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Luo S, Jiang Q, Zeng W, Wang Q, Zou Z, Yu Y, Hong D, Zeng Q, Tan S, Zhang Z, Zhang Y, Guo X, Chen J, Zhao Z, Huang S, Shi J, Chen Y, Du L, Yan C, Xi J, Song J, Zhao C. Efgartigimod for generalized myasthenia gravis: A multicenter real-world cohort study in China. Ann Clin Transl Neurol 2024; 11:2212-2221. [PMID: 38973109 PMCID: PMC11330228 DOI: 10.1002/acn3.52142] [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: 03/29/2024] [Revised: 06/10/2024] [Accepted: 06/21/2024] [Indexed: 07/09/2024] Open
Abstract
OBJECTIVE Efgartigimod, a neonatal Fc receptor antagonist, facilitates antibody degradation including pathogenic IgGs. The ADAPT study demonstrated the tolerability and efficacy of efgartigimod in the treatment of generalized myasthenia gravis (gMG). However, very limited evidence is available for the Chinese population, and it remains inconclusive about which kind of patients are selected to preferentially receive efgartigimod in real-world settings. METHODS This multicenter cohort study included gMG patients treated at 14 neuromuscular reference centers in China. The Myasthenia Gravis Activities of Daily Living (MG-ADL) score, immunosuppressants, and the incidence of treatment-emergent adverse events (TEAEs) were prospectively collected. RESULTS Of the 1640 gMG admitted between September and December 2023, 61 (3.7%) received efgartigimod for at least one treatment cycle. Among them, 56 cases (92%) were anti-AChR antibody-positive, 4 were anti-MuSK antibody-positive, and 1 was seronegative. Thymoma-associated myasthenia gravis accounted for most cases (44%, 27 out of 61). The principal causes of efgartigimod initiation included MG acute exacerbation (MGAE) (48%, 29 out of 61) and myasthenic crisis (MC) (15%, 9 out of 61). Clinically meaningful improvement was rapidly achieved in 97% (58 out of 61) of patients at 1.3 ± 0.7 weeks. By week 12, the MG-ADL score reduced to 3.8 ± 4.1 (baseline:10.5 ± 5.2) for all participants, while it reduced to 4.0 ± 4.7 for MGAE and 3.8 ± 4.2 for MC, respectively. All but one TMG patient required no additional rescue therapies after efgartigimod initiation. 11.5% (7 out of 61) reported ≥1 TEAEs. INTERPRETATION This multicenter cohort study demonstrated the efficacy of efgartigimod in rapid control of gMG. Patients with MGAE or MC would benefit from efgartigimod treatment.
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Affiliation(s)
- Sushan Luo
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological DisordersFudan UniversityShanghai200040China
| | - Qilong Jiang
- Department of MyopathyThe First Affiliated Hospital of Guangzhou University of Chinese MedicineGuangzhou510405China
| | - Wenshuang Zeng
- Department of NeurologyHongkong University Shenzhen HospitalShenzhen518053China
| | - Qinzhou Wang
- Department of NeurologyQilu Hospital of Shandong UniversityJinan250012China
| | - Zhangyu Zou
- Department of NeurologyFujian Medical University Union HospitalFuzhou350001China
| | - Yanyan Yu
- Department of NeurologyThe First Affiliated Hospital of Nanchang UniversityNanchang330006China
| | - Daojun Hong
- Department of NeurologyThe First Affiliated Hospital of Nanchang UniversityNanchang330006China
| | - Quantao Zeng
- Department of Neurology, Sichuan Provincial People's HospitalUniversity of Electronic Science and Technology of ChinaChengdu610072China
| | - Song Tan
- Department of Neurology, Sichuan Provincial People's HospitalUniversity of Electronic Science and Technology of ChinaChengdu610072China
| | - Zhouao Zhang
- Department of NeurologyAffiliated Hospital of Xuzhou Medical UniversityXuzhou221004China
| | - Yong Zhang
- Department of NeurologyAffiliated Hospital of Xuzhou Medical UniversityXuzhou221004China
| | - Xiuming Guo
- Department of NeurologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqing400016China
| | - Jing Chen
- Department of NeurologyThe Second Affiliated Hospital of Soochow UniversitySuzhou215004China
| | - Zhongyan Zhao
- Department of Neurology, Hainan General HospitalHainan Affiliated Hospital of Hainan Medical UniversityHaikou570311China
| | - Shixiong Huang
- Department of Neurology, Hainan General HospitalHainan Affiliated Hospital of Hainan Medical UniversityHaikou570311China
| | - Jianquan Shi
- Department of Neurology, Nanjing First HospitalNanjing Medical UniversityNanjing210006China
| | - Ying Chen
- Department of NeurologyThe First Affiliated Hospital of Wannan Medical CollegeWuhu241004China
| | - Lei Du
- Department of NeurologyThe First Affiliated Hospital of Xinjiang Medical UniversityUrumqi830054Xinjiang Uygur Autonomous RegionChina
| | - Chong Yan
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological DisordersFudan UniversityShanghai200040China
| | - Jianying Xi
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological DisordersFudan UniversityShanghai200040China
| | - Jie Song
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological DisordersFudan UniversityShanghai200040China
| | - Chongbo Zhao
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological DisordersFudan UniversityShanghai200040China
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Zhang Q, Lin J, Yang M, Li Z, Zhang M, Bu B. Therapeutic potential of natural killer cells in neuroimmunological diseases. Biomed Pharmacother 2024; 173:116371. [PMID: 38430631 DOI: 10.1016/j.biopha.2024.116371] [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: 12/17/2023] [Revised: 02/27/2024] [Accepted: 02/28/2024] [Indexed: 03/05/2024] Open
Abstract
Natural killer (NK) cells, a major component of the innate immune system, have prominent immunoregulatory, antitumor proliferation, and antiviral activities. NK cells act as a double-edged sword with therapeutic potential in neurological autoimmunity. Emerging evidence has identified NK cells are involved in the development and progression of neuroimmunological diseases such as multiple sclerosis, neuromyelitis optica spectrum disorders, autoimmune encephalitis, Guillain-Barré Syndrome, chronic inflammatory demyelinating polyneuropathy, myasthenia gravis, and idiopathic inflammatory myopathy. However, the regulatory mechanisms and functional roles of NK cells are highly variable in different clinical states of neuroimmunological diseases and need to be further determined. In this review, we summarize the evidence for the heterogenic involvement of NK cells in the above conditions. Further, we describe cutting-edge NK-cell-based immunotherapy for neuroimmunological diseases in preclinical and clinical development and highlight challenges that must be overcome to fully realize the therapeutic potential of NK cells.
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Affiliation(s)
- Qing Zhang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Jing Lin
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Mengge Yang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Zhijun Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, Wuhan 430030, China.
| | - Min Zhang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, Wuhan 430030, China.
| | - Bitao Bu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, Wuhan 430030, China.
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Frangiamore R, Rinaldi E, Vanoli F, Andreetta F, Mantegazza R, Antozzi C. Efgartigimod improves triple-negative myasthenia gravis. Neurol Sci 2024; 45:1307-1309. [PMID: 37875596 DOI: 10.1007/s10072-023-07122-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 10/03/2023] [Indexed: 10/26/2023]
Affiliation(s)
- Rita Frangiamore
- Neuroimmunology and Muscle Pathology Unit, Fondazione IRCCS Istituto Neurologico C. Besta, Via Giovanni Celoria 11, 20133, Milan, Italy
| | - Elena Rinaldi
- Neuroimmunology and Muscle Pathology Unit, Fondazione IRCCS Istituto Neurologico C. Besta, Via Giovanni Celoria 11, 20133, Milan, Italy
| | - Fiammetta Vanoli
- Neuroimmunology and Muscle Pathology Unit, Fondazione IRCCS Istituto Neurologico C. Besta, Via Giovanni Celoria 11, 20133, Milan, Italy
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Francesca Andreetta
- Neuroimmunology and Muscle Pathology Unit, Fondazione IRCCS Istituto Neurologico C. Besta, Via Giovanni Celoria 11, 20133, Milan, Italy
| | - Renato Mantegazza
- Neuroimmunology and Muscle Pathology Unit, Fondazione IRCCS Istituto Neurologico C. Besta, Via Giovanni Celoria 11, 20133, Milan, Italy
| | - Carlo Antozzi
- Neuroimmunology and Muscle Pathology Unit, Fondazione IRCCS Istituto Neurologico C. Besta, Via Giovanni Celoria 11, 20133, Milan, Italy.
- Immunotherapy and Apheresis Departmental Unit, Fondazione IRCCS Istituto Neurologico C. Besta, Via Giovanni Celoria 11, 20133, Milan, Italy.
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Iorio R. Myasthenia gravis: the changing treatment landscape in the era of molecular therapies. Nat Rev Neurol 2024; 20:84-98. [PMID: 38191918 DOI: 10.1038/s41582-023-00916-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2023] [Indexed: 01/10/2024]
Abstract
Myasthenia gravis (MG) is an autoimmune disorder that affects the neuromuscular junction, leading to muscle weakness and fatigue. MG is caused by antibodies against the acetylcholine receptor (AChR), the muscle-specific kinase (MuSK) or other AChR-related proteins that are expressed in the postsynaptic muscle membrane. The standard therapeutic approach for MG has relied on acetylcholinesterase inhibitors, corticosteroids and immunosuppressants, which have shown good efficacy in improving MG-related symptoms in most people with the disease; however, these therapies can carry a considerable burden of long-term adverse effects. Moreover, up to 15% of individuals with MG exhibit limited or no response to these standard therapies. The emergence of molecular therapies, including monoclonal antibodies, B cell-depleting agents and chimeric antigen receptor T cell-based therapies, has the potential to revolutionize the MG treatment landscape. This Review provides a comprehensive overview of the progress achieved in molecular therapies for MG associated with AChR antibodies and MuSK antibodies, elucidating both the challenges and the opportunities these therapies present to the field. The latest developments in MG treatment are described, exploring the potential for personalized medicine approaches.
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Affiliation(s)
- Raffaele Iorio
- Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy.
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
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Vu T, Wiendl H, Katsuno M, Reddel SW, Howard JF. Ravulizumab in Myasthenia Gravis: A Review of the Current Evidence. Neuropsychiatr Dis Treat 2023; 19:2639-2655. [PMID: 38059203 PMCID: PMC10697093 DOI: 10.2147/ndt.s374694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/17/2023] [Indexed: 12/08/2023] Open
Abstract
The terminal complement C5 inhibitor ravulizumab was engineered from the humanized monoclonal antibody eculizumab to have an extended half-life and duration of action. It binds to human terminal complement protein C5, inhibiting its cleavage into C5a and C5b, thus preventing the cascade of events that lead to architectural destruction of the postsynaptic neuromuscular junction membrane by the membrane attack complex, and consequent muscle weakness in patients with anti-acetylcholine receptor (AChR) antibody-positive generalized myasthenia gravis (gMG). The 26-week randomized, placebo-controlled period (RCP) of the phase 3 CHAMPION MG study demonstrated the rapid efficacy of ravulizumab in reducing MG symptoms. Weight-based dosing of ravulizumab every 8 weeks provided sustained efficacy, in terms of patient-reported (Myasthenia Gravis-Activities of Daily Living) and clinician-reported (Quantitative Myasthenia Gravis) endpoints in patients with anti-AChR antibody-positive gMG. Pharmacokinetic and pharmacodynamic analyses showed therapeutic serum ravulizumab concentrations (>175 µg/mL) were achieved immediately after the first dose and were maintained throughout 26 weeks, irrespective of patient body weight; inhibition of serum free C5 was immediate, complete (<0.5 μg/mL), and sustained in all patients. Interim results from the open-label extension (OLE) showed that after 60 weeks, efficacy was maintained in patients continuing on ravulizumab. Rapid and sustained improvements in efficacy, similar to those seen in patients initiating ravulizumab in the RCP, were observed after initiation of ravulizumab treatment in patients who switched from placebo in the RCP to ravulizumab in the OLE. The findings from the RCP and OLE support ravulizumab's favorable safety profile. In conclusion, ravulizumab has a simple weight-based administration and long dosing interval. Its targeted mechanism of action without generalized immunosuppression is reflected in its rapid onset of symptom improvement, sustained efficacy and good safety profile in the treatment of patients with anti-AChR antibody-positive gMG.
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Affiliation(s)
- Tuan Vu
- Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Stephen W Reddel
- Department of Neurology, Concord Hospital, University of Sydney, Sydney, NSW, Australia
| | - James F Howard
- Department of Neurology, The University of North Carolina, Chapel Hill, NC, USA
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Graber JJ. Paraneoplastic Neurologic Syndromes. Continuum (Minneap Minn) 2023; 29:1779-1808. [PMID: 38085898 DOI: 10.1212/con.0000000000001357] [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: 12/18/2023]
Abstract
OBJECTIVE Progress is ongoing in understanding paraneoplastic neurologic disorders, with new syndromes and antibodies being described and more detailed evidence available to guide workup for diagnosis and treatment to improve outcomes. Many excellent reviews have summarized the molecular features of different antibodies, but this article emphasizes the clinical features of each syndrome that may help guide initial diagnosis and treatment, which often should occur before an antibody or cancer is found to confirm the diagnosis. LATEST DEVELOPMENTS Recent findings include updated diagnostic criteria with validated sensitivity and specificity, discovery of novel antibodies, and clinical findings that increase the likelihood of an underlying paraneoplastic disorder. Suggestive syndromes that have been recently identified include faciobrachial dystonic seizures and pilomotor auras in anti-leucine-rich glioma inactivated protein 1 encephalitis, extreme delta brush on EEG in N-methyl-d-aspartate (NMDA)-receptor encephalitis, déjà vu aura in anti-glutamic acid decarboxylase 65 (GAD65) encephalitis, and sleep disturbances in several disorders. In addition, there is confirmed utility of brain positron emission tomography (PET) and CSF markers, including carcinoembryonic antigen and oligoclonal bands, as well as improved tests for the presence of leptomeningeal cancer cells in CSF. Associations of cancer immunotherapies with paraneoplastic syndromes and herpes simplex virus encephalitis (and COVID-19) with NMDA-receptor encephalitis have been described. ESSENTIAL POINTS All neurologists should be aware of advances regarding paraneoplastic neurologic syndromes, as patients can present with a wide variety of neurologic symptoms and earlier diagnosis and treatment can improve outcomes.
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Antozzi C, Mantegazza R. Impact of Ravulizumab on Patient Outcomes and Quality of Life in Generalized Myasthenia Gravis. Patient Relat Outcome Meas 2023; 14:305-312. [PMID: 37876920 PMCID: PMC10590807 DOI: 10.2147/prom.s408175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/21/2023] [Indexed: 10/26/2023] Open
Abstract
Myasthenia gravis (MG) is an autoimmune ion channel disorder in which antibodies to different end-plate antigens impair neuromuscular transmission, ultimately leading to muscle weakness and fatigability. In about 85% of patients with MG, autoantibodies against the acetylcholine receptor (AChR) activate the complement cascade, causing damage to the neuromuscular junction. MG is a chronic disorder for which standard therapies with corticosteroids, immunosuppressive drugs, and immunomodulation with plasma exchange or intravenous immunoglobulins modify the course of the disease, but the residual burden of physical, psychological, and social disability highlights several unmet needs, among these the need for specific, targeted, and well tolerated therapies able to improve the patients' quality of life. Complement inhibition paved the way to precision medicine in MG since, for the first time, a specific therapy targeting a crucial pathogenetic step has been designed, tested, and proven to be effective in a controlled fashion. Ravulizumab represents the first long-acting complement inhibitor approved for treatment of patients with generalized MG, able to provide rapid, complete, and sustained complement inhibition. Ravulizumab improved the MG Activity of Daily Living scale and other clinical parameters up to 26 weeks as shown by the CHAMPION MG trial, and by its open label extension, with the added value of being administered every 8 weeks. The schedule of administration is likely to improve patients' adherence and hence their quality of life. The introduction of complement inhibition will considerably change the traditional therapeutic strategy for MG.
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Affiliation(s)
- Carlo Antozzi
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- Immunotherapy and Apheresis Departmental Unit, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Renato Mantegazza
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
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Rath J, Moser B, Zimprich F. Thymectomy in myasthenia gravis. Curr Opin Neurol 2023; 36:416-423. [PMID: 37639450 DOI: 10.1097/wco.0000000000001189] [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: 08/31/2023]
Abstract
PURPOSE OF REVIEW Thymectomy has long been used in the treatment of patients with myasthenia gravis and antibodies against the acetylcholine receptor. However, its effectiveness has only been proven a few years ago in a randomized controlled trial in patients under the age of 65. Here, we review the current literature focusing on patient subgroups, potential biomarkers for outcome prediction and the choice of surgical approach. RECENT FINDINGS Long-term follow-up studies after thymectomy confirmed that the benefits regarding clinical outcome parameters and a reduced need for immunosuppressive treatment persist. Nevertheless, a substantial proportion of patients in real-world cohorts do not reach complete stable remission after thymectomy indicating that the underlying autoimmune process is sustained in the periphery. Our understanding of the responsible mechanisms has improved with recent studies. Presently, outcome data after thymectomy in several patient subgroups, such as those aged over 50 years, those with juvenile onset or those with purely ocular symptoms are limited and have been the focus of recent research activities. Similarly, biomarkers guiding an appropriate patient selection for thymectomy are under investigation. A number of cohort studies demonstrated that minimal invasive surgical techniques such as extended robotic thymectomy lead to similar positive outcomes as a transsternal approach with potentially fewer short-term adverse effects. SUMMARY Thymectomy is an effective treatment option in adult patients with early onset acetylcholine-receptor positive myasthenia gravis but uncertainty remains with regard to certain patient subgroups.
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Affiliation(s)
| | - Bernhard Moser
- Department of Thoracic Surgery, Medical University Vienna, Vienna, Austria
- ESTS Thymic Working Group
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Miyamoto K, Minamino M, Kuwahara M, Tsujimoto H, Ohtani K, Wakamiya N, Katayama KI, Inoue N, Ito H. Complement biomarkers reflect the pathological status of neuromyelitis optica spectrum disorders. Front Immunol 2023; 14:1090548. [PMID: 36936980 PMCID: PMC10020620 DOI: 10.3389/fimmu.2023.1090548] [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: 11/05/2022] [Accepted: 02/20/2023] [Indexed: 03/06/2023] Open
Abstract
Complement is involved in the pathogenesis of neuroimmune disease, but the detailed pathological roles of the complement pathway remain incompletely understood. Recently, eculizumab, a humanized anti-C5 monoclonal antibody, has been clinically applied against neuroimmune diseases such as myasthenia gravis and neuromyelitis optica spectrum disorders (NMOSD). Clinical application of eculizumab is also being investigated for another neuroimmune disease, Guillain-Barré syndrome (GBS). However, while the effectiveness of eculizumab for NMOSD is extremely high in many cases, there are some cases of myasthenia gravis and GBS in which eculizumab has little or no efficacy. Development of effective biomarkers that reflect complement activation in these diseases is therefore important. To identify biomarkers that could predict disease status, we retrospectively analyzed serum levels of complement factors in 21 patients with NMOSD and 25 patients with GBS. Ba, an activation marker of the alternative complement pathway, was elevated in the acute phases of both NMOSD and GBS. Meanwhile, sC5b-9, an activation marker generated by the terminal complement pathway, was elevated in NMOSD but not in GBS. Complement factor H (CFH), a complement regulatory factor, was decreased in the acute phase as well as in the remission phase of NMOSD, but not in any phases of GBS. Together, these findings suggest that complement biomarkers, such as Ba, sC5b-9 and CFH in peripheral blood, have potential utility in understanding the pathological status of NMOSD.
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Affiliation(s)
- Katsuichi Miyamoto
- Department of Neurology, Wakayama Medical University, Wakayama, Japan
- Department of Neurology, Kindai University School of Medicine, Osaka-sayama, Japan
| | - Mai Minamino
- Department of Neurology, Wakayama Medical University, Wakayama, Japan
| | - Motoi Kuwahara
- Department of Neurology, Kindai University School of Medicine, Osaka-sayama, Japan
| | - Hiroshi Tsujimoto
- Department of Molecular Genetics, Wakayama Medical University, Wakayama, Japan
| | - Katsuki Ohtani
- Department of Clinical Nutrition, Rakuno Gakuen University, Ebetsu, Japan
| | - Nobutaka Wakamiya
- Department of Medicine and Physiology, Rakuno Gakuen University, Ebetsu, Japan
| | - Kei-ichi Katayama
- Department of Molecular Genetics, Wakayama Medical University, Wakayama, Japan
| | - Norimitsu Inoue
- Department of Molecular Genetics, Wakayama Medical University, Wakayama, Japan
- *Correspondence: Norimitsu Inoue,
| | - Hidefumi Ito
- Department of Neurology, Wakayama Medical University, Wakayama, Japan
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Pinto AA, De Seze J, Jacob A, Reddel S, Yudina A, Tan K. Comparison of IVIg and TPE efficacy in the treatment of neurological disorders: a systematic literature review. Ther Adv Neurol Disord 2023; 16:17562864231154306. [PMID: 37006460 PMCID: PMC10064470 DOI: 10.1177/17562864231154306] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 01/15/2023] [Indexed: 03/31/2023] Open
Abstract
Background: Intravenous immunoglobulin (IVIg) and therapeutic plasma exchange (TPE) are among the main immunotherapies for neurological disorders. Their benefit is greatest in immune-mediated conditions, but their distinct efficacy cannot be simply explained. Objectives: This review aimed to systematically identify studies comparing the efficacy of TPE and IVIg treatments for selected autoimmune neurological disorders and identify optimal therapies for each condition. Data Sources and Methods: PubMed, MEDLINE and Embase databases were searched for original publications from 1990 to 2021. Additional publications were identified via expert recommendations. Conference abstracts older than 2017, review articles and articles without information on TPE and IVIg comparison in title and abstract were excluded. Risks of bias were descriptively addressed, without a meta-analysis. Results: Forty-four studies were included on Guillain–Barré syndrome (20 studies – 12 adult, 5 paediatric, 3 all ages), myasthenia gravis (11 studies –8 adult, 3 paediatric), chronic immune–mediated polyradiculoneuropathy (3 studies –1 adult, 2 paediatric), encephalitis (1 study in adults), neuromyelitis optica spectrum disorders (5 studies –2 adult, 3 all ages) and other conditions (4 studies – all ages). TPE and IVIg were mostly similarly efficacious, measured by clinical outcomes and disease severity scores. Some studies recommended IVIg as easy to administer. TPE procedures, however, have been simplified and the safety has been improved. TPE is currently recommended for management of neuromyelitis optica spectrum disorder relapses and some myasthenia gravis subtypes, in which rapid removal of autoantibodies is crucial. Conclusion: Despite some limitations (e.g. the low evidence levels), this review provides an extensive 30-year-long overview of treatments for various conditions. Both IVIg and TPE are usually comparably efficacious options for autoimmune neurological disorders, with few exceptions. Treatment choices should be patient-tailored and based on available clinical resources. Better designed studies are needed to provide higher-level quality of evidence regarding clinical efficacy of TPE and IVIg treatments.
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Affiliation(s)
| | - Jerome De Seze
- Department of Neurology, CHU Strasbourg, Strasbourg, France
| | - Anu Jacob
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
- Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Stephen Reddel
- Department of Neurology, University of Sydney, Sydney, NSW, Australia
| | - Anna Yudina
- Terumo Blood and Cell Technologies, Zaventem, Belgium
| | - Kevin Tan
- Department of Neurology, National Neuroscience Institute, Singapore
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