Treatment of immune neuropathies

A systematic review of steroid use in peripheral nerve pathologies and treatment

Background

The use of corticosteroids has become a part of the standard of care in various pathologies but their use in peripheral nerve injury treatment is limited. Given corticosteroids' anti-inflammatory properties and their regulatory role in neuronal protein production and myelination, corticosteroids could serve as an adjunct therapy for peripheral nerve injuries. This review aims to systematically investigate the current use of corticosteroid treatment in peripheral nerve pathologies.

Methods

The systematic search was performed on PubMed, MEDLINE, EMBASE, Scopus, Cochrane, and Web of Science using keywords such as "corticosteroid treatment," "peripheral nerve damage," "peripheral neuropathy," and "complications." The PRISMA guidelines were used to conduct the systematic review and all articles were reviewed by the corresponding author. After the initial search, individual study titles and abstracts were further screened and categorized using an inclusion and exclusion criteria followed by a final full-text review.

Results

Out of the total 27,922 identified records, 203 studies were included based on the selection criteria. These studies focused on the use and efficacy of steroids across a spectrum of compression and non-compression peripheral neuropathies such as cubital tunnel syndrome and chronic inflammatory demyelinating polyradiculoneuropathy. Various studies noted the promising role of steroids in offering pain relief, nerve block, and nerve regeneration effects. Additionally, safety considerations and potential complications regarding steroid use in peripheral nerve injuries were analyzed.

Conclusion

While there is currently limited clinical utilization of corticosteroids in peripheral nerve pathologies, the anti-inflammatory and regenerative effects that steroids provide may be a beneficial tool in managing various peripheral neuropathies and their associated pain. Additional clinical trials and investigation into the mechanism of action could improve the reputation of steroid use as peripheral nerve injury treatment.

Successful treatment of refractory Guillain-Barré syndrome with alemtuzumab in a patient with chronic lymphocytic leukemia

This is the case of a 79-year-old man with chronic lymphocytic leukemia who presented with Guillain-Barré syndrome with features overlapping with the Miller Fisher syndrome and Bickerstaff brainstem encephalitis and positive antiganglioside GQ1b antibody about 6 months after treatment with bendamustine and rituximab. His clinical and neurologic condition continued to deteriorate despite sequential treatment with corticosteroids, intravenous immunoglobulin and plasmapheresis, but in the end, he had a complete and durable response to treatment with alemtuzumab.

Multifocal motor neuropathy

PURPOSE OF THIS REVIEW

To conduct a critical review of recent studies on the clinical and therapeutic aspects of multifocal motor neuropathy, and to analyse their implications for patient management.

RECENT FINDINGS

Recent studies have contributed to defining the specific position of multifocal motor neuropathy within the spectrum of chronic immune-mediated polyneuropathies. One study compared features of this condition with multifocal acquired demyelinating sensory and motor neuropathy, while others have focused on pathological alterations at the site of conduction blocks. A further study described six new cases of multifocal acquired motor neuropathy, which should be considered as a variant of multifocal motor neuropathy. Several Cochrane reviews and review articles have shown evidence of the efficacy of intravenous immunoglobulins in the treatment of multifocal motor neuropathy. The issue of long-term intravenous immunoglobulins in multifocal motor neuropathy, however, has yielded controversial results. Two studies have shown progressive motor deterioration in most patients, correlated with electrophysiological signs indicative of axonal degeneration, while a third study found signs of sustained clinical and electrophysiological improvement after a mean follow up of 7.25 years.

SUMMARY

Multifocal motor neuropathy is a distinct clinical entity that differs from chronic inflammatory demyelinating polyradiculoneuropathy and multifocal acquired demyelinating sensory and motor neuropathy, although they share some electrophysiological characteristics. Although the aetiology remains unsolved, frequent association with high-titer antibodies against ganglioside GM1, together with an often positive response to intravenous immunoglobulins further support an autoimmune mechanism. New therapeutic strategies are required, however, that focus on the effects and the costs of treatment over long-term follow up.

Treatment of immune-mediated, dysimmune neuropathies

This review focuses on the actual status and recent advances in the treatment of immune-mediated neuropathies, including: Guillain-Barre syndrome (GBS) with its subtypes acute inflammatory demyelinating polyradiculoneuropathy, acute motor axonal neuropathy, acute motor and sensory axonal neuropathy, Miller Fisher syndrome, and acute pandysautonomia; chronic inflammatory demyelinating polyneuropathy (CIDP) with its subtypes classical CIDP, CIDP with diabetes, CIDP/monoclonal gammopathy of undetermined significance (MGUS), sensory CIDP, multifocal motor neuropathy (MMN), multifocal acquired demyelinating sensory and motor neuropathy or Lewis-Sumner syndrome, multifocal acquired sensory and motor neuropathy, and distal acquired demyelinating sensory neuropathy; IgM monoclonal gammopathies with its subtypes Waldenstrom's macroglobulinemia, myelin-associated glycoprotein-associated gammopathy, polyneuropathy, organomegaly, endocrinopathy, M-protein, skin changes syndrome, mixed cryoglobulinemia, gait ataxia, late-onset polyneuropathy syndrome, and MGUS. Concerning the treatment of GBS, there is no significant difference between intravenous immunoglobulins (IVIG), plasma exchange or plasma exchange followed by IVIG. Because of convenience and absent invasiveness, IVIG are usually preferred. In treating CIDP corticosteroids, IVIG, or plasma exchange are equally effective. Despite the high costs and relative lack of availability, IVIG are preferentially used. For the one-third of patients, who does not respond, other immunosuppressive options are available. In MMN IVIG are the treatment of choice. Inadequate response in 20% of the patients requires adjunctive immunosuppressive therapies. Neuropathies with IgM monoclonal gammopathy may respond to various chemotherapeutic agents, although the long-term effects are unknown. In addition, such treatment may be associated with serious side effects. Recent data support the use of rituximab, a monoclonal antibody against the B-cell surface-membrane-marker CD20.

Treatment of chronic inflammatory demyelinating polyneuropathy

PURPOSE OF REVIEW

Chronic inflammatory demyelinating poly(radiculo)neuropathy (CIDP) is a treatable disorder. There are three proven effective treatments available. Randomized controlled trials have only focused on short-term effects, but most patients need long-term therapy. The most up-to-date treatment options are discussed. Attention is also paid to the use of appropriate assessment scales and treatment of residual findings.

RECENT FINDINGS

A Cochrane review is available indicating that intravenous immunoglobulin is an effective treatment. Equal efficacy of intravenous immunoglobulin and steroids was shown during a 6-week treatment period. New open studies indicated possible efficacy for mycophenolate, interferon-beta and etanercept. Combinations of treatment are scarcely studied yet. Some CIDP patients may have a more acute onset of disease since maximum severity is reached within 4-8 weeks, resulting in confusion about the diagnosis. It was shown that severe fatigue can be a major complaint in CIDP patients; a training regimen might partially resolve these problems.

SUMMARY

CIDP is a treatable disorder, but most patients need long-term treatment. Intravenous immunoglobulin, steroids and plasma exchange are shown to be effective. It is suggested that other immunomodulatory agents can also be effective, but randomized trials are needed to confirm these benefits. General measures to rehabilitate patients and to manage symptoms like fatigue and other residual findings are important.

Treatment of Guillain-Barre syndrome and CIDP

Guillain-Barré syndrome (GBS) and chronic inflammatory demyelinating poly-(radiculo)neuropathy (CIDP) are immune-mediated disorders with a variable duration of progression and a range in severity of weakness. Infections can trigger GBS and exacerbate CIDP. Anti-ganglioside antibodies are important, but there is debate on the role of genetic factors in the pathogenesis of these disorders. Randomized controlled trials (RCT) have shown that intravenous immunoglobulin (IVIg) and plasma exchange (PE) are effective in both GBS and CIDP. Most CIDP patients also improve after steroid therapy. Despite current treatment options, many patients have residual deficits or need to be treated for a long period of time. Therefore, new treatment trials are highly indicated. This review focuses on the current and possible new treatment options that could be guided by recent results from laboratory experiments.

Increased circulating T cell reactivity to GM1 ganglioside in patients with Guillain–Barré syndrome

This study was performed to determine whether increased ganglioside-specific T cell reactivity can be detected in the peripheral blood of patients with Guillain-Barre syndrome (GBS) and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). T cell responsiveness to the gangliosides GM1, GM3, GD1a, GD1b, GD3, GT1b, GQ1b and sulphatide was assessed in peripheral blood mononuclear cells from untreated GBS patients (57), CIDP patients (43), patients with other peripheral neuropathies (55) and healthy control subjects (74) in a standard 6-day proliferation assay. Increased T cell reactivity to GM1 occurred in GBS patients compared to healthy controls and patients with other neuropathies. There was increased reactivity to GM3 in GBS patients compared to patients with other neuropathies but not compared to healthy controls. The frequencies of increased T cell reactivity to GM1 and GM3 in CIDP patients were intermediate between those of GBS patients and controls. We suggest that T cell reactivity to gangliosides might play a contributory role in the pathogenesis of GBS and perhaps CIDP.

A review of the medical management of chronic inflammatory demyelinating polyradiculoneuropathy

Chronic idiopathic demyelinating polyradiculoneuropathy (CIDP) is a rare condition, but merits consideration due to its disabling consequences for patients and the growing existence of efficacious therapies during the last few decades. The first step is to characterise this neuropathy among the chronic dysimmune polyneuropathies, according to clinical, electrophysiologicalal and sometimes pathologicalal and immunochemical criteria. Typical CIDP is currently defined by criteria which have progressively improved since the first attempt made by an Ad Hoc Subcommittee of the American Academy of Neurology in 1991. However, CIDP may be associated with several concurrent diseases, and other chronic demyelinating polyneuropathies may be considered as either subtypes of CIDP, such as sensory CIDP and multifocal acquired sensory and motor neuropathy, or frontiers of CIDP, such as multi-focal motor neuropathy and polyneuropathy associated with monoclonal gammopathy. These considerations are helpful in the choice of treatments, as the response to immunomodulatory agents is different according to the type of the dysimmune neuropathy. CIDP is considered to be an immune-mediated disorder and may respond dramatically to numerous short-term therapies, such as corticosteroids, plasma exchanges, or intravenous immunoglobulin. The aim of this review is both to summarise the main results of the published open and randomised controlled trials for CIDP, and to provide some information about randomised controlled trials currently in progress. The objectives of the current and future trials are firstly, to choose the best regimen for short-term treatments, and secondly, to test new immunosuppressants in long-term therapy, if the neurological condition requires it.

Acquisitions récentes dans le traitement des polyneuropathies dysimmunitaires chroniques

Chronic immune-mediated polyneuropathies encompass chronic inflammatory demyelinating polyneuropathies, polyneuropathies associated with monoclonal gammopathy and multifocal motor neuropathy with persistent conduction blocks. Their diagnosis is made on clinical, electrophysiological and sometimes immunochemical and pathological criteria. The efficacy of intravenous immunoglobulins has been reported in the short-term treatment of these neuropathies in the same way than corticosteroids and plasma exchanges, depending on the type of the polyneuropathy. The efficacy of long-term treatments needs further evaluation.