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De Bleecker JL, Remiche G, Alonso-Jiménez A, Van Parys V, Bissay V, Delstanche S, Claeys KG. Recommendations for the management of myasthenia gravis in Belgium. Acta Neurol Belg 2024; 124:1371-1383. [PMID: 38649556 PMCID: PMC11266451 DOI: 10.1007/s13760-024-02552-7] [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: 02/07/2024] [Accepted: 03/31/2024] [Indexed: 04/25/2024]
Abstract
International guidelines on the treatment of myasthenia gravis (MG) have been published but are not tailored to the Belgian situation. This publication presents recommendations from a group of Belgian MG experts for the practical management of MG in Belgium. It includes recommendations for treatment of adult patients with generalized myasthenia gravis (gMG) or ocular myasthenia gravis (oMG). Depending on the MG-related antibody a treatment sequence is suggested with therapies that can be added on if the treatment goal is not achieved. Selection of treatments was based on the level of evidence of efficacy, registration and reimbursement status in Belgium, common daily practice and the personal views and experiences of the authors. The paper reflects the situation in February 2024. In addition to the treatment considerations, other relevant aspects in the management of MG are addressed, including comorbidities, drugs aggravating disease symptoms, pregnancy, and vaccination. As many new treatments might potentially come to market, a realistic future perspective on the impact of these treatments on clinical practice is given. In conclusion, these recommendations intend to be a guide for neurologists treating patients with MG in Belgium.
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Affiliation(s)
- Jan L De Bleecker
- Department of Neurology, University Hospital Ghent and AZ Sint-Lucas, Ghent, Belgium.
| | - Gauthier Remiche
- Centre de Référence Neuromusculaire, Department of Neurology, Hôpital Universitaire de Bruxelles (HUB)-Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Alicia Alonso-Jiménez
- Department of Neurology, Faculty of Medicine and Health Sciences, Antwerp University Hospital, Translational Neurosciences, UAntwerpen, Antwerp, Belgium
| | - Vinciane Van Parys
- Department of Neurology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Véronique Bissay
- Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, NEUR Research Group and Department of Neurology, Brussels, Belgium
| | | | - Kristl G Claeys
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
- Laboratory for Muscle Diseases and Neuropathies, Department of Neurosciences, KULeuven, and Leuven Brain Institute (LBI), Leuven, Belgium
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2
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Sun F, Batra A, Dickson D, Li Y, Wu EL. Efgartigimod infusion in the treatment regimen for myasthenic crisis: A case report. Muscle Nerve 2024; 70:290-292. [PMID: 38850117 DOI: 10.1002/mus.28178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 05/24/2024] [Accepted: 05/25/2024] [Indexed: 06/09/2024]
Affiliation(s)
- Fang Sun
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Ken & Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ayush Batra
- Ken & Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Daniel Dickson
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Yuebing Li
- Department of Neurology, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - En-Ling Wu
- Department of Medicine, Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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3
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Narayanaswami P, Sanders DB. Azathioprine and mycophenolate mofetil in myasthenia gravis - Authors' reply. Lancet Neurol 2024; 23:762-763. [PMID: 39030030 DOI: 10.1016/s1474-4422(24)00234-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Accepted: 05/28/2024] [Indexed: 07/21/2024]
Affiliation(s)
- Pushpa Narayanaswami
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
| | - Donald B Sanders
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
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4
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Song J, Huan X, Chen Y, Luo Y, Zhong H, Wang Y, Yang L, Xi C, Yang Y, Xi J, Zheng J, Wu Z, Zhao C, Luo S. The safety and efficacy profile of eculizumab in myasthenic crisis: a prospective small case series. Ther Adv Neurol Disord 2024; 17:17562864241261602. [PMID: 39072008 PMCID: PMC11282533 DOI: 10.1177/17562864241261602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 05/27/2024] [Indexed: 07/30/2024] Open
Abstract
Eculizumab has improved recovery from ventilatory support in myasthenic crisis (MC) cases. However, the safety and efficacy profiles from prospective studies are still lacking. This study aimed to explore eculizumab's safety and efficacy in a prospective case series of patients with refractory MC. We followed a series of anti-acetylcholine receptor (AChR) antibody-positive myasthenia gravis (MG) patients who received eculizumab as an add-on therapy for 12 weeks during MC to facilitate the weaning process and reduced disease activity. Serum anti-AChR antibodies and peripheral immune molecules associated with the complement pathway were evaluated before and after eculizumab administration. Compared to the baseline Myasthenia Gravis Foundation of America (MGFA)-quantitative MG test (QMG) scores (22.25 ± 4.92) and MG-activities of daily living (MG-ADL; 18.25 ± 2.5) scores at crisis, improvements were observed from 4 weeks (14.5 ± 10.47 and 7.5 ± 7.59, respectively) through 12 weeks (7.5 ± 5.74 and 2.25 ± 3.86, respectively) post-treatment. Muscle strength consistently improved across ocular, bulbar, respiratory, and limb/gross domain groups. One patient died of cardiac failure at 16 weeks. Three cases remained in remission at 24 weeks, with a mean QMG score of 2.67 ± 2.89 and ADL score of 0.33 ± 0.58. No significant side effects were reported. Serum CH50 and soluble C5b-9 levels significantly declined, while there were no significant changes in serum anti-AChR antibody levels, C1q, C5a levels, or peripheral lymphocyte proportions. Eculizumab was well tolerated and showed efficacy in this case series. Large prospective cohort studies with extended follow-up periods are needed to further explore the safety and efficacy profile in real-world practice.
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Affiliation(s)
- Jie Song
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, China
| | - Xiao Huan
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, China
| | - Yuanyi Chen
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, China
| | - Yeting Luo
- Department of Neurology, Ganzhou People’s Hospital, Nanchang University, Nanchang, Jiangxi, China
| | - Huahua Zhong
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, China
| | - Yuan Wang
- Department of Blood Transfusion, Huashan Hospital, Fudan University, Shanghai, China
| | - Lei Yang
- Department of Neurosurgery & Neurocritical care, Huashan Hospital Fudan University, Shanghai, China
| | - Caihua Xi
- Department of Neurosurgery & Neurocritical care, Huashan Hospital Fudan University, Shanghai, China
| | - Yu Yang
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jianying Xi
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, China
| | - Jianming Zheng
- Department of Infectious Diseases, Huashan Hospital, National Medical Center for Infectious Diseases, Fudan University, Shanghai, China
| | - Zongtai Wu
- Faculty of Biology, University of Cambridge, Cambridge, UK
| | - Chongbo Zhao
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Sushan Luo
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai 200040, China
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5
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Habib AA, Klink AJ, Muppidi S, Parthan A, Sader SC, Balanean A, Gajra A, Nowak RJ, Howard JF. United States clinical practice experience with eculizumab in myasthenia gravis: symptoms, function, and immunosuppressant therapy use. J Neurol 2024:10.1007/s00415-024-12569-w. [PMID: 39052039 DOI: 10.1007/s00415-024-12569-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 06/28/2024] [Accepted: 07/05/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND/OBJECTIVES The phase 3 REGAIN study and its open-label extension demonstrated the efficacy of the complement C5 inhibitor eculizumab in patients with treatment-refractory, acetylcholine receptor antibody-positive generalized myasthenia gravis (gMG). The aim of the ELEVATE study was to assess the effectiveness of eculizumab in clinical practice in adults with MG in the United States. METHODS A retrospective chart review was conducted in adults with MG who initiated eculizumab treatment between October 23, 2017 and December 31, 2019. Outcomes assessed before and during eculizumab treatment using a pre- versus post-treatment study design included Myasthenia Gravis-Activities of Daily Living (MG-ADL) total scores; minimal symptom expression (MSE); physician impression of clinical change; minimal manifestation status (MMS); and concomitant medication use. RESULTS In total, 119 patients were included in the study. A significant reduction was observed in mean MG-ADL total score, from 8.0 before eculizumab initiation to 5.4 at 3 months and to 4.7 at 24 months after eculizumab initiation (both p < 0.001). At 24 months after eculizumab initiation, MSE was achieved by 19% of patients. MMS or better was achieved by 30% of patients at 24 months. Additionally, 64% of patients receiving prednisone at eculizumab initiation had their prednisone dosage reduced during eculizumab treatment and 13% discontinued prednisone; 32% were able to discontinue nonsteroidal immunosuppressant therapy. DISCUSSION Eculizumab treatment was associated with sustained improvements in MG-ADL total scores through 24 months in adults with MG. Prednisone dosage was reduced in approximately two-thirds of patients, suggesting a steroid-sparing effect for eculizumab.
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Affiliation(s)
| | | | | | - Anju Parthan
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
- FibroGen Inc., San Francisco, CA, USA
| | | | | | - Ajeet Gajra
- Cardinal Health, Dublin, OH, USA
- Hematology-Oncology Associates of CNY, East Syracuse, NY, USA
| | | | - James F Howard
- Department of Neurology, The University of North Carolina, Chapel Hill, NC, USA.
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6
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Ryder S. Integrated Applied Clinical Pharmacology in the Advancement of Rare and Ultra-Rare Disease Therapeutics. Clin Pharmacol Ther 2024. [PMID: 39034754 DOI: 10.1002/cpt.3382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 06/29/2024] [Indexed: 07/23/2024]
Abstract
The introduction of safe and effective rare/ultra-rare disease treatments is a focus of many biotherapeutic enterprises. Despite this increased activity, a significant unmet need remains, and the responsibility to meet this need is augmented by enhanced genomic, biologic, medical, analytical, and informatic tools. It is recognized that the development of an effective and safe rare/ultra-rare disease therapeutic faces a number of challenges with an important role noted for clinical pharmacology. Clinical pharmacology is foundationally an integrative discipline which must be embedded in and is interdependent upon understanding the pathogenic biology, clinical presentation, disease progression, and end-point assessment of the disease under study. This manuscript presents an overview and two case examples of this integrative approach, the development of C5-targeted therapeutics for the treatment of generalized myasthenia gravis and asfotase alpha for the treatment of hypophosphatasia. The two presented case examples show the usefulness of understanding the biological drivers and clinical course of a rare disease, having relevant animal models, procuring informative natural history data, importing assessment tools from relevant alternative areas, and using integrated applied clinical pharmacology to inform target engagement, dose, and the cascade of pharmacodynamic and clinical effects that follow. Learnings from these programs include the importance of assuring cross-validation of assays throughout a development program and continued commitment to understanding the relationship among the array of Pd end points and clinical outcomes. Using an integrative approach, substantive work remains to be done to meet the unmet needs of patients with rare/ultra-rare disease.
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7
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Li S, Zhang Y, Liu G, Song N, Ruan Z, Guo R, Tang Y, Cao X, Huang X, Gao T, Hao S, Wang Q, Chang T. Exploring the Roles of m6A-Modified circRNAs in Myasthenia Gravis Based on Multi-Omics Analysis. Mol Neurobiol 2024:10.1007/s12035-024-04352-9. [PMID: 39017976 DOI: 10.1007/s12035-024-04352-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Accepted: 07/03/2024] [Indexed: 07/18/2024]
Abstract
Myasthenia gravis (MG) is an autoimmune disease mediated by autoantibodies. The important roles of circRNAs modified by m6A methylation have been reported in the pathogenesis of other autoimmune diseases, but remain unclear in MG. To address this point, we collected peripheral blood mononuclear cells from six MG patients and six healthy controls and performed m6A‑circRNA epitranscriptomic microarray and RNA sequencing. Differentially m6A-modified circRNAs and differentially expressed genes (DEGs) were analyzed. A network was constructed containing 17 circRNAs, 30 miRNAs, and 34 DEGs. The GSE85452 dataset was downloaded. DEGs that were differentially expressed in the GSE85452 dataset were selected as seed genes. Finally, four candidate m6A-modified circRNAs (hsa_circ_0084735, hsa_circ_0018652, hsa_circ_0025731, and hsa_circ_0030997) were identified through a random walk with restart. We found that they had different degree correlations with different immune cells. The results of MeRIP-qPCR showed that the m6A methylated levels of hsa_circ_0084735 and hsa_circ_0025731 were downregulated in MG patients, while the other two circRNAs were not significantly different between MG and control group. For the first time, we explored the pathogenesis of MG at the epigenetic transcriptome level. Our results will open new perspectives for MG research and identify potential biomarkers and therapeutic targets for MG.
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Affiliation(s)
- Shuang Li
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, Xi'an, 710038, Shaanxi, China
| | - Yu Zhang
- Department of Neurosurgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an, 710038, Shaanxi, China
| | - Geyu Liu
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, Xi'an, 710038, Shaanxi, China
- The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Na Song
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, Xi'an, 710038, Shaanxi, China
| | - Zhe Ruan
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, Xi'an, 710038, Shaanxi, China
| | - Rongjing Guo
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, Xi'an, 710038, Shaanxi, China
| | - Yonglan Tang
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, Xi'an, 710038, Shaanxi, China
| | - Xiangqi Cao
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, Xi'an, 710038, Shaanxi, China
| | - Xiaoxi Huang
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, Xi'an, 710038, Shaanxi, China
| | - Ting Gao
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, Xi'an, 710038, Shaanxi, China
| | - Sijia Hao
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, Xi'an, 710038, Shaanxi, China
| | - Qingqing Wang
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, Xi'an, 710038, Shaanxi, China
| | - Ting Chang
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, Xi'an, 710038, Shaanxi, China.
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8
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Mantegazza R, Saccà F, Antonini G, Bonifati DM, Evoli A, Habetswallner F, Liguori R, Pegoraro E, Rodolico C, Schenone A, Sgarzi M, Pappagallo G. Therapeutic challenges and unmet needs in the management of myasthenia gravis: an Italian expert opinion. Neurol Sci 2024:10.1007/s10072-024-07577-7. [PMID: 38967883 DOI: 10.1007/s10072-024-07577-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 05/03/2024] [Indexed: 07/06/2024]
Abstract
Myasthenia gravis (MG) is a rare, autoimmune, neurological disorder. Most MG patients have autoantibodies against acetylcholine receptors (AChRs). Some have autoantibodies against muscle-specific tyrosine kinase (MuSK) or lipoprotein-receptor-related protein 4 (LRP4), and some are seronegative. Standard of care, which includes anti-cholinesterase drugs, thymectomy, corticosteroids (CS), and off-label use of non-steroidal immunosuppressive drugs (NSISTs), is bounded by potential side effects and limited efficacy in refractory generalized MG (gMG) patients. This highlights the need for new therapeutic approaches for MG. Eculizumab, a monoclonal antibody that inhibits the complement system, has been recently approved in Italy for refractory gMG. A panel of 11 experts met to discuss unmet therapeutic needs in the acute and chronic phases of the disease, as well as the standard of care for refractory patients. Survival was emphasized as an acute phase outcome. In the chronic phase, persistent remission and early recognition of exacerbations to prevent myasthenic crisis and respiratory failure were considered crucial. Refractory patients require treatments with fast onset of action, improved tolerability, and the ability to slow disease progression and increase life expectancy. The Panel agreed that eculizumab would presumably meet the therapeutic needs of many refractory gMG patients. The panel concluded that the unmet needs of current standard of care treatments for gMG are significant. Evaluating new therapeutic options accurately is essential to find the best balance between efficacy and tolerability for each patient. Collecting real-world data on novel molecules in routine clinical practice is necessary to address unmet needs.
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Affiliation(s)
- Renato Mantegazza
- Neuroimmunology and Neuromuscular Diseases Unit, IRCCS Foundation Carlo Besta Neurological Institute, Milan, Italy.
| | - Francesco Saccà
- NSRO Department, Federico II University of Naples, Naples, Italy
| | - Giovanni Antonini
- Department of Neurosciences, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Domenico Marco Bonifati
- Neurology Unit, Cerebro-Cardiovascular Department, Ca' Foncello Hospital Treviso, Piazzale Ospedale 1, 31100, Treviso, Italy
| | - Amelia Evoli
- Neuroscience Department, Facolta Di Medicina E Chirurgia, Università Cattolica del Sacro Cuore, Rome, Italy
- Neurology Institute, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | - Rocco Liguori
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | | | - Carmelo Rodolico
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Angelo Schenone
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal and Infantile Sciences (DINOGMI), University and IRCCS San Martino Hospital, Genoa, Italy
| | - Manlio Sgarzi
- Department of Neurology, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127, Bergamo, Italy
| | - Giovanni Pappagallo
- School of Clinical Methodology, IRCCS "Sacred Heart - Don Calabria", Negrar Di Valpolicella, Italy
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9
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Brandsema JF, Ginsberg M, Hoshino H, Mimaki M, Nagata S, Rao VK, Ruzhansky K, Suresh N, Tiongson E, Yamanouchi H, Frick G, Hicks E, Liao S, Howard JF. Eculizumab in Adolescent Patients With Refractory Generalized Myasthenia Gravis: A Phase 3, Open-Label, Multicenter Study. Pediatr Neurol 2024; 156:198-207. [PMID: 38810600 DOI: 10.1016/j.pediatrneurol.2024.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 03/10/2024] [Accepted: 04/21/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND This study evaluated the efficacy and safety of eculizumab, a terminal complement C5 inhibitor, in juvenile generalized myasthenia gravis (gMG). METHODS Adolescents aged 12 to 17 years with refractory anti-acetylcholine receptor (AChR) antibody-positive gMG received eculizumab (weekly induction [one to two doses of 600 mg or four doses of 900 mg] followed by maintenance doses [300 to 1200 mg] every two weeks for up to 26 weeks) in a phase 3, open-label multicenter study (NCT03759366). Change from baseline to week 26 in Quantitative Myasthenia Gravis (QMG) total score (primary end point) and secondary end points including Myasthenia Gravis-Activities of Daily Living (MG-ADL) total score, Myasthenia Gravis Composite score, Myasthenia Gravis Foundation of America postintervention status, EuroQol 5-Dimensions (Youth) and Neurological Quality-of-Life Pediatric Fatigue questionnaire scores, as well as pharmacokinetics, pharmacodynamics, and safety, were recorded. RESULTS Eleven adolescents (mean ± S.D. age 14.8 ± 1.8 years) were enrolled; 10 completed the primary evaluation period. Least-squares mean changes from baseline at week 26 were -5.8 (standard error [SE] 1.2; P = 0.0004) for QMG total score and -2.3 (SE 0.6; P = 0.0017) for MG-ADL total score. Overall, the primary and all secondary efficacy end point analyses met statistical significance from the first assessment and were sustained throughout. Complete terminal complement inhibition was sustained through 26 weeks in all patients. Treatment-emergent adverse events were all mild/moderate and predominantly unrelated to eculizumab. CONCLUSIONS Eculizumab was effective in reducing disease burden and was well tolerated in adolescents with refractory AChR antibody-positive gMG.
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Affiliation(s)
- John F Brandsema
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Hideki Hoshino
- Department of Pediatrics, Teikyo University School of Medicine, Tokyo, Japan
| | - Masakazu Mimaki
- Department of Pediatrics, Teikyo University School of Medicine, Tokyo, Japan
| | - Satoru Nagata
- Department of Pediatrics, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Vamshi K Rao
- Division of Neurology, Lurie Children's Hospital, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Katherine Ruzhansky
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina
| | - Niraja Suresh
- Department of Neurology, University of South Florida, Tampa, Florida
| | - Emmanuelle Tiongson
- Division of Neurology, Children's Hospital Los Angeles, Los Angeles, California
| | - Hideo Yamanouchi
- Department of Pediatrics, Comprehensive Epilepsy Center, Saitama Medical University, Saitama, Japan
| | - Glen Frick
- Alexion, AstraZeneca Rare Disease, Boston, Massachusetts.
| | - Eden Hicks
- Alexion, AstraZeneca Rare Disease, Boston, Massachusetts
| | - Serena Liao
- Alexion, AstraZeneca Rare Disease, Boston, Massachusetts
| | - James F Howard
- Department of Neurology, The University of North Carolina, Chapel Hill, North Carolina
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10
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Nelke C, Schroeter CB, Barman S, Stascheit F, Masanneck L, Theissen L, Huntemann N, Walli S, Cengiz D, Dobelmann V, Vogelsang A, Pawlitzki M, Räuber S, Konen FF, Skripuletz T, Hartung HP, König S, Roos A, Meisel A, Meuth SG, Ruck T. Identification of disease phenotypes in acetylcholine receptor-antibody myasthenia gravis using proteomics-based consensus clustering. EBioMedicine 2024; 105:105231. [PMID: 38959848 PMCID: PMC11269806 DOI: 10.1016/j.ebiom.2024.105231] [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: 03/04/2024] [Revised: 06/24/2024] [Accepted: 06/24/2024] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND The clinical heterogeneity of myasthenia gravis (MG), an autoimmune disease defined by antibodies (Ab) directed against the postsynaptic membrane, constitutes a challenge for patient stratification and treatment decision making. Novel strategies are needed to classify patients based on their biological phenotypes aiming to improve patient selection and treatment outcomes. METHODS For this purpose, we assessed the serum proteome of a cohort of 140 patients with anti-acetylcholine receptor-Ab-positive MG and utilised consensus clustering as an unsupervised tool to assign patients to biological profiles. For in-depth analysis, we used immunogenomic sequencing to study the B cell repertoire of a subgroup of patients and an in vitro assay using primary human muscle cells to interrogate serum-induced complement formation. FINDINGS This strategy identified four distinct patient phenotypes based on their proteomic patterns in their serum. Notably, one patient phenotype, here named PS3, was characterised by high disease severity and complement activation as defining features. Assessing a subgroup of patients, hyperexpanded antibody clones were present in the B cell repertoire of the PS3 group and effectively activated complement as compared to other patients. In line with their disease phenotype, PS3 patients were more likely to benefit from complement-inhibiting therapies. These findings were validated in a prospective cohort of 18 patients using a cell-based assay. INTERPRETATION Collectively, this study suggests proteomics-based clustering as a gateway to assign patients to a biological signature likely to benefit from complement inhibition and provides a stratification strategy for clinical practice. FUNDING CN and CBS were supported by the Forschungskommission of the Medical Faculty of the Heinrich Heine University Düsseldorf. CN was supported by the Else Kröner-Fresenius-Stiftung (EKEA.38). CBS was supported by the Deutsche Forschungsgemeinschaft (DFG-German Research Foundation) with a Walter Benjamin fellowship (project 539363086). The project was supported by the Ministry of Culture and Science of North Rhine-Westphalia (MODS, "Profilbildung 2020" [grant no. PROFILNRW-2020-107-A]).
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Affiliation(s)
- Christopher Nelke
- Department of Neurology, Medical Faculty, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Christina B Schroeter
- Department of Neurology, Medical Faculty, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Sumanta Barman
- Department of Neurology, Medical Faculty, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Frauke Stascheit
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Lars Masanneck
- Department of Neurology, Medical Faculty, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Lukas Theissen
- Department of Neurology, Medical Faculty, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Niklas Huntemann
- Department of Neurology, Medical Faculty, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Sara Walli
- Department of Neurology, Medical Faculty, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Derya Cengiz
- Department of Neurology, Medical Faculty, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Vera Dobelmann
- Department of Neurology, Medical Faculty, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Anna Vogelsang
- Department of Neurology, Medical Faculty, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Marc Pawlitzki
- Department of Neurology, Medical Faculty, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Saskia Räuber
- Department of Neurology, Medical Faculty, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Felix F Konen
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich Heine University Duesseldorf, Duesseldorf, Germany; Brain and Mind Center, University of Sydney, Sydney NSW, Australia; Department of Neurology, Palacky University Olomouc, Olomouc, Czech Republic
| | - Simone König
- Core Unit Proteomics, Interdisciplinary Center for Clinical Research, Medical Faculty, University of Münster, Münster, Germany
| | - Andreas Roos
- Department of Neuropaediatrics, Neuromuscular Centre, Universitätsmedizin Essen, Essen, Germany
| | - Andreas Meisel
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sven G Meuth
- Department of Neurology, Medical Faculty, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Tobias Ruck
- Department of Neurology, Medical Faculty, Heinrich Heine University Duesseldorf, Duesseldorf, Germany.
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11
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Meisel A, Saccà F, Spillane J, Vissing J. Expert consensus recommendations for improving and standardising the assessment of patients with generalised myasthenia gravis. Eur J Neurol 2024; 31:e16280. [PMID: 38523419 PMCID: PMC11236001 DOI: 10.1111/ene.16280] [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: 10/02/2023] [Revised: 01/26/2024] [Accepted: 03/05/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Regular and consistent disease assessment could provide a clearer picture of burden in generalised myasthenia gravis (gMG) and improve patient care; however, the use of assessment tools in practice lacks standardisation. This modified Delphi approach was taken to review current evidence on assessment tool use in gMG and develop expert-derived consensus recommendations for good practice. METHODS A European expert panel of 15 experienced gMG neurologists contributed to development of this consensus, four of whom formed a lead Sub-committee. The PICO (Population, Intervention, Control, Outcomes) framework was used to define six clinical questions on gMG assessment tools, a systematic literature review was conducted, and evidence-based statements were developed. According to a modified Delphi voting process, consensus was reached when ≥70% of the experts rated agreement with a statement as ≥8 on a scale of 1-10. RESULTS Eighteen expert- and evidence-based consensus statements based on six themes were developed. Key recommendations include: consistent use of the Myasthenia Gravis Activities of Daily Living score (MG-ADL) across clinical settings, followed by a simple question (e.g., Patient Acceptable Symptom State [PASS]) or scale to determine patient satisfaction in clinical practice; use of a Quantitative Myasthenia Gravis [QMG] or quality of life [QoL] assessment when the MG-ADL indicates disease worsening; and consideration of symptom state to determine the timing and frequency of recommended assessments. Expert panel consensus was reached on all 18 statements after two voting rounds. CONCLUSIONS This process provided evidence- and expert consensus-based recommendations for the use of objective and subjective assessment tools across gMG research and care to improve management and outcomes for patients.
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Affiliation(s)
- Andreas Meisel
- Department of Neurology with Experimental NeurologyNeuroscience Clinical Research CenterCharité Universitätsmedizin BerlinBerlinGermany
| | - Francesco Saccà
- GENESIS Department, Federico II University of NaplesNaplesItaly
| | - Jennifer Spillane
- National Hospital for Neurology and NeurosurgeryUCLH NHS Foundation TrustLondonUK
| | - John Vissing
- Copenhagen Neuromuscular CenterCopenhagen University Hospital RigshospitaletCopenhagenDenmark
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12
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Lin J, Xue B, Li J, Xie D, Weng Y, Zhang X, Li X, Xia J. The relationship between neuromyelitis optica spectrum disorder and autoimmune diseases. Front Immunol 2024; 15:1406409. [PMID: 38994358 PMCID: PMC11236685 DOI: 10.3389/fimmu.2024.1406409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 06/10/2024] [Indexed: 07/13/2024] Open
Abstract
Objective There have been reports of neuromyelitis optica spectrum disorder (NMOSD) coexisting with connective tissue disorders. The objective of this study was to describe the characteristics of NMOSD coexisting with autoimmune diseases (AID). Methods This retrospective study evaluated NMOSD patients with and without AID. The enrolled patients had at least one attack, with duration of more than 1 year. Data on the demographics, clinical features, and laboratory findings were assessed. The Poisson model was used to investigate the risk factors associated with the annualized relapse rate (ARR), whereas the Cox model was used to evaluate the risk factors for the first relapse. Results A total of 180 patients (154 women and 26 men) with NMOSD were identified: 45 had AID and 135 did not. Female patients had a higher prevalence of concomitant AID (p = 0.006) and a greater relapse rate within the first year. There were no statistically significant differences in the characteristics of patients. Kaplan-Meier analysis revealed that NMOSD patients with seropositive aquaporin 4 antibodies (AQP4-Ab; log-rank: p = 0.044), had a shorter time to relapse. Patients seropositive for AQP4-Ab (HR = 2.402, 95%CI = 1.092-5.283, p = 0.029) had a higher risk of suffering a first relapse, according to the Cox model. Patients with and without AID showed a similar declining tendency in terms of change in ARR throughout the first 5 years of the disease. The ARR was greater in the first year [incidence rate ratio (IRR) = 1.534, 95%CI = 1.111-2.118] and the first 2 years (IRR = 1.474, 95%CI = 1.056-2.058) in patients with coexisting AID diagnosis prior to the NMOSD onset. Conclusions Patients with NMOSD with coexisting AID had similar characteristics when compared with those without AID. NMOSD patients with AID diagnosed before onset had a higher risk of relapse in the early stage of the disease.
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Affiliation(s)
- Jie Lin
- Department of Neurology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Binbin Xue
- Department of Anesthesiology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jia Li
- Department of Neurology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Dewei Xie
- Department of Neurology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yiyun Weng
- Department of Neurology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xu Zhang
- Department of Neurology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiang Li
- Department of Neurology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Junhui Xia
- Department of Neurology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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13
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Rigamonti A, Mantero V, Scaioli V, Mauri E, Salmaggi A. Repetitive nerve stimulation and single-fibre electromyography: a biomarker of response to eculizumab in refractory myasthenia gravis? Neurol Sci 2024:10.1007/s10072-024-07663-w. [PMID: 38926246 DOI: 10.1007/s10072-024-07663-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 06/20/2024] [Indexed: 06/28/2024]
Affiliation(s)
- Andrea Rigamonti
- Neurology Unit, Ospedale A. Manzoni, ASST Lecco, Via Dell'Eremo 9-11, 23900, Lecco, Italy.
| | - Vittorio Mantero
- Neurology Unit, Ospedale A. Manzoni, ASST Lecco, Via Dell'Eremo 9-11, 23900, Lecco, Italy
| | - Vidmer Scaioli
- Neurology Unit, Ospedale A. Manzoni, ASST Lecco, Via Dell'Eremo 9-11, 23900, Lecco, Italy
| | - Eliana Mauri
- Neurology Unit, Ospedale A. Manzoni, ASST Lecco, Via Dell'Eremo 9-11, 23900, Lecco, Italy
| | - Andrea Salmaggi
- Neurology Unit, Ospedale A. Manzoni, ASST Lecco, Via Dell'Eremo 9-11, 23900, Lecco, Italy
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14
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Remijn-Nelissen L, Tannemaat MR, Ruiter AM, Campman YJM, Verschuuren JJGM. Efgartigimod in refractory autoimmune myasthenia gravis. Muscle Nerve 2024. [PMID: 38899431 DOI: 10.1002/mus.28184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 05/27/2024] [Accepted: 06/01/2024] [Indexed: 06/21/2024]
Abstract
INTRODUCTION/AIMS Efgartigimod, a neonatal Fc-receptor inhibitor, has recently been approved as treatment for myasthenia gravis (MG). In this retrospective cohort study, we aimed to systematically assess short- and long-term effectiveness of efgartigimod in patients with refractory MG. METHODS Sixteen patients with refractory autoimmune acetylcholine receptor MG were treated with efgartigimod. Data were collected from January 2021 to March 2023 on Myasthenia Gravis Activities of Daily Living (MG-ADL), Quantitative Myasthenia Gravis score (QMG), Myasthenia Gravis Composite score (MGC) and the 15-item revised version of the Myasthenia Gravis Quality of Life questionnaire (MG-QoL15r). RESULTS A favorable outcome was seen in 56% of patients at the last measurement. Out of 16 patients, 50% were an MG-ADL responder after the first treatment cycle. After 4 weeks, a clinically meaningful improvement compared to baseline was seen on the MG-ADL, QMG, and MGC. There was a statistically significant improvement on the MGQoL15r from baseline to week 4. The improvement was maintained until the last measurement for the MGC and the MGQoL15r. At the last visit, all patients had discontinued 4-weekly dosages, shifting to administration frequencies of 1, 2, or 3 weeks. Drug doses could be decreased for prednisolone (n = 7), azathioprine (n = 2), and intravenous immunoglobulin (n = 9). Frequency of plasma exchange was decreased in nine patients. DISCUSSION In patients with refractory MG, efgartigimod was effective for at least half of all patients. Patients required more frequent dosing compared to the ADAPT phase 3 trial. In 80% of the patients concurrent medication could be reduced or discontinued.
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Affiliation(s)
| | - Martijn R Tannemaat
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Annabel M Ruiter
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Yvonne J M Campman
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
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15
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Schönfelder K, Kühne L, Schulte-Kemna L, Kaufeld J, Rohn H, Kribben A, Schröppel B, Brinkkötter PT, Gäckler A. Clinical efficacy and safety of switching from eculizumab to ravulizumab in adult patients with aHUS- real-world data. BMC Nephrol 2024; 25:202. [PMID: 38898427 PMCID: PMC11188157 DOI: 10.1186/s12882-024-03638-3] [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: 01/13/2024] [Accepted: 06/12/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND The complement factor 5 (C5)-inhibitor eculizumab has been established as standard-of-care for the treatment of atypical hemolytic uremic syndrome (aHUS). In 2021, the long-acting C5-inhibitor ravulizumab was approved, extending intervals of intravenous treatment from two to eight weeks resulting in improvement of quality of life for patients and lowering direct and indirect therapy associated costs. METHODS This multicenter, retrospective data analysis of 32 adult patients with aHUS (including 10 kidney transplant recipients) treated with eculizumab for at least three months and switched to ravulizumab aims to evaluate the safety and efficacy of switching medication in the real-world setting. Hematologic parameters, kidney function, concurrent therapy and aHUS associated events were evaluated three months before and until up to 12 months after switching to ravulizumab. RESULTS Mean age (range) at ravulizumab initiation was 41 years (19-78 years) and 59% of the patients were female. Genetic analysis was available for all patients with 72% showing a pathogenic variant. Median time (range) on eculizumab before switching was 20 months (3-120 months). No new events of TMA or worsening of renal function were reported during up to 12 months of follow-up during ravulizumab treatment. CONCLUSIONS This is the largest, non-industry derived, multi-center retrospective analysis of adult patients with aHUS switching C5-inhibitor treatment from eculizumab to ravulizumab in the real-world setting. Switching to ravulizumab was safe and efficient resulting in sustained hematological stability and preservation of renal function.
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Affiliation(s)
- Kristina Schönfelder
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Lucas Kühne
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Lena Schulte-Kemna
- Section of Nephrology, Ulm University Hospital, University of Ulm, Ulm, Germany
| | - Jessica Kaufeld
- Division of Nephrology, Center for Internal Medicine, Hannover Medical School, Hannover, Germany
| | - Hana Rohn
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Andreas Kribben
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Bernd Schröppel
- Section of Nephrology, Ulm University Hospital, University of Ulm, Ulm, Germany
| | - Paul T Brinkkötter
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Anja Gäckler
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany.
- Klinik Für Nephrologie, Universitätsklinikum Essen, Hufelandstr. 55, Essen, 45147, Germany.
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Schroeter CB, Nelke C, Stascheit F, Huntemann N, Preusse C, Dobelmann V, Theissen L, Pawlitzki M, Räuber S, Willison A, Vogelsang A, Marina AD, Hartung HP, Melzer N, Konen FF, Skripuletz T, Hentschel A, König S, Schweizer M, Stühler K, Poschmann G, Roos A, Stenzel W, Meisel A, Meuth SG, Ruck T. Inter-alpha-trypsin inhibitor heavy chain H3 is a potential biomarker for disease activity in myasthenia gravis. Acta Neuropathol 2024; 147:102. [PMID: 38888758 PMCID: PMC11195637 DOI: 10.1007/s00401-024-02754-6] [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: 02/15/2024] [Revised: 06/10/2024] [Accepted: 06/10/2024] [Indexed: 06/20/2024]
Abstract
Myasthenia gravis is a chronic antibody-mediated autoimmune disease disrupting neuromuscular synaptic transmission. Informative biomarkers remain an unmet need to stratify patients with active disease requiring intensified monitoring and therapy; their identification is the primary objective of this study. We applied mass spectrometry-based proteomic serum profiling for biomarker discovery. We studied an exploration and a prospective validation cohort consisting of 114 and 140 anti-acetylcholine receptor antibody (AChR-Ab)-positive myasthenia gravis patients, respectively. For downstream analysis, we applied a machine learning approach. Protein expression levels were confirmed by ELISA and compared to other myasthenic cohorts, in addition to myositis and neuropathy patients. Anti-AChR-Ab levels were determined by a radio receptor assay. Immunohistochemistry and immunofluorescence of intercostal muscle biopsies were employed for validation in addition to interactome studies of inter-alpha-trypsin inhibitor heavy chain H3 (ITIH3). Machine learning identified ITIH3 as potential serum biomarker reflective of disease activity. Serum levels correlated with disease activity scores in the exploration and validation cohort and were confirmed by ELISA. Lack of correlation between anti-AChR-Ab levels and clinical scores underlined the need for biomarkers. In a subgroup analysis, ITIH3 was indicative of treatment responses. Immunostaining of muscle specimens from these patients demonstrated ITIH3 localization at the neuromuscular endplates in myasthenia gravis but not in controls, thus providing a structural equivalent for our serological findings. Immunoprecipitation of ITIH3 and subsequent proteomics lead to identification of its interaction partners playing crucial roles in neuromuscular transmission. This study provides data on ITIH3 as a potential pathophysiological-relevant biomarker of disease activity in myasthenia gravis. Future studies are required to facilitate translation into clinical practice.
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Affiliation(s)
- Christina B Schroeter
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Christopher Nelke
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Frauke Stascheit
- Department of Neurology, Charité - Universitätsmedizin Berlin, 10117, Berlin, Germany
| | - Niklas Huntemann
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Corinna Preusse
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
| | - Vera Dobelmann
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Lukas Theissen
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Marc Pawlitzki
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Saskia Räuber
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Alice Willison
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Anna Vogelsang
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Adela Della Marina
- Department of Neuropaediatrics, Neuromuscular Centre, Universitätsmedizin Essen, Hufelandstr. 55, 45122, Essen, Germany
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
- Brain and Mind Center, University of Sydney, 94 Mallett St, Sydney, Australia
- Department of Neurology, Palacky University Olomouc, Nová Ulice, 779 00, Olomouc, Czech Republic
| | - Nico Melzer
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Felix F Konen
- Department of Neurology, Hannover Medical School, 30625, Hannover, Germany
| | - Thomas Skripuletz
- Department of Neurology, Hannover Medical School, 30625, Hannover, Germany
| | - Andreas Hentschel
- Leibniz-Institut Für Analytische Wissenschaften - ISAS - E.V, 44227, Dortmund, Germany
| | - Simone König
- Core Unit Proteomics, Interdisciplinary Center for Clinical Research, Medical Faculty, University of Münster, 48149, Münster, Germany
| | - Michaela Schweizer
- Electron Microscopy Unit, Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf, 20251, Hamburg, Germany
| | - Kai Stühler
- Institute for Molecular Medicine, Proteome Research, University Hospital and Medical Faculty, Heinrich Heine University, 40225, Duesseldorf, Germany
- Molecular Proteomics Laboratory, Biological Medical Research Center, Heinrich Heine University, Universitätsstr 1, 40225, Duesseldorf, Germany
| | - Gereon Poschmann
- Institute for Molecular Medicine, Proteome Research, University Hospital and Medical Faculty, Heinrich Heine University, 40225, Duesseldorf, Germany
| | - Andreas Roos
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
- Department of Neuropaediatrics, Neuromuscular Centre, Universitätsmedizin Essen, Hufelandstr. 55, 45122, Essen, Germany
| | - Werner Stenzel
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology, Charité - Universitätsmedizin Berlin, 10117, Berlin, Germany
| | - Sven G Meuth
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Tobias Ruck
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany.
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Katyal N, Govindarajan R, Goyal N, Muley S, Muppidi S. Ravulizumab use for acetylcholine receptor-positive generalized myasthenia gravis in clinical practice. Front Neurol 2024; 15:1378080. [PMID: 38919970 PMCID: PMC11197931 DOI: 10.3389/fneur.2024.1378080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 05/23/2024] [Indexed: 06/27/2024] Open
Abstract
Purpose To describe the early experience of ravulizumab use in acetylcholine receptor antibody-positive generalized myasthenia gravis (AChR+ve gMG). Methods This multicenter retrospective study included AChR+ve gMG patients who were treated with ravulizumab and had both pre- and post-ravulizumab myasthenia gravis activities of daily living (MG-ADL) scores. Clinical information regarding MG history, concomitant treatment(s), MG-ADL, other MG-specific measures, and adverse events were recorded. Results A total of 18 patients with mean age of 61.83 (±16.08, n = 18) years were included in this cohort. In 10 complement inhibitor naive patients, a clinically meaningful reduction in mean Mg-ADL (baseline: 6.6 (±3.58) vs. 4.4 (±2.28), post ravulizumab) was seen. 6 out of 10 patients (60%) had clinically meaningful reduction post ravulizumab and two achieved minimum symptom expression (MSE). In 8 patients switched from eculizumab to ravulizumab, further reduction was noted in post ravulizumab mean MG-ADL (Baseline: 3.25 (±3.34) vs. 1.5 (±2.34) post ravulizumab). None of the patients who switched from eculizumab to ravulizumab experienced worsening symptoms. Eleven out of 14 (78.5%) patients on prednisone therapy were able to reduce their prednisone dose post-ravulizumab. None of the patients experienced any major side effects. Conclusion In our clinical practice, 60% of AChR+ve gMG complement inhibitor naive patients experienced a clinically meaningful improvement in MG-ADL scores with ravulizumab. Patients were safely switched from eculizumab to ravulizumab and had further improvement in their mean MG-ADL scores. Of those on prednisone therapy, the majority were able to reduce their prednisone dosage.
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Affiliation(s)
- Nakul Katyal
- Department of Neurology, University of Kentucky, Lexington, KY, United States
| | | | - Neelam Goyal
- Department of Neurology, Stanford Healthcare, Stanford, CA, United States
| | - Suraj Muley
- Department of Neurology, Honor Health, Bob Bove Neurosciences Institute, Scottsdale, AZ, United States
| | - Srikanth Muppidi
- Department of Neurology, Stanford Healthcare, Stanford, CA, United States
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Cavalcante P, Mantegazza R, Antozzi C. Targeting autoimmune mechanisms by precision medicine in Myasthenia Gravis. Front Immunol 2024; 15:1404191. [PMID: 38903526 PMCID: PMC11187261 DOI: 10.3389/fimmu.2024.1404191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 05/24/2024] [Indexed: 06/22/2024] Open
Abstract
Myasthenia Gravis (MG) is a chronic disabling autoimmune disease caused by autoantibodies to the neuromuscular junction (NMJ), characterized clinically by fluctuating weakness and early fatigability of ocular, skeletal and bulbar muscles. Despite being commonly considered a prototypic autoimmune disorder, MG is a complex and heterogeneous condition, presenting with variable clinical phenotypes, likely due to distinct pathophysiological settings related with different immunoreactivities, symptoms' distribution, disease severity, age at onset, thymic histopathology and response to therapies. Current treatment of MG based on international consensus guidelines allows to effectively control symptoms, but most patients do not reach complete stable remission and require life-long immunosuppressive (IS) therapies. Moreover, a proportion of them is refractory to conventional IS treatment, highlighting the need for more specific and tailored strategies. Precision medicine is a new frontier of medicine that promises to greatly increase therapeutic success in several diseases, including autoimmune conditions. In MG, B cell activation, antibody recycling and NMJ damage by the complement system are crucial mechanisms, and their targeting by innovative biological drugs has been proven to be effective and safe in clinical trials. The switch from conventional IS to novel precision medicine approaches based on these drugs could prospectively and significantly improve MG care. In this review, we provide an overview of key immunopathogenetic processes underlying MG, and discuss on emerging biological drugs targeting them. We also discuss on future direction of research to address the need for patients' stratification in endotypes according with genetic and molecular biomarkers for successful clinical decision making within precision medicine workflow.
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Affiliation(s)
- Paola Cavalcante
- Neurology 4 – Neuroimmunology and Neuromuscular Diseases Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Renato Mantegazza
- Neurology 4 – Neuroimmunology and Neuromuscular Diseases Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Carlo Antozzi
- Neurology 4 – Neuroimmunology and Neuromuscular Diseases Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
- Immunotherapy and Apheresis Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
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19
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Traschütz A, Fleszar Z, Hengel H, Klockgether T, Erdlenbruch F, Falkenburger BH, Klopstock T, Öztop-Çakmak Ö, Pedroso JL, Santorelli FM, Schöls L, Synofzik M. FARS-ADL across Ataxias: Construct Validity, Sensitivity to Change, and Minimal Important Change. Mov Disord 2024; 39:965-974. [PMID: 38509638 DOI: 10.1002/mds.29788] [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: 12/18/2023] [Revised: 02/05/2024] [Accepted: 03/05/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Patient-focused outcomes present a central need for trial-readiness across all ataxias. The Activities of Daily Living part of the Friedreich Ataxia Rating Scale (FARS-ADL) captures functional impairment and longitudinal change but is only validated in Friedreich Ataxia. OBJECTIVE Validation of FARS-ADL regarding disease severity and patient-meaningful impairment, and its sensitivity to change across genetic ataxias. METHODS Real-world registry data of FARS-ADL in 298 ataxia patients across genotypes were analyzed, including (1) cross-correlation with FARS-stage, Scale for the Assessment and Rating of Ataxia (SARA), Patient-Reported Outcome Measure (PROM)-ataxia, and European Quality of Life 5 Dimensions visual analogue scale (EQ5D-VAS); (2) sensitivity to change within a trial-relevant 1-year median follow-up, anchored in Patient Global Impression of Change (PGI-C); and (3) general linear modeling of factors age, sex, and depression (nine-item Patient Health Questionnaire [PHQ-9]). RESULTS FARS-ADL correlated with overall disability (rhoFARS-stage = 0.79), clinical disease severity (rhoSARA = 0.80), and patient-reported impairment (rhoPROM-ataxia = 0.69, rhoEQ5D-VAS = -0.37), indicating comprehensive construct validity. Also at item level, and validated within genotype (SCA3, RFC1), FARS-ADL correlated with the corresponding SARA effector domains; and all items correlated to EQ5D-VAS quality of life. FARS-ADL was sensitive to change at a 1-year interval, progressing only in patients with worsening PGI-C. Minimal important change was 1.1. points based on intraindividual variability in patients with stable PGI-C. Depression was captured using FARS-ADL (+0.3 points/PHQ-9 count) and EQ5D-VAS, but not FARS-stage or SARA. CONCLUSION FARS-ADL reflects both disease severity and patient-meaningful impairment across genetic ataxias, with sensitivity to change in trial-relevant timescales in patients perceiving change. It thus presents a promising patient-focused outcome for upcoming ataxia trials. © 2024 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Andreas Traschütz
- Research Division "Translational Genomics of Neurodegenerative Diseases," Hertie-Institute for Clinical Brain Research and Center of Neurology, University of Tübingen, Tübingen, Germany
- German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany
| | - Zofia Fleszar
- German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany
- Department of Neurodegenerative Diseases and Hertie-Institute for Clinical Brain Research and Center of Neurology, University of Tübingen, Tübingen, Germany
| | - Holger Hengel
- German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany
- Department of Neurodegenerative Diseases and Hertie-Institute for Clinical Brain Research and Center of Neurology, University of Tübingen, Tübingen, Germany
| | - Thomas Klockgether
- Department of Neurology, University Hospital Bonn, Bonn, Germany
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Friedrich Erdlenbruch
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Essen University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Björn H Falkenburger
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- German Center for Neurodegenerative Diseases (DZNE), Dresden, Germany
| | - Thomas Klopstock
- Department of Neurology, Friedrich-Baur-Institute, Ludwig-Maximilians-University of Munich, Munich, Germany
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | | | - José Luiz Pedroso
- Department of Neurology and Neurosurgery, School of Medicine, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | | | - Ludger Schöls
- German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany
- Department of Neurodegenerative Diseases and Hertie-Institute for Clinical Brain Research and Center of Neurology, University of Tübingen, Tübingen, Germany
| | - Matthis Synofzik
- Research Division "Translational Genomics of Neurodegenerative Diseases," Hertie-Institute for Clinical Brain Research and Center of Neurology, University of Tübingen, Tübingen, Germany
- German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany
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Hawkes MA, Wijdicks EFM. Improving Outcome in Severe Myasthenia Gravis and Guillain-Barré Syndrome. Semin Neurol 2024; 44:263-270. [PMID: 38560985 DOI: 10.1055/s-0044-1785509] [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: 04/04/2024]
Abstract
When progressive and severe, myasthenia gravis and Guillain-Barré syndrome may have the potential for fatal and unfavorable clinical outcomes. Regardless of important differences in their clinical course, the development of weakness of oropharyngeal muscles and respiratory failure with requirement of mechanical ventilation is the main driver of poor prognosis in both conditions. The need for prolonged mechanical ventilation is particularly relevant because it immobilizes the patient and care becomes extraordinarily complex due to daily risks of systemic complications. Additionally, patients with myasthenia gravis often require long-term immunosuppressive treatments with associated toxicity and infectious risks. Unlike myasthenia gravis, the recovery period is prolonged in Guillain-Barré syndrome, but often favorable, even in the more severely affected patients. Outcome, for a large part, is determined by expert neurocritical care.
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Affiliation(s)
- Maximiliano A Hawkes
- Department of Neurology, Neurocritical Care Services, Mayo Clinic, Rochester, Minnesota
| | - Eelco F M Wijdicks
- Department of Neurology, Neurocritical Care Services, Mayo Clinic, Rochester, Minnesota
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21
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Haghikia A, Schett G, Mougiakakos D. B cell-targeting chimeric antigen receptor T cells as an emerging therapy in neuroimmunological diseases. Lancet Neurol 2024; 23:615-624. [PMID: 38760099 DOI: 10.1016/s1474-4422(24)00140-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/07/2024] [Accepted: 03/27/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Neuroimmunology research and development has been marked by substantial advances, particularly in the treatment of neuroimmunological diseases, such as multiple sclerosis, myasthenia gravis, neuromyelitis optica spectrum disorders, and myelin oligodendrocyte glycoprotein antibody disease. With more than 20 drugs approved for multiple sclerosis alone, treatment has become more personalised. The approval of disease-modifying therapies, particularly those targeting B cells, has highlighted the role of immunotherapeutic interventions in the management of these diseases. Despite these successes, challenges remain, particularly for patients who do not respond to conventional therapies, underscoring the need for innovative approaches. RECENT DEVELOPMENTS The approval of monoclonal antibodies, such as ocrelizumab and ofatumumab, which target CD20, and inebilizumab, which targets CD19, for the treatment of various neuroimmunological diseases reflects progress in the understanding and management of B-cell activity. However, the limitations of these therapies in halting disease progression or activity in patients with multiple sclerosis or neuromyelitis optica spectrum disorders have prompted the exploration of cell-based therapies, particularly chimeric antigen receptor (CAR) T cells. Initially successful in the treatment of B cell-derived malignancies, CAR T cells offer a novel therapeutic mechanism by directly targeting and eliminating B cells, potentially overcoming the shortcomings of antibody-mediated B cell depletion. WHERE NEXT?: The use of CAR T cells in autoimmune diseases and B cell-driven neuroimmunological diseases shows promise as a targeted and durable option. CAR T cells act autonomously, penetrating deep tissue and effectively depleting B cells, especially in the CNS. Although the therapeutic potential of CAR T cells is substantial, their application faces hurdles such as complex logistics and management of therapy-associated toxic effects. Ongoing and upcoming clinical trials will be crucial in determining the safety, efficacy, and applicability of CAR T cells. As research progresses, CAR T cell therapy has the potential to transform treatment for patients with neuroimmunological diseases. It could offer extended periods of remission and a new standard in the management of autoimmune and neuroimmunological disorders.
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Affiliation(s)
- Aiden Haghikia
- Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany; German Center for Neurodegenerative Diseases (DZNE), Magdeburg, Germany.
| | - Georg Schett
- Department of Internal Medicine 3-Rheumatology and Immunology and Deutsches Zentrum Immuntherapie (DZI), Friedrich Alexander Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Dimitrios Mougiakakos
- Department of Haematology, Oncology, and Cell Therapy and Oncology and Health Campus Immunology, Infectiology, and Inflammation (GCI(3)), Otto-von-Guericke University, Magdeburg, Germany.
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22
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Lien PW, Joshi M, Tice JA, Agboola F, Nikitin D, Withanawasam V, Jatoi S, Touchette DR. Cost-effectiveness of eculizumab and efgartigimod for the treatment of anti-acetylcholine receptor antibody-positive generalized myasthenia gravis. J Manag Care Spec Pharm 2024; 30:517-527. [PMID: 38824625 PMCID: PMC11144987 DOI: 10.18553/jmcp.2024.30.6.517] [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: 06/04/2024]
Abstract
BACKGROUND Eculizumab and efgartigimod were approved to treat anti-acetylcholine receptor antibody-positive generalized myasthenia gravis (anti-AChR Ab-positive gMG). These relatively new biological treatments provide a more rapid onset of action and improved efficacy compared with conventional immunosuppressive treatments, but at a higher cost. OBJECTIVE To assess the cost-effectiveness of eculizumab and, separately, efgartigimod, each added to conventional therapy vs conventional therapy alone, among patients with refractory anti-AChR Ab-positive gMG and those with anti-AChR Ab-positive gMG, respectively. METHODS A Markov model with 4 health states was developed, evaluating costs and utility with a 4-week cycle length and lifetime time horizon from a health care system perspective and a modified societal perspective including productivity losses from patients and caregiver burden. Model inputs were informed by key clinical trials and relevant publications identified from targeted literature reviews, and drug costs were identified from Micromedex Red Book. Costs and outcomes were discounted at 3% per year. Incremental cost-effectiveness ratios (ICERs; cost per quality-adjusted life-year [QALY] gained) were calculated for each comparison. RESULTS Among the corresponding populations, lifetime costs and QALYs, respectively, for eculizumab were $5,515,000 and 11.85, and for conventional therapy, $308,000 and 10.29, resulting in an ICER of $3,338,000/QALY gained. For efgartigimod, lifetime costs and QALYs, respectively, were $6,773,000 and 13.22, and for conventional therapy, $322,000 and 9.98, yielding an ICER of $1,987,000/QALY gained. After applying indirect costs in a modified societal perspective, the ICERs were reduced to $3,310,000/QALY gained for eculizumab and $1,959,000/QALY gained for efgartigimod. CONCLUSIONS Eculizumab and efgartigimod are rapidly acting and effective treatments for myasthenia gravis. However, at their current price, both therapies greatly exceeded common cost-effectiveness thresholds, likely limiting patient access to these therapies.
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Affiliation(s)
- Pei-Wen Lien
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois Chicago
| | - Mrinmayee Joshi
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois Chicago
| | - Jeffrey A Tice
- Division of General Internal Medicine, University of California San Francisco
| | | | | | - Vinura Withanawasam
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois Chicago
| | - Saira Jatoi
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois Chicago
| | - Daniel R Touchette
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois Chicago
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23
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Saccà F, Salort‐Campana E, Jacob S, Cortés‐Vicente E, Schneider‐Gold C. Refocusing generalized myasthenia gravis: Patient burden, disease profiles, and the role of evolving therapy. Eur J Neurol 2024; 31:e16180. [PMID: 38117543 PMCID: PMC11236062 DOI: 10.1111/ene.16180] [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: 02/10/2023] [Revised: 11/06/2023] [Accepted: 11/27/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND AND PURPOSE Generalized myasthenia gravis (gMG) continues to present significant challenges for clinical management due to an unpredictable disease course, frequent disease fluctuations, and varying response to therapy. The recent availability of new pharmacologic therapies presents a valuable opportunity to reevaluate how this disease is classified, assessed, and managed and identify new ways to improve the clinical care of patients with gMG. METHODS Narrative review was made of publications identified via searches of PubMed and selected congresses (January 2000-September 2022). RESULTS New consensus definitions are required to ensure consistency, to better characterize patients, and to identify patients who will benefit from specific drugs and earlier use of these agents. There is a need for more frequent, standardized patient assessment to identify the cause of motor function deficits, provide a clearer picture of the disease burden and its impact on daily living and quality of life (QoL), and better support treatment decision-making. Novel approaches that target different components of the immune system will play a role in more precise treatment of patients with gMG, alongside the development of new algorithms to guide individualized patient management. CONCLUSIONS gMG has a physical, mental, and social impact, resulting in a considerable burden of disease and substantially decreased QoL, despite standard treatments. The availability of novel, targeted treatments that influence key pathological mediators of gMG, together with new biomarkers, offers the potential to optimize patient management and ultimately enables a greater number of patients to achieve minimal manifestation status and a reduced burden of disease.
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Affiliation(s)
- Francesco Saccà
- Department of Neuroscience, Reproductive Science and OdontostomatologyFederico II UniversityNaplesItaly
| | - Emmanuelle Salort‐Campana
- Reference Center of Neuromuscular Disorders and ALS, Timone University HospitalAssistance Publique–Hopitaux de MarseilleMarseilleFrance
| | - Saiju Jacob
- Institute of Immunology and ImmunotherapyUniversity of BirminghamBirminghamUK
| | - Elena Cortés‐Vicente
- Neuromuscular Diseases Unit, Department of NeurologyHospital de la Santa Creu i Sant Pau and Biomedical Research Institute Sant PauBarcelonaSpain
- Centro de Investigación Biomédica en Red de Enfermedades RarasInstituto de Salud Carlos IIIMadridSpain
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24
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Fuchs L, Shelly S, Vigiser I, Kolb H, Regev K, Schwartzmann Y, Vaknin-Dembinsky A, Dori A, Karni A. Real-World experience with efgartigimod in patients with myasthenia gravis. J Neurol 2024; 271:3462-3470. [PMID: 38528163 DOI: 10.1007/s00415-024-12293-5] [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: 01/29/2024] [Revised: 02/28/2024] [Accepted: 02/29/2024] [Indexed: 03/27/2024]
Abstract
Recommendations for the treatment of myasthenia gravis (MG) have been difficult to develop because of limited evidence from large randomized controlled trials. New drugs and treatment approaches have recently been shown to be effective in phase 3 studies in seropositive generalized (g) MG. One such drug is efgartigimod, a human-Fc-fragment of IgG1, with a high affinity for the endosomal FcRn. We conducted a multicenter study to evaluate the real-world clinical and safety effects of efgartigimod in 22 gMG patients. We evaluated the strategies for the timing of re-treatment with it. The participants received a total of 59 efgartigimod -treatment cycles. The median number of cycles was 2 (range 1-6). Twenty patients (86.3%) improved by at least 2 MG-ADL points after the first treatment cycle. The median MG-ADL score at baseline was 6.5 (range: 3-17) and 2.5 (range: 0-9) post-treatment (p < 0.001). A consistent improvement of at least 2 points in the MG-ADL score after each cycle occurs in 18 patients. The effect duration of the treatment was usually between 4 and 12 weeks. Two major clinical patterns of treatment response were found. Treatment with efgartigimod was also associated with significant reductions of prednisone doses Overall, the treatment was safe and associated with only minor adverse events. The single fatality was apparently due tosevere respiratory failure. We found that efgartigimod is clinically effective, may be used as a steroid sparing agent and is generally safe for gMG patients. We recommend a personalized preventive treatment approach until clinical stabilization, followed by discontinuation and periodic evaluations.
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Affiliation(s)
- Lior Fuchs
- Faculty of Medicine & Health Sciences, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Shahar Shelly
- Department of Neurology, Rambam Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ifat Vigiser
- Faculty of Medicine & Health Sciences, Tel Aviv University, Tel Aviv-Yafo, Israel
- Neuroimmunology and MS Unit, Neurology Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Hadar Kolb
- Neuroimmunology and MS Unit, Neurology Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Keren Regev
- Neuroimmunology and MS Unit, Neurology Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yoel Schwartzmann
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Adi Vaknin-Dembinsky
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Amir Dori
- Faculty of Medicine & Health Sciences, Tel Aviv University, Tel Aviv-Yafo, Israel
- Department of Neurology, Sheba Medical Center, Ramat-Gan, Israel
| | - Arnon Karni
- Faculty of Medicine & Health Sciences, Tel Aviv University, Tel Aviv-Yafo, Israel.
- Neuroimmunology and MS Unit, Neurology Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel.
- The Neurology Institute, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, 6423906, Tel Aviv, Israel.
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Wei Y, Guo J, Meng T, Gao T, Mai Y, Zuo W, Yang J. The potential application of complement inhibitors-loaded nanosystem for autoimmune diseases via regulation immune balance. J Drug Target 2024; 32:485-498. [PMID: 38491993 DOI: 10.1080/1061186x.2024.2332730] [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: 12/20/2023] [Accepted: 03/14/2024] [Indexed: 03/18/2024]
Abstract
The complement is an important arm of the innate immune system, once activated, the complement system rapidly generates large quantities of protein fragments that are potent mediators of inflammation. Recent studies have shown that over-activated complement is the main proinflammatory system of autoimmune diseases (ADs). In addition, activated complements interact with autoantibodies, immune cells exacerbate inflammation, further worsening ADs. With the increasing threat of ADs to human health, complement-based immunotherapy has attracted wide attention. Nevertheless, efficient and targeted delivery of complement inhibitors remains a significant challenge owing to their inherent poor targeting, degradability, and low bioavailability. Nanosystems offer innovative solutions to surmount these obstacles and amplify the potency of complement inhibitors. This prime aim to present the current knowledge of complement in ADs, analyse the function of complement in the pathogenesis and treatment of ADs, we underscore the current situation of nanosystems assisting complement inhibitors in the treatment of ADs. Considering technological, physiological, and clinical validation challenges, we critically appraise the challenges for successfully translating the findings of preclinical studies of these nanosystem assisted-complement inhibitors into the clinic, and future perspectives were also summarised. (The graphical abstract is by BioRender.).
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Affiliation(s)
- Yaya Wei
- Department of Pharmaceutics, School of Pharmacy, Ningxia Medical University, Yinchuan, China
| | - Jueshuo Guo
- Department of Pharmaceutics, School of Pharmacy, Ningxia Medical University, Yinchuan, China
| | - Tingting Meng
- Department of Pharmaceutical Preparation, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Ting Gao
- Department of Pharmaceutical Preparation, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Yaping Mai
- School of Science and Technology Centers, Ningxia Medical University, Yinchuan, China
| | - Wenbao Zuo
- Department of Pharmaceutics, School of Pharmacy, Ningxia Medical University, Yinchuan, China
| | - Jianhong Yang
- Department of Pharmaceutics, School of Pharmacy, Ningxia Medical University, Yinchuan, China
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Liu X, Li R, Li W, Liu W, Wang J, Jing Y. The rate of QMGS change predicts recurrence after thymectomy in myasthenia gravis. J Clin Neurosci 2024; 124:20-26. [PMID: 38640804 DOI: 10.1016/j.jocn.2024.04.011] [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: 10/26/2023] [Revised: 04/07/2024] [Accepted: 04/10/2024] [Indexed: 04/21/2024]
Abstract
OBJECTIVE To investigate the relationship between short-term changes in quantitative myasthenia gravis score (QMGS) after thymectomy and postoperative recurrence in myasthenia gravis (MG) patients without thymoma. METHODS A retrospective observational cohort study. The QMGS of 44 patients with non-thymomatous MG were evaluated before and 1 month after thymectomy, and the frequency and time of postoperative recurrence were recorded. The reduction rate of QMGS (rr-QMGS) was defined as (QMGS one week before thymectomy - QMGS one month after thymectomy)/ QMGS one week before thymectomy × 100 %, as an indicator of short-term symptom change after thymectomy. The receiver operating characteristic (ROC) curve was established to determine an appropriate cut-off value of rr-QMGS for distinguishing postoperative recurrence. Multivariate Cox regression analysis was applied to predict postoperative recurrence. RESULTS Postoperative recurrence occurred in 21 patients (30 times in total) during follow-up. The mean annual recurrence rate was 3.98 times/year preoperatively and 0.30 times/year postoperatively. ROC analysis determined the cut-off value of rr-QMGS was 36.7 % (sensitivity 90.5 %, specificity 52.2 %). Multivariate Cox regression analysis showed that rr-QMGS<36.7 % (hazard rate[HR]6.251, P = 0.014) is positive predictor of postoperative recurrence. Kaplan-Meier analysis showed that postoperative recurrence time was earlier in the low rr-QMGS group than in the high rr-QMGS group (12.62 vs. 36.60 months, p = 0.005). CONCLUSIONS Low rr-QMGS is associated with early postoperative recurrence. Rr-QMGS can be used to predict postoperative recurrence of non-thymomatous MG.
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Affiliation(s)
- Xinxin Liu
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Ran Li
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Wenwen Li
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Wei Liu
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Jiawei Wang
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Yun Jing
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China.
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Ruan Z, Tang Y, Gao T, Li C, Guo R, Sun C, Huang X, Li Z, Chang T. Efficacy and safety of tocilizumab in patients with refractory generalized myasthenia gravis. CNS Neurosci Ther 2024; 30:e14793. [PMID: 38894580 PMCID: PMC11187874 DOI: 10.1111/cns.14793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 04/23/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND We aimed to compare the efficacy of tocilizumab with conventional immunotherapy in refractory patients with acetylcholine receptor antibody-positive (AChR-Ab+) generalized myasthenia gravis (gMG). METHODS This single-center prospective cohort study was based on patients from an MG registry study in China and conducted from February 10, 2021 to March 31, 2022. Adult refractory patients with AChR-Ab+ gMG were assigned to tocilizumab or conventional immunotherapy groups. The primary efficacy outcome was the mean difference of MG activities of daily living (MG-ADL) change at weeks 4, 8, 12, 16, 20, 24 corresponding to that at the baseline between the two groups. A generalized estimating equation model was used for the primary outcome analysis. Safety was assessed based on adverse events. RESULTS Of 34 eligible patients, 20 (mean [standard deviation] age, 53.8 [21.9] years; 12 [60.0%] female) received tocilizumab and 14 received conventional immunotherapy (45.8 [18.0] years; 8 [57.1%] female). The tocilizumab group had greater reduction in MG-ADL score at week 4 (adjusted mean difference, -3.4; 95% CI, -4.7 to -2.0; p < 0.001) than the conventional immunotherapy group, with significant differences sustained through week 24 (adjusted mean difference, -4.5; 95% CI, -6.4 to -2.6; p < 0.001). At week 24, the proportion of patients achieving higher levels of MG-ADL (up to 7-point reduction) and QMG (up to 11-point reduction) scores improvement was significantly greater with tocilizumab. Tocilizumab had acceptable safety profiles without severe or unexpected safety issues. CONCLUSION Tocilizumab is safe and effective in improving the MG-ADL score and reducing prednisone dose in refractory AChR-Ab+ gMG, suggesting tocilizumab has the potential to be a valuable therapeutic option for such patients.
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Affiliation(s)
- Zhe Ruan
- Department of Neurology, Tangdu HospitalThe Fourth Military Medical UniversityXi'anChina
| | - Yonglan Tang
- Department of Neurology, Tangdu HospitalThe Fourth Military Medical UniversityXi'anChina
| | - Ting Gao
- Department of Neurology, Tangdu HospitalThe Fourth Military Medical UniversityXi'anChina
| | - Chunhong Li
- Department of Neurology, Tangdu HospitalThe Fourth Military Medical UniversityXi'anChina
| | - Rongjing Guo
- Department of Neurology, Tangdu HospitalThe Fourth Military Medical UniversityXi'anChina
| | - Chao Sun
- Department of Neurology, Tangdu HospitalThe Fourth Military Medical UniversityXi'anChina
| | - Xiaoxi Huang
- Department of Neurology, Tangdu HospitalThe Fourth Military Medical UniversityXi'anChina
| | - Zhuyi Li
- Department of Neurology, Tangdu HospitalThe Fourth Military Medical UniversityXi'anChina
| | - Ting Chang
- Department of Neurology, Tangdu HospitalThe Fourth Military Medical UniversityXi'anChina
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Ma C, Liu D, Wang B, Yang Y, Zhu R. Advancements and prospects of novel biologicals for myasthenia gravis: toward personalized treatment based on autoantibody specificities. Front Pharmacol 2024; 15:1370411. [PMID: 38881870 PMCID: PMC11177092 DOI: 10.3389/fphar.2024.1370411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 05/06/2024] [Indexed: 06/18/2024] Open
Abstract
Myasthenia gravis (MG) is an antibody-mediated autoimmune disease with a prevalence of 150-250 cases per million individuals. Autoantibodies include long-lived antibodies against the acetylcholine receptor (AChR), mainly of the IgG1 subclass, and IgG4, produced almost exclusively by short-lived plasmablasts, which are prevalent in muscle-specific tyrosine kinase (MuSK) myasthenia gravis. Numerous investigations have demonstrated that MG patients receiving conventional medication today still do not possess satisfactory symptom control, indicating a substantial disease burden. Subsequently, based on the type of the autoantibody and the pathogenesis, we synthesized the published material to date and reached a conclusion regarding the literature related to personalized targeted therapy for MG. Novel agents for AChR MG have shown their efficacy in clinical research, such as complement inhibitors, FcRn receptor antagonists, and B-cell activating factor (BAFF) inhibitors. Rituximab, a representative drug of anti-CD20 therapy, has demonstrated benefits in treatment of MuSK MG patients. Due to the existence of low-affinity antibodies or unidentified antibodies that are inaccessible by existing methods, the treatment for seronegative MG remains complicated; thus, special testing and therapy considerations are necessary. It may be advantageous to initiate the application of novel biologicals at an early stage of the disease. Currently, therapies can also be combined and individualized according to different types of antibodies. With such a wide range of drugs, how to tailor treatment strategies to patients with various conditions and find the most suitable solution for each MG profile are our necessary and urgent aims.
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Affiliation(s)
- Chi Ma
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Dan Liu
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Benqiao Wang
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Yingying Yang
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Ruixia Zhu
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China
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Jacob S. Treating myasthenia gravis beyond the eye clinic. Eye (Lond) 2024:10.1038/s41433-024-03133-x. [PMID: 38789789 DOI: 10.1038/s41433-024-03133-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/17/2024] [Accepted: 05/07/2024] [Indexed: 05/26/2024] Open
Abstract
Myasthenia gravis (MG) is one of the most well characterised autoimmune disorders affecting the neuromuscular junction with autoantibodies targeting the acetylcholine receptor (AChR) complex. The vast majority of patients present with ocular symptoms including double vision and ptosis, but may progress on to develop generalised fatiguable muscle weakness. Severe involvement of the bulbar muscles can lead to dysphagia, dysarthria and breathing difficulties which can progress to myasthenic crisis needing ventilatory support. Given the predominant ocular onset of the disease, it is important that ophthalmologists are aware of the differential diagnosis, investigations and management including evolving therapies. When the disease remains localised to the extraocular muscles (ocular MG) IgG1 and IgG3 antibodies against the AChR (including clustered AChR) are present in nearly 50% of patients. In generalised MG this is seen in nearly 90% patients. Other antibodies include those against muscle specific tyrosine kinase (MuSK) and lipoprotein receptor related protein 4 (LRP4). Even though decremental response on repetitive nerve stimulation is the most well recognised neurophysiological abnormality, single fibre electromyogram (SFEMG) in experienced hands is the most sensitive test which helps in the diagnosis. Initial treatment should be using cholinesterase inhibitors and then proceeding to immunosuppression using corticosteroids and steroid sparing drugs. Patients requiring bulbar muscle support may need rescue therapies including plasma exchange and intravenous immunoglobulin (IVIg). Newer therapeutic targets include those against the B lymphocytes, complement system, neonatal Fc receptors (FcRn) and various other elements of the immune system.
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Affiliation(s)
- Saiju Jacob
- University Hospitals Birmingham, Birmingham, UK.
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
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Zhang I, Jansen JP, Yungher BJ, Kielhorn A, Yee KS. Commentary: Efficacy and safety of the innovative monoclonal antibodies in adults with generalized myasthenia gravis: a Bayesian network analysis. Front Immunol 2024; 15:1403802. [PMID: 38827748 PMCID: PMC11141541 DOI: 10.3389/fimmu.2024.1403802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 04/12/2024] [Indexed: 06/04/2024] Open
Affiliation(s)
- Ina Zhang
- Evidence Synthesis and Decision Modeling, PRECISIONheor, Oakland, CA, United States
| | - Jeroen P. Jansen
- Evidence Synthesis and Decision Modeling, PRECISIONheor, Oakland, CA, United States
| | | | - Adrian Kielhorn
- Alexion, AstraZeneca Rare Disease, Boston, MA, United States
| | - Karen S. Yee
- Alexion, AstraZeneca Rare Disease, Boston, MA, United States
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Shangguan W, Li X, Wang Y, Huang Z, Dong Y, Feng M, Feng J. Design and Biological Evaluation of the Long-Acting C5-Inhibited Ornithodoros moubata Complement Inhibitor (OmCI) Modified with Fatty Acid. Bioconjug Chem 2024; 35:653-664. [PMID: 38593046 DOI: 10.1021/acs.bioconjchem.4c00126] [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: 04/11/2024]
Abstract
Disorder of complement response is a significant pathogenic factor causing some autoimmune and inflammation diseases. The Ornithodoros moubata Complement Inhibitor (OmCI), a small 17 kDa natural protein, was initially extracted from soft tick salivary glands. The protein was found binding to complement C5 specifically, inhibiting the activation of the complement pathway, which is a successful therapeutic basis of complement-mediated diseases. However, a short half-life due to rapid renal clearance is a common limitation of small proteins for clinical application. In this study, we extended the half-life of OmCI by modifying it with fatty acid, which was a method used to improve the pharmacokinetics of native peptides and proteins. Five OmCI mutants were initially designed, and single-site cysteine mutation was introduced to each of them. After purification, four OmCI mutants were obtained that showed similar in vitro biological activities. Three mutants of them were subsequently coupled with different fatty acids by nucleophilic substitution. In total, 15 modified derivatives were screened and tested for anticomplement activity in vitro. The results showed that coupling with fatty acid would not significantly affect their complement-inhibitory activity (CH50 and AH50). OmCIT90C-CM02 and OmCIT90C-CM05 were validated as the applicable OmCI bioconjugates for further pharmacokinetic assessments, and both showed improved plasma half-life in mice compared with unmodified OmCI (15.86, 17.96 vs 2.57 h). In summary, our data demonstrated that OmCI conjugated with fatty acid could be developed as the potential long-acting C5 complement inhibitor in the clinic.
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Affiliation(s)
- Wenwen Shangguan
- School of Pharmacy, Fudan University, 201203 Shanghai, China
- Shanghai Institute of Pharmaceutical Industry, China State Institute of Pharmaceutical Industry, 201203 Shanghai, China
| | - Xiaowan Li
- School of Pharmacy, Fudan University, 201203 Shanghai, China
- Shanghai Institute of Pharmaceutical Industry, China State Institute of Pharmaceutical Industry, 201203 Shanghai, China
| | - Yandan Wang
- Shanghai Institute of Pharmaceutical Industry, China State Institute of Pharmaceutical Industry, 201203 Shanghai, China
- Collaborative Innovation Center of Yangtze River Delta Region Green Pharmaceuticals, Zhejiang University of Technology, 310014 Hangzhou, China
| | - Zongqing Huang
- Shanghai Institute of Pharmaceutical Industry, China State Institute of Pharmaceutical Industry, 201203 Shanghai, China
- Shanghai Duomirui Biotechnology Co Ltd, 201203 Shanghai, China
| | - Yuanzhen Dong
- Shanghai Institute of Pharmaceutical Industry, China State Institute of Pharmaceutical Industry, 201203 Shanghai, China
- Shanghai Duomirui Biotechnology Co Ltd, 201203 Shanghai, China
| | - Meiqing Feng
- School of Pharmacy, Fudan University, 201203 Shanghai, China
| | - Jun Feng
- Shanghai Institute of Pharmaceutical Industry, China State Institute of Pharmaceutical Industry, 201203 Shanghai, China
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Lin J, Li Y, Gui M, Bu B, Li Z. Effectiveness and safety of telitacicept for refractory generalized myasthenia gravis: a retrospective study. Ther Adv Neurol Disord 2024; 17:17562864241251476. [PMID: 38751755 PMCID: PMC11095194 DOI: 10.1177/17562864241251476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 04/11/2024] [Indexed: 05/18/2024] Open
Abstract
Background Refractory generalized myasthenia gravis (GMG) remains a substantial therapeutic challenge. Telitacicept, a recombinant human B-lymphocyte stimulator receptor-antibody fusion protein, holds promise for interrupting the immunopathology of this condition. Objectives This study retrospectively assessed the effectiveness and safety of telitacicept in patients with refractory GMG. Design A single-center retrospective study. Methods Patients with refractory GMG receiving telitacicept (160 mg/week or biweekly) from January to September in 2023 were included. We assessed effectiveness using Myasthenia Gravis Foundation of America post-intervention status (MGFA-PIS), myasthenia gravis treatment status and intensity (MGSTI), quantitative myasthenia gravis (QMG), and MG-activity of daily living (ADL) scores, alongside reductions in prednisone dosage at 3- and 6-month intervals. Safety profiles were also evaluated. Results Sixteen patients with MGFA class II-V refractory GMG were included, with eight females and eight males. All patients were followed up for at least 3 months, and 11 patients reached 6 months follow-up. At the 3-month evaluation, 75% (12/16) demonstrated clinical improvement with MGFA-PIS. One patient achieved pharmacological remission, two attained minimal manifestation status, and nine showed functional improvement; three remained unchanged, and one deteriorated. By the 6-month visit, 90.1% (10/11) sustained significant symptomatic improvement. MGSTI scores and prednisone dosages significantly reduced at both follow-ups (p < 0.05). MG-ADL and QMG scores showed marked improvement at 6 months (p < 0.05). The treatment was well tolerated, with no severe adverse events such as allergy or infection reported. Conclusion Our exploratory investigation suggests that telitacicept is a feasible and well-tolerated add-on therapy for refractory GMG, offering valuable clinical evidence for this novel treatment option.
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Affiliation(s)
- Jing Lin
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yue Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Mengcui Gui
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Bitao Bu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zhijun Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei, China
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Tokuyasu D, Suzuki S, Uzawa A, Nagane Y, Masuda M, Konno S, Kubota T, Samukawa M, Sugimoto T, Ishizuchi K, Oyama M, Yasuda M, Akamine H, Onishi Y, Suzuki Y, Kawaguchi N, Minami N, Kimura T, Takahashi MP, Murai H, Utsugisawa K. Real-world experience with eculizumab and switching to ravulizumab for generalized myasthenia gravis. Ann Clin Transl Neurol 2024; 11:1338-1346. [PMID: 38572524 DOI: 10.1002/acn3.52051] [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: 09/19/2023] [Revised: 03/01/2024] [Accepted: 03/10/2024] [Indexed: 04/05/2024] Open
Abstract
OBJECTIVE Eculizumab and ravulizumab are complement protein C5 inhibitors, showing efficacy and tolerability for patients with anti-acetylcholine receptor-positive (AChR+) generalized myasthenia gravis (gMG) in phase 3 clinical trials and subsequent analyses. The purpose of the present study was to evaluate the clinical significance of eculizumab and switching to ravulizumab for refractory AChR+ gMG patients in the real-world experience. METHODS Among the database of Japan MG registry survey 2021, we studied AChR+ gMG patients who received eculizumab. We also evaluated these patients who switched from eculizumab to ravulizumab. Responder was defined as an improvement of at least 3 points in MG-ADL. We performed a questionnaire of preference between eculizumab and ravulizumab. RESULTS Among 1,106 patients with AChR+ gMG, 36 patients (3%) received eculizumab (female 78%, mean age 56.0 years). Eculizumab was preferentially used in severe and refractory MG patients. The duration of eculizumab treatment was 35 months on average. MG-ADL improved from 9.4 ± 4.9 to 5.9 ± 5.1, and 25 (70%) of the 36 gMG patients were responders. Postintervention status was markedly improved after the eculizumab treatment. Of 13 patients who did not continue eculizumab, 6 showed insufficiencies. Early onset MG was most effective. However, 15 patients switching from eculizumab to ravulizumab kept favorable response and tolerability. Questionnaire surveys showed preference for ravulizumab over eculizumab. INTERPRETATION Eculizumab and switching to ravulizumab showed to be effective for refractory AChR+ gMG patients in clinical settings.
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Affiliation(s)
- Daiki Tokuyasu
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Shigeaki Suzuki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Akiyuki Uzawa
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yuriko Nagane
- Department of Neurology, Hanamaki General Hospital, Hanamaki, Japan
| | - Masayuki Masuda
- Department of Neurology, Tokyo Medical University, Tokyo, Japan
| | - Shingo Konno
- Department of Neurology, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Tomoya Kubota
- Department of Clinical Laboratory and Biomedical Sciences, Division of Health Sciences, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Makoto Samukawa
- Department of Neurology, Kindai University Faculty of Medicine, Sayama, Japan
| | - Takamichi Sugimoto
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Hiroshima, Japan
| | - Kei Ishizuchi
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Munenori Oyama
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Manato Yasuda
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hiroyuki Akamine
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yosuke Onishi
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yasushi Suzuki
- Department of Neurology, National Hospital Organization Sendai Medical Center, Sendai, Japan
| | - Naoki Kawaguchi
- Department of Neurology, Neurology Chiba Clinic, Chiba, Japan
| | - Naoya Minami
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Sapporo, Japan
| | - Takashi Kimura
- Department of Neurology, Hyogo Medical University, Nishinomiya, Japan
| | - Masanori P Takahashi
- Department of Clinical Laboratory and Biomedical Sciences, Division of Health Sciences, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hiroyuki Murai
- Department of Neurology, International University of Health and Welfare, Narita, Japan
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Gilhus NE, Andersen H, Andersen LK, Boldingh M, Laakso S, Leopoldsdottir MO, Madsen S, Piehl F, Popperud TH, Punga AR, Schirakow L, Vissing J. Generalized myasthenia gravis with acetylcholine receptor antibodies: A guidance for treatment. Eur J Neurol 2024; 31:e16229. [PMID: 38321574 PMCID: PMC11236053 DOI: 10.1111/ene.16229] [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: 10/10/2023] [Revised: 01/16/2024] [Accepted: 01/16/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND Generalized myasthenia gravis (MG) with antibodies against the acetylcholine receptor is a chronic disease causing muscle weakness. Access to novel treatments warrants authoritative treatment recommendations. The Nordic countries have similar, comprehensive health systems, mandatory health registers, and extensive MG research. METHODS MG experts and patient representatives from the five Nordic countries formed a working group to prepare treatment guidance for MG based on a systematic literature search and consensus meetings. RESULTS Pyridostigmine represents the first-line symptomatic treatment, while ambenonium and beta adrenergic agonists are second-line options. Early thymectomy should be undertaken if a thymoma, and in non-thymoma patients up to the age of 50-65 years if not obtaining remission on symptomatic treatment. Most patients need immunosuppressive drug treatment. Combining corticosteroids at the lowest possible dose with azathioprine is recommended, rituximab being an alternative first-line option. Mycophenolate, methotrexate, and tacrolimus represent second-line immunosuppression. Plasma exchange and intravenous immunoglobulin are used for myasthenic crises and acute exacerbations. Novel complement inhibitors and FcRn blockers are effective and fast-acting treatments with promising safety profiles. Their use depends on local availability, refunding policies, and cost-benefit analyses. Adapted physical training is recommended. Planning of pregnancies with optimal treatment, information, and awareness of neonatal MG is necessary. Social support and adaptation of work and daily life activities are recommended. CONCLUSIONS Successful treatment of MG rests on timely combination of different interventions. Due to spontaneous disease fluctuations, comorbidities, and changes in life conditions, regular long-term specialized follow-up is needed. Most patients do reasonably well but there is room for further improvement. Novel treatments are promising, though subject to restricted access due to costs.
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Affiliation(s)
- Nils Erik Gilhus
- Department of NeurologyHaukeland University HospitalBergenNorway
- Department of Clinical MedicineUniversity of BergenBergenNorway
| | | | - Linda Kahr Andersen
- Copenhagen Neuromuscular Center, Department of NeurologyCopenhagen University HospitalCopenhagenDenmark
| | | | - Sini Laakso
- Department of Neurology, Brain CenterHelsinki University HospitalHelsinkiFinland
- Translational Immunology Research ProgramUniversity of HelsinkiHelsinkiFinland
| | | | - Sidsel Madsen
- The National Rehabilitation Center for Neuromuscular DiseasesAarhusDenmark
| | - Fredrik Piehl
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
- Department of NeurologyKarolinska University HospitalStockholmSweden
| | | | - Anna Rostedt Punga
- Department of Medical SciencesUppsala UniversityUppsalaSweden
- Department of Clinical NeurophysiologyUppsala University HospitalUppsalaSweden
| | | | - John Vissing
- Copenhagen Neuromuscular Center, Department of NeurologyCopenhagen University HospitalCopenhagenDenmark
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Miyake S, Serizawa K, Onishi S, Katsura Y, Baba M, Kurasawa M, Tomizawa-Shinohara H, Yorozu K, Matsumoto Y, Noguchi-Sasaki M. IL-6 receptor antibody treatment improves muscle weakness in experimental autoimmune myasthenia gravis mouse model. Front Neurol 2024; 15:1356300. [PMID: 38751878 PMCID: PMC11094227 DOI: 10.3389/fneur.2024.1356300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 04/16/2024] [Indexed: 05/18/2024] Open
Abstract
Myasthenia gravis (MG) is a chronic autoimmune disease characterized by muscle weakness and fatigue. It is caused by pathological autoantibodies against components expressed at neuromuscular junctions, such as acetylcholine receptor (AChR). Interleukin-6 (IL-6) has been suggested to play a role in the pathogenesis of MG, and IL-6 receptor (IL-6R) antibody treatment may provide a novel therapeutic option. In this study, we investigated the effects of IL-6R antibody treatment in an experimental autoimmune MG (EAMG) mouse model. We demonstrated that IL-6R antibody treatment improved muscle weakness, reduced IgG deposition at neuromuscular junctions, and the levels of AChR autoantibodies in serum. In addition, follicular helper T cells and Th17, plasma cells in lymph nodes were lower in IL-6R antibody treated mice. Our findings suggest that IL-6R blockade may be a novel and effective therapeutic strategy for the treatment of MG.
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Affiliation(s)
- Shota Miyake
- Product Research Department, Chugai Pharmaceutical Co., Ltd., Yokohama, Japan
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36
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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
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Watanabe-Kusunoki K, Anders HJ. Balancing efficacy and safety of complement inhibitors. J Autoimmun 2024; 145:103216. [PMID: 38552408 DOI: 10.1016/j.jaut.2024.103216] [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: 12/20/2023] [Revised: 03/17/2024] [Accepted: 03/26/2024] [Indexed: 05/15/2024]
Abstract
Complement inhibitors have been approved for several immune-mediated diseases and they are considered the next paradigm-shifting approach in the treatment of glomerulonephritis. The hierarchical organization of the complement system offers numerous molecular targets for therapeutic intervention. However, complement is an integral element of host defense and therefore complement inhibition can be associated with serious infectious complications. Here we give a closer look to the hierarchical complement system and how interfering with proximal versus distal or selective versus unselective molecular targets could determine efficacy and safety. Furthermore, we propose to consider the type of disease, immunological activity, and patient immunocompetence when stratifying patients, e.g., proximal/unselective targets for highly active and potentially fatal diseases while distal and selective targets may suit more chronic disease conditions with low or moderate disease activity requiring persistent complement blockade in patients with concomitant immunodeficiency. Certainly, there exists substantial promise for anti-complement therapeutics. However, balancing efficacy and safety will be key to establish powerful treatment effects with minimal adverse events, especially when complement blockade is continued over longer periods of time in chronic disorders.
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Affiliation(s)
- Kanako Watanabe-Kusunoki
- Renal Division, Department of Medicine IV, Ludwig-Maximilians (LMU) University Hospital, LMU Munich, Germany; Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hans-Joachim Anders
- Renal Division, Department of Medicine IV, Ludwig-Maximilians (LMU) University Hospital, LMU Munich, Germany.
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Makkawi S, Salamatullah HK, Alkhiri A, Faidah DE, Afif LM, Bukhari JI, Abulaban A, Al Malik Y, Levy M. Role of C5 inhibitors in neuromyelitis optica spectrum disorders with seropositive anti-aquaporin-4 antibody: A systematic review and meta-analysis. Mult Scler Relat Disord 2024; 85:105524. [PMID: 38479045 DOI: 10.1016/j.msard.2024.105524] [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: 11/30/2023] [Revised: 01/11/2024] [Accepted: 02/26/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune disorder characterized by relapses of inflammation and demyelination primarily affecting the optic nerve and the spinal cord. C5 complement inhibition is an effective therapeutic approach in the treatment of NMOSD. In this systematic review and meta-analysis, we aimed to determine the role of C5 inhibitors in the treatment of patients with seropositive anti-aquaporin-4 antibody (AQP4+IgG) NMOSD. METHODS This systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Relevant articles were systematically searched through Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science databases until October 6th, 2023. We included randomized clinical trials (RCTs) that investigated the treatment with C5 inhibitors compared to placebo in patients with seropositive NMOSD. The primary endpoint was the rates of first adjudicated relapse. Secondary endpoints included different disability and quality of life measures. The random-effects model was used for all statistical analyses. RESULTS Two RCTs with a total of 201 patients were included. C5 inhibitors demonstrated significant reduction of first adjudicated relapse (risk ratio (RR) = 0.05, 95 % CI 0.01-0.15) and Hauser Ambulation Index (HAI) (mean difference (MD): -0.79, 95 % CI -1.27 to -0.31). There was no significant difference between the two groups in Expanded Disability Status Scale (EDSS) (MD -0.23, 95 % CI -0.54-0.08). C5 inhibitors significantly improved the mean change in EQ-5D index (MD 0.08, 95 % CI 0.01-0.14; P = 0.02); however, no significant difference was shown in the mean change in EQ-5D VAS (MD 3.79, 95 % CI -1.61 to 9.19; P = 0.17). Safety measures were comparable between C5 inhibitors and placebo. CONCLUSION NMOSD Patients with AQP4+IgG receiving C5 inhibitors have lower rate of relapses and improved levels of disability and quality of life. Real-world studies are warranted to establish the long-term safety of C5 inhibitors.
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Affiliation(s)
- Seraj Makkawi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia; Department of Neurosciences, Ministry of The National Guard-Health Affairs, Jeddah, Saudi Arabia.
| | - Hassan K Salamatullah
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Ahmed Alkhiri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Dania E Faidah
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Lena M Afif
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Jawad I Bukhari
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Ahmad Abulaban
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia; Neurology Division, Department of Medicine, Ministry of The National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Yaser Al Malik
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia; Neurology Division, Department of Medicine, Ministry of The National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Michael Levy
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Ouyang Y, Chen Y, Chen K, Tang Z, Shi G, Qu C, Zhang K, Yang H. Mendelian randomization and colocalization analysis reveal novel drug targets for myasthenia gravis. Hum Genomics 2024; 18:43. [PMID: 38659056 PMCID: PMC11040902 DOI: 10.1186/s40246-024-00607-7] [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: 12/02/2023] [Accepted: 04/05/2024] [Indexed: 04/26/2024] Open
Abstract
OBJECTIVE Myasthenia gravis (MG) is a complex autoimmune disease affecting the neuromuscular junction with limited drug options, but the field of MG treatment recently benefits from novel biological agents. We performed a drug-targeted Mendelian randomization (MR) study to identify novel therapeutic targets of MG. METHODS Cis-expression quantitative loci (cis-eQTL), which proxy expression levels for 2176 druggable genes, were used for MR analysis. Causal relationships between genes and disease, identified by eQTL MR analysis, were verified by comprehensive sensitivity, colocalization, and protein quantitative loci (pQTL) MR analyses. The protein-protein interaction (PPI) analysis was also performed to extend targets, followed by enzyme-linked immunosorbent assay (ELISA) to explore the serum level of drug targets in MG patients. A phenome-wide MR analysis was then performed to assess side effects with a clinical trial review assessing druggability. RESULTS The eQTL MR analysis has identified eight potential targets for MG, one for early-onset MG and seven for late-onset MG. Further colocalization analyses indicated that CD226, CDC42BPB, PRSS36, and TNFSF12 possess evidence for colocalization with MG or late-onset MG. pQTL MR analyses identified the causal relations of TNFSF12 and CD226 with MG and late-onset MG. Furthermore, PPI analysis has revealed the protein interaction between TNFSF12-TNFSF13(APRIL) and TNFSF12-TNFSF13B(BLyS). Elevated TNFSF13 serum level of MG patients was also identified by ELISA experiments. This study has ultimately proposed three promising therapeutic targets (TNFSF12, TNFSF13, TNFSF13B) of MG. CONCLUSIONS Three drug targets associated with the BLyS/APRIL pathway have been identified. Multiple biological agents, including telitacicept and belimumab, are promising for MG therapy.
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Affiliation(s)
- Yuzhen Ouyang
- Department of Neurology, Xiangya Hospital, Central South University, 410008, Changsha, China
| | - Yu Chen
- Department of Neurosurgery, Xiangya Hospital, Central South University, 410008, Changsha, China
| | - Kangzhi Chen
- Department of Neurology, Xiangya Hospital, Central South University, 410008, Changsha, China
| | - Zhenwei Tang
- Department of Dermatology, Second Affiliated Hospital, Zhejiang University School of Medicine, 310013, Hangzhou, China
| | - Guanzhong Shi
- Department of Neurology, Xiangya Hospital, Central South University, 410008, Changsha, China
| | - Chunrun Qu
- Department of Neurosurgery, Xiangya Hospital, Central South University, 410008, Changsha, China
| | - Kaiyue Zhang
- Department of Neurology, Xiangya Hospital, Central South University, 410008, Changsha, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, 410008, Changsha, China.
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Bicskó RR, Illés Á, Hevessy Z, Ivády G, Kerekes G, Méhes G, Csépány T, Gergely L. Eculizumab Treatment of Massive Hemolysis Occurring in a Rare Co-Existence of Paroxysmal Nocturnal Hemoglobinuria and Myasthenia Gravis. Hematol Rep 2024; 16:255-259. [PMID: 38651454 PMCID: PMC11036238 DOI: 10.3390/hematolrep16020025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 04/02/2024] [Accepted: 04/16/2024] [Indexed: 04/25/2024] Open
Abstract
The co-occurrence of myasthenia gravis (MG) and paroxysmal nocturnal hemoglobinuria (PNH) is rare; only one case has been published so far. We report a 63-year-old Caucasian female patient who was diagnosed with MG at the age of 43. Thymoma was also detected, and so it was surgically resected, which resulted in reasonable disease control for nearly 20 years. Slight hemolysis began to emerge, and then myasthenia symptoms progressed, so immunosuppressive therapy was started. Due to progressive disease and respiratory failure, the patient underwent plasmapheresis, and ventilatory support was stopped. Marked hemolysis was present, and diagnostic tests confirmed PNH with type III PNH cells. Her myasthenia symptoms aggravated, mechanical ventilation had to be started again, and due to the respiratory acidosis, massive hemolysis occurred. After two plasmapheresis sessions, the patient received eculizumab at 600 mg, resulting in prompt hemolysis control. After the second dose of the treatment, the patient was extubated. Still, due to their inability to cough, she developed another respiratory failure and pneumonia-sepsis, resulting in the patient's death. This case highlights the rare association between these two serious diseases and similar immune-mediated pathophysiology mechanisms involving the complement system.
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Affiliation(s)
- Ráhel Réka Bicskó
- Department of Hematology, Institute of Internal Medicine, Faculty of Medicine, Clinical Center, University of Debrecen, 4032 Debrecen, Hungary; (Á.I.); (L.G.)
| | - Árpád Illés
- Department of Hematology, Institute of Internal Medicine, Faculty of Medicine, Clinical Center, University of Debrecen, 4032 Debrecen, Hungary; (Á.I.); (L.G.)
| | - Zsuzsanna Hevessy
- Department of Laboratory Medicine, Faculty of Medicine, Clinical Center, University of Debrecen, 4032 Debrecen, Hungary; (Z.H.); (G.I.)
| | - Gergely Ivády
- Department of Laboratory Medicine, Faculty of Medicine, Clinical Center, University of Debrecen, 4032 Debrecen, Hungary; (Z.H.); (G.I.)
| | - György Kerekes
- Intensive Care Unit, Institute of Internal Medicine, Faculty of Medicine, Clinical Center, University of Debrecen, 4032 Debrecen, Hungary;
| | - Gábor Méhes
- Department of Pathology, Faculty of Medicine, Clinical Center, University of Debrecen, 4032 Debrecen, Hungary;
| | - Tünde Csépány
- Department of Neurology, Faculty of Medicine, Clinical Center, University of Debrecen, 4032 Debrecen, Hungary;
| | - Lajos Gergely
- Department of Hematology, Institute of Internal Medicine, Faculty of Medicine, Clinical Center, University of Debrecen, 4032 Debrecen, Hungary; (Á.I.); (L.G.)
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Ünlü S, Sánchez Navarro BG, Cakan E, Berchtold D, Meleka Hanna R, Vural S, Vural A, Meisel A, Fichtner ML. Exploring the depths of IgG4: insights into autoimmunity and novel treatments. Front Immunol 2024; 15:1346671. [PMID: 38698867 PMCID: PMC11063302 DOI: 10.3389/fimmu.2024.1346671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/29/2024] [Indexed: 05/05/2024] Open
Abstract
IgG4 subclass antibodies represent the rarest subclass of IgG antibodies, comprising only 3-5% of antibodies circulating in the bloodstream. These antibodies possess unique structural features, notably their ability to undergo a process known as fragment-antigen binding (Fab)-arm exchange, wherein they exchange half-molecules with other IgG4 antibodies. Functionally, IgG4 antibodies primarily block and exert immunomodulatory effects, particularly in the context of IgE isotype-mediated hypersensitivity reactions. In the context of disease, IgG4 antibodies are prominently observed in various autoimmune diseases combined under the term IgG4 autoimmune diseases (IgG4-AID). These diseases include myasthenia gravis (MG) with autoantibodies against muscle-specific tyrosine kinase (MuSK), nodo-paranodopathies with autoantibodies against paranodal and nodal proteins, pemphigus vulgaris and foliaceus with antibodies against desmoglein and encephalitis with antibodies against LGI1/CASPR2. Additionally, IgG4 antibodies are a prominent feature in the rare entity of IgG4 related disease (IgG4-RD). Intriguingly, both IgG4-AID and IgG4-RD demonstrate a remarkable responsiveness to anti-CD20-mediated B cell depletion therapy (BCDT), suggesting shared underlying immunopathologies. This review aims to provide a comprehensive exploration of B cells, antibody subclasses, and their general properties before examining the distinctive characteristics of IgG4 subclass antibodies in the context of health, IgG4-AID and IgG4-RD. Furthermore, we will examine potential therapeutic strategies for these conditions, with a special focus on leveraging insights gained from anti-CD20-mediated BCDT. Through this analysis, we aim to enhance our understanding of the pathogenesis of IgG4-mediated diseases and identify promising possibilities for targeted therapeutic intervention.
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Affiliation(s)
- Selen Ünlü
- Koç University Research Center for Translational Medicine (KUTTAM), İstanbul, Türkiye
- Koç University School of Medicine, Istanbul, Türkiye
| | - Blanca G. Sánchez Navarro
- Department of Neurology with Experimental Neurology, Integrated Myasthenia Gravis Center, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Elif Cakan
- Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, Cambridge, MA, United States
| | - Daniel Berchtold
- Department of Neurology with Experimental Neurology, Integrated Myasthenia Gravis Center, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Rafael Meleka Hanna
- Department of Neurology with Experimental Neurology, Integrated Myasthenia Gravis Center, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Secil Vural
- Koç University Research Center for Translational Medicine (KUTTAM), İstanbul, Türkiye
- Department of Dermatology and Venereology, Koç University School of Medicine, İstanbul, Türkiye
| | - Atay Vural
- Koç University Research Center for Translational Medicine (KUTTAM), İstanbul, Türkiye
- Department of Neurology, Koç University School of Medicine, İstanbul, Türkiye
| | - Andreas Meisel
- Department of Neurology with Experimental Neurology, Integrated Myasthenia Gravis Center, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Miriam L. Fichtner
- Koç University Research Center for Translational Medicine (KUTTAM), İstanbul, Türkiye
- Department of Neurology with Experimental Neurology, Integrated Myasthenia Gravis Center, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
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Howard JF, Bresch S, Farmakidis C, Freimer M, Genge A, Hewamadduma C, Hinton J, Hussain Y, Juntas-Morales R, Kaminski HJ, Maniaol A, Mantegazza R, Masuda M, Nowak RJ, Sivakumar K, Śmiłowski M, Utsugisawa K, Vu T, Weiss MD, Zajda M, Bloemers J, Boroojerdi B, Brock M, de la Borderie G, Duda PW, Vanderkelen M, Leite MI. Long-term safety and efficacy of zilucoplan in patients with generalized myasthenia gravis: interim analysis of the RAISE-XT open-label extension study. Ther Adv Neurol Disord 2024; 17:17562864241243186. [PMID: 38638673 PMCID: PMC11025429 DOI: 10.1177/17562864241243186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 03/13/2024] [Indexed: 04/20/2024] Open
Abstract
Background Generalized myasthenia gravis (gMG) is a chronic, unpredictable disease associated with high treatment and disease burdens, with a need for more effective and well-tolerated treatments. Objectives To evaluate the long-term safety, tolerability, and efficacy of zilucoplan in a mild-to-severe, acetylcholine receptor autoantibody-positive (AChR+) gMG population. Design Ongoing, multicenter, phase III open-label extension (OLE) study. Methods Eligible patients had completed a qualifying randomized, placebo-controlled phase II or phase III zilucoplan study and received daily, self-administered subcutaneous 0.3 mg/kg zilucoplan. The primary endpoint was incidence of treatment-emergent adverse events (TEAEs). Secondary efficacy endpoints included change from baseline in Myasthenia Gravis Activities of Daily Living (MG-ADL) score. Results In total, 200 patients enrolled. At the cut-off date (8 September 2022), median (range) exposure to zilucoplan in RAISE-XT was 1.2 (0.11-4.45) years. Mean age at OLE baseline was 53.3 years. A total of 188 (94%) patients experienced a TEAE, with the most common being MG worsening (n = 52, 26%) and COVID-19 (n = 49, 25%). In patients who received zilucoplan 0.3 mg/kg in the parent study, further improvements in MG-ADL score continued through to Week 24 (least squares mean change [95% confidence interval] from double-blind baseline -6.06 [-7.09, -5.03]) and were sustained through to Week 60 (-6.04 [-7.21, -4.87]). In patients who switched from placebo in the parent study, rapid improvements in MG-ADL score were observed at the first week after switching to zilucoplan; further improvements were observed at Week 24, 12 weeks after switching (-6.46 [-8.19, -4.72]), and were sustained through to Week 60 (-6.51 [-8.37, -4.65]). Consistent results were observed in other efficacy endpoints. Conclusion Zilucoplan demonstrated a favorable long-term safety profile, good tolerability, and sustained efficacy through to Week 60 with consistent benefits in a broad AChR+ gMG population. Additional long-term data will be available in future analyses. Trial registration ClinicalTrials.gov identifier: NCT04225871 (https://clinicaltrials.gov/ct2/show/NCT04225871).
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Affiliation(s)
- James F. Howard
- Department of Neurology, UNC School of Medicine, The University College of North Carolina at Chapel Hill, 2200 Houpt Building, CB#7025, 170 Manning Drive, Chapel Hill, NC 27599-7025, USA
| | - Saskia Bresch
- Service de Neurologie, Hospital Pasteur, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Constantine Farmakidis
- Neuromuscular Division, Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Miriam Freimer
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Angela Genge
- Clinical Research Unit, Montreal Neurological Institute, Montreal, QC, Canada
| | - Channa Hewamadduma
- Academic Neuroscience Unit, Sheffield Teaching Hospitals Foundation Trust, Sheffield, UK
- Sheffield Institute for Translational Neurosciences (SITRAN), University of Sheffield, Sheffield, UK
| | - John Hinton
- Department of Neurology, Frederick P. Whiddon School of Medicine, University of South Alabama, Mobile, AL, USA
| | - Yessar Hussain
- Department of Neurology, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Raul Juntas-Morales
- Department of Neurology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Henry J. Kaminski
- Department of Neurology and Rehabilitation Medicine, George Washington University, Washington, DC, USA
| | | | - Renato Mantegazza
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale Neurologico Carlo Besta, Milan, Italy
| | - Masayuki Masuda
- Department of Neurology, Tokyo Medical University, Tokyo, Japan
| | - Richard J. Nowak
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | | | - Marek Śmiłowski
- Department of Hematology and Bone Marrow Transplantation, Medical University of Silesia, Katowice, Poland
| | | | - Tuan Vu
- Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Michael D. Weiss
- Department of Neurology, University of Washington Medical Center, Seattle, WA, USA
| | - Małgorzata Zajda
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warsaw, Poland
| | | | | | | | | | | | | | - M. Isabel Leite
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Okusa S, Takizawa T, Imai S, Oyama M, Ishizuchi K, Nakahara J, Hori S, Suzuki S. Serious Bacterial Infections Associated with Eculizumab: A Pharmacovigilance Study. Intern Med 2024; 63:1061-1066. [PMID: 37690847 PMCID: PMC11081897 DOI: 10.2169/internalmedicine.1893-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 07/30/2023] [Indexed: 09/12/2023] Open
Abstract
Objective Molecular-targeted agents, including eculizumab and rituximab, are considered treatment options for refractory myasthenia gravis (MG), but bacterial infections can occur as serious adverse events when using these agents. The present study elucidated the relative risks of bacterial infections associated with eculizumab and rituximab using a pharmacovigilance database. Methods We analyzed eculizumab- and rituximab-associated adverse events reported between 2007 and 2021 in the US Food and Drug Administration Adverse Event Reporting System (FAERS) and herein report a refractory MG patient who developed streptococcal toxic shock syndrome during eculizumab treatment. Patients We evaluated a 74-year-old Japanese woman with refractory MG who developed severe bacteremia after receiving eculizumab. Results A total of 44,215 and 108,485 adverse events were reported with eculizumab and rituximab, respectively, from among 13,742,321 individual case safety reports in the FAERS database after data cleaning. We found a strong association between eculizumab and Neisseria infections. In contrast, we found only one case of meningococcal meningitis treated with rituximab. Both eculizumab and rituximab were weakly associated with streptococcal infections. Two cases of streptococcal toxic shock syndrome were associated with rituximab. Conclusion Careful monitoring of serious bacterial infections associated with eculizumab treatment is warranted.
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Affiliation(s)
- Shohei Okusa
- Department of Neurology, Keio University School of Medicine, Japan
| | - Tsubasa Takizawa
- Department of Neurology, Keio University School of Medicine, Japan
| | - Shungo Imai
- Division of Drug Informatics, Keio University Faculty of Pharmacy, Japan
| | - Munenori Oyama
- Department of Neurology, Keio University School of Medicine, Japan
| | - Kei Ishizuchi
- Department of Neurology, Keio University School of Medicine, Japan
| | - Jin Nakahara
- Department of Neurology, Keio University School of Medicine, Japan
| | - Satoko Hori
- Division of Drug Informatics, Keio University Faculty of Pharmacy, Japan
| | - Shigeaki Suzuki
- Department of Neurology, Keio University School of Medicine, Japan
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Sonnentag SJ, Dopler A, Kleiner K, Garg BK, Mannes M, Späth N, Akilah A, Höchsmann B, Schrezenmeier H, Anliker M, Boyanapalli R, Huber-Lang M, Schmidt CQ. Triple-fusion protein (TriFu): A potent, targeted, enzyme-like inhibitor of all three complement activation pathways. J Biol Chem 2024; 300:105784. [PMID: 38401844 PMCID: PMC11065761 DOI: 10.1016/j.jbc.2024.105784] [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: 07/26/2023] [Revised: 02/05/2024] [Accepted: 02/20/2024] [Indexed: 02/26/2024] Open
Abstract
The introduction of a therapeutic anti-C5 antibody into clinical practice in 2007 inspired a surge into the development of complement-targeted therapies. This has led to the recent approval of a C3 inhibitory peptide, an antibody directed against C1s and a full pipeline of several complement inhibitors in preclinical and clinical development. However, no inhibitor is available that efficiently inhibits all three complement initiation pathways and targets host cell surface markers as well as complement opsonins. To overcome this, we engineered a novel fusion protein combining selected domains of the three natural complement regulatory proteins decay accelerating factor, factor H and complement receptor 1. Such a triple fusion complement inhibitor (TriFu) was recombinantly expressed and purified alongside multiple variants and its building blocks. We analyzed these proteins for ligand binding affinity and decay acceleration activity by surface plasmon resonance. Additionally, we tested complement inhibition in several in vitro/ex vivo assays using standard classical and alternative pathway restricted hemolysis assays next to hemolysis assays with paroxysmal nocturnal hemoglobinuria erythrocytes. A novel in vitro model of the alternative pathway disease C3 glomerulopathy was established to evaluate the potential of the inhibitors to stop C3 deposition on endothelial cells. Next to the novel engineered triple fusion variants which inactivate complement convertases in an enzyme-like fashion, stoichiometric complement inhibitors targeting C3, C5, factor B, and factor D were tested as comparators. The triple fusion approach yielded a potent complement inhibitor that efficiently inhibits all three complement initiation pathways while targeting to surface markers.
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Affiliation(s)
- Sophia J Sonnentag
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University of Ulm Medical Centre, Ulm, Germany
| | - Arthur Dopler
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University of Ulm Medical Centre, Ulm, Germany
| | - Katharina Kleiner
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University of Ulm Medical Centre, Ulm, Germany
| | | | - Marco Mannes
- Institute of Clinical and Experimental Trauma Immunology, University Hospital of Ulm, Ulm, Germany
| | - Nadja Späth
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University of Ulm Medical Centre, Ulm, Germany
| | - Amira Akilah
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University of Ulm Medical Centre, Ulm, Germany
| | - Britta Höchsmann
- Institute of Transfusion Medicine, University of Ulm, Ulm, Germany; Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, Baden-Württemberg-Hessen and University Hospital of Ulm, Ulm, Germany
| | - Hubert Schrezenmeier
- Institute of Transfusion Medicine, University of Ulm, Ulm, Germany; Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, Baden-Württemberg-Hessen and University Hospital of Ulm, Ulm, Germany
| | - Markus Anliker
- Institute of Transfusion Medicine, University of Ulm, Ulm, Germany; Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, Baden-Württemberg-Hessen and University Hospital of Ulm, Ulm, Germany
| | | | - Markus Huber-Lang
- Institute of Clinical and Experimental Trauma Immunology, University Hospital of Ulm, Ulm, Germany
| | - Christoph Q Schmidt
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University of Ulm Medical Centre, Ulm, Germany; Institute of Pharmacy, Biochemical Pharmacy Group, Martin Luther University Halle-Wittenberg, Halle, Germany.
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Hoffmann S, Verlohren S, Herdick M. [Myasthenia gravis-Gender aspects and family planning]. DER NERVENARZT 2024; 95:316-328. [PMID: 38499774 DOI: 10.1007/s00115-024-01640-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/23/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND There is evidence that gender-specific differences can influence the diagnostics, treatment and long-term disease course of myasthenia gravis (MG). In women the diagnosis is often made during childbearing age. OBJECTIVE Gender-specific differences in MG and relevant aspects in routine clinical practice are presented. In addition, current studies on family planning, pregnancy and childbirth in MG are highlighted and treatment recommendations are derived. MATERIAL AND METHODS Narrative literature review. RESULTS In addition to sociodemographic data, gender-specific differences encompass clinical as well as paraclinical factors, such as disease severity and antibody status. With few exceptions pregnancy is possible with good maternal and neonatal outcome. During pregnancy and peripartum, children of MG patients should be closely monitored for early detection and treatment of potential syndromes caused by diaplacental transfer of maternal antibodies. CONCLUSION Gender-specific factors can influence the course of MG. Adequate medical counselling and multidisciplinary collaboration are essential for MG patients who wish to have children.
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Affiliation(s)
- Sarah Hoffmann
- Department of Neurology, Neuroscience Clinical Research Center (NCRC) and Integrated Myasthenia Gravis Center, Charité - Universitätsmedizin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
| | - Stefan Verlohren
- Department of Obstetrics, Charité - Universitätsmedizin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Deutschland
| | - Meret Herdick
- Department of Neurology, Neuroscience Clinical Research Center (NCRC) and Integrated Myasthenia Gravis Center, Charité - Universitätsmedizin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
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Jaiswal S, Shrivastava T. Advances in Understanding and Managing Myasthenia Gravis: Current Trends and Future Directions. Cureus 2024; 16:e59104. [PMID: 38803727 PMCID: PMC11128376 DOI: 10.7759/cureus.59104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 04/26/2024] [Indexed: 05/29/2024] Open
Abstract
Myasthenia gravis (MG) is an autoimmune illness characterized by autoantibodies against the acetylcholine receptor (AChR), muscle-specific tyrosine kinase (MuSK), and an increasing number of extra postsynaptic proteins. Pathogenic autoantibodies reduce the number of functional AChRs in the neuromuscular junction's (NMJ) muscle end plate. The cause of the autoimmune response is unknown, but thymic abnormalities and immune regulatory deficiencies are significant. The disease's incidence is likely influenced by genetic predisposition, with sex hormones and exercise playing a role. MG can affect any age, race, or gender and can be caused by any stressor, with infections being the most frequent cause. Treatment focuses on airway support and the triggering incident. MG is a rare autoimmune disease causing fatigue-inducing weakness in the axial, respiratory, leg, and bulbar muscles. Initially affecting the eyes, most MG patients experience at least one worsening symptom during their illness. The disease is mainly caused by antibodies against the AChR, dependence on the immune system within cells, and engagement of the complement system. The complement system plays a significant role in MG, and complement inhibition can both prevent the onset and slow its development. Ocular MG affects around 15% of people, with most patients having blocking antibodies against the cholinergic receptor. There may be correlations between thymoma and other autoimmune conditions, especially thyroid illness. Treatment and management for MG involve removing autoantibodies from circulation or blocking effector mechanisms using techniques such as complement inhibition, plasmapheresis, and B-cell elimination.
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Affiliation(s)
- Shreya Jaiswal
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Tripti Shrivastava
- Physiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Gutschmidt K, Schoser B. [Myasthenia Gravis - Update]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2024; 92:139-156. [PMID: 38636491 DOI: 10.1055/a-2238-7784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
Myasthenia gravis - still a challenge for sufferers and doctors in 2023. But which therapy is best suited? Our clinically experienced experts have summarized the current guidelines for diagnosis and treatment in order to provide optimal support for those affected. Find out how you can carry out a quick and targeted diagnosis and which treatment options are available to alleviate the course of the disease.
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Tian DS, Qin C, Dong MH, Heming M, Zhou LQ, Wang W, Cai SB, You YF, Shang K, Xiao J, Wang D, Li CR, Zhang M, Bu BT, Meyer Zu Hörste G, Wang W. B cell lineage reconstitution underlies CAR-T cell therapeutic efficacy in patients with refractory myasthenia gravis. EMBO Mol Med 2024; 16:966-987. [PMID: 38409527 PMCID: PMC11018773 DOI: 10.1038/s44321-024-00043-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 02/28/2024] Open
Abstract
B-cell maturation antigen (BCMA), expressed in plasmablasts and plasma cells, could serve as a promising therapeutic target for autoimmune diseases. We reported here chimeric antigen receptor (CAR) T cells targeting BCMA in two patients with highly relapsed and refractory myasthenia gravis (one with AChR-IgG, and one with MuSk-IgG). Both patients exhibited favorable safety profiles and persistent clinical improvements over 18 months. Reconstitution of B-cell lineages with sustained reduced pathogenic autoantibodies might underlie the therapeutic efficacy. To identify the possible mechanisms underlying the therapeutic efficacy of CAR-T cells in these patients, longitudinal single-cell RNA and TCR sequencing was conducted on serial blood samples post infusion as well as their matching infusion products. By tracking the temporal evolution of CAR-T phenotypes, we demonstrated that proliferating cytotoxic-like CD8 clones were the main effectors in autoimmunity, whereas compromised cytotoxic and proliferation signature and profound mitochondrial dysfunction in CD8+ Te cells before infusion and subsequently defect CAR-T cells after manufacture might explain their characteristics in these patients. Our findings may guide future studies to improve CAR T-cell immunotherapy in autoimmune diseases.
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Affiliation(s)
- Dai-Shi Tian
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Chuan Qin
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Ming-Hao Dong
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Michael Heming
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Luo-Qi Zhou
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Wen Wang
- Nanjing IASO Biotechnology Co., Ltd, 210018, Nanjing, China
| | - Song-Bai Cai
- Nanjing IASO Biotechnology Co., Ltd, 210018, Nanjing, China
| | - Yun-Fan You
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Ke Shang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Jun Xiao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Di Wang
- Department of Hematology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Chun-Rui Li
- Department of Hematology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Min Zhang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Bi-Tao Bu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Gerd Meyer Zu Hörste
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany.
| | - Wei Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China.
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, 430030, Wuhan, China.
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Dziadkowiak E, Baczyńska D, Waliszewska-Prosół M. MuSK Myasthenia Gravis-Potential Pathomechanisms and Treatment Directed against Specific Targets. Cells 2024; 13:556. [PMID: 38534400 DOI: 10.3390/cells13060556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/17/2024] [Accepted: 03/19/2024] [Indexed: 03/28/2024] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disease in which autoantibodies target structures within the neuromuscular junction, affecting neuromuscular transmission. Muscle-specific tyrosine kinase receptor-associated MG (MuSK-MG) is a rare, often more severe, subtype of the disease with different pathogenesis and specific clinical features. It is characterized by a more severe clinical course, more frequent complications, and often inadequate response to treatment. Here, we review the current state of knowledge about potential pathomechanisms of the MuSK-MG and their therapeutic implications as well as ongoing research in this field, with reference to key points of immune-mediated processes involved in the background of myasthenia gravis.
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Affiliation(s)
- Edyta Dziadkowiak
- Department of Neurology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Dagmara Baczyńska
- Department of Molecular and Cellular Biology, Wroclaw Medical University, Borowska 211A, 50-556 Wroclaw, Poland
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50
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Skov M, Ruijs TQ, Grønnebæk TS, Skals M, Riisager A, Winther JB, Dybdahl KLT, Findsen A, Morgen JJ, Huus N, Broch-Lips M, Nielsen OB, de Cuba CMKE, Heuberger JAAC, de Kam ML, Tannemaat M, Verschuuren JJGM, Knutsen LJS, Kelly NM, Jensen KG, Arnold WD, Burghes AH, Olesen C, Bold J, Petersen TK, Quiroz JA, Hutchison J, Chin ER, Groeneveld GJ, Pedersen TH. The ClC-1 chloride channel inhibitor NMD670 improves skeletal muscle function in rat models and patients with myasthenia gravis. Sci Transl Med 2024; 16:eadk9109. [PMID: 38507469 DOI: 10.1126/scitranslmed.adk9109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 02/23/2024] [Indexed: 03/22/2024]
Abstract
Myasthenia gravis (MG) is a neuromuscular disease that results in compromised transmission of electrical signals at the neuromuscular junction (NMJ) from motor neurons to skeletal muscle fibers. As a result, patients with MG have reduced skeletal muscle function and present with symptoms of severe muscle weakness and fatigue. ClC-1 is a skeletal muscle specific chloride (Cl-) ion channel that plays important roles in regulating neuromuscular transmission and muscle fiber excitability during intense exercise. Here, we show that partial inhibition of ClC-1 with an orally bioavailable small molecule (NMD670) can restore muscle function in rat models of MG and in patients with MG. In severely affected MG rats, ClC-1 inhibition enhanced neuromuscular transmission, restored muscle function, and improved mobility after both single and prolonged administrations of NMD670. On this basis, NMD670 was progressed through nonclinical safety pharmacology and toxicology studies, leading to approval for testing in clinical studies. After successfully completing phase 1 single ascending dose in healthy volunteers, NMD670 was tested in patients with MG in a randomized, placebo-controlled, single-dose, three-way crossover clinical trial. The clinical trial evaluated safety, pharmacokinetics, and pharmacodynamics of NMD670 in 12 patients with mild MG. NMD670 had a favorable safety profile and led to clinically relevant improvements in the quantitative myasthenia gravis (QMG) total score. This translational study spanning from single muscle fiber recordings to patients provides proof of mechanism for ClC-1 inhibition as a potential therapeutic approach in MG and supports further development of NMD670.
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Affiliation(s)
- Martin Skov
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Titia Q Ruijs
- Centre for Human Drug Research, 2333 CL Leiden, Netherlands
- Leiden University Medical Centre, 2333 ZA Leiden, Netherlands
| | | | - Marianne Skals
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Anders Riisager
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | | | | | - Anders Findsen
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Jeanette J Morgen
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Nete Huus
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Martin Broch-Lips
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Ole B Nielsen
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
- Department of Biomedicine, Aarhus University, Ole Worms Alle 4, 8000 Aarhus C, Denmark
| | - Catherine M K E de Cuba
- Centre for Human Drug Research, 2333 CL Leiden, Netherlands
- Leiden University Medical Centre, 2333 ZA Leiden, Netherlands
| | | | | | | | | | - Lars J S Knutsen
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Nicholas M Kelly
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Klaus G Jensen
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - William D Arnold
- NextGen Precision Health, University of Missouri, 1030 Hitt St, Columbia, MO 65212, USA
| | - Arthur H Burghes
- Department of Biological Chemistry and Pharmacology, Ohio State University Wexner Medical Center, 1060 Carmack Road, Columbus, OH 43210, USA
- Department of Neurology, Neuromuscular Division, Ohio State University Wexner Medical Center, 395 W. 12(th) Ave, Columbus, OH 43210, USA
| | - Claus Olesen
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
- Department of Biomedicine, Aarhus University, Ole Worms Alle 4, 8000 Aarhus C, Denmark
| | - Jane Bold
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Thomas K Petersen
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Jorge A Quiroz
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - John Hutchison
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Eva R Chin
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Geert J Groeneveld
- Centre for Human Drug Research, 2333 CL Leiden, Netherlands
- Leiden University Medical Centre, 2333 ZA Leiden, Netherlands
| | - Thomas H Pedersen
- NMD Pharma A/S, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
- Department of Biomedicine, Aarhus University, Ole Worms Alle 4, 8000 Aarhus C, Denmark
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