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Kimura A. [Clinical features and pathogenesis of Glial fibrillary acidic protein (GFAP) antibody-associated disorders]. Rinsho Shinkeigaku 2024; 64:75-84. [PMID: 38281748 DOI: 10.5692/clinicalneurol.cn-001925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
Glial fibrillary acidic protein (GFAP) antibody-associated disorders (AD) were recently proposed to be immune-mediated neurological disorders. The pathogenesis of GFAP antibody-AD is poorly understood. Pathologically, there is a marked infiltration of large numbers of lymphocytes, including CD8+ and CD4+ T cells, into the meningeal and brain parenchyma, especially around the perivascular areas. GFAP-specific cytotoxic T cells are considered to be the effector cells of GFAP antibody-AD. The common phenotype of GFAP antibody-AD includes meningoencephalitis with or without myelitis. During the clinical disease course, patients present with consciousness disturbances, urinary dysfunction, movement disorders, meningeal irritation, and cognitive dysfunction. The detection of GFAP antibodies in the cerebrospinal fluid (CSF) by cell-based assay is essential for a diagnosis of GFAP antibody-AD. The CSF can be examined for lymphocyte-predominant pleocytosis and elevated protein levels. Brain linear perivascular radial enhancement patterns are observed in about half of GFAP antibody-AD patients. Spinal cord magnetic resonance imaging is used to detect longitudinal extensive spinal cord lesions. Although corticosteroid therapy is generally effective, some patients have a poor prognosis and relapse.
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Affiliation(s)
- Akio Kimura
- Department of Neurology, Gifu University Graduate School of Medicine
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Liu Q, Yang X, Zhang Bao J, Ma B, Niu X, Wang X, Zhang Q, Quan C. Clinical characteristics of patient with GFAP-IgG: a review of 31 patients from two tertiary referral centers in China. Int J Neurosci 2023:1-12. [PMID: 37897492 DOI: 10.1080/00207454.2023.2277664] [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: 07/26/2023] [Accepted: 10/26/2023] [Indexed: 10/30/2023]
Abstract
OBJECTIVE This study presents a comprehensive analysis of the clinical characteristics of 31 patients exhibiting cerebrospinal fluid (CSF) and/or serum positivity for GFAP-IgG, with a specific emphasis on 24 cases demonstrating only GFAP-IgG positivity. The investigation thoroughly evaluates their clinical, radiological, and laboratory features, as well as treatment responses, with the objective of offering clinicians potential diagnostic and therapeutic approaches. METHODS A total of 31 patients with GFAP-IgG in the CSF and/or serum were registered between August 2016 and August 2021 at the General Hospital of Ningxia Medical University and Huashan Hospital of Fudan University. We retrospectively reviewed their clinical records. RESULTS Overall, the patients were positive with GFAP-IgG in their CSF (15/31), in serum (6/31), and both CSF and serum (10/31). Among them, two were eventually diagnosed with astroglioma and primary central nervous system lymphoma, respectively; one patient had typical multiple sclerosis; three exhibited overlapping GFAP-IgG and aquaporin-4-IgG (AQP4-IgG); and one patient was coexisting N-methyl-D-aspartate receptor IgG. The remaining 24 patients were only GFAP-IgG positive. In total, 22 out of the 24 patients had abnormal MRI outcomes, involving the brain, meninges, and spinal cord. Besides, seven of the 24 patients developed optic neuritis. The CSF protein levels positively correlated with the Expanded Disability Status Scale score (EDSSs). Significantly decreased EDSSs, modified Rankin Scale score, GFAP-IgG titer, CSF protein level, and CSF white blood cell counts were observed after immunomodulatory therapy. CONCLUSION The clinical manifestations of GFAP-IgG exhibit a wide range of phenotypes that lack specificity. These findings emphasize the significance of not exclusively relying on the presence of antibodies to diagnose GFAP-A, but rather integrating them with the clinical phenotypes. GFAP-IgG testing enables the diagnosis of autoimmune GFAP astrocytopathy, a treatable autoimmune disease affecting the central nervous system. This condition provides opportunities for investigating innovative mechanisms of CNS autoimmunity and inflammation.
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Affiliation(s)
- Qiang Liu
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Diseases, Incubation Base of National Key Laboratory, Yinchuan, Ningxia Province, China
| | - Xiao Yang
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Diseases, Incubation Base of National Key Laboratory, Yinchuan, Ningxia Province, China
| | - Jingzi Zhang Bao
- Department of Neurology and Rare Disease Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders (NCND), Shanghai, China
| | - Boya Ma
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Diseases, Incubation Base of National Key Laboratory, Yinchuan, Ningxia Province, China
| | - Xiaoyan Niu
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Diseases, Incubation Base of National Key Laboratory, Yinchuan, Ningxia Province, China
| | - Xu Wang
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Diseases, Incubation Base of National Key Laboratory, Yinchuan, Ningxia Province, China
| | - Qing Zhang
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Diseases, Incubation Base of National Key Laboratory, Yinchuan, Ningxia Province, China
| | - Chao Quan
- Department of Neurology and Rare Disease Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders (NCND), Shanghai, China
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Eide PK, Hansson HA. A New Perspective on the Pathophysiology of Idiopathic Intracranial Hypertension: Role of the Glia-Neuro-Vascular Interface. Front Mol Neurosci 2022; 15:900057. [PMID: 35903170 PMCID: PMC9315230 DOI: 10.3389/fnmol.2022.900057] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 06/07/2022] [Indexed: 11/13/2022] Open
Abstract
Idiopathic intracranial hypertension (IIH) is a neurological disease characterized by symptoms and signs of increased intracranial pressure (ICP) of unknown cause. Most attention has been given to the role of cerebrospinal fluid (CSF) disturbance and intracranial venous hypertension caused by sinus vein stenosis. We previously proposed that key pathophysiological processes take place within the brain at the glia-neuro-vascular interface. However, the relative importance of the proposed mechanisms in IIH disease remains unknown. Modern treatment regimens aim to reduce intracranial CSF and venous pressures, but a substantial proportion of patients experience lasting complaints. In 2010, the first author established a database for the prospective collection of information from individuals being assessed for IIH. The database incorporates clinical, imaging, physiological, and biological data, and information about treatment/outcome. This study retrieved information from the database, asking the following research questions: In IIH subjects responding to shunt surgery, what is the occurrence of signs of CSF disturbance, sinus vein stenosis, intracranial hypertension, and microscopic evidence of structural abnormalities at the glia-neuro-vascular interface? Secondarily, do semi-quantitative measures of abnormal ultrastructure at the glia-neurovascular differ between subjects with definite IIH and non-IIH (reference) subjects? The study included 13 patients with IIH who fulfilled the diagnostic criteria and who improved following shunt surgery, i.e., patients with definite IIH. Comparisons were done regarding magnetic resonance imaging (MRI) findings, pulsatile and static ICP scores, and immune-histochemistry microscopy. Among these 13 IIH subjects, 6/13 (46%) of patients presented with magnetic resonance imaging (MRI) signs of CSF disturbance (empty sella and/or distended perioptic subarachnoid spaces), 0/13 (0%) of patients with IIH had MRI signs of sinus vein stenosis, 13/13 (100%) of patients with IIH presented with abnormal preoperative pulsatile ICP [overnight mean ICP wave amplitude (MWA) above thresholds], 3/13 (23%) patients showed abnormal static ICP (overnight mean ICP above threshold), and 12/13 (92%) of patients with IIH showed abnormal structural changes at the glia-neuro-vascular interface. Comparisons of semi-quantitative structural variables between IIH and aged- and gender-matched reference (REF) subjects showed IIH abnormalities in glial cells, neurons, and capillaries. The present data suggest a key role of disease processes affecting the glia-neuro-vascular interface.
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Affiliation(s)
- Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital—Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- *Correspondence: Per Kristian Eide
| | - Hans-Arne Hansson
- Institute of Biomedicine, University of Gothenburg, Göteborg, Sweden
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Krämer J, Wiendl H. What Have Failed, Interrupted, and Withdrawn Antibody Therapies in Multiple Sclerosis Taught Us? Neurotherapeutics 2022; 19:785-807. [PMID: 35794296 PMCID: PMC9294122 DOI: 10.1007/s13311-022-01246-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2022] [Indexed: 12/13/2022] Open
Abstract
In the past two decades, monoclonal antibodies (mAbs) have revolutionized the treatment of multiple sclerosis (MS). However, a remarkable number of mAbs failed due to negative study results were withdrawn because of unexpected serious adverse events (SAEs) or due to studies being halted for other reasons. While trials with positive outcomes are usually published in prestigious journals, negative trials are merely published as abstracts or not at all. This review summarizes MS mAbs that have either failed in phase II-III trials, have been interrupted for various reasons, or withdrawn from the market since 2015. The main conclusions that can be drawn from these 'negative' experiences are as follows. mAbs that have been proven to be safe in other autoimmune conditions, will not have the same safety profile in MS due to immunopathogenetic differences in these diseases (e.g., daclizumab). Identification of SAEs in clinical trials is difficult highlighting the importance of phase IV studies. Memory B cells are central players in MS immunopathogenesis (e.g., tabalumab). The pathophysiological mechanisms of disease progression are independent of leukocyte 'outside-in' traffic which drives relapses in MS. Therefore, therapies for progressive MS must be able to sufficiently cross the blood-brain barrier. Sufficiently long trial duration and multicomponent outcome measures are important for clinical studies in progressive MS. The success of trials on remyelination-promoting therapies mainly depends on the sufficient high dose of mAb, the optimal readout for 'proof of concept', time of treatment initiation, and appropriate selection of patients. Failed strategies are highly important to better understand assumed immunopathophysiological mechanisms and optimizing future trial designs.
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Affiliation(s)
- Julia Krämer
- Department of Neurology With Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany
| | - Heinz Wiendl
- Department of Neurology With Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany
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Kimura A, Takekoshi A, Shimohata T. Characteristics of Movement Disorders in Patients with Autoimmune GFAP Astrocytopathy. Brain Sci 2022; 12:brainsci12040462. [PMID: 35447992 PMCID: PMC9028698 DOI: 10.3390/brainsci12040462] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 03/26/2022] [Accepted: 03/29/2022] [Indexed: 11/28/2022] Open
Abstract
Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy (GFAP-A) is a type of autoimmune corticosteroid-responsive meningoencephalitis that occurs with or without myelitis. Movement disorders have been reported in GFAP-A patients but have not been characterized. In this study, we examined the characteristics of movement disorders in GFAP-A patients. We retrospectively reviewed clinical data from 87 consecutive patients with GFAP-A attending Gifu University Hospital in Japan. We compared the demographics, clinical features, cerebrospinal fluid characteristics, and neuroimaging findings from patients with and without movement disorders. Seventy-four patients (85%) had movement disorders, including ataxia (49%), tremor (45%), myoclonus (37%), dyskinesia (2%), opsoclonus (2%), rigidity (2%), myokymia (1%), and choreoathetosis (1%). GFAP-A patients with movement disorders were significantly older than those without. Movement disorders are therefore common in GFAP-A patients, and the main types of movement disorders observed in this population were ataxia, tremor, and myoclonus. These abnormal movements can serve as clinical features that facilitate the early diagnosis of GFAP-A. Elderly GFAP-A patients are more likely to have movement disorder complications than younger patients.
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Affiliation(s)
- Akio Kimura
- Correspondence: ; Tel.: +81-58-230-6253; Fax: +81-58-230-6256
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Liao H, Chen Q, Zhang M, Chen W. MRI features and evolution of autoimmune glial fibrillary acidic protein astrocytopathy: A retrospective cross-sectional and longitudinal study. Mult Scler Relat Disord 2022; 58:103512. [DOI: 10.1016/j.msard.2022.103512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 11/23/2021] [Accepted: 01/08/2022] [Indexed: 11/16/2022]
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Fang J, Tong Z, Lu W. Case Report: Need for Caution in the Diagnosis of GFAP Astrocytopathy—A Case of GFAP Astrocytopathy Coexistent With Primary Central Nervous System Lymphoma. Front Neurol 2022; 13:806224. [PMID: 35153997 PMCID: PMC8831885 DOI: 10.3389/fneur.2022.806224] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 01/11/2022] [Indexed: 11/13/2022] Open
Abstract
We reported a case of primary central nervous system lymphoma (PCNSL) coexistent with glial fibrillary acidic protein (GFAP) astrocytopathy, and discussed the problems needing attention in the diagnosis and differential diagnosis of GFAP astrocytopathy. Our patient was a 51-year-old female who presented with somnolence for a month, and memory declination for 10 days. Brain magnetic resonance imaging (MRI) demonstrated multiple abnormal enhancement lesions in bilateral basal ganglia and around the third ventricle, as well as transient T2-weighted hyper-intensity lesions at the splenium of the corpus callosum during the course of the disease. The cerebrospinal fluid (CSF) was positive for anti-GFAP antibodies by antigen-transfected HEK293 cell-based assay (indirect immunofluorescence assay). She was initially diagnosed with autoimmune GFAP astrocytopathy. After treatment with corticosteroids for about 2 months, she displayed poor response and even worsened clinical manifestations when the dose of prednisone reduced to 45 mg. Stereotactic brain biopsy was adopted and the diagnosis of large B-cell lymphoma, non-germinal center type was established on pathological examination. The results of brain biopsy also showed perivascular inflammation and CD8+ T cell infiltration, which also accorded with GFAP astrocytopathy. After chemotherapy with rituximab and methotrexate, the patient showed clinical and radiological improvement significantly. Our findings suggest that positivity of GFAP antibody calls for cautious interpretation. Cancer screening appropriate for age, sex, and risk factors is recommended for GFAP antibody-positive patients, especially for patients with atypical clinical and radiologic manifestations.
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Affiliation(s)
- Jia Fang
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Zhongyi Tong
- Department of Pathology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Wei Lu
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Wei Lu
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8
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Xiao J, Chen X, Shang K, Tang Y, Chen M, Deng G, Qin C, Tian DS. Clinical, neuroradiological, diagnostic and prognostic profile of autoimmune glial fibrillary acidic protein astrocytopathy: A pooled analysis of 324 cases from published data and a single-center retrospective study. J Neuroimmunol 2021; 360:577718. [PMID: 34600199 DOI: 10.1016/j.jneuroim.2021.577718] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/10/2021] [Accepted: 09/08/2021] [Indexed: 12/15/2022]
Abstract
Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is a recently defined autoimmune meningoencephalomyelitis, associated with GFAP-IgG antibody. A pooled analysis of 324 cases from published literature and a retrospective single-center study were performed, firstly reveals the possibility that patients with myelitic lesions respond better to initial immunotherapy, but are prone to relapse, suggesting a more aggressive and long-term immunosuppressive medication for them. Moreover, our results showed using tacrolimus at maintenance stage exhibited a less tendency to relapse, providing a possibly new choice to future clinical treatments.
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Affiliation(s)
- Jun Xiao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xin Chen
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ke Shang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yue Tang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Man Chen
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Gang Deng
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chuan Qin
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Dai-Shi Tian
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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9
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Made to Measure: Patient-Tailored Treatment of Multiple Sclerosis Using Cell-Based Therapies. Int J Mol Sci 2021; 22:ijms22147536. [PMID: 34299154 PMCID: PMC8304207 DOI: 10.3390/ijms22147536] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/25/2021] [Accepted: 06/28/2021] [Indexed: 12/14/2022] Open
Abstract
Currently, there is still no cure for multiple sclerosis (MS), which is an autoimmune and neurodegenerative disease of the central nervous system. Treatment options predominantly consist of drugs that affect adaptive immunity and lead to a reduction of the inflammatory disease activity. A broad range of possible cell-based therapeutic options are being explored in the treatment of autoimmune diseases, including MS. This review aims to provide an overview of recent and future advances in the development of cell-based treatment options for the induction of tolerance in MS. Here, we will focus on haematopoietic stem cells, mesenchymal stromal cells, regulatory T cells and dendritic cells. We will also focus on less familiar cell types that are used in cell therapy, including B cells, natural killer cells and peripheral blood mononuclear cells. We will address key issues regarding the depicted therapies and highlight the major challenges that lie ahead to successfully reverse autoimmune diseases, such as MS, while minimising the side effects. Although cell-based therapies are well known and used in the treatment of several cancers, cell-based treatment options hold promise for the future treatment of autoimmune diseases in general, and MS in particular.
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10
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Sechi E, Flanagan EP. Antibody-Mediated Autoimmune Diseases of the CNS: Challenges and Approaches to Diagnosis and Management. Front Neurol 2021; 12:673339. [PMID: 34305787 PMCID: PMC8292678 DOI: 10.3389/fneur.2021.673339] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 05/28/2021] [Indexed: 12/25/2022] Open
Abstract
Antibody-mediated disorders of the central nervous system (CNS) are increasingly recognized as neurologic disorders that can be severe and even life-threatening but with the potential for reversibility with appropriate treatment. The expanding spectrum of newly identified autoantibodies targeting glial or neuronal (neural) antigens and associated clinical syndromes (ranging from autoimmune encephalitis to CNS demyelination) has increased diagnostic precision, and allowed critical reinterpretation of non-specific neurological syndromes historically associated with systemic disorders (e.g., Hashimoto encephalopathy). The intracellular vs. cell-surface or synaptic location of the different neural autoantibody targets often helps to predict the clinical characteristics, potential cancer association, and treatment response of the associated syndromes. In particular, autoantibodies targeting intracellular antigens (traditionally termed onconeural autoantibodies) are often associated with cancers, rarely respond well to immunosuppression and have a poor outcome, although exceptions exist. Detection of neural autoantibodies with accurate laboratory assays in patients with compatible clinical-MRI phenotypes allows a definite diagnosis of antibody-mediated CNS disorders, with important therapeutic and prognostic implications. Antibody-mediated CNS disorders are rare, and reliable autoantibody identification is highly dependent on the technique used for detection and pre-test probability. As a consequence, indiscriminate neural autoantibody testing among patients with more common neurologic disorders (e.g., epilepsy, dementia) will necessarily increase the risk of false positivity, so that recognition of high-risk clinical-MRI phenotypes is crucial. A number of emerging clinical settings have recently been recognized to favor development of CNS autoimmunity. These include antibody-mediated CNS disorders following herpes simplex virus encephalitis or occurring in a post-transplant setting, and neurological autoimmunity triggered by TNFα inhibitors or immune checkpoint inhibitors for cancer treatment. Awareness of the range of clinical and radiological manifestations associated with different neural autoantibodies, and the specific settings where autoimmune CNS disorders may occur is crucial to allow rapid diagnosis and early initiation of treatment.
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Affiliation(s)
- Elia Sechi
- Department of Neurology, Mayo Clinic, Rochester, MN, United States.,Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, MN, United States.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
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Irani SR, Nath A, Zipp F. The neuroinflammation collection: a vision for expanding neuro-immune crosstalk in Brain. Brain 2021; 144:e59. [PMID: 33983376 PMCID: PMC8370408 DOI: 10.1093/brain/awab187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Department of Neurology, Oxford University Hospital, NHS Foundation Trust, Oxford, UK
| | - Avindra Nath
- Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892, USA
| | - Frauke Zipp
- Department of Neurology, Focus Program Translational Neuroscience (FTN) and Immunotherapy (FZI), Rhine Main Neuroscience Network, Johannes Gutenberg University Medical Center Mainz, Germany
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12
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Peyro-Saint-Paul L, Fedrizzi S, Defer G. Drug safety in multiple sclerosis: From reporting to signal detection and benefit-risk management. Rev Neurol (Paris) 2021; 177:582-588. [PMID: 33812676 DOI: 10.1016/j.neurol.2021.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 01/28/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pharmacovigilance (PV) rules emerged in the late 60s-early 70s. Since that time, the World Health Organization Center for International Drug Monitoring carries out the corresponding tasks. Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease of the central nervous system that generally starts in young adults between 20 and 40 years of age. Over the last 25 years, MS patients have benefited from the development of a plethora of disease modifying drugs (DMD). These changes in the therapeutic armamentarium have been associated with some serious adverse reactions challenging health authorities and neurologists involved in treatment and care for MS patients. METHODS The present review aims to describe, for MS DMDs, how adverse drug reactions are reported during clinical trials and the post-marketing period and how important signal detection and benefit-risk management have been in this disease until now. Several examples are reported to illustrate the different steps of PV processes. CONCLUSION Improvement of the PV system procedures has led to significant progress in the detection of signals, allowing better assessment of the benefit-risk balance and the implementation of risk management plans for MS treatments. The involvement of neurologists is essential to improve knowledge on the benefit-risk balance of these drugs. In addition, adverse drug reactions reporting by persons with MS should be encouraged.
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Affiliation(s)
- L Peyro-Saint-Paul
- Direction de la Recherche et de l'Enseignement, CHU de Caen Normandie, Caen, France
| | - S Fedrizzi
- Centre Régional de Pharmacovigilance, Pharmacologie, CHU de Caen Normandie, Caen, France
| | - G Defer
- Centre de Ressources et Compétences (CRC-SEP), Service de Neurologie, CHU de Caen, Normandie-Université, Caen, France; Réseau Normand pour la prise en charge de la SEP, Caen, France.
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Gklinos P, Papadopoulou M, Stanulovic V, Mitsikostas DD, Papadopoulos D. Monoclonal Antibodies as Neurological Therapeutics. Pharmaceuticals (Basel) 2021; 14:ph14020092. [PMID: 33530460 PMCID: PMC7912592 DOI: 10.3390/ph14020092] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/20/2021] [Accepted: 01/22/2021] [Indexed: 02/08/2023] Open
Abstract
Over the last 30 years the role of monoclonal antibodies in therapeutics has increased enormously, revolutionizing treatment in most medical specialties, including neurology. Monoclonal antibodies are key therapeutic agents for several neurological conditions with diverse pathophysiological mechanisms, including multiple sclerosis, migraines and neuromuscular disease. In addition, a great number of monoclonal antibodies against several targets are being investigated for many more neurological diseases, which reflects our advances in understanding the pathogenesis of these diseases. Untangling the molecular mechanisms of disease allows monoclonal antibodies to block disease pathways accurately and efficiently with exceptional target specificity, minimizing non-specific effects. On the other hand, accumulating experience shows that monoclonal antibodies may carry class-specific and target-associated risks. This article provides an overview of different types of monoclonal antibodies and their characteristics and reviews monoclonal antibodies currently in use or under development for neurological disease.
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Affiliation(s)
- Panagiotis Gklinos
- Department of Neurology, KAT General Hospital of Attica, 14561 Athens, Greece;
| | - Miranta Papadopoulou
- Center for Clinical, Experimental Surgery & Translational Research, Biomedical Research Foundation of the Academy of Athens (BRFAA), 11527 Athens, Greece;
| | - Vid Stanulovic
- Global Pharmacovigilance, R&D Sanofi, 91385 Chilly-Mazarin, France;
| | - Dimos D. Mitsikostas
- 1st Neurology Department, Aeginition Hospital, National and Kapodistrian University of Athens, 11521 Athens, Greece;
| | - Dimitrios Papadopoulos
- Laboratory of Molecular Genetics, Hellenic Pasteur Institute, 129 Vasilissis Sophias Avenue, 11521 Athens, Greece
- Salpetriere Neuropsychiatric Clinic, 149 Papandreou Street, Metamorphosi, 14452 Athens, Greece
- Correspondence:
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Karunaratne K, Ahrabian D, Monaghan B, Campion T, Yousry T, Lunn MP, Zandi MS, Howard RS, Kullmann DM, Spillane J, Walker M, Chataway J. Bortezomib for anti-NMDAR encephalitis following daclizumab treatment in a patient with multiple sclerosis. BMJ Neurol Open 2021; 3:e000096. [PMID: 34079936 PMCID: PMC8137234 DOI: 10.1136/bmjno-2020-000096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Daclizumab is an anti-CD25 monoclonal antibody developed for the treatment of relapsing remitting multiple sclerosis, which was withdrawn worldwide in March 2018, due to emerging serious immune-mediated systemic andcentral nervous system adverse events. We report a case of anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis occurring 14 weeks after stopping daclizumab, which responded to the proteasome inhibitor bortezomib. METHODS Following lack of effective clinical response to first line (corticosteroid, plasma exchange, intravenous immunoglobulin) and second line (rituximab) treatments, bortezomib therapy was commenced. The patient received six cycles of bortezomib treatment. RESULTS Clinical improvement was noted 4 weeks after the first of six cycles of bortezomib and the patient experienced sustained clinical improvement. CONCLUSION Our case provides further class IV evidence of the use of bortezomib therapy for treatment refractory anti-NMDAR encephalitis.
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Affiliation(s)
- Kushan Karunaratne
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Dariush Ahrabian
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Bernadette Monaghan
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Tom Campion
- Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, University College London Hospitals NHS Foundation Trust National Hospital for Neurology and Neurosurgery, London, UK
| | - Tarek Yousry
- Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, University College London Hospitals NHS Foundation Trust National Hospital for Neurology and Neurosurgery, London, UK
| | - Michael P Lunn
- MRC Centre for Neuromuscular Disease and Department of Molecular Neuroscience, University College London Hospitals NHS Foundation Trust National Hospital for Neurology and Neurosurgery, London, UK
- NIHR Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | - Michael S Zandi
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Neuromuscular Disorders, UCL Queen Square Institute of Neurology, London, UK
| | - Robin S Howard
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Dimitri M Kullmann
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jennifer Spillane
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Matthew Walker
- Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, University College London Hospitals NHS Foundation Trust National Hospital for Neurology and Neurosurgery, London, UK
| | - Jeremy Chataway
- NIHR Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
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15
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Xu L, Xian W, Li J, Yao X, Long Y. Purkinje cell (PC) antibody positivity in a patient with autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy. Int J Neurosci 2020; 132:1043-1048. [PMID: 33287611 DOI: 10.1080/00207454.2020.1860965] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE This case report is the first to describe the detection of antibodies against inositol 1,4,5-trisphosphate receptor 1 (ITPR1, I3PR) in a patient diagnosed with autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy. ITPR1 is known as one of the Purkinje cell antibodies present in autoimmune cerebellar ataxia (ACA). Here, we described the association between autoimmune GFAP astrocytopathy and autoimmune cerebellar disease (ACD). MATERIALS AND METHODS Demographic features, clinical characteristics, cerebrospinal fluid (CSF) parameters and neuroimaging findings were collected from this patient. Specifically, antibodies against GFAP and other proteins associated with neurological disorders were measured by immunofluorescence staining in both serum and CSF samples. RESULTS A 52-year-old woman was diagnosed with autoimmune inflammatory meningoencephalitis. She presented with cognitive dysfunction, psychiatric/behavioral abnormalities and serious insomnia with subacute onset. Brain magnetic resonance imaging (MRI) showed bilateral hyperintensity in the semioval centers on axial images and perivascular linear enhancement oriented radially to the ventricles on sagittal images. GFAP-IgG, oligoclonal bands (OBs), N-methyl-D-aspartate receptor (NMDAR)-IgG and ITPR1-IgG co-existed in her CSF. She responded well to immunoglobulin and steroid treatments. CONCLUSION Here, we describe the case of a patient with autoimmune GFAP astrocytopathy whose CSF was positive for ITPR1-IgG; however, she did not show typical ataxia manifestations or cerebellar lesions on her MRI scan. This suggests that ITPR1-IgG is not pathogenic, and the positivity of this antibody in CSF is probably associated with the presence of autoimmune inflammation.
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Affiliation(s)
- Li Xu
- Department of Neurology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong Province, China.,Department of Neurology, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, Guangdong Province, China
| | - Wenbiao Xian
- Department of Neurology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong Province, China
| | - Jin Li
- Department of Neurology, Zhuzhou 331 Hospital, Zhuzhou, Hunan Province, China
| | - Xiaoli Yao
- Department of Neurology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong Province, China
| | - Youming Long
- Department of Neurology, The Second Affiliated Hospital of GuangZhou Medical University, Guangzhou, Guangdong Province, China
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16
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Stascheit F, Li L, Mai K, Baum K, Siebert E, Ruprecht K. Delayed onset hypophysitis after therapy with daclizumab for multiple sclerosis - A report of two cases. J Neuroimmunol 2020; 351:577469. [PMID: 33387829 DOI: 10.1016/j.jneuroim.2020.577469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/22/2020] [Accepted: 12/22/2020] [Indexed: 11/25/2022]
Abstract
Daclizumab (DAC), a humanized monoclonal antibody that binds to the interleukin (IL)-2-receptor alpha chain, was approved in May 2016 for treatment of relapsing-remitting multiple sclerosis (RRMS). Approval was suspended in March 2018 after occurrence of severe liver failure and fatal meningoencephalitis in several patients treated with DAC. We report the clinical, laboratory and neuroimaging findings of 2 patients, who developed hypophysitis about 4 months after cessation of therapy with DAC. This report identifies delayed onset hypophysitis as a previously unrecognized severe side effect of DAC, highlighting the importance of continuous pharmacovigilance and patient monitoring even after cessation of DAC therapy.
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Affiliation(s)
- Frauke Stascheit
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany; NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany.
| | - Linna Li
- Department of Endocrinology, Charité - Universitätsmedizin Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany; Charité Center for Cardiovascular Research, Charité - Universitätsmedizin Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Clinical Research Unit, Charité - Universitätsmedizin Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Knut Mai
- Department of Endocrinology, Charité - Universitätsmedizin Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany; Charité Center for Cardiovascular Research, Charité - Universitätsmedizin Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Clinical Research Unit, Charité - Universitätsmedizin Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Karl Baum
- Department of Neurology, Oberhavel Kliniken, Hennigsdorf, Germany
| | - Eberhard Siebert
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Klemens Ruprecht
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany
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17
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Rommer PS, Berger K, Ellenberger D, Fneish F, Simbrich A, Stahmann A, Zettl UK. Management of MS Patients Treated With Daclizumab - a Case Series of 267 Patients. Front Neurol 2020; 11:996. [PMID: 33013658 PMCID: PMC7506133 DOI: 10.3389/fneur.2020.00996] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 07/29/2020] [Indexed: 12/25/2022] Open
Abstract
Daclizumab was approved by the FDA and the EMA in 2016 for the treatment of relapsing forms of multiple sclerosis (MS). Cases of severe inflammatory brain disease with fatal outcome led to the withdrawal of approval in Europe and the US on March 2, 2018. Approximately 8,000 patients worldwide received daclizumab, but little is known about the further therapy management of these patients after the withdrawal of daclizumab. The aim of this study is to further analyze therapy management in MS patients after safety warnings and market withdrawal. Data from two registries in Germany, the German MS Registry (GMSR) and REGIMS, were used for this analysis. In total, 267 patients were included in this study. For almost 25% of patients (in the GMSR) daclizumab was the initial treatment. Most common pre-treatments were fingolimod, dimethyl fumarate, and natalizumab; various injectables summed up to 25.9%. The most common follow-up therapies were ocrelizumab and fingolimod. In most patients, follow-up therapies were administered shortly after discontinuation of daclizumab. The wash-out time for subsequent therapies varied between 1.2 and 4.0 months. Warnings and decisions by authorities led to a rapid decline and termination of therapies in both cohorts, indicating that such warnings have an immediate impact on the treatment landscape. Therapies that were started within a short time after the discontinuation of daclizumab were subsequently replaced by other therapies and may be considered as bridging therapies.
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Affiliation(s)
- Paulus S Rommer
- Neuroimmunological Section, Department of Neurology, University of Rostock, Rostock, Germany.,Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Klaus Berger
- Institute of Epidemiology and Social Medicine, University of Münster, Münster, Germany
| | - David Ellenberger
- German MS-Register by the German MS Society, MS Forschungs- und Projektentwicklungs-gGmbH, Hanover, Germany
| | - Firas Fneish
- German MS-Register by the German MS Society, MS Forschungs- und Projektentwicklungs-gGmbH, Hanover, Germany
| | - Alexandra Simbrich
- Institute of Epidemiology and Social Medicine, University of Münster, Münster, Germany
| | - Alexander Stahmann
- German MS-Register by the German MS Society, MS Forschungs- und Projektentwicklungs-gGmbH, Hanover, Germany
| | - Uwe K Zettl
- Neuroimmunological Section, Department of Neurology, University of Rostock, Rostock, Germany
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18
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Jakimovski D, Vaughn CB, Eckert S, Zivadinov R, Weinstock-Guttman B. Long-term drug treatment in multiple sclerosis: safety success and concerns. Expert Opin Drug Saf 2020; 19:1121-1142. [PMID: 32744073 DOI: 10.1080/14740338.2020.1805430] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The portfolio of multiple sclerosis (MS) disease modifying treatments (DMTs) has significantly expanded over the past two decades. Given the lifelong use of MS pharmacotherapy, understanding their long-term safety profiles is essential in determining suitable and personalized treatment. AREAS COVERED In this narrative review, we summarize the short-, mid-, and long-term safety profile of currently available MS DMTs categories. In addition to the initial trial findings, safety outcomes derived from long-term extension studies (≥5-20 years) and safety-based prescription programs have been reviewed. In order to better understand the risk-benefit ratio for each particular DMT group, a short description of the DMT-based efficacy outcomes has been included. EXPERT OPINION Long-term extension trials, large observational studies and real-world databases allow detection of rare and potentially serious adverse events. Two-year-long trials are unable to fully capture the positive and negative effects of immune system modulation and reconstitution. DMT-based monitoring programs can provide greater insights regarding safe use of MS medications in different patient populations and clinical settings. During the process of shared DMT decision, both MS care providers and their patients should be aware of an ever-expanding number of drug-based adverse events and their influence on the risk-benefit analysis.
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Affiliation(s)
- Dejan Jakimovski
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York , Buffalo, NY, USA
| | - Caila B Vaughn
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo , Buffalo, NY, USA
| | - Svetlana Eckert
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo , Buffalo, NY, USA
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York , Buffalo, NY, USA.,Translational Imaging Center at Clinical Translational Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Stat37$e University of New York , Buffalo, NY, USA
| | - Bianca Weinstock-Guttman
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo , Buffalo, NY, USA
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19
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Li XL, Han J, Zhao HT, Long YM, Zhang BW, Wang HY. Autoimmune glial fibrillary acidic protein astrocytopathy with lesions distributed predominantly in the entire spinal cord. Ther Adv Neurol Disord 2020; 13:1756286420909973. [PMID: 32547640 PMCID: PMC7270931 DOI: 10.1177/1756286420909973] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 01/27/2020] [Indexed: 11/17/2022] Open
Abstract
Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy has been considered a novel central nervous system autoimmune disease characterized by relapse and responsiveness to corticosteroid with a specific GFAP-Immunoglobulin G (IgG) being noted in cerebrospinal fluid. We report the case of a 21-year-old girl presenting with dysuria and weariness, who subsequently developed blurry vision, slight dysphagia, slurred speech, and sensory abnormality. GFAP-IgG was detected in her cerebrospinal fluid. Magnetic resonance imaging using both T2-weighted and contrast-enhanced T1-weighted images revealed a rare finding of lesions distributed mainly in the entire spinal cord rather than typical brain lesions. After treating with corticosteroids, her clinical symptoms were alleviated, and the spinal cord lesion enhancement was reduced. Our observations extend the clinical spectrum of autoimmune GFAP astrocytopathy. We suggest that rare distributed lesions in the entire spinal cord in patients with autoimmune GFAP astrocytopathy cannot be ignored by neurologists. The identification of potential atypical lesions broadens the understanding of autoimmune GFAP astrocytopathy.
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Affiliation(s)
- Xue-Lin Li
- Department of Intensive Care Unit, Jining No. 1 People's Hospital, Jining, China
| | - Jinming Han
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Hao-Tian Zhao
- Department of Neurology, Jining No. 1 People's Hospital, Jining, China
| | - You-Ming Long
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Bing-Wei Zhang
- Department of Neurology and Psychiatry, The First Affiliate Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian, Liaoning Province 116011, China
| | - Hai-Yang Wang
- Department of Neurology, Jining No. 1 People's Hospital, No. 6, Jiankang Road, Jining, Shandong Province, 272011, China
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20
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Yetimler B, Tzartos J, Şengül B, Dursun E, Ulukan Ç, Karagiorgou K, Gezen-Ak D, Sezgin M, Papaconstantinou A, Tzartos S, Orhan EK, Ekizoğlu E, Küçükali Cİ, Baykan B, Tüzün E. Serum glial fibrillary acidic protein (GFAP)-antibody in idiopathic intracranial hypertension. Int J Neurosci 2020; 131:775-779. [PMID: 32303142 DOI: 10.1080/00207454.2020.1758084] [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: 10/24/2022]
Abstract
AIM Idiopathic intracranial hypertension (IIH), a disease of obscure origin, is characterized by headache and visual disturbances due to increased intracranial pressure. Recent line of evidence has suggested involvement of inflammation in IIH pathogenesis thus bringing forward anti-glial autoimmunity as a potential contributor of IIH. Glial fibrillary acidic protein (GFAP) is a major astrocytic autoantigen associated with a specific form of meningoencephalitis. MATERIALS AND METHODS In this study, we investigated the presence of GFAP-antibody in 65 sera (49 obtained during active disease and 16 during remission) and in 15 cerebrospinal fluid (CSF) samples of 58 consecutively recruited IIH patients using cell based assay and indirect immunohistochemistry. RESULTS GFAP-antibody was found in active period sera of 2 IIH patients with classical symptoms and good treatment response. Two remission period sera obtained at different time points from one of these cases showed lower titers of GFAP-antibody positivity. IgG from positive samples yielded an astrocytic immunoreactivity pattern. None of the CSF samples showed GFAP-antibodies. CONCLUSIONS These results suggest that anti-astrocyte autoimmunity might be present in a fraction of IIH patients. Exact pathogenic significance of this association needs to be further studied.
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Affiliation(s)
- Berrak Yetimler
- Department of Neuroscience, Aziz Sancar Institute for Experimental Medical Research, Istanbul University, Istanbul, Turkey
| | - John Tzartos
- Tzartos NeuroDiagnostics, Athens, Greece.,1st Department of Neurology, Eginition Hospital, Medical School, University of Athens, Athens, Greece
| | - Büşra Şengül
- Department of Medical Biology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Erdinç Dursun
- Department of Medical Biology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey.,Department of Neuroscience, Institute of Neurological Sciences, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Çağrı Ulukan
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | | | - Duygu Gezen-Ak
- Department of Medical Biology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Mine Sezgin
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | | | - Socrates Tzartos
- Tzartos NeuroDiagnostics, Athens, Greece.,Hellenic Pasteur Institute, Athens, Greece
| | - Elif Kocasoy Orhan
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Esme Ekizoğlu
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Cem İsmail Küçükali
- Department of Neuroscience, Aziz Sancar Institute for Experimental Medical Research, Istanbul University, Istanbul, Turkey
| | - Betül Baykan
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Erdem Tüzün
- Department of Neuroscience, Aziz Sancar Institute for Experimental Medical Research, Istanbul University, Istanbul, Turkey
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21
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Ellwardt E, Rolfes L, Klein J, Pape K, Ruck T, Wiendl H, Schroeter M, Zipp F, Meuth SG, Warnke C, Bittner S. Ocrelizumab initiation in patients with MS: A multicenter observational study. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 7:7/4/e719. [PMID: 32273482 PMCID: PMC7176249 DOI: 10.1212/nxi.0000000000000719] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 03/11/2020] [Indexed: 02/06/2023]
Abstract
Objective To provide first real-world experience on patients with MS treated with the B cell–depleting antibody ocrelizumab. Methods We retrospectively collected data of patients who had received at least 1 treatment cycle (2 infusions) of ocrelizumab at 3 large neurology centers. Patients' characteristics including premedication, clinical disease course, and documented side effects were analyzed. Results We could identify 210 patients (125 women, mean age ± SD, 42.1 ± 11.4 years) who had received ocrelizumab with a mean disease duration of 7.3 years and a median Expanded Disability Status Scale score of 3.75 (interquartile range 2.5–5.5; range 0–8). Twenty-six percent of these patients had a primary progressive MS (PPMS), whereas 74% had a relapsing-remitting (RRMS) or active secondary progressive (aSPMS) disease course. Twenty-four percent of all patients were treatment naive, whereas 76% had received immune therapies before. After ocrelizumab initiation (median follow-up was 200 days, range 30–1,674 days), 13% of patients with RRMS/aSPMS experienced a relapse (accounting for an annualized relapse rate of 0.17, 95% CI 0.10–0.24), and 5% of all patients with MS experienced a 12-week confirmed disability progression. Treatment was generally well tolerated, albeit only short-term side effects were recorded, including direct infusion-related reactions and mild infections. Conclusions We provide class IV evidence that treatment with ocrelizumab can stabilize naive and pretreated patients, indicating that ocrelizumab is an option following potent MS drugs such as natalizumab and fingolimod. Further studies are warranted to confirm these findings and to reveal safety concerns in the longer-term follow-up. Classification of evidence This study provides Class IV evidence that for patients with MS, ocrelizumab can stabilize both treatment-naive and previously treated patients.
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Affiliation(s)
- Erik Ellwardt
- From the Focus Program Translational Neurosciences (FTN) and Immunology (FZI) (E.E., K.P., F.Z., S.B.), Rhine Main Neuroscience Network (rmn), Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (L.R., T.R., H.W.), University of Muenster; Department of Neurology (J.K., M.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; and Department of Neurology (S.G.M.), Institute of Translational Neurology, University of Muenster, Germany.
| | - Leoni Rolfes
- From the Focus Program Translational Neurosciences (FTN) and Immunology (FZI) (E.E., K.P., F.Z., S.B.), Rhine Main Neuroscience Network (rmn), Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (L.R., T.R., H.W.), University of Muenster; Department of Neurology (J.K., M.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; and Department of Neurology (S.G.M.), Institute of Translational Neurology, University of Muenster, Germany
| | - Julia Klein
- From the Focus Program Translational Neurosciences (FTN) and Immunology (FZI) (E.E., K.P., F.Z., S.B.), Rhine Main Neuroscience Network (rmn), Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (L.R., T.R., H.W.), University of Muenster; Department of Neurology (J.K., M.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; and Department of Neurology (S.G.M.), Institute of Translational Neurology, University of Muenster, Germany
| | - Katrin Pape
- From the Focus Program Translational Neurosciences (FTN) and Immunology (FZI) (E.E., K.P., F.Z., S.B.), Rhine Main Neuroscience Network (rmn), Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (L.R., T.R., H.W.), University of Muenster; Department of Neurology (J.K., M.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; and Department of Neurology (S.G.M.), Institute of Translational Neurology, University of Muenster, Germany
| | - Tobias Ruck
- From the Focus Program Translational Neurosciences (FTN) and Immunology (FZI) (E.E., K.P., F.Z., S.B.), Rhine Main Neuroscience Network (rmn), Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (L.R., T.R., H.W.), University of Muenster; Department of Neurology (J.K., M.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; and Department of Neurology (S.G.M.), Institute of Translational Neurology, University of Muenster, Germany
| | - Heinz Wiendl
- From the Focus Program Translational Neurosciences (FTN) and Immunology (FZI) (E.E., K.P., F.Z., S.B.), Rhine Main Neuroscience Network (rmn), Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (L.R., T.R., H.W.), University of Muenster; Department of Neurology (J.K., M.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; and Department of Neurology (S.G.M.), Institute of Translational Neurology, University of Muenster, Germany
| | - Michael Schroeter
- From the Focus Program Translational Neurosciences (FTN) and Immunology (FZI) (E.E., K.P., F.Z., S.B.), Rhine Main Neuroscience Network (rmn), Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (L.R., T.R., H.W.), University of Muenster; Department of Neurology (J.K., M.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; and Department of Neurology (S.G.M.), Institute of Translational Neurology, University of Muenster, Germany
| | - Frauke Zipp
- From the Focus Program Translational Neurosciences (FTN) and Immunology (FZI) (E.E., K.P., F.Z., S.B.), Rhine Main Neuroscience Network (rmn), Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (L.R., T.R., H.W.), University of Muenster; Department of Neurology (J.K., M.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; and Department of Neurology (S.G.M.), Institute of Translational Neurology, University of Muenster, Germany
| | - Sven G Meuth
- From the Focus Program Translational Neurosciences (FTN) and Immunology (FZI) (E.E., K.P., F.Z., S.B.), Rhine Main Neuroscience Network (rmn), Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (L.R., T.R., H.W.), University of Muenster; Department of Neurology (J.K., M.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; and Department of Neurology (S.G.M.), Institute of Translational Neurology, University of Muenster, Germany
| | - Clemens Warnke
- From the Focus Program Translational Neurosciences (FTN) and Immunology (FZI) (E.E., K.P., F.Z., S.B.), Rhine Main Neuroscience Network (rmn), Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (L.R., T.R., H.W.), University of Muenster; Department of Neurology (J.K., M.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; and Department of Neurology (S.G.M.), Institute of Translational Neurology, University of Muenster, Germany
| | - Stefan Bittner
- From the Focus Program Translational Neurosciences (FTN) and Immunology (FZI) (E.E., K.P., F.Z., S.B.), Rhine Main Neuroscience Network (rmn), Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (L.R., T.R., H.W.), University of Muenster; Department of Neurology (J.K., M.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; and Department of Neurology (S.G.M.), Institute of Translational Neurology, University of Muenster, Germany
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22
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Soleimani B, Murray K, Hunt D. Established and Emerging Immunological Complications of Biological Therapeutics in Multiple Sclerosis. Drug Saf 2020; 42:941-956. [PMID: 30830572 DOI: 10.1007/s40264-019-00799-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Biologic immunotherapies have transformed the treatment landscape of multiple sclerosis. Such therapies include recombinant proteins (interferon beta), as well as monoclonal antibodies (natalizumab, alemtuzumab, daclizumab, rituximab and ocrelizumab). Monoclonal antibodies show particular efficacy in the treatment of the inflammatory phase of multiple sclerosis. However, the immunological perturbations caused by biologic therapies are associated with significant immunological adverse reactions. These include development of neutralising immunogenicity, secondary immunodeficiency and secondary autoimmunity. These complications can affect the balance of risks and benefits of biologic agents, and 2018 saw the withdrawal from the market of daclizumab, an anti-CD25 monoclonal antibody, due to concerns about the development of severe, unpredictable autoimmunity. Here we review established and emerging risks associated with multiple sclerosis biologic agents, with an emphasis on their immunological adverse effects. We also discuss the specific challenges that multiple sclerosis biologics pose to drug safety systems, and the potential for improvements in safety frameworks.
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Affiliation(s)
| | - Katy Murray
- Anne Rowling Clinic, University of Edinburgh, Edinburgh, UK
| | - David Hunt
- Anne Rowling Clinic, University of Edinburgh, Edinburgh, UK. .,MRC Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK.
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Abstract
PURPOSE OF REVIEW To critically assess the current landscape of disease-modifying agents for multiple sclerosis (MS). Treatment algorithms will be discussed and studies for new agents in late development or recently approved are analyzed in terms of their impact on current treatment strategies. RECENT FINDINGS A real-world study from Wales suggests that early initiation of highly effective therapy may provide more benefit that an escalation approach in relapsing MS. A study from the MSBase dataset found evidence that early treatment with highly effective therapies decreased the risk of developing secondary progressive MS. Ocrelizumab is highly efficacious in relapsing MS and in a group of patients with primary progressive MS. Another CD20 directed mAb, ofatumumab, is in phase 3. A large study examining extended interval dosing of natalizumab in an attempt to decrease the risk of developing progressive multifocal leukoencephalopathy is underway. Cladribine and alemtuzumab may work by immune reconstitution. Siponimod was recently approved by United States Federal Drug Administration for relapsing MS and active secondary progressive MS. Other S1P receptor modulators are being studied in phase 3 trials for relapsing MS. Cladribine received FDA approval as treatment for relapsing and active secondary progressive MS. Autologous hematopoetic stem-cell transplantation may be an option for treatment-refractory MS. SUMMARY Development of disease-modifying agents in MS continues to be successful. Treatment algorithms need to take new developments into account.
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Abstract
Purpose of review To describe a recently characterized autoimmune, inflammatory central nervous system (CNS) disorder known as autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy. Recent findings Affected patients present with symptoms of one or more of meningitis (headache and neck ache), encephalitis (delirium, tremor, seizures, or psychiatric symptoms), and myelitis (sensory symptoms and weakness). Optic disc papillitis (blurred vision) is common. CNS inflammation is evident in characteristic T1 postgadolinium enhancement of GFAP-enriched CNS regions, and lymphocytic cerebrospinal fluid (CSF) white cell count elevation. CSF is more reliable than serum for GFAP-immunoglobulin G (IgG) testing. Ovarian teratoma commonly coexists, particularly among patients with accompanying N-methyl-D-aspartate receptor or aquaporin-4 autoimmunity. Parainfectious autoimmunity is suspected in some other patients, though the culprit organism is rarely verified. Pathophysiologic relevance of T cells is underscored by neuropathology and cases of dysregulated T-cell function (HIV or checkpoint inhibitor cancer therapy). Corticosteroid-responsiveness is a hallmark of the disease. Relapses occur in approximately 20% of patients, necessitating transition to a steroid-sparing drug. Reported outcomes vary, though in the authors’ experience, early and sustained intervention usually portends recovery. Summary Autoimmune GFAP astrocytopathy is a treatable autoimmune CNS disease diagnosable by GFAP-IgG testing in CSF. This disease presents opportunities to explore novel mechanisms of CNS autoimmunity and inflammation.
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Affiliation(s)
- Alessia Bianchi
- NMR Research Unit, Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Institute of Neurology, University College London, London, UK/Department of Biomedicine, Neuroscience and Advanced Diagnostic, University of Palermo, Palermo, Italy
| | - Olga Ciccarelli
- NMR Research Unit, Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Institute of Neurology, University College London, London, UK
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Yasunaga M. Antibody therapeutics and immunoregulation in cancer and autoimmune disease. Semin Cancer Biol 2019; 64:1-12. [PMID: 31181267 DOI: 10.1016/j.semcancer.2019.06.001] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 06/03/2019] [Indexed: 02/04/2023]
Abstract
Cancer and autoimmune disease are closely related, and many therapeutic antibodies are widely used in clinics for the treatment of both diseases. Among them, the anti-CD20 antibody has proven to be effective against both lymphoid malignancy and autoimmune disease. Moreover, immune checkpoint blockade using the anti-PD1/PD-L1/CTLA4 antibody has improved the prognosis of patients with refractory solid tumors. At the same time, however, over-enhancement of immunoreaction can induce autoimmune reaction. Although anti-TNF antibody therapies represent a breakthrough in the treatment of autoimmune diseases, optimal management is required to control the serious associated issues, including development and progression of cancer, and it is becoming more and more important to control the immunoreaction. In addition, next-generation antibody therapeutics such as antibody-drug conjugates and bispecific antibodies, are anticipated to treat uncontrolled cancer and autoimmune disease. IL-7R signaling plays an important role in the development and progression of both lymphoid malignancy and autoimmune disease. In addition, abnormal homing activity and steroid resistance caused by IL-7R signaling may worsen prognosis. Therefore, anti-IL-7R targeting antibody therapies that enable suppression of such pathophysiological status have the potential to be beneficial for the treatment of both diseases. In this review, we discuss current antibody therapeutics in cancer and autoimmune disease, and describe a new therapeutic strategy for immunoregulation including IL-7R targeting antibodies.
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Affiliation(s)
- Masahiro Yasunaga
- Division of Developmental Therapeutics, EPOC, National Cancer Center, 6-5-1 Kashiwanoha, Kashiwa-shi, Chiba, 277-8577, Japan.
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De Giglio L, Grimaldi AE, Fubelli F, Marinelli F, Pozzilli C. Advances in preventing adverse events during monoclonal antibody management of multiple sclerosis. Expert Rev Neurother 2019; 19:417-429. [PMID: 31094239 DOI: 10.1080/14737175.2019.1610393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Decades of pharmacological research in Multiple Sclerosis (MS) led to the development of therapeutic Monoclonal Antibodies (MAbs) with many different mechanisms of action (MoA), potentially able to improve disability outcome but also determining a more complex management of patients. Areas covered: When clinicians select MS treatments, they should consider adverse events (AEs) on individual basis to minimize patients' risks. Some AEs are common and can be easily handled, but rare complications should also be taken into account. The aim of this review is to summarize existing evidence and provide practical recommendations for the management of therapeutic MAbs in MS. Expert opinion: The introduction of MAbs revolutionized MS treatment with an improvement in effectiveness. Unfortunately, this has been coupled with a more complex array of AEs needing a tighter surveillance strategy. A close interaction between general practitioners, neurologists, and other specialists is the key for a safer use of such effective drugs.
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Affiliation(s)
- Laura De Giglio
- a MS Center Sant'Andrea Hospital, Sapienza University of Rome , Rome , Italy.,b Department of Human Neuroscience , Sapienza University of Rome , Rome , Italy
| | | | - Federica Fubelli
- a MS Center Sant'Andrea Hospital, Sapienza University of Rome , Rome , Italy
| | | | - Carlo Pozzilli
- a MS Center Sant'Andrea Hospital, Sapienza University of Rome , Rome , Italy.,b Department of Human Neuroscience , Sapienza University of Rome , Rome , Italy
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Klotz L, Havla J, Schwab N, Hohlfeld R, Barnett M, Reddel S, Wiendl H. Risks and risk management in modern multiple sclerosis immunotherapeutic treatment. Ther Adv Neurol Disord 2019; 12:1756286419836571. [PMID: 30967901 PMCID: PMC6444778 DOI: 10.1177/1756286419836571] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 02/14/2019] [Indexed: 12/13/2022] Open
Abstract
In recent years, there has been a paradigm shift in the treatment of multiple
sclerosis (MS) owing to the approval of a number of new drugs with very distinct
mechanisms of action. All approved disease-modifying drugs primarily work
directly on the immune system. However, the identification of an ‘optimal
choice’ for individual patients with regard to treatment efficacy, treatment
adherence and side-effect profile has become increasingly complex including
conceptual as well as practical considerations. Similarly, there are
peculiarities and specific requirements with regard to treatment monitoring,
especially in relation to immunosuppression, the development of secondary
immune-related complications, as well as the existence of drug-specific on- and
off-target effects. Both classical immunosuppression and selective immune
interventions generate a spectrum of potential therapy-related complications.
This article provides a comprehensive overview of available immunotherapeutics
for MS and their risks, detailing individual mechanisms of action and
side-effect profiles. Furthermore, practical recommendations for patients
treated with modern MS immunotherapeutics are provided.
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Affiliation(s)
- Luisa Klotz
- Department of Neurology with Institute of Translational Neurology, University of Münster, Building A1, Albert Schweitzer Campus 1, 48149 Münster, Germany
| | - Joachim Havla
- Institute of Clinical Neuroimmunology, University Hospital; Data Integration for Future Medicine consortium (DIFUTURE), Ludwig-Maximilians University, Munich, Germany
| | - Nicholas Schwab
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Reinhard Hohlfeld
- Institute of Clinical Neuroimmunology, University Hospital, Ludwig-Maximilians University, Munich, Germany Munich Cluster for Systems Neurology, Ludwig-Maximilians University, Munich, Germany
| | | | - Stephen Reddel
- Brain and Mind Centre, University of Sydney, NSW, Australia
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Building A1, Albert Schweitzer Campus 1, 48149 Münster, Germany
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Cohan SL, Lucassen EB, Romba MC, Linch SN. Daclizumab: Mechanisms of Action, Therapeutic Efficacy, Adverse Events and Its Uncovering the Potential Role of Innate Immune System Recruitment as a Treatment Strategy for Relapsing Multiple Sclerosis. Biomedicines 2019; 7:biomedicines7010018. [PMID: 30862055 PMCID: PMC6480729 DOI: 10.3390/biomedicines7010018] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/06/2019] [Accepted: 03/06/2019] [Indexed: 01/07/2023] Open
Abstract
Daclizumab (DAC) is a humanized, monoclonal antibody that blocks CD25, a critical element of the high-affinity interleukin-2 receptor (IL-2R). DAC HYP blockade of CD25 inhibits effector T cell activation, regulatory T cell expansion and survival, and activation-induced T-cell apoptosis. Because CD25 blockade reduces IL-2 consumption by effector T cells, it increases IL-2 bioavailability allowing for greater interaction with the intermediate-affinity IL-2R, and therefore drives the expansion of CD56bright natural killer (NK) cells. Furthermore, there appears to be a direct correlation between CD56bright NK cell expansion and DAC HYP efficacy in reducing relapses and MRI evidence of disease activity in patients with RMS in phase II and phase III double-blind, placebo- and active comparator-controlled trials. Therapeutic efficacy was maintained during open-label extension studies. However, treatment was associated with an increased risk of rare adverse events, including cutaneous inflammation, autoimmune hepatitis, central nervous system Drug Reaction with Eosinophilia Systemic Symptoms (DRESS) syndrome, and autoimmune Glial Fibrillary Acidic Protein (GFAP) alpha immunoglobulin-associated encephalitis. As a result, DAC HYP was removed from clinical use in 2018. The lingering importance of DAC is that its use led to a deeper understanding of the underappreciated role of innate immunity in the potential treatment of autoimmune disease.
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Affiliation(s)
- Stanley L Cohan
- Providence Multiple Sclerosis Center, Providence Brain and Spine Institute, Portland, OR 97225, USA.
| | - Elisabeth B Lucassen
- Providence Multiple Sclerosis Center, Providence Brain and Spine Institute, Portland, OR 97225, USA.
| | - Meghan C Romba
- Providence Multiple Sclerosis Center, Providence Brain and Spine Institute, Portland, OR 97225, USA.
| | - Stefanie N Linch
- Providence Health and Services, Regional Research Department, Portland, OR 97213, USA.
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Dal-Bianco A, Wenhoda F, Rommer PS, Weber M, Altmann P, Kraus J, Leutmezer F, Salhofer-Polanyi S. Do elevated autoantibodies in patients with multiple sclerosis matter? Acta Neurol Scand 2019; 139:238-246. [PMID: 30447159 DOI: 10.1111/ane.13054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 11/08/2018] [Accepted: 11/11/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The incidence and clinical impact of serum autoantibodies in patients with multiple sclerosis (MS) are controversially discussed. The aim of the study was to reassess the value of elevated serum autoantibodies in our MS study cohort. MATERIAL & METHODS In total, 176 MS patients were retrospectively analyzed for coexistence and clinical impact of increased serum autoantibody levels. RESULTS The 18.8% of the MS cohort showed elevated serum autoantibody levels, but only 10.2% of all MS patients were diagnosed with a further autoimmune disease (AI). Patients with elevated serum autoantibodies (AABS) were not significantly more often diagnosed with a clinical manifest AI as compared to patients with negative autoantibodies (P = 0.338). MS patients with disease duration of more than 10 years showed no significant increase of positive autoantibodies as compared to patients with a more recent disease onset (P = 1). MS patients with elevated serum autoantibodies did not exhibit a significantly worse disease course (P = 0.428). CONCLUSIONS According to our data, elevated serum autoantibodies do not have the potential to serve as a prognostic tool for disease severity in patients with MS Since MS patients with positive serum AABS did not significantly more often suffer from clinical manifest AIs than MS patients with negative serum AABS, the role of routine testing of serum AABS in MS patients should be critically called into question.
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Affiliation(s)
| | - Fritz Wenhoda
- Department of Neurology; Medical University of Vienna; Vienna Austria
| | | | - Michael Weber
- Department of Radiology; Medical University of Vienna; Vienna Austria
| | - Patrick Altmann
- Department of Neurology; Medical University of Vienna; Vienna Austria
| | - Jörg Kraus
- Department of Laboratory Medicine; Paracelsus Medical University and Salzburger Landeskliniken; Salzburg Austria
- Department of Neurology, Medical Faculty; Heinrich-Heine-University; Düsseldorf Germany
| | - Fritz Leutmezer
- Department of Neurology; Medical University of Vienna; Vienna Austria
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Linker RA, Chan A. Navigating choice in multiple sclerosis management. Neurol Res Pract 2019; 1:5. [PMID: 33324871 PMCID: PMC7650058 DOI: 10.1186/s42466-019-0005-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 11/21/2018] [Indexed: 01/10/2023] Open
Abstract
Background With the advent of modern immunotherapies for relapsing-remitting multiple sclerosis (RRMS) and the increasing amount of treatment options on the market, MS has evolved as a treatable disease. Yet, at the same time, new challenges for the treating neurologists arise. Main body This review article covers some of these challenges, including when and how to start treatment, treatment monitoring, and finally considerations on what the increasing choice in treatment options brings to disease management and longer-term planning. Among others, these important issues comprise pregnancy, treatment sequencing, switching or even stopping treatment. Conclusion The ultimate goal for navigating choices in RRMS management is to choose the right drug for the right patient at the right time Throughout the article, there is a strong focus on practical aspects and individual decision making in MS to meet the concept of personalized medicine.
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Affiliation(s)
- Ralf A Linker
- Department of Neurology, University of Regensburg, Universitätsstr. 84, 93053 Regensburg, Germany
| | - Andrew Chan
- Ambulantes Neurozentrum, Inselspital, Bern University Hospital, Freiburgstr. 4, 3010 Bern, Switzerland
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32
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Stettner M, Gross CC, Mausberg AK, Pul R, Junker A, Baba HA, Schulte-Mecklenbeck A, Wiendl H, Kleinschnitz C, Meuth SG. A fatal case of daclizumab-induced liver failure in a patient with MS. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 6:e539. [PMID: 30800722 PMCID: PMC6369971 DOI: 10.1212/nxi.0000000000000539] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 12/07/2018] [Indexed: 12/28/2022]
Affiliation(s)
- Mark Stettner
- Department of Neurology (M.S., A.K.M., R.P., C.K.), University Hospital Essen; Clinic of Neurology with Institute of Translational Neurology (C.C.G., A.S.-M., H.W., S.G.M.), University Hospital Münster, University Münster; Institute of Neuropathology (A.J.), University Hospital Essen; and Institute of Pathology (H.A.B.), University Hospital Essen, Germany
| | - Catharina C Gross
- Department of Neurology (M.S., A.K.M., R.P., C.K.), University Hospital Essen; Clinic of Neurology with Institute of Translational Neurology (C.C.G., A.S.-M., H.W., S.G.M.), University Hospital Münster, University Münster; Institute of Neuropathology (A.J.), University Hospital Essen; and Institute of Pathology (H.A.B.), University Hospital Essen, Germany
| | - Anne K Mausberg
- Department of Neurology (M.S., A.K.M., R.P., C.K.), University Hospital Essen; Clinic of Neurology with Institute of Translational Neurology (C.C.G., A.S.-M., H.W., S.G.M.), University Hospital Münster, University Münster; Institute of Neuropathology (A.J.), University Hospital Essen; and Institute of Pathology (H.A.B.), University Hospital Essen, Germany
| | - Refik Pul
- Department of Neurology (M.S., A.K.M., R.P., C.K.), University Hospital Essen; Clinic of Neurology with Institute of Translational Neurology (C.C.G., A.S.-M., H.W., S.G.M.), University Hospital Münster, University Münster; Institute of Neuropathology (A.J.), University Hospital Essen; and Institute of Pathology (H.A.B.), University Hospital Essen, Germany
| | - Andreas Junker
- Department of Neurology (M.S., A.K.M., R.P., C.K.), University Hospital Essen; Clinic of Neurology with Institute of Translational Neurology (C.C.G., A.S.-M., H.W., S.G.M.), University Hospital Münster, University Münster; Institute of Neuropathology (A.J.), University Hospital Essen; and Institute of Pathology (H.A.B.), University Hospital Essen, Germany
| | - Hideo A Baba
- Department of Neurology (M.S., A.K.M., R.P., C.K.), University Hospital Essen; Clinic of Neurology with Institute of Translational Neurology (C.C.G., A.S.-M., H.W., S.G.M.), University Hospital Münster, University Münster; Institute of Neuropathology (A.J.), University Hospital Essen; and Institute of Pathology (H.A.B.), University Hospital Essen, Germany
| | - Andreas Schulte-Mecklenbeck
- Department of Neurology (M.S., A.K.M., R.P., C.K.), University Hospital Essen; Clinic of Neurology with Institute of Translational Neurology (C.C.G., A.S.-M., H.W., S.G.M.), University Hospital Münster, University Münster; Institute of Neuropathology (A.J.), University Hospital Essen; and Institute of Pathology (H.A.B.), University Hospital Essen, Germany
| | - Heinz Wiendl
- Department of Neurology (M.S., A.K.M., R.P., C.K.), University Hospital Essen; Clinic of Neurology with Institute of Translational Neurology (C.C.G., A.S.-M., H.W., S.G.M.), University Hospital Münster, University Münster; Institute of Neuropathology (A.J.), University Hospital Essen; and Institute of Pathology (H.A.B.), University Hospital Essen, Germany
| | - Christoph Kleinschnitz
- Department of Neurology (M.S., A.K.M., R.P., C.K.), University Hospital Essen; Clinic of Neurology with Institute of Translational Neurology (C.C.G., A.S.-M., H.W., S.G.M.), University Hospital Münster, University Münster; Institute of Neuropathology (A.J.), University Hospital Essen; and Institute of Pathology (H.A.B.), University Hospital Essen, Germany
| | - Sven G Meuth
- Department of Neurology (M.S., A.K.M., R.P., C.K.), University Hospital Essen; Clinic of Neurology with Institute of Translational Neurology (C.C.G., A.S.-M., H.W., S.G.M.), University Hospital Münster, University Münster; Institute of Neuropathology (A.J.), University Hospital Essen; and Institute of Pathology (H.A.B.), University Hospital Essen, Germany
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Stork L, Brück W, von Gottberg P, Pulkowski U, Kirsten F, Glatzel M, Rauer S, Scheibe F, Radbruch H, Hammer E, Stürner KH, Kaulen B, Heesen C, Hoffmann F, Brock S, Pawlitzki M, Bopp T, Metz I. Severe meningo-/encephalitis after daclizumab therapy for multiple sclerosis. Mult Scler 2019; 25:1618-1632. [DOI: 10.1177/1352458518819098] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Daclizumab is a monoclonal antibody that binds the high-affinity interleukin-2 receptor and was approved for the treatment of relapsing multiple sclerosis. Due to severe inflammatory brain disorders, the approval was suspended in March 2018. Objective and Methods: This retrospective cohort study summarizes clinical, laboratory, radiological, and histological findings of seven patients who developed meningo-/encephalitis after daclizumab therapy. Results: Patients presented with encephalitis and/or meningitis and suffered from systemic symptoms such as fever (5/7), exanthema (5/7), or gastrointestinal symptoms (4/7). Secondary autoimmune diseases developed. Blood analysis revealed an increase in eosinophils (5/7). Six patients fulfilled the diagnostic criteria for a drug reaction with eosinophilia and systemic symptoms (DRESS). Magnetic resonance imaging (MRI) showed multiple contrast-enhancing lesions, and enhancement of the ependyma (6/7), meninges (5/7), cranial or spinal nerves (2/7), and a vasculitic pattern (3/7). Histology revealed a pronounced inflammatory infiltrate consisting of lymphocytes, plasma cells and eosinophils, and densely infiltrated vessels. Most patients showed an insufficient therapeutic response and a high disability at last follow-up (median Expanded Disability Status Scale (EDSS) 8). Two patients died. Conclusion: Meningoencephalitis and DRESS may occur with daclizumab therapy. This potential lethal side effect is characterized by a dysregulated immune response. Our findings underline the importance of postmarketing drug surveillance.
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Affiliation(s)
- Lidia Stork
- Institute of Neuropathology, University Medical Center Göttingen, Göttingen, Germany
| | - Wolfgang Brück
- Institute of Neuropathology, University Medical Center Göttingen, Göttingen, Germany
| | - Phillip von Gottberg
- Institute of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Florian Kirsten
- Department of Neurology, Imland Hospital, Rendsburg, Germany
| | - Markus Glatzel
- Institute of Neuropathology, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Sebastian Rauer
- Department of Neurology, University Medical Center Freiburg, Freiburg, Germany
| | - Franziska Scheibe
- Department of Neurology, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Helena Radbruch
- Institute of Neuropathology, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Eckhard Hammer
- Department of Neurology, Marienkrankenhaus, Hamburg, Germany
| | - Klarissa H Stürner
- Department of Neurology, University Hospital Schleswig—Holstein, Kiel, Germany
| | - Barbara Kaulen
- Department of Neurology, University Hospital Hamburg Eppendorf, Hamburg, Germany; Institute of Neuroimmunology and Multiple Sclerosis, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Christoph Heesen
- Department of Neurology, University Hospital Hamburg Eppendorf, Hamburg, Germany; Institute of Neuroimmunology and Multiple Sclerosis, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Frank Hoffmann
- Department of Neurology, Martha-Maria Hospital, Halle, Germany
| | - Sebastian Brock
- Department of Neurology, Martha-Maria Hospital, Halle, Germany
| | - Marc Pawlitzki
- Department of Neurology, University Medical Center, Otto von Guericke University, Magdeburg, Germany
| | - Tobias Bopp
- Institute for Immunology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Imke Metz
- Institute of Neuropathology, University Medical Center Göttingen, Göttingen, Germany
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Dalmau J, Kolson DL, Paul F, Zamvil SS. N2 year in review and message from the editor to our reviewers. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 6:e525. [PMID: 30637299 PMCID: PMC6310359 DOI: 10.1212/nxi.0000000000000525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Josep Dalmau
- ICREA-IDIBAPS, Hospital Clínic (J.D.), University of Barcelona, Spain; the University of Pennsylvania (J.D, D.L.K.), Philadelphia, PA; the Charite University Hospital (F.P.), Berlin, Germany; and the Department of Neurology (S.S.Z.), University of California, San Francisco, CA
| | - Dennis L Kolson
- ICREA-IDIBAPS, Hospital Clínic (J.D.), University of Barcelona, Spain; the University of Pennsylvania (J.D, D.L.K.), Philadelphia, PA; the Charite University Hospital (F.P.), Berlin, Germany; and the Department of Neurology (S.S.Z.), University of California, San Francisco, CA
| | - Friedemann Paul
- ICREA-IDIBAPS, Hospital Clínic (J.D.), University of Barcelona, Spain; the University of Pennsylvania (J.D, D.L.K.), Philadelphia, PA; the Charite University Hospital (F.P.), Berlin, Germany; and the Department of Neurology (S.S.Z.), University of California, San Francisco, CA
| | - Scott S Zamvil
- ICREA-IDIBAPS, Hospital Clínic (J.D.), University of Barcelona, Spain; the University of Pennsylvania (J.D, D.L.K.), Philadelphia, PA; the Charite University Hospital (F.P.), Berlin, Germany; and the Department of Neurology (S.S.Z.), University of California, San Francisco, CA
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Rasche L, Paul F. Ozanimod for the treatment of relapsing remitting multiple sclerosis. Expert Opin Pharmacother 2018; 19:2073-2086. [PMID: 30407868 DOI: 10.1080/14656566.2018.1540592] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Ozanimod is a selective sphingosine 1-phosphate receptor 1 and 5 modulator under development by Celgene, for the treatment of relapsing remitting multiple sclerosis. Extensive clinical experience has become available for the related compound fingolimod, favoring the sphingosine 1-phosphate therapeutic concept. Off-target effects have been attributed to its low receptor specificity and have prompted the development of next generation sphingosine 1-phosphate receptor modulators. Areas covered: The authors evaluate the literature of ozanimod, using the PubMed database as well as repositories of the European Committee for Treatment and Research in Multiple Sclerosis and the American and European Academy of Neurology. Specifically, the authors cover and discuss the preclinical data on ozanimod, pharmacokinetics and dynamics, and data on efficacy and safety from the pivotal trials. Expert opinion: Superiority of ozanimod over intramuscular interferon β-1a with regard to reduction in annualized relapse rate and magnetic resonance imaging outcomes has been shown in two phase III trials. The beneficial effect on brain volume and gray matter loss are encouraging and in line with data on other newer immunomodulators. Ozanimod is a valuable contribution to the therapeutic armamentarium in MS, although the effect on disability progression is unclear and requires further investigations.
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Affiliation(s)
- Ludwig Rasche
- a NeuroCure Clinical Research Center , Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität, and Berlin Institute of Health , Berlin , Germany
| | - Friedemann Paul
- a NeuroCure Clinical Research Center , Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität, and Berlin Institute of Health , Berlin , Germany.,b Experimental and Clinical Research Center , Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität, and Berlin Institute of Health , Berlin , Germany.,c Department of Neurology , Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health , Berlin , Germany
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Borisow N, Mori M, Kuwabara S, Scheel M, Paul F. Diagnosis and Treatment of NMO Spectrum Disorder and MOG-Encephalomyelitis. Front Neurol 2018; 9:888. [PMID: 30405519 PMCID: PMC6206299 DOI: 10.3389/fneur.2018.00888] [Citation(s) in RCA: 164] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 10/01/2018] [Indexed: 12/21/2022] Open
Abstract
Neuromyelitis optica spectrum disorders (NMOSD) are autoantibody mediated chronic inflammatory diseases. Serum antibodies (Abs) against the aquaporin-4 water channel lead to recurrent attacks of optic neuritis, myelitis and/or brainstem syndromes. In some patients with symptoms of NMOSD, no AQP4-Abs but Abs against myelin-oligodendrocyte-glycoprotein (MOG) are detectable. These clinical syndromes are now frequently referred to as "MOG-encephalomyelitis" (MOG-EM). Here we give an overview on current recommendations concerning diagnosis of NMOSD and MOG-EM. These include antibody and further laboratory testing, MR imaging and optical coherence tomography. We discuss therapeutic options of acute attacks as well as longterm immunosuppressive treatment, including azathioprine, rituximab, and immunoglobulins.
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Affiliation(s)
- Nadja Borisow
- NeuroCure Clinical Research Center, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Masahiro Mori
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Satoshi Kuwabara
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Michael Scheel
- NeuroCure Clinical Research Center, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Neuroradiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Friedemann Paul
- NeuroCure Clinical Research Center, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité – Universitätsmedizin Berlin, Berlin, Germany
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