Patients with NMOSD taking low-dose TAC were retrospectively collected. We compared the annualized relapse rate (ARR) before and after the initiation of TAC. Cox proportional hazards model was used to identify the risk factors of relapse during TAC treatment with their hazard ratio (HR). The effectiveness and safety of TAC were also compared with a group of patients on mycophenolate mofetil (MMF). RESULTS A total of 42 NMOSD patients taking TAC were included, with the administered dose of 1-3mg/d. The ARR (1, 0-3) after the initiation of TAC decreased significantly compared to those before TAC treatment (0, 0-2, p < 0.001). The most common adverse events (AEs) observed included alopecia (23.8%), tremor (16.7%) and elevated blood glucose (11.9%). Multivariate Cox proportional hazards model exhibited that patients with higher baseline ARR (HR: 1.77, 0.76-4.16) and Expanded Disability Status Scale (EDSS) score (HR: 1.79, 1.20-2.68) were at a higher risk for relapse during TAC treatment (p = 0.188 and 0.004, respectively). We did not observe significant difference between TAC-treated and MMF-treated patients regarding the risk of relapse (p = 0.323). CONCLUSION Low-dose TAC was an effective and tolerable choice in treating NMOSD.
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Affiliation(s)
- Liang Wang
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Hongmei Tan
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Wenjuan Huang
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jingzi ZhangBao
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xuechun Chang
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Lei Zhou
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Chuanzhen Lu
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Min Wang
- Department of Ophthalmology and Vision Science, Eye and ENT Hospital, Fudan University, Shanghai, China
| | - Jiahong Lu
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Chongbo Zhao
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Chao Quan
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.
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Gilhus NE. Immunoactive treatment for myasthenia gravis; a Chinese experience. CNS Neurosci Ther 2020; 26:1203-1204. [PMID: 33107208 PMCID: PMC7702226 DOI: 10.1111/cns.13466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 09/30/2020] [Accepted: 09/30/2020] [Indexed: 11/28/2022] Open
Affiliation(s)
- Nils Erik Gilhus
- Department of Clinical MedicineUniversity of BergenBergenNorway
- Department of NeurologyHaukeland University HospitalBergenNorway
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15
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Li X, Shang X, Sun L. Tacrolimus reduces atherosclerotic plaque formation in ApoE -/- mice by inhibiting NLRP3 inflammatory corpuscles. Exp Ther Med 2020; 19:1393-1399. [PMID: 32010314 PMCID: PMC6966157 DOI: 10.3892/etm.2019.8340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/04/2019] [Indexed: 12/16/2022] Open
Abstract
Effect of tacrolimus on atherosclerotic plaques and its influence on Nod-like receptor protein 3 (NLRP3) inflammatory pathway were studied by establishing the mouse model of atherosclerosis. The mice were divided into 3 groups: C57BL/6 mouse group (WT group), ApoE-/- mouse group (ApoE-/- group) and ApoE-/- mouse + tacrolimus intervention group (ApoE-/- + Tac group). The area of atherosclerotic plaques and the pathological morphologic changes were observed. The NLRP3, interleukin-1β (IL-1β), IL-18, NLRP3 inflammatory corpuscles, pro-inflammatory factors IL-1β and IL-18 in the aorta were analyzed. The area of atherosclerotic plaques in ApoE-/- mice was increased significantly, and it was significantly reduced after tacrolimus intervention. After tacrolimus intervention, the arterial intima became obviously thinner and no obvious cholesterol crystals were observed. The macrophage infiltration in atherosclerotic plaques was significantly increased, and the content of smooth muscle cells was also increased. The levels of serum IL-1β, IL-18 and NLRP3 in ApoE-/- mice were significantly increased, and they remarkably declined after tacrolimus intervention. ROS content in atherosclerotic plaques was increased in ApoE-/- mice, and it remarkably declined after tacrolimus intervention. The protein content of NLRP3, ASC, Casp-1, IL-1β and IL-18 in the aorta in ApoE-/- mice was remarkably increased, and they were inhibited to some extent after tacrolimus intervention. In conclusion, it is speculated that tacrolimus may reduce the formation of AS through inhibiting ROS in macrophages and activation of NLRP3 inflammatory corpuscles and reducing the release of IL-1β and IL-18.
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Affiliation(s)
- Xiao Li
- Department of Cardiology, The Third People's Hospital of Qingdao, Qingdao, Shandong 266041, P.R. China
| | - Xingfu Shang
- Department of Cardiology, The Third People's Hospital of Qingdao, Qingdao, Shandong 266041, P.R. China
| | - Lu Sun
- Department of Cardiology, The Third People's Hospital of Qingdao, Qingdao, Shandong 266041, P.R. China
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16
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Maintenance immunosuppression in myasthenia gravis, an update. J Neurol Sci 2019; 410:116648. [PMID: 31901719 DOI: 10.1016/j.jns.2019.116648] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/25/2019] [Accepted: 12/24/2019] [Indexed: 01/08/2023]
Abstract
Therapies for myasthenia gravis (MG) include symptomatic and immunosuppressive/immunomodulatory treatment. Options for immunosuppression include corticosteroids, azathioprine, mycophenolate mofetil, cyclosporine, tacrolimus, methotrexate, rituximab, cyclophosphamide, eculizumab, intravenous immunoglobulin, subcutaneous immunoglobulin, plasmapheresis, and thymectomy. The practical aspects of long-term immunosuppressive therapy in MG are critically reviewed in this article. Application of one or more of these specific therapies is guided based on known efficacy, adverse effect profile, particular disease subtype and severity, and patient co-morbidities.
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Barnett C, Tabasinejad R, Bril V. Current pharmacotherapeutic options for myasthenia gravis. Expert Opin Pharmacother 2019; 20:2295-2303. [PMID: 31670984 DOI: 10.1080/14656566.2019.1682548] [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] [Indexed: 02/07/2023]
Abstract
Introduction: Novel options for immune-based therapy in myasthenia gravis are improving the therapeutic outlook for patients. Multiple clinical trials on immunomodulation, complement inhibitors, and FcR inhibitors are providing evidence for novel immune-based therapies that promise to improve outcomes in myasthenia patients. These more focused immune treatments are reviewed in this paper.Areas covered: This paper outlines classical treatment for myasthenia gravis and then reviews recent clinical trial evidence for novel immune therapies, particularly complement inhibitors and FcR inhibitors. Further, as immune therapies expand in other areas of medicine, such as oncology, iatrogenic myasthenia is being observed as a complication of some novel treatments.Expert opinion: Exciting new options to help patients with myasthenia gravis are now available or in phase 3 trials based on promising phase 2 results. Manipulation of the immune system can also lead to iatrogenic MG. Although novel treatments can improve care for myasthenia gravis patients, future developments that prevent the production of specific abnormal auto-antibodies are desirable.
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Affiliation(s)
- Carolina Barnett
- Department of Medicine (Neurology), University Health Network, University of Toronto - Neurology, Toronto, Ontario, Canada
| | - Raha Tabasinejad
- Department of Medicine (Neurology), University Health Network, University of Toronto - Neurology, Toronto, Ontario, Canada
| | - Vera Bril
- Department of Medicine (Neurology), University Health Network, University of Toronto - Neurology, Toronto, Ontario, Canada
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Huang K, Luo YB, Yang H. Autoimmune Channelopathies at Neuromuscular Junction. Front Neurol 2019; 10:516. [PMID: 31156543 PMCID: PMC6533877 DOI: 10.3389/fneur.2019.00516] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 04/30/2019] [Indexed: 12/22/2022] Open
Abstract
The neuromuscular junction, also called myoneural junction, is a site of chemical communication between a nerve fiber and a muscle cell. There are many types of channels at neuromuscular junction that play indispensable roles in neuromuscular signal transmission, such as voltage-gated calcium channels and voltage-gated potassium channels on presynaptic membrane, and acetylcholine receptors on post-synaptic membrane. Over the last two decades, our understanding of the role that autoantibodies play in neuromuscular junction disorders has been greatly improved. Antibodies against these channels cause a heterogeneous group of diseases, such as Lambert-Eaton syndrome, Isaacs' syndrome and myasthenia gravis. Lambert-Eaton syndrome is characterized by late onset of fatigue, skeletal muscle weakness, and autonomic symptoms. Patients with Isaacs' syndrome demonstrate muscle cramps and fasciculation. Myasthenia gravis is the most common autoimmune neuromuscular junction channelopathy characterized by fluctuation of muscle weakness. All these disorders have a high risk of tumor. Although these channelopathies share some common features, they differ for clinical features, antibodies profile, neurophysiological features, and treatments. The purpose of this review is to give a comprehensive insight on recent advances in autoimmune channelopathies at the neuromuscular junction.
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Affiliation(s)
- Kun Huang
- Neurology Department, Xiangya Hospital, Central South University, Changsha, China.,Division of Neurogenetics, Center for Neurological Diseases and Cancer, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yue-Bei Luo
- Neurology Department, Xiangya Hospital, Central South University, Changsha, China
| | - Huan Yang
- Neurology Department, Xiangya Hospital, Central South University, Changsha, China
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