1
|
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.
Collapse
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.
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Briani C, Cocito D, Campagnolo M, Doneddu PE, Nobile-Orazio E. Update on therapy of chronic immune-mediated neuropathies. Neurol Sci 2022; 43:605-614. [PMID: 33452933 DOI: 10.1007/s10072-020-04998-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/12/2020] [Indexed: 12/27/2022]
Abstract
Chronic immune-mediated neuropathies, including chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), neuropathies associated with monoclonal gammopathy, and multifocal motor neuropathy (MMN), are a group of disorders deemed to be caused by an immune response against peripheral nerve antigens. Several immune therapies have been reported to be variably effective in these neuropathies including steroids, plasma exchange, and high-dose intravenous (IVIg) or subcutaneous (SCIg) immunoglobulins. These therapies are however far from being invariably effective and may be associated with a number of side effects leading to the use of immunosuppressive agents whose efficacy has not been so far confirmed in randomized trials. More recently, new biological agents, such as rituximab, have proved to be effective in patients with neuropathy associated with IgM monoclonal gammopathy and are currently tested in CIDP.
Collapse
Affiliation(s)
- Chiara Briani
- Neurology Unit, Department of Neuroscience, University of Padova, Via Giustiniani, 5, 35128, Padova, Italy.
| | - Dario Cocito
- Istituti Clinici Scientifici Maugeri, Torino, Italy
| | - Marta Campagnolo
- Neurology Unit, Department of Neuroscience, University of Padova, Via Giustiniani, 5, 35128, Padova, Italy
| | - Pietro Emiliano Doneddu
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical and Research Institute, Rozzano, Milan, Italy
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical and Research Institute, Rozzano, Milan, Italy.,Department of Medical Biotechnology and Translational Medicine, Milan University, Milan, Italy
| |
Collapse
|
4
|
van Veen R, Wieske L, Lucke I, Adrichem ME, Merkies ISJ, van Schaik IN, Eftimov F. Assessing deterioration using impairment and functional outcome measures in chronic inflammatory demyelinating polyneuropathy: a post-hoc analysis of the IOC trial. J Peripher Nerv Syst 2022; 27:144-158. [PMID: 35507446 PMCID: PMC9321849 DOI: 10.1111/jns.12497] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/05/2022] [Accepted: 04/10/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS It is unclear whether frequently used cut-off values for outcome measures defining minimal clinically important differences (MCIDs) can accurately identify meaningful deterioration in chronic inflammatory demyelinating polyneuropathy (CIDP). METHODS We used data from the IOC trial, in which sixty clinically stable CIDP patients were randomized to IVIg withdrawal or continuation. We calculated change scores of the Inflammatory Rasch-Built Overall Disability Scale (I-RODS), grip strength, and MRC sum score (MRC-SS) and classified visits based on a treatment anchor (i.e. decision to restart/increase treatment after reaching a predefined early endpoint of deterioration). The variability of scores in patients without deterioration was calculated using the limits of agreement. We defined optimized MCIDs for deterioration and specific combinations of MCIDs from different outcome measures, and subsequently calculated the accuracies of the (combined) MCIDs. RESULTS Substantial variability was found in scores of the I-RODS, grip strength and MRC-SS in patients without deterioration over time, and most MCIDs were within the limits of the variability observed in patients without deterioration. Some MCID cut-offs were insensitive but highly specific for detecting deterioration, e.g. the MCID-SE of -1.96 of the I-RODS and -2 point on the MRC-SS. Others were sensitive, but less specific, e.g. -4 centiles of the I-RODS. Some combined MCIDs resulted in high specificities and moderate sensitivities. INTERPRETATION Our results suggest that clinically important deterioration cannot be distinguished from variability over time with currently used MCIDs on the individual level. Combinations of MCIDs might improve the accuracy of determining deterioration, but this needs validation.
Collapse
Affiliation(s)
- Robin van Veen
- Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Luuk Wieske
- Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Department of Clinical Neurophysiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Ilse Lucke
- Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Max E Adrichem
- Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Ingemar S J Merkies
- Maastricht Academic Medical Centre, Maastricht, the Netherlands.,Curaçao Medical Centre, Willemstad, Curacao
| | - Ivo N van Schaik
- Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Spaarne Gasthuis, Haarlem, the Netherlands
| | - Filip Eftimov
- Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| |
Collapse
|
5
|
Merkies ISJ, van Schaik IN, Bril V, Hartung HP, Lewis RA, Sobue G, Lawo JP, Mielke O, Cornblath DR. Analysis of Relapse by Inflammatory Rasch-built Overall Disability Scale Status in the PATH Study of Subcutaneous Immunoglobulin in Chronic Inflammatory Demyelinating Polyneuropathy. J Peripher Nerv Syst 2022; 27:159-165. [PMID: 35266243 PMCID: PMC9310622 DOI: 10.1111/jns.12487] [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: 01/25/2022] [Revised: 02/24/2022] [Accepted: 03/05/2022] [Indexed: 11/30/2022]
Abstract
Clinical trials in chronic inflammatory demyelinating polyneuropathy (CIDP) often assess efficacy using the ordinal Inflammatory Neuropathy Cause and Treatment (INCAT) disability score. Here, data from the PATH study was reanalyzed using change in Inflammatory Rasch‐built Overall Disability Scale (I‐RODS) to define CIDP relapse instead of INCAT. The PATH study comprised an intravenous immunoglobulin (IVIG) dependency period and an IVIG (IgPro10 [Privigen]) restabilization period; subjects were then randomized to weekly maintenance subcutaneous immunoglobulin (SCIG; IgPro20 [Hizentra]) 0.2 g/kg or 0.4 g/kg or placebo for 24 weeks. CIDP relapse was defined as ≥1‐point deterioration in adjusted INCAT, with a primary endpoint of relapse or withdrawal rates. This retrospective exploratory analysis redefined relapse using I‐RODS via three different cut‐off methods: an individual variability method, fixed cut‐off of ≥8‐point deterioration on I‐RODS centile score or ≥4‐point deterioration on I‐RODS raw score. Relapse or withdrawal rates were 47% for placebo, 34% for 0.2 g/kg IgPro20 and 19% for 0.4 g/kg IgPro20 using the raw score; 40%, 28% and 15%, respectively using the centile score, and 49%, 40% and 27%, respectively using the individual variability method. IgPro20 was shown to be efficacious as a maintenance therapy for CIDP when relapse was defined using I‐RODS. A stable response pattern was shown for I‐RODS across various applied cut‐offs, which could be applied in future clinical trials.
Collapse
Affiliation(s)
- Ingemar S J Merkies
- Department of Neurology, Maastricht University Medical Center, Maastricht, Netherlands.,Department of Neurology, Curaçao Medical Center, Willemstad, Curaçao
| | - Ivo N van Schaik
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands.,Spaarne Gasthuis, Haarlem, Netherlands
| | - Vera Bril
- Department of Medicine (Neurology), University Health Network, University of Toronto, Toronto, Canada.,Institute for Research and Medical Consultations, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Hans-Peter Hartung
- Department of Neurology, UKD and Center for Neurology and Neuropsychiatry, LVR Klinikum, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany.,Brain and Mind Centre, University of Sydney, Sydney, Australia.,Medical University of Vienna, Vienna, Austria
| | - 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
| | | | | | - David R Cornblath
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Querol L, Lleixà C. Novel Immunological and Therapeutic Insights in Guillain-Barré Syndrome and CIDP. Neurotherapeutics 2021; 18:2222-2235. [PMID: 34549385 PMCID: PMC8455117 DOI: 10.1007/s13311-021-01117-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2021] [Indexed: 12/22/2022] Open
Abstract
Inflammatory neuropathies are a heterogeneous group of rare diseases of the peripheral nervous system that include acute and chronic diseases, such as Guillain-Barré syndrome (GBS) and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). The etiology and pathophysiological mechanisms of inflammatory neuropathies are only partly known, but are considered autoimmune disorders in which an aberrant immune response, including cellular and humoral components, is directed towards components of the peripheral nerve causing demyelination and axonal damage. Therapy of these disorders includes broad-spectrum immunomodulatory and immunosuppressive treatments, such as intravenous immunoglobulin, corticosteroids, or plasma exchange. However, a significant proportion of patients do not respond to any of these therapies, and treatment selection is not optimized according to disease pathophysiology. Therefore, research on disease pathophysiology aiming to reveal clinically and functionally relevant disease mechanisms and the development of new treatment approaches are needed to optimize disease outcomes in CIDP and GBS. This topical review describes immunological progress that may help guide therapeutic strategies in the future in these two disorders.
Collapse
Affiliation(s)
- Luis Querol
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Mas Casanovas 90, 08041, Barcelona, Spain.
- Centro Para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER), Madrid, Spain.
| | - Cinta Lleixà
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Mas Casanovas 90, 08041, Barcelona, Spain
| |
Collapse
|
8
|
Abstract
What is in the Literature focuses on peripheral neuropathies with new and practical information related to the diagnosis, treatment, and management. Diagnostic and treatment guidelines are available for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) but not all clinicians follow them resulting in erroneous diagnoses and prolonged treatment. Secondary axonal loss in CIDP causes increased connective tissue in muscle. Antibodies to proteins at the node of Ranvier are found in a small percentage of patients with CIDP. The differential diagnosis for CIDP-like neuropathies includes amyloid neuropathy and POEMS (polyneuropathy, organomegaly, endocrinopathy, M-protein, skin changes) and amyloidosis. Upper limits for cerebral spinal fluid protein are 0.45 g/L and cell count <10/µL, but both may be too low. Hyperactive reflexes may occur in Guillain-Barré syndrome and should not exclude the diagnosis. In severely affected Guillain-Barré syndrome patients, a second dose of intravenous immune globulin within 4 weeks of onset is not likely to be effective.
Collapse
|
9
|
Beydoun SR, Sharma KR, Bassam BA, Pulley MT, Shije JZ, Kafal A. Individualizing Therapy in CIDP: A Mini-Review Comparing the Pharmacokinetics of Ig With SCIg and IVIg. Front Neurol 2021; 12:638816. [PMID: 33763019 PMCID: PMC7982536 DOI: 10.3389/fneur.2021.638816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/10/2021] [Indexed: 11/13/2022] Open
Abstract
Immunoglobulin (Ig) therapy is a first-line treatment for CIDP, which can be administered intravenously (IVIg) or subcutaneously (SCIg) and is often required long term. The differences between these modes of administration and how they can affect dosing strategies and treatment optimization need to be understood. In general, the efficacy of IVIg and SCIg appear comparable in CIDP, but SCIg may offer some safety and quality of life advantages to some patients. The differences in pharmacokinetic (PK) profile and infusion regimens account for many of the differences between IVIg and SCIg. IVIg is administered as a large bolus every 3–4 weeks resulting in cyclic fluctuations in Ig concentration that have been linked to systemic adverse events (AEs) (potentially caused by high Ig levels) and end of dose “wear-off” effects (potentially caused by low Ig concentration). SCIg is administered as a smaller weekly, or twice weekly, volume resulting in near steady-state Ig levels that have been linked to continuously maintained function and reduced systemic AEs, but an increase in local reactions at the infusion site. The reduced frequency of systemic AEs observed with SCIg is likely related to the avoidance of high Ig concentrations. Some small studies in immune-mediated neuropathies have focused on serum Ig data to evaluate its potential use as a biomarker to aid clinical decision-making. Analyzing dose data may help understand how establishing and monitoring patients' Ig concentration could aid dose optimization and the transition from IVIg to SCIg therapy.
Collapse
Affiliation(s)
- Said R Beydoun
- Neuromuscular Division, Keck School of Medicine of University of Southern California (USC), Los Angeles, CA, United States
| | - Khema R Sharma
- Neurology Department, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Bassam A Bassam
- Neurology Department, University of South Alabama College of Medicine, Mobile, AL, United States
| | - Michael T Pulley
- Department of Neurology, University of Florida College of Medicine, Jacksonville, FL, United States
| | - Jeffrey Z Shije
- Department of Neurology, University of Florida College of Medicine, Jacksonville, FL, United States
| | - Ayman Kafal
- CSL Behring, King of Prussia, PA, United States
| |
Collapse
|
10
|
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.
Collapse
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.
| | | |
Collapse
|
11
|
Querol L, Crabtree M, Herepath M, Priedane E, Viejo Viejo I, Agush S, Sommerer P. Systematic literature review of burden of illness in chronic inflammatory demyelinating polyneuropathy (CIDP). J Neurol 2020; 268:3706-3716. [PMID: 32583051 PMCID: PMC8463372 DOI: 10.1007/s00415-020-09998-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 06/10/2020] [Accepted: 06/12/2020] [Indexed: 12/13/2022]
Abstract
Background Chronic inflammatory demyelinating polyneuropathy (CIDP) is a rare neurological disorder characterised by muscle weakness and impaired sensory function. The present study provides a comprehensive literature review of the burden of illness of CIDP. Methods Systematic literature search of PubMed, Embase, and key conferences in May 2019. Search terms identified studies on the epidemiology, humanistic burden, current treatment, and economic burden of CIDP published since 2009 in English. Results Forty-five full texts and nineteen conference proceedings were identified on the epidemiology (n = 9), humanistic burden (n = 7), current treatment (n = 40), and economic burden (n = 8) of CIDP. Epidemiological studies showed incidence and prevalence of 0.2–1.6 and 0.8–8.9 per 100,000, respectively, depending on geography and diagnostic criteria. Humanistic burden studies revealed that patients experienced physical and psychosocial burden, including impaired physical function, pain and depression. Publications on current treatments reported on six main types of therapy: intravenous immunoglobulins, subcutaneous immunoglobulins, corticosteroids, plasma exchange, immunosuppressants, and immunomodulators. Treatments may be burdensome, due to adverse events and reduced independence caused by treatment administration setting. In Germany, UK, France, and the US, CIDP economic burden was driven by direct costs of treatment and hospitalisation. CIDP was associated with indirect costs driven by impaired productivity. Conclusions This first systematic review of CIDP burden of illness demonstrates the high physical and psychosocial burden of this rare disease. Future research is required to fully characterise the burden of CIDP, and to understand how appropriate treatment can mitigate burden for patients and healthcare systems. Electronic supplementary material The online version of this article (10.1007/s00415-020-09998-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Luis Querol
- Institut de Recerca Biomèdica Sant Pau, Barcelona, Spain.
| | | | - M Herepath
- Optimal Access Life Science Consulting Limited, Swansea, UK
| | | | | | - S Agush
- Huron Consulting Group, London, UK
| | | |
Collapse
|
12
|
Lamb YN, Syed YY, Dhillon S. Immune Globulin Subcutaneous (Human) 20% (Hizentra ®): A Review in Chronic Inflammatory Demyelinating Polyneuropathy. CNS Drugs 2019; 33:831-838. [PMID: 31347096 DOI: 10.1007/s40263-019-00655-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Intravenous immunoglobulin (IVIg) is well-established in the treatment of patients with chronic inflammatory demyelinating polyneuropathy (CIDP). Immune globulin subcutaneous (human) 20% liquid (Hizentra®; referred to as IgPro20 hereafter) has recently been approved in a number of countries, including the USA and those of the EU, as maintenance therapy in patients with CIDP. In the pivotal phase III PATH trial in adults with CIDP who were first stabilized on IVIg therapy, maintenance therapy with IgPro20 for 24 weeks significantly reduced CIDP relapse or study withdrawal rates versus placebo. Efficacy was sustained during ≤ 48 weeks of additional treatment with IgPro20 in the open-label PATH extension study. IgPro20 was generally well tolerated, with low rates of systemic adverse events (AEs); the most common AEs were local reactions (e.g. infusion-site erythema, infusion-site swelling). In PATH, more than one-half of IgPro20 recipients preferred this therapy to their previous IVIg therapy. IgPro20 offers a convenient alternative to IVIg with a better systemic AEs profile and thus extends the options for maintenance therapy in CIDP.
Collapse
Affiliation(s)
- Yvette N Lamb
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
| | - Yahiya Y Syed
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand
| | - Sohita Dhillon
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand
| |
Collapse
|
13
|
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.
Collapse
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
| | | |
Collapse
|