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Zhang KY, Duan WW, Luo YB, Li Y, Hu J, Yang H. Comparative effectiveness and safety of intravenous methylprednisolone and tacrolimus monotherapy in ocular myasthenia gravis with unsatisfactory prednisone responses: a retrospective study. Orphanet J Rare Dis 2024; 19:19. [PMID: 38243274 PMCID: PMC10799357 DOI: 10.1186/s13023-024-03025-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 01/11/2024] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Oral prednisone has been recognized as the first-line therapy for the treatment of ocular myasthenia gravis (OMG). However, its long-term use is complicated by numerous adverse effects and is ineffective for some OMG patients in reaching remission. This study aimed to evaluate the effectiveness and safety of intravenous methylprednisolone (IVMP) and tacrolimus monotherapy for OMG patients with unsatisfactory responses to conventional prednisone therapy. METHODS We retrospectively reviewed 57 OMG patients who had not achieved satisfactory improvement after prednisone therapy and thereby received IVMP or tacrolimus monotherapy for at least 6 months. Ocular symptoms were evaluated by the ocular-quantitative MG (QMG) score at each time point. A ≥ 2-point fall in ocular QMG score was defined as the cut-off point to indicate clinical improvement. Logistic regression analysis was performed to identify factors associated with the efficacy of IVMP at discharge. Adverse events were recorded. RESULTS Both IVMP and tacrolimus monotherapy demonstrated significant clinical efficacy, with no statistical differences observed at the study endpoint. The proportions of patients who reached the cut-off point for efficacy evaluation were higher in the IVMP group than in the tacrolimus group (1, 3, and 6 months: 51.7% (15/29) vs 12.0% (3/25), p = 0.002; 69.0% (20/29) vs 40.0% (10/25), p = 0.033; 69.0% (20/29) vs 46.4% (13/28), p = 0.085, respectively). Multivariate logistics analysis showed that high ocular QMG scores at baseline indicated favourable responses to IVMP treatment (OR = 1.781; 95% CI 1.066-2.975; p = 0.028). All the adverse events were transient and tolerable. CONCLUSION Our findings suggest that both IVMP and tacrolimus monotherapy hold promise as viable treatment options for OMG patients with unsatisfactory responses to oral prednisone. The study supports the safety and effectiveness of both therapies, with IVMP exhibiting faster improvement and favourable efficacy in patients with high ocular QMG scores.
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Affiliation(s)
- Kai-Yue Zhang
- Department of Neurology, Xiangya Hospital, Central South University, Xiangya Road, Kaifu District, Changsha, 410008, China
| | - Wei-Wei Duan
- Department of Neurology, Xiangya Hospital, Central South University, Xiangya Road, Kaifu District, Changsha, 410008, China
| | - Yue-Bei Luo
- Department of Neurology, Xiangya Hospital, Central South University, Xiangya Road, Kaifu District, Changsha, 410008, China
| | - Yi Li
- Department of Neurology, Xiangya Hospital, Central South University, Xiangya Road, Kaifu District, Changsha, 410008, China
| | - Jue Hu
- Department of Neurology, Changsha Central Hospital, Changsha, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Xiangya Road, Kaifu District, Changsha, 410008, China.
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Chen X, Qiu J, Gao Z, Liu B, Zhang C, Yu W, Yang J, Shen Y, Qi L, Yao X, Sun H, Yang X. Myasthenia gravis: Molecular mechanisms and promising therapeutic strategies. Biochem Pharmacol 2023; 218:115872. [PMID: 37865142 DOI: 10.1016/j.bcp.2023.115872] [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: 09/03/2023] [Revised: 10/16/2023] [Accepted: 10/18/2023] [Indexed: 10/23/2023]
Abstract
Myasthenia gravis (MG) is a type of autoimmune disease caused by the blockage of neuromuscular junction transmission owing to the attack of autoantibodies on transmission-related proteins. Related antibodies, such as anti-AChR, anti-MuSK and anti-LRP4 antibodies, can be detected in most patients with MG. Although traditional therapies can control most symptoms, several challenges remain to be addressed, necessitating the development of more effective and safe treatment strategies for MG. With the in-depth exploration on the mechanism and immune targets of MG, effective therapies, especially therapies using biologicals, have been reported recently. Given the important roles of immune cells, cytokines and intercellular interactions in the pathological process of MG, B-cell targeted therapy, T-cell targeted therapy, proteasome inhibitors targeting plasma cell, complement inhibitors, FcRn inhibitors have been developed for the treatment of MG. Although these novel therapies exert good therapeutic effects, they may weaken the immunity and increase the risk of infection in MG patients. This review elaborates on the pathogenesis of MG and discusses the advantages and disadvantages of the strategies of traditional treatment and biologicals. In addition, this review emphasises that combined therapy may have better therapeutic effects and reducing the risk of side effects of treatments, which has great prospects for the treatment of MG. With the deepening of research on immunotherapy targets in MG, novel opportunities and challenges in the treatment of MG will be introduced.
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Affiliation(s)
- Xin Chen
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Department of Neurology, Affiliated Hospital of Nantong University, Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Jiayi Qiu
- Department of Clinical Medicine, Medical College, Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Zihui Gao
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Department of Neurology, Affiliated Hospital of Nantong University, Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Boya Liu
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Department of Neurology, Affiliated Hospital of Nantong University, Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Chen Zhang
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Department of Neurology, Affiliated Hospital of Nantong University, Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Weiran Yu
- Department of Clinical Medicine, Medical College, Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Jiawen Yang
- Department of Clinical Medicine, Medical College, Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Yuntian Shen
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Department of Neurology, Affiliated Hospital of Nantong University, Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Lei Qi
- Department of Emergency Medicine, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Xinlei Yao
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Department of Neurology, Affiliated Hospital of Nantong University, Nantong University, Nantong, Jiangsu Province 226001, PR China.
| | - Hualin Sun
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Department of Neurology, Affiliated Hospital of Nantong University, Nantong University, Nantong, Jiangsu Province 226001, PR China.
| | - Xiaoming Yang
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Department of Neurology, Affiliated Hospital of Nantong University, Nantong University, Nantong, Jiangsu Province 226001, PR China.
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Fan Z, Lei L, Su S, Zhang S, Xie N, Li L, Lu Y, Di L, Wang M, Xu M, Shen X, Da Y. Comparison between mono-tacrolimus and mono-glucocorticoid in the treatment of myasthenia gravis. Ann Clin Transl Neurol 2023; 10:589-598. [PMID: 36808840 PMCID: PMC10109324 DOI: 10.1002/acn3.51746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 02/04/2023] [Accepted: 02/07/2023] [Indexed: 02/23/2023] Open
Abstract
OBJECTIVE Use of tacrolimus in mild to moderate myasthenia gravis (MG) is generally limited to glucocorticoid-refractory cases; the advantage of mono-tacrolimus over mono-glucocorticoids is unknown. METHODS We included mild to moderate MG patients treated with mono-tacrolimus (mono-TAC) or mono-glucocorticoids (mono-GC). The correlation between the immunotherapy options and the treatment efficacy and side effects were examined in 1:1 propensity-score matching. The main outcome was time to minimal manifestations status or better (MMS or better). Secondary outcomes include time to relapse, the mean changes in Myasthenia Gravis-specific Activities of Daily Living (MG-ADL) scores and the rate of adverse events. RESULTS Baseline characteristics showed no difference between matched groups (49 matched pairs). There were no differences in median time to MMS or better between the mono-TAC group and mono-GC group (5.1 vs. 2.8 months: unadjusted hazard ratio [HR], 0.73; 95% CI, 0.46-1.16; p = 0.180), as well as in median time to relapse (data unavailable for the mono-TAC group since 44 of 49 [89.8%] participants remained in MMS or better; 39.7 months in mono-GC group: unadjusted HR, 0.67; 95% CI, 0.23-1.97; p = 0.464). Changes in MG-ADL scores between the two groups were similar (mean differences, 0.3; 95% CI, -0.4 to 1.0; p = 0.462). The rate of adverse events was lower in the mono-TAC group compared to the mono-GC group (24.5% vs. 55.1%, p = 0.002). INTERPRETATION Mono-tacrolimus performs superior tolerability with non-inferior efficacy compared to mono-glucocorticoids in mild to moderate myasthenia gravis patients who refuse or have a contraindication to glucocorticoids.
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Affiliation(s)
- Zhirong Fan
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
- Department of NeurologyXijing Hospital, Fourth Military Medical UniversityXi'anChina
| | - Lin Lei
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
- Department of NeurologyBeijing Jishuitan HospitalBeijingChina
| | - Shengyao Su
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Shu Zhang
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Nairong Xie
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Ling Li
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
- Department of NeurologyTianjin 4th Centre HospitalTianjinChina
| | - Yan Lu
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Li Di
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Min Wang
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Min Xu
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Xin‐Ming Shen
- Department of Neurology and Neuromuscular Research LaboratoryMayo ClinicRochesterMinnesotaUSA
| | - Yuwei Da
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
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Bi Z, Cao Y, Lin J, Zhang Q, Liu C, Gui M, Bu B. Long-Term Improvement in a Chinese Cohort of Glucocorticoid-Resistant Childhood-Onset Myasthenia Gravis Patients Treated With Tacrolimus. Front Neurol 2022; 13:820205. [PMID: 35211085 PMCID: PMC8860838 DOI: 10.3389/fneur.2022.820205] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/10/2022] [Indexed: 12/30/2022] Open
Abstract
Objectives To evaluate the long-term outcome of tacrolimus for childhood-onset myasthenia gravis (CMG) with an inadequate response to glucocorticoids, and investigate factors associated with favorable outcomes following tacrolimus treatment. Methods A retrospective, observational cohort study was performed for CMG patients who had not improved satisfactorily after sufficient prednisone therapy for at least 8 weeks. All patients were given tacrolimus in doses of 2–3 mg for more than 6 months. The primary efficacy outcome was assessed using the prednisone dose, quantitative MG (QMG), and MG-activity of daily living (ADL) scores. The participants were divided into improved and unimproved groups based on changes in QMG scores to investigate the risk factors that affected tacrolimus efficacy. Results A total of 149 glucocorticoid resistant CMG patients were finally enrolled in our study, with 113 (75.8%) responding well to tacrolimus (defined as minimal manifestation status or better). One month after initiating tacrolimus, there was a noticeable improvement in prednisone dose, QMG, and ADL scores, which continued to improve throughout the study. More importantly, the prednisone was eventually stopped in 89 of the patients (78.8%). Thymus type [odds ratio (OR) = 3.156, 95% confidence interval (CI) 1.427–6.978; P = 0.005] and pre-intervention status (OR = 0.284, 95%CI 0.109–0.741; P = 0.010) were independent predictors of tacrolimus efficacy after controlling for confounding factors in multiple logistic regression. Conclusion The majority of glucocorticoid-resistant CMG patients have a good long-term prognosis after adding tacrolimus. Thymus type and pre-intervention status can serve as potential predictors affecting the efficacy of tacrolimus.
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Affiliation(s)
- Zhuajin Bi
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yayun Cao
- Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jing Lin
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qing Zhang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chenchen Liu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Mengcui Gui
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bitao Bu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Li H, Ruan Z, Gao F, Zhou H, Guo R, Sun C, Xu Q, Lu Q, Zhou Y, Zhao Z, Yu L, Wu S, Lei T, Gao T, Tang Y, Li C, Huo F, Zhu Y, Sun J, Tang B, Zhang M, Gao Y, Lu X, Li Z, Chang T. Thymectomy and Risk of Generalization in Patients with Ocular Myasthenia Gravis: A Multicenter Retrospective Cohort Study. Neurotherapeutics 2021; 18:2449-2457. [PMID: 34625864 PMCID: PMC8804035 DOI: 10.1007/s13311-021-01129-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2021] [Indexed: 02/05/2023] Open
Abstract
This study aims to investigate the association between thymectomy and the risk of generalization in patients with ocular myasthenia gravis (MG). Data on patients with ocular MG from seven neurological centers in China were retrospectively reviewed. Ocular MG naïve to immunotherapy was categorized according to whether thymectomy was performed (thymectomized group vs. nonsurgical group). Patients in the thymectomized group all underwent surgery within 2 years since ocular symptom onset. The main outcome measure was the generalization. The follow-up period was defined from the date of ocular symptom onset to the date of generalization confirmation, immunotherapy initiation, or last follow-up (defined as 60 months). Of 519 eligible patients (mean [SD] age, 48.7 [15.2] years, 46.6% women), 31 (23.7%) of 131 generalized in the thymectomized group and 122 (31.4%) of 388 did in the nonsurgical group during a median follow-up of 19 months (IQR 8.0-50.0). Thymectomy was independently associated with reduced generalization risk (adjusted HR 0.41, 95% CI 0.25-0.66, P < 0.001). Multivariable stratified analysis also verified this association across the subgroups. Kaplan-Meier curves showed that the 5-year cumulative rate was significantly lower in the thymectomized group than in the nonsurgical group. To conclude, thymectomy may be considered effective in modifying the progression from ocular to generalized MG irrespective of thymoma.
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Affiliation(s)
- Huanhuan Li
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Zhe Ruan
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Feng Gao
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Hongyu Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Rongjing Guo
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Chao Sun
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Quan Xu
- Department of Thoracic Surgery, Jiangxi Provincial People's Hospital Affiliated To Nanchang University, Nanchang, China
| | - Qiang Lu
- Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an, China
| | - Yongan Zhou
- Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an, China
| | - Zhengwei Zhao
- Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an, China
| | - Liping Yu
- Department of Neurology, Xianyang First People's Hospital, Xianyang, China
| | - Songdi Wu
- Department of Neurology, Xi'an No.1 Hospital, Xi'an, China
| | - Tao Lei
- Department of Neurology, Xi'an Fourth Hospital, Xi'an, China
| | - Ting Gao
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Yonglan Tang
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Chunhong Li
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Feiyan Huo
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Ying Zhu
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Jie Sun
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Baoli Tang
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Min Zhang
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Yanwu Gao
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Xiaodan Lu
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Zhuyi Li
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China.
| | - Ting Chang
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China.
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Itani K, Nakamura M, Wate R, Kaneko S, Fujita K, Iida S, Morise S, Murakami A, Kunieda T, Takenouchi N, Yakushiji Y, Kusaka H. Efficacy and safety of tacrolimus as long-term monotherapy for myasthenia gravis. Neuromuscul Disord 2021; 31:512-518. [PMID: 33903022 DOI: 10.1016/j.nmd.2021.02.010] [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: 08/20/2020] [Revised: 01/28/2021] [Accepted: 02/10/2021] [Indexed: 10/22/2022]
Abstract
The objective was to evaluate the long-term efficacy and safety of tacrolimus monotherapy in myasthenia gravis (MG) patients. Immunosuppressive drug-naïve MG patients were administered tacrolimus, followed by thymectomy in some of the cases according to the clinical guideline for MG. Additional aggressive immunosuppressive therapies were allowed if the patients without thymectomy did not achieve minimal manifestation (MM) or better status after 3 weeks of tacrolimus administration or in the thymectomized patients by 1-2 weeks after the operation (i.e., 1st evaluation). Of all 14 patients included in this study, 8 of them (57%) achieved MM or better status at the 1st evaluation, and the remaining 6 (43%), who had failed to gain MM or better status at the 1st evaluation, also achieved MM or better status with 1 course of aggressive immunosuppressive therapy. The quantitative MG (QMG) scores, MG-Activities of Daily Living (ADL) scales, and anti-acetylcholine receptor (AchR) antibody levels were significantly decreased at 6 months and maintained thereafter. At the end of the follow-up period (41-70 months), all patients were in MM or better status. None of the patients experienced severe adverse effects. Our small preliminary study indicates that long-term tacrolimus monotherapy is possibly effective and safe for MG patients.
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Affiliation(s)
- Kumi Itani
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka 5731010, Japan
| | - Masataka Nakamura
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka 5731010, Japan.
| | - Reika Wate
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka 5731010, Japan
| | - Satoshi Kaneko
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka 5731010, Japan
| | - Kengo Fujita
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka 5731010, Japan
| | - Shin Iida
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka 5731010, Japan
| | - Satoshi Morise
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka 5731010, Japan
| | - Aya Murakami
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka 5731010, Japan
| | - Takenobu Kunieda
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka 5731010, Japan
| | - Norihiro Takenouchi
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka 5731010, Japan; Department of Microbiology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka 5731010, Japan
| | - Yusuke Yakushiji
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka 5731010, Japan
| | - Hirofumi Kusaka
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka 5731010, Japan
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Evoli A, Iorio R. Controversies in Ocular Myasthenia Gravis. Front Neurol 2020; 11:605902. [PMID: 33329368 PMCID: PMC7734350 DOI: 10.3389/fneur.2020.605902] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 10/26/2020] [Indexed: 12/12/2022] Open
Abstract
Myasthenia gravis (MG) with symptoms limited to eye muscles [ocular MG (OMG)] is a rare disease. OMG incidence varies according to ethnicity and age of onset. In recent years, both an increase in incidence rate, particularly in the elderly, and a lower risk for secondary generalization may have contributed to the growing disease prevalence in Western countries. OMG should be considered in patients with painless ptosis and extrinsic ophthalmoparesis. Though asymmetric muscle involvement and symptom fluctuations are typical, in some cases, OMG can mimic isolated cranial nerve paresis, internuclear ophthalmoplegia, and conjugate gaze palsy. Diagnostic confirmation can be challenging in patients negative for anti-acetylcholine receptor and anti-muscle-specific tyrosine kinase antibodies on standard radioimmunoassay. Early treatment is aimed at relieving symptoms and at preventing disease progression to generalized MG. Despite the absence of high-level evidence, there is general agreement on the efficacy of steroids at low to moderate dosage; immunosuppressants are considered when steroid high maintenance doses are required. The role of thymectomy in non-thymoma patients is controversial. Prolonged exposure to immunosuppressive therapy has a negative impact on the health-related quality of life in a proportion of these patients. OMG is currently excluded from most of the treatments recently developed in generalized MG.
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Affiliation(s)
- Amelia Evoli
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Raffaele Iorio
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
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Fan Z, Li Z, Shen F, Zhang X, Lei L, Su S, Lu Y, Di L, Wang M, Xu M, Da Y. Favorable Effects of Tacrolimus Monotherapy on Myasthenia Gravis Patients. Front Neurol 2020; 11:594152. [PMID: 33193063 PMCID: PMC7652845 DOI: 10.3389/fneur.2020.594152] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 09/24/2020] [Indexed: 12/11/2022] Open
Abstract
Background and Purpose: Tacrolimus (TAC) has been proven to be a rapid-acting, steroid-sparing agent for myasthenia gravis (MG) therapy. However, evidence related to the effectiveness of TAC alone is rare. Therefore, this study was performed to investigate the effect of TAC monotherapy in MG patients. Methods: Forty-four MG patients who received TAC monotherapy were retrospectively analyzed. A mixed effect model was used to analyze improvements in MG-specific activities of daily living scale (MG-ADL), quantitative MG score (QMG) and MG-ADL subscores. Kaplan-Meier analysis was used to estimate the cumulative probability of minimal manifestations (MM) or better. Adverse events (AEs) were recorded for safety analyses. Results: Of the patients receiving TAC monotherapy, MG-ADL scores were remarkably improved at 3, 6 and 12 months compared with scores at baseline (mean difference and 95% CIs: −3.29 [−4.94, −1.64], −3.97 [−5.67, −2.27], and −4.67 [−6.48, −2.85], respectively). QMG scores significantly decreased at 6 and 12 months, with mean differences and 95% CIs of −4.67(−6.88, −2.45) and −5.77 (−7.55, −4.00), respectively. Estimated median period to achieve “MM or better” was 5.0 (95% CIs, 2.8, 7.2) months. Ocular MG (OMG) and generalized MG (GMG) showed similar therapeutic effects in cumulative probabilities of “MM or better” (P-value = 0.764). A better response was observed in MG-ADL subscores for ptosis and bulbar symptoms. AEs occurred in 37.5% of patients and were generally mild and reversible. Conclusions: TAC monotherapy is a promising option to rapidly alleviate all symptoms of MG, especially for ptosis and bulbar symptoms.
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Affiliation(s)
- Zhirong Fan
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zunbo Li
- Department of Neurology, Xi'an Gaoxin Hospital, Xi'an, China
| | - Faxiu Shen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xueping Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lin Lei
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shengyao Su
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yan Lu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Li Di
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Min Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Min Xu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuwei Da
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Barnett C, Tabasinejad R, Bril V. Current pharmacotherapeutic options for myasthenia gravis. Expert Opin Pharmacother 2019; 20:2295-2303. [PMID: 31670984 DOI: 10.1080/14656566.2019.1682548] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Novel options for immune-based therapy in myasthenia gravis are improving the therapeutic outlook for patients. Multiple clinical trials on immunomodulation, complement inhibitors, and FcR inhibitors are providing evidence for novel immune-based therapies that promise to improve outcomes in myasthenia patients. These more focused immune treatments are reviewed in this paper.Areas covered: This paper outlines classical treatment for myasthenia gravis and then reviews recent clinical trial evidence for novel immune therapies, particularly complement inhibitors and FcR inhibitors. Further, as immune therapies expand in other areas of medicine, such as oncology, iatrogenic myasthenia is being observed as a complication of some novel treatments.Expert opinion: Exciting new options to help patients with myasthenia gravis are now available or in phase 3 trials based on promising phase 2 results. Manipulation of the immune system can also lead to iatrogenic MG. Although novel treatments can improve care for myasthenia gravis patients, future developments that prevent the production of specific abnormal auto-antibodies are desirable.
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Affiliation(s)
- Carolina Barnett
- Department of Medicine (Neurology), University Health Network, University of Toronto - Neurology, Toronto, Ontario, Canada
| | - Raha Tabasinejad
- Department of Medicine (Neurology), University Health Network, University of Toronto - Neurology, Toronto, Ontario, Canada
| | - Vera Bril
- Department of Medicine (Neurology), University Health Network, University of Toronto - Neurology, Toronto, Ontario, Canada
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Safety and efficacy of tacrolimus-coated silicone plates as an alternative to mitomycin C in a rabbit model of conjunctival fibrosis. PLoS One 2019; 14:e0219194. [PMID: 31276522 PMCID: PMC6611608 DOI: 10.1371/journal.pone.0219194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 06/18/2019] [Indexed: 12/05/2022] Open
Abstract
Purpose To find safer and more effective drugs than mitomycin C to prevent conjunctival fibrosis in a rabbit model. Methods Twenty-four rabbits were involved and randomly divided into four groups. Limbus-based peritomy was performed at the superior cornea, and normal saline (NS group), mitomycin C (MMC group), SR (SR group), or TC (TC group)-coated silicone plate was inserted at the sub-Tenon’s space in each group. Conjunctival congestion was evaluated at 1 and 4 weeks postoperatively. At 4 weeks, the numbers of inflammatory cells, fibroblasts, myofibroblasts, blood vessels, and goblet cells were counted in the conjunctiva and Tenon’s capsule around the silicone plate. Results At 4 weeks, conjunctival congestion was significantly less than that observed at 1 week in the SR and TC groups (p < 0.05), whereas the number of myofibroblasts was significantly lower in the MMC and TC groups (p < 0.05). The conjunctiva was significantly less congested in the TC group versus the other groups at 1 week and 4 weeks (p < 0.05). The TC group had the lowest number of inflammatory cells and MMC group had the lowest number of goblet cells among all groups (p < 0.05). Conclusions The TC-coated silicone plate was more effective in inhibiting inflammation and fibrosis versus the MMC-coated silicone plate and was associated with fewer adverse effects in the rabbit model.
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Wang L, Xi J, Zhang S, Wu H, Zhou L, Lu J, Zhang T, Zhao C. Effectiveness and safety of tacrolimus therapy for myasthenia gravis: A single arm meta-analysis. J Clin Neurosci 2019; 63:160-167. [DOI: 10.1016/j.jocn.2019.02.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 01/27/2019] [Accepted: 02/20/2019] [Indexed: 12/31/2022]
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Wang S, Breskovska I, Gandhy S, Punga AR, Guptill JT, Kaminski HJ. Advances in autoimmune myasthenia gravis management. Expert Rev Neurother 2018; 18:573-588. [PMID: 29932785 PMCID: PMC6289049 DOI: 10.1080/14737175.2018.1491310] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Myasthenia gravis (MG) is an autoimmune neuromuscular disorder with no cure and conventional treatments limited by significant adverse effects and variable benefit. In the last decade, therapeutic development has expanded based on improved understanding of autoimmunity and financial incentives for drug development in rare disease. Clinical subtypes exist based on age, gender, thymic pathology, autoantibody profile, and other poorly defined factors, such as genetics, complicate development of specific therapies. Areas covered: Clinical presentation and pathology vary considerably among patients with some having weakness limited to the ocular muscles and others having profound generalized weakness leading to respiratory insufficiency. MG is an antibody-mediated disorder dependent on autoreactive B cells which require T-cell support. Treatments focus on elimination of circulating autoantibodies or inhibition of effector mechanisms by a broad spectrum of approaches from plasmapheresis to B-cell elimination to complement inhibition. Expert commentary: Standard therapies and those under development are disease modifying and not curative. As a rare disease, clinical trials are challenged in patient recruitment. The great interest in development of treatments specific for MG is welcome, but decisions will need to be made to focus on those that offer significant benefits to patients.
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Affiliation(s)
- Shuhui Wang
- Department of Neurology, George Washington University, Washington DC 20008
| | - Iva Breskovska
- Department of Neurology, George Washington University, Washington DC 20008
| | - Shreya Gandhy
- Department of Neurology, George Washington University, Washington DC 20008
| | - Anna Rostedt Punga
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Uppsala, Sweden
| | - Jeffery T. Guptill
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Henry J. Kaminski
- Department of Neurology, George Washington University, Washington DC 20008
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Abstract
Myasthenia gravis (MG) is an autoimmune disease involving the neuromuscular junction. Autoantibodies to the acetylcholine receptor or, less frequently, to muscle-specific kinase, attack against the postsynaptic junctional proteins, resulting in fluctuating and variable weakness of muscles. Extraocular, levator palpebrae superioris, and orbicularis oculi muscles are particularly susceptible. The majority of patients with MG present with purely ocular symptoms including ptosis and diplopia initially. About half of these patients progress to generalized disease within 2 years. The prevalence of MG in Taiwan is 140 per million with male to female ratio of 0.7. The incidence rate is higher in the elderly. Several immune-related diseases such as lymphoid malignancy, diabetes, and thyroid diseases are associated with MG in the national population-based studies in Taiwan. Ice pack test, rest test, Tensilon/neostigmine test, circulating antibody measurement, and electrophysiological studies are useful diagnostic tools with variable sensitivity and specificity. For the patients with ocular MG, acetylcholinesterase inhibitors are usually the first-line treatment. Corticosteroids and immunosuppressant could provide better disease control and may reduce the risk of conversion to generalized form although there is still some controversy. A thymectomy is also beneficial for ocular MG, especially in refractory cases. The correction of ptosis and strabismus surgery could improve the visual outcome but should be performed only in stable disease.
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Affiliation(s)
- Chao-Wen Lin
- National Taiwan University Hospital, Taipei City, Taiwan
| | - Ta-Ching Chen
- National Taiwan University Hospital, Taipei City, Taiwan
| | - Jieh-Ren Jou
- National Taiwan University Hospital, Taipei City, Taiwan.,Changhua Christian Hospital, Changhua, Taiwan
| | - Lin-Chung Woung
- National Taiwan University Hospital, Taipei City, Taiwan.,Taipei City Hospital, Taipei City, Taiwan
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Ishii S, Miwa Y, Otsuka K, Nishimi S, Nishimi A, Saito M, Miura Y, Oguro N, Tokunaga T, Takahashi R, Kasama T. Influence of renal complications on the efficacy and adverse events of tacrolimus combination therapy in patients with systemic lupus erythematosus (SLE) during a maintenance phase: a single-centre, prospective study. Lupus Sci Med 2015; 2:e000091. [PMID: 26056606 PMCID: PMC4453506 DOI: 10.1136/lupus-2015-000091] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 05/05/2015] [Accepted: 05/10/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVES The study investigated whether renal complications affected the efficacy and safety of tacrolimus combination therapy in patients with systemic lupus erythematosus (SLE) during a maintenance phase. METHODS Fifty-seven patients with SLE (A: 30 cases with renal complication, B: 27 cases without renal complications) were included. The presence of renal complications was defined as proteinuria ≥0.5 g/day and lupus nephritis on renal biopsy. Major outcome measures included SLE disease activity index (SLEDAI), steroid dose, serum anti-dsDNA Ab, C3 and creatinine (Cr) levels and estimated glomerular filtration rate (eGFR). The patient's background factors included age, gender, disease duration and ACE-I/angiotensin II receptor blocker and statin therapies. We compared these outcome measures pre treatment and after 1 year of treatment. RESULTS The SLEDAI and serum C3 levels improved in both groups from pretreatment period to post-treatment period: from 7.2±5.0 to 2.8±2.3 in A and 6.4±3.8 to 2.4±2.2 in B, p<0.001, and from 65.9±24.6 to 77.7±18.2 mg/dL in A and 81.8±23.0 to 90.6±19.4 mg/dL in B, p=0.002, respectively. The anti-dsDNA antibody level was reduced, and the serum Cr and eGFR levels were slightly elevated. No patients developed end-stage renal failure that required artificial dialysis. CONCLUSIONS Tacrolimus combination therapy had additive beneficial effects on reduced proteinuria and increased serum C3 levels in patients with SLE with renal complications during a maintenance phase.
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Affiliation(s)
- Sho Ishii
- Division of Rheumatology, Department of Medicine , Showa University School of Medicine , Tokyo , Japan
| | - Yusuke Miwa
- Division of Rheumatology, Department of Medicine , Showa University School of Medicine , Tokyo , Japan
| | - Kumiko Otsuka
- Division of Rheumatology, Department of Medicine , Showa University School of Medicine , Tokyo , Japan
| | - Shinichiro Nishimi
- Division of Rheumatology, Department of Medicine , Showa University School of Medicine , Tokyo , Japan
| | - Airi Nishimi
- Division of Rheumatology, Department of Medicine , Showa University School of Medicine , Tokyo , Japan
| | - Mayu Saito
- Division of Rheumatology, Department of Medicine , Showa University School of Medicine , Tokyo , Japan
| | - Yoko Miura
- Division of Rheumatology, Department of Medicine , Showa University School of Medicine , Tokyo , Japan
| | - Nao Oguro
- Division of Rheumatology, Department of Medicine , Showa University School of Medicine , Tokyo , Japan
| | - Takahiro Tokunaga
- Division of Rheumatology, Department of Medicine , Showa University School of Medicine , Tokyo , Japan
| | - Ryo Takahashi
- Division of Rheumatology, Department of Medicine , Showa University School of Medicine , Tokyo , Japan
| | - Tsuyoshi Kasama
- Division of Rheumatology, Department of Medicine , Showa University School of Medicine , Tokyo , Japan
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Shimizu Y, Suzuki S, Utsugisawa K, Imai T, Murai H, Nagane Y, Tsuda E, Nagasao T, Ogata H, Yazawa M, Suzuki N, Kishi K. Is Surgical Intervention Safe and Effective in the Treatment of Myasthenic Blepharoptosis? A Multicenter Survey in Japan. Eur Neurol 2014; 71:259-61. [DOI: 10.1159/000356793] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 10/27/2013] [Indexed: 11/19/2022]
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Kerty E, Elsais A, Argov Z, Evoli A, Gilhus NE. EFNS/ENS Guidelines for the treatment of ocular myasthenia. Eur J Neurol 2014; 21:687-93. [PMID: 24471489 DOI: 10.1111/ene.12359] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 12/17/2013] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND PURPOSE The symptoms of acquired autoimmune ocular myasthenia are restricted to the extrinsic eye muscles, causing double vision and drooping eyelids. These guidelines are designed to provide advice about best clinical practice based on the current state of clinical and scientific knowledge and the consensus of an expert panel. SEARCH STRATEGY Evidence for these guidelines was collected by searches in the MEDLINE and Cochrane databases. The task force working group reviewed evidence from original articles and systematic reviews. The evidence was classified (I, II, III, IV) and consensus recommendation graded (A, B or C) according to the EFNS guidance. Where there was a lack of evidence but clear consensus, good practice points are provided. CONCLUSIONS The treatment of ocular myasthenia should initially be started with pyridostigmine (good practice point). If this is not successful in relieving symptoms, oral corticosteroids should be used on an alternate-day regimen (recommendation level C). If steroid treatment does not result in good control of the symptoms or if it is necessary to use high steroid doses, steroid-sparing treatment with azathioprine should be started (recommendation level C). If ocular myasthenia gravis is associated with thymoma, thymectomy is indicated. Otherwise, the role of thymectomy in ocular myasthenia is controversial. Steroids and thymectomy may modify the course of ocular myasthenia and prevent myasthenia gravis generalization (good practice point).
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Affiliation(s)
- E Kerty
- Department of Neurology, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
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Wong SH, Huda S, Vincent A, Plant GT. Ocular Myasthenia Gravis: Controversies and Updates. Curr Neurol Neurosci Rep 2013; 14:421. [DOI: 10.1007/s11910-013-0421-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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