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Querol L, De Sèze J, Dysgaard T, Levine T, Rao TH, Rivner M, Hartung HP, Kiessling P, Shimizu S, Marmol D, Bozorg A, Colson AO, Massow U, Eftimov F. Efficacy, safety and tolerability of rozanolixizumab in patients with chronic inflammatory demyelinating polyradiculoneuropathy: a randomised, subject-blind, investigator-blind, placebo-controlled, phase 2a trial and open-label extension study. J Neurol Neurosurg Psychiatry 2024; 95:845-854. [PMID: 38729747 PMCID: PMC11347201 DOI: 10.1136/jnnp-2023-333112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 02/13/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a peripheral nerve disorder characterised by weakness and sensory loss. We assessed the neonatal Fc receptor inhibitor rozanolixizumab for CIDP management. METHODS CIDP01 (NCT03861481) was a randomised, subject-blind, investigator-blind, placebo-controlled, phase 2a study. Adults with definite or probable CIDP receiving subcutaneous or intravenous immunoglobulin maintenance therapy were randomised 1:1 to 12 once-weekly subcutaneous infusions of rozanolixizumab 10 mg/kg or placebo, stratified according to previous immunoglobulin administration route. Investigators administering treatment and assessing efficacy, and patients, were blinded. The primary outcome was a change from baseline (CFB) to day 85 in inflammatory Rasch-built Overall Disability Scale (iRODS) score. Eligible patients who completed CIDP01 entered the open-label extension CIDP04 (NCT04051944). RESULTS In CIDP01, between 26 March 2019 and 31 March 2021, 34 patients were randomised to rozanolixizumab or placebo (17 (50%) each). No significant difference in CFB to day 85 in iRODS centile score was observed between rozanolixizumab (least squares mean 2.0 (SE 3.2)) and placebo (3.4 (2.6); difference -1.5 (90% CI -7.5 to 4.5)). Overall, 14 (82%) patients receiving rozanolixizumab and 13 (76%) receiving placebo experienced a treatment-emergent adverse event during the treatment period. Across CIDP01 and CIDP04, rozanolixizumab was well tolerated over up to 614 days; no clinically meaningful efficacy results were seen. No deaths occurred. CONCLUSIONS Rozanolixizumab did not show efficacy in patients with CIDP in this study, although this could be due to a relatively high placebo stability rate. Rozanolixizumab was well tolerated over medium-to-long-term weekly use, with an acceptable safety profile.
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Affiliation(s)
- Luis Querol
- Neuromuscular Diseases Unit - Neurology Department, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
- Center for Network Research in Rare Diseases - CIBERER, Madrid, Spain
| | - Jérôme De Sèze
- Department of Neurology, Clinical Investigation Centre, University Hospital of Strasbourg, Strasbourg, France
| | - Tina Dysgaard
- Department of Neurology, Copenhagen Neuromuscular Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Todd Levine
- Honor Health Neurology, Bob Bové Neuroscience Institute, Scottsdale, Arizona, USA
| | - T Hemanth Rao
- The Neurological Institute, PA, Charlotte, North Carolina, USA
| | - Michael Rivner
- Department of Neurology, Augusta University, Augusta, Atlanta, Georgia, USA
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
- Brain and Mind Center, Medical Faculty, University of Sydney, Sydney, New South Wales, Australia
- Department of Neurology, Palacký University, Olomouc, Czech Republic
| | | | | | | | - Ali Bozorg
- UCB Pharma, Morrisville, North Carolina, USA
| | | | | | - Filip Eftimov
- Department of Neurology, Amsterdam Neuroscience, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
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2
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Kapoor M, Khoo A, Lunn MPT, Reddel S, Carr AS. Immunoglobulin use in neurology: a practical approach. Pract Neurol 2024:pn-2022-003655. [PMID: 39097408 DOI: 10.1136/pn-2022-003655] [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: 07/03/2024] [Indexed: 08/05/2024]
Abstract
Human immunoglobulin, delivered either intravenously (IVIg) or subcutaneously, is used to treat a range of immune-mediated neurological disorders. It has a role in acute or subacute inflammatory disease control and as a maintenance therapy in chronic disease management. This review considers mechanisms of IVIg action and the evidence for IVIg in neurological conditions. We use Guillain-Barré syndrome and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) as frameworks to demonstrate an approach to IVIg use in acute and chronic dysimmune neurological conditions across two different healthcare systems: the UK and Australia. We highlight the benefits and limitations of IVIg and focus on practical considerations such as informed consent, managing risks and adverse effects, optimal dosing and monitoring response. We use these basic clinical practice principles to discuss the judicious use of an expensive and scarce blood product with international relevance.
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Affiliation(s)
- Mahima Kapoor
- Neuroscience / FMNHS / School of Translational Medicine, Monash University, Melbourne, Victoria, Australia
| | - Anthony Khoo
- Flinders University College of Medicine and Public Health, Adelaide, South Australia, Australia
- Department of Neurology, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Michael P T Lunn
- Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
- UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Stephen Reddel
- ANZAC Research Institute, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Aisling S Carr
- UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
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3
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Svačina MKR, Meißner A, Schweitzer F, Ladwig A, Pitarokoili K, Kofler DM, Sprenger‐Svačina A, Schneider C, Kohle F, Klein I, Wüstenberg H, Lehmann HC. Immunomodulatory effects of intravenous and subcutaneous immunoglobulin in chronic inflammatory demyelinating polyneuropathy: An observational study. Eur J Neurol 2024; 31:e16079. [PMID: 37789648 PMCID: PMC11235934 DOI: 10.1111/ene.16079] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/23/2023] [Accepted: 09/14/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND AND PURPOSE It is not known whether the route of administration affects the mechanisms of action of therapeutic immunoglobulin in chronic inflammatory demyelinating polyneuropathy (CIDP). The aim of this study, therefore, was to compare the immunomodulatory effects of intravenous (IVIg) and subcutaneous immunoglobulin (SCIg) in patients with CIDP and in IVIg-treated common variable immunodeficiency (CVID) patients. METHODS Serum and peripheral blood mononuclear cell samples were obtained from 30 CIDP patients receiving IVIg, 10 CIDP patients receiving SCIg, and 15 patients with CVID receiving IVIg. Samples and clinical data were obtained prior to IVIg/SCIg and at 3 days, 7 days, and, in CIDP patients receiving IVIg, 21 days post-administration. Serum cytokines were assessed by Luminex-based multiplex assay and enzyme-linked immunosorbent assay. Immune cells were characterized by flow cytometry. RESULTS Immune cell profiles of CIDP and CVID patients differed in frequencies of myeloid dendritic cells and cytotoxic natural killer cells. During treatment with IVIg or SCIg in CIDP patients, cellular immunomarkers were largely similar. CIDP patients receiving IVIg had higher macrophage inflammatory protein (MIP)-1α (p = 0.01), interleukin (IL)-4 (p = 0.04), and IL-33 (p = 0.04) levels than SCIg recipients. IVIg treatment more broadly modulated cytokines in CIDP than SCIg treatment. CONCLUSIONS Our study demonstrates that the modulation of cellular immunomarkers in CIDP is independent of the application route of therapeutic immunoglobulin. Minor differences were observed between CIDP and CVID patients. In contrast, cytokines were differentially modulated by IVIg and SCIg in CIDP.
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Affiliation(s)
- Martin K. R. Svačina
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | - Anika Meißner
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | - Finja Schweitzer
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | - Anne Ladwig
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | | | - David M. Kofler
- Medical Clinic I, Department of Immunology and RheumatologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | - Alina Sprenger‐Svačina
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | - Christian Schneider
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
- Department of NeurologySt. Katharinen HospitalFrechenGermany
| | - Felix Kohle
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | - Ines Klein
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | - Hauke Wüstenberg
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | - Helmar C. Lehmann
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
- Department of NeurologyClinic of Leverkusen gGmbHLeverkusenGermany
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4
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Allen JA. SARS-CoV-2 Vaccination and Autoimmune Neuropathies: Rebalancing the Risk. Neurology 2023; 100:55-56. [PMID: 36127140 DOI: 10.1212/wnl.0000000000201366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 08/16/2022] [Indexed: 02/05/2023] Open
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5
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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.
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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
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Kapoor M, Carr A, Foiani M, Heslegrave A, Zetterberg H, Malaspina A, Compton L, Hutton E, Rossor A, Reilly MM, Lunn MP. Association of plasma neurofilament light chain with disease activity in chronic inflammatory demyelinating polyradiculoneuropathy. Eur J Neurol 2022; 29:3347-3357. [PMID: 35837802 PMCID: PMC9796374 DOI: 10.1111/ene.15496] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/06/2022] [Accepted: 06/25/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND PURPOSE This study was undertaken to explore associations between plasma neurofilament light chain (pNfL) concentration (pg/ml) and disease activity in patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and examine the usefulness of pNfL concentrations in determining disease remission. METHODS We examined pNfL concentrations in treatment-naïve CIDP patients (n = 10) before and after intravenous immunoglobulin (IVIg) induction treatment, in pNfL concentrations in patients on maintenance IVIg treatment who had stable (n = 15) versus unstable disease (n = 9), and in clinically stable IVIg-treated patients (n = 10) in whom we suspended IVIg to determine disease activity and ongoing need for maintenance IVIg. pNfL concentrations in an age-matched healthy control group were measured for comparison. RESULTS Among treatment-naïve patients, pNfL concentration was higher in patients before IVIg treatment than healthy controls and subsequently reduced to be comparable to control group values after IVIg induction. Among CIDP patients on IVIg treatment, pNfL concentration was significantly higher in unstable patients than stable patients. A pNFL concentration > 16.6 pg/ml distinguished unstable treated CIDP from stable treated CIDP (sensitivity = 86.7%, specificity = 66.7%, area under receiver operating characteristic curve = 0.73). Among the treatment withdrawal group, there was a statistically significant correlation between pNfL concentration at time of IVIg withdrawal and the likelihood of relapse (r = 0.72, p < 0.05), suggesting an association of higher pNfL concentration with active disease. CONCLUSIONS pNfL concentrations may be a sensitive, clinically useful biomarker in assessing subclinical disease activity.
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Affiliation(s)
- Mahima Kapoor
- Department of Neuromuscular DiseasesUniversity College London Queen Square Institute of NeurologyLondonUK
- Department of NeurosciencesCentral Clinical School, Monash University, Alfred CentreMelbourneVictoriaAustralia
| | - Aisling Carr
- Department of Neuromuscular DiseasesUniversity College London Queen Square Institute of NeurologyLondonUK
- Centre for Neuromuscular diseasesNational Hospital for Neurology and NeurosurgeryLondonUK
| | - Martha Foiani
- Department of Neurodegenerative DiseaseUniversity College London Queen Square Institute of NeurologyLondonUK
- UK Dementia Research Institute at University College LondonLondonUK
| | - Amanda Heslegrave
- Department of Neurodegenerative DiseaseUniversity College London Queen Square Institute of NeurologyLondonUK
- UK Dementia Research Institute at University College LondonLondonUK
| | - Henrik Zetterberg
- Department of Neurodegenerative DiseaseUniversity College London Queen Square Institute of NeurologyLondonUK
- UK Dementia Research Institute at University College LondonLondonUK
- Clinical Neurochemistry LaboratorySahlgrenska University HospitalMölndalSweden
- Department of Psychiatry and NeurochemistryInstitute of Neuroscience and Physiology, Sahlgrenska Academy at University of GothenburgMölndalSweden
- Hong Kong Center for Neurodegenerative DiseasesHong KongChina
| | - Andrea Malaspina
- Department of Neuromuscular DiseasesUniversity College London Queen Square Institute of NeurologyLondonUK
- University College London Queen Square Motor Neuron Disease Centre, Queen Square Institute of NeurologyLondonUK
- Centre for Neuroscience and TraumaBlizard Institute, Barts and London School of Medicine and Dentistry, Queen Mary University of LondonLondonUK
- ALS Biomarkers StudyUniversity College LondonLondonUK
| | - Laura Compton
- Centre for Neuromuscular diseasesNational Hospital for Neurology and NeurosurgeryLondonUK
| | - Elspeth Hutton
- Department of NeurosciencesCentral Clinical School, Monash University, Alfred CentreMelbourneVictoriaAustralia
| | - Alexander Rossor
- Department of Neuromuscular DiseasesUniversity College London Queen Square Institute of NeurologyLondonUK
- Centre for Neuromuscular diseasesNational Hospital for Neurology and NeurosurgeryLondonUK
| | - Mary M. Reilly
- Department of Neuromuscular DiseasesUniversity College London Queen Square Institute of NeurologyLondonUK
- Centre for Neuromuscular diseasesNational Hospital for Neurology and NeurosurgeryLondonUK
| | - Michael P. Lunn
- Department of Neuromuscular DiseasesUniversity College London Queen Square Institute of NeurologyLondonUK
- Centre for Neuromuscular diseasesNational Hospital for Neurology and NeurosurgeryLondonUK
- Neuroimmunology and CSF LaboratoryUniversity College London Queen Square Institute of NeurologyLondonUK
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7
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Yi J, Dalakas MC. Long-term Effectiveness of IVIg Maintenance Therapy in 36 Patients With GAD Antibody–Positive Stiff-Person Syndrome. NEUROLOGY - NEUROIMMUNOLOGY NEUROINFLAMMATION 2022; 9:9/5/e200011. [PMID: 35798561 PMCID: PMC9262284 DOI: 10.1212/nxi.0000000000200011] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 05/10/2022] [Indexed: 11/18/2022]
Abstract
Background and Objectives IVIg has been the preferred immunotherapy in stiff-person syndrome (SPS) based on a 3-month controlled trial, but whether it is also effective in inducing long-term benefits or arresting disease progression is unknown. The information is needed because SPS is a progressively disabling disease and IVIg is liberally used as chronic therapy without efficacy data. The present study explores the long-term effects of IVIg in the largest cohort of well-characterized patients with SPS followed by the same clinicians over 10 years. Methods Data of 36 patients (32 glutamic acid decarboxylase [GAD] positive), diagnosed and treated with monthly maintenance IVIg by the same neurologists, were analyzed. Response was assessed by physician-observed changes, patients' reports of symptom improvement, modified Rankin Scale (mRS) scores, and dependency trials evaluating symptom recurrence after stopping IVIg, prolonging infusion frequency, decreasing monthly dose, or wearing-off effects in between doses. Clinically meaningful long-term response was defined by improved mRS scores, improvement in physician-assessed stiffness, balance and gait, and functional decline with dependency trials. Results Twenty-four of 36 (67%) patients had clinically meaningful response over a median 40-month period. Patients with improved mRS scores by 1–2 points manifested improved gait, posture, balance and decreased stiffness, spasms, and startle response; some patients using a wheelchair and those ambulating with devices walked unassisted. In 25% of responders, treatment benefit was sustained for a 40-month median period, but in 29.1%, it declined over a 39-month period; 12.5% exhibited a conditioning effect. Three of 5 patients with cerebellar GAD-SPS variant also improved over time. The 12 patients who did not respond the first 3 months remained unresponsive even if IVIg continued for several months. Discussion This is a large study in 36 patients with SPS demonstrating that monthly maintenance IVIg therapy offers long-term benefits in 67% of patients for a median 3.3-year period. Because 29.1% experienced diminishing benefit over time due to disease progression, the study highlights the need for more effective therapies.
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Affiliation(s)
- Jessica Yi
- From the Department of Neurology (J.Y., M.C.D.), Thomas Jefferson University, Philadelphia, PA; and National and Kapodistrian University of Athens (M.C.D.)
| | - Marinos C Dalakas
- From the Department of Neurology (J.Y., M.C.D.), Thomas Jefferson University, Philadelphia, PA; and National and Kapodistrian University of Athens (M.C.D.). marinos.dalakas@jefferson
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8
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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.
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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
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9
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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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10
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Kapoor M, Compton L, Rossor A, Hutton E, Manji H, Lunn M, Reilly M, Carr A. An approach to assessing immunoglobulin dependence in chronic inflammatory demyelinating inflammatory polyneuropathy. J Peripher Nerv Syst 2021; 26:461-468. [PMID: 34637194 DOI: 10.1111/jns.12470] [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: 09/13/2021] [Revised: 10/02/2021] [Accepted: 10/03/2021] [Indexed: 12/16/2022]
Abstract
Regular immunoglobulin treatment maintains strength and prevents disability in chronic inflammatory demyelinating polyneuropathy (CIDP). Discrimination between active disease, with optimum symptom control on treatment, and disease in remission not requiring treatment is essential for therapeutic decision-making and clinical trial design. To compare treatment cessation versus gradual dose reduction in assessment of disease activity (immunoglobulin dependence) in a cohort of stable CIDP patients on maintenance immunoglobulin treatment. An approach to restabilization of immunoglobulin-dependent individuals is also described. Retrospective review of IVIg cessation or gradual reduction in 33 patients with stable CIDP on maintenance IVIg. Demographic, clinical and treatment data were collected; clinical monitoring data were recorded prospectively as part of routine clinical practice. A total of 21/33 patients (62.6%) were immunoglobulin dependent, (gradual dose reduction:11, cessation:10). Mean change in Inflammatory Rasch-built Overall Disability Scale (I-RODS) (-15, standard deviation [SD] 16) and Medical Research Council Sum Score (MRC-SS) (-4, SD: 4) was clinically and statistically meaningful (>75% exceeded minimum clinically important differences). Mean time to deterioration was 5.0 (SD: 4.6) months, shorter in cessation group (3.5 months) than gradual reduction group (8.8 months). All patients were restabilized to previous baseline (M: 2.3, SD: 4.3 months), half within 1 week of retreatment. A total of 12 patients (37.4%) remained stable without treatment for ≥2 years (remission). A total of 50% were identified rapidly by cessation and 50% by gradual dose reduction requiring mean 4.8 (SD: 2.8) years follow-up and costing £113 623 per person Ig spend. No predictors of disease activity were identified. A treatment cessation trial with close clinical monitoring is an efficient, cost-effective and safe approach to assessing disease activity in CIDP.
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Affiliation(s)
- Mahima Kapoor
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK.,Department of Neurosciences, Central Clinical School, Monash University, The Alfred Centre, Level 6, Melbourne, Australia
| | - Laura Compton
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Alex Rossor
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Elsbeth Hutton
- Department of Neurosciences, Central Clinical School, Monash University, The Alfred Centre, Level 6, Melbourne, Australia
| | - Hadi Manji
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Mike Lunn
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Mary Reilly
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Aisling Carr
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
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11
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Dalakas MC. Update on Intravenous Immunoglobulin in Neurology: Modulating Neuro-autoimmunity, Evolving Factors on Efficacy and Dosing and Challenges on Stopping Chronic IVIg Therapy. Neurotherapeutics 2021; 18:2397-2418. [PMID: 34766257 PMCID: PMC8585501 DOI: 10.1007/s13311-021-01108-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2021] [Indexed: 02/07/2023] Open
Abstract
In the last 25 years, intravenous immunoglobulin (IVIg) has had a major impact in the successful treatment of previously untreatable or poorly controlled autoimmune neurological disorders. Derived from thousands of healthy donors, IVIg contains IgG1 isotypes of idiotypic antibodies that have the potential to bind pathogenic autoantibodies or cross-react with various antigenic peptides, including proteins conserved among the "common cold"-pre-pandemic coronaviruses; as a result, after IVIg infusions, some of the patients' sera may transiently become positive for various neuronal antibodies, even for anti-SARS-CoV-2, necessitating caution in separating antibodies derived from the infused IVIg or acquired humoral immunity. IVIg exerts multiple effects on the immunoregulatory network by variably affecting autoantibodies, complement activation, FcRn saturation, FcγRIIb receptors, cytokines, and inflammatory mediators. Based on randomized controlled trials, IVIg is approved for the treatment of GBS, CIDP, MMN and dermatomyositis; has been effective in, myasthenia gravis exacerbations, and stiff-person syndrome; and exhibits convincing efficacy in autoimmune epilepsy, neuromyelitis, and autoimmune encephalitis. Recent evidence suggests that polymorphisms in the genes encoding FcRn and FcγRIIB may influence the catabolism of infused IgG or its anti-inflammatory effects, impacting on individualized dosing or efficacy. For chronic maintenance therapy, IVIg and subcutaneous IgG are effective in controlled studies only in CIDP and MMN preventing relapses and axonal loss up to 48 weeks; in practice, however, IVIg is continuously used for years in all the aforementioned neurological conditions, like is a "forever necessary therapy" for maintaining stability, generating challenges on when and how to stop it. Because about 35-40% of patients on chronic therapy do not exhibit objective neurological signs of worsening after stopping IVIg but express subjective symptoms of fatigue, pains, spasms, or a feeling of generalized weakness, a conditioning effect combined with fear that discontinuing chronic therapy may destabilize a multi-year stability status is likely. The dilemmas of continuing chronic therapy, the importance of adjusting dosing and scheduling or periodically stopping IVIg to objectively assess necessity, and concerns in accurately interpreting IVIg-dependency are discussed. Finally, the merit of subcutaneous IgG, the ineffectiveness of IVIg in IgG4-neurological autoimmunities, and genetic factors affecting IVIg dosing and efficacy are addressed.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
- Neuroimmunology Unit, Dept. of Pathophysiology, National and Kapodistrian University of Athens Medical School, Athens, Greece.
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12
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Allen JA, Eftimov F, Querol L. Outcome measures and biomarkers in chronic inflammatory demyelinating polyradiculoneuropathy: from research to clinical practice. Expert Rev Neurother 2021; 21:805-816. [PMID: 34130574 DOI: 10.1080/14737175.2021.1944104] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an immune-mediated syndrome characterized clinically by weakness and/or numbness that evolves over 2 months or more. The heterogeneity of clinical features necessitates an individualized approach to disease monitoring that takes lessons learned from clinical trials and applies them to clinical practice.Areas covered: This review discusses the importance of clinimetrics and biomarkers in CIDP diagnosis and disease monitoring. Highlighted are the challenges of defining responses to immunotherapy, the usefulness, and limitations of utilizing evidence-based clinical outcome measures during routine clinical care, and the evolving understanding of how diagnostic and disease activity biomarkers may reshape our treatment and disease monitoring paradigms.Expert opinion: Although disability and impairment outcome measures are commonly used in CIDP to indicate disease status, the nonspecific nature of these metrics limits the ability to attribute a change in any given metric to a change in CIDP. This interpretive challenge may be magnified by inconsistencies in the direction of change as well as a strong placebo effect. There is a need to improve our understanding of minimally important changes in existing outcome measures as a means to personalize treatment and to better assess disease activity status with biomarker discovery.
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Affiliation(s)
- Jeffrey A Allen
- Department of Neurology, University of Minnesota, Minneapolis, MN, USA
| | - Filip Eftimov
- Department of Neurology, Amsterdam Neuroscience, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Luis Querol
- Neuromuscular Diseases Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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13
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Hu J, Sun C, Lu J, Zhao C, Lin J. Efficacy of rituximab treatment in chronic inflammatory demyelinating polyradiculoneuropathy: a systematic review and meta-analysis. J Neurol 2021; 269:1250-1263. [PMID: 34120208 DOI: 10.1007/s00415-021-10646-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/01/2021] [Accepted: 06/03/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Current standard treatment in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) has been proved effective, but it is poorly effective in refractory patients and unclear for anti-IgG4 antibody-associated CIDP. Rituximab is a B cell-depleting monoclonal antibody. It has been applied as one of the management strategies in CIDP, but its efficacy is unknown. OBJECTIVE To perform a systematic review and a meta-analysis of the efficacy of rituximab treatment in CIDP patients. METHODS Through searches in MEDLINE, PubMed, EMBASE, BIOSOS, Web of Science, and Cochrane library on March 31st, 2021, 15 studies were identified. Patients' characteristics, treatment regime and outcome measure were extracted. RESULTS Ninety-six patients in 15 studies were included. The pooled estimate of responsiveness was 75% (95% CI 72-78%). The standard mean difference (SMD) of Inflammatory Neuropathy Cause and Treatment (INCAT) disability score improvement was 1.7 (95% CI 1.0-2.3, p value < 0.0001) and the Medical Research Council (MRC) score for muscle power is 1.3 (95% CI - 2.6 to - 0.1, p value 0.04). All of the anti-IgG4 antibody-positive patients showed excellent responses to rituximab treatment. CONCLUSION Rituximab was effective in the treatment in CIDP patients, especially in anti-IgG4 antibody-positive patients. Randomized clinical trials are needed to determine the effectiveness and safety of rituximab in CIDP patients.
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Affiliation(s)
- Jianian Hu
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Middle Wulumuqi Road, Shanghai, 200040, China
| | - Chong Sun
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Middle Wulumuqi Road, Shanghai, 200040, China
| | - Jiahong Lu
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Middle Wulumuqi Road, Shanghai, 200040, China
| | - Chongbo Zhao
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Middle Wulumuqi Road, Shanghai, 200040, China
| | - Jie Lin
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Middle Wulumuqi Road, Shanghai, 200040, China.
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14
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Abstract
This edition of What is in the Literature focuses on chronic immune neuropathies as they represent treatable conditions. There are formal criteria to solidify the diagnosis of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), but patients are encountered who have clinical and electrodiagnostic features of CIDP but do not fulfill diagnostic criteria. These patients are addressed in recent publications. CIDP (and variants) and other forms of immune-mediated neuropathies (multifocal motor neuropathy) are responsive early on to treatment, but long-term factors are less well described, and a number of publications focus on extended consequences. Acute immune neuropathies have been described in the setting of viral illness, and recent publications look at the question as to whether they are associated with the COVID-19 pandemic. Finally, idiopathic sensory neuropathies are the most common polyneuropathy, and consensus efforts to codify features into subtypes can be used clinically for a more precise diagnosis.
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Affiliation(s)
- Mark B Bromberg
- Department of Neurology, University of Utah, Salt Lake City, UT
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15
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Allen JA. Measuring treatment response to chronic inflammatory demyelinating polyneuropathy in clinical practice: More than just asking. Muscle Nerve 2021; 64:1-3. [PMID: 34008182 DOI: 10.1002/mus.27325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/07/2021] [Accepted: 05/16/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Jeffrey A Allen
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
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16
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Lewis RA, Cornblath DR, Hartung HP, Sobue G, Lawo JP, Mielke O, Durn BL, Bril V, Merkies ISJ, Bassett P, Cleasby A, van Schaik IN. Placebo effect in chronic inflammatory demyelinating polyneuropathy: The PATH study and a systematic review. J Peripher Nerv Syst 2020; 25:230-237. [PMID: 32627277 PMCID: PMC7497019 DOI: 10.1111/jns.12402] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 11/28/2022]
Abstract
The Polyneuropathy And Treatment with Hizentra (PATH) study required subjects with chronic inflammatory demyelinating polyneuropathy (CIDP) to show dependency on immunoglobulin G (IgG) and then be restabilized on IgG before being randomized to placebo or one of two doses of subcutaneous immunoglobulin (SCIG). Nineteen of the 51 subjects (37%) randomized to placebo did not relapse over the next 24 weeks. This article explores the reasons for this effect. A post‐hoc analysis of the PATH placebo group was undertaken. A literature search identified other placebo‐controlled CIDP trials for review and comparison. In PATH, subjects randomized to placebo who did not relapse were significantly older, had more severe disease, and took longer to deteriorate in the IgG dependency period compared with those who relapsed. Published trials in CIDP, whose primary endpoint was stability or deterioration, had a mean non‐deterioration (placebo effect) of 43%, while trials with a primary endpoint of improvement had a placebo response of only 11%. Placebo is an important variable in the design of CIDP trials. Trials designed to show clinical improvement will have a significantly lower effect of this phenomenon than those designed to show stability or deterioration.
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Affiliation(s)
- Richard A Lewis
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - David R Cornblath
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hans-Peter Hartung
- Department of Neurology, UKD and Center for Neurology and Neuropsychiatry, LVR Klinikum, Heinrich Heine University, Düsseldorf, Germany
| | - Gens Sobue
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | - Orell Mielke
- CSL Behring, Marburg, King of Prussia, Pennsylvania, USA
| | - Billie L Durn
- CSL Behring, Marburg, King of Prussia, Pennsylvania, USA
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Ingemar S J Merkies
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands.,Curaçao Medical Center, Willemstad, Curaçao
| | | | | | - Ivo N van Schaik
- Department of Neurology, Amsterdam University Medical Centres, Amsterdam, The Netherlands.,The Netherlands and Spaarne Gasthuis, Haarlem, The Netherlands
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