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Rajabally YA. Chronic Inflammatory Demyelinating Polyradiculoneuropathy: Current Therapeutic Approaches and Future Outlooks. Immunotargets Ther 2024; 13:99-110. [PMID: 38435981 PMCID: PMC10906673 DOI: 10.2147/itt.s388151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 02/02/2024] [Indexed: 03/05/2024] Open
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a treatable autoimmune disorder, for which different treatment options are available. Current first-line evidence-based therapies for CIDP include intravenous and subcutaneous immunoglobulins, corticosteroids and plasma exchanges. Despite lack of evidence, cyclophosphamide, rituximab and mycophenolate mofetil are commonly used in circumstances of refractoriness and, more debatably, of perceived overdependence on first-line therapies. Rituximab is currently the object of a randomized controlled trial for CIDP. Based on case series, and although rarely considered, haematopoietic autologous stem cell transplants may be effective in refractory disease, with low mortality and high remission rates. A new therapeutic option has appeared with efgartigimod, a neonatal Fc receptor blocker, recently shown to significantly lower relapse rate versus placebo, after withdrawal from previous immunotherapy. Other neonatal Fc receptor blockers, nipocalimab and batoclimab, are under study. The C1 complement-inhibitor SAR445088, acting in the proximal portion of the classical complement system, is currently the subject of a new study in treatment-responsive, refractory and treatment-naïve subjects. Finally, Bruton Tyrosine Kinase inhibitors, which exert anti-B cell effects, may represent another future research avenue. The widening of the therapeutic armamentarium enhances the need for improved evaluation of treatment effects and reliable biomarkers in CIDP.
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Affiliation(s)
- Yusuf A Rajabally
- Inflammatory Neuropathy Clinic, Department of Neurology, University Hospitals Birmingham, Birmingham, B15 2TH, United Kingdom
- Aston Medical School, Aston University, Birmingham, United Kingdom
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Lochmann H, Wyrobnik M, Kupper C, Rewitzer C, Klostermann F. Theory of mind and executive dysfunction in chronic inflammatory demyelinating polyneuropathy. Eur J Neurol 2024; 31:e16053. [PMID: 37688443 DOI: 10.1111/ene.16053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 07/23/2023] [Accepted: 08/17/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND AND PURPOSE Although chronic inflammatory demyelinating polyneuropathy (CIDP) is understood as a disease affecting the peripheral nervous system, mild cognitive dysfunction, particularly in the executive domain, has been described to form part of the condition. Here our interest lay in CIDP-related theory of mind (ToM) capacities as an aspect of social cognition relevant for many aspects of everyday life. METHODS Twenty-nine patients with CIDP and 23 healthy controls participated in this study. They were subjected to overview cognitive testing, different executive function (EF) tasks, as well as to the Faux Pas Recognition Task (FPRT) for assessing cognitive ToM and the Reading the Mind in the Eyes Test (RMET) with respect to affective ToM. RESULTS Persons with CIDP and controls did not differ with respect to their overall cognitive state. However, in the German verbal fluency standard, the digit span forward and the digit span backward tests used as EF tasks patients performed significantly worse than controls. Further, performance was abnormally low in the FPRT, whilst the groups did not differ with respect to RMET results. The FPRT and digit span backward results correlated with each other. CONCLUSIONS Patients with CIDP showed deficits in cognitive ToM performance together with EF dysfunction, whilst affective ToM was preserved. Altogether, the results suggest that low cognitive ToM capacities in patients with CIDP arise as a particular aspect of disease-related executive dysfunction.
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Affiliation(s)
- Hannah Lochmann
- Department of Neurology, Motor and Cognition Group, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin (CBF), Berlin, Germany
| | - Michelle Wyrobnik
- Department of Neurology, Motor and Cognition Group, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin (CBF), Berlin, Germany
- Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany
- Institute of Psychology, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Christin Kupper
- Department of Neurology, Motor and Cognition Group, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin (CBF), Berlin, Germany
| | - Charlotte Rewitzer
- Department of Neurology, Motor and Cognition Group, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin (CBF), Berlin, Germany
| | - Fabian Klostermann
- Department of Neurology, Motor and Cognition Group, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin (CBF), Berlin, Germany
- Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany
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Broers MC, Wieske L, Erdag E, Gürlek C, Bunschoten C, van Doorn PA, Eftimov F, Kuitwaard K, de Vries JM, de Wit MCY, Nagtzaam MM, Franken SC, Zhu L, Paunovic M, de Wit M, Schreurs MW, Lleixà C, Martín-Aguilar L, Pascual-Goñi E, Querol L, Jacobs BC, Huizinga R, Titulaer MJ. Clinical relevance of distinguishing autoimmune nodopathies from CIDP: longitudinal assessment in a large cohort. J Neurol Neurosurg Psychiatry 2023; 95:52-60. [PMID: 37879898 DOI: 10.1136/jnnp-2023-331378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 07/28/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND The aim of this study was to determine treatment response and whether it is associated with antibody titre change in patients with autoimmune nodopathy (AN) previously diagnosed as chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), and to compare clinical features and treatment response between AN and CIDP. METHODS Serum IgG antibodies to neurofascin-155 (NF155), contactin-1 (CNTN1) and contactin-associated protein 1 (CASPR1) were detected with cell-based assays in patients diagnosed with CIDP. Clinical improvement was determined using the modified Rankin scale, need for alternative and/or additional treatments and assessment of the treating neurologist. RESULTS We studied 401 patients diagnosed with CIDP and identified 21 patients with AN (10 anti-NF155, 6 anti-CNTN1, 4 anti-CASPR1 and 1 anti-NF155/anti-CASPR1 double positive). In patients with AN ataxia (68% vs 28%, p=0.001), cranial nerve involvement (34% vs 11%, p=0.012) and autonomic symptoms (47% vs 22%, p=0.025) were more frequently reported; patients with AN improved less often after intravenous immunoglobulin treatment (39% vs 80%, p=0.002) and required additional/alternative treatments more frequently (84% vs 34%, p<0.001), compared with patients with CIDP. Antibody titres decreased or became negative in patients improving on treatment. Treatment withdrawal was associated with a titre increase and clinical deterioration in four patients. CONCLUSIONS Distinguishing CIDP from AN is important, as patients with AN need a different treatment approach. Improvement and relapses were associated with changes in antibody titres, supporting the pathogenicity of these antibodies.
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Affiliation(s)
- Merel C Broers
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Luuk Wieske
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Ece Erdag
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Cemre Gürlek
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Carina Bunschoten
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Pieter A van Doorn
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Filip Eftimov
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Krista Kuitwaard
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Juna M de Vries
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Marie-Claire Y de Wit
- Department of Pediatric Neurology, Erasmus MC, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Mariska Mp Nagtzaam
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Suzanne C Franken
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Louisa Zhu
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Manuela Paunovic
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Maurice de Wit
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Marco Wj Schreurs
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Cinta Lleixà
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Lorena Martín-Aguilar
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Elba Pascual-Goñi
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Luis Querol
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro para la de Investigación Biomédica en Red en Enfermedades Raras, CIBERER, Madrid, Spain
| | - Bart C Jacobs
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Ruth Huizinga
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Maarten J Titulaer
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Mendoza M, Tran C, Bril V, Katzberg HD, Barnett-Tapia C. Symptom and Treatment Satisfaction in Members of the US and Canadian GBS/CIDP Foundations with a Diagnosis of Chronic Inflammatory Demyelinating Polyneuropathy. Adv Ther 2023; 40:5188-5203. [PMID: 37751023 DOI: 10.1007/s12325-023-02661-4] [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: 06/06/2023] [Accepted: 08/21/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION Current guidelines for defining good outcomes in patients with chronic inflammatory demyelinating polyneuropathy (CIDP) are predominately defined by experts. At present, we do not have a patient-anchored definition of what constitutes a "good" outcome. Our study aimed to assess the symptom burden of people living with CIDP, as well as satisfaction with treatments and clinical outcomes. METHODS We conducted an online-survey in CIDP patients registered with the US and Canadian GBS/CIDP foundations. Respondents answered general demographic and clinical questions, as well as satisfaction with current symptom burden and treatments, plus validated outcome measures. RESULTS A total of 318 individuals with self-reported CIDP completed the online survey, of whom 128 (40%) considered their current disease burden as satisfactory while 190 (60%) did not. Of 305 patients who answered the treatment satisfaction question, 222(74%) were satisfied with their treatments. Patients who were satisfied with their current symptoms had, on average, better scores in quality of life and disease severity scales, although regression modeling showed that only ability to walk, stable symptoms, and health utility scores were associated with symptom satisfaction. Treatment satisfaction was associated with stable symptoms, use of IVIG, and use of one versus no medication. CONCLUSIONS A high proportion of members of the US and Canadian GBS/CIDP Foundations reporting a diagnosis of CIDP were unsatisfied with current symptoms, despite a high level of overall satisfaction with treatments. There is an unmet need for improving long-term outcomes in people with a diagnosis of CIDP, and for studying patient-centered long-term treatment goals.
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Affiliation(s)
- Meg Mendoza
- Toronto General Hospital, Ellen and Martin Prosserman Centre for Neuromuscular Disease, 200 Elizabeth Street 5ECW-334, Toronto, ON, M5G2C4, Canada
| | - Christopher Tran
- Division of Neurology, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Vera Bril
- Toronto General Hospital, Ellen and Martin Prosserman Centre for Neuromuscular Disease, 200 Elizabeth Street 5ECW-334, Toronto, ON, M5G2C4, Canada
- Division of Neurology, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Hans D Katzberg
- Toronto General Hospital, Ellen and Martin Prosserman Centre for Neuromuscular Disease, 200 Elizabeth Street 5ECW-334, Toronto, ON, M5G2C4, Canada
- Division of Neurology, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Carolina Barnett-Tapia
- Toronto General Hospital, Ellen and Martin Prosserman Centre for Neuromuscular Disease, 200 Elizabeth Street 5ECW-334, Toronto, ON, M5G2C4, Canada.
- Division of Neurology, University Health Network and University of Toronto, Toronto, ON, Canada.
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Foster MA, Lunn MP, Carr AS. First-line immunosuppression in neuromuscular diseases. Pract Neurol 2023:pn-2023-003708. [PMID: 37173131 DOI: 10.1136/pn-2023-003708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2023] [Indexed: 05/15/2023]
Abstract
Autoimmune neuromuscular diseases are common and often treatable causes for peripheral nervous system dysfunction. If not optimally managed, they result in meaningful impairments and disability. The treating neurologist should aim to maximise clinical recovery with minimal iatrogenic risk. This requires careful patient and medication selection, appropriate counselling and close monitoring of clinical efficacy and safety. Here, we summarise our consensus departmental approach to first-line immunosuppression in neuromuscular diseases. We combine multispecialty evidence and expertise with a focus on autoimmune neuromuscular diseases to create guidance on starting, dosing and monitoring for toxic effects of the commonly used drugs. These include corticosteroids, steroid-sparing agents and cyclophosphamide. We also provide efficacy monitoring advice, as clinical response informs dosage and drug choice. The principles of this approach could be applied across much of the spectrum of immune-mediated neurological disorders where there is significant therapeutic crossover.
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Affiliation(s)
- Michael A Foster
- UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
- Division of Neurology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Michael Pt Lunn
- UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
- Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Aisling S Carr
- UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
- Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
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Fehmi J, Bellanti R, Misbah SA, Bhattacharjee A, Rinaldi S. Treatment of CIDP. Pract Neurol 2023; 23:46-53. [PMID: 36109154 DOI: 10.1136/pn-2021-002991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2022] [Indexed: 02/02/2023]
Abstract
Chronic inflammatory demyelinating polyneuropathy is a disabling but treatable disorder. However, misdiagnosis is common, and it can be difficult to optimise its treatment. Various agents are used both for first and second line. First-line options are intravenous immunoglobulin, corticosteroids and plasma exchange. Second-line therapies may be introduced as steroid-sparing agents or as more potent escalation therapy. It is also important to consider symptomatic treatment of neuropathic pain and non-pharmacological interventions. We discuss the evidence for the various treatments and explain the practicalities of the different approaches. We also outline strategies for monitoring response and assessing the ongoing need for therapy.
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Affiliation(s)
- Janev Fehmi
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Roberto Bellanti
- Neurology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Siraj A Misbah
- Clinical Immunology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Simon Rinaldi
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Cook M, Pasnoor M, Ajroud-Driss S, Brannagan TH, Dimachkie MM, Allen JA. CIDP prognosis in patients with IVIG treatment-related fluctuations. Muscle Nerve 2023; 67:69-73. [PMID: 36330716 PMCID: PMC10098814 DOI: 10.1002/mus.27746] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 10/22/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION/AIMS Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an acquired immune-mediated peripheral nerve disorder with variable prognosis and long-term dependence on immunotherapy. Frequent assessment of grip strength can be a useful tool to identify intravenous immunoglobulin (IVIG) treatment-related fluctuations (TRFs) and optimize IVIG treatment in real-time, but the long-term implications of TRFs are unknown. We aimed to explore the impact that real-time TRFs had on long-term CIDP prognosis, strength impairment, and disability. METHODS This retrospective observational cohort study analyzed standard of care clinical and treatment outcomes in patients who participated in a published prospective study of intra-IVIG-cycle grip strength quantification. Patients were analyzed based upon the presence or absence of TRFs, as determined in the initial prospective study. RESULTS Data were available for 23 CIDP patients with a mean follow-up period of 44.7 mo. There were no differences in baseline or follow-up strength, disability, or IVIG usage in patients with a low number of fluctuations compared to those with a high number of fluctuations. In both groups, drug-free remission was achieved in about one-third of patients. DISCUSSION TRFs are important to identify in order to optimize treatment in real time, but poorly predict long-term disease activity status. The presence of minor TRFs are unlikely to result in substantial accumulation of disability over time. Periodic IVIG optimization trials using objective outcomes are encouraged in all CIDP patients receiving chronic IVIG treatment as a means to identify the lowest effective IVIG dose and frequency.
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Affiliation(s)
- Melissa Cook
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mamatha Pasnoor
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Senda Ajroud-Driss
- Department of Neurology, Northwestern University, Chicago, Illinois, USA
| | - Thomas H Brannagan
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Mazen M Dimachkie
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jeffrey A Allen
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
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Markvardsen LK, Sindrup SH, Christiansen I, Sheikh AM, Holbech JV, Andersen H. Standardized Tapering off Subcutaneous Immunoglobulin in Chronic Inflammatory Demyelinating Polyneuropathy. J Neuromuscul Dis 2023; 10:787-796. [PMID: 37393512 PMCID: PMC10578281 DOI: 10.3233/jnd-221615] [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] [Accepted: 06/12/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND Attempting discontinuation of treatment in patients with chronic inflammatory demyelinating polyneuropathy (CIDP) is recommended. However, there is no evidence based regimen for tapering off subcutaneous immunoglobulin (SCIG). This trial investigated stepwise tapering off SCIG to detect remission and the lowest effective dosage. During tapering off, frequent vs less frequent clinical evaluation was compared. METHODS Patients with CIDP receiving a stable SCIG dosage followed a standardized tapering off regimen: 90%, 75%, 50%, 25% and 0% of the initial dose every 12th week, pending no deterioration occurred. In case of relapse during tapering off, the lowest effective dose was identified. Treatment with SCIG was registered for two years after participation. Disability score and grip strength were primary parameters. Participants were randomized to clinical evaluation every 6th week (frequent) or 12th week (less frequent). RESULTS Fifty-five patients were included of which thirty-five relapsed. Twenty patients (36%) were able to discontinue treatment without relapse. In relapsing patients, median dosage could be reduced by 10% (range, 0-75). After two years, 18 of 20 patients were still in remission without treatment. Frequent clinical evaluation did not detect deterioration more frequently than less frequent evaluation; RR 0.5 (95% CI, 0.2-1.2) (p = 0.17). CONCLUSION In stable CIDP patients, SCIG could be completely tapered off in 36% of the patients and only in 10% of these patients relapse occurred during the following two years. More frequent evaluation was not superior to detect deterioration.
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Affiliation(s)
- Lars K. Markvardsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Neurology, Aalborg University Hospital, Aalborg, Denmark
| | - Søren H. Sindrup
- Department of Neurology, Odense UniversityHospital, Odense, Denmark
| | | | - Aisha M. Sheikh
- Department of Neurology, Rigshospitalet, Copenhagen, Denmark
| | - Jakob V. Holbech
- Department of Neurology, Odense UniversityHospital, Odense, Denmark
| | - Henning Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
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Lewis RA, van Doorn PA, Sommer C. Tips in navigating the diagnostic complexities of chronic inflammatory demyelinating polyradiculoneuropathy. J Neurol Sci 2022; 443:120478. [PMID: 36368137 DOI: 10.1016/j.jns.2022.120478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/29/2022] [Accepted: 10/23/2022] [Indexed: 11/06/2022]
Abstract
The 2021 guideline of the European Academy of Neurology/Peripheral Nerve Society on chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) includes important revisions to the previous 2010 guideline. This article highlights the new criteria and recommendations for the differential diagnosis of CIDP. In the revised guideline, the CIDP spectrum has been modified to include typical CIDP and four well-characterized CIDP variants, namely distal, multifocal/focal, motor and sensory CIDP, replacing the term 'atypical' CIDP. To improve the diagnosis of CIDP, the revised guideline attempts to improve the specificity of the diagnostic criteria for typical CIDP and the four CIDP variants. Specific clinical and electrodiagnostic (including both motor and sensory conduction) criteria are provided for typical CIDP and each of the CIDP variants. The levels of diagnostic certainty have been changed to CIDP and possible CIDP, with the removal of probable CIDP (due to the lack of difference in the accuracy of the electrodiagnostic criteria for probable CIDP) and definite CIDP (due to the lack of a gold standard for diagnosis). If the clinical and electrodiagnostic criteria allow only for a diagnosis of possible CIDP, cerebrospinal fluid analysis, nerve ultrasound, nerve magnetic resonance imaging, objective treatment response, and nerve biopsy can be used as supportive criteria to upgrade the diagnosis to CIDP. Although the revised guideline needs to be validated and its strengths and weaknesses assessed, using the guideline will likely improve the accuracy of diagnosis of CIDP and variants of CIDP, and aid in distinguishing CIDP from conditions with similar features.
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Affiliation(s)
| | - Pieter A van Doorn
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
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Fargeot G, Gitiaux C, Magy L, Pereon Y, Delmont E, Viala K, Echaniz-Laguna A. French recommendations for the management of adult & pediatric chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Rev Neurol (Paris) 2022; 178:953-968. [PMID: 36182621 DOI: 10.1016/j.neurol.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 05/31/2022] [Accepted: 06/05/2022] [Indexed: 11/22/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a rare autoimmune disorder of the peripheral nervous system, primarily affecting the myelin sheath. The pathophysiology of CIDP is complex, involving both humoral and cellular immunity. The diagnosis of CIDP should be suspected in patients with symmetrical proximal and distal motor weakness and distal sensory symptoms of progressive onset, associated with decreased/abolished tendon reflexes. Treatments include intraveinous immunoglobulins, steroids and plasma exchange, with usually an induction phase followed by a maintenance therapy with progressive weaning. Treatment should be rapidly initiated to prevent axonal degeneration, which may compromise recovery. CIDP outcome is variable, ranging from mild distal paresthesiae to complete loss of ambulation. There have been several breakthroughs in the diagnosis and management of CIDP the past ten years, e.g. discovery of antibodies against the node of Ranvier, contribution of nerve ultrasound and magnetic resonance imaging to diagnosis, and demonstration of subcutaneous immunoglobulins efficiency. This led us to elaborate French recommendations for the management of adult & pediatric CIDP patients. These recommendations include diagnosis assessment, treatment, and follow-up.
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Affiliation(s)
- G Fargeot
- Neurophysiology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.
| | - C Gitiaux
- Department of Paediatric Neurophysiology, Necker-Enfants-Malades Hospital, AP-HP, Paris University, Paris, France
| | - L Magy
- Department of Neurology, National Reference Center for 'Rare Peripheral Neuropathies', University Hospital of Limoges, Limoges, France
| | - Y Pereon
- CHU Nantes, Centre de Référence Maladies Neuromusculaires AOC, Filnemus, Euro-NMD, Explorations Fonctionnelles, Hôtel-Dieu, Nantes, France
| | - E Delmont
- Reference Center for Neuromuscular Diseases and ALS Timone University Hospital, Aix-Marseille University, Marseille, France
| | - K Viala
- Neurophysiology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - A Echaniz-Laguna
- Neurology Department, CHU de Bicêtre, AP-HP, Le-Kremlin-Bicêtre, France; French National Reference Center for Rare Neuropathies (NNERF), Le-Kremlin-Bicêtre, France; Inserm U1195, Paris-Saclay University, Le-Kremlin-Bicêtre, France
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11
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Rajabally YA, Ouaja R, Kasiborski F, Pujol S, Nobile‐Orazio E. Assessment timing and choice of outcome measure in determining treatment response in chronic inflammatory demyelinating polyneuropathy: A post hoc analysis of the PRISM trial. Muscle Nerve 2022; 66:562-567. [PMID: 36057106 PMCID: PMC9828128 DOI: 10.1002/mus.27713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 08/26/2022] [Accepted: 08/26/2022] [Indexed: 01/12/2023]
Abstract
INTRODUCTION/AIMS Treatment response and its timing are variable in chronic inflammatory demyelinating polyneuropathy (CIDP). In this study we assessed the variability using multiple outcome measures. METHODS We performed a post hoc analysis of the PRISM trial, a 24-week prospective, multicenter, single-arm, open-label, phase III study of a 10% intravenous immunoglobulin preparation for CIDP. We ascertained timing of response with primary/secondary outcome measures. RESULTS At 6 weeks after treatment initiation, 13 of 40 subjects (32.5%) were defined as responders on the primary outcome measure, the adjusted Inflammatory Neuropathy Cause And Treatment (INCAT) scale. This increased to 20 of 41 (48.8%) at 12 weeks and to 32 of 42 (76.2%) at 24 weeks. Use of minimal important difference (MID)-determined amelioration of the inflammatory Rasch-built Overall Disability Scale (I-RODS), or of the Medical Research Council sum score (MRCSS), or of dominant hand-grip strength, in addition to the adjusted INCAT, indicated a sensitivity of 41.7% in identifying adjusted INCAT nonresponders at week 12 who subsequently responded at week 24. Specificity was 60% vs INCAT nonresponders at week 24. Consideration of amelioration of any amplitude on any secondary outcome measure indicated a 75% sensitivity, but only 30% specificity vs adjusted INCAT nonresponders at week 24. DISCUSSION Immunoglobulin treatment continuation may be justified for up to 24 weeks in CIDP. Additional outcome measures may help in the early treatment stages to predict delayed response on the adjusted INCAT. However, their use is limited by high false-positive rates. More robust, reliable, and relevant outcome measures are needed to detect early improvement in immunoglobulin-treated CIDP.
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Affiliation(s)
- Yusuf A. Rajabally
- Aston Medical SchoolAston UniversityBirminghamUK,Inflammatory Neuropathy ClinicUniversity Hospitals BirminghamBirminghamUK
| | | | | | | | - Eduardo Nobile‐Orazio
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Research Hospital, Department of Medical Biotechnology and Translational MedicineMilan UniversityMilanItaly
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12
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Adrichem ME, Lucke IM, Vrancken AFJE, Goedee HS, Wieske L, Dijkgraaf MGW, Voermans NC, Notermans NC, Faber CG, Visser LH, Kuitwaard K, van Doorn PA, Merkies ISJ, de Haan RJ, van Schaik IN, Eftimov F. Withdrawal of intravenous immunoglobulin in chronic inflammatory demyelinating polyradiculoneuropathy. Brain 2022; 145:1641-1652. [PMID: 35139161 PMCID: PMC9166547 DOI: 10.1093/brain/awac054] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 12/07/2021] [Accepted: 12/21/2021] [Indexed: 12/01/2022] Open
Abstract
Intravenous immunoglobulins are an efficacious treatment for chronic inflammatory demyelinating polyradiculoneuropathy. Biomarkers for disease activity are lacking, making the need for ongoing treatment difficult to assess, leading to potential overtreatment and high health-care costs. Our objective was to determine whether intravenous immunoglobulin withdrawal is non-inferior to continuing intravenous immunoglobulin treatment and to determine how often patients are overtreated. We performed a randomized, double-blind, intravenous immunoglobulin-controlled non-inferiority trial in seven centres in the Netherlands (Trial registration: ISRCTN 13637698; www.isrctn.com/ISRCTN13637698). Adults with clinically stable chronic inflammatory demyelinating polyradiculoneuropathy using intravenous immunoglobulin maintenance treatment for at least 6 months were included. Patients received either intravenous immunoglobulin withdrawal (placebo) as investigational treatment or continuation of intravenous immunoglobulin treatment (control). The primary outcome was the mean change in logit scores from baseline to 24-week follow-up on the patient-reported Inflammatory Rasch–Overall Disability Scale. The non-inferiority margin was predefined as between-group difference in mean change scores of −0.65. Patients who deteriorated could reach a relapse end point according to predefined criteria. Patients with a relapse end point after intravenous immunoglobulin withdrawal entered a restabilization phase. All patients from the withdrawal group who remained stable were included in an open-label extension phase of 52 weeks. We included 60 patients, of whom 29 were randomized to intravenous immunoglobulin withdrawal and 31 to continuation of treatment. The mean age was 58 years (SD 14.7) and 67% was male. The between-group difference in mean change Inflammatory Rasch–Overall Disability Scale scores was −0.47 (95% CI −1.24 to 0.31), indicating that non-inferiority of intravenous immunoglobulin withdrawal could not be established. In the intravenous immunoglobulin withdrawal group, 41% remained stable for 24 weeks, compared to 58% in the intravenous immunoglobulin continuation group (−17%; 95% CI −39 to 8). Of the intravenous immunoglobulin withdrawal group, 28% remained stable at the end of the extension phase. Of the patients in the restabilization phase, 94% restabilized within 12 weeks. In conclusion, it remains inconclusive whether intravenous immunoglobulin withdrawal is non-inferior compared to continuing treatment, partly due to larger than expected confidence intervals leading to an underpowered study. Despite these limitations, a considerable proportion of patients could stop treatment and almost all patients who relapsed were restabilized quickly. Unexpectedly, a high proportion of intravenous immunoglobulin-treated patients experienced a relapse end point, emphasizing the need for more objective measures for disease activity in future trials, as the patient-reported outcome measures might not have been able to identify true relapses reliably. Overall, this study suggests that withdrawal attempts are safe and should be performed regularly in clinically stable patients.
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Affiliation(s)
- Max E Adrichem
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9 1105 AZ Amsterdam, The Netherlands
| | - Ilse M Lucke
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9 1105 AZ Amsterdam, The Netherlands
| | - Alexander F J E Vrancken
- Department of Neurology, University Medical Center, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - H Stephan Goedee
- Department of Neurology, University Medical Center, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Luuk Wieske
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9 1105 AZ Amsterdam, The Netherlands
| | - Marcel G W Dijkgraaf
- Department of Clinical Epidemiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9 1105 AZ Amsterdam, The Netherlands
| | - Nicol C Voermans
- Department of Neurology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Nicolette C Notermans
- Department of Neurology, University Medical Center, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Catharina G Faber
- Department of Neurology, Maastricht Academic Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Leo H Visser
- Department of Neurology, Elisabeth-Tweesteden Hospital, Hilvarenbeekse weg 60, 5022 GC Tilburg, The Netherlands
| | - Krista Kuitwaard
- Department of Neurology, Albert Schweitzer Hospital, Albert Schweitzerplaats 25 3318 AT Dordrecht, The Netherlands
| | - Pieter A van Doorn
- Department of Neurology, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Ingemar S J Merkies
- Department of Neurology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands.,Department of Neurology, Curaçao Medical Center, 193 JHJ. Hamelbergweg, Willemstad, Curacao, The Netherlands
| | - Rob J de Haan
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9 1105 AZ Amsterdam, The Netherlands
| | - Ivo N van Schaik
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9 1105 AZ Amsterdam, The Netherlands.,Board of directors, Spaarne Gasthuis, Boerhaavelaan 22, 2035 RC Haarlem, The Netherlands
| | - Filip Eftimov
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9 1105 AZ Amsterdam, The Netherlands
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13
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Lozeron P. Polineuropatie infiammatorie demielinizzanti croniche. Neurologia 2022. [DOI: 10.1016/s1634-7072(21)46001-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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14
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Rajabally YA. Contemporary challenges in the diagnosis and management of chronic inflammatory demyelinating polyneuropathy. Expert Rev Neurother 2022; 22:89-99. [PMID: 35098847 DOI: 10.1080/14737175.2022.2036125] [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 Despite extensive research, multiple inter-related diagnostic and management challenges remain for chronic inflammatory demyelinating polyneuropathy (CIDP). AREAS COVERED A literature review was performed on diagnosis and treatment in CIDP. The clinical features and disease course were evaluated. Investigative techniques, including electrophysiology, cerebrospinal fluid examination, neuropathology, imaging and neuroimmunology, were considered in relation to technical aspects, sensitivity, specificity, availability and cost. Available evidenced-based treatments and those with possible efficacy despite lack of evidence, were considered, as well as current methods for evaluation of treatment effects. EXPERT OPINION CIDP remains a clinical diagnosis, supported first and foremost by electrophysiology. Other investigative techniques have limited impact. Most patients with CIDP respond to available first-line treatments and immunosuppression may be efficacious in those who do not. Consideration of the natural history and of the high reported remission rate, of under-recognised associated disabling features, of treatment administration modalities and assessment methods, require enhanced attention.
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Affiliation(s)
- Yusuf A Rajabally
- Inflammatory Neuropathy Clinic, Department of Neurology, University Hospitals Birmingham, Birmingham, UK.,Aston Medical School, Aston University, Birmingham, UK
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15
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Keh RYS, Selby DA, Jones S, Gosal D, Lavin T, Lilleker JB, Carr AS, Lunn MP. Predicting long-term trends in inflammatory neuropathy outcome measures using latent class modelling. J Peripher Nerv Syst 2021; 27:84-93. [PMID: 34936164 DOI: 10.1111/jns.12481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/17/2021] [Accepted: 12/18/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Immunoglobulin (Ig) is used to treat chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and multifocal motor neuropathy with conduction block (MMNCB). Regular infusions may be used for symptom control. Disease activity is monitored with clinical outcome measurements. We examined outcome measure variation during clinically stable periods in Ig-treated CIDP and MMNCB patients. We explored utility of serial outcome measurement in long-term outcome prediction. METHODS Retrospective longitudinal analysis of a single neuroscience centre's Ig-treated CIDP and MMNCB patients, 2009-2020, was performed. Mean and percentage change for grip strength, Rasch-built overall disability scales (RODS) and MRC sum scores (MRC-SS) during periods of clinical stability were compared to score-specific minimal clinically important differences (MCID). Latent class mixed modelling (LCMM) was used to identify longitudinal trends and factors influencing long-term outcome. RESULTS We identified 85 CIDP and 23 MMNCB patients (1,423 datapoints; 5635 treatment-months). Group-averaged outcome measures varied little over time. Intra-individual variation exceeded MCID for RODS in 44.2% CIDP and 16.7% MMNCB datapoints, grip strength in 10.6% (CIDP) and 8.8%/27.2% (MMNCB right/left hand) and MRC-SS in 43.5% (CIDP) and 20% (MMNCB). Multivariate LCMM identified subclinical trends toward improvement (32 patients) and deterioration (73 patients) in both cohorts. At baseline, CIDP 'deteriorators' were older than 'improvers' (66.2 versus 57 years, p=0.025). No other individual factors predicted categorisation. The best model for 'deteriorator' identification was contiguous sub-MCID decline in more than one outcome measure (CIDP: sensitivity 74%, specificity 59%; MMNCB: sensitivity 73%, specificity 88%). DISCUSSION Outcome measure interpretation determines therapeutic decision-making in Ig-dependent neuropathy patients, but intra-individual variation is common, often exceeding MCID. Here we show sub-MCID contiguous changes in more than one outcome measurement are a better predictor of long-term outcome. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Ryan Yann Shern Keh
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester, UK.,MRC Centre for Neuromuscular Diseases, National Hospital of Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | - David Antony Selby
- Division of Musculoskeletal and Dermatological Sciences, University of Manchester, Manchester, UK
| | - Sam Jones
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - David Gosal
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - Timothy Lavin
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - James B Lilleker
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester, UK.,Division of Musculoskeletal and Dermatological Sciences, University of Manchester, Manchester, UK
| | - Aisling S Carr
- MRC Centre for Neuromuscular Diseases, National Hospital of Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | - Michael P Lunn
- MRC Centre for Neuromuscular Diseases, National Hospital of Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK.,Institute of Neurology, University College London, London, UK
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16
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Bus SRM, Wieske L, Keddie S, van Schaik IN, Eftimov F. Subcutaneous immunoglobulin for chronic inflammatory demyelinating polyradiculoneuropathy. Hippokratia 2021. [DOI: 10.1002/14651858.cd014542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Sander RM Bus
- Department of Neurology, Amsterdam Neuroscience; Amsterdam UMC, University of Amsterdam; Amsterdam Netherlands
| | - Luuk Wieske
- Department of Neurology, Amsterdam Neuroscience; Amsterdam UMC, University of Amsterdam; Amsterdam Netherlands
| | - Stephen Keddie
- Faculty of Brain Sciences; Institute of Neurology; London UK
| | - Ivo N van Schaik
- Department of Neurology, Amsterdam Neuroscience; Amsterdam University Medical Centers, location AMC, University of Amsterdam; Amsterdam Netherlands
| | - Filip Eftimov
- Department of Neurology, Amsterdam Neuroscience; Amsterdam UMC, University of Amsterdam; Amsterdam Netherlands
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17
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Stascheit F, Hotter B, Klose S, Meisel C, Meisel A, Klehmet J. Calprotectin in Chronic Inflammatory Demyelinating Polyneuropathy and Variants-A Potential Novel Biomarker of Disease Activity. Front Neurol 2021; 12:723009. [PMID: 34589050 PMCID: PMC8473624 DOI: 10.3389/fneur.2021.723009] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/12/2021] [Indexed: 12/04/2022] Open
Abstract
Background: In chronic inflammatory demyelinating polyneuropathy (CIDP), there is an urgent need for biomarkers to monitor ongoing disease activity. Serum calprotectin (CLP) induces signaling pathways involved in inflammatory processes and has been shown to correlate with markers of disease activity in other autoimmune disorders. Thus, we wanted to study the potential value of CLP in comparison to serum neurofilament light chain (sNfl) to monitor disease activity. Materials and Methods: Sera from 63 typical and atypical CIDP and 6 MMN patients with varying degrees of disease activity were analyzed in comparison with 40 healthy controls (HC) in a cross-sectional design. Association of CLP and sNfl levels with socio-demographics, disease duration, CIDP disease activity scale (CDAS), and impairment status [medical research council-sum score (MRC-SS), the inflammatory neuropathy cause and treatment disability score (INCAT-DS), grip strength, and maximum walking distance], patient-reported outcome (PRO) parameters [SF-36 questionnaire, Beck's depression index (BDI), and fatigue severity scale (FSS)], as well as treatment regime were investigated using uni- and multivariate analysis. Results: CLP and sNfl levels were significantly higher in all CIDP patients compared to HC (p = 0.0009). Multivariate analysis adjusted for age and gender revealed that CLP acts as an independent predictor for CIDP and MMN. CLP was significantly associated with active disease course according to CDAS and correlated with MRC-SS, whereas sNfl correlated with parameters of disease impairment. There was no correlation with PRO, except for sNfl and the mental health composite score. Subgroup analysis revealed no differences between typical CIDP and atypical variants. Conclusions: CLP was elevated in CIDP and variants and was associated with active disease course, whereas sNfl shows further potential as biomarker of axonal degeneration. Thus, CLP might be a suitable additive biomarker for measurement of ongoing inflammation, which is greatly needed to guide better patient care in CIDP.
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Affiliation(s)
- Frauke Stascheit
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Benjamin Hotter
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sarah Klose
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Christian Meisel
- Department of Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Department of Immunology, Labor Berlin, Charité Vivantes GmbH, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,German Myasthenia Gravis Society (Deutsche Myasthenie Gesellschaft, DMG), Bremen, Germany
| | - Juliane Klehmet
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Jüdisches Krankenhaus Berlin, Berlin, Germany
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18
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Van den Bergh PYK, van Doorn PA, Hadden RDM, Avau B, Vankrunkelsven P, Allen JA, Attarian S, Blomkwist-Markens PH, Cornblath DR, Eftimov F, Goedee HS, Harbo T, Kuwabara S, Lewis RA, Lunn MP, Nobile-Orazio E, Querol L, Rajabally YA, Sommer C, Topaloglu HA. European Academy of Neurology/Peripheral Nerve Society guideline on diagnosis and treatment of chronic inflammatory demyelinating polyradiculoneuropathy: Report of a joint Task Force-Second revision. Eur J Neurol 2021; 28:3556-3583. [PMID: 34327760 DOI: 10.1111/ene.14959] [Citation(s) in RCA: 153] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To revise the 2010 consensus guideline on chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). METHODS Seventeen disease experts, a patient representative, and two Cochrane methodologists constructed 12 Population/Intervention/Comparison/Outcome (PICO) questions regarding diagnosis and treatment to guide the literature search. Data were extracted and summarized in GRADE summary of findings (for treatment PICOs) or evidence tables (for diagnostic PICOs). RESULTS Statements were prepared according to the GRADE Evidence-to-Decision frameworks. Typical CIDP and CIDP variants were distinguished. The previous term "atypical CIDP" was replaced by "CIDP variants" because these are well characterized entities (multifocal, focal, distal, motor, or sensory CIDP). The levels of diagnostic certainty were reduced from three (definite, probable, possible CIDP) to only two (CIDP and possible CIDP), because the diagnostic accuracy of criteria for probable and definite CIDP did not significantly differ. Good Practice Points were formulated for supportive criteria and investigations to be considered to diagnose CIDP. The principal treatment recommendations were: (a) intravenous immunoglobulin (IVIg) or corticosteroids are strongly recommended as initial treatment in typical CIDP and CIDP variants; (b) plasma exchange is strongly recommended if IVIg and corticosteroids are ineffective; (c) IVIg should be considered as first-line treatment in motor CIDP (Good Practice Point); (d) for maintenance treatment, IVIg, subcutaneous immunoglobulin or corticosteroids are recommended; (e) if the maintenance dose of any of these is high, consider either combination treatments or adding an immunosuppressant or immunomodulatory drug (Good Practice Point); and (f) if pain is present, consider drugs against neuropathic pain and multidisciplinary management (Good Practice Point).
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Affiliation(s)
- Peter Y K Van den Bergh
- Neuromuscular Reference Centre, Department of Neurology, University Hospital Saint-Luc, Brussels, Belgium
| | - Pieter A van Doorn
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | - Bert Avau
- Cochrane Belgium, CEBAM, Leuven, Belgium and CEBaP, Belgian Red Cross, Mechelen, Belgium
| | | | - Jeffrey A Allen
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shahram Attarian
- Centre de Référence des Maladies Neuromusculaires et de la SLA, APHM, CHU Timone, Marseille, France
| | | | - David R Cornblath
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Filip Eftimov
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - H Stephan Goedee
- Department of Neuromuscular Disorders, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Thomas Harbo
- Department of Neurology, Århus University Hospital, Århus, Denmark
| | - Satoshi Kuwabara
- Department of Neurology, Chiba University Hospital, Chiba, Japan
| | - Richard A Lewis
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michael P Lunn
- Department of Neurology and MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical and Research Center, Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Luis Querol
- Neuromuscular Diseases Unit-Neurology Department, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
| | - Yusuf A Rajabally
- Regional Neuromuscular Service, Neurology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Claudia Sommer
- Neurology Clinic, University Hospital Würzburg, Würzburg, Germany
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19
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Clinical outcome of CIDP one year after start of treatment: a prospective cohort study. J Neurol 2021; 269:945-955. [PMID: 34173873 PMCID: PMC8782785 DOI: 10.1007/s00415-021-10677-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/17/2021] [Accepted: 06/17/2021] [Indexed: 10/31/2022]
Abstract
OBJECTIVE To assess clinical outcome in treatment-naive patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). METHODS We included adult treatment-naive patients participating in the prospective International CIDP Outcome Study (ICOS) that fulfilled the European Federation of Neurological Societies/Peripheral Nerve Society (EFNS/PNS) diagnostic criteria for CIDP. Patients were grouped based on initial treatment with (1) intravenous immunoglobulin (IVIg), (2) corticosteroid monotherapy or (3) IVIg and corticosteroids (combination treatment). Outcome measures included the inflammatory Rasch-built overall disability scale (I-RODS), grip strength, and Medical Research Council (MRC) sum score. Treatment response, treatment status, remissions (improved and untreated), treatment changes, and residual symptoms or deficits were assessed at 1 year. RESULTS Forty patients were included of whom 18 (45%) initially received IVIg, 6 (15%) corticosteroids, and 16 (40%) combination treatment. Improvement on ≥ 1 of the outcome measures was seen in 31 (78%) patients. At 1 year, 19 (48%) patients were still treated and fourteen (36%) patients were in remission. Improvement was seen most frequently in patients started on IVIg (94%) and remission in those started on combination treatment (44%). Differences between groups did not reach statistical significance. Residual symptoms or deficits ranged from 25% for neuropathic pain to 96% for any sensory deficit. CONCLUSIONS Improvement was seen in most patients. One year after the start of treatment, more than half of the patients were untreated and around one-third in remission. Residual symptoms and deficits were common regardless of treatment.
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20
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Van den Bergh PYK, van Doorn PA, Hadden RDM, Avau B, Vankrunkelsven P, Allen JA, Attarian S, Blomkwist-Markens PH, Cornblath DR, Eftimov F, Goedee HS, Harbo T, Kuwabara S, Lewis RA, Lunn MP, Nobile-Orazio E, Querol L, Rajabally YA, Sommer C, Topaloglu HA. European Academy of Neurology/Peripheral Nerve Society guideline on diagnosis and treatment of chronic inflammatory demyelinating polyradiculoneuropathy: Report of a joint Task Force-Second revision. J Peripher Nerv Syst 2021; 26:242-268. [PMID: 34085743 DOI: 10.1111/jns.12455] [Citation(s) in RCA: 143] [Impact Index Per Article: 47.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 12/14/2022]
Abstract
To revise the 2010 consensus guideline on chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Seventeen disease experts, a patient representative, and two Cochrane methodologists constructed 12 Population/Intervention/Comparison/Outcome (PICO) questions regarding diagnosis and treatment to guide the literature search. Data were extracted and summarized in GRADE summary of findings (for treatment PICOs) or evidence tables (for diagnostic PICOs). Statements were prepared according to the GRADE Evidence-to-Decision frameworks. Typical CIDP and CIDP variants were distinguished. The previous term "atypical CIDP" was replaced by "CIDP variants" because these are well characterized entities (multifocal, focal, distal, motor, or sensory CIDP). The levels of diagnostic certainty were reduced from three (definite, probable, possible CIDP) to only two (CIDP and possible CIDP), because the diagnostic accuracy of criteria for probable and definite CIDP did not significantly differ. Good Practice Points were formulated for supportive criteria and investigations to be considered to diagnose CIDP. The principal treatment recommendations were: (a) intravenous immunoglobulin (IVIg) or corticosteroids are strongly recommended as initial treatment in typical CIDP and CIDP variants; (b) plasma exchange is strongly recommended if IVIg and corticosteroids are ineffective; (c) IVIg should be considered as first-line treatment in motor CIDP (Good Practice Point); (d) for maintenance treatment, IVIg, subcutaneous immunoglobulin or corticosteroids are recommended; (e) if the maintenance dose of any of these is high, consider either combination treatments or adding an immunosuppressant or immunomodulatory drug (Good Practice Point); and (f) if pain is present, consider drugs against neuropathic pain and multidisciplinary management (Good Practice Point).
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Affiliation(s)
- Peter Y K Van den Bergh
- Neuromuscular Reference Centre, Department of Neurology, University Hospital Saint-Luc, Brussels, Belgium
| | - Pieter A van Doorn
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | - Bert Avau
- Cochrane Belgium, CEBAM, Leuven, Belgium and CEBaP, Belgian Red Cross, Mechelen, Belgium
| | | | - Jeffrey A Allen
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shahram Attarian
- Centre de Référence des Maladies Neuromusculaires et de la SLA, APHM, CHU Timone, Marseille, France
| | | | - David R Cornblath
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Filip Eftimov
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - H Stephan Goedee
- Department of Neuromuscular Disorders, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Thomas Harbo
- Department of Neurology, Århus University Hospital, Århus, Denmark
| | - Satoshi Kuwabara
- Department of Neurology, Chiba University Hospital, Chiba, Japan
| | - Richard A Lewis
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michael P Lunn
- Department of Neurology and MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical and Research Center, Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Luis Querol
- Neuromuscular Diseases Unit-Neurology Department, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
| | - Yusuf A Rajabally
- Regional Neuromuscular Service, Neurology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Claudia Sommer
- Neurology Clinic, University Hospital Würzburg, Würzburg, Germany
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21
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Gingele S, Koch M, Saparilla AC, Körner GM, von Hörsten J, Gingele M, Seeliger T, Konen FF, Hümmert MW, Neyazi A, Stangel M, Skripuletz T. Switch from intravenous to subcutaneous immunoglobulin IgPro20 in CIDP patients: a prospective observational study under real-world conditions. Ther Adv Neurol Disord 2021; 14:17562864211009100. [PMID: 33948119 PMCID: PMC8053839 DOI: 10.1177/17562864211009100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 03/18/2021] [Indexed: 11/17/2022] Open
Abstract
Background: IgPro20 is the first approved subcutaneous immunoglobulin (SCIg) preparation for the treatment of patients with chronic inflammatory demyelinating polyneuropathy (CIDP). Two different doses of the SCIg preparation were investigated in the pivotal PATH study. Real-world data, and particularly the efficacy of an equivalent dose switch from intravenous immunoglobulin (IVIg) to SCIg, are still not available. Methods: In this prospective observational study, 41 patients with CIDP treated with intravenous immunoglobulin (IVIg) were changed to an equivalent (1:1) dose of IgPro20 1 week after last IVIg treatment. Patients were examined at the time of switch from IVIg to SCIg, after 3 and after 6 months and efficacy, treatment preferences and systemic and local reactions were assessed. Results: Various clinical outcome parameters demonstrated overall stability regarding disability, general activity and social participation, grip and muscle strength, as well as gait impairment. Treatment satisfaction remained unchanged between IVIg and SCIg therapy. However, 88% of patients favoured treatment with subcutaneous IgPro20 over IVIg 6 months after switch to IgPro20. Conclusion: Results demonstrate that the switch of IVIg to an equivalent dose of SCIg represents an effective and preferred treatment option for CIDP patients.
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Affiliation(s)
- Stefan Gingele
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Moritz Koch
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | - Gudrun M Körner
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | - Marina Gingele
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Tabea Seeliger
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | - Martin W Hümmert
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Alexandra Neyazi
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Martin Stangel
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Thomas Skripuletz
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany
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22
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Allen JA, Merkies ISJ, Lewis RA. Monitoring Clinical Course and Treatment Response in Chronic Inflammatory Demyelinating Polyneuropathy During Routine Care: A Review of Clinical and Laboratory Assessment Measures. JAMA Neurol 2021; 77:1159-1166. [PMID: 32338716 DOI: 10.1001/jamaneurol.2020.0781] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Identifying clinical change in many neurologic diseases, including chronic inflammatory demyelinating polyneuropathy (CIDP), can be challenging. At the same time, how change is defined heavily influences a patient's diagnostic and treatment pathway. It can be especially problematic when equivocal subjective observations are interpreted as clinically meaningful and then used to make diagnostic and treatment decisions. Change in clinical trials is strictly defined by a preselected metric, but there is a perception that formal outcomes collection during routine clinical care is neither feasible nor necessary. Given the importance placed on how change is interpreted, there is a need to select assessments that can be applied to routine care that are representative of the neurologic disease state. Observations For an outcome measure to be useful during clinical trials, it must have good reliability, validity, be responsive to change, and have clinical meaning. To be useful during routine clinical care, the assessment must additionally be easy to collect without the need for extensive training or equipment and should provide an immediately available result that can be rapidly quantified and interpreted. Chronic inflammatory demyelinating polyneuropathy is clinically heterogeneous and so is best evaluated with a diverse group of assessment tools. Assessing strength impairment, disability, and quality of life is ideally suited for everyday practice when caring for patients with CIDP. While electrophysiologic studies, imaging, cerebrospinal fluid, and nodal/paranodal antibodies can provide diagnostic data, they are less practical and helpful longitudinal assessment tools. Conclusions and Relevance Sound clinimetric outcome measures in CIDP are widely available and have the potential to help clinicians objectify treatment response and disease progression. Such data are critically important when justifying the need for ongoing or periodic immunotherapy, documenting relapse or deterioration, or providing reassurance of disease improvement, stability, or remission.
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Affiliation(s)
- Jeffrey A Allen
- Department of Neurology, University of Minnesota, Minneapolis
| | - Ingemar S J Merkies
- Department of Neurology, Maastricht University Medical Centre+, Maastricht, the Netherlands.,Department of Neurology, St Elisabeth Hospital, Willemstad, Curaçao
| | - Richard A Lewis
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California
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23
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Motte J, Fisse AL, Köse N, Grüter T, Mork H, Athanasopoulos D, Fels M, Otto S, Siglienti I, Schneider-Gold C, Hellwig K, Yoon MS, Gold R, Pitarokoili K. Treatment response to cyclophosphamide, rituximab, and bortezomib in chronic immune-mediated sensorimotor neuropathies: a retrospective cohort study. Ther Adv Neurol Disord 2021; 14:1756286421999631. [PMID: 33747132 PMCID: PMC7940507 DOI: 10.1177/1756286421999631] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 02/10/2021] [Indexed: 12/13/2022] Open
Abstract
Background: Up to 20% of patients with chronic immune-mediated sensorimotor neuropathies (CIN) do not respond adequately to first-line therapies. However, studies on further treatment are scarce. Methods: We analyzed retrospectively 200 CIN patients regarding disease characteristics and response to therapy with cyclophosphamide (CYP), rituximab (RTX), and bortezomib (BTZ). Treatment response was defined as improvement or stabilization of inflammatory neuropathy cause and treatment overall disability score (INCAT-ODSS). Results: A total of 48 of 181 patients (26.5%) received therapy with CYP, RTX, or BTZ. The most frequently and first used therapy was CYP (69%). More than 40% of patients needed a second or third treatment. Overall, 71 treatments were applied in 48 patients. The combination of up to all three treatments enhanced the response-rate to 90%. Treatment within 24 months after initial diagnosis resulted in significantly higher response rate than late treatment (79% versus 50 %, p = 0.04, χ2-test, n = 46) and in lower disability in long-term follow up (INCAT-ODSS 3.8 versus 5.8, p = 0.02, t-test, n = 48). Patients with Lewis-Sumner syndrome (n = 9) and autoantibody mediated neuropathies (n = 13) had excellent response rates after treatment with RTX (90–100%). In contrast, typical chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) showed a response rate of 64% in CYP, 64% in RTX, and 75% in BTZ. Conclusion: Treatment with CYP, RTX, or BTZ was effective in this cohort of CIN refractory to first-line treatment. Our data increase evidence for an early use of these therapies. High efficacy of RTX in Lewis-Sumner syndrome in contrast to typical CIDP suggests a distinct pathophysiology.
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Affiliation(s)
- Jeremias Motte
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, Bochum, 44791, Germany
| | - Anna Lena Fisse
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Nuray Köse
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Thomas Grüter
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Hannah Mork
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | | | - Miriam Fels
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Susanne Otto
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Ines Siglienti
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | | | - Kerstin Hellwig
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Min-Suk Yoon
- Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Kalliopi Pitarokoili
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
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24
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Bus SRM, Zambreanu L, Abbas A, Rajabally YA, Hadden RDM, de Haan RJ, de Borgie CAJM, Lunn MP, van Schaik IN, Eftimov F. Intravenous immunoglobulin and intravenous methylprednisolone as optimal induction treatment in chronic inflammatory demyelinating polyradiculoneuropathy: protocol of an international, randomised, double-blind, placebo-controlled trial (OPTIC). Trials 2021; 22:155. [PMID: 33608058 PMCID: PMC7894234 DOI: 10.1186/s13063-021-05083-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 01/29/2021] [Indexed: 11/28/2022] Open
Abstract
Background International guidelines recommend either intravenous immunoglobulin (IVIg) or corticosteroids as first-line treatment for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). IVIg treatment usually leads to rapid improvement and is generally safe, but does not seem to lead to long-term remissions. Corticosteroids act more slowly and are associated with more side effects, but may induce long-term remissions. The hypothesis of this study is that combined IVIg and corticosteroid induction treatment will lead to more frequent long-term remissions than IVIg treatment alone. Methods An international, randomised, double-blind, placebo-controlled trial, in adults with ‘probable’ or ‘definite’ CIDP according to the EFNS/PNS 2010 criteria. Three groups of patients are included: (1) treatment naïve, (2) known CIDP patients with a relapse after > 1 year without treatment, and (3) patients with CIDP who improved within 3 months after a single course of IVIg, who subsequently deteriorate at any interval without having received additional treatment. Patients are randomised to receive 7 courses of IVIg and 1000 mg intravenous methylprednisolone (IVMP) (in sodium chloride 0.9%) or IVIg and placebo (sodium chloride 0.9%), every 3 weeks for 18 weeks. IVIg treatment consists of a loading dose of 2 g/kg (over 3–5 days) followed by 6 courses of IVIg 1/g/kg (over 1–2 days). The primary outcome is remission at 1 year, defined as improvement in disability from baseline, sustained between week 18 and week 52 without further treatment. Secondary outcomes include changes in disability, impairment, pain, fatigue, quality of life, care use and costs and (long-term) safety. Discussion In case of superiority of the combined treatment, patients will experience the advantages of two proven efficacious treatments, namely rapid improvement due to IVIg and long-term remission due to corticosteroids. Long-term remission would reduce the need for maintenance IVIg treatment and may decrease health care costs. Additionally, we expect that the combined treatment leads to a higher proportion of patients with improvement as some patients who do not respond to IVIg will respond to corticosteroids. Risks of short and long-term additional adverse events of the combined treatment need to be assessed. Trial registration ISRCTN registry ISRCTN15893334. Prospectively registered on 12 February 2018.
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Affiliation(s)
- S R M Bus
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - L Zambreanu
- Department of Neurology, National Hospital for Neurology and Neurosurgery, Centre for Neuromuscular Disease, London, UK
| | - A Abbas
- Department of Neurology, University Hospitals of Birmingham, Regional Neuromuscular Service, Birmingham, UK
| | - Y A Rajabally
- Department of Neurology, University Hospitals of Birmingham, Regional Neuromuscular Service, Birmingham, UK
| | - R D M Hadden
- Department of Neurology, King's College Hospital, London, UK
| | - R J de Haan
- Clinical Research Unit, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - C A J M de Borgie
- Clinical Research Unit, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - M P Lunn
- Department of Neurology, National Hospital for Neurology and Neurosurgery, Centre for Neuromuscular Disease, London, UK
| | - I N van Schaik
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Spaarne Gasthuis, Haarlem, the Netherlands
| | - F Eftimov
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
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25
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Allen JA, Pasnoor M, Dimachkie MM, Ajroud-Driss S, Brannagan TH, Cook AA, Walton T, Fiecas MB, Kissel JT, Merkies I, Gorson KC, Lewis RA. Quantifying Treatment-Related Fluctuations in CIDP: Results of the GRIPPER Study. Neurology 2021; 96:e1876-e1886. [PMID: 33593867 DOI: 10.1212/wnl.0000000000011703] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 01/04/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE The objective of this study was to explore the extent of IV immunoglobulin (IVIG) treatment-related fluctuations (TRFs) by using home collection of daily grip strength in patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and to use that information to develop evidence-based treatment optimization strategies. METHODS This prospective observational study included 25 patients with well-defined CIDP. Participants recorded grip strength daily for 6 months. Disability and gait metrics were collected weekly. Serum immunoglobulin G levels were obtained at peak, trough, and midcycle IVIG intervals. Day-to-day grip strength changes <10% were considered random. To identify patients with TRFs, 3-day averaged grip strength was calculated on each consecutive day after an IVIG infusion. TRFs were defined as ≥10% 3-day averaged grip strength difference compared to the pre-IVIG baseline. RESULTS Participants successfully recorded grip strength on all but 9% of recordable days. Twelve patients (48%) were classified as low/no fluctuaters and 13 (52%) as frequent fluctuaters. In the frequent fluctuating group, grip strength improved over 1 week and thereafter was relatively stable until the third week after infusion. Grip strength was significantly correlated with measures of disability. CONCLUSIONS Grip strength collection by patients at home is reliable, valid, and feasible. A change in grip strength by ≥10% is a useful, practical, and evidence-based approach that may be used to identify clinically meaningful TRFs. From these data, we propose a treatment optimization strategy for patients with CIDP on chronic IVIG that may be applied to routine clinic care during both face-to-face and virtual video or telephone patient encounters. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov Identifier: NCT02414490.
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Affiliation(s)
- Jeffrey A Allen
- From the Department of Neurology (J.A.A.), and School of Public Heath (M.B.F.), Division of Biostatistics, University of Minnesota, Minneapolis; Department of Neurology (M.P., M.M.D.), University of Kansas Medical Center, Kansas City; Department of Neurology (S.A.-D.), Northwestern University, Chicago, IL; Department of Neurology (T.H.B.), Columbia University Medical Center, New York, NY; Neurology at Johns Creek (A.A.C.), LLC, Atlanta, GA; BriovaRx (T.W.), Lenexa, KS; Department of Neurology (J.T.K.), Ohio State University, Columbus; Department of Neurology (I.M.), Maastricht University Medical Centre+; Curaçao Medical Center (I.M.), Willemstad, the Netherlands; Department of Neurology (K.C.G.), St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA; and Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Mamatha Pasnoor
- From the Department of Neurology (J.A.A.), and School of Public Heath (M.B.F.), Division of Biostatistics, University of Minnesota, Minneapolis; Department of Neurology (M.P., M.M.D.), University of Kansas Medical Center, Kansas City; Department of Neurology (S.A.-D.), Northwestern University, Chicago, IL; Department of Neurology (T.H.B.), Columbia University Medical Center, New York, NY; Neurology at Johns Creek (A.A.C.), LLC, Atlanta, GA; BriovaRx (T.W.), Lenexa, KS; Department of Neurology (J.T.K.), Ohio State University, Columbus; Department of Neurology (I.M.), Maastricht University Medical Centre+; Curaçao Medical Center (I.M.), Willemstad, the Netherlands; Department of Neurology (K.C.G.), St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA; and Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Mazen M Dimachkie
- From the Department of Neurology (J.A.A.), and School of Public Heath (M.B.F.), Division of Biostatistics, University of Minnesota, Minneapolis; Department of Neurology (M.P., M.M.D.), University of Kansas Medical Center, Kansas City; Department of Neurology (S.A.-D.), Northwestern University, Chicago, IL; Department of Neurology (T.H.B.), Columbia University Medical Center, New York, NY; Neurology at Johns Creek (A.A.C.), LLC, Atlanta, GA; BriovaRx (T.W.), Lenexa, KS; Department of Neurology (J.T.K.), Ohio State University, Columbus; Department of Neurology (I.M.), Maastricht University Medical Centre+; Curaçao Medical Center (I.M.), Willemstad, the Netherlands; Department of Neurology (K.C.G.), St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA; and Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Senda Ajroud-Driss
- From the Department of Neurology (J.A.A.), and School of Public Heath (M.B.F.), Division of Biostatistics, University of Minnesota, Minneapolis; Department of Neurology (M.P., M.M.D.), University of Kansas Medical Center, Kansas City; Department of Neurology (S.A.-D.), Northwestern University, Chicago, IL; Department of Neurology (T.H.B.), Columbia University Medical Center, New York, NY; Neurology at Johns Creek (A.A.C.), LLC, Atlanta, GA; BriovaRx (T.W.), Lenexa, KS; Department of Neurology (J.T.K.), Ohio State University, Columbus; Department of Neurology (I.M.), Maastricht University Medical Centre+; Curaçao Medical Center (I.M.), Willemstad, the Netherlands; Department of Neurology (K.C.G.), St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA; and Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Thomas H Brannagan
- From the Department of Neurology (J.A.A.), and School of Public Heath (M.B.F.), Division of Biostatistics, University of Minnesota, Minneapolis; Department of Neurology (M.P., M.M.D.), University of Kansas Medical Center, Kansas City; Department of Neurology (S.A.-D.), Northwestern University, Chicago, IL; Department of Neurology (T.H.B.), Columbia University Medical Center, New York, NY; Neurology at Johns Creek (A.A.C.), LLC, Atlanta, GA; BriovaRx (T.W.), Lenexa, KS; Department of Neurology (J.T.K.), Ohio State University, Columbus; Department of Neurology (I.M.), Maastricht University Medical Centre+; Curaçao Medical Center (I.M.), Willemstad, the Netherlands; Department of Neurology (K.C.G.), St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA; and Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Albert A Cook
- From the Department of Neurology (J.A.A.), and School of Public Heath (M.B.F.), Division of Biostatistics, University of Minnesota, Minneapolis; Department of Neurology (M.P., M.M.D.), University of Kansas Medical Center, Kansas City; Department of Neurology (S.A.-D.), Northwestern University, Chicago, IL; Department of Neurology (T.H.B.), Columbia University Medical Center, New York, NY; Neurology at Johns Creek (A.A.C.), LLC, Atlanta, GA; BriovaRx (T.W.), Lenexa, KS; Department of Neurology (J.T.K.), Ohio State University, Columbus; Department of Neurology (I.M.), Maastricht University Medical Centre+; Curaçao Medical Center (I.M.), Willemstad, the Netherlands; Department of Neurology (K.C.G.), St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA; and Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Timothy Walton
- From the Department of Neurology (J.A.A.), and School of Public Heath (M.B.F.), Division of Biostatistics, University of Minnesota, Minneapolis; Department of Neurology (M.P., M.M.D.), University of Kansas Medical Center, Kansas City; Department of Neurology (S.A.-D.), Northwestern University, Chicago, IL; Department of Neurology (T.H.B.), Columbia University Medical Center, New York, NY; Neurology at Johns Creek (A.A.C.), LLC, Atlanta, GA; BriovaRx (T.W.), Lenexa, KS; Department of Neurology (J.T.K.), Ohio State University, Columbus; Department of Neurology (I.M.), Maastricht University Medical Centre+; Curaçao Medical Center (I.M.), Willemstad, the Netherlands; Department of Neurology (K.C.G.), St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA; and Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Mark B Fiecas
- From the Department of Neurology (J.A.A.), and School of Public Heath (M.B.F.), Division of Biostatistics, University of Minnesota, Minneapolis; Department of Neurology (M.P., M.M.D.), University of Kansas Medical Center, Kansas City; Department of Neurology (S.A.-D.), Northwestern University, Chicago, IL; Department of Neurology (T.H.B.), Columbia University Medical Center, New York, NY; Neurology at Johns Creek (A.A.C.), LLC, Atlanta, GA; BriovaRx (T.W.), Lenexa, KS; Department of Neurology (J.T.K.), Ohio State University, Columbus; Department of Neurology (I.M.), Maastricht University Medical Centre+; Curaçao Medical Center (I.M.), Willemstad, the Netherlands; Department of Neurology (K.C.G.), St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA; and Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - John T Kissel
- From the Department of Neurology (J.A.A.), and School of Public Heath (M.B.F.), Division of Biostatistics, University of Minnesota, Minneapolis; Department of Neurology (M.P., M.M.D.), University of Kansas Medical Center, Kansas City; Department of Neurology (S.A.-D.), Northwestern University, Chicago, IL; Department of Neurology (T.H.B.), Columbia University Medical Center, New York, NY; Neurology at Johns Creek (A.A.C.), LLC, Atlanta, GA; BriovaRx (T.W.), Lenexa, KS; Department of Neurology (J.T.K.), Ohio State University, Columbus; Department of Neurology (I.M.), Maastricht University Medical Centre+; Curaçao Medical Center (I.M.), Willemstad, the Netherlands; Department of Neurology (K.C.G.), St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA; and Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Ingemar Merkies
- From the Department of Neurology (J.A.A.), and School of Public Heath (M.B.F.), Division of Biostatistics, University of Minnesota, Minneapolis; Department of Neurology (M.P., M.M.D.), University of Kansas Medical Center, Kansas City; Department of Neurology (S.A.-D.), Northwestern University, Chicago, IL; Department of Neurology (T.H.B.), Columbia University Medical Center, New York, NY; Neurology at Johns Creek (A.A.C.), LLC, Atlanta, GA; BriovaRx (T.W.), Lenexa, KS; Department of Neurology (J.T.K.), Ohio State University, Columbus; Department of Neurology (I.M.), Maastricht University Medical Centre+; Curaçao Medical Center (I.M.), Willemstad, the Netherlands; Department of Neurology (K.C.G.), St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA; and Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Kenneth C Gorson
- From the Department of Neurology (J.A.A.), and School of Public Heath (M.B.F.), Division of Biostatistics, University of Minnesota, Minneapolis; Department of Neurology (M.P., M.M.D.), University of Kansas Medical Center, Kansas City; Department of Neurology (S.A.-D.), Northwestern University, Chicago, IL; Department of Neurology (T.H.B.), Columbia University Medical Center, New York, NY; Neurology at Johns Creek (A.A.C.), LLC, Atlanta, GA; BriovaRx (T.W.), Lenexa, KS; Department of Neurology (J.T.K.), Ohio State University, Columbus; Department of Neurology (I.M.), Maastricht University Medical Centre+; Curaçao Medical Center (I.M.), Willemstad, the Netherlands; Department of Neurology (K.C.G.), St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA; and Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Richard A Lewis
- From the Department of Neurology (J.A.A.), and School of Public Heath (M.B.F.), Division of Biostatistics, University of Minnesota, Minneapolis; Department of Neurology (M.P., M.M.D.), University of Kansas Medical Center, Kansas City; Department of Neurology (S.A.-D.), Northwestern University, Chicago, IL; Department of Neurology (T.H.B.), Columbia University Medical Center, New York, NY; Neurology at Johns Creek (A.A.C.), LLC, Atlanta, GA; BriovaRx (T.W.), Lenexa, KS; Department of Neurology (J.T.K.), Ohio State University, Columbus; Department of Neurology (I.M.), Maastricht University Medical Centre+; Curaçao Medical Center (I.M.), Willemstad, the Netherlands; Department of Neurology (K.C.G.), St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA; and Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA
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26
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Fisse AL, Motte J, Grüter T, Sgodzai M, Pitarokoili K, Gold R. Comprehensive approaches for diagnosis, monitoring and treatment of chronic inflammatory demyelinating polyneuropathy. Neurol Res Pract 2020; 2:42. [PMID: 33324942 PMCID: PMC7722337 DOI: 10.1186/s42466-020-00088-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 09/04/2020] [Indexed: 02/08/2023] Open
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is the most common chronic inflammatory neuropathy. CIDP is diagnosed according to the European Federation of Neurological Societies/Peripheral Nerve Society (EFNS/PNS) criteria, which combine clinical features with the electrophysiological evidence of demyelination. However, firstly, diagnosis is challenging, as some patients e.g. with severe early axonal damage do not fulfil the criteria. Secondly, objective and reliable tools to monitor the disease course are lacking. Thirdly, about 25% of CIDP patients do not respond to evidence-based first-line therapy. Recognition of these patients is difficult and treatment beyond first-line therapy is based on observational studies and case series only. Individualized immunomodulatory treatment does not exist due to the lack of understanding of essential aspects of the underlying pathophysiology. Novel diagnostic imaging techniques and molecular approaches can help to solve these problems but do not find enough implementation. This review gives a comprehensive overview of novel diagnostic techniques and monitoring approaches for CIDP and how these can lead to individualized treatment and better understanding of pathophysiology.
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Affiliation(s)
- Anna Lena Fisse
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Jeremias Motte
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Thomas Grüter
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Melissa Sgodzai
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Kalliopi Pitarokoili
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
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27
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Kuitwaard K, Brusse E, Jacobs BC, Vrancken AFJE, Eftimov F, Notermans NC, van der Kooi AJ, Fokkink WJR, Nieboer D, Lingsma HF, Merkies ISJ, van Doorn PA. Randomized trial of intravenous immunoglobulin maintenance treatment regimens in chronic inflammatory demyelinating polyradiculoneuropathy. Eur J Neurol 2020; 28:286-296. [PMID: 32876962 PMCID: PMC7820989 DOI: 10.1111/ene.14501] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 08/26/2020] [Indexed: 12/28/2022]
Abstract
Background and purpose High peak serum immunoglobulin G (IgG) levels may not be needed for maintenance intravenous immunoglobulin (IVIg) treatment in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and such high levels may cause side effects. More frequent lower dosing may lead to more stable IgG levels and higher trough levels, which might improve efficacy. The aim of this trial is to investigate whether high frequent low dosage IVIg treatment is more effective than low frequent high dosage IVIg treatment. Methods In this randomized placebo‐controlled crossover trial, we included patients with CIDP proven to be IVIg‐dependent and receiving an individually established stable dose and interval of IVIg maintenance treatment. In the control arm, patients received their individual IVIg dose and interval followed by a placebo infusion at half the interval. In the intervention arm, patients received half their individual dose at half the interval. After a wash‐out phase patients crossed over. The primary outcome measure was handgrip strength (assessed using a Martin Vigorimeter). Secondary outcome indicators were health‐related quality of life (36‐item Short‐Form Health Survey), disability (Inflammatory Rasch‐built Overall Disability Scale), fatigue (Rasch‐built Fatigue Severity Scale) and side effects. Results Twenty‐five patients were included and were treated at baseline with individually adjusted dosages of IVIg ranging from 20 to 80 g and intervals ranging from 14 to 35 days. Three participants did not complete the trial; the main analysis was therefore based on the 22 patients completing both treatment periods. There was no significant difference in handgrip strength change from baseline between the two treatment regimens (coefficient −2.71, 95% CI −5.4, 0.01). Furthermore, there were no significant differences in any of the secondary outcomes or side effects. Conclusions More frequent lower dosing does not further improve the efficacy of IVIg in stable IVIg‐dependent CIDP and does not result in fewer side effects.
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Affiliation(s)
- K Kuitwaard
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands.,Department of Neurology, Albert Schweitzer hospital, Dordrecht, The Netherlands
| | - E Brusse
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - B C Jacobs
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands.,Department of Immunology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - A F J E Vrancken
- Department of Neurology, Brain Centre Rudolf Magnus University Medical Centre Utrecht, Utrecht, The Netherlands
| | - F Eftimov
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - N C Notermans
- Department of Neurology, Brain Centre Rudolf Magnus University Medical Centre Utrecht, Utrecht, The Netherlands
| | - A J van der Kooi
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - W-J R Fokkink
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands.,Department of Immunology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - D Nieboer
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - H F Lingsma
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - I S J Merkies
- Department of Neurology, Curaçao Medical Centre Willemstad, Willemstad, Curaçao.,Department of Neurology, School of Medical Health and Neuroscience, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - P A van Doorn
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
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28
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Doneddu PE, Mandia D, Gentile F, Gallia F, Liberatore G, Terenghi F, Ruiz M, Nobile-Orazio E. Home monitoring of maintenance intravenous immunoglobulin therapy in patients with chronic inflammatory neuropathy. J Peripher Nerv Syst 2020; 25:238-246. [PMID: 32470190 DOI: 10.1111/jns.12396] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/20/2020] [Accepted: 05/21/2020] [Indexed: 11/30/2022]
Abstract
To evaluate the utility of different outcome measures to monitor dose adjustment of intravenous immunoglobulin (IVIg) therapy in patients with chronic inflammatory neuropathy (CIN). We assessed the adjustment of IVIg maintenance therapy in 20 patients (10 CIDP and 10 MMN) by regularly monitoring grip strength (GS) using a Martin Vigorimeter, RODS, and quality of life using the SF-36 questionnaire. These measures were regularly performed by the patient at home. We also assessed the extended MRC sumscore (eMRC sumscore) at each outpatient visit for IVIg infusion. We also enrolled 30 healthy controls to measure any possible training effect of GS with time and to analyze random fluctuation of GS. Clinically relevant change was detected by eMRC sumscore in 14 (93%) patients, by RODS in 11 (73%) patients, and by GS in 8 (53%) patients. Early sensitivity was greatest for RODS (73%), followed by GS (53%), and eMRC sumscore (27%). This differed from CIDP, with an early change in RODS in 100% of patients, and MMN with an early change in GS in 75%. None of the outcome measures alone was sufficient to detect clinically significant changes in all patients. Home monitoring of outcome measures objectively assisted clinical decision during individualization of IVIg treatment. We recommend a multimodal approach using different outcome measures to monitor the individual patient with CIN.
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Affiliation(s)
| | | | | | | | | | | | - Marta Ruiz
- Humanitas Clinical and Research Institute, Milan, Italy
| | - Eduardo Nobile-Orazio
- Humanitas Clinical and Research Institute, Milan, Italy.,Department of Medical Biotechnology and Translational Medicine, Milan University, Milan, Italy
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29
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Doneddu PE, Hadden RDM. Daily grip strength response to intravenous immunoglobulin in chronic immune neuropathies. Muscle Nerve 2020; 62:103-110. [PMID: 32319099 DOI: 10.1002/mus.26898] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 04/14/2020] [Accepted: 04/16/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Monitoring grip strength at home may detect improvement between intravenous immunoglobulin (IVIg) treatments in patients with chronic inflammatory neuropathies (CINs). METHODS Fifteen patients recorded grip strength each day, from one IVIg treatment until the next. We analyzed grip strength changes comparing thresholds of 8 kPa and 14 kPa. "Random" fluctuations of grip strength were distinguished from treatment response by smoothing the data. RESULTS "Random" fluctuations of at least 8 kPa occurred in 27% of patients. Smoothed daily grip strength increased by at least 8 kPa above baseline in 11 (73%) patients. Grip strength increased by at least 8 kPa for 3 consecutive days in 9 (60%) patients, and 5-day block mean increased by at least 8 kPa in 10 (67%) patients. DISCUSSION Home monitoring of grip strength confirmed treatment response in most patients with CINs on IVIg. To detect improvement in an individual patient, we suggest a threshold of at least 8 kPa on 3 consecutive days or on 5-day block mean.
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Affiliation(s)
- Pietro E Doneddu
- Department of Neurology, King's College Hospital, King's College London, London, UK
| | - Robert D M Hadden
- Department of Neurology, King's College Hospital, King's College London, London, UK
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30
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Herraets IJT, Goedee HS, Telleman JA, van Eijk RPA, van Asseldonk JT, Visser LH, van den Berg LH, van der Pol WL. Nerve ultrasound improves detection of treatment-responsive chronic inflammatory neuropathies. Neurology 2020; 94:e1470-e1479. [PMID: 31959710 DOI: 10.1212/wnl.0000000000008978] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 11/07/2019] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To examine the diagnostic accuracy of nerve ultrasound in a prospective cohort of consecutive patients with a clinical suspicion of chronic inflammatory neuropathies, including chronic inflammatory demyelinating polyneuropathy, Lewis-Sumner syndrome, and multifocal motor neuropathy, and to determine the added value in the detection of treatment-responsive patients. METHODS Between February 2015 and July 2018, we included 100 consecutive incident patients with a clinical suspicion of chronic inflammatory neuropathy. All patients underwent nerve ultrasound, extensive standardized nerve conduction studies (NCS), and other relevant diagnostic investigations. We evaluated treatment response using predefined criteria. A diagnosis of chronic inflammatory neuropathy was established when NCS were abnormal (fulfilling criteria of demyelination of the European Federation of Neurological Societies/Peripheral Nerve Society) or when the degree of nerve enlargement detected by sonography was compatible with chronic inflammatory neuropathy and there was response to treatment. RESULTS A diagnosis of chronic inflammatory neuropathy was established in 38 patients. Sensitivity and specificity of nerve ultrasound and NCS were 97.4% and 69.4% and 78.9% and 93.5%, respectively. The added value of nerve ultrasound in detection of treatment-responsive chronic inflammatory neuropathy was 21.1% compared to NCS alone. CONCLUSIONS Nerve ultrasound and NCS are complementary techniques with superior sensitivity in the former and specificity in the latter. Addition of nerve ultrasound significantly improves the detection of chronic inflammatory neuropathies. Therefore, it deserves a prominent place in the diagnostic workup of chronic inflammatory neuropathies. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that nerve ultrasound is an accurate diagnostic tool to detect chronic inflammatory neuropathies.
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Affiliation(s)
- Ingrid J T Herraets
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - H Stephan Goedee
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Johan A Telleman
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Ruben P A van Eijk
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - J Thies van Asseldonk
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Leo H Visser
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Leonard H van den Berg
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - W Ludo van der Pol
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands.
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31
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Adrichem ME, Bus SR, Wieske L, Mohammed H, Verhamme C, Hadden R, van Schaik IN, Eftimov F. Combined intravenous immunoglobulin and methylprednisolone as induction treatment in chronic inflammatory demyelinating polyneuropathy (OPTIC protocol): a prospective pilot study. Eur J Neurol 2019; 27:506-513. [PMID: 31571349 PMCID: PMC7028131 DOI: 10.1111/ene.14096] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 09/27/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE We hypothesized that combining intravenous immunoglobulin (IVIg) and intravenous methylprednisolone (IVMP) leads to more frequent remission compared with IVIg alone while maintaining the fast efficacy of IVIg. In this uncontrolled pilot study, we evaluated remission, rate of improvement and safety in patients with chronic inflammatory demyelinating polyradiculoneuropathy receiving induction treatment with combined IVIg and IVMP. METHODS Consecutive treatment-naive patients with chronic inflammatory demyelinating polyradiculoneuropathy were treated with IVIg infusions, consisting of a 2 g/kg loading dose and 1 g/kg maintenance treatment every 3 weeks, combined with 3-weekly 1-g IVMP infusions, for a total of 18 weeks. The cumulative steroid dose was 7 g. Primary outcome was remission at 1 year in patients who completed the treatment schedule. Remission was defined as improvement at 18 weeks without the need for further immune treatment between end of the treatment schedule and 1-year follow-up. Improvement was defined as a minimal clinically important difference on the Inflammatory Rasch-Built Overall Disability Scale and/or an increase of ≥8 kPa in grip strength between baseline and week 18. RESULTS A total of 20 patients were included; 17 completed the treatment schedule. A total of 13 (76%) of these patients improved at 18 weeks after start of treatment and 10 (59%) patients were in remission at 1 year. Serious adverse events were found in four patients. CONCLUSIONS Short-term combined induction treatment with IVIg and IVMP induced remission in almost 60% of patients who completed the treatment schedule. Combined induction therapy was generally well tolerated. A randomized controlled trial is currently running to confirm efficacy and safety of IVMP as add-on treatment to IVIg.
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Affiliation(s)
- M E Adrichem
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - S R Bus
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - L Wieske
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - H Mohammed
- Department of Neurology, Maidstone Hospital, Maidstone, Kent, UK
| | - C Verhamme
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - R Hadden
- Department of Neurology, Maidstone Hospital, Maidstone, Kent, UK
| | - I N van Schaik
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - F Eftimov
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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32
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van Schaik IN, Mielke O, Bril V, van Geloven N, Hartung HP, Lewis RA, Sobue G, Lawo JP, Praus M, Durn BL, Cornblath DR, Merkies ISJ. Long-term safety and efficacy of subcutaneous immunoglobulin IgPro20 in CIDP: PATH extension study. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 6:e590. [PMID: 31355323 PMCID: PMC6624149 DOI: 10.1212/nxi.0000000000000590] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 05/16/2019] [Indexed: 11/18/2022]
Abstract
Objective To investigate the long-term safety and efficacy of weekly subcutaneous IgPro20 (Hizentra, CSL Behring) in chronic inflammatory demyelinating polyneuropathy (CIDP). Methods In a 48-week open-label prospective extension study to the PATH study, patients were initially started on 0.2 g/kg or on 0.4 g/kg weekly and-if clinically stable-switched to 0.2 g/kg weekly after 24 weeks. Upon CIDP relapse on the 0.2 g/kg dose, 0.4 g/kg was (re)initiated. CIDP relapse was defined as a deterioration by at least 1 point in the total adjusted Inflammatory Neuropathy Cause and Treatment score. Results Eighty-two patients were enrolled. Sixty-two patients initially received 0.4 g/kg, 20 patients 0.2 g/kg weekly. Seventy-two received both doses during the study. Sixty-six patients (81%) completed the 48-week study duration. Overall relapse rates were 10% in 0.4 g/kg-treated patients and 48% in 0.2 g/kg-treated patients. After dose reduction from 0.4 to 0.2 g/kg, 51% (27/53) of patients relapsed, of whom 92% (24 of 26) improved after reinitiation of the 0.4 g/kg dose. Two-thirds of patients (19/28) who completed the PATH study without relapse remained relapse-free on the 0.2 g/kg dose after dose reduction in the extension study. Sixty-two patients had adverse events (AEs) (76%), of which most were mild or moderate with no related serious AEs. Conclusions Subcutaneous treatment with IgPro20 provided long-term benefit at both 0.4 and 0.2 g/kg weekly doses with lower relapse rates on the higher dose. Long-term dosing should be individualized to find the most appropriate dose in a given patient. Classification of evidence This study provides Class IV evidence that for patients with CIDP, long-term treatment with SCIG beyond 24 weeks is safe and efficacious.
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Affiliation(s)
- Ivo N van Schaik
- Department of Neurology (I.N.S.), Amsterdam University Medical Centers, University of Amsterdam, The Netherlands; Spaarne Gasthuis (I.N.S.), Haarlem, The Netherlands; CSL Behring (O.M., M.P., B.L.D.), Marburg, Germany and King of Prussia, PA; Department of Medicine (Neurology) (V.B.), University Health Network, University of Toronto, Canada; Medical Statistics (N.G.), Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (G.S.), Nagoya University Graduate School of Medicine, Japan; Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (I.S.J.M.), Maastricht University Medical Center, The Netherlands
| | - Orell Mielke
- Department of Neurology (I.N.S.), Amsterdam University Medical Centers, University of Amsterdam, The Netherlands; Spaarne Gasthuis (I.N.S.), Haarlem, The Netherlands; CSL Behring (O.M., M.P., B.L.D.), Marburg, Germany and King of Prussia, PA; Department of Medicine (Neurology) (V.B.), University Health Network, University of Toronto, Canada; Medical Statistics (N.G.), Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (G.S.), Nagoya University Graduate School of Medicine, Japan; Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (I.S.J.M.), Maastricht University Medical Center, The Netherlands
| | - Vera Bril
- Department of Neurology (I.N.S.), Amsterdam University Medical Centers, University of Amsterdam, The Netherlands; Spaarne Gasthuis (I.N.S.), Haarlem, The Netherlands; CSL Behring (O.M., M.P., B.L.D.), Marburg, Germany and King of Prussia, PA; Department of Medicine (Neurology) (V.B.), University Health Network, University of Toronto, Canada; Medical Statistics (N.G.), Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (G.S.), Nagoya University Graduate School of Medicine, Japan; Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (I.S.J.M.), Maastricht University Medical Center, The Netherlands
| | - Nan van Geloven
- Department of Neurology (I.N.S.), Amsterdam University Medical Centers, University of Amsterdam, The Netherlands; Spaarne Gasthuis (I.N.S.), Haarlem, The Netherlands; CSL Behring (O.M., M.P., B.L.D.), Marburg, Germany and King of Prussia, PA; Department of Medicine (Neurology) (V.B.), University Health Network, University of Toronto, Canada; Medical Statistics (N.G.), Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (G.S.), Nagoya University Graduate School of Medicine, Japan; Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (I.S.J.M.), Maastricht University Medical Center, The Netherlands
| | - Hans-Peter Hartung
- Department of Neurology (I.N.S.), Amsterdam University Medical Centers, University of Amsterdam, The Netherlands; Spaarne Gasthuis (I.N.S.), Haarlem, The Netherlands; CSL Behring (O.M., M.P., B.L.D.), Marburg, Germany and King of Prussia, PA; Department of Medicine (Neurology) (V.B.), University Health Network, University of Toronto, Canada; Medical Statistics (N.G.), Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (G.S.), Nagoya University Graduate School of Medicine, Japan; Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (I.S.J.M.), Maastricht University Medical Center, The Netherlands
| | - Richard A Lewis
- Department of Neurology (I.N.S.), Amsterdam University Medical Centers, University of Amsterdam, The Netherlands; Spaarne Gasthuis (I.N.S.), Haarlem, The Netherlands; CSL Behring (O.M., M.P., B.L.D.), Marburg, Germany and King of Prussia, PA; Department of Medicine (Neurology) (V.B.), University Health Network, University of Toronto, Canada; Medical Statistics (N.G.), Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (G.S.), Nagoya University Graduate School of Medicine, Japan; Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (I.S.J.M.), Maastricht University Medical Center, The Netherlands
| | - Gen Sobue
- Department of Neurology (I.N.S.), Amsterdam University Medical Centers, University of Amsterdam, The Netherlands; Spaarne Gasthuis (I.N.S.), Haarlem, The Netherlands; CSL Behring (O.M., M.P., B.L.D.), Marburg, Germany and King of Prussia, PA; Department of Medicine (Neurology) (V.B.), University Health Network, University of Toronto, Canada; Medical Statistics (N.G.), Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (G.S.), Nagoya University Graduate School of Medicine, Japan; Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (I.S.J.M.), Maastricht University Medical Center, The Netherlands
| | - John-Philip Lawo
- Department of Neurology (I.N.S.), Amsterdam University Medical Centers, University of Amsterdam, The Netherlands; Spaarne Gasthuis (I.N.S.), Haarlem, The Netherlands; CSL Behring (O.M., M.P., B.L.D.), Marburg, Germany and King of Prussia, PA; Department of Medicine (Neurology) (V.B.), University Health Network, University of Toronto, Canada; Medical Statistics (N.G.), Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (G.S.), Nagoya University Graduate School of Medicine, Japan; Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (I.S.J.M.), Maastricht University Medical Center, The Netherlands
| | - Michaela Praus
- Department of Neurology (I.N.S.), Amsterdam University Medical Centers, University of Amsterdam, The Netherlands; Spaarne Gasthuis (I.N.S.), Haarlem, The Netherlands; CSL Behring (O.M., M.P., B.L.D.), Marburg, Germany and King of Prussia, PA; Department of Medicine (Neurology) (V.B.), University Health Network, University of Toronto, Canada; Medical Statistics (N.G.), Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (G.S.), Nagoya University Graduate School of Medicine, Japan; Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (I.S.J.M.), Maastricht University Medical Center, The Netherlands
| | - Billie L Durn
- Department of Neurology (I.N.S.), Amsterdam University Medical Centers, University of Amsterdam, The Netherlands; Spaarne Gasthuis (I.N.S.), Haarlem, The Netherlands; CSL Behring (O.M., M.P., B.L.D.), Marburg, Germany and King of Prussia, PA; Department of Medicine (Neurology) (V.B.), University Health Network, University of Toronto, Canada; Medical Statistics (N.G.), Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (G.S.), Nagoya University Graduate School of Medicine, Japan; Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (I.S.J.M.), Maastricht University Medical Center, The Netherlands
| | - David R Cornblath
- Department of Neurology (I.N.S.), Amsterdam University Medical Centers, University of Amsterdam, The Netherlands; Spaarne Gasthuis (I.N.S.), Haarlem, The Netherlands; CSL Behring (O.M., M.P., B.L.D.), Marburg, Germany and King of Prussia, PA; Department of Medicine (Neurology) (V.B.), University Health Network, University of Toronto, Canada; Medical Statistics (N.G.), Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (G.S.), Nagoya University Graduate School of Medicine, Japan; Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (I.S.J.M.), Maastricht University Medical Center, The Netherlands
| | - Ingemar S J Merkies
- Department of Neurology (I.N.S.), Amsterdam University Medical Centers, University of Amsterdam, The Netherlands; Spaarne Gasthuis (I.N.S.), Haarlem, The Netherlands; CSL Behring (O.M., M.P., B.L.D.), Marburg, Germany and King of Prussia, PA; Department of Medicine (Neurology) (V.B.), University Health Network, University of Toronto, Canada; Medical Statistics (N.G.), Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands; Department of Neurology (H.-P.H.), Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (R.A.L.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (G.S.), Nagoya University Graduate School of Medicine, Japan; Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (I.S.J.M.), Maastricht University Medical Center, The Netherlands
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Quantitative grip force assessment of muscular weakness in chronic inflammatory demyelinating polyneuropathy. BMC Neurol 2019; 19:118. [PMID: 31176377 PMCID: PMC6556046 DOI: 10.1186/s12883-019-1339-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 05/22/2019] [Indexed: 11/10/2022] Open
Abstract
Background In patients suffering from Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) disease severity is assessed by Medical Research Counsil (MRC) Scale or Inflammatory Neuropathy Cause and Treatment (INCAT) disability score. However, none of these methods is appropriate to objectively assess muscle weakness or to detect very small subclinical changes. More objective and quantitative measures are needed in order to evaluate treatment efficiency or to detect subclinical affection of upper limps for early diagnosis. The goal of our study was to objectively quantify muscular weakness in CIDP patients with the non-invasive Quantitative Motor (Q-Motor) test of Grip Force Assessment (QGFA) as well as the Involuntary Movement Assessment (QIMA) and to search for differences between typical and atypical CIDP variants. In addition, we hypothesized that Q-Motor findings correlate with disease severity scales such as MRC or INCAT score. Methods In this cross-sectional exploratory proof-of-concept study subjects with confirmed diagnosis of typical or atypical CIDP were examined and compared to healthy controls (HC). For Q-Motor tests all subjects had to lift a device (250 g and 500 g) equipped with an electromagnetic sensor that measured grip force (GF) and three-dimensional changes in position and orientation. The measures “grip force variability” (GFV), “position index” (PI) and “orientation index” (OI) were provided to assess involuntary movements due to muscular weakness. Results 33 patients with CIDP and 28 HC were included. All measures were significantly elevated in CIDP patients for both devices in the right and left hand compared to healthy controls. Subgroup analysis revealed no differences between typical and atypical CIDP variants. INCAT score only weakly correlated with OI and PI. However, there was a stronger correlation between MRC and QIMA parameters in both hands. Conclusion Q-Motor assessments were capable to objectively assess muscular weakness in CIDP. In particular, QIMA measures detected subclinical generalized muscle weakness even in patients with milder disability. Sensitivity and rater-independence of Q-Motor assessments support a further exploration of QIMA measures as potential endpoints for future clinical trials in CIDP.
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Mielke O, Bril V, Cornblath DR, Lawo JP, van Geloven N, Hartung HP, Lewis RA, Merkies ISJ, Sobue G, Durn B, Shebl A, van Schaik IN. Restabilization treatment after intravenous immunoglobulin withdrawal in chronic inflammatory demyelinating polyneuropathy: Results from the pre-randomization phase of the Polyneuropathy And Treatment with Hizentra study. J Peripher Nerv Syst 2019; 24:72-79. [PMID: 30672067 PMCID: PMC6593755 DOI: 10.1111/jns.12303] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/13/2018] [Accepted: 01/12/2019] [Indexed: 11/29/2022]
Abstract
In patients with chronic inflammatory demyelinating polyneuropathy (CIDP), intravenous immunoglobulin (IVIG) is recommended to be periodically reduced to assess the need for ongoing therapy. However, little is known about the effectiveness of restabilization with IVIG in patients who worsen after IVIG withdrawal. In the Polyneuropathy And Treatment with Hizentra (PATH) study, the pre‐randomization period included sudden stopping of IVIG followed by 12 weeks of observation. Those deteriorating were then restabilized with IVIG. Of 245 subjects who stopped IVIG, 28 did not show signs of clinical deterioration within 12 weeks. Two hundred and seven received IVIG restabilization with an induction dose of 2 g/kg bodyweight (bw) IgPro10 (Privigen, CSL Behring, King of Prussia, Pennsylvania) and maintenance doses of 1 g/kg bw every 3 weeks for up to 13 weeks. Signs of clinical improvement were seen in almost all (n = 188; 91%) subjects. During IVIG restabilization, 35 subjects either did not show CIDP stability (n = 21, analyzed as n = 22 as an additional subject was randomized in error) or withdrew for other reasons (n = 14). Of the 22 subjects who did not achieve clinical stability, follow‐up information in 16 subjects after an additional 4 weeks was obtained. Nine subjects were reported to have improved, leaving a maximum of 27 subjects (13%) who either showed no signs of clinical improvement during the restabilization phase and 4 weeks post‐study or withdrew for other reasons. In conclusion, sudden IVIG withdrawal was effective in detecting ongoing immunoglobulin G dependency with a small risk for subjects not returning to their baseline 17 weeks after withdrawal.
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Affiliation(s)
- Orell Mielke
- CSL Behring, Marburg, Germany, and King of Prussia, Pennsylvania
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada.,Institute for Research and Medical Consultations, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - David R Cornblath
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John-Philip Lawo
- CSL Behring, Marburg, Germany, and King of Prussia, Pennsylvania
| | - Nan van Geloven
- Medical Statistics, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Hans-Peter Hartung
- Department of Neurology, UKD and Center for Neurology and Neuropsychiatry, LVR Klinikum, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Richard A Lewis
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ingemar S J Merkies
- Department of Neurology, Maastricht University Medical Center, Maastricht, the Netherlands.,Department of Neurology, St Elisabeth Hospital, Willemstad, Curaçao
| | - Gen Sobue
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Billie Durn
- CSL Behring, Marburg, Germany, and King of Prussia, Pennsylvania
| | - Amgad Shebl
- CSL Behring, Marburg, Germany, and King of Prussia, Pennsylvania
| | - Ivo N van Schaik
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
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Bunschoten C, Eftimov F, van der Pol WL, Jacobs BC. International chronic inflammatory demyelinating polyneuropathy outcome study (ICOS): Protocol of a prospective observational cohort study on clinical and biological predictors of disease course and outcome. J Peripher Nerv Syst 2019; 24:34-38. [PMID: 30570196 DOI: 10.1111/jns.12296] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 12/14/2018] [Indexed: 12/29/2022]
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is a heterogeneous immune-mediated disorder with extensive variation in clinical presentation, electrophysiological phenotype, treatment response and long-term outcome. This heterogeneity may reflect the existence of distinct subtypes of CIDP with a different pathogenesis that require personalized treatment. The International CIDP Outcome Study (ICOS) is a prospective, observational, multicenter cohort study that aims to describe this variation and to define clinical and biological determinants and predictors of these subtypes, disease activity, treatment response and outcome. All patients fulfilling the European Federation of Neurological Societies/Peripheral Nerve Society 2010 diagnostic criteria for CIDP can participate, independent of age, duration and severity of the disease or treatment. We collect data on the clinical presentation, diagnostics, validated clinical outcome measures, (response to) treatment, and we collect biomaterials (DNA, cerebrospinal fluid and serial serum samples). We aim to include at least 1000 CIDP patients with a follow-up of at least 2 years. ICOS started in November 2015 in three academic medical centers in The Netherlands and by October 2018 169 patients are included: 69 new and 100 prevalent cases. ICOS is based on the format of the International Guillain-Barré syndrome (GBS) Outcome Study (IGOS). Dutch centers are invited to participate in ICOS that will continue as an independent national registry. International centers will be able to collect data and biomaterials according to the ICOS protocol by using the optional ICOS module within the INCbase infrastructure. ICOS will help to standardize the collection of data and biosamples for future research in CIDP.
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Affiliation(s)
- Carina Bunschoten
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Filip Eftimov
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - W-Ludo van der Pol
- Department of Neurology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bart C Jacobs
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Rajabally YA. Assessing the benefit of treatment in chronic inflammatory demyelinating polyneuropathy: the challenges of clinical practice. Neurodegener Dis Manag 2018; 8:285-288. [DOI: 10.2217/nmt-2018-0027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Yusuf A Rajabally
- Aston Brain Centre, School of Life & Health Sciences, Aston University, Birmingham, UK
- Regional Neuromuscular Clinic, University Hospitals Birmingham, Birmingham, UK
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Abstract
PURPOSE OF REVIEW This article reviews the chronic demyelinating neuropathies, with a focus on the diagnosis and treatment of immune-mediated neuropathies and the features that can help differentiate immune-mediated neuropathies from other chronic demyelinating peripheral nerve conditions. RECENT FINDINGS Advances in clinical phenotyping and outcomes assessment have enabled neurologists to improve disease recognition, treatment, and disease monitoring. Our understanding of the immunopathogenesis of demyelinating neuropathies is evolving. Identification of new antibodies and recognition that node of Ranvier dysfunction may be an early pathogenic feature may herald further diagnostic and treatment advancements. SUMMARY The chronic demyelinating polyneuropathies are heterogeneous. The clinical and diagnostic features are sometimes overlapping, and the specific disorders are variable in pathogenesis, treatment, and prognosis. This heterogeneity underscores the importance of achieving diagnostic accuracy and implementing disease-specific treatment approaches.
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Hughes R, Dalakas MC, Merkies I, Latov N, Léger JM, Nobile-Orazio E, Sobue G, Genge A, Cornblath D, Merschhemke M, Ervin CM, Agoropoulou C, Hartung HP, Day T, Spies J, Roberts L, Van Damme P, Van den Bergh PYK, Maertens de Noordhout A, Dionne A, Larue S, Massie R, Melanson M, Camu W, De Seze J, Le Masson G, Pouget J, Schmidt J, Kimiskidis VK, Chapman J, Drory VE, Fazio R, Gallia F, Kusunoki S, Mori M, Iijima M, Okamoto T, Baba M, Faber CG, van Schaik IN, Fryze W, Motta E, Selmaj K, Casasnovas C, Sola AG, Illa I, Holt J, Miller JAL, Lunn MP, Brannagan TH, Brown M, Kelemen J, Iyadurai S, Rezania K, Sharma KR, Tandan R, Gudesblatt M, Lawson V, Amato AA. Oral fingolimod for chronic inflammatory demyelinating polyradiculoneuropathy (FORCIDP Trial): a double-blind, multicentre, randomised controlled trial. Lancet Neurol 2018; 17:689-698. [DOI: 10.1016/s1474-4422(18)30202-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 05/01/2018] [Accepted: 05/14/2018] [Indexed: 12/17/2022]
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Knak KL, Andersen LK, Christiansen I, Markvardsen LK. Does grip strength reflect isokinetic muscle strength in lower limbs in patients with chronic inflammatory demyelinating polyneuropathy? Muscle Nerve 2018; 58:449-452. [PMID: 29603302 DOI: 10.1002/mus.26136] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2018] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Grip strength (GS) is a common measure of general muscle strength in patients with chronic inflammatory demyelinating polyneuropathy (CIDP). However, it is important to investigate the correlation and responsiveness of GS compared with isokinetic muscle strength (IKS) and function of the lower limbs. METHODS Seventy patients with CIDP were evaluated with GS, IKS, and functional measures of the lower limbs. Reevaluation was performed after 2 and 10/12 weeks. Correlation and response analyses were performed. RESULTS GS correlated with IKS at the ankle (IKSankle ; maximum Spearman's rank-order correlation [RS ] = 0.58) and with walking performance (maximum RS = -0.38). IKSankle was more responsive to detect change (standardized response mean [SRM] = 0.57) than GS (SRM = 0.27). DISCUSSION GS does not seem to be an appropriate surrogate measure of IKS and function of the lower limbs in patients with CIDP. Muscle Nerve 58: 449-452, 2018.
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Affiliation(s)
- Kirsten L Knak
- Department of Neurology, Copenhagen Neuromuscular Center, Rigshospitalet, Juliane Maries Vej 28, 6921nm Copenhagen, 2100, Denmark
| | - Linda K Andersen
- Department of Neurology, Copenhagen Neuromuscular Center, Rigshospitalet, Juliane Maries Vej 28, 6921nm Copenhagen, 2100, Denmark
| | - Ingelise Christiansen
- Department of Neurology, Copenhagen Neuromuscular Center, Rigshospitalet, Juliane Maries Vej 28, 6921nm Copenhagen, 2100, Denmark
| | - Lars K Markvardsen
- Department of Neurology, Aarhus University Hospital, Nørrebrogade 44 Aarhus, 8000, Denmark
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van Schaik IN, Bril V, van Geloven N, Hartung HP, Lewis RA, Sobue G, Lawo JP, Praus M, Mielke O, Durn BL, Cornblath DR, Merkies ISJ, Sabet A, George K, Roberts L, Carne R, Blum S, Henderson R, Van Damme P, Demeestere J, Larue S, D'Amour C, Bril V, Breiner A, Kunc P, Valis M, Sussova J, Kalous T, Talab R, Bednar M, Toomsoo T, Rubanovits I, Gross-Paju K, Sorro U, Saarela M, Auranen M, Pouget J, Attarian S, Le Masson G, Wielanek-Bachelet A, Desnuelle C, Delmont E, Clavelou P, Aufauvre D, Schmidt J, Zschuentssch J, Sommer C, Kramer D, Hoffmann O, Goerlitz C, Haas J, Chatzopoulos M, Yoon R, Gold R, Berlit P, Jaspert-Grehl A, Liebetanz D, Kutschenko A, Stangel M, Trebst C, Baum P, Bergh F, Klehmet J, Meisel A, Klostermann F, Oechtering J, Lehmann H, Schroeter M, Hagenacker T, Mueller D, Sperfeld A, Bethke F, Drory V, Algom A, Yarnitsky D, Murinson B, Di Muzio A, Ciccocioppo F, Sorbi S, Mata S, Schenone A, Grandis M, Lauria G, Cazzato D, Antonini G, Morino S, Cocito D, Zibetti M, Yokota T, Ohkubo T, Kanda T, Kawai M, Kaida K, Onoue H, Kuwabara S, Mori M, Iijima M, Ohyama K, Baba M, Tomiyama M, Nishiyama K, Akutsu T, Yokoyama K, Kanai K, van Schaik I, Eftimov F, Notermans N, Visser N, Faber C, Hoeijmakers J, Rejdak K, Chyrchel-Paszkiewicz U, Casanovas Pons C, Alberti Aguiló M, Gamez J, Figueras M, Marquez Infante C, Benitez Rivero S, Lunn M, Morrow J, Gosal D, Lavin T, Melamed I, Testori A, Ajroud-Driss S, Menichella D, Simpson E, Chi-Ho Lai E, Dimachkie M, Barohn R, Beydoun S, Johl H, Lange D, Shtilbans A, Muley S, Ladha S, Freimer M, Kissel J, Latov N, Chin R, Ubogu E, Mumfrey S, Rao T, MacDonald P, Sharma K, Gonzalez G, Allen J, Walk D, Hobson-Webb L, Gable K. Subcutaneous immunoglobulin for maintenance treatment in chronic inflammatory demyelinating polyneuropathy (PATH): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet Neurol 2018; 17:35-46. [DOI: 10.1016/s1474-4422(17)30378-2] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 09/28/2017] [Accepted: 10/02/2017] [Indexed: 10/18/2022]
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Mahdi‐Rogers M, Brassington R, Gunn AA, van Doorn PA, Hughes RAC. Immunomodulatory treatment other than corticosteroids, immunoglobulin and plasma exchange for chronic inflammatory demyelinating polyradiculoneuropathy. Cochrane Database Syst Rev 2017; 5:CD003280. [PMID: 28481421 PMCID: PMC6481566 DOI: 10.1002/14651858.cd003280.pub5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a disease that causes progressive or relapsing and remitting weakness and numbness. It is probably caused by an autoimmune process. Immunosuppressive or immunomodulatory drugs would be expected to be beneficial. This review was first published in 2003 and has been updated most recently in 2016. OBJECTIVES To assess the effects of immunomodulatory and immunosuppressive agents other than corticosteroids, immunoglobulin, and plasma exchange in CIDP. SEARCH METHODS On 24 May 2016, we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 4) in the Cochrane Library, MEDLINE, Embase, CINAHL, and LILACS for completed trials, and clinical trial registers for ongoing trials. We contacted the authors of the trials identified and other disease experts seeking other published and unpublished trials. SELECTION CRITERIA We sought randomised and quasi-randomised trials of all immunosuppressive agents, such as azathioprine, cyclophosphamide, methotrexate, ciclosporin, mycophenolate mofetil, and rituximab, and all immunomodulatory agents, such as interferon (IFN) alfa and IFN beta, in participants fulfilling standard diagnostic criteria for CIDP. We included all comparisons of these agents with placebo, another treatment, or no treatment. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We wanted to measure the change in disability after one year as our primary outcome. Our secondary outcomes were change in disability after four or more weeks (from randomisation); change in impairment after at least one year; change in maximum motor nerve conduction velocity and compound muscle action potential amplitude after one year; and for participants who were receiving corticosteroids or intravenous immunoglobulin (IVIg), the amount of this medication given during at least one year after randomisation. Participants with one or more serious adverse events during the first year was also a secondary outcome. MAIN RESULTS Four trials fulfilled the selection criteria: one of azathioprine (27 participants), two of IFN beta-1a (77 participants in total) and one of methotrexate (60 participants). The risk of bias was considered low in the trials of IFN beta-1a and methotrexate but high in the trial of azathioprine. None of the trials showed significant benefit in any of the outcomes selected by their authors. The results of the outcomes which approximated most closely to the primary outcome for this review were as follows.In the azathioprine trial there was a median improvement in the Neuropathy Impairment Scale (scale range 0 to 280) after nine months of 29 points (range 49 points worse to 84 points better) in the azathioprine and prednisone treated participants compared with 30 points worse (range 20 points worse to 104 points better) in the prednisone alone group. There were no reports of adverse events.In a cross-over trial of IFN beta-1a with 20 participants, the treatment periods were 12 weeks. The median improvement in the Guy's Neurological Disability Scale (range 1 to 10) was 0.5 grades (interquartile range (IQR) 1.8 grades better to zero grade change) in the IFN beta-1a treatment period and 0.5 grades (IQR 1.8 grades better to 1.0 grade worse) in the placebo treatment period. There were no serious adverse events in either treatment period.In a parallel group trial of IFN beta-1a with 67 participants, none of the outcomes for this review was available. The trial design involved withdrawal from ongoing IVIg treatment. The primary outcome used by the trial authors was total IVIg dose administered from week 16 to week 32 in the placebo group compared with the IFN beta-1a groups. This was slightly but not significantly lower in the combined IFN beta-1a groups (1.20 g/kg) compared with the placebo group (1.34 g/kg, P = 0.75). There were four participants in the IFN beta-1a group and none in the placebo group with one or more serious adverse events, risk ratio (RR) 4.50 (95% confidence interval (CI) 0.25 to 80.05).The methotrexate trial had a similar design involving withdrawal from ongoing corticosteroid or IVIg treatment. At the end of the trial (approximately 40 weeks) there was no significant difference in the change in the Overall Neuropathy Limitations Scale, a disability scale (scale range 0 to 12), the median change being 0 (IQR -1 to 0) in the methotrexate group and 0 (IQR -0.75 to 0) in the placebo group. These changes in disability might have been confounded by the reduction in corticosteroid or IVIg dose required by the protocol. There were three participants in the methotrexate group and one in the placebo with one or more serious adverse events, RR 3.56 (95% CI 0.39 to 32.23). AUTHORS' CONCLUSIONS Low-quality evidence from randomised trials does not show significant benefit from azathioprine or interferon beta-1a and moderate-quality evidence from one randomised trial does not show significant benefit from a relatively low dose of methotrexate for the treatment of CIDP. None of the trials was large enough to rule out small or moderate benefit. The evidence from observational studies is insufficient to avoid the need for randomised controlled trials to discover whether these drugs are beneficial. Future trials should have improved designs, more sensitive outcome measures relevant to people with CIDP, and longer treatment durations.
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Affiliation(s)
| | - Ruth Brassington
- National Hospital for Neurology and NeurosurgeryQueen Square Centre for Neuromuscular DiseasesPO Box 114LondonUKWC1N 3BG
| | - Angela A Gunn
- National Hospital for Neurology and NeurosurgeryMRC Centre for Neuromuscular DiseasesPO Box 114LondonUKWC1N 3BG
| | - Pieter A van Doorn
- Erasmus University Medical CenterDepartment of NeurologyPO Box 2040RotterdamNetherlands3000 CA
| | - Richard AC Hughes
- National Hospital for Neurology and NeurosurgeryMRC Centre for Neuromuscular DiseasesPO Box 114LondonUKWC1N 3BG
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Katzberg HD, Latov N, Walker FO. Measuring disease activity and clinical response during maintenance therapy in CIDP: from ICE trial outcome measures to future clinical biomarkers. Neurodegener Dis Manag 2017; 7:147-156. [DOI: 10.2217/nmt-2016-0058] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Some patients with chronic inflammatory demyelinating polyradiculoneuropathy who respond to initial intravenous immunoglobulin require repeated courses over prolonged periods of time; however, evidence to guide dosage and interval of intravenous immunoglobulin during maintenance therapy is limited. Optimizing treatment requires assessment of underlying disease activity and clinical outcome. Electrophysiological measures of demyelination, and clinical measures using handgrip strength and walking velocity promise to be particularly informative. Major advances in resolution and image processing have expanded clinical applications for ultrasound to include the study of peripheral nerves. Ultrasonography shows promise in diagnosing chronic inflammatory demyelinating polyradiculoneuropathy and distinguishing it from other conditions, providing first ever insight into gross pathology of peripheral nerves. Ultrasonography may also have a role in monitoring disease activity and treatment response.
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Affiliation(s)
- Hans D Katzberg
- University of Toronto, Toronto General Hospital/UHN, Toronto, ON, Canada
| | | | - Francis O Walker
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Vo ML, Chin RL, Miranda C, Latov N. Changes in spatiotemporal gait parameters following intravenous immunoglobulin treatment for chronic inflammatory demyelinating polyneuropathy. Muscle Nerve 2017; 56:732-736. [DOI: 10.1002/mus.25553] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 12/23/2016] [Accepted: 12/28/2016] [Indexed: 11/09/2022]
Affiliation(s)
- Mary L. Vo
- Peripheral Neuropathy Center, Weill Cornell Medical College1305 York Avenue, 2nd Floor, New York New York10021 USA
| | - Russell L. Chin
- Peripheral Neuropathy Center, Weill Cornell Medical College1305 York Avenue, 2nd Floor, New York New York10021 USA
| | - Caroline Miranda
- Department of NeurologyNew York Presbyterian Hospital‐Weill Cornell Medical CollegeNew York New York USA
| | - Norman Latov
- Peripheral Neuropathy Center, Weill Cornell Medical College1305 York Avenue, 2nd Floor, New York New York10021 USA
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Haliloğlu G, Yüksel D, Temuçin CM, Topaloğlu H. Challenges in pediatric chronic inflammatory demyelinating polyneuropathy. Neuromuscul Disord 2016; 26:817-824. [DOI: 10.1016/j.nmd.2016.09.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 08/09/2016] [Accepted: 09/20/2016] [Indexed: 10/21/2022]
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van Schaik IN, van Geloven N, Bril V, Hartung HP, Lewis RA, Sobue G, Lawo JP, Mielke O, Cornblath DR, Merkies ISJ. Subcutaneous immunoglobulin for maintenance treatment in chronic inflammatory demyelinating polyneuropathy (The PATH Study): study protocol for a randomized controlled trial. Trials 2016; 17:345. [PMID: 27455854 PMCID: PMC4960813 DOI: 10.1186/s13063-016-1466-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 07/02/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Subcutaneous administration of Ig (SCIg) has gained popularity as an alternative route of administration but has never been rigorously examined in chronic inflammatory demyelinating polyneuropathy (CIDP). METHODS/DESIGN The primary objective of the PATH study (Polyneuropathy and Treatment with Hizentra) is to determine the efficacy of two different doses of SCIg IgPro20 (0.2 g/kg bw or 0.4 g/kg bw) in a 24-week maintenance treatment of CIDP in comparison to placebo. The primary efficacy endpoint will be the proportion of patients who show CIDP relapse (1-point deterioration on the adjusted Inflammatory Neuropathy Cause and Treatment (INCAT) disability score) or are withdrawn within 24 weeks after randomization for any reason. IVIg-dependent adult patients with definite or probable CIDP according to the European Federation of Neurological Societies/Peripheral Nerve Society who fulfil the inclusion and exclusion criteria will be eligible. Based on sample-size calculation and relapse assumptions in the three arms, a sample size of 58 is needed per arm (overall sample size will be 350, of which 174 will be randomized). All eligible patients will progress through three study periods: an IgG dependency period (≤12 weeks) to select those who are Ig dependent; an IVIg restabilization period (10 or 13 weeks), which will be performed using the 10 % IgPro10 product; and an SC treatment period (24 weeks, followed by a 1-week completion visit after last follow-up). Patients showing IVIg restabilization will be randomized to demonstrate the efficacy of SCIg IgPro20 maintenance treatment over placebo. After completing the study, subjects are eligible to enter a long-term, open-label, extension study of 1 year or return to their previous treatment. In case of CIDP relapse during the 24-week SC treatment period, IgPro10 rescue medication will be offered. Safety, tolerability, and patients' preference of Ig administration route will be examined. DISCUSSION The PATH trial, which started in March 2012, is expected to finish at the end of 2016. The results will increase knowledge about the efficacy, safety, and tolerability of SCIg in maintenance management of CIDP patients. TRIAL REGISTRATION ClinicalTrials.gov, NCT01545076 . Registered on 1 March 2012.
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Affiliation(s)
- Ivo N van Schaik
- Department of Neurology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Nan van Geloven
- Department of Biostatistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Vera Bril
- Department of Medicine (Neurology), University Health Network, University of Toronto, Toronto, Canada
| | | | - Richard A Lewis
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Gen Sobue
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | - Orell Mielke
- CSL Behring Biotherapies for Life™, Marburg, Germany
| | - David R Cornblath
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ingemar S J Merkies
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
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Draak THP, Pruppers MHJ, van Nes SI, Vanhoutte EK, Bakkers M, Gorson KC, Van der Pol WL, Lewis RA, Notermans NC, Nobile-Orazio E, Léger JM, Van den Bergh PYK, Lauria G, Bril V, Katzberg H, Lunn MPT, Pouget J, van der Kooi AJ, van den Berg LH, van Doorn PA, Cornblath DR, Hahn AF, Faber CG, Merkies ISJ. Grip strength comparison in immune-mediated neuropathies: Vigorimeter vs. Jamar. J Peripher Nerv Syst 2016; 20:269-76. [PMID: 26115516 DOI: 10.1111/jns.12126] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Revised: 04/21/2015] [Accepted: 06/11/2015] [Indexed: 01/06/2023]
Abstract
The Jamar dynamometer and Vigorimeter have been used to assess grip strength in immune-mediated neuropathies, but have never been compared to each other. Therefore, we performed a comparison study between these two devices in patients with immune-mediated neuropathies. Grip strength data were collected in 102 cross-sectional stable and 163 longitudinal (new diagnoses or changing condition) patients with Guillain-Barré syndrome (GBS), chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), gammopathy-related polyneuropathy (MGUSP), and multifocal motor neuropathy (MMN). Stable patients were assessed twice (validity/reliability studies). Longitudinal patients were assessed 3-5 times during 1 year. Responsiveness comparison between the two tools was examined using combined anchor-/distribution-based minimum clinically important difference (MCID) techniques. Patients were asked to indicate their preference for the Jamar or Vigorimeter. Both tools correlated highly with each other (ρ = 0.86, p < 0.0001) and showed good intra-class correlation coefficients (Jamar [Right/Left hands]: ICC 0.997/0.96; Vigori: ICC 0.95/0.98). Meaningful changes were comparable between the two instruments, being higher in GBS compared to CIDP patients. In MGUSP/MMN poor responsiveness was seen. Significant more patients preferred the Vigorimeter. In conclusion, validity, reliability, and responsiveness aspects were comparable between the Jamar dynamometer and Vigorimeter. However, based on patients' preference, the Vigorimeter is recommended in future studies in immune-mediated neuropathies.
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Affiliation(s)
- Thomas H P Draak
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Mariëlle H J Pruppers
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Sonja I van Nes
- Department of Neurology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Els K Vanhoutte
- Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Mayienne Bakkers
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Kenneth C Gorson
- Department of Neurology, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - W-Ludo Van der Pol
- Department of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Centre, Utrecht, The Netherlands
| | - Richard A Lewis
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Nicolette C Notermans
- Department of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Centre, Utrecht, The Netherlands
| | - Eduardo Nobile-Orazio
- Department of Neurological Sciences, Milan University, Humanitas Clinical Institute, Milan, Italy
| | - Jean-Marc Léger
- Department of Neurology, Hôpital de la Salpêtrière, Paris, France
| | | | - Giuseppe Lauria
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Department of Clinical Neurosciences, Milan, Italy
| | - Vera Bril
- Department of Neurology, Toronto General Hospital, Toronto, Canada
| | - Hans Katzberg
- Department of Neurology, Toronto General Hospital, Toronto, Canada
| | - Michael P T Lunn
- Department of Neurology, Centre for Neuromuscular Disease, National Hospital for Neurology and Neurosurgery, London, UK
| | - Jean Pouget
- Department of Neurology, Centre de Référence des Maladies Neuromusculaires et de la SLA, Hôpital de La Timone, Marseille, France
| | | | - Leonard H van den Berg
- Department of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Centre, Utrecht, The Netherlands
| | - Pieter A van Doorn
- Department of Neurology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - David R Cornblath
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Angelika F Hahn
- Department of Neurology, London Health Science Center, London, Canada
| | - Catharina G Faber
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Ingemar S J Merkies
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Neurology, Spaarne Hospital, Hoofddorp, The Netherlands
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Allen JA, Bril V. Improving the management of chronic inflammatory demyelinating polyradiculoneuropathy. Neurodegener Dis Manag 2016; 6:237-47. [DOI: 10.2217/nmt-2015-0011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
This article considers several issues of current interest relating to the management of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), including diagnostic pitfalls, differences between CIDP patients with and without concurrent diabetes mellitus and how to best measure treatment response in daily practice. Despite the availability of diagnostic criteria, many patients diagnosed with CIDP do not meet these criteria; reasons for misdiagnosis are discussed. There are no definitive predictors of treatment response in CIDP; however, certain clinical and electrophysiological characteristics may be helpful. Patients with CIDP and concurrent diabetes present an additional diagnostic challenge; the differences between these groups, including possible differences in response predictors are discussed. Finally, the most appropriate outcome measures for use in daily practice are considered.
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Affiliation(s)
- Jeffrey A Allen
- Neuromuscular Division, Department of Neurology, University of Minnesota, Minneapolis, MN 55455, USA
| | - Vera Bril
- Division of Neurology, Department of Medicine, The Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, Canada
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Draak THP, Gorson KC, Vanhoutte EK, van Nes SI, van Doorn PA, Cornblath DR, van den Berg LH, Faber CG, Merkies ISJ. Correlation of the patient's reported outcome Inflammatory-RODS with an objective metric in immune-mediated neuropathies. Eur J Neurol 2016; 23:1248-53. [PMID: 27129110 DOI: 10.1111/ene.13025] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Accepted: 03/22/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE There is increasing interest in using patient-reported outcome measures (PROMs) in clinical studies to capture individual changes over time. However, PROMs have also been criticized because they are entirely subjective. Our objective was to examine the relationship between a subjective PROM and an objective outcome tool in patients with Guillain-Barré syndrome (GBS), chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and gammopathy-related polyneuropathy (MGUSP). METHODS The Inflammatory Rasch-built Overall Disability Scale (I-RODS©, a multi-item scale that examines functionality) was completed by 137 patients with newly diagnosed (or relapsing) GBS (55), CIDP (59) and MGUSP (23) who were serially examined (GBS/CIDP, T0/T1/T3/T6/T12 months; MGUSP, T0/T3/T12). Possible association between the I-RODS findings and the vigorimeter scores, an objective linear instrument to assess grip strength, was examined. RESULTS A significant correlating trend was found between the I-RODS and grip strength scores for the overall group and in each illness, independently. CONCLUSION The objectivity of patients' subjective report on their functional state based on a strong correlation between the I-RODS and grip strength in patients with GBS, CIDP and MGUSP has been demonstrated. These findings provide further support to use the I-RODS and grip strength in future clinical studies in these conditions.
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Affiliation(s)
- T H P Draak
- Department of Neurology, University Medical Centre Maastricht, Maastricht, The Netherlands
| | - K C Gorson
- Department of Neurology, St Elizabeth's Medical Centre, Tufts University School of Medicine, Boston, MA, USA
| | - E K Vanhoutte
- Department of Clinical Genetics, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - S I van Nes
- Department of Neurology, Havenziekenhuis, Rotterdam, The Netherlands
| | - P A van Doorn
- Department of Neurology, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - D R Cornblath
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - L H van den Berg
- Department of Neurology, Rudolf Magnus Institute of Neuroscience University Medical Centre Utrecht, Utrecht, The Netherlands
| | - C G Faber
- Department of Neurology, University Medical Centre Maastricht, Maastricht, The Netherlands
| | - I S J Merkies
- Department of Neurology, University Medical Centre Maastricht, Maastricht, The Netherlands.,Department of Neurology, Spaarne Hospital, Hoofddorp, The Netherlands
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Vo ML, Martin P, Latov N. Correlation of Changes in Gait Parameters, With Phenotype, Outcome Measures, and Electrodiagnostic Abnormalities in a Patient With Anti-MAG Neuropathy After Exacerbation and Improvement. J Clin Neuromuscul Dis 2015; 17:22-26. [PMID: 26301376 DOI: 10.1097/cnd.0000000000000087] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Gait impairment is a common presentation in patients with IgM anti-myelin-associated glycoprotein (anti-MAG) antibody demyelinating neuropathy. However, current methods used to assess gait are limited. We report spatiotemporal gait parameters captured by GAITRite, a computerized walkway with embedded pressure sensors. The patient worsened after treatment with rituximab and subsequently improved with intravenous immunoglobulin. Serial gait assessments were performed at baseline and after treatment. Spatiotemporal gait parameters correlated with Medical Research Council sum score, Inflammatory Neuropathy Cause and Treatment disability score, and grip strength. Quantitative gait assessment may provide a new dimension to standard clinical evaluation and may help to clarify treatment response in patients with anti-MAG neuropathy when used in combination with other validated assessment tools.
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Affiliation(s)
- Mary L Vo
- Departments of *Neurology; and †Hematology and Oncology, Weill Cornell Medical College, New York, NY
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50
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Van den Bergh PYK, Lunn MP. Future needs in peripheral neuropathy outcome measures. J Peripher Nerv Syst 2015; 20:341-6. [PMID: 26306616 DOI: 10.1111/jns.12142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 07/05/2015] [Indexed: 11/28/2022]
Affiliation(s)
| | - Michael P Lunn
- Centre for Neuromuscular Disease, National Hospital for Neurology and Neurosurgery, London, UK
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