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Antonini G, Habetswallner F, Inghilleri M, Mantegazza R, Rodolico C, Saccà F, Sgarzi M, deRuyck F, Paci S, Phillips G, Crippa L, Veronesi C, Perrone V, Degli Esposti L. Real world study on prevalence, treatment and economic burden of myasthenia gravis in Italy. Heliyon 2023; 9:e16367. [PMID: 37274644 PMCID: PMC10238888 DOI: 10.1016/j.heliyon.2023.e16367] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 05/12/2023] [Accepted: 05/14/2023] [Indexed: 06/06/2023] Open
Abstract
The purpose of this study was to investigate the epidemiology, management, and economic burden of myasthenia gravis in settings of real clinical practice. The analysis used administrative databases covering around 12 million subjects across Italy and included all adult patients with hospitalization discharge diagnosis or active exemption code for myasthenia gravis or with ≥1 pyridostigmine prescription from 2011 to 2018. The estimated prevalence of myasthenia gravis during 2018 was in the range 13.5-29.3/100,000 people (depending on the criteria applied), corresponding to 8190-17,728 alive patients, when reproportioning data to the entire Italian population. Overall 4397 patients with myasthenia gravis (mean age 61.7 years, 46.6% males) were included. A large pyridostigmine use was observed (84.0%-46.8% from 1st to 3rd year of follow-up), followed by corticosteroids (54.5%-44.6% from 1st to 3rd year of follow-up) and non-steroidal immunosuppressants (16% over follow-up). Total direct healthcare costs for myasthenia gravis were 4-times higher than those of the general population (€3771 and €869, respectively), and up to 9-fold increased when considering patients with exacerbation (€7827). These findings showed the epidemiologic burden of myasthenia gravis and the complexity of the therapeutic management for the affected patients, with large use of treatments and elevated healthcare expenditures.
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Affiliation(s)
- Giovanni Antonini
- Department of Neurology Mental Health and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, University of Rome La Sapienza, Rome, Italy
| | | | - Maurizio Inghilleri
- Neuromuscular Disorders Unit, Department of Human Neurosciences, Sapienza University, Rome, Italy
| | - Renato Mantegazza
- Neurology IV-Neuroimmunology and Neuromuscular Diseases Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Carmelo Rodolico
- Neurology and Neuromuscular Disorders Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Francesco Saccà
- NSRO Department, University of Naples Federico II, Napoli, Italy
| | - Manlio Sgarzi
- Department of Neurology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | | | | | | | | - Chiara Veronesi
- CliCon S.r.l. Società Benefit Health, Economics & Outcomes Research, Bologna, Italy
| | - Valentina Perrone
- CliCon S.r.l. Società Benefit Health, Economics & Outcomes Research, Bologna, Italy
| | - Luca Degli Esposti
- CliCon S.r.l. Società Benefit Health, Economics & Outcomes Research, Bologna, Italy
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Alcantara M, Barnett C, Katzberg H, Bril V. An update on the use of immunoglobulins as treatment for myasthenia gravis. Expert Rev Clin Immunol 2022; 18:703-715. [PMID: 35639497 DOI: 10.1080/1744666x.2022.2084074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Myasthenia gravis (MG) is an antibody mediated disease where pathogenic antibodies interact with the acetylcholine receptor or other proteins at the post-synaptic neuromuscular junction. There is growing evidence that immunoglobulin infusions are beneficial for clinical exacerbations and chronic refractory disease and may be an option for patients unresponsive to conventional immunosuppressive therapies. AREAS COVERED We performed an extensive literature review, looking for evidence on the use of immunoglobulins for the treatment of MG, by conducting a search in MEDLINE (1946 to present), EMBASE (1947 to present) and Clinicaltrials.gov. We have included studies on the use of intravenous immunoglobulins (IVIG) and subcutaneous immunoglobulins (SCIG) for acute deterioration and chronic disease. EXPERT OPINION The use of IVIG in MG provides an option for rapid improvement in critical deterioration, being preferred over more invasive and less available therapies such as plasmapheresis. For refractory MG, the addition of IVIG can improve a patient's status and reduce the dosage of immunosuppressive medications. The alternative of SCIG is also effective and has advantages of infusion time flexibility, fewer side-effects, and patient independence. The safety and efficacy of both interventions, patient preferences and quality of life may direct therapeutic choices in the future.
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Affiliation(s)
- Monica Alcantara
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Carolina Barnett
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto
| | - Hans Katzberg
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
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Diez Porras L, Homedes C, Alberti MA, Velez Santamaria V, Casasnovas C. Quality of Life in Myasthenia Gravis and Correlation of MG-QOL15 with Other Functional Scales. J Clin Med 2022; 11:jcm11082189. [PMID: 35456281 PMCID: PMC9025772 DOI: 10.3390/jcm11082189] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/04/2022] [Accepted: 04/11/2022] [Indexed: 01/25/2023] Open
Abstract
Health-related quality of life (HRQOL) in myasthenia gravis (MG) is frequently decreased. Further, there are many validated clinical scales and questionnaires to evaluate the clinical status in MG. We aimed to determine if there was an improvement in HRQOL following an intensive treatment for MG, identify which demographic and clinical features influenced patients’ HRQOL, and investigate if the questionnaire MG-QOL15 correlated with other evaluation scales. We recruited 45 patients with generalised MG who were starting immunomodulatory treatment with intravenous immunoglobulins and prednisone for the first time. At each visit, we administered several validated scales for MG. The mean MG-QOL15 score improved significantly at 4 and 6 weeks of the study. Additionally, the MG-QOL15 score correlated strong with the Myasthenia Gravis-Activities of Daily Living (MG-ADL) and the Neuro-QOL Fatigue and weakest with the Quantitative Myasthenia Gravis Scoring System (QMG). The QMG score prior to study enrolment was associated with HRQOL. We observed that HRQOL in MG improved after receiving an intensive immunomodulatory treatment and achieving better control of the symptoms. The questionnaire MG-QOL15 correlated positively with other clinical measures. As MG is a fluctuating condition, and some symptoms are difficult to examine, we direct physicians toward the use of scales and questionnaires composed of items perceived by the patient.
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Affiliation(s)
- Laura Diez Porras
- Neurometabolic Diseases Group, Bellvitge Biomedical Research Institute (IDIBELL), 199 Granvia de l’Hospitalet, 08908 L’Hospitalet de Llobregat, Spain; (L.D.P.); (C.H.); (M.A.A.); (V.V.S.)
| | - Christian Homedes
- Neurometabolic Diseases Group, Bellvitge Biomedical Research Institute (IDIBELL), 199 Granvia de l’Hospitalet, 08908 L’Hospitalet de Llobregat, Spain; (L.D.P.); (C.H.); (M.A.A.); (V.V.S.)
| | - Maria Antonia Alberti
- Neurometabolic Diseases Group, Bellvitge Biomedical Research Institute (IDIBELL), 199 Granvia de l’Hospitalet, 08908 L’Hospitalet de Llobregat, Spain; (L.D.P.); (C.H.); (M.A.A.); (V.V.S.)
- Neuromuscular Unit, Department of Neurology, Bellvitge University Hospital, Feixa Llarga Street n/n, 08907 L’Hospitalet del Llobregat, Spain
| | - Valentina Velez Santamaria
- Neurometabolic Diseases Group, Bellvitge Biomedical Research Institute (IDIBELL), 199 Granvia de l’Hospitalet, 08908 L’Hospitalet de Llobregat, Spain; (L.D.P.); (C.H.); (M.A.A.); (V.V.S.)
- Neuromuscular Unit, Department of Neurology, Bellvitge University Hospital, Feixa Llarga Street n/n, 08907 L’Hospitalet del Llobregat, Spain
| | - Carlos Casasnovas
- Neurometabolic Diseases Group, Bellvitge Biomedical Research Institute (IDIBELL), 199 Granvia de l’Hospitalet, 08908 L’Hospitalet de Llobregat, Spain; (L.D.P.); (C.H.); (M.A.A.); (V.V.S.)
- Neuromuscular Unit, Department of Neurology, Bellvitge University Hospital, Feixa Llarga Street n/n, 08907 L’Hospitalet del Llobregat, Spain
- Center for Biomedical Research on Rare Diseases (CIBERER), ISCIII, 3–5 Monforte de Lemos, Pabellón 121, 28029 Madrid, Spain
- Correspondence:
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Alhaidar MK, Abumurad S, Soliven B, Rezania K. Current Treatment of Myasthenia Gravis. J Clin Med 2022; 11:jcm11061597. [PMID: 35329925 PMCID: PMC8950430 DOI: 10.3390/jcm11061597] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 02/04/2023] Open
Abstract
Myasthenia gravis (MG) is the most extensively studied antibody-mediated disease in humans. Substantial progress has been made in the treatment of MG in the last century, resulting in a change of its natural course from a disease with poor prognosis with a high mortality rate in the early 20th century to a treatable condition with a large proportion of patients attaining very good disease control. This review summarizes the current treatment options for MG, including non-immunosuppressive and immunosuppressive treatments, as well as thymectomy and targeted immunomodulatory drugs.
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Abbas AS, Hardy N, Ghozy S, Dibas M, Paranjape G, Evanson KW, Reierson NL, Cowie K, Kamrowski S, Schmidt S, Tang Y, Davis AR, Touchette JC, Kallmes KM, Hassan AE, Tarchand R, Mehta M, Pederson JM, Abdelmegeed M. Characteristics, treatment, and outcomes of Myasthenia Gravis in COVID-19 patients: A systematic review. Clin Neurol Neurosurg 2022; 213:107140. [PMID: 35091255 PMCID: PMC8782728 DOI: 10.1016/j.clineuro.2022.107140] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 01/19/2022] [Accepted: 01/20/2022] [Indexed: 12/28/2022]
Abstract
Objective Recent studies suggest that the clinical course and outcomes of patients with coronavirus disease 2019 (COVID-19) and myasthenia gravis (MG) are highly variable. We performed a systematic review of the relevant literature with a key aim to assess the outcomes of invasive ventilation, mortality, and hospital length of stay (HLoS) for patients presenting with MG and COVID-19. Methods We searched the PubMed, Scopus, Web of Science, and MedRxiv databases for original articles that reported patients with MG and COVID-19. We included all clinical studies that reported MG in patients with confirmed COVID-19 cases via RT-PCR tests. We collected data on patient background characteristics, symptoms, time between MG and COVID-19 diagnosis, MG and COVID-19 treatments, HLoS, and mortality at last available follow-up. We reported summary statistics as counts and percentages or mean±SD. When necessary, inverse variance weighting was used to aggregate patient-level data and summary statistics. Results Nineteen studies with 152 patients (mean age 54.4 ± 12.7 years; 79/152 [52.0%] female) were included. Hypertension (62/141, 44.0%) and diabetes (30/141, 21.3%) were the most common comorbidities. The mean time between the diagnosis of MG and COVID-19 was7.0 ± 6.3 years. Diagnosis of COVID-19 was confirmed in all patients via RT-PCR tests. Fever (40/59, 67.8%) and ptosis (9/55, 16.4%) were the most frequent COVID-19 and MG symptoms, respectively. Azithromycin and ceftriaxone were the most common COVID-19 treatments, while prednisone and intravenous immunoglobulin were the most common MG treatments. Invasive ventilation treatment was required for 25/59 (42.4%) of patients. The mean HLoS was 18.2 ± 9.9 days. The mortality rate was 18/152 (11.8%). Conclusion This report provides an overview of the characteristics, treatment, and outcomes of MG in COVID-19 patients. Although COVID-19 may exaggerate the neurological symptoms and worsens the outcome in MG patients, we did not find enough evidence to support this notion. Further studies with larger numbers of patients with MG and COVID-19 are needed to better assess the clinical outcomes in these patients.
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Pathak R, Katel A, Massarelli E, Villaflor VM, Sun V, Salgia R. Immune Checkpoint Inhibitor-Induced Myocarditis with Myositis/Myasthenia Gravis Overlap Syndrome: A Systematic Review of Cases. Oncologist 2021; 26:1052-1061. [PMID: 34378270 DOI: 10.1002/onco.13931] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/30/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The development of immune checkpoint inhibitors (ICIs) represents a paradigm shift in the treatment of cancers. Despite showing remarkable efficacy, these agents can be associated with life-threatening immune-related adverse events. In recent years, several cases of myocarditis with myositis and/or myasthenia gravis overlap syndrome (IM3OS) have been reported. However, given the rarity, the clinical features and outcomes of these cases remain poorly understood. We, therefore, attempted to systematically review and summarize all cases of IM3OS reported in the literature. MATERIALS AND METHODS Studies reporting IM3OS were identified in Embase and MEDLINE. Only case reports and case series published in journals or presented at conferences were included. We conducted a systematic review according to the PRISMA Harms guidelines. RESULTS A total of 60 cases were eligible. The patients' median age was 71 years, and the majority (67%) were males; melanoma was the most common indication for ICIs (38%). The most-reported symptoms were fatigue (80%) and muscle weakness (78%). The median number of doses to the development of IM3OS was one. The average creatine kinase level was 9,645 IU/L. Cardiac arrhythmias occurred in 67% of patients, and 18% had depressed ejection fraction. Initial treatment consisted of immunosuppression with high-dose steroids and supportive therapies. Sixty percent of the patients died in hospital because of acute complications. CONCLUSION IM3OS can be associated with significant mortality and morbidity. Prospective studies are needed to understand the optimal approach to diagnose and manage these patients and to develop biomarkers to predict the occurrence and severity of this rare but serious condition. IMPLICATIONS FOR PRACTICE Clinicians should suspect coexisting myositis and/or myasthenia gravis in all patients with immune checkpoint inhibitor-induced myocarditis, given their propensity to occur together. Early recognition and prompt treatment with the help of a multidisciplinary team might help improve the outcomes of this life-threatening condition.
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Affiliation(s)
- Ranjan Pathak
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, USA
| | - Anjan Katel
- Department of Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal
| | - Erminia Massarelli
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, USA
| | - Victoria M Villaflor
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, USA
| | - Virginia Sun
- Department of Population Science, City of Hope, Duarte, California, USA
| | - Ravi Salgia
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, USA
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Sheikh S, Alvi U, Soliven B, Rezania K. Drugs That Induce or Cause Deterioration of Myasthenia Gravis: An Update. J Clin Med 2021; 10:jcm10071537. [PMID: 33917535 PMCID: PMC8038781 DOI: 10.3390/jcm10071537] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/24/2021] [Accepted: 03/31/2021] [Indexed: 12/20/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune neuromuscular disorder which is characterized by presence of antibodies against acetylcholine receptors (AChRs) or other proteins of the postsynaptic membrane resulting in damage to postsynaptic membrane, decreased number of AChRs or blocking of the receptors by autoantibodies. A number of drugs such as immune checkpoint inhibitors, penicillamine, tyrosine kinase inhibitors and interferons may induce de novo MG by altering the immune homeostasis mechanisms which prevent emergence of autoimmune diseases such as MG. Other drugs, especially certain antibiotics, antiarrhythmics, anesthetics and neuromuscular blockers, have deleterious effects on neuromuscular transmission, resulting in increased weakness in MG or MG-like symptoms in patients who do not have MG, with the latter usually being under medical circumstances such as kidney failure. This review summarizes the drugs which can cause de novo MG, MG exacerbation or MG-like symptoms in nonmyasthenic patients.
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