1
|
Zheng Y, Sun C, Zhao Y, Meng Q, Hu J, Qiao K, Sun J, Xi J, Luo S, Lu J, Zhao C, Lin J. Long-term and low-dose rituximab treatment for chronic inflammatory demyelinating polyneuropathy. J Peripher Nerv Syst 2024; 29:350-355. [PMID: 39152723 DOI: 10.1111/jns.12653] [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: 04/10/2024] [Revised: 07/29/2024] [Accepted: 08/02/2024] [Indexed: 08/19/2024]
Abstract
OBJECTIVE To evaluate the efficacy and safety of a low-dose, long-term rituximab regimen in the treatment of idiopathic CIDP. METHODS This study included 15 CIDP patients treated with rituximab. Patients were administered 600 mg of rituximab intravenously every 6 months. Baseline evaluation was conducted before the initiation of rituximab treatment and subsequent evaluations were conducted 6 months after each rituximab infusion at on-site visits. Clinical improvement was objectively determined by improvement of scale score at least decrease ≥1 INCAT or mRS or increase ≥4 MRC or ≥8 cI-RODS after each infusion compared to baseline evaluation. RESULTS Fifteen CIDP patients were included and 10 of them were typical CIDP and five were distal CIDP. Nine in 15 (60%) patients after first infusion and three in six (50%) patients after second infusion exhibited significant clinical improvement compared to baseline evaluation. Additionally, rituximab facilitated a reduction or cessation of other medications in 73% of patients at last visit. The safety profile was favorable, with no reported adverse events. CONCLUSION Rituximab presents a promising therapeutic option for idiopathic CIDP, offering both efficacy and safety with a low-dose, long-term regimen.
Collapse
Affiliation(s)
- Yongsheng Zheng
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders (NCND), Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital Fudan University, Shanghai, China
| | - Chong Sun
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders (NCND), Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital Fudan University, Shanghai, China
| | - Yanyin Zhao
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders (NCND), Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital Fudan University, Shanghai, China
| | - Quanhua Meng
- Department of Neurology, Deyang People's Hospital, Deyang, China
| | - Jianian Hu
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders (NCND), Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital Fudan University, Shanghai, China
| | - Kai Qiao
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Jian Sun
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Jianying Xi
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders (NCND), Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital Fudan University, Shanghai, China
| | - Sushan Luo
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders (NCND), Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital Fudan University, Shanghai, China
| | - Jiahong Lu
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Chongbo Zhao
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders (NCND), Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital Fudan University, Shanghai, China
| | - Jie Lin
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
- National Center for Neurological Disorders (NCND), Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital Fudan University, Shanghai, China
| |
Collapse
|
2
|
Talers T, Pastare D, Karelis G, Sankova E. Therapy-resistant autoimmune nodopathy with anti-neurofascin 155 antibodies: a case report. Front Hum Neurosci 2024; 18:1405617. [PMID: 39045506 PMCID: PMC11264605 DOI: 10.3389/fnhum.2024.1405617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 06/10/2024] [Indexed: 07/25/2024] Open
Abstract
This study reports the case of a previously healthy man in his late 20s who began experiencing symptoms 3 months before admission to our hospital, including arm and leg weakness and distal hypesthesia. Initially, the patient responded to corticosteroid therapy. However, as his symptoms progressed, he underwent plasmapheresis and received intravenous immunoglobulin therapy, neither of which led to any discernible improvement. With rapid symptom progression during subsequent hospital visits, further investigation led to the detection of neurofascin 155 antibodies. Based on existing evidence of its efficacy, rituximab treatment was initiated. To date, the patient has received three doses of rituximab, which has been partially ineffective. Thus, treatment is ongoing and includes a combination of rituximab and subcutaneous immunoglobulin.
Collapse
Affiliation(s)
| | - Daina Pastare
- Riga Stradins University, Riga, Latvia
- Department of Neurology and Neurosurgery, Riga East University Hospital, Riga, Latvia
| | - Guntis Karelis
- Riga Stradins University, Riga, Latvia
- Department of Neurology and Neurosurgery, Riga East University Hospital, Riga, Latvia
| | - Eva Sankova
- Department of Neurology and Neurosurgery, Riga East University Hospital, Riga, Latvia
| |
Collapse
|
3
|
Rajabally YA. Chronic Inflammatory Demyelinating Polyradiculoneuropathy: Current Therapeutic Approaches and Future Outlooks. Immunotargets Ther 2024; 13:99-110. [PMID: 38435981 PMCID: PMC10906673 DOI: 10.2147/itt.s388151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 02/02/2024] [Indexed: 03/05/2024] Open
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a treatable autoimmune disorder, for which different treatment options are available. Current first-line evidence-based therapies for CIDP include intravenous and subcutaneous immunoglobulins, corticosteroids and plasma exchanges. Despite lack of evidence, cyclophosphamide, rituximab and mycophenolate mofetil are commonly used in circumstances of refractoriness and, more debatably, of perceived overdependence on first-line therapies. Rituximab is currently the object of a randomized controlled trial for CIDP. Based on case series, and although rarely considered, haematopoietic autologous stem cell transplants may be effective in refractory disease, with low mortality and high remission rates. A new therapeutic option has appeared with efgartigimod, a neonatal Fc receptor blocker, recently shown to significantly lower relapse rate versus placebo, after withdrawal from previous immunotherapy. Other neonatal Fc receptor blockers, nipocalimab and batoclimab, are under study. The C1 complement-inhibitor SAR445088, acting in the proximal portion of the classical complement system, is currently the subject of a new study in treatment-responsive, refractory and treatment-naïve subjects. Finally, Bruton Tyrosine Kinase inhibitors, which exert anti-B cell effects, may represent another future research avenue. The widening of the therapeutic armamentarium enhances the need for improved evaluation of treatment effects and reliable biomarkers in CIDP.
Collapse
Affiliation(s)
- Yusuf A Rajabally
- Inflammatory Neuropathy Clinic, Department of Neurology, University Hospitals Birmingham, Birmingham, B15 2TH, United Kingdom
- Aston Medical School, Aston University, Birmingham, United Kingdom
| |
Collapse
|
4
|
Bellanti R, Keddie S, Lunn MP, Rinaldi S. Ultrasensitive assay technology and fluid biomarkers for the evaluation of peripheral nerve disease. J Neurol Neurosurg Psychiatry 2024; 95:114-124. [PMID: 37821222 DOI: 10.1136/jnnp-2023-332031] [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: 06/15/2023] [Accepted: 08/22/2023] [Indexed: 10/13/2023]
Abstract
The field of biomarker discovery is rapidly expanding. The introduction of ultrasensitive immunoassays and the growing precision of genetic technologies are poised to revolutionise the assessment and monitoring of many diseases. Given the difficulties in imaging and tissue diagnosis, there is mounting interest in serum and cerebrospinal fluid biomarkers of peripheral neuropathy. Realised and potential fluid biomarkers of peripheral nerve disease include neuronal biomarkers of axonal degeneration, glial biomarkers for peripheral demyelinating disorders, immunopathogenic biomarkers (such as the presence and titre of antibodies or the levels of cytokines) and genetic biomarkers. Several are already starting to inform clinical practice, whereas others remain under evaluation as potential indicators of disease activity and treatment response. As more biomarkers become available for clinical use, it has become increasingly difficult for clinicians and researchers to keep up-to-date with the most recent discovery and interpretation. In this review, we aim to inform practising neurologists, neuroscientists and other clinicians about recent advances in fluid biomarker technology, with a focus on single molecule arrays (Simoa), chemiluminescent enzyme immunoassays (CLEIA), electrochemiluminescence (ECL), proximity extension assays (PEA), and microfluidic technology. We discuss established and emerging fluid biomarkers of peripheral neuropathy, their clinical applications, limitations and potential future developments.
Collapse
Affiliation(s)
- Roberto Bellanti
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Department of Neuromuscular Diseases, Queen Square Institute of Neurology, University College London, London, UK
| | - Stephen Keddie
- Department of Neuromuscular Diseases, The Royal London Hospital, London, UK
| | - Michael P Lunn
- Department of Neuromuscular Diseases, Queen Square Institute of Neurology, University College London, London, UK
- Department of Neuroinflammation, National Hospital for Neurology and Neurosurgery, London, UK
| | - Simon Rinaldi
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| |
Collapse
|
5
|
Liu B, Hu J, Sun C, Qiao K, Xi J, Zheng Y, Sun J, Luo S, Zhao Y, Lu J, Lin J, Zhao C. Effectiveness and safety of rituximab in autoimmune nodopathy: a single-center cohort study. J Neurol 2023; 270:4288-4295. [PMID: 37195346 DOI: 10.1007/s00415-023-11759-2] [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: 03/02/2023] [Revised: 04/29/2023] [Accepted: 05/02/2023] [Indexed: 05/18/2023]
Abstract
Autoimmune nodopathy is a peripheral neuropathy characterized by acquired motor and sensory deficit with autoantibodies against the node of Ranvier or paranodal region in the peripheral nervous system. The clinical and pathological characteristics of the disease are distinct from that of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), and the standard treatment for CIDP is partially effective. Rituximab is a chimeric monoclonal antibody which binds and depletes B cells in peripheral blood. This prospective observational study included 19 patients with autoimmune nodopathy. Participants received intravenous rituximab treatment 100 mg the first day and 500 mg the next day and given every 6 months. The Inflammatory Neuropathy Cause and Treatment (INCAT) disability score, Inflammatory Rasch-Built Overall Disability Scale (I-RODS), Medical Research Council (MRC) sum score, and Neuropathy Impairment Score (NIS) were collected at entry and before the rituximab infusion every 6 months. At the last visit, 94.7% (18/19) of the patients showed clinical improvement on either the INCAT, I-RODS, MRC, or NIS scale. After the first infusion, 9 patients (47.7%) showed improvement on the INCAT score, and 11 patients (57.9%) on cI-RODS. In patients who received more than one rituximab infusion, the improvement of INCAT score and cI-RODS at the last assessment was higher than that after the first infusion. We also observed tapered or withdrawn concomitant oral medications in these patients.
Collapse
Affiliation(s)
- Bingyou Liu
- Department of Neuology, Huashan Hospital, Fudan University, Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Jianian Hu
- Department of Neuology, Huashan Hospital, Fudan University, Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Chong Sun
- Department of Neuology, Huashan Hospital, Fudan University, Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Kai Qiao
- Department of Neuology, Huashan Hospital, Fudan University, Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Jianying Xi
- Department of Neuology, Huashan Hospital, Fudan University, Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Yongsheng Zheng
- Department of Neuology, Huashan Hospital, Fudan University, Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Jian Sun
- Department of Neuology, Huashan Hospital, Fudan University, Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Sushan Luo
- Department of Neuology, Huashan Hospital, Fudan University, Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Yanyin Zhao
- Department of Neuology, Huashan Hospital, Fudan University, Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Jiahong Lu
- Department of Neuology, Huashan Hospital, Fudan University, Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Jie Lin
- Department of Neuology, Huashan Hospital, Fudan University, Shanghai, China.
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China.
- National Center for Neurological Disorders, Shanghai, China.
| | - Chongbo Zhao
- Department of Neuology, Huashan Hospital, Fudan University, Shanghai, China
- Huashan Rare Disease Center, Huashan Hospital, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| |
Collapse
|
6
|
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
|
7
|
Doneddu PE, Ruiz M, Bianchi E, Liberatore G, Manganelli F, Cocito D, Cosentino G, Benedetti L, Marfia GA, Filosto M, Briani C, Giannotta C, Nobile-Orazio E. A diagnostic score for anti-myelin-associated-glycoprotein neuropathy or chronic inflammatory demyelinating polyradiculoneuropathy in patients with anti-myelin-associated-glycoprotein antibody. Eur J Neurol 2023; 30:501-510. [PMID: 35191144 PMCID: PMC10078711 DOI: 10.1111/ene.15296] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/10/2022] [Accepted: 02/16/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND PURPOSE A diagnostic score was developed to discriminate anti-myelin-associated-glycoprotein (MAG) neuropathy from chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and applied it to patients with atypical anti-MAG neuropathy. METHODS The clinical and electrophysiological features of patients with a diagnosis of typical anti-MAG neuropathy were compared to those of patients with a diagnosis of CIDP. The association of each feature with the diagnosis was assessed in the two groups. Features showing a significant association with the diagnosis were included in a multivariable logistic regression model and adjusted odds ratios were estimated for each feature. A score ranging from 1 to 3 was applied to each feature based on the magnitude of the estimated odds ratios. The score was then applied to patients with a clinical diagnosis of CIDP who also had high anti-MAG antibody titers (CIDP-MAG). RESULTS Thirty-one anti-MAG neuropathy patients, 45 typical CIDP patients and 16 CIDP-MAG patients were included. Scores in anti-MAG antibody patients ranged from 1 to 5 and in CIDP patients from -7 to -1. Using the score, 4/16 CIDP-MAG patients were diagnosed to have anti-MAG neuropathy and 12/16 patients to have CIDP. Response to intravenous immunoglobulin in the CIDP-MAG patients classified as CIDP was similar to that of definite CIDP patients and higher than that of anti-MAG neuropathy patients. CONCLUSIONS Our score allowed an accurate discrimination to be made, amongst patients with anti-MAG antibodies, of those affected by CIDP and the patients with anti-MAG neuropathy. This score may help proper treatment to be chosen for patients with anti-MAG antibodies with a CIDP-like presentation.
Collapse
Affiliation(s)
- Pietro E Doneddu
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Marta Ruiz
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Elisa Bianchi
- Laboratorio di Malattie Neurologiche, IRCCS-Istituto Mario Negri, Milan, Italy
| | - Giuseppe Liberatore
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Fiore Manganelli
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples 'Federico II', Naples, Italy
| | - Dario Cocito
- Presidio Sanitario Major, Istituti Clinici Scientifici Maugeri, Turin, Italy
| | - Giuseppe Cosentino
- IRCCS Foundation C. Mondino National Neurological Institute, Pavia, Italy
| | - Luana Benedetti
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa and IRCCS AOU San Martino-IST, Genoa, Italy
| | - Girola A Marfia
- Dysimmune Neuropathies Unit, Department of Systems Medicine, Tor Vergata University of Rome, Rome, Italy
| | - Massimiliano Filosto
- Department of Clinical and Experimental Sciences, NeMO-Brescia Clinical Center for Neuromuscular Diseases, University of Brescia, Brescia, Italy
| | - Chiara Briani
- Neurology Unit, Department of Neuroscience, University of Padova, Padova, Italy
| | - Claudia Giannotta
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Medical Biotechnology and Translational Medicine, Milan University, Milan, Italy
| |
Collapse
|
8
|
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
|
9
|
Briani C, Visentin A. Therapeutic Monoclonal Antibody Therapies in Chronic Autoimmune Demyelinating Neuropathies. Neurotherapeutics 2022; 19:874-884. [PMID: 35349079 PMCID: PMC9294114 DOI: 10.1007/s13311-022-01222-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2022] [Indexed: 02/07/2023] Open
Abstract
Autoimmune diseases of the peripheral nervous system have so far been treated mainly with exogenous high-dose intravenous immunoglobulins (IVIg), that act through several mechanisms, including neutralization of pathogenic autoantibodies, modulation of lymphocyte activity, interference with antigen presentation, and interaction with Fc receptors, cytokines, and the complement system. Other therapeutic strategies have recently been developed, in part to address the increasing shortage of IVIg, prime among which is the use of B cell depleting monoclonal antibodies, or small molecule inhibitors targeting the B-cell specific kinases. Rituximab, a chimeric monoclonal antibody against CD20 + B lymphocytes, is currently the most used, especially in anti-MAG antibody neuropathy and autoimmune neuropathies with antibodies to nodal/paranodal antigens that are unresponsive to IVIg. After several reports of its efficacy in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), rituximab is currently under investigation in three Phase 2 trials in CIDP. In addition, the possible role of complement activation in the pathogenesis of chronic autoimmune neuropathies has brought into consideration drugs that can block the complement cascade, such as eculizumab, a monoclonal antibody already assessed in acute polyradiculoneuropathies, and approved for myasthenia gravis. Preliminary data on eculizumab in multifocal motor neuropathy have been published, but randomized controlled studies are pending. Moreover, the neonatal Fc receptor, that recycles IgGs by preventing their lysosome degradation, is an important and attractive pharmacological target. Antibodies against FcRn, which reduce circulating IgG (both pathogenic and non-pathogenic) have been developed. The FcRn blocker efgartigimod, a humanized IgG1-derived Fc fragment, which competitively inhibits the FcRn, has recently been approved for the treatment of myasthenia gravis and is currently under investigation in CIDP. In addition, the anti-human FcRn monoclonal antibody rozanolixizumab is currently being assessed in phase 2 trials in CIDP. However, none of the abovementioned monoclonal antibodies is currently approved for treatment of any immune-mediated neuropathies. While more specific and individualized therapies are being developed, the possibility of combined treatments targeting different pathogenic mechanisms deserves consideration as well.
Collapse
Affiliation(s)
- Chiara Briani
- Department of Neurosciences, Neurology Unit, University of Padova, Padova, Italy.
| | - Andrea Visentin
- Department of Medicine, Hematology Unit, University of Padova, Padova, Italy
| |
Collapse
|
10
|
Comi C. Meet the Editorial Board Member. Curr Pharm Biotechnol 2022. [DOI: 10.2174/138920102303220103145104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Cristoforo Comi
- Department of Clinical and Experimental Medicine
University of Eastern Piedmont “Amedeo Avogadro”
Maggiore Hospital, Novara, Italy
| |
Collapse
|
11
|
Chisari CG, Sgarlata E, Arena S, Toscano S, Luca M, Patti F. Rituximab for the treatment of multiple sclerosis: a review. J Neurol 2022; 269:159-183. [PMID: 33416999 PMCID: PMC7790722 DOI: 10.1007/s00415-020-10362-z] [Citation(s) in RCA: 78] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 12/03/2020] [Accepted: 12/08/2020] [Indexed: 01/07/2023]
Abstract
In the last decades, evidence suggesting the direct or indirect involvement of B cells on multiple sclerosis (MS) pathogenesis has accumulated. The increased amount of data on the efficacy and safety of B-cell-depleting therapies from several studies has suggested the addition of these drugs as treatment options to the current armamentarium of disease modifying therapies (DMTs) for MS. Particularly, rituximab (RTX), a chimeric monoclonal antibody directed at CD20 positive B lymphocytes resulting in cell-mediated apoptosis, has been demonstrated to reduce inflammatory activity, incidence of relapses and new brain lesions on magnetic resonance imaging (MRI) in patients with relapsing-remitting MS (RRMS). Additional evidence also demonstrated that patients with progressive MS (PMS) may benefit from RTX, which also showed to be well tolerated, with acceptable safety risks and favorable cost-effectiveness profile.Despite these encouraging results, RTX is currently approved for non-Hodgkin's lymphoma, chronic lymphocytic leukemia, several forms of vasculitis and rheumatoid arthritis, while it can only be administered off-label for MS treatment. Between Northern European countries exist different rules for using not licensed drug for treating MS. The Sweden MS register reports a high rate (53.5%) of off-label RTX prescriptions in relation to other annually started DMTs to treat MS patients, while Danish and Norwegian neurologists have to use other anti-CD20 drugs, as ocrelizumab, in most of the cases.In this paper, we review the pharmacokinetics, pharmacodynamics, clinical efficacy, safety profile and cost effectiveness aspects of RTX for the treatment of MS. Particularly, with the approval of new anti-CD20 DMTs, the recent worldwide COVID-19 emergency and the possible increased risk of infection with this class of drugs, this review sheds light on the use of RTX as an alternative treatment option for MS management, while commenting the gaps of knowledge regarding this drug.
Collapse
Affiliation(s)
- Clara Grazia Chisari
- Department "GF Ingrassia", Section of Neurosciences, University of Catania, Catania, Italy
| | - Eleonora Sgarlata
- Department "GF Ingrassia", Section of Neurosciences, University of Catania, Catania, Italy
- Stroke Unit, Department of Medicine, Umberto I Hospital, Siracusa, Italy
| | - Sebastiano Arena
- Department "GF Ingrassia", Section of Neurosciences, University of Catania, Catania, Italy
| | - Simona Toscano
- Department "GF Ingrassia", Section of Neurosciences, University of Catania, Catania, Italy
| | - Maria Luca
- Department "GF Ingrassia", Section of Neurosciences, University of Catania, Catania, Italy
| | - Francesco Patti
- Department "GF Ingrassia", Section of Neurosciences, University of Catania, Catania, Italy.
| |
Collapse
|
12
|
El-Abassi RN, Soliman M, Levy MH, England JD. Treatment and Management of Autoimmune Neuropathies. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00015-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
|
13
|
Fatehi F, Okhovat AA, Panahi A, Ziaaddini B, Rajabally YA, Nafissi S. Retrospective analysis of response to rituximab in chronic inflammatory demyelinating polyneuropathy refractory to first-line therapy. J Peripher Nerv Syst 2021; 26:469-474. [PMID: 34469032 DOI: 10.1111/jns.12461] [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: 09/26/2020] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 11/30/2022]
Abstract
Few case reports/series describe the efficacy of rituximab in refractory chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), which is preferred in the presence of anti-nodal/paranodal antibodies. We aimed at evaluating the clinical response to rituximab in a subset of patients with refractory CIDP for whom the anti-nodal/paranodal antibodies status was unknown, as not available in Iran. We retrospectively analyzed the response to rituximab in 14 Iranian patients with refractory CIDP (3 children, 11 adults), in whom the anti-nodal/paranodal antibodies status was unknown. The subjects were evaluated with the Medical Research Council (MRC) sum score (MRCSS), Inflammatory Neuropathy Cause and Treatment (INCAT) disability scores, and electrophysiology, before and after treatment. Mean age was 34.4 ± 20.7 years, disease duration pre-rituximab treatment was 27.8 ± 18.8 (range: 6-60) months, and mean follow-up duration was 18.5 ± 11.0 (range: 4-36) months. Considering the INCAT sum score, one worsened during post-rituximab treatment, and three patients did not change. Considering MRCSS, notably, four patients achieved normalization of their MRCSS. Regarding the corticosteroid dose, two patients could discontinue prednisolone. As rated by a pre-defined scoring system, nerve conduction parameters improved significantly post-rituximab in the treated cohort (P = .006). All patients tolerated rituximab infusions without adverse effects. Rituximab may be effective in refractory CIDP, even though worsening may occur in some patients. Anti-nodal/paranodal antibodies assay, when available, and other criteria may help drive therapeutic decision-making on rituximab as second-line treatment.
Collapse
Affiliation(s)
- Farzad Fatehi
- Neurology Department, Neuromuscular Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Asghar Okhovat
- Neurology Department, Neuromuscular Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Akram Panahi
- Neurology Department, Neuromuscular Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Bentolhoda Ziaaddini
- Neurology Department, Neuromuscular Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Yusuf A Rajabally
- Neurology Department, Neuromuscular Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Aston Medical School, Aston University, Birmingham, UK
| | - Shahriar Nafissi
- Neurology Department, Neuromuscular Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
14
|
Van den Bergh PYK, van Doorn PA, Hadden RDM, Avau B, Vankrunkelsven P, Allen JA, Attarian S, Blomkwist-Markens PH, Cornblath DR, Eftimov F, Goedee HS, Harbo T, Kuwabara S, Lewis RA, Lunn MP, Nobile-Orazio E, Querol L, Rajabally YA, Sommer C, Topaloglu HA. European Academy of Neurology/Peripheral Nerve Society guideline on diagnosis and treatment of chronic inflammatory demyelinating polyradiculoneuropathy: Report of a joint Task Force-Second revision. Eur J Neurol 2021; 28:3556-3583. [PMID: 34327760 DOI: 10.1111/ene.14959] [Citation(s) in RCA: 169] [Impact Index Per Article: 56.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To revise the 2010 consensus guideline on chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). METHODS Seventeen disease experts, a patient representative, and two Cochrane methodologists constructed 12 Population/Intervention/Comparison/Outcome (PICO) questions regarding diagnosis and treatment to guide the literature search. Data were extracted and summarized in GRADE summary of findings (for treatment PICOs) or evidence tables (for diagnostic PICOs). RESULTS Statements were prepared according to the GRADE Evidence-to-Decision frameworks. Typical CIDP and CIDP variants were distinguished. The previous term "atypical CIDP" was replaced by "CIDP variants" because these are well characterized entities (multifocal, focal, distal, motor, or sensory CIDP). The levels of diagnostic certainty were reduced from three (definite, probable, possible CIDP) to only two (CIDP and possible CIDP), because the diagnostic accuracy of criteria for probable and definite CIDP did not significantly differ. Good Practice Points were formulated for supportive criteria and investigations to be considered to diagnose CIDP. The principal treatment recommendations were: (a) intravenous immunoglobulin (IVIg) or corticosteroids are strongly recommended as initial treatment in typical CIDP and CIDP variants; (b) plasma exchange is strongly recommended if IVIg and corticosteroids are ineffective; (c) IVIg should be considered as first-line treatment in motor CIDP (Good Practice Point); (d) for maintenance treatment, IVIg, subcutaneous immunoglobulin or corticosteroids are recommended; (e) if the maintenance dose of any of these is high, consider either combination treatments or adding an immunosuppressant or immunomodulatory drug (Good Practice Point); and (f) if pain is present, consider drugs against neuropathic pain and multidisciplinary management (Good Practice Point).
Collapse
Affiliation(s)
- Peter Y K Van den Bergh
- Neuromuscular Reference Centre, Department of Neurology, University Hospital Saint-Luc, Brussels, Belgium
| | - Pieter A van Doorn
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | - Bert Avau
- Cochrane Belgium, CEBAM, Leuven, Belgium and CEBaP, Belgian Red Cross, Mechelen, Belgium
| | | | - Jeffrey A Allen
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shahram Attarian
- Centre de Référence des Maladies Neuromusculaires et de la SLA, APHM, CHU Timone, Marseille, France
| | | | - David R Cornblath
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Filip Eftimov
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - H Stephan Goedee
- Department of Neuromuscular Disorders, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Thomas Harbo
- Department of Neurology, Århus University Hospital, Århus, Denmark
| | - Satoshi Kuwabara
- Department of Neurology, Chiba University Hospital, Chiba, Japan
| | - Richard A Lewis
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michael P Lunn
- Department of Neurology and MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical and Research Center, Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Luis Querol
- Neuromuscular Diseases Unit-Neurology Department, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
| | - Yusuf A Rajabally
- Regional Neuromuscular Service, Neurology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Claudia Sommer
- Neurology Clinic, University Hospital Würzburg, Würzburg, Germany
| | | |
Collapse
|
15
|
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.
Collapse
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.
| |
Collapse
|
16
|
Van den Bergh PYK, van Doorn PA, Hadden RDM, Avau B, Vankrunkelsven P, Allen JA, Attarian S, Blomkwist-Markens PH, Cornblath DR, Eftimov F, Goedee HS, Harbo T, Kuwabara S, Lewis RA, Lunn MP, Nobile-Orazio E, Querol L, Rajabally YA, Sommer C, Topaloglu HA. European Academy of Neurology/Peripheral Nerve Society guideline on diagnosis and treatment of chronic inflammatory demyelinating polyradiculoneuropathy: Report of a joint Task Force-Second revision. J Peripher Nerv Syst 2021; 26:242-268. [PMID: 34085743 DOI: 10.1111/jns.12455] [Citation(s) in RCA: 166] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 12/14/2022]
Abstract
To revise the 2010 consensus guideline on chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Seventeen disease experts, a patient representative, and two Cochrane methodologists constructed 12 Population/Intervention/Comparison/Outcome (PICO) questions regarding diagnosis and treatment to guide the literature search. Data were extracted and summarized in GRADE summary of findings (for treatment PICOs) or evidence tables (for diagnostic PICOs). Statements were prepared according to the GRADE Evidence-to-Decision frameworks. Typical CIDP and CIDP variants were distinguished. The previous term "atypical CIDP" was replaced by "CIDP variants" because these are well characterized entities (multifocal, focal, distal, motor, or sensory CIDP). The levels of diagnostic certainty were reduced from three (definite, probable, possible CIDP) to only two (CIDP and possible CIDP), because the diagnostic accuracy of criteria for probable and definite CIDP did not significantly differ. Good Practice Points were formulated for supportive criteria and investigations to be considered to diagnose CIDP. The principal treatment recommendations were: (a) intravenous immunoglobulin (IVIg) or corticosteroids are strongly recommended as initial treatment in typical CIDP and CIDP variants; (b) plasma exchange is strongly recommended if IVIg and corticosteroids are ineffective; (c) IVIg should be considered as first-line treatment in motor CIDP (Good Practice Point); (d) for maintenance treatment, IVIg, subcutaneous immunoglobulin or corticosteroids are recommended; (e) if the maintenance dose of any of these is high, consider either combination treatments or adding an immunosuppressant or immunomodulatory drug (Good Practice Point); and (f) if pain is present, consider drugs against neuropathic pain and multidisciplinary management (Good Practice Point).
Collapse
Affiliation(s)
- Peter Y K Van den Bergh
- Neuromuscular Reference Centre, Department of Neurology, University Hospital Saint-Luc, Brussels, Belgium
| | - Pieter A van Doorn
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | - Bert Avau
- Cochrane Belgium, CEBAM, Leuven, Belgium and CEBaP, Belgian Red Cross, Mechelen, Belgium
| | | | - Jeffrey A Allen
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shahram Attarian
- Centre de Référence des Maladies Neuromusculaires et de la SLA, APHM, CHU Timone, Marseille, France
| | | | - David R Cornblath
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Filip Eftimov
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - H Stephan Goedee
- Department of Neuromuscular Disorders, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Thomas Harbo
- Department of Neurology, Århus University Hospital, Århus, Denmark
| | - Satoshi Kuwabara
- Department of Neurology, Chiba University Hospital, Chiba, Japan
| | - Richard A Lewis
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michael P Lunn
- Department of Neurology and MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical and Research Center, Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Luis Querol
- Neuromuscular Diseases Unit-Neurology Department, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
| | - Yusuf A Rajabally
- Regional Neuromuscular Service, Neurology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Claudia Sommer
- Neurology Clinic, University Hospital Würzburg, Würzburg, Germany
| | | |
Collapse
|
17
|
Farag M, Sibtain N, Burge J, Chaudhry V, Silber E. Atypical inflammatory demyelinating syndrome with central and peripheral nerve involvement. Mult Scler Relat Disord 2021; 51:102926. [PMID: 34049139 DOI: 10.1016/j.msard.2021.102926] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/23/2021] [Indexed: 10/21/2022]
Abstract
We report a patient who has peripheral demyelination in the form of chronic inflammatory demyelinating polyneuropathy (CIDP) with central demyelination following a relapsing-remitting disease course. The patient developed bilateral sequential optic neuritis predating the diagnosis of CIPD, then developed a profound brainstem syndrome with ataxia, dysarthria, a complex eye movement disorder, visual disturbance and urinary incontinence. Interval imaging fulfilled McDonald criteria for multiple sclerosis (MS) with a right parieto-occipital tumefactive lesion showing contrast enhancement and new lesions in the right temporal white matter and midbrain tegmentum. Oligoclonal bands (OCBs) were matched and serum antibodies against aquaporin-4 (AQP-4) and myelin oligodendrocyte glycoprotein (MOG) were negative. Genetic sequence analysis and deletion/duplication testing revealed variants of uncertain significance with compound heterozygosity for point mutations in two genes, DYNC1H1 and SH3TC2, which are associated with Charcot-Marie-Tooth (CMT) disease though the patient was negative for known CMT mutations. The patient responded poorly to steroids and regular intravenous immunoglobulin (IVIg) but clinically improved following aggressive immunomodulatory therapy with pulsed steroids and plasmapheresis, followed by Rituximab. Combined central and peripheral demyelination (CCPD) is rare. Autoimmune mechanisms are postulated in the pathogenesis. Whether overlap of central and pe- ripheral demyelination is coincidental or caused by a shared epitope in both the peripheral and central nervous systems still remains to be elucidated. There is no clear therapeutic consensus in the treatment of both central and peripheral demyelination, though immunomodulating treatment strategies may minimise disability and improve prognosis.
Collapse
Affiliation(s)
- Mena Farag
- Department of Neurology, King's College Hospital, Denmark Hill, London, SE5 9RS.
| | - Naomi Sibtain
- Department of Neuroradiology, King's College Hospital, Denmark Hill, London, SE5 9RS
| | - James Burge
- Department of Neurophysiology, King's College Hospital, Denmark Hill, London, SE5 9RS
| | - Vinay Chaudhry
- Johns Hopkins University School of Medicine, 601 North Caroline Street, Baltimore, MD 21287
| | - Eli Silber
- Department of Neurology, King's College Hospital, Denmark Hill, London, SE5 9RS
| |
Collapse
|
18
|
Motte J, Fisse AL, Köse N, Grüter T, Mork H, Athanasopoulos D, Fels M, Otto S, Siglienti I, Schneider-Gold C, Hellwig K, Yoon MS, Gold R, Pitarokoili K. Treatment response to cyclophosphamide, rituximab, and bortezomib in chronic immune-mediated sensorimotor neuropathies: a retrospective cohort study. Ther Adv Neurol Disord 2021; 14:1756286421999631. [PMID: 33747132 PMCID: PMC7940507 DOI: 10.1177/1756286421999631] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 02/10/2021] [Indexed: 12/13/2022] Open
Abstract
Background: Up to 20% of patients with chronic immune-mediated sensorimotor neuropathies (CIN) do not respond adequately to first-line therapies. However, studies on further treatment are scarce. Methods: We analyzed retrospectively 200 CIN patients regarding disease characteristics and response to therapy with cyclophosphamide (CYP), rituximab (RTX), and bortezomib (BTZ). Treatment response was defined as improvement or stabilization of inflammatory neuropathy cause and treatment overall disability score (INCAT-ODSS). Results: A total of 48 of 181 patients (26.5%) received therapy with CYP, RTX, or BTZ. The most frequently and first used therapy was CYP (69%). More than 40% of patients needed a second or third treatment. Overall, 71 treatments were applied in 48 patients. The combination of up to all three treatments enhanced the response-rate to 90%. Treatment within 24 months after initial diagnosis resulted in significantly higher response rate than late treatment (79% versus 50 %, p = 0.04, χ2-test, n = 46) and in lower disability in long-term follow up (INCAT-ODSS 3.8 versus 5.8, p = 0.02, t-test, n = 48). Patients with Lewis-Sumner syndrome (n = 9) and autoantibody mediated neuropathies (n = 13) had excellent response rates after treatment with RTX (90–100%). In contrast, typical chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) showed a response rate of 64% in CYP, 64% in RTX, and 75% in BTZ. Conclusion: Treatment with CYP, RTX, or BTZ was effective in this cohort of CIN refractory to first-line treatment. Our data increase evidence for an early use of these therapies. High efficacy of RTX in Lewis-Sumner syndrome in contrast to typical CIDP suggests a distinct pathophysiology.
Collapse
Affiliation(s)
- Jeremias Motte
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, Bochum, 44791, Germany
| | - Anna Lena Fisse
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Nuray Köse
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Thomas Grüter
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Hannah Mork
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | | | - Miriam Fels
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Susanne Otto
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Ines Siglienti
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | | | - Kerstin Hellwig
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Min-Suk Yoon
- Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Kalliopi Pitarokoili
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| |
Collapse
|
19
|
Autologous Hematopoietic Stem Cell Transplantation for Chronic Inflammatory Demyelinating Polyradiculoneuropathy. Can J Neurol Sci 2021; 48:760-766. [PMID: 33631093 DOI: 10.1017/cjn.2021.30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) refractory to conventional therapy can lead to marked disability and represents a therapeutic challenge. OBJECTIVE To report five cases of treatment-refractory disabling CIDP treated with autologous hematopoietic stem cell transplantation (AHSCT). METHODS This was a retrospective cohort study from a tertiary care referral center for both neuromuscular disease and AHSCT. Patients with CIDP treated with AHSCT between 2008 and 2020 were included. All patients had major persistent and disabling neuropathic deficits despite combinations of intensive immunosuppressive therapy. The primary outcome measures were: Medical Research Council sum score, Overall Neuropathy Limitations Scale and requirement for ongoing CIDP immunotherapy after transplantation. We also analyzed safety outcomes by documenting all severe AHSCT-related complications. RESULTS Five patients with refractory CIDP underwent AHSCT. Three were classified as manifesting a typical syndrome, two were classified as the multifocal Lewis Sumner variant. The mean age at time of CIDP diagnosis was 33.4 years (range 24-46 years), with a median delay of 46 months (range 21-135 months) between diagnosis and AHSCT. The median follow-up period was 41 months. All five patients were able to wean off CIDP-related immunotherapy. Marked improvements in Medical Research Council scale and overall Neuropathy Limitations Scale were noted in 4/5 patients. One patient with longstanding neurogenic atrophy showed no improvement in disability scales. There were no treatment-related deaths or critical illnesses. CONCLUSIONS AHSCT can achieve marked sustained clinical improvement of refractory CIDP and may allow for weaning off long-term complex immunotherapies.
Collapse
|
20
|
Lewis D, Osman C, Allen D, Pinto AA, Duncombe A, Katifi HA. Refractory CIDP with chronic lymphocytic leukaemia responding to chemoimmunotherapy. Pract Neurol 2020; 21:practneurol-2020-002672. [PMID: 33376152 DOI: 10.1136/practneurol-2020-002672] [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: 12/14/2020] [Indexed: 11/04/2022]
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) has a variable clinical course with 15% remaining refractory to treatment. We report a woman with severe refractory CIDP and coexisting chronic lymphocytic leukaemia (CLL) who improved dramatically after chemoimmunotherapy appropriate for the CLL, including rituximab. A subsequent CIDP relapse after 15 months responded again to similar treatment, and the improvement has been maintained with 3-monthly rituximab infusions as sole ongoing therapy. The case suggests that CIDP refractory to conventional treatment may have associated pathology, in this case haematological malignancy, and that treating the malignancy can effectively treat the CIDP.
Collapse
Affiliation(s)
- Dana Lewis
- Department of Medicine, Southampton University Hospitals NHS Trust, Southampton, UK
| | - Chinar Osman
- Wessex Neurological Centre, Southampton University Hospitals NHS Trust, Southampton, UK
| | - David Allen
- Wessex Neurological Centre, Southampton University Hospitals NHS Trust, Southampton, UK
| | - Ashwin Arnold Pinto
- Wessex Neurological Centre, Southampton University Hospitals NHS Trust, Southampton, UK
| | - Andrew Duncombe
- Department of Haematology, Southampton University Hospitals NHS Trust, Southampton, UK
| | - Haider A Katifi
- Wessex Neurological Centre, Southampton University Hospitals NHS Trust, Southampton, UK
| |
Collapse
|
21
|
Terhoeven P, Seybold J, Utz KS, Nickel FT, Lee DH, Linker RA. Longer-term effects of intravenous immunoglobulin treatment in chronic inflammatory demyelinating polyneuropathy: Who benefits? J Neurol Sci 2020; 419:117169. [PMID: 33035867 DOI: 10.1016/j.jns.2020.117169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 09/04/2020] [Accepted: 09/30/2020] [Indexed: 12/25/2022]
Abstract
Intravenous immunoglobulins (IVIg) represent an established cornerstone for the immunotherapy of chronic inflammatory demyelinating polyneuropathy (CIDP). Efficacy of IVIg for CIDP was proven in a large phase III trial. Yet, data on longer-term efficacy and effects in distinct subgroups are scarce. Our trial investigates the long-term efficacy of IVIg treatment in CIDP patients. In this observational real-world study, we retrospectively analyzed 49 CIDP patients receiving continuous IVIg treatment with a mean initial dosage of 87 g (1 g/kg body weight) every 4 weeks over a mean time of 45 months between 2010 and 2018. INCAT-Scores before the start of treatment and at the end of the observation period were compared. Over the observation period, IVIg treatment led to a median improvement of one INCAT score point. Subgroup analyses revealed a more pronounced improvement of INCAT scores in female CIDP patients, individuals with relapsing disease courses, patients with more pronounced motor impairment (higher initial INCAT scores) and in the cohort without need for concomitant other immunotherapies. These data argue for sustained beneficial effects of longer-term immunotherapy with IVIg in CIDP, particularly in females and relapsing disease forms with higher disease activity.
Collapse
Affiliation(s)
- Pauline Terhoeven
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054 Erlangen, Germany
| | - Julia Seybold
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054 Erlangen, Germany; Department of Neurology, University Regensburg, Universitätsstr. 84, 93053 Regensburg, Germany
| | - Kathrin S Utz
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054 Erlangen, Germany
| | - Florian T Nickel
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054 Erlangen, Germany
| | - De-Hyung Lee
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054 Erlangen, Germany; Department of Neurology, University Regensburg, Universitätsstr. 84, 93053 Regensburg, Germany
| | - Ralf A Linker
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054 Erlangen, Germany; Department of Neurology, University Regensburg, Universitätsstr. 84, 93053 Regensburg, Germany.
| |
Collapse
|
22
|
Fisse AL, Motte J, Grüter T, Sgodzai M, Pitarokoili K, Gold R. Comprehensive approaches for diagnosis, monitoring and treatment of chronic inflammatory demyelinating polyneuropathy. Neurol Res Pract 2020; 2:42. [PMID: 33324942 PMCID: PMC7722337 DOI: 10.1186/s42466-020-00088-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 09/04/2020] [Indexed: 02/08/2023] Open
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is the most common chronic inflammatory neuropathy. CIDP is diagnosed according to the European Federation of Neurological Societies/Peripheral Nerve Society (EFNS/PNS) criteria, which combine clinical features with the electrophysiological evidence of demyelination. However, firstly, diagnosis is challenging, as some patients e.g. with severe early axonal damage do not fulfil the criteria. Secondly, objective and reliable tools to monitor the disease course are lacking. Thirdly, about 25% of CIDP patients do not respond to evidence-based first-line therapy. Recognition of these patients is difficult and treatment beyond first-line therapy is based on observational studies and case series only. Individualized immunomodulatory treatment does not exist due to the lack of understanding of essential aspects of the underlying pathophysiology. Novel diagnostic imaging techniques and molecular approaches can help to solve these problems but do not find enough implementation. This review gives a comprehensive overview of novel diagnostic techniques and monitoring approaches for CIDP and how these can lead to individualized treatment and better understanding of pathophysiology.
Collapse
Affiliation(s)
- Anna Lena Fisse
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Jeremias Motte
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Thomas Grüter
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Melissa Sgodzai
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Kalliopi Pitarokoili
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| |
Collapse
|
23
|
Gwathmey K. Chronic Inflammatory Demyelinating Polyradiculoneuropathy and Its Variants. Continuum (Minneap Minn) 2020; 26:1205-1223. [PMID: 33002999 DOI: 10.1212/con.0000000000000907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and its variants comprise a group of immune-mediated neuropathies with distinctive clinical presentations and electrodiagnostic features. Prompt recognition of these treatable disorders is mandatory as delays result in significant disability and morbidity. This article highlights the clinical presentation, pathophysiology, diagnostic evaluation, and treatment approach of these polyneuropathies. RECENT FINDINGS The spectrum of CIDP is expanding with the recent characterization of neuropathies associated with nodal and paranodal antibodies. These neuropathies are distinguished by their unique presentations and are often refractory to IV immunoglobulin (IVIg) therapy. Subcutaneous immunoglobulins have recently been approved as a treatment option for CIDP and join corticosteroids, IVIg, and plasma exchange as first-line treatment. SUMMARY CIDP is characterized by progressive symmetric proximal and distal weakness, large fiber sensory loss, and areflexia, with clinical nadir reached more than 8 weeks after symptom onset. Autoimmune demyelinating neuropathies fall on a continuum, with differences in the type of nerve fibers affected and pattern of deficits. Distinguishing between typical CIDP and its variants allows for selection of the most appropriate treatment.
Collapse
|
24
|
Refractory CIDP: Clinical characteristics, antibodies and response to alternative treatment. J Neurol Sci 2020; 418:117098. [PMID: 32841917 DOI: 10.1016/j.jns.2020.117098] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/11/2020] [Accepted: 08/13/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To review the clinical characteristics, antibodies, and response to alternative treatments in a cohort of patients with refractory CIDP. METHODS We reviewed the charts of all CIDP patients seen at the Oregon Health & Science University neuromuscular clinic between 2017 and 2019. We collected demographics, clinical characteristics, antibodies, and response to treatments. RESULTS Among 45 CIDP patients studied, 34 (76%) showed improvement with first-line therapy (steroids, IVIG and/or plasmapheresis) and 11 (24%) were considered refractory to first line therapy. Of the latter, 7 of 11 patients (64%) responded to alternative treatment (cyclophosphamide or rituximab). Three were refractory to all treatment. Most patients were ambulatory without aid and a few were in remission. One patient died from complications of alcoholic liver cirrhosis. Thrombosis was seen in three patients receiving IVIG. Six patients (13%) tested positive for Neurofascin (NF) antibodies. Four tested positive for NF155 IgM antibodies only and of those, one responded to IVIG, two partially responded to IVIG and one was refractory. One patient tested positive for NF155 IgG4. Another tested positive for NF155 IgG4 and NF155 IgM. Both patients with IgG4 antibodies were refractory to IVIG, one responded to rituximab and one was refractory to all treatment. CONCLUSION Less than a quarter of our CIDP patients did not respond to steroids, IVIG, and/or plasmapheresis. Most of the refractory patients responded to rituximab or cyclophosphamide. Patients with IgG4 NF antibodies were resistant to IVIG. The majority of refractory CIDP patients were seronegative and disease management relied on clinical judgement.
Collapse
|
25
|
Posa A, Emmer A, Kornhuber M. Severe CIDP-MGUS responsive to Rituximab. Heliyon 2020; 6:e04230. [PMID: 32596526 PMCID: PMC7306592 DOI: 10.1016/j.heliyon.2020.e04230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 05/26/2020] [Accepted: 06/12/2020] [Indexed: 11/30/2022] Open
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is a relatively rare disease with progressive limb weakness and sensory loss. A few patients show a severely progressing course without major response to intravenous immunoglobulin or plasma exchange therapy. CIDP-MGUS (monoclonal gammopathy of undetermined significance) is a seldom CIDP variant that has been rarely addressed in therapeutic studies. In the presented CIDP-MGUS case, B cell depletion with rituximab had a favourable effect on the disease course, clinically and in nerve conduction studies.
Collapse
Affiliation(s)
- Andreas Posa
- Martin-Luther-University Halle-Wittenberg, Department of Neurology, Ernst-Grube-Straße 40, 06120, Halle (Saale), Germany
| | - Alexander Emmer
- Martin-Luther-University Halle-Wittenberg, Department of Neurology, Ernst-Grube-Straße 40, 06120, Halle (Saale), Germany
| | - Malte Kornhuber
- Martin-Luther-University Halle-Wittenberg, Department of Neurology, Ernst-Grube-Straße 40, 06120, Halle (Saale), Germany
| |
Collapse
|
26
|
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
|
27
|
Bendamustine–rituximab (BR) combined therapy for treatment of immuno-mediated neuropathies associated with hematologic malignancy. J Neurol Sci 2020; 413:116777. [DOI: 10.1016/j.jns.2020.116777] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/14/2020] [Accepted: 03/13/2020] [Indexed: 02/03/2023]
|
28
|
Cohen JC, Lewis RA. Rituximab for chronic inflammatory demyelinating polyneuropathy—A potential therapeutic option. Muscle Nerve 2020; 61:549-551. [DOI: 10.1002/mus.26871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 03/21/2020] [Accepted: 03/23/2020] [Indexed: 11/07/2022]
Affiliation(s)
- Joss C. Cohen
- Department of Neurology, Cedars‐Sinai Medical Center Los Angeles California
| | - Richard A. Lewis
- Department of Neurology, Cedars‐Sinai Medical Center Los Angeles California
| |
Collapse
|
29
|
Tang L, Huang Q, Qin Z, Tang X. Distinguish CIDP with autoantibody from that without autoantibody: pathogenesis, histopathology, and clinical features. J Neurol 2020; 268:2757-2768. [PMID: 32266541 DOI: 10.1007/s00415-020-09823-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 04/01/2020] [Accepted: 04/03/2020] [Indexed: 12/13/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is considered to be an immune-mediated heterogeneous disease involving cellular and humoral immunity. In recent years, autoantibodies against nodal/paranodal protein neurofascin155 (NF155), neurofascin186 (NF186), contactin-1 (CNTN1), and contactin-associated protein 1 (CASPR1) have been identified in a small subset of patients with CIDP, which disrupt axo-glial interactions at nodes/paranodes. Although CIDP electrodiagnosis was made in patients with anti-nodal/paranodal component autoantibodies, macrophage-induced demyelination, the characteristic of typical CIDP, was not observed. Apart from specific histopathology, the pathogenic mechanisms and clinical manifestations of CIDP with autoantibody are also distinct. We herein compared pathogenesis, histopathology, clinical manifestations, and therapeutic response in CIDP with autoantibody vs. CIDP without autoantibody. CIDP with autoantibodies should be considered as an independent disease entity, not a subtype of CIDP due to many differences. They possibly should be classified as CIDP-like chronic nodo-paranodopathy, which can better characterize these disorders, help diagnose and make the most effective therapeutic decisions.
Collapse
Affiliation(s)
- Lisha Tang
- Department of Neurology, The Second Xiangya Hospital, Central South University, Renmin Road 139#, Changsha, 410011, Hunan, China
| | - Qianyi Huang
- Department of Neurology, The Second Xiangya Hospital, Central South University, Renmin Road 139#, Changsha, 410011, Hunan, China
| | - Zhen Qin
- Department of Neurology, The Second Xiangya Hospital, Central South University, Renmin Road 139#, Changsha, 410011, Hunan, China
| | - Xiangqi Tang
- Department of Neurology, The Second Xiangya Hospital, Central South University, Renmin Road 139#, Changsha, 410011, Hunan, China.
| |
Collapse
|
30
|
Shimizu S, Iijima M, Fukami Y, Tamura N, Nakatochi M, Ando M, Nishi R, Koike H, Kaida K, Koga M, Kanda T, Ogata H, Kira JI, Mori M, Kuwabara S, Katsuno M. Efficacy and Safety of Rituximab in Refractory CIDP With or Without IgG4 Autoantibodies (RECIPE): Protocol for a Double-Blind, Randomized, Placebo-Controlled Clinical Trial. JMIR Res Protoc 2020; 9:e17117. [PMID: 32234705 PMCID: PMC7160709 DOI: 10.2196/17117] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 01/27/2020] [Accepted: 01/27/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an immune-mediated peripheral neuropathy that is currently classified into several clinical subtypes, which are presumed to have different pathogenic mechanisms. Recently, studies identified a subgroup of patients with CIDP who were positive for IgG4 autoantibodies against paranodal proteins, such as neurofascin-155 and contactin-1, who respond poorly to first-line therapies for typical CIDP, including intravenous immunoglobulin therapy. OBJECTIVE This study aims to evaluate the efficacy and safety of intravenous rituximab according to IgG4 autoantibody status in patients with refractory CIDP. METHODS The Evaluation of the Efficacy and Safety of Rituximab in Refractory CIDP Patients with IgG4 Autoantibodies in the Exploratory Clinical (RECIPE) trial consists of 2 cohorts: a multicenter, placebo-controlled, randomized study cohort of 15 patients with IgG4 autoantibody-positive CIDP (rituximab:placebo = 2:1) and an open-label trial cohort of 10 patients with antibody-negative CIDP. The primary endpoint is improvement in functional outcome assessed using the adjusted Inflammatory Neuropathy Cause and Treatment Disability Scale score at 26, 38, or 52 weeks after the start of treatment with rituximab in patients with CIDP and anti-paranodal protein antibodies. Secondary outcome measures include grip strength, manual muscle testing sum scores, results of nerve conduction studies, and other functional scales. RESULTS We plan to enroll 25 cases for the full analysis set. Recruitment is ongoing, with 14 patients enrolled as of January 2020. Enrollment will close in September 2020, and the study is planned to end in December 2021. CONCLUSIONS This randomized controlled trial will determine if rituximab is safe and effective in patients with anti-paranodal antibodies. An open-label study will provide additional data on the effects of rituximab in patients with antibody-negative CIDP. The results of the RECIPE trial are expected to provide evidence for the positioning of rituximab as a pathogenesis-based therapeutic for refractory CIDP. TRIAL REGISTRATION ClinicalTrials.gov NCT03864185, https://clinicaltrials.gov/ct2/show/NCT03864185 ; The Japan Registry of Clinical Trials jRCT2041180037, https://jrct.niph.go.jp/en-latest-detail/jRCT2041180037. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/17117.
Collapse
Affiliation(s)
- Shinobu Shimizu
- Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Masahiro Iijima
- Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan.,Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuki Fukami
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Natsuko Tamura
- Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan.,Center for Integrated Medical Research, Hiroshima University Hospital, Hiroshima, Japan
| | - Masahiro Nakatochi
- Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan.,Department of Nursing, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahiko Ando
- Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Ryoji Nishi
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kenichi Kaida
- Department of Neurology, Anti-aging and Vascular Medicine, National Defense Medical College, Tokorozawa, Japan
| | - Michiaki Koga
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Takashi Kanda
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Hidenori Ogata
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Jun-Ichi Kira
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masahiro Mori
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Satoshi Kuwabara
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| |
Collapse
|
31
|
Muley SA, Jacobsen B, Parry G, Usman U, Ortega E, Walk D, Allen J, Pasnoor M, Varon M, Dimachkie MM. Rituximab in refractory chronic inflammatory demyelinating polyneuropathy. Muscle Nerve 2020; 61:575-579. [PMID: 31922613 DOI: 10.1002/mus.26804] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 12/24/2019] [Accepted: 01/01/2020] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Chronic inflammatory demyelinating polyneuropathy (CIDP) is a disorder in which early effective treatment is important to minimize disability from axonal degeneration. It has been suggested that some patients with CIDP may benefit from rituximab therapy, but there is no definitive evidence for this. METHODS Baseline and post-rituximab-therapy neuromuscular Medical Research Council (MRC) sum scores, Inflammatory Neuropathy Cause and Treatment (INCAT) disability score, and functional status were assessed in 11 patients with refactory CIDP. RESULTS The MRC sum score, INCAT disability score, and functional status improved in all patients after rituximab therapy. DISCUSSION Our study provides evidence of the efficacy of rituximab therapy in at least some patients with CIDP. A placebo-controlled study to assess the effectiveness of rituximab therapy in CIDP with and without nodal antibodies is required to identify disease markers that predict responsiveness.
Collapse
Affiliation(s)
- Suraj A Muley
- Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Bill Jacobsen
- Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Gareth Parry
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota
| | - Uzma Usman
- Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Erik Ortega
- Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - David Walk
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota
| | - Jeff Allen
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota
| | - Mamatha Pasnoor
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas
| | - Matthew Varon
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas
| | - Mazen M Dimachkie
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas
| |
Collapse
|
32
|
Franques J. [Chronic inflammatory demyelinating polyneuropathy: Diagnosis and therapeutic update]. Rev Med Interne 2019; 40:808-815. [PMID: 31677862 DOI: 10.1016/j.revmed.2019.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 06/19/2019] [Accepted: 07/17/2019] [Indexed: 10/25/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathies are acquired demyelinating neuropathies belonging to the group of autoimmune neuropathies. Since specific biological markers are present in less than 10% of cases, the diagnosis is based on the clinical and electrophysiological analysis of each patient. Furthermore, a decision-making algorithm ranking all other available paraclinical tools will guide the physician to the diagnosis of atypical forms. In nearly 80% of cases, these dysimmune neuropathies are responsive to first-line treatments, namely intravenous immunoglobulins, corticosteroids and plasma exchanges. A second line treatment may be proposed in case of no response, intolerance or inaccessibility to the three reference treatments. While some immunosuppressants or monoclonal antibodies can sometimes be very effective, there is currently no predictive marker or recommendation available to determine which treatment will be most appropriate for which patient.
Collapse
Affiliation(s)
- J Franques
- Hôpital européen, 6, rue Désirée-Clary, 13003 Marseille, France; Hôpital La Casamance, 33, boulevard des Farigoules, 13400 Aubagne, France.
| |
Collapse
|
33
|
Lehmann HC, Burke D, Kuwabara S. Chronic inflammatory demyelinating polyneuropathy: update on diagnosis, immunopathogenesis and treatment. J Neurol Neurosurg Psychiatry 2019; 90:981-987. [PMID: 30992333 DOI: 10.1136/jnnp-2019-320314] [Citation(s) in RCA: 125] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 02/26/2019] [Accepted: 03/24/2019] [Indexed: 11/03/2022]
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is an immune-mediated neuropathy typically characterised by symmetrical involvement, and proximal as well as distal muscle weakness (typical CIDP). However, there are several 'atypical' subtypes, such as multifocal acquired demyelinating sensory and motor neuropathy (Lewis-Sumner syndrome) and 'distal acquired demyelinating symmetric neuropathy', possibly having different immunopathogenesis and treatment responses. In the absence of diagnostic and pathogenetic biomarkers, diagnosis and treatment may be difficult, but recent progress has been made in the application of neuroimaging tools demonstrating nerve hypertrophy and in identifying subgroups of patients who harbour antibodies against nodal proteins such as neurofascin and contactin-1. Despite its relative rarity, CIDP represents a significant economic burden, mostly due to costly treatment with immunoglobulin. Recent studies have demonstrated the efficacy of subcutaneous as well as intravenous immunoglobulin as maintenance therapy, and newer immunomodulating drugs can be used in refractory cases. This review provides an overview focusing on advances over the past several years.
Collapse
Affiliation(s)
| | - David Burke
- Institute of Clinical Neurosciences, University of Sydney, Sydney, New South Wales, Australia
| | | |
Collapse
|
34
|
Rodríguez Y, Vatti N, Ramírez-Santana C, Chang C, Mancera-Páez O, Gershwin ME, Anaya JM. Chronic inflammatory demyelinating polyneuropathy as an autoimmune disease. J Autoimmun 2019; 102:8-37. [DOI: 10.1016/j.jaut.2019.04.021] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/13/2019] [Accepted: 04/23/2019] [Indexed: 12/12/2022]
|
35
|
Abstract
PURPOSE OF REVIEW Induction of lymphocyte depletion is increasingly used as a therapeutic strategy for central and peripheral neuroinflammatory disease. However, there is also a growing recognition of the treatment-related complication of secondary antibody deficiency (SAD). Although the occurrence of hypogammaglobulinaemia is a recognized phenomenon during immunomodulation, robust data on the coexistence of impaired responses to immunization, and significant and/or atypical infections is scarce. Here we review the literature on SAD in anti-CD20 therapy. RECENT FINDINGS Several factors that may increase the incidence of SAD have now been identified, including low levels of immunoglobulins prior to the commencement of B-cell ablation therapy, duration of maintenance therapy, and concurrent or prior use of other immunosuppressing agents such as cyclophosphamide and steroids. Measurement of disease-specific antibodies and vaccine response are likely to be helpful adjuncts to measurement of serum immunoglobulin levels during B-cell depleting therapy. Supportive treatment may include amending the treatment schedule to limit cumulative dose. SUMMARY B-cell depleting agents offer considerable therapeutic benefit in neurology. We propose modifications in current practice that include risk stratification and early identification of SAD, with the aim of minimising morbidity and mortality related to this underappreciated condition.
Collapse
|
36
|
Whittam DH, Tallantyre EC, Jolles S, Huda S, Moots RJ, Kim HJ, Robertson NP, Cree BAC, Jacob A. Rituximab in neurological disease: principles, evidence and practice. Pract Neurol 2019; 19:5-20. [PMID: 30498056 DOI: 10.1136/practneurol-2018-001899] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Rituximab is a widely used B-cell-depleting monoclonal antibody. It is unlicensed for use in neurological disorders and there are no treatment guidelines. However, as a rapidly acting, targeted therapy with growing evidence of efficacy and tolerability in several neuroinflammatory disorders, it is an attractive alternative to conventional immunomodulatory medications. This practical review aims to explain the basic principles of B-cell depletion with therapeutic monoclonal antibodies. We present the evidence for using rituximab in neurological diseases, and describe the practical aspects of prescribing, including dosing, monitoring, safety, treatment failure and its use in special circumstances such as coexisting viral hepatitis, pregnancy and lactation. We provide an administration guide, checklist and patient information leaflet, which can be adapted for local use. Finally, we review the safety data of rituximab and ocrelizumab (a newer and recently licensed B-cell-depleting therapy for multiple sclerosis) and suggest monitoring and risk reduction strategies.
Collapse
Affiliation(s)
- Daniel H Whittam
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Emma C Tallantyre
- Helen Durham Centre for Neuroinflammation, University Hospital or Wales, Cardiff, UK
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
- School of Medicine, Cardiff University, Cardiff, UK
| | - Saif Huda
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Robert J Moots
- Department of Musculoskeletal Diseases, Institute of Ageing and Chronic Diseases, University of Liverpool, Liverpool, UK
| | - Ho Jin Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, South Korea
| | - Neil P Robertson
- Helen Durham Centre for Neuroinflammation, University Hospital or Wales, Cardiff, UK
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Bruce A C Cree
- Weill Institute for Neurosciences, University of California, San Francisco, California, USA
| | - Anu Jacob
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
- School of Medicine, University of Liverpool, Liverpool, UK
| |
Collapse
|
37
|
Roux T, Debs R, Maisonobe T, Lenglet T, Delorme C, Louapre C, Leblond V, Viala K. Rituximab in chronic inflammatory demyelinating polyradiculoneuropathy with associated diseases. J Peripher Nerv Syst 2018; 23:235-240. [PMID: 30203907 DOI: 10.1111/jns.12287] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 09/03/2018] [Accepted: 09/06/2018] [Indexed: 11/29/2022]
Abstract
We aimed to analyse the response to rituximab in a cohort of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) patients with associated disorders. We conducted a clinical and electrophysiological retrospective monocentric study in 28 CIDP patients. Response to rituximab was defined as (a) a five-point increase in the Medical Research Council sum score or a one-point decrease in the Overall Neuropathy Limitations Scale score, compared to the score at the first rituximab infusion, or (b) the discontinuation of, or reduced need for, the last treatments before rituximab initiation. Twenty-one patients (75%) were responders to rituximab. The median time before response was 6 months (1-10 months). Only two patients needed to be treated again during a median follow-up of 2.0 years (0.75-9 years). Interestingly, the response rate was good in patients with associated autoimmune disease (5/8) and similar to the response rate observed in patients with a haematological disease (16/20) (P = 0.63). A shorter disease duration was associated with a better clinical response to rituximab (odds ratio 0.81, P = 0.025) and the response rate was better (P = 0.05) in common forms (83.3%) than in sensory forms (42.9%). No major adverse events were recorded. Rituximab is efficacious in CIDP patients with haematological or autoimmune disease. It improves clinical response and decreases dependence on first-line treatments.
Collapse
Affiliation(s)
- Thomas Roux
- Department of Clinical Neurophysiology, APHP, Pitié-Salpêtrière Hospital, Paris, France
| | - Rabab Debs
- Department of Clinical Neurophysiology, APHP, Pitié-Salpêtrière Hospital, Paris, France.,Medical School, Pierre et Marie Curie University-Paris VI, Paris, France
| | - Thierry Maisonobe
- Department of Clinical Neurophysiology, APHP, Pitié-Salpêtrière Hospital, Paris, France.,Medical School, Pierre et Marie Curie University-Paris VI, Paris, France
| | - Timothée Lenglet
- Department of Clinical Neurophysiology, APHP, Pitié-Salpêtrière Hospital, Paris, France.,Medical School, Pierre et Marie Curie University-Paris VI, Paris, France
| | - Cécile Delorme
- Department of Clinical Neurophysiology, APHP, Pitié-Salpêtrière Hospital, Paris, France.,Medical School, Pierre et Marie Curie University-Paris VI, Paris, France
| | - Céline Louapre
- Department of Neurology, APHP, Pitié-Salpêtrière Hospital, Paris, France
| | - Véronique Leblond
- Department of Haematology, APHP, Pitié-Salpêtrière Hospital, Paris, France
| | - Karine Viala
- Department of Clinical Neurophysiology, APHP, Pitié-Salpêtrière Hospital, Paris, France.,Medical School, Pierre et Marie Curie University-Paris VI, Paris, France
| |
Collapse
|
38
|
MacIsaac J, Siddiqui R, Jamula E, Li N, Baker S, Webert KE, Evanovitch D, Heddle NM, Arnold DM. Systematic review of rituximab for autoimmune diseases: a potential alternative to intravenous immune globulin. Transfusion 2018; 58:2729-2735. [DOI: 10.1111/trf.14841] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 05/13/2018] [Accepted: 05/16/2018] [Indexed: 01/19/2023]
Affiliation(s)
- John MacIsaac
- Department of Medicine, Michael G. DeGroote School of Medicine; McMaster University; Hamilton Ontario Canada
| | - Reda Siddiqui
- Department of Medicine, Michael G. DeGroote School of Medicine; McMaster University; Hamilton Ontario Canada
| | - Erin Jamula
- Department of Medicine, Michael G. DeGroote School of Medicine; McMaster University; Hamilton Ontario Canada
| | - Na Li
- Department of Medicine, Michael G. DeGroote School of Medicine; McMaster University; Hamilton Ontario Canada
| | - Steven Baker
- Department of Medicine, Michael G. DeGroote School of Medicine; McMaster University; Hamilton Ontario Canada
| | | | - Denise Evanovitch
- Ontario Regional Blood Coordinating Network (ORBCoN); Hamilton Ontario Canada
| | - Nancy M. Heddle
- Department of Medicine, Michael G. DeGroote School of Medicine; McMaster University; Hamilton Ontario Canada
- Canadian Blood Services; Hamilton Ontario Canada
| | - Donald M. Arnold
- Department of Medicine, Michael G. DeGroote School of Medicine; McMaster University; Hamilton Ontario Canada
- Canadian Blood Services; Hamilton Ontario Canada
| |
Collapse
|
39
|
Dyck PJB, Tracy JA. History, Diagnosis, and Management of Chronic Inflammatory Demyelinating Polyradiculoneuropathy. Mayo Clin Proc 2018; 93:777-793. [PMID: 29866282 DOI: 10.1016/j.mayocp.2018.03.026] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 03/21/2018] [Accepted: 03/28/2018] [Indexed: 12/15/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is probably the best recognized progressive immune-mediated peripheral neuropathy. It is characterized by a symmetrical, motor-predominant peripheral neuropathy that produces both distal and proximal weakness. Large-fiber abnormalities (weakness and ataxia) predominate, whereas small-fiber abnormalities (autonomic and pain) are less common. The pathophysiology of CIDP is inflammatory demyelination that manifests as slowed conduction velocities, temporal dispersion, and conduction block on nerve conduction studies and as segmental demyelination, onion-bulb formation, and endoneurial inflammatory infiltrates on nerve biopsies. Although spinal fluid protein levels are generally elevated, this finding is not specific for the diagnosis of ClDP. Other neuropathies can resemble CIDP, and it is important to identify these to ensure correct treatment of these various conditions. Consequently, metastatic bone surveys (for osteosclerotic myeloma), serum electrophoresis with immunofixation (for monoclonal gammopathies), and human immunodeficiency virus testing should be considered for testing in patients with suspected CIDP. Chronic inflammatory demyelinating polyradiculoneuropathy can present as various subtypes, the most common being the classical symmetrical polyradiculoneuropathy and the next most common being a localized asymmetrical form, multifocal CIDP. There are 3 well-established, first-line treatments of CIDP-corticosteroids, plasma exchange, and intravenous immunoglobulin-with most experts using intravenous immunoglobulin as first-line therapy. Newer immune-modulating drugs can be used in refractory cases. Treatment response in CIDP should be judged by objective measures (improvement in the neurological or electrophysiological examination), and treatment needs to be individualized to each patient.
Collapse
|
40
|
Rajabally YA, Stettner M, Kieseier BC, Hartung HP, Malik RA. CIDP and other inflammatory neuropathies in diabetes — diagnosis and management. Nat Rev Neurol 2017; 13:599-611. [DOI: 10.1038/nrneurol.2017.123] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
41
|
Pitarokoili K, Yoon MS, Kröger I, Reinacher-Schick A, Gold R, Schneider-Gold C. Severe refractory CIDP: a case series of 10 patients treated with bortezomib. J Neurol 2017; 264:2010-2020. [DOI: 10.1007/s00415-017-8599-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 08/17/2017] [Accepted: 08/18/2017] [Indexed: 11/29/2022]
|
42
|
Savasta S, Foiadelli T, Vegezzi E, Cortese A, Lozza A, Pichiecchio A, Franciotta D, Marchioni E. Efficacy of rituximab as third-line therapy in combined central and peripheral demyelination. Neurol Clin Pract 2017; 7:534-537. [PMID: 29431175 DOI: 10.1212/cpj.0000000000000388] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Salvatore Savasta
- Department of Pediatrics (SS, TF), University of Pavia, IRCCS Policllinico S. Matteo Foundation; Neuroscience Consortium (EV), University of Pavia, Monza Policlinico and Pavia Mondino; Department of Neurology (EM, EV), C. Mondino National Neurological Institute; C. Mondino National Neurological Institute (AC, AL, AP, DF), Pavia, Italy; and Molecular Neuroscience (AC), University College London Institute of Neurology, UK
| | - Thomas Foiadelli
- Department of Pediatrics (SS, TF), University of Pavia, IRCCS Policllinico S. Matteo Foundation; Neuroscience Consortium (EV), University of Pavia, Monza Policlinico and Pavia Mondino; Department of Neurology (EM, EV), C. Mondino National Neurological Institute; C. Mondino National Neurological Institute (AC, AL, AP, DF), Pavia, Italy; and Molecular Neuroscience (AC), University College London Institute of Neurology, UK
| | - Elisa Vegezzi
- Department of Pediatrics (SS, TF), University of Pavia, IRCCS Policllinico S. Matteo Foundation; Neuroscience Consortium (EV), University of Pavia, Monza Policlinico and Pavia Mondino; Department of Neurology (EM, EV), C. Mondino National Neurological Institute; C. Mondino National Neurological Institute (AC, AL, AP, DF), Pavia, Italy; and Molecular Neuroscience (AC), University College London Institute of Neurology, UK
| | - Andrea Cortese
- Department of Pediatrics (SS, TF), University of Pavia, IRCCS Policllinico S. Matteo Foundation; Neuroscience Consortium (EV), University of Pavia, Monza Policlinico and Pavia Mondino; Department of Neurology (EM, EV), C. Mondino National Neurological Institute; C. Mondino National Neurological Institute (AC, AL, AP, DF), Pavia, Italy; and Molecular Neuroscience (AC), University College London Institute of Neurology, UK
| | - Alessandro Lozza
- Department of Pediatrics (SS, TF), University of Pavia, IRCCS Policllinico S. Matteo Foundation; Neuroscience Consortium (EV), University of Pavia, Monza Policlinico and Pavia Mondino; Department of Neurology (EM, EV), C. Mondino National Neurological Institute; C. Mondino National Neurological Institute (AC, AL, AP, DF), Pavia, Italy; and Molecular Neuroscience (AC), University College London Institute of Neurology, UK
| | - Anna Pichiecchio
- Department of Pediatrics (SS, TF), University of Pavia, IRCCS Policllinico S. Matteo Foundation; Neuroscience Consortium (EV), University of Pavia, Monza Policlinico and Pavia Mondino; Department of Neurology (EM, EV), C. Mondino National Neurological Institute; C. Mondino National Neurological Institute (AC, AL, AP, DF), Pavia, Italy; and Molecular Neuroscience (AC), University College London Institute of Neurology, UK
| | - Diego Franciotta
- Department of Pediatrics (SS, TF), University of Pavia, IRCCS Policllinico S. Matteo Foundation; Neuroscience Consortium (EV), University of Pavia, Monza Policlinico and Pavia Mondino; Department of Neurology (EM, EV), C. Mondino National Neurological Institute; C. Mondino National Neurological Institute (AC, AL, AP, DF), Pavia, Italy; and Molecular Neuroscience (AC), University College London Institute of Neurology, UK
| | - Enrico Marchioni
- Department of Pediatrics (SS, TF), University of Pavia, IRCCS Policllinico S. Matteo Foundation; Neuroscience Consortium (EV), University of Pavia, Monza Policlinico and Pavia Mondino; Department of Neurology (EM, EV), C. Mondino National Neurological Institute; C. Mondino National Neurological Institute (AC, AL, AP, DF), Pavia, Italy; and Molecular Neuroscience (AC), University College London Institute of Neurology, UK
| |
Collapse
|
43
|
Wongseelashote S, Tayal V, Bourke PF. Off-label use of rituximab in autoimmune disease in the Top End of the Northern Territory, 2008-2016. Intern Med J 2017; 48:165-172. [PMID: 28742259 DOI: 10.1111/imj.13554] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 07/18/2017] [Accepted: 07/18/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Rituximab, an anti-CD20 B-cell depleting monoclonal antibody, is increasingly prescribed off-label for a range of autoimmune diseases. There has not previously been an audit of off-label rituximab use in the Northern Territory, where the majority of patients are Aboriginal. AIMS To evaluate retrospectively off-label rituximab use in autoimmune diseases in the Top End of the Northern Territory. METHODS We performed a retrospective audit of 8 years of off-label rituximab use at the Royal Darwin Hospital, the sole tertiary referral centre for the Darwin, Katherine and East Arnhem regions. Electronic and paper records were reviewed for demographic information, diagnosis/indication for rituximab, doses, previous/concomitant immunosuppression, clinical outcomes and specific adverse events. RESULTS Rituximab was prescribed off-label to 66 patients for 24 autoimmune diseases. The majority of patients (62.1%) were Aboriginal and 60.6% female. The most common indications were refractory/relapsing disease despite standard therapies (68.7%) or severe disease with rituximab incorporated into an induction immunosuppressive regimen (19.4%). Systemic lupus erythematosus was the underlying diagnosis in 28.8% of cases. A clinically significant response was demonstrated in 74.2% of cases overall. There were 18 clinically significant infections; however, 13 were in patients receiving concurrent immunosuppressive therapy. There was a total of nine deaths from any cause. CONCLUSION Rituximab has been used off-label for a range of autoimmune diseases in this population with a high proportion of Aboriginal patients successfully and safely in the majority of cases.
Collapse
Affiliation(s)
- Sarah Wongseelashote
- General and Acute Care Medicine, Royal Darwin Hospital, Tiwi, Northern Territory, Australia
| | - Vipin Tayal
- Division of Medicine (Rheumatology), Royal Darwin Hospital, Tiwi, Northern Territory, Australia
| | - Peter Francis Bourke
- Division of Medicine (Rheumatology), Royal Darwin Hospital, Tiwi, Northern Territory, Australia.,Division of Integrated Medicine and Emergency Services (Clinical Immunology), Cairns Hospital, Cairns, Queensland, Australia
| |
Collapse
|
44
|
Kedra J, Foltz V, Viala K, Tan S, Fautrel B. Lewis–Sumner syndrome in a patient with rheumatoid arthritis: Link between rheumatoid arthritis and demyelinating polyradiculoneuropathies. Joint Bone Spine 2017; 84:485-487. [DOI: 10.1016/j.jbspin.2017.02.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 02/22/2017] [Indexed: 11/29/2022]
|
45
|
Nobile-Orazio E, Gallia F, Terenghi F, Bianco M. Comparing treatment options for chronic inflammatory neuropathies and choosing the right treatment plan. Expert Rev Neurother 2017; 17:755-765. [DOI: 10.1080/14737175.2017.1340832] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Eduardo Nobile-Orazio
- Department of Medical Biotechnology and Translational Medicine (BIOMETRA), University of Milan, Milan, Italy
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical Institute, Milan, Italy
| | - Francesca Gallia
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical Institute, Milan, Italy
| | - Fabrizia Terenghi
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical Institute, Milan, Italy
| | - Mariangela Bianco
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical Institute, Milan, Italy
| |
Collapse
|
46
|
Mahdi‐Rogers M, Brassington R, Gunn AA, van Doorn PA, Hughes RAC. Immunomodulatory treatment other than corticosteroids, immunoglobulin and plasma exchange for chronic inflammatory demyelinating polyradiculoneuropathy. Cochrane Database Syst Rev 2017; 5:CD003280. [PMID: 28481421 PMCID: PMC6481566 DOI: 10.1002/14651858.cd003280.pub5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a disease that causes progressive or relapsing and remitting weakness and numbness. It is probably caused by an autoimmune process. Immunosuppressive or immunomodulatory drugs would be expected to be beneficial. This review was first published in 2003 and has been updated most recently in 2016. OBJECTIVES To assess the effects of immunomodulatory and immunosuppressive agents other than corticosteroids, immunoglobulin, and plasma exchange in CIDP. SEARCH METHODS On 24 May 2016, we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 4) in the Cochrane Library, MEDLINE, Embase, CINAHL, and LILACS for completed trials, and clinical trial registers for ongoing trials. We contacted the authors of the trials identified and other disease experts seeking other published and unpublished trials. SELECTION CRITERIA We sought randomised and quasi-randomised trials of all immunosuppressive agents, such as azathioprine, cyclophosphamide, methotrexate, ciclosporin, mycophenolate mofetil, and rituximab, and all immunomodulatory agents, such as interferon (IFN) alfa and IFN beta, in participants fulfilling standard diagnostic criteria for CIDP. We included all comparisons of these agents with placebo, another treatment, or no treatment. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We wanted to measure the change in disability after one year as our primary outcome. Our secondary outcomes were change in disability after four or more weeks (from randomisation); change in impairment after at least one year; change in maximum motor nerve conduction velocity and compound muscle action potential amplitude after one year; and for participants who were receiving corticosteroids or intravenous immunoglobulin (IVIg), the amount of this medication given during at least one year after randomisation. Participants with one or more serious adverse events during the first year was also a secondary outcome. MAIN RESULTS Four trials fulfilled the selection criteria: one of azathioprine (27 participants), two of IFN beta-1a (77 participants in total) and one of methotrexate (60 participants). The risk of bias was considered low in the trials of IFN beta-1a and methotrexate but high in the trial of azathioprine. None of the trials showed significant benefit in any of the outcomes selected by their authors. The results of the outcomes which approximated most closely to the primary outcome for this review were as follows.In the azathioprine trial there was a median improvement in the Neuropathy Impairment Scale (scale range 0 to 280) after nine months of 29 points (range 49 points worse to 84 points better) in the azathioprine and prednisone treated participants compared with 30 points worse (range 20 points worse to 104 points better) in the prednisone alone group. There were no reports of adverse events.In a cross-over trial of IFN beta-1a with 20 participants, the treatment periods were 12 weeks. The median improvement in the Guy's Neurological Disability Scale (range 1 to 10) was 0.5 grades (interquartile range (IQR) 1.8 grades better to zero grade change) in the IFN beta-1a treatment period and 0.5 grades (IQR 1.8 grades better to 1.0 grade worse) in the placebo treatment period. There were no serious adverse events in either treatment period.In a parallel group trial of IFN beta-1a with 67 participants, none of the outcomes for this review was available. The trial design involved withdrawal from ongoing IVIg treatment. The primary outcome used by the trial authors was total IVIg dose administered from week 16 to week 32 in the placebo group compared with the IFN beta-1a groups. This was slightly but not significantly lower in the combined IFN beta-1a groups (1.20 g/kg) compared with the placebo group (1.34 g/kg, P = 0.75). There were four participants in the IFN beta-1a group and none in the placebo group with one or more serious adverse events, risk ratio (RR) 4.50 (95% confidence interval (CI) 0.25 to 80.05).The methotrexate trial had a similar design involving withdrawal from ongoing corticosteroid or IVIg treatment. At the end of the trial (approximately 40 weeks) there was no significant difference in the change in the Overall Neuropathy Limitations Scale, a disability scale (scale range 0 to 12), the median change being 0 (IQR -1 to 0) in the methotrexate group and 0 (IQR -0.75 to 0) in the placebo group. These changes in disability might have been confounded by the reduction in corticosteroid or IVIg dose required by the protocol. There were three participants in the methotrexate group and one in the placebo with one or more serious adverse events, RR 3.56 (95% CI 0.39 to 32.23). AUTHORS' CONCLUSIONS Low-quality evidence from randomised trials does not show significant benefit from azathioprine or interferon beta-1a and moderate-quality evidence from one randomised trial does not show significant benefit from a relatively low dose of methotrexate for the treatment of CIDP. None of the trials was large enough to rule out small or moderate benefit. The evidence from observational studies is insufficient to avoid the need for randomised controlled trials to discover whether these drugs are beneficial. Future trials should have improved designs, more sensitive outcome measures relevant to people with CIDP, and longer treatment durations.
Collapse
Affiliation(s)
| | - Ruth Brassington
- National Hospital for Neurology and NeurosurgeryQueen Square Centre for Neuromuscular DiseasesPO Box 114LondonUKWC1N 3BG
| | - Angela A Gunn
- National Hospital for Neurology and NeurosurgeryMRC Centre for Neuromuscular DiseasesPO Box 114LondonUKWC1N 3BG
| | - Pieter A van Doorn
- Erasmus University Medical CenterDepartment of NeurologyPO Box 2040RotterdamNetherlands3000 CA
| | - Richard AC Hughes
- National Hospital for Neurology and NeurosurgeryMRC Centre for Neuromuscular DiseasesPO Box 114LondonUKWC1N 3BG
| | | |
Collapse
|
47
|
Velardo D, Riva N, Del Carro U, Bianchi F, Comi G, Fazio R. Rituximab in refractory chronic inflammatory demyelinating polyradiculoneuropathy: report of four cases. J Neurol 2017; 264:1011-1014. [PMID: 28337614 DOI: 10.1007/s00415-017-8462-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 03/12/2017] [Accepted: 03/14/2017] [Indexed: 11/24/2022]
Affiliation(s)
- Daniele Velardo
- Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology (INSPE), San Raffaele Scientific Institute, Via Olgettina 48, Milan, 20132, Italy.
| | - Nilo Riva
- Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology (INSPE), San Raffaele Scientific Institute, Via Olgettina 48, Milan, 20132, Italy
| | - Ubaldo Del Carro
- Division of Neuroscience, Department of Neurophysiology, Institute of Experimental Neurology (INSPE), San Raffaele Scientific Institute, Via Olgettina 48, Milan, 20132, Italy
| | - Francesca Bianchi
- Division of Neuroscience, Department of Neurophysiology, Institute of Experimental Neurology (INSPE), San Raffaele Scientific Institute, Via Olgettina 48, Milan, 20132, Italy
| | - Giancarlo Comi
- Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology (INSPE), San Raffaele Scientific Institute, Via Olgettina 48, Milan, 20132, Italy
| | - Raffaella Fazio
- Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology (INSPE), San Raffaele Scientific Institute, Via Olgettina 48, Milan, 20132, Italy
| |
Collapse
|
48
|
Léger JM, Haghi Ashtiani B, Guimaraes-Costa R. Investigated and emerging treatments for chronic inflammatory demyelinating polyradiculoneuropathy. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1285225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
49
|
Debs R, Reach P, Cret C, Demeret S, Saheb S, Maisonobe T, Viala K. A new treatment regimen with high-dose and fractioned immunoglobulin in a special subgroup of severe and dependent CIDP patients. Int J Neurosci 2016; 127:864-872. [PMID: 27918219 DOI: 10.1080/00207454.2016.1269328] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Chronic inflammatory demyelinating polyneuropathy (CIDP) is treated with intravenous immunoglobulins (IVIg), corticosteroids or plasma exchange (PE). IVIg dosage is not universal and markers for treatment management are needed. METHODS We report the response to high-dose and fractioned IVIg in a subgroup of definite CIDP patients, resistant to corticosteroids and PE, responders to IVIg but with an efficacy window <15 d. RESULTS Four patients were included with similar predominantly clinical motor form and conduction abnormalities. Treatment management consisted of fractioning IVIg and increasing the monthly cumulated dose (mean: 3 g/kg/month). Serum IgG concentration was measured and correlated to the clinical state. Monitoring of serum IgG helped to guide IVIg administration dosage and frequency. A mean of 10 months was required to improve symptoms; therapy was then switched to subcutaneous (SC) route (maintenance dose: 3.5 g/kg/month). The mean Overall Neuropathy Limitations Scale was improved from 11 to 3.2 and the mean Medical Research Council scale from 26 to 90. CONCLUSION It is important to distinguish patients with short IVIg efficacy window from those with classical resistance since the former may benefit from fractioning and increasing the IVIg dose. The monitoring of serum IgG level and its correlation to the clinical response could be of help in monitoring each individual's dosage.
Collapse
Affiliation(s)
- Rabab Debs
- a Département de Neurophysiologie , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France.,c Service de neurologie 1, Centre diagnostique et thérapeutique des neuropathies périphériques , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France
| | - Pauline Reach
- a Département de Neurophysiologie , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France.,c Service de neurologie 1, Centre diagnostique et thérapeutique des neuropathies périphériques , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France
| | - Corina Cret
- b Neurology Department , Centre Hospitalier de Meaux , Meaux , France
| | - Sophie Demeret
- c Service de neurologie 1, Centre diagnostique et thérapeutique des neuropathies périphériques , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France
| | - Samir Saheb
- d Centre Clinique d'Hémobiothérapie, service d'Hématologie , Groupe Hospitalier Pitié-Salpêtrière , AP-HP , Paris , France
| | - Thierry Maisonobe
- a Département de Neurophysiologie , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France.,c Service de neurologie 1, Centre diagnostique et thérapeutique des neuropathies périphériques , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France
| | - Karine Viala
- a Département de Neurophysiologie , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France.,c Service de neurologie 1, Centre diagnostique et thérapeutique des neuropathies périphériques , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France
| |
Collapse
|
50
|
Ellrichmann G, Gold R, Ayzenberg I, Yoon MS, Schneider-Gold C. Two years' long-term follow up in chronic inflammatory demyelinating polyradiculoneuropathy: efficacy of intravenous immunoglobulin treatment. Ther Adv Neurol Disord 2016; 10:91-101. [PMID: 28382108 DOI: 10.1177/1756285616679369] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Administration of intravenous immunoglobulins (IVIgs) is established for long-term treatment of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Prevention of secondary axonal loss going along with permanent clinical disability and muscular atrophy is a major aim in CIDP therapy. To assess long-term clinical efficacy of IVIg treatment despite heterogenous disease course and variable complaints reported by the patients, long-term electrophysiological monitoring was performed for systematic evaluation of therapeutic efficacy of IVIg. METHODS A total of 21 patients with CIDP treated with IVIg 1 g/kg bodyweight every 3-6 weeks were examined electrophysiologically every 12 months over a period of 2 years. RESULTS Assessment of clinical symptoms, using the Inflammatory Neuropathy Cause and Treatment (INCAT) and Hughes functional grading score (F-score) revealed improvement of motor and sensory symptoms over a period of 2 years. As electrophysiological results remained stable, IVIg treatment seems to be suitable to prevent axonal loss in CIDP. CONCLUSIONS This study confirms efficacy of IVIg as firstline therapy in CIDP. Doses and frequency of IVIg application should be adapted based on clinical evaluation and analysis of long-term electrophysiological findings.
Collapse
Affiliation(s)
- Gisa Ellrichmann
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, D-44791 Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Germany
| | - Ilya Ayzenberg
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Germany
| | - Min-Suk Yoon
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Germany
| | | |
Collapse
|