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Alfaidi N, Karmastaji S, Matic A, Bril V. FcRn Inhibitor Therapies in Neurologic Diseases. CNS Drugs 2024; 38:425-441. [PMID: 38724842 DOI: 10.1007/s40263-024-01090-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2024] [Indexed: 05/18/2024]
Abstract
In the last decade, the landscape of treating autoimmune diseases has evolved with the emergence and approval of novel targeted therapies. Several new biological agents offer selective and target-specific immunotherapy and therefore fewer side effects, such as neonatal Fc receptor (FcRn)-targeting therapy. Neonatal Fc receptor-targeted therapies are engineered to selectively target FcRn through various methods, such as Fc fragments or monoclonal anti-FcRn antibodies. These approaches enhance the breakdown of autoantibodies by blocking the immunoglobulin G recycling pathway. This mechanism reduces overall plasma immunoglobulin levels, including the levels of pathogenic autoantibodies, without affecting the other immunoglobulin class immunoglobulin A, immunoglobulin E, immunoglobulin M, and immunoglobulin D levels. Drugs that inhibit FcRn include efgartigimod, rozanolixizumab, batoclimab, and nipocalimab. These medications can be administered either intravenously or subcutaneously. Numerous clinical trials are currently underway to investigate their effectiveness, safety, and tolerability in various neurological conditions, including myasthenia gravis and other neurological disorders such as chronic inflammatory demyelinating polyneuropathy, myositis, neuromyelitis optica, and myelin oligodendrocyte glycoprotein antibody disease. Positive results from clinical trials of efgartigimod and rozanolixizumab led to their approval for the treatment of generalized myasthenia gravis. Additional clinical trials are still ongoing. Neonatal Fc receptor inhibitor agents seem to be well tolerated. Reported adverse events include headache (most commonly observed with efgartigimod and rozanolixizumab), upper respiratory tract infection, urinary tract infection, diarrhea, pyrexia, and nausea. Additionally, some of these agents may cause transient hypoalbuminemia and hypercholesterolemia notably reported with batoclimab and nipocalimab. In this review, we discuss the available clinical data for FcRN inhibitor agents in treating different neurological autoimmune diseases.
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Affiliation(s)
- Nouf Alfaidi
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, 5EC-309, TGH 200 Elizabeth St, Toronto, ON, M5G 2C4, Canada
| | - Salama Karmastaji
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, 5EC-309, TGH 200 Elizabeth St, Toronto, ON, M5G 2C4, Canada
| | - Alexandria Matic
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, 5EC-309, TGH 200 Elizabeth St, Toronto, ON, M5G 2C4, Canada
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, 5EC-309, TGH 200 Elizabeth St, Toronto, ON, M5G 2C4, Canada.
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Zhang Z, Yang M, Luo T, Du X, Wang Z, Huang X, Zhang Y. Rescue treatment with add-on efgartigimod in a patient with impending myasthenic crisis: a case report. Ther Adv Neurol Disord 2024; 17:17562864241254895. [PMID: 38813520 PMCID: PMC11135074 DOI: 10.1177/17562864241254895] [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: 01/12/2024] [Accepted: 04/26/2024] [Indexed: 05/31/2024] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disorder characterized by fluctuating muscle weakness. Severe patients may develop life-threatening respiratory failure and experience crisis. Plasma exchange or intravenous immunoglobulin (IVIg) is the first-line treatment option for myasthenia crisis, but some patients still poorly respond to them. Here, we first reported a generalized MG patient from China who was in a state of impending myasthenic crisis and did not respond effectively to IVIg but was successfully rescued by add-on efgartigimod. Especially, we also detected meaningful changes in T-cell and B-cell subsets after efgartigimod, promoting a potential role of efgartigimod in re-establishing immune homeostasis.
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Affiliation(s)
- Zhouao Zhang
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Mingjin Yang
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Tiancheng Luo
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Xue Du
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Zhouyi Wang
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Xiaoyu Huang
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, No. 99 Huaihai West Road, Quanshan District, Xuzhou, Jiangsu 210000, China
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Yong Zhang
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, No. 99 Huaihai West Road, Quanshan District, Xuzhou, Jiangsu 221004, China
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3
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Li J, Wu X, Chu T, Tan X, Wang S, Qu R, Chen Z, Wang Z. The efficacy and safety of FcRn inhibitors in patients with myasthenia gravis: a systematic review and meta-analysis. J Neurol 2024; 271:2298-2308. [PMID: 38431900 DOI: 10.1007/s00415-024-12247-x] [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: 12/03/2023] [Revised: 02/08/2024] [Accepted: 02/08/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Myasthenia gravis (MG) is an autoimmune disease that causes local or generalized muscle weakness. Complement inhibitors and targeting of the neonatal Fc receptor (FcRn) to block IgG cycling are two novel and successful mechanisms. METHODS PubMed, EMBASE, the Cochrane Library, and ClinicalTrials.gov were systematically searched to identify relevant studies published before May 18, 2023. Review Manager 5.3 software was used to assess the data. RESULTS We pooled 532 participants from six randomized controlled trials (RCTs). Compared to the placebo, the FcRn inhibitors were more efficacy in Myasthenia Gravis Activities of Daily Living (MG-ADL) (MD = - 1.69 [- 2.35, - 1.03], P < 0.00001), MG-ADL responder (RR = 2.01 [1.62, 2.48], P < 0.00001), Quantitative Myasthenia Gravis (QMG) (MD = - 2.45 [- 4.35, - 0.55], P = 0.01), Myasthenia Gravis Composite (MGC) (MD = - 2.97 [- 4.27, - 1.67], P < 0.00001), 15-item revised version of the Myasthenia Gravis Quality of Life (MGQoL15r) (MD = - 2.52 [- 3.54, - 1.50], P < 0.00001), without increasing the risk of safety. The subgroup analysis showed that efgartigimod was more effective than placebo in MG-ADL responders. Rozanolixizumab was more effective than the placebo except in QMG, and batoclimab was more effective than the placebo except in MG-ADL responder. Nipocalizumab did not show satisfactory efficacy in all outcomes. With the exception of rozanolixizumab, all drugs showed non-inferior safety profiles to placebo. CONCLUSION FcRn inhibitors have good efficacy and safety in patients with MG. Among them, efgartigimod and nipocalimab were effective without causing an increased safety risk. Rozanolixizumab, despite its superior efficacy, caused an increased incidence of adverse events. Current evidence does not suggest that nipocalimab is effective in patients with MG.
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Affiliation(s)
- Jiaxuan Li
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China
| | - Xin Wu
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China
| | - Tianchen Chu
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China
| | - Xin Tan
- Department of Neurology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu Province, China
| | - Shixin Wang
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China
| | - Ruisi Qu
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China
| | - Zhouqing Chen
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China.
| | - Zhong Wang
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China.
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Fisse AL, Schäfer E, Hieke A, Schröder M, Klimas R, Brünger J, Huckemann S, Grüter T, Sgodzai M, Schneider-Gold C, Gold R, Nguyen HP, Pitarokoili K, Motte J, Arning L. Association of the neonatal Fc receptor promoter variable number of tandem repeat polymorphism with immunoglobulin response in patients with chronic inflammatory demyelinating polyneuropathy. Eur J Neurol 2024; 31:e16205. [PMID: 38205888 DOI: 10.1111/ene.16205] [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: 09/14/2023] [Revised: 12/04/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND AND PURPOSE Chronic inflammatory demyelinating polyneuropathy (CIDP) is an autoimmune disease with humoral and cellular autoimmunity causing demyelination of peripheral nerves, commonly treated with intravenous immunoglobulins (IVIg). The neonatal Fc receptor (FcRn), encoded by the FCGRT gene, prevents the degradation of immunoglobulin G (IgG) by recycling circulating IgG. A variable number of tandem repeat (VNTR) polymorphism in the promoter region of the FCGRT gene is associated with different expression levels of mRNA and protein. Thus, patients with genotypes associated with relatively low FcRn expression may show a poorer treatment response to IVIg due to increased IVIg degradation. METHODS VNTR genotypes were analyzed in 144 patients with CIDP. Patients' clinical data, including neurological scores and treatment data, were collected as part of the Immune-Mediated Neuropathies Biobank registry. RESULTS Most patients (n = 124, 86%) were VNTR 3/3 homozygotes, and 20 patients (14%) were VNTR 2/3 heterozygotes. Both VNTR 3/3 and VNTR 2/3 genotype groups showed no difference in clinical disability and immunoglobulin dosage. However, patients with a VNTR 2 allele were more likely to receive subcutaneous immunoglobulins (SCIg) than patients homozygous for the VNTR 3 allele (25% vs. 9.7%, p = 0.02) and were more likely to receive second-line therapy (75% vs. 54%, p = 0.05). CONCLUSIONS The VNTR 2/3 genotype is associated with the administration of SCIg, possibly reflecting a greater benefit from SCIg due to more constant immunoglobulin levels without lower IVIg levels between the treatment circles. Also, the greater need for second-line treatment in VNTR 2/3 patients could be an indirect sign of a lower response to immunoglobulins.
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Affiliation(s)
- Anna Lena Fisse
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
- Immune-Mediated Neuropathies Biobank, Ruhr University Bochum, Bochum, Germany
| | - Emelie Schäfer
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
- Immune-Mediated Neuropathies Biobank, Ruhr University Bochum, Bochum, Germany
| | - Alina Hieke
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
- Immune-Mediated Neuropathies Biobank, Ruhr University Bochum, Bochum, Germany
| | - Maximilian Schröder
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
- Immune-Mediated Neuropathies Biobank, Ruhr University Bochum, Bochum, Germany
| | - Rafael Klimas
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
- Immune-Mediated Neuropathies Biobank, Ruhr University Bochum, Bochum, Germany
| | - Jil Brünger
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
- Immune-Mediated Neuropathies Biobank, Ruhr University Bochum, Bochum, Germany
| | - Sophie Huckemann
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
- Immune-Mediated Neuropathies Biobank, Ruhr University Bochum, Bochum, Germany
| | - Thomas Grüter
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
- Immune-Mediated Neuropathies Biobank, Ruhr University Bochum, Bochum, Germany
| | - Melissa Sgodzai
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
- Immune-Mediated Neuropathies Biobank, Ruhr University Bochum, Bochum, Germany
| | | | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
- Immune-Mediated Neuropathies Biobank, Ruhr University Bochum, Bochum, Germany
| | - Huu Phuc Nguyen
- Department of Human Genetics, Ruhr University Bochum, Bochum, Germany
| | - Kalliopi Pitarokoili
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
- Immune-Mediated Neuropathies Biobank, Ruhr University Bochum, Bochum, Germany
| | - Jeremias Motte
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
- Immune-Mediated Neuropathies Biobank, Ruhr University Bochum, Bochum, Germany
| | - Larissa Arning
- Department of Human Genetics, Ruhr University Bochum, Bochum, Germany
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Strohl WR. Structure and function of therapeutic antibodies approved by the US FDA in 2023. Antib Ther 2024; 7:132-156. [PMID: 38617189 PMCID: PMC11011201 DOI: 10.1093/abt/tbae007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 04/16/2024] Open
Abstract
In calendar year 2023, the United States Food and Drug Administration (US FDA) approved a total of 55 new molecular entities, of which 12 were in the class of therapeutic antibodies. Besides antibody protein drugs, the US FDA also approved another five non-antibody protein drugs, making the broader class of protein drugs about 31% of the total approved drugs. Among the 12 therapeutic antibodies approved by the US FDA, 8 were relatively standard IgG formats, 3 were bivalent, bispecific antibodies and 1 was a trivalent, bispecific antibody. In 2023, no new antibody-drug conjugates, immunocytokines or chimeric antigen receptor-T cells were approved. Of the approved antibodies, two targeted programmed cell death receptor-1 (PD-1) for orphan indications, two targeted CD20 for diffuse large B cell lymphoma, two targeted different receptors (B-cell maturation antigen [BCMA] and G-coupled protein receptor class C, group 5, member D [GPRC5D]) for treatment of multiple myeloma, and one each that targeted amyloid-β protofibrils for Alzheimer's disease, neonatal Fc receptor alpha-chain for myasthenia gravis, complement factor C5 for CD55 deficiency with hyper-activation of complement, angiopathic thrombosis and severe protein-losing enteropathy disease, interleukin (IL)-23p19 for severely active ulcerative colitis, IL-17A-F for plaque psoriasis and respiratory syncytial virus (RSV)-F protein for season-long RSV prophylaxis in infants.
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Affiliation(s)
- William R Strohl
- Scientific Advisor Department, BiStro Biotechnology Consulting, 1086 Tullo Farm Rd., Bridgewater, NJ 08807, USA
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6
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Chase RC, Koop AH, Shaikh M, Imperial RJ, Harnois DM, Loo NM, O'Brien JJ. Successful treatment of severe passenger lymphocyte syndrome with efgartigimod synergy. Transfusion 2024; 64:755-760. [PMID: 38425280 DOI: 10.1111/trf.17748] [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: 05/13/2023] [Revised: 01/08/2024] [Accepted: 01/30/2024] [Indexed: 03/02/2024]
Abstract
INTRODUCTION This case describes passenger lymphocyte syndrome (PLS) generating human platelet antigen 1a (HPA-1a) alloantibodies against the recipient's platelets after liver transplant. Given the rarity of PLS, especially in liver transplant with HPA-1a alloantibodies, disease course and management options are poorly described. METHODS The patient had cirrhosis secondary to nonalcoholic steatohepatitis complicated by hepatocellular carcinoma, encephalopathy, and severe ascites. The model for end-stage liver disease (MELD) score was 15 at presentation. The patient developed hepatic artery thrombosis after an orthotopic liver transplant and was relisted for transplant with a MELD score of 40. The patient received a hepatitis C virus antibody positive, hepatitis C virus nucleic amplification test positive donor liver on postoperative day (POD) 7 after first transplant. On POD 7 after the second transplant, the patient developed profound thrombocytopenia refractory to platelet infusion. They were found to have serum antibody to HPA-1a based upon serum platelet alloantibody testing. The donor was later found to be negative for HPA-1a by genetic testing. However, the patient's native platelets were HPA-1a positive. The patient was diagnosed with PLS. RESULTS The patient's treatment course included 57 units of platelets transfused, emergency splenectomy, rituximab, plasma exchange, intravenous immunoglobulin (IVIG), eltrombopag, romiplostim, and efgartigimod. DISCUSSION The synergistic effect of efgartigimod with eltrombopag and romiplostim most likely resolved the patient's thrombocytopenia. This case represents a novel use of efgartigimod in the treatment of passenger lymphocyte syndrome following liver transplant.
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Affiliation(s)
| | - Andree H Koop
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Marwan Shaikh
- Division of Hematology and Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Robin J Imperial
- Division of Hematology and Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Denise M Harnois
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Nicole M Loo
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Jennifer J O'Brien
- Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida, USA
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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.
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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
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Mina-Osorio P, Tran MH, Habib AA. Therapeutic Plasma Exchange Versus FcRn Inhibition in Autoimmune Disease. Transfus Med Rev 2024; 38:150767. [PMID: 37867088 DOI: 10.1016/j.tmrv.2023.150767] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 08/31/2023] [Accepted: 09/01/2023] [Indexed: 10/24/2023]
Abstract
Therapeutic plasma exchange (TPE or PLEX) is used in a broad range of autoimmune diseases, with the goal of removing autoantibodies from the circulation. A newer approach for the selective removal of immunoglobulin G (IgG) antibodies is the use of therapeutic molecules targeting the neonatal Fc receptor (FcRn). FcRn regulates IgG recycling, and its inhibition results in a marked decrease in circulating autoantibodies of the IgG subtype. The difference between FcRn inhibition and PLEX is often questioned. With anti-FcRn monoclonal antibodies (mAbs) and fragments only recently entering this space, limited data are available regarding long-term efficacy and safety. However, the biology of FcRn is well understood, and mounting evidence regarding the efficacy, safety, and potential differences among compounds in development is available, allowing us to compare against nonselective plasma protein depletion methods such as PLEX. FcRn inhibitors may have distinct advantages and disadvantages over PLEX in certain scenarios. Use of PLEX is preferred over FcRn inhibition where removal of antibodies other than IgG or when concomitant repletion of missing plasma proteins is needed for therapeutic benefit. Also, FcRn targeting has not yet been studied for use in acute flares or crisis states of IgG-mediated diseases. Compared with PLEX, FcRn inhibition is associated with less invasive access requirements, more specific removal of IgG versus other immunoglobulins without a broad impact on circulating proteins, and any impacts on other therapeutic drug levels are restricted to other mAbs. In addition, the degree of IgG reduction is similar with FcRn inhibitors compared with that afforded by PLEX. Here we describe the scientific literature regarding the use of PLEX and FcRn inhibitors in autoimmune diseases and provide an expert discussion around the potential benefits of these options in varying clinical conditions and scenarios.
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Affiliation(s)
| | - Minh-Ha Tran
- Department of Pathology, School of Medicine, University of California, Irvine, Irvine, CA, USA
| | - Ali A Habib
- Department of Neurology, School of Medicine, University of California, Irvine, Irvine, CA, USA
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9
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Svačina MKR, Meißner A, Schweitzer F, Ladwig A, Pitarokoili K, Kofler DM, Sprenger-Svačina A, Schneider C, Kohle F, Klein I, Wüstenberg H, Lehmann HC. Immunomodulatory effects of intravenous and subcutaneous immunoglobulin in chronic inflammatory demyelinating polyneuropathy: An observational study. Eur J Neurol 2024; 31:e16079. [PMID: 37789648 DOI: 10.1111/ene.16079] [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: 06/29/2023] [Revised: 08/23/2023] [Accepted: 09/14/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND AND PURPOSE It is not known whether the route of administration affects the mechanisms of action of therapeutic immunoglobulin in chronic inflammatory demyelinating polyneuropathy (CIDP). The aim of this study, therefore, was to compare the immunomodulatory effects of intravenous (IVIg) and subcutaneous immunoglobulin (SCIg) in patients with CIDP and in IVIg-treated common variable immunodeficiency (CVID) patients. METHODS Serum and peripheral blood mononuclear cell samples were obtained from 30 CIDP patients receiving IVIg, 10 CIDP patients receiving SCIg, and 15 patients with CVID receiving IVIg. Samples and clinical data were obtained prior to IVIg/SCIg and at 3 days, 7 days, and, in CIDP patients receiving IVIg, 21 days post-administration. Serum cytokines were assessed by Luminex-based multiplex assay and enzyme-linked immunosorbent assay. Immune cells were characterized by flow cytometry. RESULTS Immune cell profiles of CIDP and CVID patients differed in frequencies of myeloid dendritic cells and cytotoxic natural killer cells. During treatment with IVIg or SCIg in CIDP patients, cellular immunomarkers were largely similar. CIDP patients receiving IVIg had higher macrophage inflammatory protein (MIP)-1α (p = 0.01), interleukin (IL)-4 (p = 0.04), and IL-33 (p = 0.04) levels than SCIg recipients. IVIg treatment more broadly modulated cytokines in CIDP than SCIg treatment. CONCLUSIONS Our study demonstrates that the modulation of cellular immunomarkers in CIDP is independent of the application route of therapeutic immunoglobulin. Minor differences were observed between CIDP and CVID patients. In contrast, cytokines were differentially modulated by IVIg and SCIg in CIDP.
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Affiliation(s)
- Martin K R Svačina
- Department of Neurology, Faculty of Medicine, University Hospital of Cologne, Cologne, Germany
| | - Anika Meißner
- Department of Neurology, Faculty of Medicine, University Hospital of Cologne, Cologne, Germany
| | - Finja Schweitzer
- Department of Neurology, Faculty of Medicine, University Hospital of Cologne, Cologne, Germany
| | - Anne Ladwig
- Department of Neurology, Faculty of Medicine, University Hospital of Cologne, Cologne, Germany
| | - Kalliopi Pitarokoili
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Bochum, Germany
| | - David M Kofler
- Medical Clinic I, Department of Immunology and Rheumatology, Faculty of Medicine, University Hospital of Cologne, Cologne, Germany
| | - Alina Sprenger-Svačina
- Department of Neurology, Faculty of Medicine, University Hospital of Cologne, Cologne, Germany
| | - Christian Schneider
- Department of Neurology, Faculty of Medicine, University Hospital of Cologne, Cologne, Germany
- Department of Neurology, St. Katharinen Hospital, Frechen, Germany
| | - Felix Kohle
- Department of Neurology, Faculty of Medicine, University Hospital of Cologne, Cologne, Germany
| | - Ines Klein
- Department of Neurology, Faculty of Medicine, University Hospital of Cologne, Cologne, Germany
| | - Hauke Wüstenberg
- Department of Neurology, Faculty of Medicine, University Hospital of Cologne, Cologne, Germany
| | - Helmar C Lehmann
- Department of Neurology, Faculty of Medicine, University Hospital of Cologne, Cologne, Germany
- Department of Neurology, Clinic of Leverkusen gGmbH, Leverkusen, Germany
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10
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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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Golfinopoulou R, Giudicelli V, Manso T, Kossida S. Delving into Molecular Pathways: Analyzing the Mechanisms of Action of Monoclonal Antibodies Integrated in IMGT/mAb-DB for Myasthenia Gravis. Vaccines (Basel) 2023; 11:1756. [PMID: 38140161 PMCID: PMC10747390 DOI: 10.3390/vaccines11121756] [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: 09/30/2023] [Revised: 11/20/2023] [Accepted: 11/22/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Myasthenia Gravis (MG) is a rare autoimmune disease presenting with auto-antibodies that affect the neuromuscular junction. In addition to symptomatic treatment options, novel therapeutics include monoclonal antibodies (mAbs). IMGT®, the international ImMunoGeneTics information system®, extends the characterization of therapeutic antibodies with a systematic description of their mechanisms of action (MOA) and makes them available through its database for mAbs and fusion proteins, IMGT/mAb-DB. METHODS Using available literature data combined with amino acid sequence analyses from mAbs managed in IMGT/2Dstructure-DB, the IMGT® protein database, biocuration allowed us to define in a standardized way descriptions of MOAs of mAbs that target molecules towards MG treatment. RESULTS New therapeutic targets include FcRn and molecules such as CD38, CD40, CD19, MS4A1, and interleukin-6 receptor. A standardized graphical representation of the MOAs of selected mAbs was created and integrated within IMGT/mAb-DB. The main mechanisms involved in these mAbs are either blocking or neutralizing. Therapies directed to B cell depletion and plasma cells have a blocking MOA with an immunosuppressant effect along with Fc-effector function (MS4A1, CD38) or FcγRIIb engager effect (CD19). Monoclonal antibodies targeting the complement also have a blocking MOA with a complement inhibitor effect, and treatments targeting T cells have a blocking MOA with an immunosuppressant effect (CD40) and Fc-effector function (IL6R). On the other hand, FcRn antagonists present a neutralizing MOA with an FcRn inhibitor effect. CONCLUSION The MOA of each new mAb needs to be considered in association with the immunopathogenesis of each of the subtypes of MG in order to integrate the new mAbs as a viable and safe option in the therapy decision process. In IMGT/mAb-DB, mAbs for MG are characterized by their sequence, domains, and chains, and their MOA is described.
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Affiliation(s)
- Rebecca Golfinopoulou
- IMGT, The International ImMunoGeneTics Information System, National Center for Scientific Research (CNRS), Institute of Human Genetics (IGH), University of Montpellier (UM), 34090 Montpellier, France; (R.G.); (V.G.)
- Department of Biotechnology, School of Applied Biology and Biotechnology, Agricultural University of Athens, 11855 Athens, Greece
| | - Véronique Giudicelli
- IMGT, The International ImMunoGeneTics Information System, National Center for Scientific Research (CNRS), Institute of Human Genetics (IGH), University of Montpellier (UM), 34090 Montpellier, France; (R.G.); (V.G.)
| | - Taciana Manso
- IMGT, The International ImMunoGeneTics Information System, National Center for Scientific Research (CNRS), Institute of Human Genetics (IGH), University of Montpellier (UM), 34090 Montpellier, France; (R.G.); (V.G.)
| | - Sofia Kossida
- IMGT, The International ImMunoGeneTics Information System, National Center for Scientific Research (CNRS), Institute of Human Genetics (IGH), University of Montpellier (UM), 34090 Montpellier, France; (R.G.); (V.G.)
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12
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Cocito D, Peci E, Torrieri MC, Clerico M. Subcutaneous Immunoglobulin in Chronic Inflammatory Demyelinating Polyneuropathy: A Historical Perspective. J Clin Med 2023; 12:6961. [PMID: 38002576 PMCID: PMC10671960 DOI: 10.3390/jcm12226961] [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: 10/16/2023] [Revised: 10/30/2023] [Accepted: 11/03/2023] [Indexed: 11/26/2023] Open
Abstract
The therapeutic administration of subcutaneous immunoglobulin (SCIg) offers various advantages over intravenous immunoglobulin (IVIg). This narrative review examines and compares SCIg versus IVIg in chronic inflammatory demyelinating polyneuropathy (CIDP). SCIg is as effective as IVIg but is better tolerated and easier to administer, as intravenous access is not required. Furthermore, SCIg administration is more convenient and cost-effective than IVIg, enabling flexible treatment scheduling at home and improving patients' overall quality of life. The availability of highly concentrated immunoglobulin G (IgG) subcutaneous solutions, such as IgPro20, a 20% IgG solution stabilized with L-proline, allows for the administration of larger volumes in a single session, while the parallel development of new technological devices enables the delivery of higher doses over a shorter time. Based on the results of the PATH study, SCIg has become a well-established therapy in CIDP. In addition to discussing the advantages of SCIg, this review summarizes the evolution of SCIg by discussing all the relevant clinical studies which have considered its use in the treatment of CIDP.
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Affiliation(s)
- Dario Cocito
- Clinical and Biological Sciences Department, University of Turin, 10043 Orbassano, Italy
| | - Erdita Peci
- Clinical and Biological Sciences Department, University of Turin, 10043 Orbassano, Italy
| | | | - Marinella Clerico
- Academic Neurology Unit, San Luigi Gonzaga University Hospital, Clinical and Biological Sciences Department, University of Turin, 10043 Orbassano, Italy;
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Hou YB, Chang S, Chen S, Zhang WJ. Intravenous immunoglobulin in kidney transplantation: Mechanisms of action, clinical applications, adverse effects, and hyperimmune globulin. Clin Immunol 2023; 256:109782. [PMID: 37742791 DOI: 10.1016/j.clim.2023.109782] [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: 07/24/2023] [Revised: 09/11/2023] [Accepted: 09/20/2023] [Indexed: 09/26/2023]
Abstract
Intravenous immunoglobulin (IVIG) has been developed for over 40 years. The mechanisms of action of IVIG are complex and diverse, and there may be multiple mechanisms that combine to influence it. IVIG has been used in kidney transplantation for desensitization, treatment of antibody-mediated rejection, and ABO-incompatible transplantation. and treatment or prevention of some infectious diseases. Hyperimmune globulins such as cytomegalovirus hyperimmune globulin (CMV-IG) and hepatitis B hyperimmune globulin (HBIG) have also been used to protect against cytomegalovirus and hepatitis B virus, respectively. However, IVIG is also associated with some rare but serious adverse effects and some application risks, and clinicians need to weigh the pros and cons and develop individualized treatment programs to benefit more patients. This review will provide an overview of the multiple mechanisms of action, clinical applications, adverse effects, and prophylactic measures of IVIG, and hyperimmune globulin will also be introduced in it.
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Affiliation(s)
- Yi-Bo Hou
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology; Key Laboratory of Organ Transplantation, Ministry of Education; NHC Key Laboratory of Organ Transplantation; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan 430030, China
| | - Sheng Chang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology; Key Laboratory of Organ Transplantation, Ministry of Education; NHC Key Laboratory of Organ Transplantation; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan 430030, China
| | - Song Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology; Key Laboratory of Organ Transplantation, Ministry of Education; NHC Key Laboratory of Organ Transplantation; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan 430030, China
| | - Wei-Jie Zhang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology; Key Laboratory of Organ Transplantation, Ministry of Education; NHC Key Laboratory of Organ Transplantation; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan 430030, China.
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Danieli MG, Antonelli E, Auria S, Buti E, Shoenfeld Y. Low-dose intravenous immunoglobulin (IVIg) in different immune-mediated conditions. Autoimmun Rev 2023; 22:103451. [PMID: 37748542 DOI: 10.1016/j.autrev.2023.103451] [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: 08/30/2023] [Accepted: 09/20/2023] [Indexed: 09/27/2023]
Abstract
IVIg has been used for a long time as a replacement therapy for primary and secondary immunodeficiencies. Beside this supplementary role, when used at higher doses (i.e., 2 g/kg/monthly) it exerts an immunomodulatory role able to control multiple autoimmune and systemic inflammatory diseases. Several mechanisms of action have been described and hypothesized, nonetheless a synergistic action on the different component of the immune response seems to be crucial. The other side of the coin are the costs which showed an increase during the years due to the production of highly purified preparations which limit side reactions. This renders the product not easily accessible especially for low-income countries. Moreover, it is based on plasma donations that experienced a significant shrinkage after the COVID-19 pandemic and the consequences are still impactful. Due to the above-mentioned problems different authors tried to find out if a lower dosage of IVIg (< 2 g/kg/monthly) might exert an immunoregulatory role. In this review we aimed to summarize the current literature about a possible beneficial effect of a lower dosage of IVIg in multiple conditions that would help to treat a vast majority of patients. Even though in some cases (e.g., Kawasaki disease and immune thrombocytopenia) results are promising, for other conditions more research is needed.
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Affiliation(s)
- Maria Giovanna Danieli
- SOS Immunologia delle Malattie Rare e dei Trapianti, AOU delle Marche e Università Politecnica delle Marche, Ancona, Italy; Postgraduate School of Allergy and Clinical Immunology, Università Politecnica delle Marche, Ancona, Italy.
| | - Eleonora Antonelli
- Postgraduate School of Internal Medicine, Università Politecnica delle Marche, Ancona, Italy
| | - Stefania Auria
- Postgraduate School of Allergy and Clinical Immunology, Università Politecnica delle Marche, Ancona, Italy
| | - Elena Buti
- Postgraduate School of Allergy and Clinical Immunology, Università Politecnica delle Marche, Ancona, Italy
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Reichman University Herzliya, Israel.
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15
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Tavee J, Brannagan TH, Lenihan MW, Muppidi S, Kellermeyer L, D Donofrio P. Updated consensus statement: Intravenous immunoglobulin in the treatment of neuromuscular disorders report of the AANEM ad hoc committee. Muscle Nerve 2023; 68:356-374. [PMID: 37432872 DOI: 10.1002/mus.27922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 06/05/2023] [Indexed: 07/13/2023]
Abstract
Intravenous immune globulin (IVIG) is an immune-modulating biologic therapy that is increasingly being used in neuromuscular disorders despite the paucity of high-quality evidence for various specific diseases. To address this, the AANEM created the 2009 consensus statement to provide guidance on the use of IVIG in neuromuscular disorders. Since then, there have been several randomized controlled trials for IVIG, a new FDA-approved indication for dermatomyositis and a revised classification system for myositis, prompting the AANEM to convene an ad hoc panel to update the existing guidelines.New recommendations based on an updated systemic review of the literature were categorized as Class I-IV. Based on Class I evidence, IVIG is recommended in the treatment of chronic inflammatory demyelinating polyneuropathy, Guillain-Barré Syndrome (GBS) in adults, multifocal motor neuropathy, dermatomyositis, stiff-person syndrome and myasthenia gravis exacerbations but not stable disease. Based on Class II evidence, IVIG is also recommended for Lambert-Eaton myasthenic syndrome and pediatric GBS. In contrast, based on Class I evidence, IVIG is not recommended for inclusion body myositis, post-polio syndrome, IgM paraproteinemic neuropathy and small fiber neuropathy that is idiopathic or associated with tri-sulfated heparin disaccharide or fibroblast growth factor receptor-3 autoantibodies. Although only Class IV evidence exists for IVIG use in necrotizing autoimmune myopathy, it should be considered for anti-hydroxy-3-methyl-glutaryl-coenzyme A reductase myositis given the risk of long-term disability. Insufficient evidence exists for the use of IVIG in Miller-Fisher syndrome, IgG and IgA paraproteinemic neuropathy, autonomic neuropathy, chronic autoimmune neuropathy, polymyositis, idiopathic brachial plexopathy and diabetic lumbosacral radiculoplexopathy.
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Affiliation(s)
- Jinny Tavee
- National Jewish Health, Division of Neurology, Denver, Colorado, USA
| | - Thomas H Brannagan
- Vagelos College of Physicians and Surgeons, Neurological Institute, Columbia University, New York, New York, USA
| | | | - Sri Muppidi
- Stanford Neuroscience Health Center, Palo Alto, California, USA
| | | | - Peter D Donofrio
- Neurology Clinic, Vanderbilt University, Nashville, Tennessee, USA
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16
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Şorodoc V, Constantin M, Asaftei A, Lionte C, Ceasovschih A, Sîrbu O, Haliga RE, Şorodoc L. The use of intravenous immunoglobulin in the treatment of Hashimoto's encephalopathy: case based review. Front Neurol 2023; 14:1243787. [PMID: 37745658 PMCID: PMC10513043 DOI: 10.3389/fneur.2023.1243787] [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: 07/11/2023] [Accepted: 08/25/2023] [Indexed: 09/26/2023] Open
Abstract
Background Hashimoto's encephalopathy (HE) is a controversial immunological neuropsychiatric disease, with a poorly understood pathogenesis. It is characterized by symptoms of acute or subacute encephalopathy which usually occur in the presence of elevated levels of antithyroid antibodies. Even though it is also known as steroid responsive encephalopathy associated with autoimmune thyroiditis (SREAT), some cases appear to be steroid-resistant. This review examined whether treatment of Hashimoto's encephalopathy with intravenous immunoglobulin (IVIG) is associated with better clinical outcomes than the standard therapy. Additionally, we presented a case of a 59-year-old man who presented with severe neurological manifestations and was successfully treated with intravenous immunoglobulin. Methods The online databases PubMed and EMBASE were searched. Results A total of 1,365 articles were identified. After the deletion of 112 duplicates, 1,253 studies were screened by evaluating the title and abstract, focusing on Hashimoto's encephalopathy cases where IVIG were used. 846 studies were excluded because they were not relevant to the topic or included pediatric population. Therefore, 407 full-text articles were assessed for eligibility. The final analysis included 14 eligible articles after 393 were excluded (irrelevant texts, not written in English, full-text not available). In the majority of the selected case-reports, IVIG was associated with a good outcome, sometimes even with dramatic improvements in patient's status. Conclusion In last years, intravenous immunoglobulin therapy proved its utility in Hashimoto's encephalopathy's treatment, being a well tolerated therapy associated with remarkable improvement in patient's status. Further research is still needed in order to define the optimal treatment protocol for Hashimoto's encephalopathy and to establish if intravenous immunoglobulin can also be used as a first-line therapy, alone or in combination with steroids.
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Affiliation(s)
- Victoriţa Şorodoc
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, Iasi, Romania
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Mihai Constantin
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, Iasi, Romania
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Andreea Asaftei
- 2nd Rheumatology Department, Clinical Rehabilitation Hospital, Iasi, Romania
| | - Cătălina Lionte
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, Iasi, Romania
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Alexandr Ceasovschih
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, Iasi, Romania
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Oana Sîrbu
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, Iasi, Romania
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Raluca Ecaterina Haliga
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, Iasi, Romania
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Laurenţiu Şorodoc
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, Iasi, Romania
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
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17
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Liang Y, Chen J, Wang C, Yu B, Zhang Y, Liu Z. Investigating the mechanism of Echovirus 30 cell invasion. Front Microbiol 2023; 14:1174410. [PMID: 37485505 PMCID: PMC10359910 DOI: 10.3389/fmicb.2023.1174410] [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: 02/26/2023] [Accepted: 06/23/2023] [Indexed: 07/25/2023] Open
Abstract
Viruses invade susceptible cells through a complex mechanism before injecting their genetic material into them. This causes direct damage to the host cell, as well as resulting in disease in the corresponding system. Echovirus type 30 (E30) is a member of the Enterovirus B group and has recently been reported to cause central nervous system (CNS) disorders, leading to viral encephalitis and viral meningitis in children. In this review, we aim to help in improving the understanding of the mechanisms of CNS diseases caused by E30 for the subsequent development of relevant drugs and vaccines.
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Affiliation(s)
- Yucai Liang
- Department of Microbiology, Weifang Medical University, Weifang, China
| | - Junbing Chen
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Gastrointestinal Cancer Center, Peking University Cancer Hospital and Institute, Beijing, China
| | - Congcong Wang
- Department of Microbiology, Weifang Medical University, Weifang, China
| | - Bowen Yu
- Department of Immunology, Weifang Medical University, Weifang, China
| | - Yong Zhang
- National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Zhijun Liu
- Department of Microbiology, Weifang Medical University, Weifang, China
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18
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Matic A, Alfaidi N, Bril V. An evaluation of rozanolixizumab-noli for the treatment of anti-AChR and anti-MuSK antibody-positive generalized myasthenia gravis. Expert Opin Biol Ther 2023; 23:1163-1171. [PMID: 38099334 DOI: 10.1080/14712598.2023.2296126] [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: 10/30/2023] [Accepted: 12/13/2023] [Indexed: 12/26/2023]
Abstract
INTRODUCTION Myasthenia gravis (MG) is an auto-immune disease characterized by fluctuating symptoms of muscle weakness and fatigue. Corticosteroids and corticosteroid-sparing broad-spectrum immunosuppression play a great role in the treatment of myasthenia gravis. However, debilitating side effects and long time to treatment effect highlight the need for development of novel target-specific medications. Rozanolixizumab is a highly specific neonatal Fc receptor (FcRn) inhibitor that acts on immunoglobulin G (IgG) homeostasis. Results from the MycarinG Phase III randomized controlled trial demonstrated significant efficacy of rozanolixizumab in generalized MG in terms of primary outcome and all secondary endpoints, tolerability, and safety compared to placebo. AREAS COVERED We included different trials on myasthenia gravis and rozanolixizumab which include Phase II (NCT03052751) and Phase III MycarinG (NCT03971422) studies. EXPERT OPINION Clinical trials have demonstrated that rozanolixizumab has strong efficacy with a 78% reduction in pathogenic IgG like plasma exchange (PLEX) and has therapeutic benefits comparable with PLEX and IVIG. It has less treatment adverse events and is easily accessible through subcutaneous infusion. The safety and effectiveness of rozanolixizumab need to be assessed further in the real-world context in post-marketing studies. If current trial information holds true, rozanolixizumab may become a medication of choice for MG in succeeding years.
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Affiliation(s)
- Alexandria Matic
- The Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Nouf Alfaidi
- The Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Vera Bril
- The Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Dziadkowiak E, Nowakowska-Kotas M, Rałowska-Gmoch W, Budrewicz S, Koszewicz M. Molecular, Electrophysiological, and Ultrasonographic Differences in Selected Immune-Mediated Neuropathies with Therapeutic Implications. Int J Mol Sci 2023; 24:ijms24119180. [PMID: 37298132 DOI: 10.3390/ijms24119180] [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: 03/31/2023] [Revised: 05/16/2023] [Accepted: 05/19/2023] [Indexed: 06/12/2023] Open
Abstract
The spectrum of immune-mediated neuropathies is broad and the different subtypes are still being researched. With the numerous subtypes of immune-mediated neuropathies, establishing the appropriate diagnosis in normal clinical practice is challenging. The treatment of these disorders is also troublesome. The authors have undertaken a literature review of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), Guillain-Barre syndrome (GBS) and multifocal motor neuropathy (MMN). The molecular, electrophysiological and ultrasound features of these autoimmune polyneuropathies are analyzed, highlighting the differences in diagnosis and ultimately treatment. The immune dysfunction can lead to damage to the peripheral nervous system. In practice, it is suspected that these disorders are caused by autoimmunity to proteins located in the node of Ranvier or myelin components of peripheral nerves, although disease-associated autoantibodies have not been identified for all disorders. The electrophysiological presence of conduction blocks is another important factor characterizing separate subgroups of treatment-naive motor neuropathies, including multifocal CIDP (synonyms: multifocal demyelinating neuropathy with persistent conduction block), which differs from multifocal motor neuropathy with conduction block (MMN) in both responses to treatment modalities and electrophysiological features. Ultrasound is a reliable method for diagnosing immune-mediated neuropathies, particularly when alternative diagnostic examinations yield inconclusive results. In overall terms, the management of these disorders includes immunotherapy such as corticosteroids, intravenous immunoglobulin or plasma exchange. Improvements in clinical criteria and the development of more disease-specific immunotherapies should expand the therapeutic possibilities for these debilitating diseases.
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Affiliation(s)
- Edyta Dziadkowiak
- Department of Neurology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Marta Nowakowska-Kotas
- Department of Neurology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Wiktoria Rałowska-Gmoch
- Department of Neurology, The St. Jadwiga's Regional Specialist Neuropsychiatric Centre, Wodociągowa 4, 45-221 Opole, Poland
| | - Sławomir Budrewicz
- Department of Neurology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Magdalena Koszewicz
- Department of Neurology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
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Shastri A, Al Aiyan A, Kishore U, Farrugia ME. Immune-Mediated Neuropathies: Pathophysiology and Management. Int J Mol Sci 2023; 24:7288. [PMID: 37108447 PMCID: PMC10139406 DOI: 10.3390/ijms24087288] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 03/12/2023] [Accepted: 03/21/2023] [Indexed: 04/29/2023] Open
Abstract
Dysfunction of the immune system can result in damage of the peripheral nervous system. The immunological mechanisms, which include macrophage infiltration, inflammation and proliferation of Schwann cells, result in variable degrees of demyelination and axonal degeneration. Aetiology is diverse and, in some cases, may be precipitated by infection. Various animal models have contributed and helped to elucidate the pathophysiological mechanisms in acute and chronic inflammatory polyradiculoneuropathies (Guillain-Barre Syndrome and chronic inflammatory demyelinating polyradiculoneuropathy, respectively). The presence of specific anti-glycoconjugate antibodies indicates an underlying process of molecular mimicry and sometimes assists in the classification of these disorders, which often merely supports the clinical diagnosis. Now, the electrophysiological presence of conduction blocks is another important factor in characterizing another subgroup of treatable motor neuropathies (multifocal motor neuropathy with conduction block), which is distinct from Lewis-Sumner syndrome (multifocal acquired demyelinating sensory and motor neuropathy) in its response to treatment modalities as well as electrophysiological features. Furthermore, paraneoplastic neuropathies are also immune-mediated and are the result of an immune reaction to tumour cells that express onconeural antigens and mimic molecules expressed on the surface of neurons. The detection of specific paraneoplastic antibodies often assists the clinician in the investigation of an underlying, sometimes specific, malignancy. This review aims to discuss the immunological and pathophysiological mechanisms that are thought to be crucial in the aetiology of dysimmune neuropathies as well as their individual electrophysiological characteristics, their laboratory features and existing treatment options. Here, we aim to present a balance of discussion from these diverse angles that may be helpful in categorizing disease and establishing prognosis.
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Affiliation(s)
- Abhishek Shastri
- Central and North West London NHS Foundation Trust, London NW1 3AX, UK
| | - Ahmad Al Aiyan
- Department of Veterinary Medicine, UAE University, Al Ain P.O. Box 15551, United Arab Emirates
| | - Uday Kishore
- Department of Veterinary Medicine, UAE University, Al Ain P.O. Box 15551, United Arab Emirates
| | - Maria Elena Farrugia
- Department of Neurology, Institute of Neurological Sciences, Southern General Hospital, Glasgow G51 4TF, UK
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21
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Kohle F, Dalakas MC, Lehmann HC. Repurposing MS immunotherapies for CIDP and other autoimmune neuropathies: unfulfilled promise or efficient strategy? Ther Adv Neurol Disord 2023; 16:17562864221137129. [PMID: 36620728 PMCID: PMC9810996 DOI: 10.1177/17562864221137129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 10/19/2022] [Indexed: 01/03/2023] Open
Abstract
Despite advances in the treatment of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and other common autoimmune neuropathies (AN), still-many patients with these diseases do not respond satisfactorily to the available treatments. Repurposing of disease-modifying therapies (DMTs) from other autoimmune conditions, particularly multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD), is a promising strategy that may accelerate the establishment of novel treatment choices for AN. This approach appears attractive due to homologies in the pathogenesis of these diseases and the extensive post-marketing experience that has been gathered from treating MS and NMOSD patients. The idea is also strengthened by a number of studies that explored the efficacy of DMTs in animal models of AN but also in some CIDP patients. We here review the available preclinical and clinical data of approved MS therapeutics in terms of their applicability to AN, especially CIDP. Promising therapeutic approaches appear to be B cell-directed and complement-targeting strategies, such as anti-CD20/anti-CD19 agents, Bruton's tyrosine kinase inhibitors and anti-C5 agents, as they exert their effects in the periphery. This is a major advantage because, in contrast to MS, their action in the periphery is sufficient to exert significant immunomodulation.
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Affiliation(s)
- Felix Kohle
- Department of Neurology, Faculty of Medicine,
University of Cologne and University Hospital Cologne, Cologne,
Germany
| | - Marinos C. Dalakas
- Department of Neurology, Thomas Jefferson
University, Philadelphia, PA, USA,Neuroimmunology Unit, National and Kapodistrian
University of Athens Medical School, Athens, Greece
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22
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Tsuo K, Zhou W, Wang Y, Kanai M, Namba S, Gupta R, Majara L, Nkambule LL, Morisaki T, Okada Y, Neale BM, Daly MJ, Martin AR. Multi-ancestry meta-analysis of asthma identifies novel associations and highlights the value of increased power and diversity. CELL GENOMICS 2022; 2:100212. [PMID: 36778051 PMCID: PMC9903683 DOI: 10.1016/j.xgen.2022.100212] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 09/01/2022] [Accepted: 10/12/2022] [Indexed: 11/09/2022]
Abstract
Asthma is a complex disease that varies widely in prevalence across populations. The extent to which genetic variation contributes to these disparities is unclear, as the genetics underlying asthma have been investigated primarily in populations of European descent. As part of the Global Biobank Meta-analysis Initiative, we conducted a large-scale genome-wide association study of asthma (153,763 cases and 1,647,022 controls) via meta-analysis across 22 biobanks spanning multiple ancestries. We discovered 179 asthma-associated loci, 49 of which were not previously reported. Despite the wide range in asthma prevalence among biobanks, we found largely consistent genetic effects across biobanks and ancestries. The meta-analysis also improved polygenic risk prediction in non-European populations compared with previous studies. Additionally, we found considerable genetic overlap between age-of-onset subtypes and between asthma and comorbid diseases. Our work underscores the multi-factorial nature of asthma development and offers insight into its shared genetic architecture.
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Affiliation(s)
- Kristin Tsuo
- Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston, MA, USA
- Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Wei Zhou
- Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston, MA, USA
- Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Ying Wang
- Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston, MA, USA
- Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Masahiro Kanai
- Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston, MA, USA
- Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
- Department of Statistical Genetics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Shinichi Namba
- Department of Statistical Genetics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Rahul Gupta
- Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston, MA, USA
- Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Howard Hughes Medical Institute and Department of Molecular Biology, Massachusetts General Hospital, Boston, MA, USA
| | - Lerato Majara
- Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Lethukuthula L. Nkambule
- Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston, MA, USA
- Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Takayuki Morisaki
- Division of Molecular Pathology, The Institute of Medical Science, The University of Tokyo, Minatu-ku, Tokyo, Japan
| | - Yukinori Okada
- Department of Statistical Genetics, Osaka University Graduate School of Medicine, Suita, Japan
- Laboratory for Systems Genetics, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan
- Laboratory of Statistical Immunology, Immunology Frontier Research Center (WPI-IFReC), Osaka University, Suita 565-0871, Japan
- Department of Genome Informatics, Graduate School of Medicine, The University of Tokyo, Tokyo 113-0033, Japan
- Center for Infectious Disease Education and Research (CiDER), Osaka University, Suita 565-0871, Japan
| | - Benjamin M. Neale
- Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston, MA, USA
- Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Global Biobank Meta-analysis Initiative
- Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston, MA, USA
- Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
- Department of Statistical Genetics, Osaka University Graduate School of Medicine, Suita, Japan
- Howard Hughes Medical Institute and Department of Molecular Biology, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Division of Molecular Pathology, The Institute of Medical Science, The University of Tokyo, Minatu-ku, Tokyo, Japan
- Laboratory for Systems Genetics, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan
- Laboratory of Statistical Immunology, Immunology Frontier Research Center (WPI-IFReC), Osaka University, Suita 565-0871, Japan
- Department of Genome Informatics, Graduate School of Medicine, The University of Tokyo, Tokyo 113-0033, Japan
- Center for Infectious Disease Education and Research (CiDER), Osaka University, Suita 565-0871, Japan
- Institute for Molecular Medicine Finland, University of Helsinki, Helsinki, Finland
| | - Mark J. Daly
- Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston, MA, USA
- Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Institute for Molecular Medicine Finland, University of Helsinki, Helsinki, Finland
| | - Alicia R. Martin
- Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston, MA, USA
- Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
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23
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Suzuki S, Uzawa A, Murai H. Efgartigimod for generalized myasthenia gravis with or without anti-acetylcholine receptor antibodies: a worldwide and Japanese perspective. Expert Rev Clin Immunol 2022; 18:1207-1215. [PMID: 36227228 DOI: 10.1080/1744666x.2022.2136167] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION The management of myasthenia gravis (MG) has been improved due to immunotherapy advances, but 20% of individuals with MG are refractory to the conventional therapy, and the need for novel biological drugs remains. AREA COVERED The Japanese clinical guidelines for MG published in May 2022 include the concept that treatment is often lifelong and should aim to maintain a sufficient quality of life and mental health. We provide an overview of the therapeutic strategy for generalized MG in Japan, in comparison with the international consensus. We summarize the clinical efficacy, safety, and tolerability of efgartigimod, the first approved anti-neonatal Fc receptor inhibitor for MG. A phase III study showed that efgartigimod was well-tolerated and efficacious in patients with generalized MG. EXPERT OPINION Efgartigimod is a promising biological drug for patients with moderate to severe generalized MG with or without anti-acetylcholine receptor antibodies in Japan.
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Affiliation(s)
- Shigeaki Suzuki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Akiyuki Uzawa
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hiroyuki Murai
- Department of Neurology, International University of Health and Welfare, Narita, Japan
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24
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Dalakas MC, Latov N, Kuitwaard K. Intravenous immunoglobulin in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP): mechanisms of action and clinical and genetic considerations. Expert Rev Neurother 2022; 22:953-962. [PMID: 36645654 DOI: 10.1080/14737175.2022.2169134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an autoimmune peripheral nerve disorder that is characterized by subacute onset, progressive or relapsing weakness, and sensory deficits. Proven treatments include intravenous immunoglobulin (IVIg), corticosteroids, and plasma exchange. This review focuses on the mechanisms of action, pharmacodynamics, genetic variations, and disease characteristics that can affect the efficacy of IVIg. AREAS COVERED The proposed mechanisms of action of IVIg that can mediate its therapeutic effects are reviewed. These include anti-idiotypic interactions, inhibition of neonatal Fc receptors (FcRn), anti-complement activity, upregulation of inhibitory FcγRIIB receptors, and downregulation of macrophage activation or co-stimulatory and adhesion molecules. Clinical and genetic factors that can affect the therapeutic response include misdiagnosis, degree of axonal damage, pharmacokinetic variability, and genetic variations. EXPERT OPINION The mechanisms of action of IVIg in CIDP and their relative contribution to its efficacy are subject of ongoing investigation. Studies in other autoimmune neurological conditions, in addition, highlight the role of key immunopathological pathways and factors that are likely to be affected. Further investigation into the pathogenesis of CIDP and the mechanisms of action of IVIg may lead to the development of improved diagnostics, better utilization of IVIg, and more targeted and effective therapies.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson Neuroimmunology Unit, Philadelphia, PA and National and Department of Pathophysiology, Kapodistrian University of Athens, Greece
| | - Norman Latov
- Neuroimmunology Unit, Weill Cornell Medical College, New York, NY, USA
| | - Krista Kuitwaard
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Neurology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
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25
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Focosi D, McConnell S, Casadevall A, Cappello E, Valdiserra G, Tuccori M. Monoclonal antibody therapies against SARS-CoV-2. THE LANCET. INFECTIOUS DISEASES 2022; 22:e311-e326. [PMID: 35803289 PMCID: PMC9255948 DOI: 10.1016/s1473-3099(22)00311-5] [Citation(s) in RCA: 116] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/26/2022] [Accepted: 05/03/2022] [Indexed: 12/13/2022]
Abstract
Monoclonal antibodies (mAbs) targeting the spike protein of SARS-CoV-2 have been widely used in the ongoing COVID-19 pandemic. In this paper, we review the properties of mAbs and their effect as therapeutics in the pandemic, including structural classification, outcomes in clinical trials that led to the authorisation of mAbs, and baseline and treatment-emergent immune escape. We show how the omicron (B.1.1.529) variant of concern has reset treatment strategies so far, discuss future developments that could lead to improved outcomes, and report the intrinsic limitations of using mAbs as therapeutic agents.
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Affiliation(s)
- Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Pisa, Italy
| | - Scott McConnell
- Department of Medicine, Johns Hopkins School of Public Health and School of Medicine, Baltimore, MD, USA
| | - Arturo Casadevall
- Department of Medicine, Johns Hopkins School of Public Health and School of Medicine, Baltimore, MD, USA
| | - Emiliano Cappello
- Unit of Adverse Drug Reactions Monitoring, Pisa University Hospital, Pisa, Italy; Unit of Pharmacology and Pharmacovigilance, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giulia Valdiserra
- Unit of Adverse Drug Reactions Monitoring, Pisa University Hospital, Pisa, Italy; Unit of Pharmacology and Pharmacovigilance, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Marco Tuccori
- Unit of Pharmacology and Pharmacovigilance, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
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26
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Segú-Vergés C, Caño S, Calderón-Gómez E, Bartra H, Sardon T, Kaveri S, Terencio J. Systems biology and artificial intelligence analysis highlights the pleiotropic effect of IVIg therapy in autoimmune diseases with a predominant role on B cells and complement system. Front Immunol 2022; 13:901872. [PMID: 36248801 PMCID: PMC9563374 DOI: 10.3389/fimmu.2022.901872] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 08/31/2022] [Indexed: 11/26/2022] Open
Abstract
Intravenous immunoglobulin (IVIg) is used as treatment for several autoimmune and inflammatory conditions, but its specific mechanisms are not fully understood. Herein, we aimed to evaluate, using systems biology and artificial intelligence techniques, the differences in the pathophysiological pathways of autoimmune and inflammatory conditions that show diverse responses to IVIg treatment. We also intended to determine the targets of IVIg involved in the best treatment response of the evaluated diseases. Our selection and classification of diseases was based on a previously published systematic review, and we performed the disease characterization through manual curation of the literature. Furthermore, we undertook the mechanistic evaluation with artificial neural networks and pathway enrichment analyses. A set of 26 diseases was selected, classified, and compared. Our results indicated that diseases clearly benefiting from IVIg treatment were mainly characterized by deregulated processes in B cells and the complement system. Indeed, our results show that proteins related to B-cell and complement system pathways, which are targeted by IVIg, are involved in the clinical response. In addition, targets related to other immune processes may also play an important role in the IVIg response, supporting its wide range of actions through several mechanisms. Although B-cell responses and complement system have a key role in diseases benefiting from IVIg, protein targets involved in such processes are not necessarily the same in those diseases. Therefore, IVIg appeared to have a pleiotropic effect that may involve the collaborative participation of several proteins. This broad spectrum of targets and 'non-specificity' of IVIg could be key to its efficacy in very different diseases.
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Affiliation(s)
| | - Silvia Caño
- Grifols Innovation and New Technologies (GIANT) Ltd., Dublin, Ireland
| | | | - Helena Bartra
- Health Department, Anaxomics Biotech, Barcelona, Spain
| | - Teresa Sardon
- Health Department, Anaxomics Biotech, Barcelona, Spain
| | - Srini Kaveri
- Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - José Terencio
- Grifols Innovation and New Technologies (GIANT) Ltd., Dublin, Ireland
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27
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Ding Z, Zhang X, Li H. Application of IgG antibody titer and subtype in diagnosis and severity assessment of hemolytic disease of the newborn. Transl Pediatr 2022; 11:1544-1551. [PMID: 36247885 PMCID: PMC9561511 DOI: 10.21037/tp-22-385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 08/26/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND To analyze the effect of different times of pregnancy of type O pregnant women on the occurrence of ABO hemolytic disease of the newborn (ABO-HDN). METHODS From December 2018 to December 2021, 725 pregnant women with O blood group (husbands with non-O blood group) who met the inclusion criteria were collected. There were 116 cases of ABO-HDN, which were summarized and analyzed. The pregnant women were divided into primigravida and non-primigravida groups. The influence of the number of pregnancies on the occurrence of ABO-HDN was compared, and the antibody titer of pregnant women with type O blood was monitored. The relationship between antibody titer and HDN in pregnant women was analyzed by hemolysis test and indirect bilirubin concentration. RESULTS In the primigravida group, 0 patients with HDN had a titer ≤1:64, 8 (8/26) had a titer of 1:128, 9 (9/20) had a titer of 1:256, 2 (2/4) had a titer of 1:512, and 2 (2/3) had a titer >1:512. In the non-primigravida group, there were 0 cases with a titer ≤1:64, 32 cases (32/78) with a titer of 1:128, and 26 cases (26/46) with a titer of 1:256. The number of cases of ABO incompatibility in maternal and infant groups with different titers of IgG anti-A (B) antibody were 377 cases in the <1:64 group, 130 cases in the 1:64 group, 104 cases in the 1:128 group, 66 cases in the 1:256 group, 32 cases in the 1:512 group, and 16 cases in the >1:512 group. The positive rates of ABO-HDN were 0.0% (0/0), 0.0% (0/0), 38.5% (40/104), 53.0% (35/66), 81.3% (26/32) and 93.8% (15/16), respectively, and the difference was statistically significant (P<0.05). CONCLUSIONS The occurrence of ABO-HDN was not significantly related to the blood type of the pregnant woman's husband. Therefore, in order to reduce the degree of hemolysis and avoid the occurrence of bilirubin encephalopathy or even death, pregnant women with antibody titer >1:64 in second or subsequent pregnancies should be closely monitored.
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Affiliation(s)
- Zijun Ding
- Department of Neonatology, Shanxi Provincial Children's Hospital, Taiyuan, China
| | - Xinhua Zhang
- Department of Neonatology, Shanxi Provincial Children's Hospital, Taiyuan, China
| | - Hai Li
- Department of Neonatology, Shanxi Provincial Children's Hospital, Taiyuan, China
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28
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Dos Santos JBR, Gomes RM, da Silva MRR. Abdeg technology for the treatment of myasthenia gravis: efgartigimod drug experience. Expert Rev Clin Immunol 2022; 18:879-888. [PMID: 35892247 DOI: 10.1080/1744666x.2022.2106972] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Myasthenia gravis is characterized by fluctuating muscle weakness that improves with rest and worsens with effort or throughout the day. AREAS COVERED Efgartigimod is a human IgG1-derived Fc fragment modified at five residues to increase its affinity for the neonatal Fc receptor by Abdeg technology. Thus, efgartigimod binds to the neonatal Fc receptor and decreases the levels of IgG, including autoantibodies of this isotype. For acetylcholine receptor (AChR) antibody-positive patients, efgartigimod had a higher proportion of MG-ADL responders than placebo in the first treatment cycle. The mean changes of multiple outcomes from baseline were better for efgartigimod than placebo from weeks 1 to 7 in the first treatment cycle. The decrease of IgG and AChR autoantibodies was 61.3% and 57.6% one week after the first treatment cycle ends, respectively. The most common adverse events were headache, nasopharyngitis, nausea, and diarrhea, which occurred in the same proportion in the efgartigimod and placebo groups. Urinary and upper respiratory tract infections were twice as frequent in efgartigimod-treated patients. EXPERT OPINION Efgartigimod was efficacious and safe for generalized myasthenia patients with AChR antibody-positive patients. These findings need to be confirmed in AChR antibody-negative patients, and long-term safety studies are currently ongoing.
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Affiliation(s)
- Jéssica Barreto Ribeiro Dos Santos
- Health Economics and Technology Assessment Group; Center for Exact, Natural and Health Sciences; Federal University of Espírito Santo, Alto Universitário S/N, Guararema, Alegre, Espírito Santo, 29500-000, Brazil
| | - Rosângela Maria Gomes
- Department of Management and Incorporation of Technologies and Innovation in Health; Secretariat of Science, Technology and Strategic Inputs; Ministry of Health of Brazil, Brasilia, Federal District, 70058-900, Brazil
| | - Michael Ruberson Ribeiro da Silva
- Health Economics and Technology Assessment Group; Center for Exact, Natural and Health Sciences; Federal University of Espírito Santo, Alto Universitário S/N, Guararema, Alegre, Espírito Santo, 29500-000, Brazil
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29
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Ciano-Petersen NL, Muñiz-Castrillo S, Birzu C, Vogrig A, Farina A, Villagrán-García M, Joubert B, Psimaras D, Honnorat J. Cytokine dynamics and targeted immunotherapies in autoimmune encephalitis. Brain Commun 2022; 4:fcac196. [PMID: 35999839 PMCID: PMC9392471 DOI: 10.1093/braincomms/fcac196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/20/2022] [Accepted: 08/16/2022] [Indexed: 11/13/2022] Open
Abstract
Autoimmune encephalitides constitute a diverse group of immune-mediated central nervous system disorders mainly characterized by the presence of antibodies targeting neuronal or glial antigens. Despite the notable contribution of antibody discovery to the understanding of their physiopathology, the specific immune cells and inflammatory mediators involved in autoimmune encephalitis are still poorly defined. However, cytokines have recently emerged as crucial signalling molecules in the pathogenesis of autoimmune encephalitis. Cytokines are biologically active, soluble, low-molecular-weight proteins or glycoproteins involved in a wide variety of physiological functions, including central nervous system development and homeostasis, immune surveillance, as well as proliferation and maturation of immune cells. Since unbalanced cytokine expression is considered a hallmark of many autoimmune central nervous system disorders, their identification and quantification has become an essential element in personalized medicine applied to the field of neuroimmunology. Several studies have explored the cytokine profile of autoimmune encephalitis, but their interpretation and comparison is challenging due to their small sample sizes and extremely high heterogeneity, especially regarding the cytokines analysed, type of sample used, and associated neural antibody. Only the cytokine profile of anti-N-methyl-D-aspartate receptor encephalitis has extensively been investigated, with findings suggesting that, although humoral immunity is the main effector, T cells may also be relevant for the development of this disorder. A better understanding of cytokine dynamics governing neuroinflammation might offer the opportunity of developing new therapeutic strategies against specific immune cells, cytokines, antibodies, or intracellular signalling cascades, therefore leading to better outcomes and preventing undesired side effects of the presently used strategies. In this review, we first summarize the current knowledge about the role of cytokines in the pathogenesis of autoimmune encephalitis, combining theoretical analysis with experimental validations, to assess their suitability as clinical biomarkers. Second, we discuss the potential applicability of the novel targeted immunotherapies in autoimmune encephalitis depending on the immunobiology of the associated antibody, their limitations, as well as the main limitations that should be addressed in future studies.
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Affiliation(s)
- Nicolás Lundahl Ciano-Petersen
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique , Bron , France
- SynatAc Team, Institute MeLiS, INSERM U1314/CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1 , Lyon , France
- Neuroimmunology and Neuroinflammation group. Biomedical Research Institute of Málaga (IBIMA) , Málaga , Spain
- Red Andaluza de Investigación Clínica y Traslacional en Neurología (Neuro-RECA). Hospital Regional Universitario de Málaga , Málaga , Spain
| | - Sergio Muñiz-Castrillo
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique , Bron , France
- SynatAc Team, Institute MeLiS, INSERM U1314/CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1 , Lyon , France
| | - Cristina Birzu
- Service de Neurologie 2-Mazarin, Centre de Recherche de l’Institut du Cerveau et de la Moelle Epinière, Groupe Hospitalier Pitie-Salpetrière et Université Pierre et Marie Curie-Paris 6, AP-HP , Paris , France
| | - Alberto Vogrig
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique , Bron , France
- SynatAc Team, Institute MeLiS, INSERM U1314/CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1 , Lyon , France
| | - Antonio Farina
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique , Bron , France
- SynatAc Team, Institute MeLiS, INSERM U1314/CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1 , Lyon , France
| | - Macarena Villagrán-García
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique , Bron , France
- SynatAc Team, Institute MeLiS, INSERM U1314/CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1 , Lyon , France
| | - Bastien Joubert
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique , Bron , France
- SynatAc Team, Institute MeLiS, INSERM U1314/CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1 , Lyon , France
| | - Dimitri Psimaras
- Service de Neurologie 2-Mazarin, Centre de Recherche de l’Institut du Cerveau et de la Moelle Epinière, Groupe Hospitalier Pitie-Salpetrière et Université Pierre et Marie Curie-Paris 6, AP-HP , Paris , France
| | - Jérôme Honnorat
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique , Bron , France
- SynatAc Team, Institute MeLiS, INSERM U1314/CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1 , Lyon , France
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Demain JG, Bonilla FA. Efgartigimod: Potential Impact on IVIG Therapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1930. [PMID: 35551894 DOI: 10.1016/j.jaip.2022.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 04/12/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Jeffrey G Demain
- Allergy Asthma & Immunology Center of Alaska, Department of Pediatrics, University of Washington, WWAMI School of Medical Education, University of Alaska, Anchorage, Alaska.
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Dalakas MC. Role of complement, anti-complement therapeutics, and other targeted immunotherapies in myasthenia gravis. Expert Rev Clin Immunol 2022; 18:691-701. [PMID: 35730504 DOI: 10.1080/1744666x.2022.2082946] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Several patients with myasthenia gravis (MG) do not adequately respond to available drugs or exhibit poor tolerance, necessitating the need for new therapies. AREAS COVERED The paper discusses the rapidly evolving target-specific immunotherapies that promise long-standing remissions in the management of MG. It is specifically focused on the role of complement, anti-complement therapeutics, and the anti-FcRn and B cell monoclonals. EXPERT OPINION Anti-AChR antibodies cause internalization of the receptors and activate complement leading to in situ MAC formation that damages the post-synaptic membrane of the neuromuscular junction. Inhibiting MAC formation by antibodies targeting key complements subcomponents is a reasonable therapeutic goal. Indeed, the anti-C5 monoclonal antibodies, Eculizumab, Ravulizumab, and Zilucoplan, have been successfully tested in MG with Eculizumab first and now Ravulizumab FDA-approved for refractory MG based on sustained long-term benefits. Among the biologics that inhibit FcRn, Efgartigimod caused rapid reduction of the circulating IgG in the lysosomes, and induced sustained clinical remission with good safety profile leading to FDA-approved indication. Anti-B cell agents, like Rituximab, can induce sustained long-term remissions, especially in IgG4 antibody-mediated Musk-MG, by targeting short-lived antibody-secreting plasmablasts. These biologics offer effective targeted immunotherapies with good tolerance promising to change the therapeutic algorithm in the chronic MG management.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.,Neuroimmunology Unit, National and Kapodistrian University, University of Athens Medical School, Athens, Greece
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Hiya S, Fujiwara S, Tanaka F, Kohara N, Kawamoto M. High-dose immunoglobulin-dependent chronic demyelinating inflammatory polyneuropathy successfully managed with subcutaneous immunoglobulin using pharmacokinetic analysis. eNeurologicalSci 2022; 27:100404. [PMID: 35603015 PMCID: PMC9121235 DOI: 10.1016/j.ensci.2022.100404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 04/26/2022] [Accepted: 05/06/2022] [Indexed: 11/26/2022] Open
Abstract
Immunoglobulin G therapy for chronic inflammatory demyelinating polyneuropathy (CIDP) often requires individual dose adjustments because of the heterogeneity of pathogenesis and varying catabolic rates. However, currently available pharmacokinetic studies of immunoglobulin G therapy do not consider individual differences. We conducted a pharmacokinetic study of both intravenous immunoglobulin and subcutaneous immunoglobulin in a single patient with CIDP who was dependent on high-dose immunoglobulin treatment. This patient—a 77-year-old man with symmetrical limb weakness, diffuse demyelination determined by a nerve conduction study, and lacking autoantibodies—was treated with intravenous immunoglobulin and experienced severe fluctuations in symptoms. We transitioned him to subcutaneous immunoglobulin: his serum immunoglobulin G levels stabilised and he experienced symptomatic relief. Monitoring of serum immunoglobulin G concentrations revealed volatile changes following intravenous immunoglobulin administration which stabilised following subcutaneous immunoglobulin treatment. This suggests that subcutaneous immunoglobulin is a preferable long-term treatment option, especially for high-dose immunoglobulin-dependent patients with CIDP. When the target serum IgG level is high, IVIg accelerates IgG catabolism and causes volatile changes in serum IgG levels. SCIg can promote a stable serum IgG concentration with the same monthly dosage as IVIg treatment, without accelerating catabolism. This may improve clinical outcomes. SCIg might be a successful treatment option for other patients with CIDP whose symptoms are uncontrolled or sub-optimally controlled by high-dose IVIg.
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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.
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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
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Nelke C, Spatola M, Schroeter CB, Wiendl H, Lünemann JD. Neonatal Fc Receptor-Targeted Therapies in Neurology. Neurotherapeutics 2022; 19:729-740. [PMID: 34997443 PMCID: PMC9294083 DOI: 10.1007/s13311-021-01175-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2021] [Indexed: 12/23/2022] Open
Abstract
Autoantibodies are increasingly recognized for their pathogenic potential in a growing number of neurological diseases. While myasthenia gravis represents the prototypic antibody (Ab)-mediated neurological disease, many more disorders characterized by Abs targeting neuronal or glial antigens have been identified over the past two decades. Depletion of humoral immune components including immunoglobulin G (IgG) through plasma exchange or immunoadsorption is a successful therapeutic strategy in most of these disease conditions. The neonatal Fc receptor (FcRn), primarily expressed by endothelial and myeloid cells, facilitates IgG recycling and extends the half-life of IgG molecules. FcRn blockade prevents binding of endogenous IgG to FcRn, which forces these antibodies into lysosomal degradation, leading to IgG depletion. Enhancing the degradation of endogenous IgG by FcRn-targeted therapies proved to be a powerful therapeutic approach in patients with generalized MG and is currently being tested in clinical trials for several other neurological diseases including autoimmune encephalopathies, neuromyelitis optica spectrum disorders, and inflammatory neuropathies. This review illustrates mechanisms of FcRn-targeted therapies and appraises their potential to treat neurological diseases.
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Affiliation(s)
- Christopher Nelke
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Marianna Spatola
- MIT and Harvard Medical School, Ragon Institute of MGH, Cambridge, MA, USA
| | - Christina B Schroeter
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Heinz Wiendl
- Department of Neurology With Institute of Translational Neurology, University Hospital Münster, Munster, Germany
| | - Jan D Lünemann
- Department of Neurology With Institute of Translational Neurology, University Hospital Münster, Munster, Germany.
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Dalakas MC. Stiff-person Syndrome and GAD Antibody-spectrum Disorders: GABAergic Neuronal Excitability, Immunopathogenesis and Update on Antibody Therapies. Neurotherapeutics 2022; 19:832-847. [PMID: 35084720 PMCID: PMC9294130 DOI: 10.1007/s13311-022-01188-w] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2022] [Indexed: 01/10/2023] Open
Abstract
Although antibodies against Glutamic Acid Decarboxylase (GAD) were originally associated with Stiff Person Syndrome (SPS), they now denote the "GAD antibody-spectrum disorders (GAD-SD)" that include Cerebellar Ataxia, Autoimmune Epilepsy, Limbic Encephalitis, PERM and eye movement disorder. In spite of the unique clinical phenotype that each of these disorders has, there is significant overlapping symptomatology characterized by autoimmune neuronal excitability. In addition to GAD, three other autoantibodies, against glycine receptors, amphiphysin and gephyrin, are less frequently or rarely associated with SPS-SD. Very high serum anti-GAD antibody titers are a key diagnostic feature for all GAD-SD, commonly associated with the presence of GAD antibodies in the CSF, a reduced CSF GABA level and increased anti-GAD-specific IgG intrathecal synthesis denoting stimulation of B-cell clones in the CNS. Because anti-GAD antibodies from the various hyperexcitability syndromes recognize the same dominant GAD epitope, the clinical heterogeneity among GAD-SD patients remains unexplained. The paper highlights the biologic basis of autoimmune hyperexcitability connected with the phenomenon of reciprocal inhibition as the fundamental mechanism of the patients' muscle stiffness and spasms; addresses the importance of high-GAD antibody titers in diagnosis, pinpointing the diagnostic challenges in patients with low-GAD titers or their distinction from functional disorders; and discusses whether high GAD-antibodies are disease markers or pathogenic in the context of their association with reduced GABA level in the brain and CSF. Finally, it focuses on therapies providing details on symptomatic GABA-enhancing drugs and the currently available immunotherapies in a step-by-step approach. The prospects of future immunotherapeutic options with antibody therapies are also summarized.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
- Neuroimmunology Unit National and Kapodistrian University of Athens Medical School, Athens, Greece.
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36
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Dalakas MC, Meisel A. Immunomodulatory effects and clinical benefits of intravenous immunoglobulin in myasthenia gravis. Expert Rev Neurother 2022; 22:313-318. [PMID: 35350948 DOI: 10.1080/14737175.2022.2057223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Myasthenia gravis (MG) is an antibody-mediated disease that develops in the majority of patients mainly as a result of acetylcholine receptor (AChR) autoantibodies. This process is mediated by a series of immunoregulatory events. Therapeutic targets for MG include suppression of circulating antibodies or antibody production, suppression of complement activation, and immunomodulation of cytokines or T cells. Intravenous immunoglobulin (IVIg) has an effect on all of these mechanisms. AREAS COVERED This narrative review explores the broad immunomodulatory effects of IVIg in MG and provides an update on IVIg treatment for MG. EXPERT OPINION IVIg has a range of immunomodulatory effects on therapeutic targets relevant to the immunopathogenesis of MG. An emerging area of research is the pharmacogenomics of IVIg in MG related to FcRn and IgG catabolism. New data indicate that the FcRn VNTR3 genotype can affect the efficacy of IVIg in certain MG patients and may have an impact on IgG kinetics and selected dosing. Immune globulin 10% caprylate/chromatography purified (IVIg-C) has been shown to reverse the symptoms of severe acute exacerbation in patients with MG. Available data support the use of IVIg-C as an effective and safe treatment for this severely ill subgroup of patients during a relapse.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Andreas Meisel
- Department of Neurology, Integrated Center for Myasthenia Gravis, Charité - University Medicine Berlin, Germany
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Dalakas MC. Complement in autoimmune inflammatory myopathies, the role of myositis-associated antibodies, COVID-19 associations, and muscle amyloid deposits. Expert Rev Clin Immunol 2022; 18:413-423. [PMID: 35323101 DOI: 10.1080/1744666x.2022.2054803] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The inflammatory myopathies (IM) have now evolved into distinct subsets requiring clarification about their immunopathogenesis to guide applications of targeted therapies. AREAS COVERED Immunohistopathologic criteria of IM with a focus on complement, anti-complement therapeutics, and other biologic immunotherapies. The COVID19-triggered muscle autoimmunity along with the correct interpretation of muscle amyloid deposits is discussed. EXPERT OPINION The IM, unjustifiably referred as idiopathic, comprise Dermatomyositis (DM), Necrotizing Autoimmune Myositis (NAM), Anti-synthetase syndrome-overlap myositis (Anti-SS-OM), and Inclusion-Body-Myositis (IBM). In DM, complement activation with MAC-mediated endomysial microvascular destruction and perifascicular atrophy is the fundamental process, while innate immunity activation factors, INF1 and MxA, sense and secondarily enhance inflammation. Complement participates in muscle fiber necrosis from any cause and may facilitate muscle-fiber necrosis in NAM but seems unlikely that myositis-associated antibodies participate in complement-fixing. Accordingly, anti-complement therapeutics should be prioritized for DM. SARS-CoV-2 can potentially trigger muscle autoimmunity, but systematic studies are needed as the reported autopsy findings are not clinically relevant. In IBM, tiny amyloid deposits within muscle fibers are enhanced by inflammatory mediators contributing to myodegeneration; in contrast, spotty amyloid deposits in the endomysial connective tissue do not represent 'amyloid myopathy' but only have diagnostic value for amyloidosis due to any cause.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.,University of Athens Medical School, Neuroimmunology Unit, National and Kapodistrian University, Athens, Greece
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Svačina MKR, Lehmann HC. Chronic Inflammatory Demyelinating Polyneuropathy (CIDP): Current Therapies and Future Approaches. Curr Pharm Des 2022; 28:854-862. [PMID: 35339172 DOI: 10.2174/1381612828666220325102840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 01/08/2022] [Indexed: 11/22/2022]
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is an acquired immune-mediated polyradiculoneuropathy leading to disability via inflammatory demyelination of peripheral nerves. Various therapeutic approaches with different mechanisms of action are established for the treatment of CIDP. Of those, corticosteroids, intravenous or subcutaneous immunoglobulin, or plasma exchange are established first-line therapies as suggested by the recently revised EAN/PNS guidelines for the management of CIDP. In special cases, immunosuppressants or rituximab may be used. Novel therapeutic approaches currently undergoing clinical studies include molecules or monoclonal antibodies interacting with Fc receptors on immune cells to alleviate immune-mediated neuronal damage. Despite various established therapies and the current development of novel therapeutics, treatment of CIDP remains challenging due to an inter-individually heterogeneous disease course and the lack of surrogate parameters to predict the risk of clinical deterioration.
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Affiliation(s)
- Martin K R Svačina
- Department of Neurology, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Helmar C Lehmann
- Department of Neurology, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
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Koneczny I, Tzartos J, Mané-Damas M, Yilmaz V, Huijbers MG, Lazaridis K, Höftberger R, Tüzün E, Martinez-Martinez P, Tzartos S, Leypoldt F. IgG4 Autoantibodies in Organ-Specific Autoimmunopathies: Reviewing Class Switching, Antibody-Producing Cells, and Specific Immunotherapies. Front Immunol 2022; 13:834342. [PMID: 35401530 PMCID: PMC8986991 DOI: 10.3389/fimmu.2022.834342] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/28/2022] [Indexed: 12/24/2022] Open
Abstract
Organ-specific autoimmunity is often characterized by autoantibodies targeting proteins expressed in the affected tissue. A subgroup of autoimmunopathies has recently emerged that is characterized by predominant autoantibodies of the IgG4 subclass (IgG4-autoimmune diseases; IgG4-AID). This group includes pemphigus vulgaris, thrombotic thrombocytopenic purpura, subtypes of autoimmune encephalitis, inflammatory neuropathies, myasthenia gravis and membranous nephropathy. Although the associated autoantibodies target specific antigens in different organs and thus cause diverse syndromes and diseases, they share surprising similarities in genetic predisposition, disease mechanisms, clinical course and response to therapies. IgG4-AID appear to be distinct from another group of rare immune diseases associated with IgG4, which are the IgG4-related diseases (IgG4-RLD), such as IgG4-related which have distinct clinical and serological properties and are not characterized by antigen-specific IgG4. Importantly, IgG4-AID differ significantly from diseases associated with IgG1 autoantibodies targeting the same organ. This may be due to the unique functional characteristics of IgG4 autoantibodies (e.g. anti-inflammatory and functionally monovalent) that affect how the antibodies cause disease, and the differential response to immunotherapies of the IgG4 producing B cells/plasmablasts. These clinical and pathophysiological clues give important insight in the immunopathogenesis of IgG4-AID. Understanding IgG4 immunobiology is a key step towards the development of novel, IgG4 specific treatments. In this review we therefore summarize current knowledge on IgG4 regulation, the relevance of class switching in the context of health and disease, describe the cellular mechanisms involved in IgG4 production and provide an overview of treatment responses in IgG4-AID.
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Affiliation(s)
- Inga Koneczny
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
- *Correspondence: Inga Koneczny,
| | - John Tzartos
- Neuroimmunology, Tzartos NeuroDiagnostics, Athens, Greece
- 2nd Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Marina Mané-Damas
- Research Group Neuroinflammation and Autoimmunity, Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Vuslat Yilmaz
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Maartje G. Huijbers
- Department of Human Genetics, Leiden University Medical Center, Leiden, Netherlands
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Konstantinos Lazaridis
- Department of Immunology, Laboratory of Immunology, Hellenic Pasteur Institute, Athens, Greece
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Erdem Tüzün
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Pilar Martinez-Martinez
- Research Group Neuroinflammation and Autoimmunity, Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Socrates Tzartos
- Neuroimmunology, Tzartos NeuroDiagnostics, Athens, Greece
- Department of Neurobiology, Hellenic Pasteur Institute, Athens, Greece
| | - Frank Leypoldt
- Neuroimmunology, Institute of Clinical Chemistry and Department of Neurology, UKSH Kiel/Lübeck, Kiel University, Kiel, Germany
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Goebel A, Andersson D, Helyes Z, Clark JD, Dulake D, Svensson C. The autoimmune aetiology of unexplained chronic pain. Autoimmun Rev 2022; 21:103015. [PMID: 34902604 DOI: 10.1016/j.autrev.2021.103015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 12/08/2021] [Indexed: 01/10/2023]
Abstract
Chronic pain is the leading cause of life years lived with disability worldwide. The aetiology of most chronic pain conditions has remained poorly understood and there is a dearth of effective therapies. The WHO ICD-11 has categorised unexplained chronic pain states as 'chronic primary pains' (CPP), which are further defined by their association with significant distress and/or dysfunction. The new mechanistic term, 'nociplasticic pain' has been developed to illustrate their presumed generation by a structurally intact, but abnormally functioning nociceptive system. Recently, researchers have unravelled the surprising, ubiquitous presence of pain-sensitising autoantibodies in four investigated CPP indicating autoimmune causation. In persistent complex regional pain syndrome, fibromyalgia syndrome, chronic post-traumatic limb pain, and non-inflammatory joint pain associated with rheumatoid arthritis, passive transfer experiments have shown that either IgG or IgM antibodies from patient-donors cause symptoms upon injection to rodents that closely resemble those of the clinical disorders. Targets of antibody-binding and downstream effects vary between conditions, and more research is needed to elucidate the molecular and cellular details. The central nervous system appears largely unaffected by antibody binding, suggesting that the clinically evident CNS symptoms associated with CPP might arise downstream of peripheral processes. In this narrative review pertinent findings are described, and it is suggested that additional symptom-based disorders might be examined for the contribution of antibody-mediated autoimmune mechanisms.
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Affiliation(s)
- Andreas Goebel
- Pain Research Institute, Institute for Life Course and Medical Sciences, University of Liverpool, UK and Walton Centre NHS Foundation Trust, Liverpool, UK.
| | - David Andersson
- Institute of Psychiatry, Psychology and Neuroscience, Wolfson Centre for Age-Related Disease, King's College London, UK
| | - Zsuzsanna Helyes
- Department of Pharmacology and Pharmacotherapy, Medical School & Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - J David Clark
- Anaesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, USA
| | | | - Camilla Svensson
- Department of Physiology and Pharmacology, Center for Molecular Medicine, Karolinska Institutet, Stockholm 171 76, Sweden
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Abstract
Efgartigimod (efgartigimod alfa-fcab, Vyvgart™) is a first-in-class neonatal Fc receptor antagonist being developed by argenx for the treatment of autoimmune diseases including myasthenia gravis. In December 2021, intravenous efgartigimod received its first approval in the USA for the treatment of generalized myasthenia gravis in adults who are anti-acetylcholine receptor (AChR) antibody positive. Intravenous efgartigimod has also been evaluated for generalized myasthenia gravis in various other countries, with the agent subsequently approved in Japan in January 2022 for generalized myasthenia gravis patients regardless of antibody status and in preregistration stage in the EU. Several clinical studies of intravenous and subcutaneous formulation of efgartigimod are also being investigated for other autoimmune diseases including bullous pemphigoid, chronic inflammatory demyelinating polyradiculoneuropathy, immune thrombocytopenia, autoimmune myositis and pemphigus. This article summarizes the milestones in the development of efgartigimod leading to this first approval for generalized myasthenia gravis.
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Affiliation(s)
- Young-A Heo
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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Schneider-Gold C, Gilhus NE. Advances and challenges in the treatment of myasthenia gravis. Ther Adv Neurol Disord 2022; 14:17562864211065406. [PMID: 34987614 PMCID: PMC8721395 DOI: 10.1177/17562864211065406] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 11/18/2021] [Indexed: 01/04/2023] Open
Abstract
Myasthenia gravis (MG) is a chronic autoimmune disease with fluctuating muscle weakness and fatigability. Standard immunomodulatory treatment may fail to achieve sufficient improvement with minimal symptom expression or remission of myasthenic symptoms, despite adequate dosing and duration of treatment. Treatment-resistant MG poses a challenge for both patients and treating neurologists and requires new therapeutic approaches. The spectrum of upcoming immunotherapies that more specifically address distinct targets of the main immunological players in MG pathogenesis includes T-cell directed monoclonal antibodies that block the intracellular cascade associated with T-cell activation, monoclonal antibodies directed against key B-cell molecules, as well as monoclonal antibodies against the fragment crystallizable neonatal receptor (FcRn), cytokines and transmigration molecules, and also drugs that inhibit distinct elements of the complement system activated by the pathogenic MG antibodies. The review gives an overview on new drugs being evaluated in still ongoing or recently finished controlled clinical trials and drugs of potential benefit in MG due to their mechanisms of action and positive effects in other autoimmune disorders. Also, the challenges associated with the new therapeutic options are discussed briefly.
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Affiliation(s)
- Christiane Schneider-Gold
- Department of Neurology, St. Josef Hospital, Ruhr-University of Bochum, Gudrunstrasse 56, Bochum D-44791, Germany
| | - Nils Erik Gilhus
- Department of Clinical Medicine, University of Bergen, Bergen, NorwayDepartment of Neurology, Haukeland University Hospital, Bergen, Norway
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Dalakas MC. IgG4-Mediated Neurologic Autoimmunities: Understanding the Pathogenicity of IgG4, Ineffectiveness of IVIg, and Long-Lasting Benefits of Anti-B Cell Therapies. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2022; 9:9/1/e1116. [PMID: 34845096 PMCID: PMC8630661 DOI: 10.1212/nxi.0000000000001116] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/08/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Describe the unique functions of immunoglobulin G4 (IgG4) in IgG4-neurologic disorders (IgG4-ND) and explain why, in contrast to their IgG1-counterparts, they respond poorly to intravenous immune globulin (IVIg) but effectively to anti-B cell therapies. METHODS The IgG4 structure and isotype switch, B cells and plasmablasts relevant to IgG4 production, and IgG4-induced disruption of the targeted antigens are reviewed and compared with IgG1-mediated autoimmune ND, where IVIg inhibits IgG1-triggered inflammatory effects. RESULTS The main IgG4-ND include muscle-specific kinase myasthenia; nodal/paranodal chronic inflammatory demyelinating polyradiculoneuropathy with antibodies to neurofascin-155, contactin-1/caspr-1, or pan-neurofascins; antileucine-rich, glioma-inactivated-1 and contactin-associated protein-like 2 associated-limbic encephalitis, Morvan syndrome, or neuromyotonia; and anti-IgLON5 disorder. The IgG4, because of its unique structural features in the hinge region, has noninflammatory properties being functionally monovalent and bispecific, unable to engage in cross-linking and internalization of the targeted antigen. In contrast to IgG1 subclass which is bivalent and monospecific, IgG4 does not activate complement and cannot bind to inhibitory Fcγ receptor (FcγRIIb) to activate cellular and complement-mediated immune responses, the key functions inhibited by IVIg. Because IVIg contains only 0.7%-2.6% IgG4, its idiotypes are of IgG1 subclass and cannot effectively neutralize IgG4 or sufficiently enhance IgG4 catabolism by saturating FcRn. In contrast, rituximab, by targeting memory B cells and IgG4-producing CD20-positive short-lived plasma cells, induces long-lasting clinical benefits. DISCUSSION Rituximab is the preferred treatment in IgG4-ND patients with severe disease by effectively targeting the production of pathogenic IgG-4 antibodies. In contrast, IVIG is ineffective because it inhibits immunoinflammatory functions irrelevant to the mechanistic effects of IgG4 and contains IgG-1 idiotypes that cannot sufficiently neutralize or possibly catabolize IgG4. Controlled studies with anti-CD19/20 monoclonals that also activate FcγRIIb may be more promising in treating IgG4-ND.
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Affiliation(s)
- Marinos C Dalakas
- From Thomas Jefferson University, Philadelphia, PA; and the University of Athens Medical School, Greece.
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Dalakas MC. Update on Intravenous Immunoglobulin in Neurology: Modulating Neuro-autoimmunity, Evolving Factors on Efficacy and Dosing and Challenges on Stopping Chronic IVIg Therapy. Neurotherapeutics 2021; 18:2397-2418. [PMID: 34766257 PMCID: PMC8585501 DOI: 10.1007/s13311-021-01108-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2021] [Indexed: 02/07/2023] Open
Abstract
In the last 25 years, intravenous immunoglobulin (IVIg) has had a major impact in the successful treatment of previously untreatable or poorly controlled autoimmune neurological disorders. Derived from thousands of healthy donors, IVIg contains IgG1 isotypes of idiotypic antibodies that have the potential to bind pathogenic autoantibodies or cross-react with various antigenic peptides, including proteins conserved among the "common cold"-pre-pandemic coronaviruses; as a result, after IVIg infusions, some of the patients' sera may transiently become positive for various neuronal antibodies, even for anti-SARS-CoV-2, necessitating caution in separating antibodies derived from the infused IVIg or acquired humoral immunity. IVIg exerts multiple effects on the immunoregulatory network by variably affecting autoantibodies, complement activation, FcRn saturation, FcγRIIb receptors, cytokines, and inflammatory mediators. Based on randomized controlled trials, IVIg is approved for the treatment of GBS, CIDP, MMN and dermatomyositis; has been effective in, myasthenia gravis exacerbations, and stiff-person syndrome; and exhibits convincing efficacy in autoimmune epilepsy, neuromyelitis, and autoimmune encephalitis. Recent evidence suggests that polymorphisms in the genes encoding FcRn and FcγRIIB may influence the catabolism of infused IgG or its anti-inflammatory effects, impacting on individualized dosing or efficacy. For chronic maintenance therapy, IVIg and subcutaneous IgG are effective in controlled studies only in CIDP and MMN preventing relapses and axonal loss up to 48 weeks; in practice, however, IVIg is continuously used for years in all the aforementioned neurological conditions, like is a "forever necessary therapy" for maintaining stability, generating challenges on when and how to stop it. Because about 35-40% of patients on chronic therapy do not exhibit objective neurological signs of worsening after stopping IVIg but express subjective symptoms of fatigue, pains, spasms, or a feeling of generalized weakness, a conditioning effect combined with fear that discontinuing chronic therapy may destabilize a multi-year stability status is likely. The dilemmas of continuing chronic therapy, the importance of adjusting dosing and scheduling or periodically stopping IVIg to objectively assess necessity, and concerns in accurately interpreting IVIg-dependency are discussed. Finally, the merit of subcutaneous IgG, the ineffectiveness of IVIg in IgG4-neurological autoimmunities, and genetic factors affecting IVIg dosing and efficacy are addressed.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
- Neuroimmunology Unit, Dept. of Pathophysiology, National and Kapodistrian University of Athens Medical School, Athens, Greece.
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Lamamy J, Boulard P, Brachet G, Tourlet S, Gouilleux-Gruart V, Ramdani Y. "Ways in which the neonatal Fc-receptor is involved in autoimmunity". J Transl Autoimmun 2021; 4:100122. [PMID: 34568803 PMCID: PMC8449123 DOI: 10.1016/j.jtauto.2021.100122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 09/06/2021] [Indexed: 11/18/2022] Open
Abstract
Since the neonatal IgG Fc receptor (FcRn) was discovered, its role has evolved from immunoglobulin recycling and biodistribution to antigen presentation and immune complex routing, bringing it to the center of both humoral and cellular immune responses. FcRn is thus involved in the pathophysiology of immune-related diseases such as cancer, infection, and autoimmune disorders. This review focuses on the role of FcRn in autoimmunity, based on the available data from both animal models and human studies. The knowledge concerning ways in which FcRn is involved in autoimmune response has led to the development of inhibitors for the treatment of autoimmune diseases, also described here. Up to date, the literature remains scarce, shedding light on the need for further studies to fully understand the various pathophysiological roles of this unique receptor. FcRn is an intracellular receptor with a key role in IgG and immune complex management. FcRn-targeting therapies are a promising way of treatment in antibodies mediated diseases.
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Affiliation(s)
- Juliette Lamamy
- EA7501, GICC, Université François Rabelais de Tours, F-37032, Tours, France
| | - Pierre Boulard
- Laboratoire d'immunologie, CHU Tours, F-37032, Tours, France
| | | | | | | | - Yanis Ramdani
- Service de Médecine Interne, CHU Tours, F-37032, Tours, France
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