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Tannemaat MR, Huijbers MG, Verschuuren JJGM. Myasthenia gravis-Pathophysiology, diagnosis, and treatment. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:283-305. [PMID: 38494283 DOI: 10.1016/b978-0-12-823912-4.00026-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Myasthenia gravis (MG) is an autoimmune disease characterized by dysfunction of the neuromuscular junction resulting in skeletal muscle weakness. It is equally prevalent in males and females, but debuts at a younger age in females and at an older age in males. Ptosis, diplopia, facial bulbar weakness, and limb weakness are the most common symptoms. MG can be classified based on the presence of serum autoantibodies. Acetylcholine receptor (AChR) antibodies are found in 80%-85% of patients, muscle-specific kinase (MuSK) antibodies in 5%-8%, and <1% may have low-density lipoprotein receptor-related protein 4 (Lrp4) antibodies. Approximately 10% of patients are seronegative for antibodies binding the known disease-related antigens. In patients with AChR MG, 10%-20% have a thymoma, which is usually detected at the onset of the disease. Important differences between clinical presentation, treatment responsiveness, and disease mechanisms have been observed between these different serologic MG classes. Besides the typical clinical features and serologic testing, the diagnosis can be established with additional tests, including repetitive nerve stimulation, single fiber EMG, and the ice pack test. Treatment options for MG consist of symptomatic treatment (such as pyridostigmine), immunosuppressive treatment, or thymectomy. Despite the treatment with symptomatic drugs, steroid-sparing immunosuppressants, intravenous immunoglobulins, plasmapheresis, and thymectomy, a large proportion of patients remain chronically dependent on corticosteroids (CS). In the past decade, the number of treatment options for MG has considerably increased. Advances in the understanding of the pathophysiology have led to new treatment options targeting B or T cells, the complement cascade, the neonatal Fc receptor or cytokines. In the future, these new treatments are likely to reduce the chronic use of CS, diminish side effects, and decrease the number of patients with refractory disease.
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Affiliation(s)
- Martijn R Tannemaat
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Maartje G Huijbers
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands; Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
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Sikorski PM, Kusner LL, Kaminski HJ. Myasthenia Gravis. Clin Immunol 2023. [DOI: 10.1016/b978-0-7020-8165-1.00065-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
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Zubair AS, Roy B, Baehring JM, Nowak RJ. Myasthenia Gravis in the Setting of Immune Checkpoint Inhibitor Therapy: Practical Considerations and Opinion-Based Approach to Acute Management. Cureus 2022; 14:e30638. [PMID: 36439604 PMCID: PMC9683636 DOI: 10.7759/cureus.30638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2022] [Indexed: 11/06/2022] Open
Abstract
Use of immune checkpoint inhibitors (ICI) is increasing in patients with oncologic disease. Three classes of checkpoint inhibitors exist: anti-PD1 (nivolumab, pembrolizumab), anti-CTLA4 (ipilimumab), and anti-PDL1 (atezolizumab, avelumab, durvalumab). ICI therapy has been used in multiple malignancies including renal cell cancer, non-small-cell lung cancer, and melanoma. These therapies have led to improved oncologic treatment and outcomes in patients but can lead to immune-related or inflammatory adverse effects. Neuromuscular system side effects, particularly at the neuromuscular junction, have been observed, including myasthenia gravis (MG). This narrative review serves to summarize key available information regarding myasthenia gravis in the setting of immune checkpoint inhibitor use including the molecular targets of checkpoint inhibitors, the clinical manifestations of MG in patients with checkpoint inhibitor therapy, and potential treatment options. Studies have shown that the use of checkpoint inhibitor therapy can trigger MG, and that patients with ICI-related MG can have more severe disease. Recognition and understanding of the range of neurologic complications, including neuromuscular disorders, which can be seen with ICI therapy is a critical step toward developing better treatment algorithms and improved clinical outcomes. Future investigations which include deep mechanistic studies to further our understanding of the immunopathologic triggers and predictive markers of ICI-related MG will be important to address the current knowledge gaps.
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Tonev D, Georgieva R, Vavrek E. Our Clinical Experience in the Treatment of Myasthenia Gravis Acute Exacerbations with a Novel Nanomembrane-Based Therapeutic Plasma Exchange Technology. J Clin Med 2022; 11:jcm11144021. [PMID: 35887784 PMCID: PMC9322121 DOI: 10.3390/jcm11144021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/07/2022] [Accepted: 07/08/2022] [Indexed: 11/16/2022] Open
Abstract
According to the American Academy of Neurology 2011 guidelines, there is insufficient evidence to support or refute the use of therapeutic plasma exchange (TPE) for myasthenia gravis (MG). The goal of this study was to determine whether a novel nanomembrane-based TPE could be useful in the treatment of MG. Thirty-six adult patients, MGFA 4/4B and 5, with acute MG episodes were enrolled into a single-center retrospective before-and-after study to compare a conventional treatment group (n = 24) with a nanomembrane-based TPE group (n = 12). TPE or intravenous immunoglobulins (IVIG) infusions were used in impending/manifested myasthenic crises, especially in patients at high-risk for prolonged invasive ventilation (IMV) and in those tolerating non-invasive ventilation (NIV). The clinical improvement was assessed using the Myasthenia Muscle Score (0–100), with ≥20 increase for responders. The primary outcome measures included the rates of implemented TPE, IVIG, and corticosteroids immunotherapies, NIV/IMV, early tracheotomy, MMS scores, extubation time, neuro-ICU/hospital LOS, complications, and mortality rates. The univariate analysis found that IMV was lower in the nanomembrane-based group (42%) compared to the conventional treatment group (83%) (p = 0.02). The multivariate analysis using binary logistic regression revealed TPE and NIV as independent predictors for short-term (≤7 days) respiratory support (p = 0.014 for TPE; p = 0.002 for NIV). The novel TPE technology moved our clinical practice towards proactive rather than protective treatment in reducing prolonged IMV during MG acute exacerbations.
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Affiliation(s)
- Dimitar Tonev
- Department of Anesthesiology and Intensive Care, Medical University of Sofia, Academician Ivan Geshov Blvd 15, 1431 Sofia, Bulgaria; (R.G.); (E.V.)
- Department of Anesthesiology and Intensive Care, University Hospital “Tsaritsa Yoanna-ISUL”, Belo More Str. 8, 1527 Sofia, Bulgaria
- Correspondence:
| | - Radostina Georgieva
- Department of Anesthesiology and Intensive Care, Medical University of Sofia, Academician Ivan Geshov Blvd 15, 1431 Sofia, Bulgaria; (R.G.); (E.V.)
- Neurological Intensive Care Unit, Department of Neurology, University Hospital “Tsaritsa Yoanna-ISUL”, Belo More Str. 8, 1527 Sofia, Bulgaria
| | - Evgeniy Vavrek
- Department of Anesthesiology and Intensive Care, Medical University of Sofia, Academician Ivan Geshov Blvd 15, 1431 Sofia, Bulgaria; (R.G.); (E.V.)
- Neurological Intensive Care Unit, Department of Neurology, University Hospital “Tsaritsa Yoanna-ISUL”, Belo More Str. 8, 1527 Sofia, Bulgaria
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Kaminski HJ, Denk J. Corticosteroid Treatment-Resistance in Myasthenia Gravis. Front Neurol 2022; 13:886625. [PMID: 35547366 PMCID: PMC9083070 DOI: 10.3389/fneur.2022.886625] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/21/2022] [Indexed: 12/25/2022] Open
Abstract
Chronic, high-dose, oral prednisone has been the mainstay of myasthenia gravis treatment for decades and has proven to be highly beneficial in many, toxic in some way to all, and not effective in a significant minority. No patient characteristics or biomarkers are predictive of treatment response leading to many patients suffering adverse effects with no benefit. Presently, measurements of treatment response, whether taken from clinician or patient perspective, are appreciated to be limited by lack of good correlation, which then complicates correlation to biological measures. Treatment response may be limited because disease mechanisms are not influenced by corticosteroids, limits on dosage because of adverse effects, or individual differences in corticosteroids. This review evaluates potential mechanisms that underlie lack of response to glucocorticoids in patients with myasthenia gravis.
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Affiliation(s)
- Henry J Kaminski
- Department of Neurology and Rehabilitation Medicine, George Washington University, Washington, DC, United States
| | - Jordan Denk
- Department of Neurology and Rehabilitation Medicine, George Washington University, Washington, DC, United States
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Dalakas MC, Meisel A. Immunomodulatory effects and clinical benefits of intravenous immunoglobulin in myasthenia gravis. Expert Rev Neurother 2022; 22:313-318. [PMID: 35350948 DOI: 10.1080/14737175.2022.2057223] [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 that develops in the majority of patients mainly as a result of acetylcholine receptor (AChR) autoantibodies. This process is mediated by a series of immunoregulatory events. Therapeutic targets for MG include suppression of circulating antibodies or antibody production, suppression of complement activation, and immunomodulation of cytokines or T cells. Intravenous immunoglobulin (IVIg) has an effect on all of these mechanisms. AREAS COVERED This narrative review explores the broad immunomodulatory effects of IVIg in MG and provides an update on IVIg treatment for MG. EXPERT OPINION IVIg has a range of immunomodulatory effects on therapeutic targets relevant to the immunopathogenesis of MG. An emerging area of research is the pharmacogenomics of IVIg in MG related to FcRn and IgG catabolism. New data indicate that the FcRn VNTR3 genotype can affect the efficacy of IVIg in certain MG patients and may have an impact on IgG kinetics and selected dosing. Immune globulin 10% caprylate/chromatography purified (IVIg-C) has been shown to reverse the symptoms of severe acute exacerbation in patients with MG. Available data support the use of IVIg-C as an effective and safe treatment for this severely ill subgroup of patients during a relapse.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Andreas Meisel
- Department of Neurology, Integrated Center for Myasthenia Gravis, Charité - University Medicine Berlin, Germany
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Tahir N, Mahboob A, Piao X, Ying G, Shrestha J, Sherchan R, Zahra F. Nivolumab, a Double-Edged Sword: A Case Report of Nivolumab-Induced Myasthenia Gravis. J Med Cases 2021; 12:424-428. [PMID: 34691341 PMCID: PMC8510662 DOI: 10.14740/jmc3783] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 09/22/2021] [Indexed: 11/11/2022] Open
Abstract
Nivolumab is a checkpoint inhibitor approved to treat various solid organs malignancies. Although checkpoint inhibitors are very efficacious, these medications are also associated with a variety of side effects that could be life-threatening. We present a case of nivolumab-induced myasthenia gravis in a patient with stage IV esophageal cancer, who was found to have generalized weakness, blurry vision, diplopia, and later developed acute hypoxic respiratory failure with subsequent intubation. The patient was treated with intravenous immunoglobulin and plasmapheresis, and later started on pyridostigmine and high-dose steroids with minimal improvement. Goals of care were discussed with the patient and family, and the decision was made to discharge the patient home with hospice care. Nivolumab-induced myasthenia gravis is very aggressive with a poor prognosis if not appropriately managed in time. Hence we strongly recommend a multidisciplinary approach, including neurologists, to monitor patients on nivolumab therapy to reduce morbidity and mortality associated with it.
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Affiliation(s)
- Nayha Tahir
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, Internal Medicine Residency Program at Northwestern Medicine Hospital, McHenry, IL, USA
| | | | - Xuanzhen Piao
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Grace Ying
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, Internal Medicine Residency Program at Northwestern Medicine Hospital, McHenry, IL, USA
| | - Jishna Shrestha
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, Internal Medicine Residency Program at Northwestern Medicine Hospital, McHenry, IL, USA
| | - Robin Sherchan
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, Internal Medicine Residency Program at Northwestern Medicine Hospital, McHenry, IL, USA
| | - Farha Zahra
- Department of Internal Medicine, Northwestern Medicine McHenry Hospital, McHenry, IL, USA
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Fan Z, Li Z, Shen F, Zhang X, Lei L, Su S, Lu Y, Di L, Wang M, Xu M, Da Y. Favorable Effects of Tacrolimus Monotherapy on Myasthenia Gravis Patients. Front Neurol 2020; 11:594152. [PMID: 33193063 PMCID: PMC7652845 DOI: 10.3389/fneur.2020.594152] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 09/24/2020] [Indexed: 12/11/2022] Open
Abstract
Background and Purpose: Tacrolimus (TAC) has been proven to be a rapid-acting, steroid-sparing agent for myasthenia gravis (MG) therapy. However, evidence related to the effectiveness of TAC alone is rare. Therefore, this study was performed to investigate the effect of TAC monotherapy in MG patients. Methods: Forty-four MG patients who received TAC monotherapy were retrospectively analyzed. A mixed effect model was used to analyze improvements in MG-specific activities of daily living scale (MG-ADL), quantitative MG score (QMG) and MG-ADL subscores. Kaplan-Meier analysis was used to estimate the cumulative probability of minimal manifestations (MM) or better. Adverse events (AEs) were recorded for safety analyses. Results: Of the patients receiving TAC monotherapy, MG-ADL scores were remarkably improved at 3, 6 and 12 months compared with scores at baseline (mean difference and 95% CIs: −3.29 [−4.94, −1.64], −3.97 [−5.67, −2.27], and −4.67 [−6.48, −2.85], respectively). QMG scores significantly decreased at 6 and 12 months, with mean differences and 95% CIs of −4.67(−6.88, −2.45) and −5.77 (−7.55, −4.00), respectively. Estimated median period to achieve “MM or better” was 5.0 (95% CIs, 2.8, 7.2) months. Ocular MG (OMG) and generalized MG (GMG) showed similar therapeutic effects in cumulative probabilities of “MM or better” (P-value = 0.764). A better response was observed in MG-ADL subscores for ptosis and bulbar symptoms. AEs occurred in 37.5% of patients and were generally mild and reversible. Conclusions: TAC monotherapy is a promising option to rapidly alleviate all symptoms of MG, especially for ptosis and bulbar symptoms.
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Affiliation(s)
- Zhirong Fan
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zunbo Li
- Department of Neurology, Xi'an Gaoxin Hospital, Xi'an, China
| | - Faxiu Shen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xueping Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lin Lei
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shengyao Su
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yan Lu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Li Di
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Min Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Min Xu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuwei Da
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Use of glucocorticoids in the critical care setting: Science and clinical evidence. Pharmacol Ther 2020; 206:107428. [DOI: 10.1016/j.pharmthera.2019.107428] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/02/2019] [Indexed: 02/07/2023]
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Safa H, Johnson DH, Trinh VA, Rodgers TE, Lin H, Suarez-Almazor ME, Fa'ak F, Saberian C, Yee C, Davies MA, Tummala S, Woodman K, Abdel-Wahab N, Diab A. Immune checkpoint inhibitor related myasthenia gravis: single center experience and systematic review of the literature. J Immunother Cancer 2019; 7:319. [PMID: 31753014 PMCID: PMC6868691 DOI: 10.1186/s40425-019-0774-y] [Citation(s) in RCA: 152] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/05/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Myasthenia gravis (MG) is a rare but life-threatening adverse event of immune checkpoint inhibitors (ICI). Given the limited evidence, data from a large cohort of patients is needed to aid in recognition and management of this fatal complication. METHODS We reviewed our institutional databases to identify patients who had cancer and MG in the setting of ICI. We systematically reviewed the literature through August 2018 to identify all similar reported patients. We collected data on clinical and diagnostic features, management, and outcomes of these cases. RESULTS Sixty-five patients were identified. Median age was 73 years; 42 (65%) were males, 31 (48%) had metastatic melanoma, and 13 (20%) had a preexisting MG before ICI initiation. Most patients received anti-PD-1 (82%). Sixty-three patients (97%) developed ICI-related MG (new onset or disease flare) after a median of 4 weeks (1 to 16 weeks) of ICI initiation. Twenty-four patients (37%) experienced concurrent myositis, and respiratory failure occurred in 29 (45%). ICI was discontinued in 61 patients (97%). Death was reported in 24 patients (38%); 15 (23%) due to MG complication. A better outcome was observed in patients who received intravenous immunoglobulin (IVIG) or plasmapheresis (PLEX) as first-line therapy than in those who received steroids alone (95% vs 63% improvement of MG symptoms, p = 0.011). CONCLUSIONS MG is a life-threatening adverse event of acute onset and rapid progression after ICI initiation. Early use of IVIG or PLEX, regardless of initial symptoms severity, may lead to better outcomes than steroids alone. Our data suggest the need to reassess the current recommendations for management of ICI-related MG until prospective longitudinal studies are conducted to establish the ideal management approach for these patients.
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Affiliation(s)
- Houssein Safa
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Daniel H Johnson
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Van Anh Trinh
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Theresa E Rodgers
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Heather Lin
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria E Suarez-Almazor
- Section of Rheumatology and Clinical Immunology, Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Faisal Fa'ak
- Department of Internal Medicine, Piedmont Athens Regional Medical Center, Athens, Georgia
| | - Chantal Saberian
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cassian Yee
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael A Davies
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sudhakar Tummala
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Karin Woodman
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Noha Abdel-Wahab
- Section of Rheumatology and Clinical Immunology, Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Rheumatology and Rehabilitation, Faculty of Medicine, Assiut University Hospitals, Assiut, Egypt
| | - Adi Diab
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Liu F, Wang Q, Chen X. Myasthenic crisis treated in a Chinese neurological intensive care unit: clinical features, mortality, outcomes, and predictors of survival. BMC Neurol 2019; 19:172. [PMID: 31324153 PMCID: PMC6642475 DOI: 10.1186/s12883-019-1384-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 06/27/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Myasthenic crisis (MC) often requires admission to an intensive care unit (ICU). METHODS We retrospectively investigated 113 consecutive patients with first MC admitted to the neurological ICU. Patients' demographic, clinical and other characteristics were examined, as well as therapeutic interventions, mortality and functional outcome. RESULTS MC patients at first onset admitted to neurological ICU had a mortality rate of 18.6%. PCO2 level before intubation and score on Myasthenia Gravis-Activities of Daily Living (MG-ADL) scale at MC onset correlated with duration of ventilation and length of ICU stay. Compared with patients with good functional outcome, patients with intermediate or poor functional outcome were older at first MC onset, had lower pH and PO2, and had higher PCO2 before intubation. Multivariate logistic analysis identified pre-intubation PCO2 level as an independent predictor of survival. Cox regression showed that age at first MC onset requiring ICU management was the factor which significantly influenced the mortality. CONCLUSIONS Our results suggest that PCO2 before intubation and MG-ADL score at MC onset may be useful indicators of more severe disease likely to require extensive respiratory support and ICU management. Higher pre-intubation PCO2 indicates chronic respiratory acidosis that can increase risk of severe disability and death, especially in patients with older age at first MC onset.
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Affiliation(s)
- Fan Liu
- Department of Nursing, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Qiong Wang
- Neurological Intensive Care Unit, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xueping Chen
- Department of Neurology, West China Hospital, Sichuan University, 610041, Guoxuexiang #37, Chengdu, Sichuan, China.
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Lee YG, Kim US. Efficacy and Safety of Low-to-Moderate Dose Oral Corticosteroid Treatment in Ocular Myasthenia Gravis. J Pediatr Ophthalmol Strabismus 2018; 55:339-342. [PMID: 30074608 DOI: 10.3928/01913913-20180620-01] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 04/18/2018] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate the response to corticosteroid therapy as a primary treatment for ocular myasthenia gravis. METHODS Patients diagnosed as having ocular myasthenia gravis by an acetylcholine receptor binding antibody test between January 2011 and September 2015 were included in the study and started receiving treatment with a corticosteroid. Patients with a blowout fracture, hyperthyroidism, diabetes mellitus, hypertension, cardiovascular disease, or history of strabismus surgery were excluded. Disappearance of diplopia and ptosis were considered a response to treatment. RESULTS Methylprednisolone therapy was administered to 29 patients (19 men and 10 women; average age: 49 ± 16.5 years) as an initial treatment. A total of 6 patients were lost to follow-up. Twenty-three of 29 patients (82.6%) were regarded as having presented a response to treatment. The average treatment duration was 3 weeks for patients responding to primary treatment. Eight patients complained of adverse effects from steroid therapy such as heartburn, insomnia, weight gain, and myalgia. CONCLUSIONS A corticosteroid could be considered as an initial treatment for patients diagnosed as having ocular myasthenia gravis by an acetylcholine receptor binding antibody test. [J Pediatr Ophthalmol Strabismus. 2018;55(5):339-342.].
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Neurological complications of systemic tumor therapy. Wien Med Wochenschr 2018; 169:33-40. [PMID: 30232660 DOI: 10.1007/s10354-018-0654-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 08/02/2018] [Indexed: 12/11/2022]
Abstract
The treatment of malignant tumors has considerably improved in recent years, and also the number of "long term cancer survivors" is increasing.The spectrum of anti-tumoral agents is increasing at a fast pace and in addition to conventional therapies such as surgery, radiotherapy, and chemotherapy, new drugs with entirely new mechanisms are appearing. Side effects of old and new drugs can affect the central and peripheral nervous system, the neuromuscular junction, and muscle. These side effects often have to be distinguished from other causes and need neurological expertise. Although the majority of patients still receive conventional therapies, several new strategies such as immune therapies are being implemented. These drugs have also drug specific side effects, which do not always follow the classical principles of "toxicity."This review focuses on the well-known and described side effects of conventional cancer therapies and adds new observations on new drugs.
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Wang S, Breskovska I, Gandhy S, Punga AR, Guptill JT, Kaminski HJ. Advances in autoimmune myasthenia gravis management. Expert Rev Neurother 2018; 18:573-588. [PMID: 29932785 PMCID: PMC6289049 DOI: 10.1080/14737175.2018.1491310] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Myasthenia gravis (MG) is an autoimmune neuromuscular disorder with no cure and conventional treatments limited by significant adverse effects and variable benefit. In the last decade, therapeutic development has expanded based on improved understanding of autoimmunity and financial incentives for drug development in rare disease. Clinical subtypes exist based on age, gender, thymic pathology, autoantibody profile, and other poorly defined factors, such as genetics, complicate development of specific therapies. Areas covered: Clinical presentation and pathology vary considerably among patients with some having weakness limited to the ocular muscles and others having profound generalized weakness leading to respiratory insufficiency. MG is an antibody-mediated disorder dependent on autoreactive B cells which require T-cell support. Treatments focus on elimination of circulating autoantibodies or inhibition of effector mechanisms by a broad spectrum of approaches from plasmapheresis to B-cell elimination to complement inhibition. Expert commentary: Standard therapies and those under development are disease modifying and not curative. As a rare disease, clinical trials are challenged in patient recruitment. The great interest in development of treatments specific for MG is welcome, but decisions will need to be made to focus on those that offer significant benefits to patients.
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Affiliation(s)
- Shuhui Wang
- Department of Neurology, George Washington University, Washington DC 20008
| | - Iva Breskovska
- Department of Neurology, George Washington University, Washington DC 20008
| | - Shreya Gandhy
- Department of Neurology, George Washington University, Washington DC 20008
| | - Anna Rostedt Punga
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Uppsala, Sweden
| | - Jeffery T. Guptill
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Henry J. Kaminski
- Department of Neurology, George Washington University, Washington DC 20008
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Gamez J, Salvado M, Casellas M, Manrique S, Castillo F. Intravenous immunoglobulin as monotherapy for myasthenia gravis during pregnancy. J Neurol Sci 2017; 383:118-122. [PMID: 29246598 DOI: 10.1016/j.jns.2017.10.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 10/04/2017] [Accepted: 10/24/2017] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Pregnant women with myasthenia gravis (MG) are at increased risk of complications and adverse outcomes, including the teratogenic effects of many drugs used to treat MG women of childbearing age. The effectiveness of intravenous immunoglobulins (IVIg) on other autoimmune mediated diseases has been extensively reported in recent years, although little is known about the role of IVIg in the treatment of MG during pregnancy. We designed this study to determine the effectiveness of IVIg as monotherapy during pregnancy for women with MG. MATERIAL AND METHODS Five pregnant MG patients (mean age at delivery 36.4years, SD 5.8, range 29.4-45.2) were studied in 2013-14. Their treatment was switched to monthly IVIg cycles 2months before the pregnancy. Follow-up included monthly neurological QMG throughout the pregnancy and postpartum, obstetrical monitoring during monthly visits in the first two trimesters of the pregnancy, fortnightly visits between week 32 and week 36, and weekly visits after 36weeks, and neonatal follow-up after delivery. RESULTS We observed no exacerbations during pregnancy, delivery or post-partum. The mean QMG score at baseline (before pregnancy) was 7.4 points in five women with generalized forms of MG. The maximum mean value reached during pregnancy was 8.6 points. The mean pregnancy duration was 38 w+5 d. No infant with transient neonatal myasthenia gravis. CONCLUSIONS These results suggest that monotherapy with IVIg during pregnancy in MG patients could be promising, although confirmation is required in studies with larger populations.
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Affiliation(s)
- Josep Gamez
- Myasthenia Gravis Unit, Neurology Department, Vall d'Hebron University Hospital, VHIR, European Reference Network on Rare Neuromuscular Diseases (ERN EURO-NMD), Department of Medicine, UAB, Barcelona, Spain.
| | - Maria Salvado
- Myasthenia Gravis Unit, Neurology Department, Vall d'Hebron University Hospital, VHIR, European Reference Network on Rare Neuromuscular Diseases (ERN EURO-NMD), Department of Medicine, UAB, Barcelona, Spain
| | - Manel Casellas
- Myasthenia Gravis Unit, Obstetrics Department, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Susana Manrique
- Myasthenia Gravis Unit, Anesthetics Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Felix Castillo
- Myasthenia Gravis Unit, Neonatology Department, Vall d'Hebron University Hospital, Barcelona, Spain
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Qi G, Liu P, Dong H, Gu S, Yang H, Xue Y. Metastatic Thymoma-Associated Myasthenia Gravis: Favorable Response to Steroid Pulse Therapy Plus Immunosuppressive Agent. Med Sci Monit 2017; 23:1217-1223. [PMID: 28278141 PMCID: PMC5356615 DOI: 10.12659/msm.902442] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Our study retrospectively reviewed the therapeutic effect of steroid pulse therapy in combination with an immunosuppressive agent in myasthenia gravis (MG) patients with metastatic thymoma. MATERIAL AND METHODS MG patients with metastatic thymoma that underwent methylprednisolone pulse therapy plus cyclophosphamide were retrospectively analyzed. Patients initially received methylprednisolone pulse therapy followed by oral methylprednisolone. Cyclophosphamide was prescribed simultaneously at the beginning of treatment. Clinical outcomes, including therapeutic efficacy and adverse effects of MG and thymoma, were assessed. RESULTS Twelve patients were recruited. According to histological classification, 4 cases were type B2 thymoma, 3 were type B3, 2 were type B1, and 1 was type AB. After combined treatment for 15 days, both the thymoma and MG responded dramatically to high-dose methylprednisolone plus cyclophosphamide. The symptoms of MG were improved in all patients, with marked improvement in 6 patients and basic remission in 4. Interestingly, complete remission of thymoma was achieved in 5 patients and partial remission in 7 patients. Myasthenic crisis was observed in 1 patient and was relieved after intubation and ventilation. Adverse reactions were observed in 7 patients (58.3%), most commonly infections, and all were resolved without discontinuation of therapy. During the follow-up, all patients were stabilized except for 1 with pleural metastasis who received further treatment and another 1 who died from myasthenic crisis. CONCLUSIONS The present study in a series of MG patients with metastatic thymoma indicated that steroid pulse therapy in combination with immunosuppressive agents was an effective and well-tolerated for treatment of both metastatic thymoma and MG. Glucocorticoid pulse therapy plus immunosuppressive agents should therefore be considered in MG patients with metastatic thymoma.
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Affiliation(s)
- Guoyan Qi
- Myasthenia Gravis Treatment Center of Hebei Province, 1st Hospital of Shijiazhuang, Shijiazhuang, Hebei, China (mainland)
| | - Peng Liu
- Myasthenia Gravis Treatment Center of Hebei Province, 1st Hospital of Shijiazhuang, Shijiazhuang, Hebei, China (mainland)
| | - Huimin Dong
- Myasthenia Gravis Treatment Center of Hebei Province, 1st Hospital of Shijiazhuang, Shijiazhuang, Hebei, China (mainland)
| | - Shanshan Gu
- Myasthenia Gravis Treatment Center of Hebei Province, 1st Hospital of Shijiazhuang, Shijiazhuang, Hebei, China (mainland)
| | - Hongxia Yang
- Myasthenia Gravis Treatment Center of Hebei Province, 1st Hospital of Shijiazhuang, Shijiazhuang, Hebei, China (mainland)
| | - Yinping Xue
- Myasthenia Gravis Treatment Center of Hebei Province, 1st Hospital of Shijiazhuang, Shijiazhuang, Hebei, China (mainland)
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Hoffmann S, Siedler J, Brandt AU, Piper SK, Kohler S, Sass C, Paul F, Reilmann R, Meisel A. Quantitative motor assessment of muscular weakness in myasthenia gravis: a pilot study. BMC Neurol 2015; 15:265. [PMID: 26701600 PMCID: PMC4690227 DOI: 10.1186/s12883-015-0517-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 12/11/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Muscular weakness in myasthenia gravis (MG) is commonly assessed using Quantitative Myasthenia Gravis Score (QMG). More objective and quantitative measures may complement the use of clinical scales and might detect subclinical affection of muscles. We hypothesized that muscular weakness in patients with MG can be quantified with the non-invasive Quantitative Motor (Q-Motor) test for Grip Force Assessment (QGFA) and Involuntary Movement Assessment (QIMA) and that pathological findings correlate with disease severity as measured by QMG. METHODS This was a cross-sectional pilot study investigating patients with confirmed diagnosis of MG. Data was compared to healthy controls (HC). Subjects were asked to lift a device (250 and 500 g) equipped with electromagnetic sensors that measured grip force (GF) and three-dimensional changes in position and orientation. These were used to calculate the position index (PI) and orientation index (OI) as measures for involuntary movements due to muscular weakness. RESULTS Overall, 40 MG patients and 23 HC were included. PI and OI were significantly higher in MG patients for both weights in the dominant and non-dominant hand. Subgroup analysis revealed that patients with clinically ocular myasthenia gravis (OMG) also showed significantly higher values for PI and OI in both hands and for both weights. Disease severity correlates with QIMA performance in the non-dominant hand. CONCLUSION Q-Motor tests and particularly QIMA may be useful objective tools for measuring motor impairment in MG and seem to detect subclinical generalized motor signs in patients with OMG. Q-Motor parameters might serve as sensitive endpoints for clinical trials in MG.
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Affiliation(s)
- Sarah Hoffmann
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany. .,Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Jana Siedler
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Alexander U Brandt
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Sophie K Piper
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany. .,Centrum für Schlaganfallforschung Berlin (CSB), Klinik für Neurologie, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Siegfried Kohler
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany. .,Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Christian Sass
- George-Huntington-Institute, Technology-Park, Johann-Krane Weg 27, 48149, Muenster, Germany. .,Department of Neurology, Asklepios Klinikum Harburg, Eißendorfer Pferdeweg 52, 21075, Hamburg, Germany.
| | - Friedemann Paul
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany. .,Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Ralf Reilmann
- George-Huntington-Institute, Technology-Park, Johann-Krane Weg 27, 48149, Muenster, Germany. .,Department of Radiology, Universitätsklinikum Münster, Albert-Schweitzer Campus 1, 48149, Muenster, Germany. .,Department of Neurodegenerative Diseases and Hertie-Institute for Clinical Brain Research, University of Tuebingen, Hoppe-Seyler Str. 3, 72076, Tuebingen, Germany.
| | - Andreas Meisel
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany. .,Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
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Neuromuscular issues in systemic disease. Curr Neurol Neurosci Rep 2015; 15:48. [PMID: 26008813 DOI: 10.1007/s11910-015-0565-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The neuromuscular system can be involved in several systemic conditions. Clinical manifestations can appear at onset or throughout the course of the disease process. New investigational methods, including imaging of peripheral nerves, new laboratory tests, and antibodies, are available. In addition to symptomatic therapies, specific treatment options, such as for familial amyloid neuropathy and Fabry's disease, are becoming increasingly available. Pathomechanisms vary depending on the underlying disease process. In addition to metabolic, hormonal, immune, and antibody-mediated mechanisms, in some generalized diseases, genetic causes need to be considered. This review focuses on different aspects of the peripheral nervous system including the nerve roots, plexuses, mononeuropathies and generalized neuropathies, neuromuscular junction disorders, muscle, and autonomic nervous system.
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