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Liu Y, Chen S, Wang Y, Zhang Z, Zhang H, Wang Z, Tao Z, Wang J, Zhang P. Dexamethasone improves thymoma-associated myasthenia gravis via the AKT-mTOR pathway. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:817-828. [PMID: 37498332 PMCID: PMC10791733 DOI: 10.1007/s00210-023-02641-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 07/19/2023] [Indexed: 07/28/2023]
Abstract
Clinically, thymoma patients are often complicated with myasthenia gravis (MG). Dexamethasone, a glucocorticoid with anti-inflammatory effects, could be used as an immunosuppressant for thymoma-associated MG, but the mechanism of action remains to be explored. In this study, Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis, weighted gene co-expression network analysis (WGCNA) of potential targets was performed by screening the intersection targets of dexamethasone and thymoma-associated MG from the database. Furthermore, the key targets and core active components were identified by topological analysis of the protein-protein interaction (PPI) network. Molecular docking technology was applied to screen the complexes with stable binding of dexamethasone and core targets. Patients with thymoma were divided into two groups according to whether they received dexamethasone before operation, and immunohistochemistry and western blot were used to verify the selected target of dexamethasone in treating thymoma-associated MG. The results showed that the action pathway of dexamethasone on the disease was closely enriched to phosphatidylinositol 3-kinase (PI3K)-protein kinase B (PKB/AKT), mammalian target of rapamycin (mTOR) signaling pathways. The expressions of AKT1 and its downstream molecule mTOR in the thymoma microenvironment of thymoma-associated MG patients who did not receive dexamethasone before operation were higher than those in the group receiving dexamethasone before operation. This study demonstrates that dexamethasone can promote apoptosis through the AKT-mTOR pathway for the treatment of thymoma-associated MG, as validated by network pharmacology predictions and clinical specimen experiments, and can be verified by large-scale clinical trials in the future. This study also provides theoretical support and new research perspectives for this disease.
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Affiliation(s)
- Yuxin Liu
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Si Chen
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Yan Wang
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Zeyang Zhang
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Hui Zhang
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Ziyi Wang
- School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Ziyou Tao
- Department of Thoracic Surgery, The First Affiliated Hospital of Zhengzhou University, No.1 Jianshe East Road, Zhengzhou, China
| | - Jianyao Wang
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Peng Zhang
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Tianjin, China.
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2
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Bi Z, Cao Y, Liu C, Gui M, Lin J, Zhang Q, Li Y, Ji S, Bu B. Remission and relapses of myasthenia gravis on long-term tacrolimus: a retrospective cross-sectional study of a Chinese cohort. Ther Adv Chronic Dis 2022; 13:20406223221122538. [PMID: 36093262 PMCID: PMC9459458 DOI: 10.1177/20406223221122538] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 08/02/2022] [Indexed: 11/23/2022] Open
Abstract
Objective: To identify the factors that predict the remission and relapses in myasthenia
gravis (MG) patients improved by prednisone and tacrolimus treatment. Methods: A retrospective, observational cohort analysis of MG patients who achieved
remission after receiving prednisone and tacrolimus were performed at Tongji
Hospital. The main outcome measures were the time to remission, prednisone
discontinuation, tacrolimus reduction–associated relapse, and treatment
outcome. Results: After adding tacrolimus, 256 patients were able to achieve remission with a
mean time to remission of 2.1 ± 1.4 months. After a median follow-up of
2.9 years, 167 patients (65.2%) discontinued prednisone, and 20 patients
(7.8%) achieved complete stable remission. Moreover, 53 of the 109 patients
who were tapering tacrolimus experienced relapses. In multivariable
analysis, female sex, low tacrolimus concentrations, and quantitative
myasthenia gravis (QMG) scores have a positive correlation with the time to
remission; concomitant additional autoimmune disease (AID) and high
anti-acetylcholine receptor antibody (AChR-ab) levels were significantly
associated with low probabilities of prednisone discontinuation [odds ratio
(OR) = 0.312–0.912, respectively]; rapid tacrolimus decrement speed
(⩾0.76 mg/year) was an independent predictor for the development of relapse
during tapering tacrolimus (OR = 5.662). Conclusion: Sex, tacrolimus concentrations, and QMG scores can be used as potential
predictors of the time to remission in MG patients treated with tacrolimus
and prednisone. Prednisone should be tapered slowly, especially in patients
with additional AID or high serum titers of AChR-ab. To avoid symptoms
recurrence, the dose of tacrolimus should reduce slowly, not exceeding
0.76 mg/year.
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Affiliation(s)
- Zhuajin Bi
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yayun Cao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Chenchen Liu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Mengcui Gui
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jing Lin
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qing Zhang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yue Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Suqiong Ji
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bitao Bu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan 430030, Hubei Province, China
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Zheng Y, Yuan X, Zhang C, Liu R, Jin H, Hao H, Li F, Zhao Y, Yuan Y, Wang Z, Gao F. Efficacy and Safety of Tacrolimus Therapy for a Single Chinese Cohort With Very-Late-Onset Myasthenia Gravis. Front Neurol 2022; 13:843523. [PMID: 35432159 PMCID: PMC9007732 DOI: 10.3389/fneur.2022.843523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 02/15/2022] [Indexed: 11/28/2022] Open
Abstract
Background and Purpose Previous studies have found tacrolimus to be a favorable drug for treating different types of myasthenia gravis (MG), but few have focused on very-late-onset MG (VLOMG). This study evaluated the efficacy and safety of tacrolimus for VLOMG therapy. Methods This was a retrospective single-center cohort study of 70 patients with VLOMG (onset ≥65 years) who visited Peking University First Hospital in 2019. Participants were divided into the tacrolimus (Tac) group and the control group based on tacrolimus usage. We further divided the Tac group into patients treated without corticosteroids and with corticosteroids. Sociodemographic features, clinical profiles, and outcomes were compared between different therapies and further analyzed by multivariate regression. Details of tacrolimus treatment, comorbidities, and adverse drug reactions (ADRs) were described. Results Among 70 patients, the median (interquartile range) age at onset was 71 (68–77) years, and the follow-up duration was 27 (27-29) months. Most patients were types I (28%) and III (40%) according to the MG Foundation of America (MGFA) classification. In the Tac group, tacrolimus treatment was maintained for 36 (27-38) months. The dosage at the final evaluation was 1.0 (1.0–1.75) mg/day, and the last blood concentration test was 4.25 (2.85–5.7) ng/ml. A total of 43% reached remission, and 37% improved based on MGFA postintervention status (MGFA-PIS). For the 9 patients, newly diagnosed at enrollment within this group, MG activities of daily living (MG-ADL) decreased significantly from 3 (2-5) to 2 (1-2) (p = 0.041). Regarding the 13 patients, coadministering Wuzhi capsules the tacrolimus concentration increased from 2.75 (1.4–3.8) ng/ml to 5.95 (5.1–7.0) ng/ml (p = 0.012). No significant differences in outcomes were observed between tacrolimus treatment without and with corticosteroids or between the Tac group and the control group. A total of 93% had at least one comorbidity. ADRs related to tacrolimus emerged in 25% (9/36) of patients, most of which were not serious and reversible. Conclusions Tacrolimus is effective and safe in treating VLOMG. Tacrolimus monotherapy without corticosteroids can be used as an initial and maintenance treatment for VLOMG. Wuzhi capsules work well in elevating tacrolimus concentrations in this population.
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Affiliation(s)
- Yiming Zheng
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Xiaoqiu Yuan
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Caifeng Zhang
- Department of Neurology, Peking University First Hospital, Beijing, China
- North China University of Science and Technology Affiliated Hospital, Qinhuangdao, China
| | - Ran Liu
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Haiqiang Jin
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Hongjun Hao
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Fan Li
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Yawen Zhao
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Yun Yuan
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Zhaoxia Wang
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Feng Gao
- Department of Neurology, Peking University First Hospital, Beijing, China
- *Correspondence: Feng Gao
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4
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Bi Z, Cao Y, Lin J, Zhang Q, Liu C, Gui M, Bu B. Long-Term Improvement in a Chinese Cohort of Glucocorticoid-Resistant Childhood-Onset Myasthenia Gravis Patients Treated With Tacrolimus. Front Neurol 2022; 13:820205. [PMID: 35211085 PMCID: PMC8860838 DOI: 10.3389/fneur.2022.820205] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/10/2022] [Indexed: 12/30/2022] Open
Abstract
Objectives To evaluate the long-term outcome of tacrolimus for childhood-onset myasthenia gravis (CMG) with an inadequate response to glucocorticoids, and investigate factors associated with favorable outcomes following tacrolimus treatment. Methods A retrospective, observational cohort study was performed for CMG patients who had not improved satisfactorily after sufficient prednisone therapy for at least 8 weeks. All patients were given tacrolimus in doses of 2–3 mg for more than 6 months. The primary efficacy outcome was assessed using the prednisone dose, quantitative MG (QMG), and MG-activity of daily living (ADL) scores. The participants were divided into improved and unimproved groups based on changes in QMG scores to investigate the risk factors that affected tacrolimus efficacy. Results A total of 149 glucocorticoid resistant CMG patients were finally enrolled in our study, with 113 (75.8%) responding well to tacrolimus (defined as minimal manifestation status or better). One month after initiating tacrolimus, there was a noticeable improvement in prednisone dose, QMG, and ADL scores, which continued to improve throughout the study. More importantly, the prednisone was eventually stopped in 89 of the patients (78.8%). Thymus type [odds ratio (OR) = 3.156, 95% confidence interval (CI) 1.427–6.978; P = 0.005] and pre-intervention status (OR = 0.284, 95%CI 0.109–0.741; P = 0.010) were independent predictors of tacrolimus efficacy after controlling for confounding factors in multiple logistic regression. Conclusion The majority of glucocorticoid-resistant CMG patients have a good long-term prognosis after adding tacrolimus. Thymus type and pre-intervention status can serve as potential predictors affecting the efficacy of tacrolimus.
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Affiliation(s)
- Zhuajin Bi
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yayun Cao
- Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jing Lin
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qing Zhang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chenchen Liu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Mengcui Gui
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bitao Bu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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5
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Itani K, Nakamura M, Wate R, Kaneko S, Fujita K, Iida S, Morise S, Murakami A, Kunieda T, Takenouchi N, Yakushiji Y, Kusaka H. Efficacy and safety of tacrolimus as long-term monotherapy for myasthenia gravis. Neuromuscul Disord 2021; 31:512-518. [PMID: 33903022 DOI: 10.1016/j.nmd.2021.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 01/28/2021] [Accepted: 02/10/2021] [Indexed: 10/22/2022]
Abstract
The objective was to evaluate the long-term efficacy and safety of tacrolimus monotherapy in myasthenia gravis (MG) patients. Immunosuppressive drug-naïve MG patients were administered tacrolimus, followed by thymectomy in some of the cases according to the clinical guideline for MG. Additional aggressive immunosuppressive therapies were allowed if the patients without thymectomy did not achieve minimal manifestation (MM) or better status after 3 weeks of tacrolimus administration or in the thymectomized patients by 1-2 weeks after the operation (i.e., 1st evaluation). Of all 14 patients included in this study, 8 of them (57%) achieved MM or better status at the 1st evaluation, and the remaining 6 (43%), who had failed to gain MM or better status at the 1st evaluation, also achieved MM or better status with 1 course of aggressive immunosuppressive therapy. The quantitative MG (QMG) scores, MG-Activities of Daily Living (ADL) scales, and anti-acetylcholine receptor (AchR) antibody levels were significantly decreased at 6 months and maintained thereafter. At the end of the follow-up period (41-70 months), all patients were in MM or better status. None of the patients experienced severe adverse effects. Our small preliminary study indicates that long-term tacrolimus monotherapy is possibly effective and safe for MG patients.
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Affiliation(s)
- Kumi Itani
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka 5731010, Japan
| | - Masataka Nakamura
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka 5731010, Japan.
| | - Reika Wate
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka 5731010, Japan
| | - Satoshi Kaneko
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka 5731010, Japan
| | - Kengo Fujita
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka 5731010, Japan
| | - Shin Iida
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka 5731010, Japan
| | - Satoshi Morise
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka 5731010, Japan
| | - Aya Murakami
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka 5731010, Japan
| | - Takenobu Kunieda
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka 5731010, Japan
| | - Norihiro Takenouchi
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka 5731010, Japan; Department of Microbiology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka 5731010, Japan
| | - Yusuke Yakushiji
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka 5731010, Japan
| | - Hirofumi Kusaka
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka 5731010, Japan
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Bennani HN, Lagrange E, Noble J, Malvezzi P, Motte L, Chevallier E, Rostaing L, Jouve T. Treatment of refractory myasthenia gravis by double-filtration plasmapheresis and rituximab: A case series of nine patients and literature review. J Clin Apher 2020; 36:348-363. [PMID: 33349954 DOI: 10.1002/jca.21868] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 12/03/2020] [Accepted: 12/08/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Myasthenia gravis (MG) is an autoimmune disease mediated by circulating autoantibodies (anti-AchR, anti-MuSK, etc.). More than 20% of myasthenic patients are refractory to conventional treatments (plasma exchange, IVIg, steroids, azathioprine, mycophenolate mofetil). Rituximab (B-lymphocyte-depleting anti-CD20) and apheresis (double-filtration plasmapheresis [DFPP] and immunoadsorption [IA]) are interesting therapeutic alternatives. METHODS This monocentric pilot study included nine refractory myasthenic patients (March 2018 to May 2020) treated by DFPP and/or IA associated with rituximab (375 mg/m2 ). Clinical responses were assessed using the Myasthenia Gravis Foundation of America (MGFA) score. RESULTS Average age of patients was 53 ± 17 years. Gender ratio (M/F) was 3:6. The combination of apheresis and rituximab reduced median MGFA score from IV to II after 12 months of follow-up. Clinical improvement assessed by MGFA score was sustained in the long-term for all patients, during an average follow-up of 14 ± 9 months, allowing them to be self-sufficient and out sick-leave. The median number of apheresis sessions was 7 (5-30). The dose of prednisolone was reduced in two patients from 40 mg/d and 30 mg/d to 7.5 mg/d and 10 mg/d, respectively. It was stopped in a patient who was taking 30 mg/d. No infectious, bleeding, or thrombosis complications were noted. CONCLUSION The combination of rituximab and DFPP was effective to treat refractory MG.
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Affiliation(s)
- Hamza N Bennani
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble, La Tronche, France
| | - Emmeline Lagrange
- Exploration Fonctionnelle du Système Nerveux instead of Service de Neurologie, CHU Grenoble, La Tronche, France
| | - Johan Noble
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble, La Tronche, France
| | - Paolo Malvezzi
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble, La Tronche, France
| | - Lionel Motte
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble, La Tronche, France
| | - Eloi Chevallier
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble, La Tronche, France
| | - Lionel Rostaing
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble, La Tronche, France.,Université Grenoble-Alpes, La Tronche, France
| | - Thomas Jouve
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble, La Tronche, France.,Université Grenoble-Alpes, La Tronche, France
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Zhang C, Bu B, Yang H, Wang L, Liu W, Duan RS, Zhang M, Zeng P, Du C, Yang L, Shi FD. Immunotherapy choice and maintenance for generalized myasthenia gravis in China. CNS Neurosci Ther 2020; 26:1241-1254. [PMID: 33103369 PMCID: PMC7702233 DOI: 10.1111/cns.13468] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 09/19/2020] [Accepted: 09/21/2020] [Indexed: 12/12/2022] Open
Abstract
Aims To compare long‐term efficacy and safety of immunotherapeutic strategies as maintenance to prevent disease relapses of generalized myasthenia gravis (MG) in real‐world settings. Methods This is a retrospective cohort study on generalized MG conducted in seven major neurological centers across China. Eligible participants were patients with generalized MG who were under minimal manifestation status or better. Main outcome measures were probability of patients free of relapses and causes of drug discontinuation. Results Among 1064 patients enrolled, the median (interquartile range) age was 50.3 (37.0‐62.5) years and 641 (60.2%) were women. Disease relapse was significantly lower for rituximab (6.1%) compared with all the other monotherapies (hazard ratio [HR] = 0.18, 95% confidence interval [CI] 0.06 to 0.56, P = .0030). As combination therapies, tacrolimus in combination with corticosteroids reduced risk of disease relapses compared with azathioprine with corticosteroids (HR = 0.45, 95% CI 0.25 to 0.81, P = .0077) or mycophenolate mofetil with corticosteroids (HR = 0.32, 95% CI 0.15 to 0.67, P = .0020). Otherwise, lower‐dose corticosteroids or azathioprine as monotherapy significantly increased risk of disease relapses (HR = 2.78, 95% CI 1.94 to 3.99, P < .0001; HR = 2.14, 95% CI 1.42 to 3.23, P = .0003, respectively). The proportion of discontinuation was lowest in patients with rituximab (20.4%) as monotherapy and tacrolimus with corticosteroids (23.6%). Overall, combination treatment of immunosuppressants with corticosteroids had a lower rate of discontinuation compared with corresponding monotherapy (HR = 0.51, 95% CI 0.36 to 0.71, P < .0001). Conclusions Rituximab as monotherapy and tacrolimus with corticosteroids displayed better clinical efficacy as well as drug maintenance to prevent disease relapses in patients with generalized MG.
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Affiliation(s)
- Chao Zhang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, China.,National Clinical Research Center for Neurological Diseases of China, Jing-Jin Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bitao Bu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Lihua Wang
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Weibin Liu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Rui-Sheng Duan
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Meini Zhang
- Department of Neurology, The First Hospital of Shanxi Medical University, Taiyuan, China
| | - Pei Zeng
- National Clinical Research Center for Neurological Diseases of China, Jing-Jin Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chen Du
- National Clinical Research Center for Neurological Diseases of China, Jing-Jin Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Li Yang
- National Clinical Research Center for Neurological Diseases of China, Jing-Jin Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fu-Dong Shi
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, China.,National Clinical Research Center for Neurological Diseases of China, Jing-Jin Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Dos Santos A, Noury J‐B, Genestet S, Nadaj‐Pakleza A, Cassereau J, Baron C, Videt D, Michel L, Pereon Y, Wiertlewski S, Magot A. Efficacy and safety of rituximab in myasthenia gravis: a French multicentre real‐life study. Eur J Neurol 2020; 27:2277-2285. [DOI: 10.1111/ene.14391] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/26/2020] [Accepted: 06/03/2020] [Indexed: 12/30/2022]
Affiliation(s)
- A. Dos Santos
- Department of Neurology University Hospital of Nantes Nantes France
| | - J. ‐B. Noury
- Reference Centre for Neuromuscular Diseases AOC University Hospital of Brest Brest France
| | - S. Genestet
- Reference Centre for Neuromuscular Diseases AOC University Hospital of Brest Brest France
| | - A. Nadaj‐Pakleza
- Reference Centre for Neuromuscular Diseases University Hospital of Strasbourg Strasbourg France
| | - J. Cassereau
- Reference Centre for Neuromuscular Diseases AOC University Hospital of Angers Angers France
| | - C. Baron
- Department of Clinical Neurophysiology University Hospital of Poitiers Poitiers France
| | - D. Videt
- Department of Neurology Centre Hospitalier Bretagne Atlantique Vannes France
| | - L. Michel
- Department of Neurology University Hospital of Rennes Rennes France
| | - Y. Pereon
- Reference Centre for Neuromuscular Diseases AOC University Hospital of Nantes Nantes France
| | - S. Wiertlewski
- Department of Neurology University Hospital of Nantes Nantes France
| | - A. Magot
- Reference Centre for Neuromuscular Diseases AOC University Hospital of Nantes Nantes France
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9
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Patel A, Lynch F, Shepherd SA. Newer Immunotherapies for the Treatment of Acute Neuromuscular Disease in the Critical Care Unit. Curr Treat Options Neurol 2020; 22:7. [PMID: 32052202 DOI: 10.1007/s11940-020-0616-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OPINION STATEMENT PURPOSE OF REVIEW: In this review, we discuss current treatment options for commonly encountered neuromuscular disorders in intensive care units. We will discuss epidemiology, pathophysiology, and acute and chronic treatment options for myasthenia gravis, Guillain-Barré syndrome, West Nile virus, Botulism, and amyotrophic lateral sclerosis. RECENT FINDINGS Eculizumab is the newest immunomodulator therapy approved by the Food and Drug Administration in treatment of myasthenia gravis, shown to improve long-term functional outcomes. Edaravone is the newest therapy in management of amyotrophic lateral sclerosis, shown to slow functional deterioration. Efgartigimod showed great promise in a phase 2 safety and efficacy trial in the treatment of stable generalized myasthenia gravis. Eculizumab was found to be safe in a small phase 2 trial for use in Guillain-Barré syndrome. Currently, therapies such as plasma exchange, intravenous immunoglobulins, and steroids remain the mainstay of treatment in the ICU for many neuromuscular disorders. While there are some newer immunotherapies available, few have been studied in the acute setting. However, with the advent of new immunotherapies and biologics, changes in these approaches may be on the horizon.
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Affiliation(s)
- Alok Patel
- Department of Neurology, Rush University Medical Center, 1725 W Harrison St, Suite 1121, Chicago, IL, 60612, USA
| | - Fiona Lynch
- Department of Neurology, Rush University Medical Center, 1725 W Harrison St, Suite 1121, Chicago, IL, 60612, USA
| | - Starane A Shepherd
- Department of Neurology, Rush University Medical Center, 1725 W Harrison St, Suite 1121, Chicago, IL, 60612, USA.
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Maintenance immunosuppression in myasthenia gravis, an update. J Neurol Sci 2019; 410:116648. [PMID: 31901719 DOI: 10.1016/j.jns.2019.116648] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/25/2019] [Accepted: 12/24/2019] [Indexed: 01/08/2023]
Abstract
Therapies for myasthenia gravis (MG) include symptomatic and immunosuppressive/immunomodulatory treatment. Options for immunosuppression include corticosteroids, azathioprine, mycophenolate mofetil, cyclosporine, tacrolimus, methotrexate, rituximab, cyclophosphamide, eculizumab, intravenous immunoglobulin, subcutaneous immunoglobulin, plasmapheresis, and thymectomy. The practical aspects of long-term immunosuppressive therapy in MG are critically reviewed in this article. Application of one or more of these specific therapies is guided based on known efficacy, adverse effect profile, particular disease subtype and severity, and patient co-morbidities.
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11
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Wu FB, Yang YY, Wang XB, Wang Z, Zhang WW, Liu ZY, Qian YQ. A sample processing method for immunoassay of whole blood tacrolimus. Anal Biochem 2019; 576:13-19. [DOI: 10.1016/j.ab.2019.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 04/06/2019] [Accepted: 04/08/2019] [Indexed: 02/03/2023]
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12
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Shumei Y, Yi L, Huanyu M, Zhibin L, Wanlin J, Liqun X, Huan Y. IL-2 gene polymorphisms affect tacrolimus response in myasthenia gravis. Eur J Clin Pharmacol 2019; 75:795-800. [PMID: 30729267 DOI: 10.1007/s00228-019-02642-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 01/29/2019] [Indexed: 12/26/2022]
Abstract
PURPOSE The IL-2 gene polymorphisms have been reported to be associated with the development of autoimmune disease. However, there are no published studies examining the influence of the IL-2 gene polymorphisms on the response of myasthenia gravis (MG) patients to tacrolimus (Tac). The goal of this study was to investigate the relationship between the polymorphisms of IL-2 and Tac response in MG patients. METHODS Ninety-two MG patients treated with Tac were studied, including 57 Tac-effective patients and 35 Tac-ineffective patients. Then, we selected four single-nucleotide polymorphisms (SNPs: rs2069776, rs2069772, rs2069762, rs2069763) in the IL-2 gene. Next, we analyzed the distribution of genotypes, allelic frequencies of SNPs, and haplotype frequencies among polymorphisms in the two groups of patients. RESULTS The distribution of the allelic frequency of the rs2069762 variant differed between the Tac-effective and Tac-ineffective patients (P = 0.02). Genotypes G/T and G/G of rs2069762 were differently distributed between the two groups when the wild genotype T/T was assigned as a reference (P < 0.001 for G/T; P = 0.003 for G/G). Patients with the TAGG haplotype tended to be Tac-ineffective (P < 0.001, OR: 0.15, 95% CI: 0.05-0.43). CONCLUSION Myasthenia gravis patients with the rs2069762 variant, rs2069762 G/T and G/G genotype, and TAGG haplotype for IL-2 tended to respond poorly to Tac treatment.
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Affiliation(s)
- Yang Shumei
- Department of Neurology, Xiangya Hospital, Central South University, 87 Xiangya road, Changsha, Hunan, China
| | - Li Yi
- Department of Neurology, Xiangya Hospital, Central South University, 87 Xiangya road, Changsha, Hunan, China
| | - Meng Huanyu
- Department of Neurology, Xiangya Hospital, Central South University, 87 Xiangya road, Changsha, Hunan, China
| | - Li Zhibin
- Department of Neurology, Xiangya Hospital, Central South University, 87 Xiangya road, Changsha, Hunan, China
| | - Jin Wanlin
- Department of Neurology, Xiangya Hospital, Central South University, 87 Xiangya road, Changsha, Hunan, China
| | - Xu Liqun
- Department of Neurology, Xiangya Hospital, Central South University, 87 Xiangya road, Changsha, Hunan, China
| | - Yang Huan
- Department of Neurology, Xiangya Hospital, Central South University, 87 Xiangya road, Changsha, Hunan, China.
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Prabhakar H, Ali Z. Intensive Care Management of the Neuromuscular Patient. TEXTBOOK OF NEUROANESTHESIA AND NEUROCRITICAL CARE 2019. [PMCID: PMC7120052 DOI: 10.1007/978-981-13-3390-3_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Neuromuscular emergencies are a distinct group of acute neurological diseases with distinct characteristic presentations. Patients who suffer from this group of diseases are at immediate risk of losing protection of their native airway as well as aspirating orogastric contents. This is secondary to weakness of the muscles of the oropharynx and respiratory muscles. Although some neuromuscular emergencies such as myasthenia gravis or Guillain-Barré syndrome are well understood, others such as critical illness myopathy and neuropathy are less well characterized. In this chapter, we have discussed the pathophysiology, diagnostic evaluation, and management options in patients who are admitted to the intensive care unit. We have also emphasized the importance of a thorough understanding of the use of pharmacological anesthetic agents in this patient population.
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Affiliation(s)
- Hemanshu Prabhakar
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Zulfiqar Ali
- Division of Neuroanesthesiology, Department of Anesthesiology, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir India
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Li Y, Guptill JT, Russo MA, Massey JM, Juel VC, Hobson-Webb LD, Howard JF, Chopra M, Liu W, Yi JS. Tacrolimus inhibits Th1 and Th17 responses in MuSK-antibody positive myasthenia gravis patients. Exp Neurol 2018; 312:43-50. [PMID: 30472069 DOI: 10.1016/j.expneurol.2018.11.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/25/2018] [Accepted: 11/22/2018] [Indexed: 12/17/2022]
Abstract
Muscle specific tyrosine kinase antibody positive myasthenia gravis (MuSK- MG) is characterized by autoantibodies against the MuSK protein of the neuromuscular junction resulting in weakness of bulbar and proximal muscles. We previously demonstrated that patients with MuSK-MG have increased pro-inflammatory Th1 and Th17 responses. Tacrolimus, an immunosuppressant used in AChR-MG and transplantation patients, inhibits T cell responses through interference with IL-2 transcription. The therapeutic efficacy and immunological effect of tacrolimus in MuSK-MG is unclear. In the current study we examined the proliferation, phenotype and cytokine production of CD4+ and CD8+ T cells in peripheral blood mononuclear cells of MuSK-MG following a 3-day in vitro culture with or without tacrolimus. We determined that tacrolimus profoundly suppressed CD4 and CD8 T cell proliferation and significantly suppressed Th1 and Th17 responses, as demonstrated by a reduced frequency of IFN-γ, IL-2, and IL-17 producing CD4 T cells and reduced frequencies of IFN-γ and IL-2 producing CD8 T cells. Tacrolimus also inhibits pathogenic Th17 cells coproducing IL-17 and IFN-γ. In addition, tacrolimus suppressed follicular T helper cell (Tfh) and regulatory T helper cell (Treg) subsets. These findings provide preliminary support for tacrolimus as a potential alternative immunosuppressive therapy for MuSK-MG.
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Affiliation(s)
- Yingkai Li
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jeffrey T Guptill
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Melissa A Russo
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Janice M Massey
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Vern C Juel
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Lisa D Hobson-Webb
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - James F Howard
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Manisha Chopra
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Weibin Liu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - John S Yi
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.
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15
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Tong O, Delfiner L, Herskovitz S. Pain, Headache, and Other Non-motor Symptoms in Myasthenia Gravis. Curr Pain Headache Rep 2018; 22:39. [DOI: 10.1007/s11916-018-0687-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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16
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Yin DT, Huang L, Han B, Chen X, Yin SM, Zhou W, Chu J, Liang T, Yun TY, Liu Y. Independent long-term result of robotic thymectomy for myasthenia gravis, a single center experience. J Thorac Dis 2018; 10:321-329. [PMID: 29600063 DOI: 10.21037/jtd.2017.12.07] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Robotic thymectomy has been suggested a feasible and safe approach for myasthenia gravis (MG). Few investigations have revealed the independent effect of robotic thymectomy without the confounding impact of immunosuppressive (IM) therapy. Methods Between May 2009 and December 2012, robotic extended thymectomy was carried out for patients with diagnosis of MG. The clinical data, subsequent neurological therapy and postintervention status were collected. Results Data of 37 cases was available for analysis. The mean follow-up was 70.0±13.3 months. The median age was 40 years. Twelve (32.4%) patients kept free of IM therapy, and 25 (67.6%) patients accepted postoperatively. The overall 5-year complete stable remission (CSR) rate was 40.6% and improvement rate was 81.6%. The young (age ≤40) displayed a significant better CSR rate (P=0.015) and a trend of better improvement rate (P=0.050) compared to the old (age >40). Patients without usage of IM therapy showed significant higher CSR rate (P=0.014) and improvement rate (P=0.024) compared to those with usage of IM therapy. Patients with Myasthenia Gravis Foundation of America (MGFA) classes I showed a trend of higher remission rate by multivariate analysis. No significant differences were found for the remission rate according to gender, pathology, and the duration of symptoms. Conclusions The mono-therapy of robotic thymectomy may bring with a satisfactory long-term result for part of MG patients. Precision selection and individualized therapy are of the most importance.
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Affiliation(s)
- Dong-Tao Yin
- Department of Thoracic Surgery, The PLA General Hospital, Beijing 100853, China.,Department of Thoracic Surgery, The General Hospital of the PLA Rocket Force, Beijing 100088, China
| | - Ling Huang
- Department of Neurology, The General Hospital of the PLA Rocket Force, Beijing 100088, China
| | - Bing Han
- Department of Thoracic Surgery, The General Hospital of the PLA Rocket Force, Beijing 100088, China
| | - Xiu Chen
- Department of Thoracic Surgery, The General Hospital of the PLA Rocket Force, Beijing 100088, China
| | - Shi-Min Yin
- Department of Neurology, The General Hospital of the PLA Rocket Force, Beijing 100088, China
| | - Wen Zhou
- Department of Cadre's Ward, The General Hospital of the PLA Rocket Force, Beijing 100088, China
| | - Jian Chu
- Department of Thoracic Surgery, The General Hospital of the PLA Rocket Force, Beijing 100088, China
| | - Tao Liang
- Department of Thoracic Surgery, The General Hospital of the PLA Rocket Force, Beijing 100088, China
| | - Tian-Yang Yun
- Department of Thoracic Surgery, The PLA General Hospital, Beijing 100853, China
| | - Yang Liu
- Department of Thoracic Surgery, The PLA General Hospital, Beijing 100853, China
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Morren J, Li Y. Myasthenia gravis with muscle-specific tyrosine kinase antibodies: A narrative review. Muscle Nerve 2018; 58:344-358. [DOI: 10.1002/mus.26107] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 02/09/2018] [Accepted: 02/18/2018] [Indexed: 12/14/2022]
Affiliation(s)
- John Morren
- Neuromuscular Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk S90; Cleveland Ohio 44195 USA
| | - Yuebing Li
- Neuromuscular Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk S90; Cleveland Ohio 44195 USA
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18
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Kaminski HJ, Alnosair E, Algahtani RM. Clinical trials for myasthenia gravis: a historical perspective. Ann N Y Acad Sci 2018; 1413:5-10. [PMID: 29377153 DOI: 10.1111/nyas.13545] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 10/09/2017] [Accepted: 10/10/2017] [Indexed: 11/30/2022]
Abstract
Symposia dedicated to myasthenia gravis and related disorders date back to 1947 and serve as markers of the progress for the field. We provide a brief historical review of therapy development through the lens of the publications that arose from the close to quinquennial meetings that have been supported nearly since their inception by the Myasthenia Gravis Foundation of America and the New York Academy of Sciences. One can appreciate great advances, false starts, and dead ends that are found in all fields of medicine. We tally up the score card for MG and find points scored, but the win is not yet close.
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Affiliation(s)
- Henry J Kaminski
- Department of Neurology, GW-Medical Faculty Associates, George Washington University, Washington, DC
| | - Eman Alnosair
- Department of Neurology, GW-Medical Faculty Associates, George Washington University, Washington, DC
| | - Rami M Algahtani
- Department of Neurology, GW-Medical Faculty Associates, George Washington University, Washington, DC
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Gamez J, Salvado M, Casellas M, Manrique S, Castillo F. Intravenous immunoglobulin as monotherapy for myasthenia gravis during pregnancy. J Neurol Sci 2017; 383:118-122. [PMID: 29246598 DOI: 10.1016/j.jns.2017.10.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 10/04/2017] [Accepted: 10/24/2017] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Pregnant women with myasthenia gravis (MG) are at increased risk of complications and adverse outcomes, including the teratogenic effects of many drugs used to treat MG women of childbearing age. The effectiveness of intravenous immunoglobulins (IVIg) on other autoimmune mediated diseases has been extensively reported in recent years, although little is known about the role of IVIg in the treatment of MG during pregnancy. We designed this study to determine the effectiveness of IVIg as monotherapy during pregnancy for women with MG. MATERIAL AND METHODS Five pregnant MG patients (mean age at delivery 36.4years, SD 5.8, range 29.4-45.2) were studied in 2013-14. Their treatment was switched to monthly IVIg cycles 2months before the pregnancy. Follow-up included monthly neurological QMG throughout the pregnancy and postpartum, obstetrical monitoring during monthly visits in the first two trimesters of the pregnancy, fortnightly visits between week 32 and week 36, and weekly visits after 36weeks, and neonatal follow-up after delivery. RESULTS We observed no exacerbations during pregnancy, delivery or post-partum. The mean QMG score at baseline (before pregnancy) was 7.4 points in five women with generalized forms of MG. The maximum mean value reached during pregnancy was 8.6 points. The mean pregnancy duration was 38 w+5 d. No infant with transient neonatal myasthenia gravis. CONCLUSIONS These results suggest that monotherapy with IVIg during pregnancy in MG patients could be promising, although confirmation is required in studies with larger populations.
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Affiliation(s)
- Josep Gamez
- Myasthenia Gravis Unit, Neurology Department, Vall d'Hebron University Hospital, VHIR, European Reference Network on Rare Neuromuscular Diseases (ERN EURO-NMD), Department of Medicine, UAB, Barcelona, Spain.
| | - Maria Salvado
- Myasthenia Gravis Unit, Neurology Department, Vall d'Hebron University Hospital, VHIR, European Reference Network on Rare Neuromuscular Diseases (ERN EURO-NMD), Department of Medicine, UAB, Barcelona, Spain
| | - Manel Casellas
- Myasthenia Gravis Unit, Obstetrics Department, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Susana Manrique
- Myasthenia Gravis Unit, Anesthetics Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Felix Castillo
- Myasthenia Gravis Unit, Neonatology Department, Vall d'Hebron University Hospital, Barcelona, Spain
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Wang L, Zhang S, Xi J, Li W, Zhou L, Lu J, Lu J, Zhang T, Zhao C. Efficacy and safety of tacrolimus for myasthenia gravis: a systematic review and meta-analysis. J Neurol 2017; 264:2191-2200. [PMID: 28921038 DOI: 10.1007/s00415-017-8616-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 09/03/2017] [Accepted: 09/05/2017] [Indexed: 10/18/2022]
Abstract
To evaluate the efficacy and safety of tacrolimus in patients with myasthenia gravis (MG), a systematic review and meta-analysis was performed. We searched PubMed and Embase for randomized controlled trials and clinical controlled trials in English language. Demographic and clinical characteristics of the MG patients were extracted. Differences in the current glucocorticoids (GC) dose in each included study were the primary outcome measure. The adverse events reported in each included study were used as safety evaluation. There were 5 trials included involving 683 patients. In this systematic review, we identified treatment with tacrolimus did not exhibit a statistically significant difference in the GC dose reduction at 6 months and 12 months compared with placebo. The standard mean differences in the GC dose reduction were -1.95 [(-4.20 to 0.30); p = 0.09] at 6 months and -1.72 [(-4.21 to 0.77); p = 0.18] at 12 months. But GC dose reduction from baseline in the tacrolimus group exceeded that in the controlled group. The weighted mean differences were -1.34 [(-2.46 to 0.23); p = 0.02] in the quantitative myasthenia gravis score and -1.10 [(-1.84 to -0.36); p = 0.004] in the myasthenia gravis activities of daily living score at 6 months. Adverse events were recorded in 80 of 347 patients (23%) treated with tacrolimus and most of them were mild. This meta-analysis proves that tacrolimus therapy is beneficial to improve clinical symptoms in MG patients. Tacrolimus may be a worthy therapy to relieve MG symptoms.
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Affiliation(s)
- Liang Wang
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Suxian Zhang
- Department of Chinese Traditional Medicine, Jing'an District Centre Hospital of Shanghai, Shanghai, 200040, China
| | - Jianying Xi
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Wenhui Li
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, 200040, China
| | - Lei Zhou
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Jun Lu
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Jiahong Lu
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Tiansong Zhang
- Department of Chinese Traditional Medicine, Jing'an District Centre Hospital of Shanghai, Shanghai, 200040, China.
| | - Chongbo Zhao
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, 200040, China. .,Department of Neurology, Jing'an District Centre Hospital of Shanghai, Shanghai, 200040, China.
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Population pharmacokinetic analysis of tacrolimus in Chinese myasthenia gravis patients. Acta Pharmacol Sin 2017; 38:1195-1204. [PMID: 28552913 DOI: 10.1038/aps.2016.174] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 12/24/2016] [Indexed: 12/12/2022] Open
Abstract
The importance of tacrolimus in the treatment of myasthenia gravis (MG) as a substitute for corticosteroid-dependent immunosuppressive therapy is increasing. Thus far, however, no population pharmacokinetic (PopPK) analysis of tacrolimus in treating MG patients has been published. This article aimed to construct a PopPK model of tacrolimus for Chinese MG patients with the goal of improving its performance in MG treatment. A total of 253 trough concentration records were obtained from 83 Chinese MG patients. The effects of demographics, lifestyle and health status, biochemical test data, disease progression and treatment-related information (including co-administered medications) as covariates on the various parameters were investigated. The covariate selection was based on biological plausibility, clinical significance, statistical significance and reduction in inter-individual variability (IIV). Bootstrap and normalized prediction distribution error (NPDE) analysis were performed to validate the final model. A one-compartment PopPK model with first-order elimination and a fixed absorption phase was constructed. The estimated apparent oral clearance (CL/F) and apparent oral volume of distribution (V/F) were 3.6 L/h and 1700 L, respectively, in the MG patients. Hematocrit and blood urea nitrogen were identified as two covariates that significantly influenced the CL/F. Immunoglobulin treatment (PRO) also had the potential to influence V/F, which was consistent with the clinical observations and the high protein-binding property of tacrolimus. Other covariates including age, weight, gender and co-administered medications had no obvious influence on CL/F or V/F. The first PopPK model of tacrolimus in MG patients was established. The identified covariates were of biological plausibility and clinical importance to help individualize the dosing schedule in MG patients.
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Zhou L, Liu W, Li W, Li H, Zhang X, Shang H, Zhang X, Bu B, Deng H, Fang Q, Li J, Zhang H, Song Z, Ou C, Yan C, Liu T, Zhou H, Bao J, Lu J, Shi H, Zhao C. Tacrolimus in the treatment of myasthenia gravis in patients with an inadequate response to glucocorticoid therapy: randomized, double-blind, placebo-controlled study conducted in China. Ther Adv Neurol Disord 2017; 10:315-325. [PMID: 28861121 PMCID: PMC5557184 DOI: 10.1177/1756285617721092] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 05/19/2017] [Indexed: 02/05/2023] Open
Abstract
Background To determine the efficacy of low-dose, immediate-release tacrolimus in patients with myasthenia gravis (MG) with inadequate response to glucocorticoid therapy in a randomized, double-blind, placebo-controlled study. Methods Eligible patients had inadequate response to glucocorticoids (GCs) after ⩾6 weeks of treatment with prednisone ⩾0.75 mg/kg/day or 60–100 mg/day. Patients were randomized to receive 3 mg tacrolimus or placebo daily (orally) for 24 weeks. Concomitant glucocorticoids and pyridostigmine were allowed. Patients continued GC therapy from weeks 1–4; from week 5, the dose was decreased at the discretion of the investigator. The primary efficacy outcome measure was a reduction, relative to baseline, in quantitative myasthenia gravis (QMG) score assessed using a generalized linear model; supportive analyses used alternative models. Results Of 138 patients screened, 83 [tacrolimus (n = 45); placebo (n = 38)] were enrolled and treated. The change in adjusted mean QMG score from baseline to week 24 was −4.9 for tacrolimus and −3.3 for placebo (least squares mean difference: –1.7, 95% confidence interval: −3.5, −0.1; p = 0.067). A post-hoc analysis demonstrated a statistically significant difference for QMG score reduction of ⩾4 points in the tacrolimus group (68.2%) versus the placebo group (44.7%; p = 0.044). Adverse event profiles were similar between treatment groups. Conclusions Tacrolimus 3 mg treatment for patients with MG and inadequate response to GCs did not demonstrate a statistically significant improvement in the primary endpoint versus placebo over 24 weeks; however, a post-hoc analysis demonstrated a statistically significant difference for QMG score reduction of ⩾4 points in the tacrolimus group versus the placebo group. This study was limited by the low number of patients, the absence of testing for acetylcholine receptor antibody and the absence of stratification by disease duration (which led to a disparity between the two groups). ClinicalTrials.gov identifier: NCT01325571
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Affiliation(s)
- Lei Zhou
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Weibin Liu
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wei Li
- Department of Neurology, Qilu Hospital of Shandong University, Shandong, China
| | - Haifeng Li
- Department of Neurology, Qilu Hospital of Shandong University, Shandong, China
| | - Xu Zhang
- Department of Neurology, The Affiliated Hospital of Medical College Qingdao University, Qingdao, China
| | - Huifang Shang
- Department of Neurology, West China Hospital, Sichuan University, Sichuan, China
| | - Xu Zhang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Zhejiang, China
| | - Bitao Bu
- Department of Neurology, Tongji Hospital, Tongji Medical College of Huazhong University of Science & Technology, Wuhan, China
| | - Hui Deng
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Qi Fang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Jiangsu, China
| | - Jimei Li
- Department of Neurology, Beijing Friendship Hospital Affiliated to Capital University of Medical Sciences, Beijing, China
| | - Hua Zhang
- Department of Neurology, Beijing Hospital, Beijing, China
| | - Zhi Song
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Changyi Ou
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chuanzhu Yan
- Department of Neurology, Qilu Hospital of Shandong University, Shandong, China
| | - Tao Liu
- Department of Neurology, The Affiliated Hospital of Medical College Qingdao University, Qingdao, China
| | - Hongyu Zhou
- Department of Neurology, West China Hospital, Sichuan University, Sichuan, China
| | - Jianhong Bao
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Zhejiang, China
| | - Jiahong Lu
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Huawei Shi
- Astellas Pharma China, Inc., Beijing, China
| | - Chongbo Zhao
- Department of Neurology, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Rd, Shanghai, 200040, China
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Tao X, Wang W, Jing F, Wang Z, Chen Y, Wei D, Huang X. Long-term efficacy and side effects of low-dose tacrolimus for the treatment of Myasthenia Gravis. Neurol Sci 2016; 38:325-330. [DOI: 10.1007/s10072-016-2769-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 11/11/2016] [Indexed: 12/01/2022]
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Citirak G, Cejvanovic S, Andersen H, Vissing J. Effect of Gender, Disease Duration and Treatment on Muscle Strength in Myasthenia Gravis. PLoS One 2016; 11:e0164092. [PMID: 27741232 PMCID: PMC5065212 DOI: 10.1371/journal.pone.0164092] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 09/20/2016] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The aim of this observational, cross-sectional study was to quantify the potential presence of muscle weakness among patients with generalized myasthenia gravis (gMG). The influence of gender, treatment intensity and disease duration on muscle strength and disease progression was also assessed. METHODS Muscle strength was tested in 8 muscle groups by manual muscle testing and by hand-held dynamometry in 107 patients with gMG and 89 healthy age- and gender-matched controls. Disease duration, severity and treatment history were reviewed and compared with muscle strength. RESULTS Patients had reduced strength in all tested muscle group compared to control subjects (p<0.05). Women with gMG were stronger than men (decrease in strength 22.6% vs. 32.7% in men, P<0.05). Regional differences in muscle weakness were also evident, with proximal muscles being more affected. Interestingly, muscle strength did not correlate with disease duration and treatment intensity. CONCLUSIONS The results of this study show that in patients with gMG; 1) there is significant muscle weakness, 2) muscle weakness is more pronounced in men than women, 3) shoulder abductors, hip flexors, and neck muscles are the most affected muscle groups and 4) disease duration or treatment intensity alone are not predictors of loss of muscle strength in gMG.
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Affiliation(s)
- Gülsenay Citirak
- Neuromuscular Research Unit, Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Sanja Cejvanovic
- Neuromuscular Research Unit, Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Henning Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - John Vissing
- Neuromuscular Research Unit, Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- * E-mail:
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Maintenance immunosuppression in myasthenia gravis. J Neurol Sci 2016; 369:294-302. [DOI: 10.1016/j.jns.2016.08.057] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 07/20/2016] [Accepted: 08/26/2016] [Indexed: 11/17/2022]
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Gupta A, Goyal V, Srivastava AK, Shukla G, Behari M. Remission And relapse of myasthenia gravis on long-term azathioprine: An ambispective study. Muscle Nerve 2016; 54:405-12. [DOI: 10.1002/mus.25052] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 01/11/2016] [Accepted: 01/14/2016] [Indexed: 02/05/2023]
Affiliation(s)
- Anirban Gupta
- Department of Neurology, Cardiothoracic and Neurosciences Centre, Room 706; All India Institute of Medical Sciences; New Delhi 110029 India
| | - Vinay Goyal
- Department of Neurology, Cardiothoracic and Neurosciences Centre, Room 706; All India Institute of Medical Sciences; New Delhi 110029 India
| | - Achal Kumar Srivastava
- Department of Neurology, Cardiothoracic and Neurosciences Centre, Room 706; All India Institute of Medical Sciences; New Delhi 110029 India
| | - Garima Shukla
- Department of Neurology, Cardiothoracic and Neurosciences Centre, Room 706; All India Institute of Medical Sciences; New Delhi 110029 India
| | - Madhuri Behari
- Department of Neurology, Cardiothoracic and Neurosciences Centre, Room 706; All India Institute of Medical Sciences; New Delhi 110029 India
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Melzer N, Ruck T, Fuhr P, Gold R, Hohlfeld R, Marx A, Melms A, Tackenberg B, Schalke B, Schneider-Gold C, Zimprich F, Meuth SG, Wiendl H. Clinical features, pathogenesis, and treatment of myasthenia gravis: a supplement to the Guidelines of the German Neurological Society. J Neurol 2016; 263:1473-94. [PMID: 26886206 PMCID: PMC4971048 DOI: 10.1007/s00415-016-8045-z] [Citation(s) in RCA: 148] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Revised: 01/20/2016] [Accepted: 01/21/2016] [Indexed: 01/20/2023]
Abstract
Myasthenia gravis (MG) is an autoimmune antibody-mediated disorder of neuromuscular synaptic transmission. The clinical hallmark of MG consists of fluctuating fatigability and weakness affecting ocular, bulbar and (proximal) limb skeletal muscle groups. MG may either occur as an autoimmune disease with distinct immunogenetic characteristics or as a paraneoplastic syndrome associated with tumors of the thymus. Impairment of central thymic and peripheral self-tolerance mechanisms in both cases is thought to favor an autoimmune CD4(+) T cell-mediated B cell activation and synthesis of pathogenic high-affinity autoantibodies of either the IgG1 and 3 or IgG4 subclass. These autoantibodies bind to the nicotinic acetylcholine receptor (AchR) itself, or muscle-specific tyrosine-kinase (MuSK), lipoprotein receptor-related protein 4 (LRP4) and agrin involved in clustering of AchRs within the postsynaptic membrane and structural maintenance of the neuromuscular synapse. This results in disturbance of neuromuscular transmission and thus clinical manifestation of the disease. Emphasizing evidence from clinical trials, we provide an updated overview on immunopathogenesis, and derived current and future treatment strategies for MG divided into: (a) symptomatic treatments facilitating neuromuscular transmission, (b) antibody-depleting treatments, and
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Affiliation(s)
- Nico Melzer
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Tobias Ruck
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Peter Fuhr
- Department of Neurology, University of Basel, Basel, Switzerland
| | - Ralf Gold
- Department of Neurology, University of Bochum, Bochum, Germany
| | - Reinhard Hohlfeld
- Institute of Clinical Neuroimmunology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Alexander Marx
- Institute of Pathology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Arthur Melms
- Department of Neurology, University of Erlangen, Erlangen, Germany
| | - Björn Tackenberg
- Department of Neurology, University of Marburg, Marburg, Germany
| | - Berthold Schalke
- Department of Neurology, University of Regensburg, Regensburg, Germany
| | | | - Fritz Zimprich
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Sven G. Meuth
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Heinz Wiendl
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
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Park KH, Jung J, Lee JH, Hong YH. Blood Transcriptome Profiling in Myasthenia Gravis Patients to Assess Disease Activity: A Pilot RNA-seq Study. Exp Neurobiol 2016; 25:40-7. [PMID: 26924932 PMCID: PMC4766113 DOI: 10.5607/en.2016.25.1.40] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 02/05/2016] [Accepted: 02/05/2016] [Indexed: 01/08/2023] Open
Abstract
Myasthenia gravis (MG) is an antibody-mediated autoimmune disease characterized by exertional weakness. There is no biomarker to reflect disease activity and guide treatment decision. Here, we reported a pilot blood transcriptome study using RNA sequencing (RNA-seq) that identified differences of 5 samples in active status and 5 in remission from 8 different patients and 2 patients provided samples for both active and remission phase. We found a total of 28 differentially expressed genes (DEGs) possibly related to disease activity (23 up-regulated and 5 down-regulated). The DEGs were enriched for the cell motion and cell migration processes in which included were ICAM1, CCL3, S100P and GAB2. The apoptosis and cell death pathway was also significantly enriched, which includes NFKBIA, ZC3H12A, TNFAIP3, and PPP1R15A. Our result suggests that transcript abundance profiles of the genes involved in cell trafficking and apoptosis may be a molecular signature of the disease activity in MG patients.
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Affiliation(s)
- Kee Hong Park
- Department of Neurology, Gyeongsang National University Hospital, Jinju 52727, Korea
| | - Junghee Jung
- Department of Bioinformatics, Macrogen Inc., Seoul 08511, Korea
| | - Jung-Hee Lee
- Department of Biomedical Science, Hallym University, Chuncheon 24252, Korea
| | - Yoon-Ho Hong
- Department of Neurology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul 07061, Korea
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Hu MY, Stathopoulos P, O'connor KC, Pittock SJ, Nowak RJ. Current and future immunotherapy targets in autoimmune neurology. HANDBOOK OF CLINICAL NEUROLOGY 2016; 133:511-36. [PMID: 27112694 DOI: 10.1016/b978-0-444-63432-0.00027-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Randomized controlled treatment trials of autoimmune neurologic disorders are generally lacking and data pertaining to treatment are mostly derived from expert opinion, large case series, and anecdotal reports. The treatment of autoimmune neurologic disorders comprises oncologic therapy (where appropriate) and immunotherapy. In this chapter, we first describe the standard acute and chronic immunotherapies and provide a practical overview of their use in the clinic (mechanisms of action, dosing, monitoring, and side effects). Novel approaches to treatment of autoimmune neurologic disorders, through new drug discovery or repurposing, are dependent on improved mechanistic understanding of immunopathology. Such approaches, with emphasis on monoclonal antibodies, are discussed using the paradigm of three autoimmune neurologic disorders whose immunopathogenesis is better understood, specifically myasthenia gravis, neuromyelitis optica, and chronic inflammatory demyelinating polyradiculoneuropathy. It is important to realize that the treatment strategy and management plan must be individualized for each patient. In general these are influenced by the following: clinical severity, antibody type, presence or absence of cancer, and prior treatment response, if known.
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Affiliation(s)
- Melody Y Hu
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | | | - Kevin C O'connor
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA.
| | - Sean J Pittock
- Departments of Laboratory Medicine/Pathology and Neurology, Mayo Clinic, College of Medicine, Rochester, MN, USA
| | - Richard J Nowak
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
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Cruz JL, Wolff ML, Vanderman AJ, Brown JN. The emerging role of tacrolimus in myasthenia gravis. Ther Adv Neurol Disord 2015; 8:92-103. [PMID: 25922621 DOI: 10.1177/1756285615571873] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To describe and evaluate the available evidence assessing the role of tacrolimus in the management of patients with myasthenia gravis (MG). DATA SOURCES A literature search of MEDLINE (1946 to September 2014) and EMBASE (1947 to September 2014) was performed using the terms 'tacrolimus' and 'myasthenia gravis'. Citations of retrieved articles were examined for relevance. STUDY SELECTION AND DATA EXTRACTION The search was limited to prospective clinical trials focused on clinical outcomes in patients with generalized MG. Case reports, retrospective evaluations and non-English articles were excluded. DATA SYNTHESIS A total of 12 studies met inclusion criteria, of which seven articles evaluated tacrolimus in steroid-dependent patients and two examined the utility of tacrolimus in patients failing corticosteroids and cyclosporine. Other studies evaluated early initiation of tacrolimus after thymectomy, effectiveness of tacrolimus in de novo MG and the effectiveness of tacrolimus post-thymectomy in thymoma patients versus nonthymoma. A total of eight trials showed statistically significant improvements in quantitative MG score (QMGS) and postintervention status criteria - Myasthenia Gravis Foundation of America (PSC-MGFA). Of the trials examining steroid reduction with tacrolimus, two reported high rates of complete withdrawal; however, the most robust trial was unable to detect a difference in mean steroid dose. Long-term effects of tacrolimus (up to 5 years) were assessed in eight trials, which consistently showed positive effects on QMGS or reduction in adjunct therapies. CONCLUSIONS There is limited yet promising information to suggest a beneficial role for tacrolimus in reducing QMGS and corticosteroid burden in patients with refractory symptoms or new-onset MG. Long-term use appears to be safe in this population.
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Affiliation(s)
- Jennifer L Cruz
- Drug Information, Geriatric Research and Education Clinical Center, Durham VA Medical Center, 508 Fulton Street (119), Durham, NC 27705, USA
| | - Marissa L Wolff
- Geriatrics, Geriatric Research and Education Clinical Center, Durham VA Medical Center, Durham, NC, USA
| | - Adam J Vanderman
- Geriatrics, Geriatric Research and Education Clinical Center, Durham VA Medical Center, Durham, NC, USA
| | - Jamie N Brown
- Pharmacy Service, Durham VA Medical Center, Durham, NC, USA
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Kadota Y, Horio H, Mori T, Sawabata N, Goto T, Yamashita SI, Nagayasu T, Iwasaki A. Perioperative management in myasthenia gravis: republication of a systematic review and a proposal by the guideline committee of the Japanese Association for Chest Surgery 2014. Gen Thorac Cardiovasc Surg 2015; 63:201-15. [PMID: 25608954 DOI: 10.1007/s11748-015-0518-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Indexed: 01/21/2023]
Abstract
Thymectomy is regarded as a useful therapeutic option for myasthenia gravis (MG), though perioperative management in MG patients is largely empirical. While evidence-based medicine is limited in the perioperative management of MG patients, treatment guidelines are required as a benchmark. We selected issues faced by physicians in clinical practice in the perioperative management of extended thymectomy for MG, and examined them with a review of the literature. The present guidelines have reached the stage of consensus within the Japanese Association for Chest Surgery.
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Affiliation(s)
- Yoshihisa Kadota
- Guidelines Committees of Japanese Association for Chest Surgery, Kyoto, Japan,
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Mitsui T, Kuroda Y, Ueno SI, Matsui N, Kaji R. FK506 attenuates thymic output in patients with myasthenia gravis. Arch Med Sci 2013; 9:1090-6. [PMID: 24482655 PMCID: PMC3902727 DOI: 10.5114/aoms.2013.39797] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Revised: 04/21/2011] [Accepted: 05/11/2011] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Myasthenia gravis (MG) is an antibody-mediated, T-cell-dependent autoimmune disease. The symptoms are caused by high-affinity IgG against the muscle acetylcholine receptor (AChR) at the neuromuscular junction. The production of these antibodies in B-cells depends on AChR-specific CD4(+) T-cells and the thymus gland seems to play a significant role in the pathogenesis of MG. Altered thymic T-cell export seems to be associated with a pathological mechanism in myasthenia gravis. Tacrolimus (FK506) has recently been used to treat MG. MATERIAL AND METHODS We examined the effects of tacrolimus on thymic T-cell export in patients with MG. Sixteen patients with nonthymomatous and/or thymectomized MG were treated with oral administrations of tacrolimus. To assess the effect of tacrolimus on the thymic output, we assayed the levels of T-cell receptor excision circle (TREC), a molecular marker of thymus emigrants. RESULTS T-cell receptor excision circle was not significantly different from those in age-matched controls before tacrolimus therapy, but they were partially decreased 4 months after tacrolimus therapy. T-cell receptor excision circle levels were significantly decreased in the thymomatous group (p < 0.05), but not in the nonthymomatous group. Tacrolimus treatment significantly attenuated TREC levels in cultured CD4(-)CD8(+) cells (p < 0.05), but total cell counts were not significantly changed. CONCLUSIONS These results indicate that TREC levels may become a marker of the curative effect of tacrolimus therapy for thymomatous MG, and that tacrolimus suppresses not only activating T-lymphocytes, but also naïve T-cells.
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Affiliation(s)
- Takao Mitsui
- Tokushima National Hospital, National Hospital Organization, Tokushima, Japan
- Department of Clinical Neuroscience, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Yukiko Kuroda
- Tokushima National Hospital, National Hospital Organization, Tokushima, Japan
- Department of Clinical Neuroscience, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Shu-ichi Ueno
- Department of Psychiatry, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Naoko Matsui
- Department of Clinical Neuroscience, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Ryuji Kaji
- Department of Clinical Neuroscience, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan
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Alkhawajah NM, Oger J. Late-onset myasthenia gravis: A review when incidence in older adults keeps increasing. Muscle Nerve 2013; 48:705-10. [DOI: 10.1002/mus.23964] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2013] [Indexed: 01/26/2023]
Affiliation(s)
- Nuha M. Alkhawajah
- Division of Neurology, Department of Medicine and Brain Research Centre, UBC Hospital; University of British Columbia; 2211 Westbrook Mall Vancouver British Columbia V6T 2B5 Canada
| | - Joel Oger
- Division of Neurology, Department of Medicine and Brain Research Centre, UBC Hospital; University of British Columbia; 2211 Westbrook Mall Vancouver British Columbia V6T 2B5 Canada
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Mori T, Mori K, Suzue M, Ito H, Kagami S. Effective treatment of a 13-year-old boy with steroid-dependent ocular myasthenia gravis using tacrolimus. Brain Dev 2013; 35:445-8. [PMID: 22840813 DOI: 10.1016/j.braindev.2012.06.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Revised: 06/17/2012] [Accepted: 06/29/2012] [Indexed: 10/28/2022]
Abstract
Over the past several years, tacrolimus has attracted attention as a new therapeutic drug for myasthenia gravis (MG), but few reports have considered its use for MG in pediatric patients, and most of these have focused on severe systemic MG. In this case report, we used tacrolimus to successfully treat a 13-year-old boy with ocular MG who had suffered from severe steroid complications, including a failure of thrive and osteoporosis. He first showed symptoms of ocular MG at age 2 years 3 months. At age 13 years, he was receiving PSL (3.75 mg/day), but the symptoms of ocular MG recurred. We increased the dosage of oral PSL up to 30 mg/day, and three courses of mPSL pulse therapy were applied, but these therapies had only limited effect, and his symptoms worsened. Tacrolimus was started at 0.4 mg/day (0.011 mg/kg/day), and every 2 weeks the dose was gradually increased by 0.2 mg/day. His symptoms of MG began to improve 3 weeks after the initial administration of tacrolimus. Approximately 3 months after the start of tacrolimus administration, PSL was discontinued. Currently, at 1 year and 4 months after the start of tacrolimus administration, while slight ptosis is observed in the evening, it does not influence his daily life, and his condition remains comparable to that when he stopped taking PSL. No adverse effects of tacrolimus have been recognized. In pediatric patients with steroid-dependent ocular MG without thymectomy, tacrolimus may be a safe and effective alternative to steroid and thymectomy.
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Affiliation(s)
- Tatsuo Mori
- Department of Pediatrics, Institute of Health Bioscience, The University of Tokushima Graduate School, Tokushima, Japan.
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van Sonderen A, Wirtz PW, Verschuuren JJGM, Titulaer MJ. Paraneoplastic syndromes of the neuromuscular junction: therapeutic options in myasthenia gravis, lambert-eaton myasthenic syndrome, and neuromyotonia. Curr Treat Options Neurol 2013; 15:224-39. [PMID: 23263888 DOI: 10.1007/s11940-012-0213-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OPINION STATEMENT Myasthenia gravis (MG), Lambert-Eaton myasthenic syndrome (LEMS) and neuromyotonia are neuromuscular transmission disorders occurring with or without associated malignancy. Due to the common antibody-mediated pathophysiology, immunosuppression has an important role in the treatment of each of these disorders. Symptomatic treatment is more variable. Pyridostigmine is first-line treatment in generalized MG. Response seems to be better in patients with acetylcholine receptor (AChR) antibodies than in patients with antibodies against muscle-specific tyrosine kinase (MuSK). Pyridostigmine can be sufficient in mild MG, although most patients need additional immunosuppressive therapy. If so, prednisolone is efficient in the majority of the patients, with a relatively early onset of clinical effect. High drug dosage and treatment duration should be limited as much as possible because of serious corticosteroid-related side effects. As long-term treatment is needed in most patients for sustainable remission, adding non-steroid immunosuppressive drugs should be considered. Their therapeutic response is usually delayed and often takes a period of several months. In the meantime, corticosteroids are continued and doses are tapered down over a period of several months. There are no trials comparing different immunosuppressive drugs. Choice is mainly based on the clinician's familiarity with certain drugs and their side effects, combined with patients' characteristics. Most commonly used is azathioprine. Alternatively, tacrolimus, cyclosporine A, mycophenolate mofetil or rituximab can be used. The use of cyclophosphamide is limited to refractory cases, due to serious side effects. Plasma exchange and intravenous immunoglobulin induce rapid but temporary improvement, and are reserved for severe disease exacerbations because of high costs of treatment. It is recommended that computed tomography (CT) of the thorax is performed in every AChR-positive MG patient, and that patients are referred for thymectomy in case of thymoma. In patients without thymoma, thymectomy can be considered as well, especially in younger, AChR-positive patients with severe disease. However, definite proof of benefit is lacking and an international randomized trial to clarify this topic is currently ongoing. When LEMS is suspected, always search for malignancy, especially small cell lung carcinoma with continued screening up to two years. In paraneoplastic LEMS, cancer treatment usually results in clinical improvement of the myasthenic symptoms. 3,4-Diaminopyridine is first-line symptomatic treatment in LEMS. It is usually well tolerated and effective. When immunosuppressive therapy is needed, the same considerations apply to LEMS as described for MG. Peripheral nerve hyperexcitability in neuromyotonia can be treated with anticonvulsant drugs such as phenytoin, valproic acid or carbamazepine. When response in insufficient, start prednisolone in mild disease and consider the addition of azathioprine. Plasma exchange or intravenous immunoglobulin is indicated in severe neuromyotonia and in patients with neuromyotonia combined with central nervous system symptoms, a clinical picture known as Morvan's syndrome.
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Abstract
Juvenile myasthenia gravis is an uncommon autoimmune disorder. Its management is not standardized. Juvenile myasthenia gravis is pathophysiologically similar to myasthenia gravis in adults. However, a number of significant particularities related to race, age at onset, severity, and antibody status complicate the management. We summarize the unique clinical features of juvenile myasthenia gravis and review the therapeutic options.
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Affiliation(s)
- Cristian M Ionita
- Connecticut Children's Medical Center, Department of Pediatrics, and Division of Pediatric Neurology, Department of Neurology, University of Connecticut School of Medicine, Hartford, CT 06106, USA.
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Yagi Y, Sanjo N, Yokota T, Mizusawa H. Tacrolimus Monotherapy: A Promising Option for Ocular Myasthenia Gravis. Eur Neurol 2013; 69:344-5. [DOI: 10.1159/000347068] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 01/13/2013] [Indexed: 11/19/2022]
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Kraker J, Zivković SA. Autoimmune neuromuscular disorders. Curr Neuropharmacol 2012; 9:400-8. [PMID: 22379454 PMCID: PMC3151594 DOI: 10.2174/157015911796558000] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2009] [Revised: 03/27/2010] [Accepted: 03/27/2010] [Indexed: 12/25/2022] Open
Abstract
Autoimmune neuromuscular disorders affecting peripheral nerves, neuromuscular junction or muscle have a wide clinical spectrum with diverse pathogenetic mechanisms. Peripheral nervous system may be targeted in the context of complex immune reactions involving different cytokines, antigen-presenting cells, B cells and different types of T cells. Various immunomodulating and cytotoxic treatments block proliferation or activation of immune cells by different mechanisms attempting to control the response of the immune system and limit target organ injury. Most treatment protocols for autoimmune neuromuscular disorders are based on the use of corticosteroids, intravenous immunoglobulins and plasmapheresis, with cytotoxic agents mostly used as steroid-sparing medications. More recently, development of specific monoclonal antibodies targeting individual cell types allowed a different approach targeting specific immune pathways, but these new treatments are also associated with various adverse effects and their long-term efficacy is still unknown.
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Affiliation(s)
- Jessica Kraker
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Dentistry and the myasthenia gravis patient: a review of the current state of the art. Oral Surg Oral Med Oral Pathol Oral Radiol 2012; 114:e1-8. [PMID: 22732850 DOI: 10.1016/j.tripleo.2011.08.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Revised: 08/12/2011] [Accepted: 08/17/2011] [Indexed: 11/21/2022]
Abstract
Myasthenia gravis (MG) is a chronic neuromuscular disease characterized by muscular weakness and fatigability. Dental management of patients diagnosed with MG presents a challenge to the oral health care provider. The purpose of this article was to review the etiology, pathogenesis, diagnosis, and clinical signs and symptoms associated with MG, highlighting the role of the oral health care provider in the process of diagnosis and management of the oral and dental complications that might be associated with the disease, while avoiding myasthenic crisis. A discussion of the recent approaches to treatment of the disease and current research on MG is presented.
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Abstract
Therapy for autoimmune demyelinating disorders has evolved rapidly over the past 10 years to include traditional immunosuppressants as well as novel biologicals. Antibody-mediated neuromuscular disorders are treated with therapies that acutely modulate pathogenic antibodies or chronically inhibit the humoral immune response. In other inflammatory autoimmune disorders of the peripheral and central nervous system, corticosteroids, often combined with conventional immunosuppression, and immunomodulatory treatments are used. Because autoimmune neurologic disorders are so diverse, evidence from randomized controlled trials is limited for most of the immunotherapies used in neurology. This review provides an overview of the immunotherapies currently used for neurologic disorders.
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Affiliation(s)
- Donna Graves
- Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9036, USA
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Kim JY, Park KD, Richman DP. Treatment of myasthenia gravis based on its immunopathogenesis. J Clin Neurol 2011; 7:173-83. [PMID: 22259613 PMCID: PMC3259491 DOI: 10.3988/jcn.2011.7.4.173] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Revised: 04/25/2011] [Accepted: 04/25/2011] [Indexed: 12/21/2022] Open
Abstract
The prognosis of myasthenia gravis (MG) has improved dramatically due to advances in critical-care medicine and symptomatic treatments. Its immunopathogenesis is fundamentally a T-cell-dependent autoimmune process resulting from loss of tolerance toward self-antigens in the thymus. Thymectomy is based on this immunological background. For MG patients who are inadequately controlled with sufficient symptomatic treatment or fail to achieve remission after thymectomy, remission is usually achieved through the addition of other immunotherapies. These immunotherapies can be classified into two groups: rapid induction and long-term maintenance. Rapid induction therapy includes intravenous immunoglobulin (IVIg) and plasma exchange (PE). These produce improvement within a few days after initiation, and so are useful for acute exacerbation including myasthenic crisis or in the perioperative period. High-dose prednisone has been more universally preferred for remission induction, but it acts more slowly than IVIg and PE, commonly only after a delay of several weeks. Slow tapering of steroids after a high-dose pulse offers a method of maintaining the state of remission. However, because of significant side effects, other immunosuppressants (ISs) are frequently added as "steroid-sparing agents". The currently available ISs exert their immunosuppressive effects by three mechanisms: 1) blocking the synthesis of DNA and RNA, 2) inhibiting T-cell activation and 3) depleting the B-cell population. In addition, newer drugs including antisense molecule, tumor necrosis factor alpha receptor blocker and complement inhibitors are currently under investigation to confirm their effectiveness. Until now, the treatment of MG has been based primarily on experience rather than gold-standard evidence from randomized controlled trials. It is hoped that well-organized studies and newer experimental trials will lead to improved treatments.
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Affiliation(s)
- Jee Young Kim
- Department of Neurology, Kwandong University College of Medicine, Myongji Hospital, Goyang, Korea
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Abstract
OPINION STATEMENT Autoimmune neuromuscular disorders in childhood include Guillain-Barré syndrome and its variants, chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), juvenile myasthenia gravis (JMG), and juvenile dermatomyositis (JDM), along with other disorders rarely seen in childhood. In general, these diseases have not been studied as extensively as they have been in adults. Thus, treatment protocols for these diseases in pediatrics are often based on adult practice, but despite the similarities in disease processes, the most widely used treatments have different effects in children. For example, some of the side effects of chronic steroid use, including linear growth deceleration, bone demineralization, and chronic weight issues, are more consequential in children than in adults. Although steroids remain a cornerstone of therapy in JDM and are useful in many cases of CIDP and JMG, other immunomodulatory therapies with similar efficacy may be used more frequently in some children to avoid these long-term sequelae. Steroids are less expensive than most other therapies, but chronic steroid therapy in childhood may lead to significant and costly medical complications. Another example is plasma exchange. This treatment modality presents challenges in pediatrics, as younger children require central venous access for this therapy. However, in older children and adolescents, plasma exchange is often feasible via peripheral venous access, making this treatment more accessible than might be expected in this age group. Intravenous immunoglobulin also is beneficial in several of these disorders, but its high cost may present barriers to its use in the future. Newer steroid-sparing immunomodulatory agents, such as azathioprine, tacrolimus, mycophenolate mofetil, and rituximab, have not been studied extensively in children. They show promising results from case reports and retrospective cohort studies, but there is a need for comparative studies looking at their relative efficacy, tolerability, and long-term adverse effects (including secondary malignancy) in children.
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Affiliation(s)
- Hugh J. McMillan
- Division of Neurology, Children’s Hospital of Eastern Ontario, Ottawa, Ontario Canada
| | - Basil T. Darras
- Department of Neurology, Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Peter B. Kang
- Department of Neurology, Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115 USA
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Finnis MF, Jayawant S. Juvenile myasthenia gravis: a paediatric perspective. Autoimmune Dis 2011; 2011:404101. [PMID: 22110902 PMCID: PMC3206364 DOI: 10.4061/2011/404101] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 08/10/2011] [Indexed: 11/25/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disease in which antibodies are directed against the postsynaptic membrane of the neuromuscular junction, resulting in muscle weakness and fatigability. Juvenile myasthenia gravis (JMG) is a rare condition of childhood and has many clinical features that are distinct from adult MG. Prepubertal children in particular have a higher prevalence of isolated ocular symptoms, lower frequency of acetylcholine receptor antibodies, and a higher probability of achieving remission. Diagnosis in young children can be complicated by the need to differentiate from congenital myasthenic syndromes, which do not have an autoimmune basis. Treatment commonly includes anticholinesterases, corticosteroids with or without steroid-sparing agents, and newer immune modulating agents. Plasma exchange and intravenous immunoglobulin (IVIG) are effective in preparation for surgery and in treatment of myasthenic crisis. Thymectomy increases remission rates. Diagnosis and management of children with JMG should take account of their developmental needs, natural history of the condition, and side-effect profiles of treatment options.
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Affiliation(s)
- Maria F Finnis
- Department of Paediatric Neurology, Children's Hospital, John Radcliffe Hospital, Oxford OX3 9DU, UK
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Abstract
Myasthenia gravis is an autoimmune neuromuscular disorder. There are several treatment options, including symptomatic treatment (acetylcholinesterase inhibitors), short-term immunosuppression (corticosteroids), long-term immunosuppression (azathioprine, cyclosporine, cyclophosphamide, methotrexate, mycophenolate mofetil, rituximab, tacrolimus), rapid acting short-term immunomodulation (intravenous immunoglobulin, plasma exchange), and long-term immunomodulation (thymectomy). This review explores in detail these different treatment options. Potential future treatments are also discussed.
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Abstract
OPINION STATEMENT Treatment of patients with acquired (autoimmune) myasthenia gravis should rely on evidence-based therapeutic choices, taking into account the individual's needs according to disease severity (mild to severe), extent (ocular or generalized), comorbidities (including other autoimmune diseases, infections, thymoma, and pregnancy), age, iatrogenic factors (the risks and benefits of therapy), patient autonomy and quality of life, financial burden to the patient, and associated health care costs. Therapy is aimed at managing symptoms by improving neuromuscular junction transmission (cholinesterase inhibitors) and/or modifying the underlying immunopathogenetic cause of acquired myasthenia gravis via immunosuppression or immunomodulation. Myasthenic patients with operable thymoma should be referred for surgery and closely followed up for tumor recurrence. A concerted international effort is addressing treatment recommendations for thymectomy in myasthenic patients with no radiologic evidence of thymoma who are positive for circulating acetylcholine receptor antibodies. There is a lack of evidence-based treatment guidelines for both acute and long-term management of ocular myasthenia. Acute management of myasthenic crisis requires intensive monitoring of the patient and institution of an efficient and safe treatment such as plasma exchange. Patient education is essential to a comprehensive long-term treatment plan.
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Khorzad R, Whelan M, Sisson A, Shelton GD. Myasthenia gravis in dogs with an emphasis on treatment and critical care management. J Vet Emerg Crit Care (San Antonio) 2011; 21:193-208. [PMID: 21631705 DOI: 10.1111/j.1476-4431.2011.00636.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To review the human and veterinary literature on the pathophysiology of myasthenia gravis (MG) and describe treatment options for clinical use in people and animals. DATA SOURCES Human and veterinary clinical reports, studies and reviews, textbooks, and recent research findings in MG from 1996 present, with a focus on treatment and patient management. HUMAN DATA SYNTHESIS MG is a well-described condition in people with new research and treatment options available. Many of the newest therapeutic options available in veterinary medicine for MG are based on current strategies used in people with this condition. Seronegative MG is well described in people and provides insight to clinical cases encountered in veterinary medicine when the index of suspicion is high though serologic tests are negative. VETERINARY DATA SYNTHESIS Previous studies in veterinary medicine focused on the use of acetylcholinesterase inhibitors as the main form of treatment in canine MG. Recent studies, mainly case series and case reports, emphasize the use of immunomodulatory treatments as an alternative for long-term treatment. However, there are no randomized, controlled studies on treatment with immunomodulatory therapy for MG in dogs available to assess the efficacy of this treatment strategy. CONCLUSIONS Although early recognition of clinical signs is most important in the outcome of patients with MG, further understanding the pathophysiology of MG may lead to earlier diagnosis and novel treatment strategies. The discovery of additional autoantibodies against striated muscle proteins in dogs, should enhance our understanding of diseases affecting the neuromuscular junction. In addition, clinical data for canine MG could be applied to other autoimmune disorders.
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Affiliation(s)
- Roxanna Khorzad
- Department of Emergency and Critical Care, Angell Animal Medical Center, Boston, MA 02130, USA
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Suitability of chemiluminescent enzyme immunoassay for the measurement of blood tacrolimus concentrations in rheumatoid arthritis. Clin Biochem 2011; 44:397-402. [DOI: 10.1016/j.clinbiochem.2010.12.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Revised: 12/16/2010] [Accepted: 12/27/2010] [Indexed: 01/19/2023]
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