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Mishuk AU, Chen L, Li C, Huo N, Hansen RA, Harris I, Kiptanui Z, Qian J. Patient factors associated with oral generic olanzapine initiation and substitution among Medicaid beneficiaries: a new user cohort study. Curr Med Res Opin 2021; 37:655-664. [PMID: 33507825 DOI: 10.1080/03007995.2021.1882413] [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] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Generic drugs typically are less expensive than branded products; however, several factors can limit generic drug utilization. This study assesses the associations of patient factors with generic olanzapine initiation and substitution. METHODS A retrospective new user cohort study was conducted using the 2011-2012 Medicaid administrative claims data. Beneficiaries continuously enrolled during the 6 month washout period prior to their initial oral brand or generic olanzapine prescription were included and followed up to 12 months. Among brand olanzapine new users, time to generic substitution and competing risk outcomes was estimated using the Fine-Gray cumulative incidence function. Patient demographic and health service utilization factors were assessed in the multivariate cause-specific hazards model. RESULTS Among olanzapine new users, 70.7% patients initiated generic treatment. Beneficiaries aged ≥21, and living in the Midwest and West regions were more likely to initiate generic olanzapine. Among brand new users, 28.2% switched to generic olanzapine, 23.6% switched to an alternative atypical antipsychotic treatment and 38.0% discontinued within 12 months. Beneficiaries who resided in urban areas (adjusted hazard ratio [AHR) = 0.53, 95% CI = 0.37-0.75) and had prior hospitalizations (AHR = 0.85, 95% CI = 0.75-0.96) had lower rates of generic substitution, whereas those with emergency department (ED) visits (AHR = 1.06, 95% CI = 1.02-1.10) had a higher rate of generic substitution. In addition, beneficiaries in different age subgroups also had different rates of generic substitution in different regions. CONCLUSION Medicaid beneficiaries' age, geographic region, prior hospitalization and ED utilization were associated with generic olanzapine initiation and substitution. Tailored educational outreach targeting these patient subgroups might improve generic olanzapine utilization.
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Affiliation(s)
| | - Li Chen
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Chao Li
- Auburn University Harrison School of Pharmacy, Auburn, AL, USA
| | - Nan Huo
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Jingjing Qian
- Auburn University Harrison School of Pharmacy, Auburn, AL, USA
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Restrepo-Jiménez P, Rodríguez Y, González P, Chang C, Gershwin ME, Anaya JM. The immunotherapy of Guillain-Barré syndrome. Expert Opin Biol Ther 2018; 18:619-631. [DOI: 10.1080/14712598.2018.1468885] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Paula Restrepo-Jiménez
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - Yhojan Rodríguez
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - Paulina González
- Neurology Service, Clínica Universitaria Bolivariana, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Christopher Chang
- Division of Rheumatology, Allergy and Clinical Immunology, University of California Davis, School of Medicine, Davis, CA, USA
| | - M. Eric Gershwin
- Division of Rheumatology, Allergy and Clinical Immunology, University of California Davis, School of Medicine, Davis, CA, USA
| | - Juan-Manuel Anaya
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
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Abstract
Imminent neuromuscular respiratory failure is recognized by shortness of breath, restlessness, and tachycardia and is often followed by tachypnea, constantly interrupting speech, asynchronous breathing and sometimes paradoxical breathing and use of scalene and sternocleidomastoid muscles. Once a patient presents with such a constellation of signs, there are some difficult decisions to be made and include assessment of the severity of respiratory failure and in particular when to intubate. Failure of the patient to manage secretions as a result of oropharyngeal weakness rather than neuromuscular respiratory weakness may be another reason for acute intubation. Any patient with rapidly worsening weakness on presentation will need admission and observation in an intensive care unit. This chapter summarizes the pathophysiology of acute neuromuscular respiratory failure, its clinical recognition and respiratory management and outcome expectations.
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Affiliation(s)
- E F M Wijdicks
- Division of Critical Care Neurology, Mayo Clinic and Neurosciences Intensive Care Unit, Mayo Clinic Campus, Saint Marys Hospital, Rochester, MN, USA.
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Oaklander AL, Lunn MPT, Hughes RAC, van Schaik IN, Frost C, Chalk CH. Treatments for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP): an overview of systematic reviews. Cochrane Database Syst Rev 2017; 1:CD010369. [PMID: 28084646 PMCID: PMC5468847 DOI: 10.1002/14651858.cd010369.pub2] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a chronic progressive or relapsing and remitting disease that usually causes weakness and sensory loss. The symptoms are due to autoimmune inflammation of peripheral nerves. CIPD affects about 2 to 3 per 100,000 of the population. More than half of affected people cannot walk unaided when symptoms are at their worst. CIDP usually responds to treatments that reduce inflammation, but there is disagreement about which treatment is most effective. OBJECTIVES To summarise the evidence from Cochrane systematic reviews (CSRs) and non-Cochrane systematic reviews of any treatment for CIDP and to compare the effects of treatments. METHODS We considered all systematic reviews of randomised controlled trials (RCTs) of any treatment for any form of CIDP. We reported their primary outcomes, giving priority to change in disability after 12 months.Two overview authors independently identified published systematic reviews for inclusion and collected data. We reported the quality of evidence using GRADE criteria. Two other review authors independently checked review selection, data extraction and quality assessments.On 31 October 2016, we searched the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects (in theCochrane Library), MEDLINE, Embase, and CINAHL Plus for systematic reviews of CIDP. We supplemented the RCTs in the existing CSRs by searching on the same date for RCTs of any treatment of CIDP (including treatment of fatigue or pain in CIDP), in the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL Plus. MAIN RESULTS Five CSRs met our inclusion criteria. We identified 23 randomised trials, of which 15 had been included in these CSRs. We were unable to compare treatments as originally planned, because outcomes and outcome intervals differed. CorticosteroidsIt is uncertain whether daily oral prednisone improved impairment compared to no treatment because the quality of the evidence was very low (1 trial, 28 participants). According to moderate-quality evidence (1 trial, 41 participants), six months' treatment with high-dose monthly oral dexamethasone did not improve disability more than daily oral prednisolone. Observational studies tell us that prolonged use of corticosteroids sometimes causes serious side-effects. Plasma exchangeAccording to moderate-quality evidence (2 trials, 59 participants), twice-weekly plasma exchange produced more short-term improvement in disability than sham exchange. In the largest observational study, 3.9% of plasma exchange procedures had complications. Intravenous immunoglobulinAccording to high-quality evidence (5 trials, 269 participants), intravenous immunoglobulin (IVIg) produced more short-term improvement than placebo. Adverse events were more common with IVIg than placebo (high-quality evidence), but serious adverse events were not (moderate-quality evidence, 3 trials, 315 participants). One trial with 19 participants provided moderate-quality evidence of little or no difference in short-term improvement of impairment with plasma exchange in comparison to IVIg. There was little or no difference in short-term improvement of disability with IVIg in comparison to oral prednisolone (moderate-quality evidence; 1 trial, 29 participants) or intravenous methylprednisolone (high-quality evidence; 1 trial, 45 participants). One unpublished randomised open trial with 35 participants found little or no difference in disability after three months of IVIg compared to oral prednisone; this trial has not yet been included in a CSR. We know from observational studies that serious adverse events related to IVIg do occur. Other immunomodulatory treatmentsIt is uncertain whether the addition of azathioprine (2 mg/kg) to prednisone improved impairment in comparison to prednisone alone, as the quality of the evidence is very low (1 trial, 27 participants). Observational studies show that adverse effects truncate treatment in 10% of people.According to low-quality evidence (1 trial, 60 participants), compared to placebo, methotrexate 15 mg/kg did not allow more participants to reduce corticosteroid or IVIg doses by 20%. Serious adverse events were no more common with methotrexate than with placebo, but observational studies show that methotrexate can cause teratogenicity, abnormal liver function, and pulmonary fibrosis.According to moderate-quality evidence (2 trials, 77 participants), interferon beta-1a (IFN beta-1a) in comparison to placebo, did not allow more people to withdraw from IVIg. According to moderate-quality evidence, serious adverse events were no more common with IFN beta-1a than with placebo.We know of no other completed trials of immunosuppressant or immunomodulatory agents for CIDP. Other treatmentsWe identified no trials of treatments for fatigue or pain in CIDP. Adverse effectsNot all trials routinely collected adverse event data; when they did, the quality of evidence was variable. Adverse effects in the short, medium, and long term occur with all interventions. We are not able to make reliable comparisons of adverse events between the interventions included in CSRs. AUTHORS' CONCLUSIONS We cannot be certain based on available evidence whether daily oral prednisone improves impairment compared to no treatment. However, corticosteroids are commonly used, based on widespread availability, low cost, very low-quality evidence from observational studies, and clinical experience. The weakness of the evidence does not necessarily mean that corticosteroids are ineffective. High-dose monthly oral dexamethasone for six months is probably no more or less effective than daily oral prednisolone. Plasma exchange produces short-term improvement in impairment as determined by neurological examination, and probably produces short-term improvement in disability. IVIg produces more short-term improvement in disability than placebo and more adverse events, although serious side effects are probably no more common than with placebo. There is no clear difference in short-term improvement in impairment with IVIg when compared with intravenous methylprednisolone and probably no improvement when compared with either oral prednisolone or plasma exchange. According to observational studies, adverse events related to difficult venous access, use of citrate, and haemodynamic changes occur in 3% to17% of plasma exchange procedures.It is uncertain whether azathioprine is of benefit as the quality of evidence is very low. Methotrexate may not be of benefit and IFN beta-1a is probably not of benefit.We need further research to identify predictors of response to different treatments and to compare their long-term benefits, safety and cost-effectiveness. There is a need for more randomised trials of immunosuppressive and immunomodulatory agents, routes of administration, and treatments for symptoms of CIDP.
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Affiliation(s)
| | - Michael PT Lunn
- National Hospital for Neurology and NeurosurgeryDepartment of Neurology and MRC Centre for Neuromuscular DiseasesQueen SquareLondonUKWC1N 3BG
| | - Richard AC Hughes
- National Hospital for Neurology and NeurosurgeryMRC Centre for Neuromuscular DiseasesPO Box 114Queen SquareLondonUKWC1N 3BG
| | - Ivo N van Schaik
- Academic Medical Centre, University of AmsterdamDepartment of NeurologyMeibergdreef 9PO Box 22700AmsterdamNetherlands1100 DE
| | - Chris Frost
- London School of Hygiene & Tropical MedicineDepartment of Medical StatisticsKeppel StreetLondonUKWC1E 7HT
| | - Colin H Chalk
- McGill UniversityDepartment of Neurology & NeurosurgeryMontreal General Hospital ‐ Room L7‐3131650 Cedar AvenueMontrealQCCanadaH3G 1A4
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Barahona Afonso AF, João CMP. The Production Processes and Biological Effects of Intravenous Immunoglobulin. Biomolecules 2016; 6:15. [PMID: 27005671 PMCID: PMC4808809 DOI: 10.3390/biom6010015] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 03/01/2016] [Accepted: 03/01/2016] [Indexed: 12/17/2022] Open
Abstract
Immunoglobulin is a highly diverse autologous molecule able to influence immunity in different physiological and diseased situations. Its effect may be visible both in terms of development and function of B and T lymphocytes. Polyclonal immunoglobulin may be used as therapy in many diseases in different circumstances such as primary and secondary hypogammaglobulinemia, recurrent infections, polyneuropathies, cancer, after allogeneic transplantation in the presence of infections and/or GVHD. However, recent studies have broadened the possible uses of polyclonal immunoglobulin showing that it can stimulate certain sub-populations of T cells with effects on T cell proliferation, survival and function in situations of lymphopenia. These results present a novel and considerable impact of intravenous immunoglobulin (IVIg) treatment in situations of severe lymphopenia, a situation that can occur in cancer patients after chemo and radiotherapy treatments. In this review paper the established and experimental role of polyclonal immunoglobulin will be presented and discussed as well as the manufacturing processes involved in their production.
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Affiliation(s)
- Ana Filipa Barahona Afonso
- Department of Chemistry, Universidade de Évora, Colégio Luís António Verney, Rua Romão Ramalho 59, 7000-671 Évora, Portugal.
| | - Cristina Maria Pires João
- Hematology Department, Champalimaud Center for the Unknown, Av. Brasília, 1400-038 Lisboa, Portugal.
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Rose MR, Jones K, Leong K, Walter MC, Miller J, Dalakas MC, Brassington R, Griggs R. Treatment for inclusion body myositis. Cochrane Database Syst Rev 2015; 7:CD001555. [PMID: 35658164 PMCID: PMC9645777 DOI: 10.1002/14651858.cd001555.pub5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Inclusion body myositis (IBM) is a late-onset inflammatory muscle disease (myopathy) associated with progressive proximal and distal limb muscle atrophy and weakness. Treatment options have attempted to target inflammatory and atrophic features of this condition (for example with immunosuppressive and immunomodulating drugs, anabolic steroids, and antioxidant treatments), although as yet there is no known effective treatment for reversing or minimising the progression of inclusion body myositis. In this review we have considered the benefits, adverse effects, and costs of treatment in targeting cardinal effects of the condition, namely muscle atrophy, weakness, and functional impairment. OBJECTIVES To assess the effects of treatment for IBM. SEARCH METHODS On 7 October 2014 we searched the Cochrane Neuromuscular Disease Group Specialized Register, the Cochrane Central Register for Controlled Trials (CENTRAL), MEDLINE, and EMBASE. Additionally in November 2014 we searched clinical trials registries for ongoing or completed but unpublished trials. SELECTION CRITERIA We considered randomised or quasi-randomised trials, including cross-over trials, of treatment for IBM in adults compared to placebo or any other treatment for inclusion in the review. We specifically excluded people with familial IBM and hereditary inclusion body myopathy, but we included people who had connective tissue and autoimmune diseases associated with IBM, which may or may not be identified in trials. We did not include studies of exercise therapy or dysphagia management, which are topics of other Cochrane systematic reviews. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. MAIN RESULTS The review included 10 trials (249 participants) using different treatment regimens. Seven of the 10 trials assessed single agents, and 3 assessed combined agents. Many of the studies did not present adequate data for the reporting of the primary outcome of the review, which was the percentage change in muscle strength score at six months. Pooled data from two trials of interferon beta-1a (n = 58) identified no important difference in normalised manual muscle strength sum scores from baseline to six months (mean difference (MD) -0.06, 95% CI -0.15 to 0.03) between IFN beta-1a and placebo (moderate-quality evidence). A single trial of methotrexate (MTX) (n = 44) provided moderate-quality evidence that MTX did not arrest or slow disease progression, based on reported percentage change in manual muscle strength sum scores at 12 months. None of the fully published trials were adequately powered to detect a treatment effect. We assessed six of the nine fully published trials as providing very low-quality evidence in relation to the primary outcome measure. Three trials (n = 78) compared intravenous immunoglobulin (combined in one trial with prednisone) to a placebo, but we were unable to perform meta-analysis because of variations in study analysis and presentation of trial data, with no access to the primary data for re-analysis. Other comparisons were also reported in single trials. An open trial of anti-T lymphocyte immunoglobulin (ATG) combined with MTX versus MTX provided very low-quality evidence in favour of the combined therapy, based on percentage change in quantitative muscle strength sum scores at 12 months (MD 12.50%, 95% CI 2.43 to 22.57). Data from trials of oxandrolone versus placebo, azathioprine (AZA) combined with MTX versus MTX, and arimoclomol versus placebo did not allow us to report either normalised or percentage change in muscle strength sum scores. A complete analysis of the effects of arimoclomol is pending data publication. Studies of simvastatin and bimagrumab (BYM338) are ongoing. All analysed trials reported adverse events. Only 1 of the 10 trials interpreted these for statistical significance. None of the trials included prespecified criteria for significant adverse events. AUTHORS' CONCLUSIONS Trials of interferon beta-1a and MTX provided moderate-quality evidence of having no effect on the progression of IBM. Overall trial design limitations including risk of bias, low numbers of participants, and short duration make it difficult to say whether or not any of the drug treatments included in this review were effective. An open trial of ATG combined with MTX versus MTX provided very low-quality evidence in favour of the combined therapy based on the percentage change data given. We were unable to draw conclusions from trials of IVIg, oxandrolone, and AZA plus MTX versus MTX. We need more randomised controlled trials that are larger, of longer duration, and that use fully validated, standardised, and responsive outcome measures.
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Affiliation(s)
- Michael R Rose
- King's College Hospital NHS Foundation TrustDepartment of NeurologyAcademic Neuroscience CentreDenmark HillLondonUKSE5 9RS
| | - Katherine Jones
- King's College Hospital NHS Foundation TrustDepartment of NeurologyAcademic Neuroscience CentreDenmark HillLondonUKSE5 9RS
| | - Kevin Leong
- NHLI, Imperial College LondonICTEM Builiding; 4th FloorHammersmith CampusW12 0HSUK
| | - Maggie C Walter
- Ludwig‐Maximilians‐UniversityDepartment of Neurology, Friedrich‐Baur‐Institute, Laboratory for Molecular MyologyZiemssenstr.1MunichGermany80336
| | - James Miller
- Royal Victoria Infirmaryc/o Department of Neurology, Newcastle upon Tyne Hospitals TrustQueen Victoria RoadNewcastle Upon TyneUKNE1 4LP
| | - Marinos C Dalakas
- Thomas Jefferson UniversityDepartment of Neurology, Sidney Kimmel Medical College901 Walnut Street4th FloorPhiladelphiaPAUSA19107
| | - Ruth Brassington
- National Hospital for Neurology and NeurosurgeryMRC Centre for Neuromuscular DiseasesPO Box 114LondonUKWC1N 3BG
| | - Robert Griggs
- University of RochesterDepartment of Neurology601 Elmwood AvenueRochesterNYUSA14642
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Berger T, Jacobi C, Haas J, Ransmayr G, Guger M, Zettl UK, Di Pauli F, Taumberger B, Wietek S, Meuer S, Reindl M, Giese T. Predicting therapeutic efficacy of intravenous immunoglobulin (IVIG) in individual patients with relapsing remitting multiple sclerosis (RRMS) by functional genomics. J Neuroimmunol 2014; 277:145-52. [DOI: 10.1016/j.jneuroim.2014.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 09/30/2014] [Accepted: 10/03/2014] [Indexed: 12/30/2022]
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Clinical presentation, pathogenesis, diagnosis, and treatment of epidermolysis bullosa acquisita. ISRN DERMATOLOGY 2013; 2013:812029. [PMID: 23956869 PMCID: PMC3727188 DOI: 10.1155/2013/812029] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 06/02/2013] [Indexed: 11/18/2022]
Abstract
Epidermolysis bullosa acquisita (EBA) is a chronic mucocutaneous autoimmune skin blistering disease. The pathogenic relevance of autoantibodies targeting type VII collagen (COL7) has been well-documented. Therefore, EBA is a prototypical autoimmune disease with a well-characterized pathogenic relevance of autoantibody binding to the target antigen. EBA is a rare disease with an incidence of 0.2 new cases per million and per year. The current treatment of EBA relies on general immunosuppressive therapy, which does not lead to remission in all cases. Therefore, there is a high, so far unmet medical need for the development of novel therapeutic options. During the last 10 years, several novel in vitro and in vivo models of EBA have been established. These models demonstrated a critical role of the genetic background, T cells, and cytokines for mediating the loss of tolerance towards COL7. Neutrophils, complement activation, Fc gamma receptor engagement, cytokines, several molecules involved in cell signaling, release of reactive oxygen species, and matrix metalloproteinases are crucial for autoantibody-induced tissue injury in EBA. Based on this growing understanding of the diseases' pathogenesis, several potential novel therapeutic targets have emerged. In this review, the clinical presentation, pathogenesis, diagnosis, and current treatment options for EBA are discussed in detail.
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Jennum P, Frederiksen JL, Wanscher B, Kjellberg J. The socioeconomic consequences of optic neuritis with and without multiple sclerosis: a controlled national study. Acta Neurol Scand 2013; 127:242-50. [PMID: 22812660 DOI: 10.1111/j.1600-0404.2012.01703.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2012] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Optic neuritis (ON) often precedes multiple sclerosis (MS). MS is associated with a significant socioeconomic burden. However, the burden of ON with and without MS before and after its diagnosis has never been calculated. METHODS Using complete national records from the Danish National Patient Registry (1998-2006), we identified 1677 patients with ON and compared them with 6708 randomly selected citizens matched for age, sex and geography. A societal perspective is taken towards the cost analyses. Costs included in the analysis are those of the health sector, including all contacts with primary and secondary sectors, and the use and costs of drugs. Productivity losses included labour supply and income. All social transfer payments were also calculated. RESULTS Patients with ON had higher rates of contact with healthcare services, medication use and income from employment, all of which incurred a higher socioeconomic cost. Employed patients had lower income than control subjects. The total annual excess costs relative to matched controls were €3501 for ON patients and €9215 for patients with a dual diagnosis of ON and MS. The ON and ON+MS patients received an annual mean excess social transfer income of €1175 and €4619. ON/ON+MS patients presented social and economic consequences up to 8 years before diagnosis, and these increased after the diagnosis was established. CONCLUSIONS ON, especially if combined with a diagnosis of MS, has a significant socioeconomic consequence for the individual patient and for society. Productivity losses are a far more important economic factor than health sector costs.
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Affiliation(s)
- P. Jennum
- Department of Clinical Neurophysiology, Faculty of Health Sciences; Danish Center for Sleep Medicine, Center for Healthy Aging, Glostrup Hospital, University of Copenhagen; Copenhagen; Denmark
| | - J. L. Frederiksen
- Department of Neurology; Glostrup Hospital, University of Copenhagen; Glostrup; Denmark
| | - B. Wanscher
- Department of Clinical Neurophysiology, Faculty of Health Sciences; Danish Center for Sleep Medicine, Center for Healthy Aging, Glostrup Hospital, University of Copenhagen; Copenhagen; Denmark
| | - J. Kjellberg
- Danish Institute for Health Services Research; Copenhagen; Denmark
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Direct Medical Costs of Liquid Intravenous Immunoglobulins in Children, Adolescents, and Adults in Spain. J Clin Pharmacol 2013; 52:566-75. [DOI: 10.1177/0091270011399575] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Immunoglobulin therapy. Clin Immunol 2013. [DOI: 10.1016/b978-0-7234-3691-1.00098-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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12
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Jennum P, Wanscher B, Frederiksen J, Kjellberg J. The socioeconomic consequences of multiple sclerosis: a controlled national study. Eur Neuropsychopharmacol 2012; 22:36-43. [PMID: 21669514 DOI: 10.1016/j.euroneuro.2011.05.001] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Revised: 04/21/2011] [Accepted: 05/01/2011] [Indexed: 11/15/2022]
Abstract
Multiple sclerosis (MS) has serious negative effects on health-, social-, and work-related issues for the patients and their families, thus causing significant socioeconomic burden. The objective of the study was to determine healthcare costs and indirect illness costs in MS patient in a national sample. We used all national records from the Danish National Patient Registry (1998-2006), and identified 10,849 MS patients which were compared with 43,396 randomly age-, sex- and social matched citizens. Healthcare sector costs included frequencies and costs of hospitalizations and weighted outpatient use, frequencies of visits and hospitalizations and costs from primary sectors, and the use and costs of drugs. Productivity costs (the value of lost productivity from time off from work due to illness) and all social transfer payments were also calculated. Patients with MS had significantly higher rates of health-related contact and medication use and very low employment rate which incurred a higher socioeconomic cost. The income level of employed MS patients was significantly lower than that of control subjects. The annual total health sector costs and productivity costs were €14,575 for MS patients vs. €1163 for control subjects (p<0.001), corresponding to an annual mean excess health-related cost of €13,413 for each patient with MS. In addition, the MS patients received an annual mean excess social transfer income of €6843. MS present social and economical consequences more than eight years before diagnosis. We conclude that MS causes major socioeconomic consequences for the individual patient and for society. Productivity costs are a far more important economic factor, especially due to reduced employment, which are enhanced by the early age of diagnose onset.
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Affiliation(s)
- Poul Jennum
- Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Glostrup Hospital, Copenhagen, Denmark.
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von Geldern G, McPharlin T, Becker K. Immune mediated diseases and immune modulation in the neurocritical care unit. Neurotherapeutics 2012; 9:99-123. [PMID: 22161307 PMCID: PMC3271148 DOI: 10.1007/s13311-011-0096-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
This chapter will review the spectrum of immune-mediated diseases that affect the nervous system and may result in an admission to the neurological intensive care unit. Immunomodulatory strategies to treat acute exacerbations of neurological diseases caused by aberrant immune responses are discussed, but strategies for long-term immunosuppression are not presented. The recommendations for therapeutic intervention are based on a synthesis of the literature, and include recommendations by the Cochrane Collaborative, the American Academy of Neurology, and other key organizations. References from recent publications are provided for the disorders and therapies in which randomized clinical trials and large evidenced-based reviews do not exist. The chapter concludes with a brief review of the mechanisms of action, dosing, and side effects of commonly used immunosuppressive strategies in the neurocritical care unit.
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Affiliation(s)
- Gloria von Geldern
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD 21287 USA
| | - Thomas McPharlin
- University of Washington School of Pharmacy, Seattle, WA 98104 USA
| | - Kyra Becker
- Department of Neurology, University of Washington School of Medicine, Seattle, WA 98104 USA
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Meuth SG, Bittner S, Ulzheimer JC, Kleinschnitz C, Kieseier BC, Wiendl H. Therapeutic approaches to multiple sclerosis: an update on failed, interrupted, or inconclusive trials of neuroprotective and alternative treatment strategies. BioDrugs 2010; 24:317-30. [PMID: 20795753 DOI: 10.2165/11537190-000000000-00000] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Currently approved multiple sclerosis (MS) therapeutics have a mainly anti-inflammatory mode of action. However, a number of promising clinical trials have been initiated that either focus on neuroprotection or follow completely different treatment strategies. So far, all of these clinical trials have failed to show efficacy or had to be halted prematurely because of unexpected adverse events. Some others show results that are of unknown significance with regard to a reliable assessment of true efficacy versus safety. For example, trials addressing the highly promising sodium channel blockers are under close observation because of potential adverse effects after drug withdrawal. Previously failed therapeutic approaches in MS have indicated that there are discrepancies between the theoretical expectations and practical outcomes of different compounds. Learning from these failures helps to optimize future study designs and to reduce risks to patients. This review summarizes trials on MS treatments since 2001 that failed or were interrupted, attempts to analyze the underlying reasons for failure, and discusses the implications for our current view of MS pathogenesis, clinical practice, and the design of future studies. In order to maintain clarity, this review focuses on neuroprotective and various other treatment strategies. Clinical trials addressing anti-inflammatory research strategies are presented elsewhere.
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Affiliation(s)
- Sven G Meuth
- Department of Neurology, University of Wuerzburg, Wuerzburg, Germany
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Abstract
Recent clinical studies in multiple sclerosis have provided new data on glatiramer acetate, interferon-beta preparations and natalizumab, which will have important implications for optimising patient care. Once a diagnosis has been made with confidence, early initiation of immunotherapy is warranted because of the presence of continuous inflammatory disease activity. Approval for therapy in patients with a clinically isolated syndrome has been granted to several first-line treatments, and most recently to glatiramer acetate. The utility of systematic frequent MRI monitoring of disease activity and response to therapy is not yet clearly established. Treatment efficacy after initiating therapy at the first demyelinating episode has to be followed carefully and re-evaluated whenever necessary. The occurrence of further relapses, confirmed disability progression or MRI evidence of persistent or aggravated disease activity would be regarded as evidence for an inadequate treatment response. However, limitations of clinical scores in faithfully reflecting disease activity at all times, as well as uncertainties about the discriminatory capacity of surrogate measures such as MRI, need to be clarified before clear-cut recommendations on treatment failure can be advocated. Escalation therapy is reserved for patients presenting with 'aggressive disease', which can be operationally defined as the occurrence of two severe relapses within twelve months, together with either MRI evidence for persistent disease activity or a two-point progression of disability on the EDSS.
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Ruiz-Antorán B, Agustí Escasany A, Vallano Ferraz A, Danés Carreras I, Riba N, Mateu Escudero S, Costa J, Sánchez Santiago MB, Laredo L, Durán Quintana JA, Castillo JR, Abad-Santos F, Payares Herrera C, Sádaba Díaz de Rada B, Gómez Ontañón E. Use of non-specific intravenous human immunoglobulins in Spanish hospitals; need for a hospital protocol. Eur J Clin Pharmacol 2010; 66:633-41. [PMID: 20204337 DOI: 10.1007/s00228-010-0800-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2009] [Accepted: 02/08/2010] [Indexed: 11/29/2022]
Abstract
UNLABELLED Intravenous immunoglobulin (IVIG) use in non-approved indications, the increase in consumption and its high cost recommend rationalisation in its utilisation. AIMS To assess the use of IVIG in Spanish hospitals. METHODS An observational, prospective and multicentre drug utilisation study was conducted in 13 tertiary Spanish hospitals. Data were collected for 3 months in patients receiving any IVIG. Patient demographics, indication for IVIG use, dosage regimen and cost of treatment were collected. RESULTS Five hundred and fifty-four patients (mean age of 52 years) were included in the study. A total of 1,287 prescriptions were administered, and the average number of prescriptions per patient was 2.3. The mean daily dose was 24 g (range 0.6-90 g). Overall, IVIG was prescribed for authorised indications in 335 patients (60%) with 953 prescriptions (74%), for non-authorised indications with scientific evidentiary support in 86 patients (16%) with 137 prescriptions (11%), and non-authorised and non-accepted indications in 133 patients (24%) with 197 prescriptions (15%). The most frequent authorised indications were primary and secondary immunodeficiencies, and the most frequent non-authorised and non-accepted indications were multiple sclerosis and bullous dermatosis. The mean cost of IVIG per patient for authorised indications was 2,636.2 <euro>, non-authorised indications with scientific support 5,262.1 <euro> and non-accepted indications 3,555.8 <euro>. CONCLUSIONS IVIG is prescribed for a significant number of non-authorised and non-accepted indications with a notable cost. There is an important variability in IVIG prescriptions between hospitals, indicating room for improvement in IVIG use and the need for a consensus of protocol use.
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Affiliation(s)
- Belen Ruiz-Antorán
- Clinical Pharmacology Department, Puerta de Hierro Majadahonda University Hospital, C/ Manuel de Falla 1, 28222, Majadahonda, Madrid, Spain.
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Liumbruno GM, Bennardello F, Lattanzio A, Piccoli P, Rossettias G. Recommendations for the use of albumin and immunoglobulins. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2009; 7:216-34. [PMID: 19657486 PMCID: PMC2719274 DOI: 10.2450/2009.0094-09] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Giancarlo Maria Liumbruno
- UU.OO.CC. di Immunoematologia e Medicina Trasfusionale e Patologia Clinica, Ospedale San Giovanni Calibita Fatebenefratelli, Roma, Italy.
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Monomeric IgG is neuroprotective via enhancing microglial recycling endocytosis and TNF-alpha. J Neurosci 2009; 28:12199-211. [PMID: 19020014 DOI: 10.1523/jneurosci.3856-08.2008] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
In brain, monomeric immunoglobin G (IgG) is regarded as quiescent and only poised to initiate potentially injurious inflammatory reactions via immune complex formation associated with phagocytosis and tumor necrosis factor alpha (TNF-alpha) production in response to disease. Using rat hippocampal slice and microglial cultures, here we show instead that physiological levels (i.e., 0.2-20 microg/ml) of monomeric IgG unassociated with disease triggered benign low-level proinflammatory signaling that was neuroprotective against CA1 area excitotoxicity and followed a U-shaped or hormetic dose-response. The data indicate that physiological IgG levels activated microglia by enhancing recycling endocytosis plus TNF-alpha release from these cells to produce the neuroprotection. Minocycline, known for its anti-inflammatory and neuroprotective effects when given after disease onset, abrogated IgG-mediated neuroprotection and related microglial effects when given before injury. In contrast, E-prostanoid receptor subtype 2 (EP2) activation, which served as an exemplary paracrine stimulus like the one expected from neuronal activity, amplified IgG-mediated increased microglial recycling endocytosis and TNF-alpha production. Furthermore, like monomeric IgG these EP2 related effects took days to be effective, suggesting both were adaptive anabolic effects consistent with those seen from other long-term preconditioning stimuli requiring de novo protein synthesis. The data provide the first evidence that brain monomeric IgG at physiological levels can have signaling function via enhanced recycling endocytosis/TNF-alpha production from microglia unassociated with disease and that these IgG-mediated changes may be a means by which paracrine signaling from neuronal activity influences microglia to evoke neuroprotection. The data provide further support that low-level proinflammatory neural immune signaling unassociated with disease enhances brain function.
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Elovaara I, Apostolski S, van Doorn P, Gilhus NE, Hietaharju A, Honkaniemi J, van Schaik IN, Scolding N, Soelberg Sørensen P, Udd B. EFNS guidelines for the use of intravenous immunoglobulin in treatment of neurological diseases. Eur J Neurol 2008; 15:893-908. [DOI: 10.1111/j.1468-1331.2008.02246.x] [Citation(s) in RCA: 219] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ballow M. Immunoglobulin therapy: replacement and immunomodulation. Clin Immunol 2008. [DOI: 10.1016/b978-0-323-04404-2.10085-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Considerations for general anesthesia combined with epidural anesthesia in a patient with stiff-person syndrome. J Anesth 2007; 21:490-2. [PMID: 18008116 DOI: 10.1007/s00540-007-0542-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2007] [Accepted: 05/17/2007] [Indexed: 10/22/2022]
Abstract
We report the successful management of anesthesia in a patient with stiff-person syndrome (SPS) undergoing a thymectomy using a volatile anesthetic combined with epidural anesthesia. The anesthetic concern in patients with SPS is the possibility of postoperative hypotonia due to the presence of excessive gamma-aminobutyric acid (GABA) resulting from an interaction between the anesthetic agents and preoperatively taken therapeutic drugs. Epidural anesthesia has the advantages of decreasing the required amount of anesthetics with GABAergic action, and relieving the postoperative pain that causes the symptoms of SPS. Epidural anesthesia could be a useful technique in SPS patients.
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Multiple sclerosis therapy: An update on recently finished trials. J Neurol 2007; 254:1473-90. [DOI: 10.1007/s00415-007-0684-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2007] [Revised: 06/14/2007] [Accepted: 06/19/2007] [Indexed: 10/22/2022]
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Constantine MM, Thomas W, Whitman L, Kahwash E, Dolan S, Smith S, Caudle C, Burton E, Anderson D. Intravenous immunoglobulin utilization in the Canadian Atlantic provinces: a report of the Atlantic Collaborative Intravenous Immune Globulin Utilization Working Group. Transfusion 2007; 47:2072-80. [DOI: 10.1111/j.1537-2995.2007.01400.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Schaub A, Wymann S, Heller M, Ghielmetti M, Beleznay Z, Stadler BM, Bolli R, Miescher S. Self-Reactivity in the Dimeric Intravenous Immunoglobulin Fraction. Ann N Y Acad Sci 2007; 1110:681-93. [PMID: 17911483 DOI: 10.1196/annals.1423.071] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Therapeutic intravenous immunoglobulin (IVIg) preparations contain antibodies reflecting the cumulative antigen experience of the donor population. IVIg contains variable amounts of monomeric and dimeric IgG, but there is little information available on their comparative antibody specificities. We have isolated highly purified fractions of monomeric and dimeric IgG by size-exclusion chromatography. Following treatment of all fractions at pH4, analyses by immunodot and immunocytology on human cell lines showed a preferential recognition of autoantigens in the dimeric IgG fraction. Investigation of the HEp-2 cytoplasmic proteome by 2D-PAGE, Western blot, and subsequent identification of IVIg reactive spots by mass spectrometry (LC-MS/MS) showed that IVIg recognized only a restricted set of the total proteins. Similar experiments showed that more antigens were recognized by the dimeric IgG fraction, especially when the dissociated dimer fraction was used, as compared to its monomeric counterpart. These observations are consistent with idiotype-anti-idiotype masking of auto-specific Abs in the dimeric fraction of IVIg.
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Affiliation(s)
- Alexander Schaub
- Institute of Immunology, University Hospital Bern, Bern, Switzerland
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Kumar A, Teuber SS, Gershwin ME. Intravenous immunoglobulin: striving for appropriate use. Int Arch Allergy Immunol 2006; 140:185-98. [PMID: 16682800 DOI: 10.1159/000093204] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Intravenous immunoglobulin (IVIG) is the mainstay therapy in human immune deficiency states characterized by qualitative and quantitative reductions in B cells. In addition, however, there is widespread use of IVIG in a number of other areas, including neuroimmunologic, infectious, dermatologic, hematologic, autoimmune, inflammatory and idiopathic disorders. In many of these cases, there are little objective data to support the use. METHODS We performed a review of more than 400 publications in PubMed using the key words 'intravenous immunoglobulin' and excluded publications that focused on immune deficiency, for which the indication for IVIG is already clear. RESULTS For a number of off-label indications, there is significant evidence of efficacy and IVIG has become the standard of care for many clinical syndromes other than immune deficiency. In some conditions, however, the data have not been well controlled or randomized and are often limited to case reports that are difficult to interpret. Although the critical shortage of IVIG of the last decade is no longer an issue, IVIG is expensive and not without risk. The use of IVIG should be based not only on clinical data, but also, and especially, on the biological rationale for its use. CONCLUSIONS The appropriate use of IVIG is an important issue that is difficult to resolve, and will continue to challenge clinicians based on expense and potentially limited supply, including the intrinsic limitations of donor plasma. The establishment of national and international voluntary registries to report use of IVIG in disorders for which evidence is lacking would be a first step toward facilitating randomized, controlled clinical trials.
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Affiliation(s)
- Arvind Kumar
- Division of Rheumatology, Allergy and Clinical Immunology, Department of Internal Medicine,University of California at Davis School of Medicine, Davis, Calif. 95616, USA
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