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Gilhus NE, Andersen H, Andersen LK, Boldingh M, Laakso S, Leopoldsdottir MO, Madsen S, Piehl F, Popperud TH, Punga AR, Schirakow L, Vissing J. Generalized myasthenia gravis with acetylcholine receptor antibodies: A guidance for treatment. Eur J Neurol 2024; 31:e16229. [PMID: 38321574 PMCID: PMC11236053 DOI: 10.1111/ene.16229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/16/2024] [Accepted: 01/16/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND Generalized myasthenia gravis (MG) with antibodies against the acetylcholine receptor is a chronic disease causing muscle weakness. Access to novel treatments warrants authoritative treatment recommendations. The Nordic countries have similar, comprehensive health systems, mandatory health registers, and extensive MG research. METHODS MG experts and patient representatives from the five Nordic countries formed a working group to prepare treatment guidance for MG based on a systematic literature search and consensus meetings. RESULTS Pyridostigmine represents the first-line symptomatic treatment, while ambenonium and beta adrenergic agonists are second-line options. Early thymectomy should be undertaken if a thymoma, and in non-thymoma patients up to the age of 50-65 years if not obtaining remission on symptomatic treatment. Most patients need immunosuppressive drug treatment. Combining corticosteroids at the lowest possible dose with azathioprine is recommended, rituximab being an alternative first-line option. Mycophenolate, methotrexate, and tacrolimus represent second-line immunosuppression. Plasma exchange and intravenous immunoglobulin are used for myasthenic crises and acute exacerbations. Novel complement inhibitors and FcRn blockers are effective and fast-acting treatments with promising safety profiles. Their use depends on local availability, refunding policies, and cost-benefit analyses. Adapted physical training is recommended. Planning of pregnancies with optimal treatment, information, and awareness of neonatal MG is necessary. Social support and adaptation of work and daily life activities are recommended. CONCLUSIONS Successful treatment of MG rests on timely combination of different interventions. Due to spontaneous disease fluctuations, comorbidities, and changes in life conditions, regular long-term specialized follow-up is needed. Most patients do reasonably well but there is room for further improvement. Novel treatments are promising, though subject to restricted access due to costs.
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Affiliation(s)
- Nils Erik Gilhus
- Department of NeurologyHaukeland University HospitalBergenNorway
- Department of Clinical MedicineUniversity of BergenBergenNorway
| | | | - Linda Kahr Andersen
- Copenhagen Neuromuscular Center, Department of NeurologyCopenhagen University HospitalCopenhagenDenmark
| | | | - Sini Laakso
- Department of Neurology, Brain CenterHelsinki University HospitalHelsinkiFinland
- Translational Immunology Research ProgramUniversity of HelsinkiHelsinkiFinland
| | | | - Sidsel Madsen
- The National Rehabilitation Center for Neuromuscular DiseasesAarhusDenmark
| | - Fredrik Piehl
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
- Department of NeurologyKarolinska University HospitalStockholmSweden
| | | | - Anna Rostedt Punga
- Department of Medical SciencesUppsala UniversityUppsalaSweden
- Department of Clinical NeurophysiologyUppsala University HospitalUppsalaSweden
| | | | - John Vissing
- Copenhagen Neuromuscular Center, Department of NeurologyCopenhagen University HospitalCopenhagenDenmark
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Anderson A, Rowles W, Poole S, Balan A, Bevan C, Brandstadter R, Ciplea AI, Cooper J, Fabian M, Hale TW, Jacobs D, Kakara M, Krysko KM, Longbrake EE, Marcus J, Repovic P, Riley CS, Romeo AR, Rutatangwa A, West T, Hellwig K, LaHue SC, Bove R. Anti-CD20 monoclonal antibody therapy in postpartum women with neurological conditions. Ann Clin Transl Neurol 2023; 10:2053-2064. [PMID: 37675826 PMCID: PMC10647007 DOI: 10.1002/acn3.51893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 09/08/2023] Open
Abstract
OBJECTIVE Postpartum, patients with multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) have increased risk for disease activity. Anti-CD20 IgG1 monoclonal antibodies (mAb) are increasingly used as disease-modifying therapies (DMTs). Patients may wish to both breastfeed and resume DMT postpartum. This study aimed to determine the transfer of anti-CD20 IgG1 mAbs, ocrelizumab, and rituximab (OCR/RTX), into mature breastmilk and describe maternal and infant outcomes. METHODS Fifty-seven cis-women receiving OCR/RTX after 59 pregnancies and their infants were enrolled and followed up to 12M postpartum or 90 days post-infusion. Breastmilk was collected pre-infusion and serially up to 90 days and assayed for mAb concentration. Medical records and patients' questionnaire responses were obtained to assess neurologic, breastfeeding, and infant development outcomes. RESULTS The median average concentration of mAb in breastmilk was low (OCR: 0.08 μg/mL, range 0.05-0.4; RTX: 0.03 μg/mL, range 0.005-0.3). Concentration peaked 1-7 days post-infusion in most (77%) and was nearly undetectable after 90 days. Median average relative infant dose was <1% (OCR: 0.1%, range 0.07-0.7; RTX: 0.04%, range 0.005-0.3). Forty-three participants continued to breastfeed post-infusion. At 8-12 months, the proportion of infants' growth between the 3rd and 97th World Health Organization percentiles did not differ for breastfed (36/40) and non-breastfed (14/16, p > 0.05) infants; neither did the proportion with normal development (breastfed: 37/41, non-breastfed: 11/13; p > 0.05). After postpartum infusion, two mothers experienced a clinical relapse. INTERPRETATION These confirm minimal transfer of mAb into breastmilk. Anti-CD20 mAb therapy stabilizes MS activity before conception to the postpartum period, and postpartum treatments appears to be safe and well-tolerated for both mother and infant.
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Affiliation(s)
- Annika Anderson
- UCSF Weill Institute for NeurosciencesUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - William Rowles
- UCSF Weill Institute for NeurosciencesUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Shane Poole
- UCSF Weill Institute for NeurosciencesUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Ayushi Balan
- UCSF Weill Institute for NeurosciencesUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Carolyn Bevan
- Department of NeurologyNorthwestern UniversityChicagoIllinoisUSA
| | - Rachel Brandstadter
- Department of NeurologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | | | | | | | - Thomas W. Hale
- Texas Tech University Health Sciences CenterAmarilloTexasUSA
| | - Dina Jacobs
- Department of NeurologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Mihir Kakara
- Department of NeurologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Kristen M. Krysko
- Division of Neurology, Department of Medicine, St Michael's HospitalUniversity of TorontoTorontoONCanada
- Li Ka Shing Knowledge InstituteUniversity of TorontoTorontoONCanada
| | | | - Jacqueline Marcus
- Department of NeurologyKaiser Permanente San FranciscoSan FranciscoCaliforniaUSA
| | - Pavle Repovic
- Department of NeurologySwedish Medical CenterSeattleWashingtonUSA
| | - Claire S. Riley
- Department of NeurologyColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Andrew R. Romeo
- Department of NeurologyUniversity of MichiganAnn ArborMichiganUSA
| | - Alice Rutatangwa
- UCSF Weill Institute for NeurosciencesUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | | | | | - Sara C. LaHue
- UCSF Weill Institute for NeurosciencesUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
- Buck Institute for Research on AgingNovatoCaliforniaUSA
| | - Riley Bove
- UCSF Weill Institute for NeurosciencesUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
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3
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Marshall NE, Blanton MB, Doratt BM, Malherbe DC, Rincon M, Messaoudi I. Monoclonal Antibody Therapy of Breastfeeding Patient Infected with SARS-CoV-2: A Case Report. Breastfeed Med 2023; 18:626-630. [PMID: 37615569 PMCID: PMC10460680 DOI: 10.1089/bfm.2023.0102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
Introduction: Although safety data demonstrated the efficacy and effectiveness of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination for all individuals over 6 months of age, including pregnant and breastfeeding individuals, optimal treatment courses for symptomatic pregnant and lactating individuals infected with SARS-CoV-2 remain to be defined. Case Description: A coronavirus disease 2019 (COVID-19)-vaccinated breastfeeding woman received anti-SARS-CoV-2 monoclonal antibody treatment casirivimab-imdevimab 5 days after diagnosis of a symptomatic breakthrough SARS-CoV-2 infection. Results and Conclusions: The patient did not present with obvious defects in innate or adaptive cellular subsets, but compared with controls had minimal maternal antibody response to recommended pregnancy vaccinations including SARS-CoV-2 and tetanus, diphtheria, pertussis (TDaP). The outcome of the monoclonal antibody infusion treatment was favorable as it transiently increased SARS-CoV-2 antibody titers in plasma and human milk compartments.
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Affiliation(s)
- Nicole E. Marshall
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| | - Madison B. Blanton
- Department of Microbiology, Immunology, and Molecular Genetics, College of Medicine, University of Kentucky, Lexington, Kentucky, USA
- Department of Pharmaceutical Sciences, University of Kentucky, Lexington, Kentucky, USA
| | - Brianna M. Doratt
- Department of Microbiology, Immunology, and Molecular Genetics, College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Delphine C. Malherbe
- Department of Microbiology, Immunology, and Molecular Genetics, College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Monica Rincon
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| | - Ilhem Messaoudi
- Department of Microbiology, Immunology, and Molecular Genetics, College of Medicine, University of Kentucky, Lexington, Kentucky, USA
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4
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Gklinos P, Dobson R. Monoclonal Antibodies in Pregnancy and Breastfeeding in Patients with Multiple Sclerosis: A Review and an Updated Clinical Guide. Pharmaceuticals (Basel) 2023; 16:ph16050770. [PMID: 37242553 DOI: 10.3390/ph16050770] [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: 04/22/2023] [Revised: 05/18/2023] [Accepted: 05/19/2023] [Indexed: 05/28/2023] Open
Abstract
The use of high-efficacy disease-modifying therapies (DMTs) early in the course of multiple sclerosis (MS) has been shown to improve clinical outcomes and is becoming an increasingly popular treatment strategy. As a result, monoclonal antibodies, including natalizumab, alemtuzumab, ocrelizumab, ofatumumab, and ublituximab, are frequently used for the treatment of MS in women of childbearing age. To date, only limited evidence is available on the use of these DMTs in pregnancy. We aim to provide an updated overview of the mechanisms of action, risks of exposure and treatment withdrawal, and pre-conception counseling and management during pregnancy and post-partum of monoclonal antibodies in women with MS. Discussing treatment options and family planning with women of childbearing age is essential before commencing a DMT in order to make the most suitable choice for each individual patient.
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Affiliation(s)
- Panagiotis Gklinos
- Department of Neurology, Aeginition University Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Population Health, QMUL, London EC1M 6BQ, UK
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London E1 1FR, UK
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5
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Abstract
Migraine is a global neurologic disease that is highly prevalent, especially in women. Studies have observed a predisposition for the development of migraine in women, although the mechanisms involved have yet to be fully elucidated. This review aimed to summarize the recent evidence regarding the epidemiology, pathophysiology, and treatment of migraine and highlight key sex differences. We also identify gaps in care for both women and men living with migraine and discuss the presence of migraine-related stigma and how this may impact the efficacy of clinical care.
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LaHue SC, Paolini S, Waters JFR, O'Neal MA. Opinion and Special Article: The Need for Specialized Training in Women's Neurology. Neurology 2023; 100:38-42. [PMID: 36180236 PMCID: PMC9827127 DOI: 10.1212/wnl.0000000000201451] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 09/08/2022] [Indexed: 01/11/2023] Open
Abstract
Women's Neurology is an emerging subspecialty that focuses on neurologic disorders across a woman's lifetime. This new domain recognizes that both health and disease are directly affected by hormonal and reproductive changes throughout the life span. This field includes neurologic diseases with a higher prevalence in women and diseases that require specialized management during pregnancy, postpartum period, lactation, and menopause. A survey was sent to US neurology residency program directors to understand the state of training in the area. Their responses highlighted an urgent need for additional education in this field for neurology residents. In this study, we discuss the educational gaps in this area, the clinical benefits of a women's neurology discipline, and the instructional gaps in this area and provide practical recommendations for training programs in women's neurology using 2 innovative fellowship programs.
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Affiliation(s)
- Sara C LaHue
- From the Department of Neurology (S.C.L.), University of California San Francisco; Department of Neurology (S.C.L.), Weill Institute for Neurosciences, University of California San Francisco; Department of Neurology (S.P.), University of South Carolina School of Medicine, Columbia; Department of Neurology (J.F.R.W.), University of Pittsburgh Medical Center, PA; and Department of Neurology (M.A.O.N.), Brigham and Women's Hospital, Boston, MA.
| | - Stephanie Paolini
- From the Department of Neurology (S.C.L.), University of California San Francisco; Department of Neurology (S.C.L.), Weill Institute for Neurosciences, University of California San Francisco; Department of Neurology (S.P.), University of South Carolina School of Medicine, Columbia; Department of Neurology (J.F.R.W.), University of Pittsburgh Medical Center, PA; and Department of Neurology (M.A.O.N.), Brigham and Women's Hospital, Boston, MA
| | - Janet F R Waters
- From the Department of Neurology (S.C.L.), University of California San Francisco; Department of Neurology (S.C.L.), Weill Institute for Neurosciences, University of California San Francisco; Department of Neurology (S.P.), University of South Carolina School of Medicine, Columbia; Department of Neurology (J.F.R.W.), University of Pittsburgh Medical Center, PA; and Department of Neurology (M.A.O.N.), Brigham and Women's Hospital, Boston, MA
| | - Mary A O'Neal
- From the Department of Neurology (S.C.L.), University of California San Francisco; Department of Neurology (S.C.L.), Weill Institute for Neurosciences, University of California San Francisco; Department of Neurology (S.P.), University of South Carolina School of Medicine, Columbia; Department of Neurology (J.F.R.W.), University of Pittsburgh Medical Center, PA; and Department of Neurology (M.A.O.N.), Brigham and Women's Hospital, Boston, MA
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7
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Landi D, Bovis F, Grimaldi A, Annovazzi PO, Bertolotto A, Bianchi A, Borriello G, Brescia Morra V, Bucello S, Buscarinu MC, Caleri F, Capobianco M, Capra R, Cellerino M, Centonze D, Cerqua R, Chisari CG, Clerico M, Cocco E, Cola G, Cordioli C, Curti E, d'Ambrosio A, D'Amico E, De Luca G, Di Filippo M, Di Lemme S, Fantozzi R, Ferraro D, Ferraro E, Gallo A, Gasperini C, Granella F, Inglese M, Lanzillo R, Lorefice L, Lus G, Malucchi S, Margoni M, Mataluni G, Mirabella M, Moiola L, Nicoletti CG, Nociti V, Patti F, Pinardi F, Portaccio E, Pozzilli C, Ragonese P, Rasia S, Salemi G, Signoriello E, Vitetta F, Totaro R, Sormani MP, Amato MP, Marfia GA. Exposure to natalizumab throughout pregnancy: effectiveness and safety in an Italian cohort of women with multiple sclerosis. J Neurol Neurosurg Psychiatry 2022:jnnp-2022-329657. [PMID: 36180219 DOI: 10.1136/jnnp-2022-329657] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 08/23/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Assessing the risk of clinical and radiological reactivation during pregnancy and post partum in women with multiple sclerosis (MS) treated with natalizumab (NTZ) throughout pregnancy (LONG_EXP) compared with women interrupting treatment before (NO_EXP) and within >-30 days and ≤90 days from conception (SHORT_EXP), and describing newborns' outcomes. METHODS Maternal clinical and radiological outcomes and obstetric and fetal outcomes were retrospectively collected and compared among groups (NO_EXP, SHORT_EXP, LONG_EXP). Predictors of clinical and radiological reactivation were investigated through univariable and multivariable analysis. RESULTS 170 eligible pregnancies from 163 women referring to 29 Italian MS centres were included. Annualised relapse rate (ARR) was significantly lower in LONG_EXP (n=66, 0.02 (0.001-0.09)) compared with NO_EXP (n=31, 0.43 (0.21-0.75), p=0.002) and SHORT_EXP (n=73, 0.46 (0.30-0.66), p=0.0004) during pregnancy, and in LONG_EXP (0.12 (0.05-0.24)) compared with SHORT_EXP (0.30 (0.17-0.50), p=0.008) during post partum. Gadolinium-enhancing (Gd+) lesions were less frequent in LONG_EXP (n=6/50, 2.00%) compared with NO_EXP (n=9/21, 42.86%) and SHORT_EXP after delivery (n=17/49, 34.69%, p=0.010).Delaying NTZ resumption after delivery significantly increased the risk of relapses (OR=1.29 (95% CI 1.07 to 1.57), p=0.009) and Gd+ lesions (OR=1.49 (95% CI 1.17 to 1.89, p=0.001). Newborns' weight, length, head circumference and gestational age did not differ among groups after adjusting for confounders. Anaemia was tracked in 4/69 LONG_EXP newborns. Congenital anomaly rate was within the expected range for the untreated MS population. CONCLUSIONS Our findings indicate that in women with MS treated with NTZ before conception, continuation of NTZ throughout pregnancy and its early resumption after delivery mitigate the risk of clinical and radiological reactivation. This approach has no major impact on newborns' outcomes.
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Affiliation(s)
- Doriana Landi
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, University of Rome Tor Vergata, Roma, Italy
| | - Francesca Bovis
- Department of Health Sciences, Section of Biostatistics, University of Genova, Genoa, Italy
| | - Alfonso Grimaldi
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, University of Rome Tor Vergata, Roma, Italy
| | - Pietro Osvaldo Annovazzi
- Multiple Sclerosis Center, Neurology II Unit, ASST Valle Olona, Gallarate Hospital, Gallarate, Italy
| | - Antonio Bertolotto
- Multiple Sclerosis Center (CRESM), Department of Neurology, 'San Luigi Gonzaga' University Hospital, Orbassano, Italy
| | - Alessia Bianchi
- Unit of Neurology, Department of Biomedicine, Neurosciences and Advanced Diagnostics, Palermo University, Palermo, Italy
| | - Giovanna Borriello
- Multiple Sclerosis Center, 'S. Andrea' Hospital, Sapienza University of Rome, Rome, Italy
| | - Vincenzo Brescia Morra
- Department of Neurosciences Reproductive Sciences and Odontostomatology, Multiple Sclerosis Center, Federico II University, Naples, Italy
| | - Sebastiano Bucello
- Multiple Sclerosis Center, "E. Muscatello" Hospital - ASP8, Augusta (SR), Italy
| | - Maria Chiara Buscarinu
- Department of Neuroscience, Mental Health and Sensory Organs, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Francesca Caleri
- Multiple Sclerosis Center, Department of Neurology, 'F. Tappeiner' Hospital, Merano (BZ), Italy
| | - Marco Capobianco
- Multiple Sclerosis Center (CRESM), Department of Neurology, 'San Luigi Gonzaga' University Hospital, Orbassano, Italy
| | - Ruggero Capra
- Multiple Sclerosis Center, Spedali Civili of Brescia, Montichiari (BS), Italy
| | - Maria Cellerino
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genova, Italy
| | - Diego Centonze
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Unit of Neurology, IRCCS Neuromed, Pozzilli (IS), Italy
| | - Raffaella Cerqua
- Neurological Clinic, Department of Experimental and Clinical Medicine, Ospedali Riuniti, Ancona, Italy
| | - Clara Grazia Chisari
- Department of Medical and Surgical Sciences and Advanced Technologies 'G.F. Ingrassia', Section of Neurosciences, University of Catania, Catania, Italy
| | - Marinella Clerico
- Clinical and Biological Sciences Department, Neurology Unit, University of Torino, 'San Luigi Gonzaga' Hospital, Orbassano, Italy
| | - Eleonora Cocco
- Multiple Sclerosis Center, Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Gaia Cola
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, University of Rome Tor Vergata, Roma, Italy
| | - Cinzia Cordioli
- Multiple Sclerosis Center, Spedali Civili of Brescia, Montichiari (BS), Italy
| | - Erica Curti
- Unit of Neurology, Department of General and Specialized Medicine, Parma University Hospital, Parma, Italy
| | - Alessandro d'Ambrosio
- I Division of Neurology, Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", Napoli, Italy
| | - Emanuele D'Amico
- Department of Medical and Surgical Sciences and Advanced Technologies 'G.F. Ingrassia', Section of Neurosciences, University of Catania, Catania, Italy
| | - Giovanna De Luca
- Multiple Sclerosis Center, 'SS Annunziata' Hospital, 'Gabriele d'Annunzio' University Chieti-Pesacara, Chieti, Italy
| | - Massimiliano Di Filippo
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | | | | | - Diana Ferraro
- Department of Biomedical Metabolic and Neurosciences, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Antonio Gallo
- I Division of Neurology, Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", Napoli, Italy
| | - Claudio Gasperini
- Department of Neurosciences, 'San Camillo Forlanini' Hospital, Rome, Italy
| | - Franco Granella
- Unit of Neurology, Department of General and Specialized Medicine, Parma University Hospital, Parma, Italy
| | - Matilde Inglese
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genova, Italy
- Department of Neurology, Policlinico 'San Martino Hospital'-Sistema Sanitario Regione, Genoa, Italy
| | - Roberta Lanzillo
- Department of Neurosciences Reproductive Sciences and Odontostomatology, Multiple Sclerosis Center, Federico II University, Naples, Italy
| | - Lorena Lorefice
- Multiple Sclerosis Centre, Binaghi Hospital, ATS Sardegna-Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Giacomo Lus
- Department of Advanced Medical and Surgical Sciences, II Division of Neurology, Multiple Sclerosis Center, University of Campania 'L. Vanvitelli', Naples, Italy
| | - Simona Malucchi
- Multiple Sclerosis Center (CRESM), Department of Neurology, 'San Luigi Gonzaga' University Hospital, Orbassano, Italy
| | - Monica Margoni
- Multiple Sclerosis Center of the Veneto Region, Department of Neurosciences, University of Padua, Padua, Italy
| | - Giorgia Mataluni
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, University of Rome Tor Vergata, Roma, Italy
| | - Massimiliano Mirabella
- Department of Neurosciences, Centro di Ricerca Sclerosi Multipla (CERSM), Università Cattolica del Sacro Cuore, Rome, Italy, 'A.Gemelli' University Hospital, Rome, Italy
| | - Lucia Moiola
- Multiple Sclerosis Center, Neurology Department, San Raffaele Hospital IRCCS, Milan, Italy
| | - Carolina Gabri Nicoletti
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, University of Rome Tor Vergata, Roma, Italy
| | - Viviana Nociti
- Department of Neurosciences, Centro di Ricerca Sclerosi Multipla (CERSM), Università Cattolica del Sacro Cuore, Rome, Italy, 'A.Gemelli' University Hospital, Rome, Italy
| | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies 'G.F. Ingrassia', Section of Neurosciences, University of Catania, Catania, Italy
| | - Federica Pinardi
- UOSI Multiple Sclerosis Rehabilitation, IRCCS Istituto delle scienze neurologiche, Bologna, Italy
| | - Emilio Portaccio
- Division Neurological Rehabilitation, Department of NEUROFARBA, University of Florence, Florence, Italy
| | - Carlo Pozzilli
- Multiple Sclerosis Center, Department of Human Neurosciences, 'S.Andrea' Hospital, Sapienza University of Rome, Rome, Italy
| | - Paolo Ragonese
- Unit of Neurology, Department of Biomedicine, Neurosciences and Advanced Diagnostics, Palermo University, Palermo, Italy
| | - Sarah Rasia
- Multiple Sclerosis Center, Spedali Civili of Brescia, Montichiari (BS), Italy
| | - Giuseppe Salemi
- Unit of Neurology, Department of Biomedicine, Neurosciences and Advanced Diagnostics, Palermo University, Palermo, Italy
| | - Elisabetta Signoriello
- Department of Advanced Medical and Surgical Sciences, II Division of Neurology, Multiple Sclerosis Center, University of Campania 'L. Vanvitelli', Naples, Italy
| | - Francesca Vitetta
- Neurology Unit, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Rocco Totaro
- Demyelinating Disease Center, Neurology Unit, University of L'Aquila, L'Aquila, Italy
| | - Maria Pia Sormani
- Department of Health Sciences, Section of Biostatistics, University of Genova, Genoa, Italy
| | - Maria Pia Amato
- Division Neurological Rehabilitation, Department of NEUROFARBA, University of Florence, Florence, Italy
- IRCCS, Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Girolama Alessandra Marfia
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, University of Rome Tor Vergata, Roma, Italy
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8
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Rød BE, Torkildsen Ø, Myhr KM, Bø L, Wergeland S. Safety of breast feeding during rituximab treatment in multiple sclerosis. J Neurol Neurosurg Psychiatry 2022; 94:jnnp-2022-329545. [PMID: 35879056 PMCID: PMC9763193 DOI: 10.1136/jnnp-2022-329545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/29/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND There are limited data on the safety of breast feeding during rituximab therapy. Our objective is to determine exposure from breast feeding and biological effects of rituximab in breastfed infants. METHODS In our case series of six mother-infant pairs, the nursing mothers with relapsing-remitting multiple sclerosis received rituximab during breast feeding. As part of clinical follow-up, six serial breast milk samples, and blood samples from both mothers and infants, were collected and analysed. RESULTS The median average rituximab concentration (Cavg) in breast milk was 0.04 µg/mL and the estimated relative infant dose (RID) was 0.07%. The highest measured concentration of rituximab in the breast milk samples was 0.25 µg/mL, giving an estimated RID of 0.26%.All infant serum rituximab concentrations were below 0.01 µg/mL. The CD19 +B cell count values were within the 10th- 90th percentiles of reported normal ranges in healthy infants. CONCLUSIONS We found minimal transfer of rituximab into breast milk and could not reliably detect levels of rituximab in infant serum. B cell counts in infants were unaffected.
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Affiliation(s)
- Brit Ellen Rød
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Øivind Torkildsen
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Kjell-Morten Myhr
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Lars Bø
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Norwegian Multiple Sclerosis Competence Centre, Haukeland University Hospital, Bergen, Norway
| | - Stig Wergeland
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Norwegian MS-Registry and Biobank, Haukeland University Hospital, Bergen, Norway
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Bove R, Hellwig K, Pasquarelli N, Borriello F, Dobson R, Oreja-Guevara C, Lin CJ, Zecevic D, Craveiro L, McElrath T, Vukusic S. Ocrelizumab during pregnancy and lactation: Rationale and design of the MINORE and SOPRANINO studies in women with MS and their infants. Mult Scler Relat Disord 2022; 64:103963. [PMID: 35753176 DOI: 10.1016/j.msard.2022.103963] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/26/2022] [Accepted: 06/10/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Most disease-modifying therapies (DMTs) approved for the treatment of multiple sclerosis (MS) are not recommended during pregnancy, and discouraged while breastfeeding. However, discontinuation of some DMTs before pregnancy can leave women vulnerable to MS relapses. Although available data on ocrelizumab suggest no increased risk in terms of pregnancy or neonatal outcomes, it is unknown whether ocrelizumab transfers across the placenta or is absorbed through breastmilk; and if so, whether infant B cell development, immune responses or growth and development are affected. This manuscript describes two studies designed to address these uncertainties. METHODS/DESIGN MINORE and SOPRANINO are multicentre open-label studies. MINORE, which addresses placental transfer, will recruit 44 women with MS or clinically isolated syndrome (CIS) exposed to ocrelizumab between 6 months before the last menstrual period (LMP) to the end of the first trimester. It will evaluate pharmacodynamic effects of potential in utero exposure through the proportion of infants with B cell numbers below lower limit of normal (LLN) at week 6 of life (primary endpoint); as well as through vaccine-induced antibody responses (reflecting B cell function) during the first year of life. Placental transfer will be assessed through measurement of ocrelizumab concentrations in paired samples at delivery (maternal blood as well as umbilical cord blood), and infant serum at week 6 of life. SOPRANINO, which evaluates breastmilk transfer, will recruit 20 women with MS or CIS who resume or initiate ocrelizumab treatment while breastfeeding. The effect of potential exposure through breastmilk will be assessed through the proportion of infants with B cell levels below LLN at 30 days after the mother's first post-partum ocrelizumab infusion (co-primary endpoint). Infant exposure via breastmilk will be assessed through ocrelizumab average daily infant dose in breastmilk over 60 days after the same infusion (co-primary endpoint). Vaccine-induced responses will be measured as in MINORE. Both studies will also measure infant growth and development over the first year of life and safety outcomes in both mothers and infants. All analyses will be descriptive, under an estimand framework. DISCUSSION Both studies are designed to mimic real-world clinical practice. Treatment decisions for ocrelizumab are independent from study participation; as such, these studies will recruit women who decide, along with their physicians, to continue their pregnancies despite potential in utero exposure (for MINORE); or to breastfeed while under ocrelizumab treatment (for SOPRANINO). MINORE is the first prospective study to measure placental transfer of any DMT in MS, and to perform comprehensive assessments in infants and mothers. Results may inform the optimal contraception period for women treated with ocrelizumab who are planning a pregnancy. Similarly, SOPRANINO is the first prospective study to measure pharmacodynamic effects of ocrelizumab in breastfed infants in addition to pharmacokinetic parameters in breastmilk. SOPRANINO may establish whether breastfeeding is safe for infants whose mothers received treatment with ocrelizumab. CONCLUSION By collecting detailed pharmacokinetic, pharmacodynamic and safety information, MINORE and SOPRANINO will contribute to understanding the risk/benefit of ocrelizumab in pregnant and lactating women with MS.
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Affiliation(s)
- Riley Bove
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States.
| | - Kerstin Hellwig
- Katholisches Klinikum Bochum, St. Josef Hospital, Universitätsklinikum der Ruhr-Universität, Bochum, Germany
| | | | | | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | | | | | | | | | - Thomas McElrath
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Sandra Vukusic
- Service de Neurologie et Sclérose en Plaques, Fondation Eugène Devic EDMUS contre la Sclérose en Plaques, Hôpital Neurologique Pierre Wertheimer, Lyon, France
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Bove RM, Houtchens MK. Pregnancy Management in Multiple Sclerosis and Other Demyelinating Diseases. Continuum (Minneap Minn) 2022; 28:12-33. [DOI: 10.1212/con.0000000000001108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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11
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LaHue SC, Anderson A, Krysko KM, Rutatangwa A, Dorsey MJ, Hale T, Mahadevan U, Rogers EE, Rosenstein MG, Bove R. Transfer of monoclonal antibodies into breastmilk in neurologic and non-neurologic diseases. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 7:e769. [PMID: 32461351 PMCID: PMC7286664 DOI: 10.1212/nxi.0000000000000769] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 04/23/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To review currently available data on the transfer of monoclonal antibodies (mAbs) in the breastmilk of women receiving treatment for neurologic and non-neurologic diseases. METHODS We systematically searched the medical literature for studies referring to 19 selected mAb therapies frequently used in neurologic conditions and "breastmilk," "breast milk," "breastfeeding," or "lactation." From an initial list of 288 unique references, 29 distinct full-text studies met the eligibility criteria. One additional study was added after the literature search based on expert knowledge of an additional article. These 30 studies were reviewed. These assessed the presence of our selected mAbs in human breastmilk in samples collected from a total of 155 individual women. RESULTS Drug concentrations were typically low in breastmilk and tended to peak within 48 hours, although maximum levels could occur up to 14 days from infusion. Most studies did not evaluate the breastmilk to maternal serum drug concentration ratio, but in those evaluating this, the highest ratio was 1:20 for infliximab. Relative infant dose, a metric comparing the infant with maternal drug dose (<10% is generally considered safe), was evaluated for certolizumab (<1%), rituximab (<1%), and natalizumab (maximum of 5.3%; cumulative effects of monthly dosing are anticipated). Importantly, a total of 368 infants were followed for ≥6 months after exposure to breastmilk of mothers treated with mAbs; none experienced reported developmental delay or serious infections. CONCLUSIONS The current data are reassuring for low mAb drug transfer to breastmilk, but further studies are needed, including of longer-term effects on infant immunity and childhood development.
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Affiliation(s)
- Sara C LaHue
- From the Department of Neurology (S.C.L., A.A., K.M.K., A.R., R.B.), School of Medicine, University of California San Francisco; Department of Neurology (S.C.L., A.A., K.M.K., A.R., R.B.), Weill Institute for Neurosciences, University of California San Francisco; Department of Pediatrics (M.J.D.), Division of Allergy, Immunology and Blood and Marrow Transplant, University of California San Francisco, CA; Department of Pediatrics (T.H.), Texas Tech University School of Medicine, Amarillo, TX; Department of Gastroenterology (U.M.), University of California San Francisco; Department of Pediatrics (E.E.R.), University of California San Francisco; and Department of Obstetrics (M.G.R.), Gynecology, and Reproductive Sciences, University of California San Francisco, CA
| | - Annika Anderson
- From the Department of Neurology (S.C.L., A.A., K.M.K., A.R., R.B.), School of Medicine, University of California San Francisco; Department of Neurology (S.C.L., A.A., K.M.K., A.R., R.B.), Weill Institute for Neurosciences, University of California San Francisco; Department of Pediatrics (M.J.D.), Division of Allergy, Immunology and Blood and Marrow Transplant, University of California San Francisco, CA; Department of Pediatrics (T.H.), Texas Tech University School of Medicine, Amarillo, TX; Department of Gastroenterology (U.M.), University of California San Francisco; Department of Pediatrics (E.E.R.), University of California San Francisco; and Department of Obstetrics (M.G.R.), Gynecology, and Reproductive Sciences, University of California San Francisco, CA
| | - Kristen M Krysko
- From the Department of Neurology (S.C.L., A.A., K.M.K., A.R., R.B.), School of Medicine, University of California San Francisco; Department of Neurology (S.C.L., A.A., K.M.K., A.R., R.B.), Weill Institute for Neurosciences, University of California San Francisco; Department of Pediatrics (M.J.D.), Division of Allergy, Immunology and Blood and Marrow Transplant, University of California San Francisco, CA; Department of Pediatrics (T.H.), Texas Tech University School of Medicine, Amarillo, TX; Department of Gastroenterology (U.M.), University of California San Francisco; Department of Pediatrics (E.E.R.), University of California San Francisco; and Department of Obstetrics (M.G.R.), Gynecology, and Reproductive Sciences, University of California San Francisco, CA
| | - Alice Rutatangwa
- From the Department of Neurology (S.C.L., A.A., K.M.K., A.R., R.B.), School of Medicine, University of California San Francisco; Department of Neurology (S.C.L., A.A., K.M.K., A.R., R.B.), Weill Institute for Neurosciences, University of California San Francisco; Department of Pediatrics (M.J.D.), Division of Allergy, Immunology and Blood and Marrow Transplant, University of California San Francisco, CA; Department of Pediatrics (T.H.), Texas Tech University School of Medicine, Amarillo, TX; Department of Gastroenterology (U.M.), University of California San Francisco; Department of Pediatrics (E.E.R.), University of California San Francisco; and Department of Obstetrics (M.G.R.), Gynecology, and Reproductive Sciences, University of California San Francisco, CA
| | - Morna J Dorsey
- From the Department of Neurology (S.C.L., A.A., K.M.K., A.R., R.B.), School of Medicine, University of California San Francisco; Department of Neurology (S.C.L., A.A., K.M.K., A.R., R.B.), Weill Institute for Neurosciences, University of California San Francisco; Department of Pediatrics (M.J.D.), Division of Allergy, Immunology and Blood and Marrow Transplant, University of California San Francisco, CA; Department of Pediatrics (T.H.), Texas Tech University School of Medicine, Amarillo, TX; Department of Gastroenterology (U.M.), University of California San Francisco; Department of Pediatrics (E.E.R.), University of California San Francisco; and Department of Obstetrics (M.G.R.), Gynecology, and Reproductive Sciences, University of California San Francisco, CA
| | - Thomas Hale
- From the Department of Neurology (S.C.L., A.A., K.M.K., A.R., R.B.), School of Medicine, University of California San Francisco; Department of Neurology (S.C.L., A.A., K.M.K., A.R., R.B.), Weill Institute for Neurosciences, University of California San Francisco; Department of Pediatrics (M.J.D.), Division of Allergy, Immunology and Blood and Marrow Transplant, University of California San Francisco, CA; Department of Pediatrics (T.H.), Texas Tech University School of Medicine, Amarillo, TX; Department of Gastroenterology (U.M.), University of California San Francisco; Department of Pediatrics (E.E.R.), University of California San Francisco; and Department of Obstetrics (M.G.R.), Gynecology, and Reproductive Sciences, University of California San Francisco, CA
| | - Uma Mahadevan
- From the Department of Neurology (S.C.L., A.A., K.M.K., A.R., R.B.), School of Medicine, University of California San Francisco; Department of Neurology (S.C.L., A.A., K.M.K., A.R., R.B.), Weill Institute for Neurosciences, University of California San Francisco; Department of Pediatrics (M.J.D.), Division of Allergy, Immunology and Blood and Marrow Transplant, University of California San Francisco, CA; Department of Pediatrics (T.H.), Texas Tech University School of Medicine, Amarillo, TX; Department of Gastroenterology (U.M.), University of California San Francisco; Department of Pediatrics (E.E.R.), University of California San Francisco; and Department of Obstetrics (M.G.R.), Gynecology, and Reproductive Sciences, University of California San Francisco, CA
| | - Elizabeth E Rogers
- From the Department of Neurology (S.C.L., A.A., K.M.K., A.R., R.B.), School of Medicine, University of California San Francisco; Department of Neurology (S.C.L., A.A., K.M.K., A.R., R.B.), Weill Institute for Neurosciences, University of California San Francisco; Department of Pediatrics (M.J.D.), Division of Allergy, Immunology and Blood and Marrow Transplant, University of California San Francisco, CA; Department of Pediatrics (T.H.), Texas Tech University School of Medicine, Amarillo, TX; Department of Gastroenterology (U.M.), University of California San Francisco; Department of Pediatrics (E.E.R.), University of California San Francisco; and Department of Obstetrics (M.G.R.), Gynecology, and Reproductive Sciences, University of California San Francisco, CA
| | - Melissa G Rosenstein
- From the Department of Neurology (S.C.L., A.A., K.M.K., A.R., R.B.), School of Medicine, University of California San Francisco; Department of Neurology (S.C.L., A.A., K.M.K., A.R., R.B.), Weill Institute for Neurosciences, University of California San Francisco; Department of Pediatrics (M.J.D.), Division of Allergy, Immunology and Blood and Marrow Transplant, University of California San Francisco, CA; Department of Pediatrics (T.H.), Texas Tech University School of Medicine, Amarillo, TX; Department of Gastroenterology (U.M.), University of California San Francisco; Department of Pediatrics (E.E.R.), University of California San Francisco; and Department of Obstetrics (M.G.R.), Gynecology, and Reproductive Sciences, University of California San Francisco, CA
| | - Riley Bove
- From the Department of Neurology (S.C.L., A.A., K.M.K., A.R., R.B.), School of Medicine, University of California San Francisco; Department of Neurology (S.C.L., A.A., K.M.K., A.R., R.B.), Weill Institute for Neurosciences, University of California San Francisco; Department of Pediatrics (M.J.D.), Division of Allergy, Immunology and Blood and Marrow Transplant, University of California San Francisco, CA; Department of Pediatrics (T.H.), Texas Tech University School of Medicine, Amarillo, TX; Department of Gastroenterology (U.M.), University of California San Francisco; Department of Pediatrics (E.E.R.), University of California San Francisco; and Department of Obstetrics (M.G.R.), Gynecology, and Reproductive Sciences, University of California San Francisco, CA.
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Gilhus NE. Myasthenia Gravis Can Have Consequences for Pregnancy and the Developing Child. Front Neurol 2020; 11:554. [PMID: 32595594 PMCID: PMC7304249 DOI: 10.3389/fneur.2020.00554] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 05/15/2020] [Indexed: 12/24/2022] Open
Abstract
Myasthenia gravis (MG) with onset below 50 years, thymic hyperplasia and acetylcholine receptor (AChR) antibodies is more common in females than in males. For a relatively large group of MG patients, pregnancy represents therefore an important question. The muscle weakness, the circulating autoantibodies, the hyperplastic thymus, the MG drug treatment, and any autoimmune comorbidity may all influence both mother and child health during pregnancy and also during breastfeeding in the postpartum period. Mother's MG remains stable in most patients during pregnancy. Pyridostigmine, prednisolone, and azathioprine are regarded as safe during pregnancy. Mycophenolate, methotrexate and cyclophosphamide are teratogenic and should not be used by women with the potential to become pregnant. Rituximab should not be given during the last few months before conception and not during pregnancy. Intravenous immunoglobulin and plasma exchange can be used for exacerbations or when need for intensified therapy. Pregnancies in MG women are usually without complications. Their fertility is near normal. Vaginal delivery is recommended. MG patients have an increased rate of Cesarean section, partly due to their muscle weakness and to avoid exhaustion, partly as a precaution that is often unnecessary. Around 10% of the newborn develop neonatal myasthenia during the first few days after birth. This is transient and usually mild with some sucking and swallowing difficulties. In rare cases, transplacental transfer of AChR antibodies leads to permanent muscle weakness in the child, and arthrogryposis with joint contractures. Repeated spontaneous abortions have been described due to AChR antibodies. MG women should always give birth at hospitals with experience in newborn intensive care. MG does not represent a reason for not having children, and the patients should be supported in their wish of becoming pregnant.
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Affiliation(s)
- Nils Erik Gilhus
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway
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Celius EG. Breastfeeding and treatment of multiple sclerosis. Mult Scler 2020; 27:801-802. [PMID: 32507035 PMCID: PMC7983324 DOI: 10.1177/1352458520931786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Elisabeth G Celius
- Department of Neurology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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