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Habib AA, Klink AJ, Muppidi S, Parthan A, Sader SC, Balanean A, Gajra A, Nowak RJ, Howard JF. United States clinical practice experience with eculizumab in myasthenia gravis: symptoms, function, and immunosuppressant therapy use. J Neurol 2024; 271:6114-6126. [PMID: 39052039 PMCID: PMC11377470 DOI: 10.1007/s00415-024-12569-w] [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: 02/27/2024] [Revised: 06/28/2024] [Accepted: 07/05/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND/OBJECTIVES The phase 3 REGAIN study and its open-label extension demonstrated the efficacy of the complement C5 inhibitor eculizumab in patients with treatment-refractory, acetylcholine receptor antibody-positive generalized myasthenia gravis (gMG). The aim of the ELEVATE study was to assess the effectiveness of eculizumab in clinical practice in adults with MG in the United States. METHODS A retrospective chart review was conducted in adults with MG who initiated eculizumab treatment between October 23, 2017 and December 31, 2019. Outcomes assessed before and during eculizumab treatment using a pre- versus post-treatment study design included Myasthenia Gravis-Activities of Daily Living (MG-ADL) total scores; minimal symptom expression (MSE); physician impression of clinical change; minimal manifestation status (MMS); and concomitant medication use. RESULTS In total, 119 patients were included in the study. A significant reduction was observed in mean MG-ADL total score, from 8.0 before eculizumab initiation to 5.4 at 3 months and to 4.7 at 24 months after eculizumab initiation (both p < 0.001). At 24 months after eculizumab initiation, MSE was achieved by 19% of patients. MMS or better was achieved by 30% of patients at 24 months. Additionally, 64% of patients receiving prednisone at eculizumab initiation had their prednisone dosage reduced during eculizumab treatment and 13% discontinued prednisone; 32% were able to discontinue nonsteroidal immunosuppressant therapy. DISCUSSION Eculizumab treatment was associated with sustained improvements in MG-ADL total scores through 24 months in adults with MG. Prednisone dosage was reduced in approximately two-thirds of patients, suggesting a steroid-sparing effect for eculizumab.
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Affiliation(s)
| | | | | | - Anju Parthan
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
- FibroGen Inc., San Francisco, CA, USA
| | | | | | - Ajeet Gajra
- Cardinal Health, Dublin, OH, USA
- Hematology-Oncology Associates of CNY, East Syracuse, NY, USA
| | | | - James F Howard
- Department of Neurology, The University of North Carolina, Chapel Hill, NC, USA.
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Howard JF, Vu T, Mantegazza R, Kushlaf H, Suzuki S, Wiendl H, Beasley KN, Liao S, Meisel A. Efficacy of ravulizumab in patients with generalized myasthenia gravis by time from diagnosis: A post hoc subgroup analysis of the CHAMPION MG study. Muscle Nerve 2024; 69:556-565. [PMID: 38380691 DOI: 10.1002/mus.28044] [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: 04/14/2023] [Revised: 01/05/2024] [Accepted: 01/14/2024] [Indexed: 02/22/2024]
Abstract
INTRODUCTION/AIMS The CHAMPION MG study demonstrated that ravulizumab significantly improved Myasthenia Gravis-Activities of Daily Living (MG-ADL) and Quantitative Myasthenia Gravis (QMG) total scores versus placebo in adults with acetylcholine receptor antibody-positive generalized myasthenia gravis (AChR+ gMG). This post hoc analysis aimed to assess these outcomes by time from MG diagnosis. METHODS Changes from baseline to week 26 in MG-ADL and QMG total scores were analyzed by time from MG diagnosis to study entry (≤2 vs. >2 years). Within each subgroup, least-squares (LS) mean changes for ravulizumab and placebo were compared using mixed models for repeated measures. RESULTS In ravulizumab-treated patients, differences in LS mean (standard error of the mean) changes from baseline to week 26 were not statistically significant in the ≤2-years subgroup versus the >2-years subgroup for MG-ADL (-4.3 [0.70] vs. -2.9 [0.37]; p = .0511) or QMG (-4.3 [0.94] vs. -2.5 [0.50]; p = .0822) scores. No clear trends were observed in the placebo group. LS mean changes from baseline were significantly greater for ravulizumab versus placebo in both the ≤2 and >2 years from diagnosis subgroups for MG-ADL and QMG scores (all p < .05). The difference in treatment effect between the ≤2-years and >2-years subgroups was not statistically significant. No clinically meaningful between-subgroup differences in treatment-emergent adverse events were observed in ravulizumab-treated patients. DISCUSSION Ravulizumab treatment improved clinical outcomes for patients with AChR+ gMG regardless of time from diagnosis. A numerical trend was observed favoring greater treatment effect with earlier versus later treatment after diagnosis. Further studies are required for confirmation.
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Affiliation(s)
- James F Howard
- The University of North Carolina, Chapel Hill, North Carolina, USA
| | - Tuan Vu
- University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | | | | | | | | | | | - Serena Liao
- Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, USA
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Croitoru CG, Pavel-Tanasa M, Cuciureanu DI, Hodorog DN, Cianga P. Autoimmune and Non-Autoimmune Comorbidities in Myasthenic Patients of East-European Descent: A Case-Control Study. J Clin Med 2024; 13:2273. [PMID: 38673546 PMCID: PMC11051044 DOI: 10.3390/jcm13082273] [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: 02/17/2024] [Revised: 04/08/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024] Open
Abstract
Background: As the life expectancy of patients with myasthenia gravis (MG) is improving, so the number of comorbidities continues to rise, with a potentially significant impact on the overall morbidity and mortality. The main aim of the study was to assess comorbidities of MG in a group of patients of East-European descent. Methods: We retrospectively compared 185 adult myasthenic patients with 895 sex- and age-matched controls, admitted from January 2013 to December 2021. Results: Of these patients, 60% had late-onset MG (LOMG), with a clear predominance of women in both the LOMG and early-onset (EOMG) types; and 23.8% of the patients had a radiological description consistent with thymoma. All myasthenic patients had at least one comorbidity; 20 (10.8%) of the patients associated at least one autoimmune comorbidity. Obesity (p < 0.01), type 2 diabetes (p < 0.0001), cerebrovascular diseases (p < 0.0001), essential hypertension (p < 0.01), and cardiac arrythmias (p < 0.0001) were more frequent in patients than in the control group. The granulocyte-to-lymphocyte ratio was higher in the myasthenic patients compared to the controls (p < 0.01 for LOMG). Discussion: We, thus, suggest a common chronic low-grade inflammatory background as a possible connection between MG subtypes and some of these apparently unconnected comorbidities. Conclusions: The East-European origin of the patients offered a different social and cultural angle of a disease studied mainly on populations of West-European and Asian descent.
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Affiliation(s)
- Cristina Georgiana Croitoru
- I Neurology Clinic, “Prof. Dr. Nicolae Oblu” Emergency Clinical Hospital, 700309 Iași, Romania
- Department of Immunology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania;
| | - Mariana Pavel-Tanasa
- Department of Immunology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania;
| | - Dan Iulian Cuciureanu
- I Neurology Clinic, “Prof. Dr. Nicolae Oblu” Emergency Clinical Hospital, 700309 Iași, Romania
- Department Medical III, Discipline of Neurology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Diana Nicoleta Hodorog
- I Neurology Clinic, “Prof. Dr. Nicolae Oblu” Emergency Clinical Hospital, 700309 Iași, Romania
- Department Medical III, Discipline of Neurology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Petru Cianga
- Department of Immunology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania;
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Zhen L, Zhao X, Li W, Wu J, Shang H, Chen S, Zhu X, Wang Y, Yu X, Hu G, Sun Z, Zhang Y, Zhang J, Fang H, Zhang Y, Zhang Q, Cui X, Lv J, Yang J, Gao F. Effectiveness of early glucocorticoids in myasthenia gravis: a retrospective cohort study. Front Neurol 2023; 14:1259484. [PMID: 38187148 PMCID: PMC10770254 DOI: 10.3389/fneur.2023.1259484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 11/23/2023] [Indexed: 01/09/2024] Open
Abstract
Purpose This study aimed to clarify the effect of early glucocorticoid (GC) application on achieving minimal manifestation (MM) status or better in the treatment of myasthenia gravis (MG) in the early clinical phase. Methods A retrospective analysis was performed using data from 336 patients with MG who received GC therapy from January 2015 to September 2022 in the Zhengzhou University Henan Institute of Medical and Pharmaceutical Sciences Myasthenia Gravis Biobank (ZMB). Patients were divided into two groups: the early mono-GC group (treated with GC within 6 months of MG onset) and the delayed mono-GC group. Results Kaplan-Meier analysis showed that the early mono-GC group achieved MM status earlier and more frequently than the delayed mono-GC group (log-rank test, p = 0.0082; hazard ratio [HR], 1.66; p = 0.011). The early mono-GC group had a lower maintenance oral GC dose than the delayed mono-GC group. In multivariate Cox regression analysis, early mono-GC (HR, 1.50; p = 0.043), early-onset MG (EOMG) (HR, 1.74; p = 0.034), and ocular MG (OMG) (HR, 1.90; p = 0.007) were associated with MM status or better. In conclusion, early mono-GC, EOMG, and OMG were positive predictors of treatment goals. In EOMG, OMG, and acetylcholine receptor antibody-positive MG (AChR-MG) subgroups, the maintenance oral GC doses in the early mono-GC group were significantly lower than the doses in the delayed mono-GC group (p < 0.05). Conclusion Early intervention with GC led to better long-term outcomes and reduced the necessary maintenance dose of oral GC for patients with MG. EOMG and OMG were positive predictors of MM status or better with mono-GC.
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Affiliation(s)
- Lulu Zhen
- Department of Neurology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Xue Zhao
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Wenbo Li
- Department of Neurology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Jinru Wu
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
- Basic Medical College, Zhengzhou University, Zhengzhou, China
| | - Haodong Shang
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
- BGI College, Zhengzhou University, Zhengzhou, China
| | - Shufan Chen
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
- BGI College, Zhengzhou University, Zhengzhou, China
| | - Xiaoyan Zhu
- Department of Neurology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Yiren Wang
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
- Basic Medical College, Zhengzhou University, Zhengzhou, China
| | - Xiaoxiao Yu
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
- BGI College, Zhengzhou University, Zhengzhou, China
| | - Guanlian Hu
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
- BGI College, Zhengzhou University, Zhengzhou, China
| | - Zhan Sun
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
- BGI College, Zhengzhou University, Zhengzhou, China
| | - Yingna Zhang
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Jing Zhang
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Hua Fang
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Yunke Zhang
- Department of Encephalopathy, First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, China
| | - Qingyong Zhang
- Myasthenia Gravis Comprehensive Diagnosis and Treatment Center, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Xinzheng Cui
- Myasthenia Gravis Comprehensive Diagnosis and Treatment Center, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Jie Lv
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Junhong Yang
- Department of Encephalopathy, First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, China
| | - Feng Gao
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
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Sansoni J, Menon N, Viali L, White S, Vucic S. Clinical features, treatments, their impact, and quality of life for Myasthenia Gravis patients in Australia. J Clin Neurosci 2023; 118:16-22. [PMID: 37844489 DOI: 10.1016/j.jocn.2023.09.023] [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: 04/08/2023] [Revised: 07/07/2023] [Accepted: 09/28/2023] [Indexed: 10/18/2023]
Abstract
This survey provides an update on the experience of Myasthenia Gravis (MG) patients in Australia. Items were drawn from the 2011 Australian Survey and a 2019 US survey allowing for comparative discussion of survey findings. Patients were recruited through the Myasthenia Alliance Australia. Following consent, patients completed an online survey using REDCap software. Questions included demographics, clinical features, treatment side-effects and quality of life (QOL) scales. Samples for completion of survey sections ranged from N = 242-280 representing a power level of over 80%. Female and seronegative patients reported a significantly greater symptom load, earlier disease onset, longer time to diagnosis, more MG exacerbations, treatment side-effects, and poorer QOL. For exacerbation management there was a higher rate of oral corticosteroid use (66%), a lower use of Intravenous Immunoglobulin (IVIg, 47%) and particularly, Therapeutic Plasma Exchange (TPE, 4.5%) within this sample. Although steroid induced side-effects were rarer (9-34%), a comparatively high use of corticosteroids was reported for current and overall treatments including those for MG crises (52-83%). Common treatment side-effects reported by 57-85% of patients, included fatigue, weight gain, a decrease in the ability to fight infections, gastrointestinal symptoms, and muscle weakness. The impact of MG on daily activities and QOL was considerable, but those who had a thymectomy reported better QOL. The survey identified areas for potential practice improvement in MG treatments (corticosteroids, IVIg, TPE), particularly for exacerbation management, and review is recommended. Further research on gender and antibody status differentials regarding clinical features is required.
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Affiliation(s)
- Janet Sansoni
- Biological Data Science Institute, Australian National University, Acton, ACT 2601, Australia; Health Outcomes Collaboration, 2 Bramston St, Fadden, ACT 2904, Australia.
| | - Nidhi Menon
- Biological Data Science Institute, Australian National University, Acton, ACT 2601, Australia
| | - Lachlan Viali
- Biological Data Science Institute, Australian National University, Acton, ACT 2601, Australia
| | - Susan White
- Myasthenia Alliance Australia, 17 Aldridge Ave, Corrimal East, NSW 2518, Australia; Myasthenia Gravis Association of Queensland Inc., PO Box16, Mt Gravatt, Queensland 4122, Australia
| | - Steve Vucic
- Brain and Nerve Research Centre, University of Sydney Concord Clinical School, Concord, NSW 2139, Australia
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Matic A, Alfaidi N, Bril V. An evaluation of rozanolixizumab-noli for the treatment of anti-AChR and anti-MuSK antibody-positive generalized myasthenia gravis. Expert Opin Biol Ther 2023; 23:1163-1171. [PMID: 38099334 DOI: 10.1080/14712598.2023.2296126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 12/13/2023] [Indexed: 12/26/2023]
Abstract
INTRODUCTION Myasthenia gravis (MG) is an auto-immune disease characterized by fluctuating symptoms of muscle weakness and fatigue. Corticosteroids and corticosteroid-sparing broad-spectrum immunosuppression play a great role in the treatment of myasthenia gravis. However, debilitating side effects and long time to treatment effect highlight the need for development of novel target-specific medications. Rozanolixizumab is a highly specific neonatal Fc receptor (FcRn) inhibitor that acts on immunoglobulin G (IgG) homeostasis. Results from the MycarinG Phase III randomized controlled trial demonstrated significant efficacy of rozanolixizumab in generalized MG in terms of primary outcome and all secondary endpoints, tolerability, and safety compared to placebo. AREAS COVERED We included different trials on myasthenia gravis and rozanolixizumab which include Phase II (NCT03052751) and Phase III MycarinG (NCT03971422) studies. EXPERT OPINION Clinical trials have demonstrated that rozanolixizumab has strong efficacy with a 78% reduction in pathogenic IgG like plasma exchange (PLEX) and has therapeutic benefits comparable with PLEX and IVIG. It has less treatment adverse events and is easily accessible through subcutaneous infusion. The safety and effectiveness of rozanolixizumab need to be assessed further in the real-world context in post-marketing studies. If current trial information holds true, rozanolixizumab may become a medication of choice for MG in succeeding years.
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Affiliation(s)
- Alexandria Matic
- The Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Nouf Alfaidi
- The Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Vera Bril
- The Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Uzawa A, Suzuki S, Kuwabara S, Akamine H, Onishi Y, Yasuda M, Ozawa Y, Kawaguchi N, Kubota T, Takahashi MP, Suzuki Y, Watanabe G, Kimura T, Sugimoto T, Samukawa M, Minami N, Masuda M, Konno S, Nagane Y, Utsugisawa K. Impact of Early Treatment with Intravenous High-Dose Methylprednisolone for Ocular Myasthenia Gravis. Neurotherapeutics 2023; 20:518-523. [PMID: 36607596 PMCID: PMC10121971 DOI: 10.1007/s13311-022-01335-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 01/07/2023] Open
Abstract
The efficacy of intravenous high-dose methylprednisolone (IVMP) in ocular myasthenia gravis (MG) has not been fully established. This study aimed to elucidate the effects of early intervention with IVMP for achieving the therapeutic targets (minimal manifestations [MM] or MM or better status with prednisolone ≤ 5 mg/day [MM5mg]) in ocular MG. In this observational study, we included a total of 1710 consecutive patients with MG enrolled in the Japan MG Registry in 2021. Of these, 204 patients with ocular MG who received immunotherapy were analyzed. The clinical course and time to first achieve MM or MM5mg after starting immunotherapy were compared between the early IVMP group (treated with IVMP within 3 months of treatment initiation) and the non-early IVMP group. Despite having greater clinical severity before immunotherapy and lower oral prednisolone doses throughout the course, the early IVMP group (n = 55) showed a higher rate of achievement of MM (P = 0.0040, log-rank test; hazard ratio 1.58, 95% confidence interval [CI] 1.13-2.20, P < 0.0001) and MM5mg (P = 0.0005, log-rank test; hazard ratio 1.78, 95% CI 1.27-2.51, P < 0.0001) compared with the non-early IVMP group (n = 149). In conclusion, an early intervention with IVMP is likely to increase the probability of achieving a better long-term outcome and reducing the total dose of corticosteroids in ocular MG.
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Affiliation(s)
- Akiyuki Uzawa
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba-Shi, Chiba, 260-8670, Japan.
| | - Shigeaki Suzuki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Kuwabara
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba-Shi, Chiba, 260-8670, Japan
| | - Hiroyuki Akamine
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba-Shi, Chiba, 260-8670, Japan
| | - Yosuke Onishi
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba-Shi, Chiba, 260-8670, Japan
| | - Manato Yasuda
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba-Shi, Chiba, 260-8670, Japan
| | - Yukiko Ozawa
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba-Shi, Chiba, 260-8670, Japan
| | - Naoki Kawaguchi
- Department of Neurology, Neurology Chiba Clinic, Chiba, Japan
| | - Tomoya Kubota
- Department of Clinical Laboratory and Biomedical Sciences, Division of Health Sciences, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masanori P Takahashi
- Department of Clinical Laboratory and Biomedical Sciences, Division of Health Sciences, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yasushi Suzuki
- Department of Neurology, National Hospital Organization Sendai Medical Center, Sendai, Japan
| | - Genya Watanabe
- Department of Neurology, National Hospital Organization Sendai Medical Center, Sendai, Japan
| | - Takashi Kimura
- Department of Neurology, Hyogo Medical University, Nishinomiya, Japan
| | - Takamichi Sugimoto
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Hiroshima, Japan
| | - Makoto Samukawa
- Department of Neurology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Naoya Minami
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Sapporo, Japan
| | - Masayuki Masuda
- Department of Neurology, Tokyo Medical University, Tokyo, Japan
| | - Shingo Konno
- Department of Neurology, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Yuriko Nagane
- Department of Neurology, Hanamaki General Hospital, Hanamaki, Japan
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Uzawa A, Suzuki S, Kuwabara S, Akamine H, Onishi Y, Yasuda M, Ozawa Y, Kawaguchi N, Kubota T, Takahashi MP, Suzuki Y, Watanabe G, Kimura T, Sugimoto T, Samukawa M, Minami N, Masuda M, Konno S, Nagane Y, Utsugisawa K. Effectiveness of early cycles of fast-acting treatment in generalised myasthenia gravis. J Neurol Neurosurg Psychiatry 2023; 94:467-473. [PMID: 36693723 DOI: 10.1136/jnnp-2022-330519] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 01/10/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND Early fast-acting treatment (EFT) is the aggressive use of fast-acting therapies such as plasmapheresis, intravenous immunoglobulin and/or intravenous high-dose methylprednisolone (IVMP) from the early phases of treatment. EFT is reportedly beneficial for early achievement of minimal manifestations (MM) or better status with ≤5 mg/day prednisolone (MM5mg), a practical therapeutic target for myasthenia gravis (MG). OBJECTIVE The current study aimed to clarify which specific EFT regimen is efficacious and the patient characteristics that confer sensitivity to EFT. METHODS We recruited a total of 1710 consecutive patients with MG who enrolled in the Japan MG Registry for this large-cohort study. Among them, 1066 with generalised MG who had received immunotherapy were analysed. Prognostic background factors were matched in a 1:1 ratio using propensity score matching analysis between patients treated with EFT (n=350) and those treated without EFT (n=350). The clinical course and time to first achieve MM5mg after starting immunotherapy was analysed in relation to treatment combinations and patient characteristics. RESULTS Kaplan-Meier analyses showed that EFT had a significant effect on the achievement of MM5mg (p<0.0001, log-rank test; HR 1.82, p<0.0001). Notably, EFT was efficacious for any type of MG, and the inclusion of IVMP resulted in earlier and more frequent achievement of MM5mg (p=0.0352, log-rank test; HR 1.46, p=0.0380). In addition, early administration of calcineurin inhibitors also promoted MM5mg achievement. CONCLUSION Early cycles of intervention with EFT and early use of calcineurin inhibitors provides long-term benefits in terms of achieving therapeutic targets for generalised MG, regardless of clinical subtype.
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Affiliation(s)
- Akiyuki Uzawa
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shigeaki Suzuki
- Department of Neurology, Keio University School of Medicine Graduate School of Medicine, Shinjuku-ku, Japan
| | - Satoshi Kuwabara
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hiroyuki Akamine
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yosuke Onishi
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Manato Yasuda
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yukiko Ozawa
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Naoki Kawaguchi
- Department of Neurology, Neurology Chiba Clinic, Chiba, Japan
| | - Tomoya Kubota
- Department of Clinical Laboratory and Biomedical Sciences, Division of Health Sciences, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Masanori P Takahashi
- Department of Clinical Laboratory and Biomedical Sciences, Division of Health Sciences, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yasushi Suzuki
- Department of Neurology, National Hospital Organisation Sendai Medical Center, Sendai, Miyagi, Japan
| | - Genya Watanabe
- Department of Neurology, National Hospital Organisation Sendai Medical Center, Sendai, Miyagi, Japan
| | - Takashi Kimura
- Department of Neurology, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Takamichi Sugimoto
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Hiroshima, Japan
| | - Makoto Samukawa
- Department of Neurology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Naoya Minami
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Sapporo, Japan
| | - Masayuki Masuda
- Department of Neurology, Tokyo Medical University, Tokyo, Japan
| | - Shingo Konno
- Department of Neurology, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Yuriko Nagane
- Department of Neurology, Hanamaki General Hospital, Hanamaki, Japan
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Benatar M, Cutter G, Kaminski HJ. The best and worst of times in therapy development for myasthenia gravis. Muscle Nerve 2023; 67:12-16. [PMID: 36321730 PMCID: PMC9780175 DOI: 10.1002/mus.27742] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/23/2022] [Accepted: 10/25/2022] [Indexed: 11/13/2022]
Abstract
Within the last 5 years, the US Food and Drug Administration (FDA) has approved complement and neonatal Fc receptor (FcRN) inhibitors for treatment of generalized myasthenia gravis, and several other therapies are in late-stage clinical trials or under regulatory review. However, questions about which patients are most likely to benefit from which therapies, and the relative effectiveness of these very expensive drugs, has resulted in uncertainty around the place that they should occupy in the existing therapeutic armamentarium. MGNet (a Rare Diseases Clinical Research Consortium funded by the National Institute of Neurological Diseases and Stroke) held two meetings during the 14th International Conference of the Myasthenia Gravis Foundation of America to discuss the most critical needs for clinical trial readiness and biomarker development in the context of therapy development for myasthenia gravis. Herein we provide a summary of these discussions, but not a consensus opinion, and offer a series of recommendations to guide focused research in the most critical areas. We welcome ongoing discussion through comments on this work.
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Affiliation(s)
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL
| | - Henry J. Kaminski
- Department of Neurology & Rehabilitation Medicine, George Washington University, Washington DC
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Ding C, Ni L, Liu Q, Zhou C, Wang G, Chu PK, Wu Z. Cold air plasma improving rheumatoid arthritis via mitochondrial apoptosis pathway. Bioeng Transl Med 2023; 8:e10366. [PMID: 36684093 PMCID: PMC9842019 DOI: 10.1002/btm2.10366] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 06/03/2022] [Accepted: 06/12/2022] [Indexed: 01/25/2023] Open
Abstract
Rheumatoid arthritis (RA) has plagued physicians and patients for years due to the lack of targeted treatment. In this study, inspired by the commonality between rheumatoid arthritis fibroblast-like synoviocytes (RA-FLS) and cancer cells, the therapeutic effects of cold air plasma (CAP) on RA are studied systematically and thoroughly. In/ex vivo results show that CAP with the proper dosage significantly relieves symptoms including synovial hyperplasia, inflammatory infiltration, and angiogenesis and eliminates the root cause by triggering the self-antioxidant capability of the surrounding tissue. The mechanism on the molecular and cellular level is also revealed that the spontaneous reactive oxygen species (ROS) cascade induces the mitochondrial apoptosis pathway on RA-FLS. This study reveals a new strategy for targeted treatment of RA and the mechanistic study provides the theoretical foundation for future development of plasma medicine.
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Affiliation(s)
- Chengbiao Ding
- School of Nuclear Science and TechnologyUniversity of Science and Technology of ChinaHefeiChina
- Department of Rehabilitation MedicineThe Second Hospital of Anhui Medical UniversityHefeiAnhuiChina
| | - Leying Ni
- Department of Rehabilitation MedicineThe Second Hospital of Anhui Medical UniversityHefeiAnhuiChina
| | - Qi Liu
- School of Nuclear Science and TechnologyUniversity of Science and Technology of ChinaHefeiChina
| | - Chenxu Zhou
- Department of Rehabilitation MedicineThe Second Hospital of Anhui Medical UniversityHefeiAnhuiChina
| | - Guomin Wang
- Department of PhysicsCity University of Hong KongKowloon, Hong KongChina
- Department of Biomedical EngineeringCity University of Hong KongKowloon, Hong KongChina
- Department of Materials Science and EngineeringCity University of Hong KongKowloon, Hong KongChina
| | - Paul K. Chu
- Department of PhysicsCity University of Hong KongKowloon, Hong KongChina
- Department of Biomedical EngineeringCity University of Hong KongKowloon, Hong KongChina
- Department of Materials Science and EngineeringCity University of Hong KongKowloon, Hong KongChina
| | - Zhengwei Wu
- School of Nuclear Science and TechnologyUniversity of Science and Technology of ChinaHefeiChina
- CAS Key Laboratory of Geospace EnvironmentUniversity of Science and Technology of ChinaHefeiChina
- Institute of Advanced TechnologyUniversity of Science and Technology of ChinaHefeiChina
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Thapa L, Thapa M, Bhattarai S, Shrestha AM, Sharma N, Rai N, Pokharel M, Paudel R. D-penicillamine Induced Myasthenia Gravis in Wilson's Disease: A Case Report. JNMA J Nepal Med Assoc 2022; 60:644-647. [PMID: 36705187 PMCID: PMC9297353 DOI: 10.31729/jnma.7607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 06/25/2022] [Indexed: 01/31/2023] Open
Abstract
Myasthenia gravis is a neuromuscular junction disorder characterised by fluctuating muscle weakness, improved by using anti-cholinesterase drugs. In addition to the autoimmune aetiology, various factors such as infections, surgery, and drugs are known to precipitate the condition. We report a case of a 15-year-old boy with D-penicillamine-induced myasthenia gravis who presented with facial diplegia, dysphagia, and drooling of saliva, 6 years after the initiation of treatment for Wilson's disease. Therefore, clinicians should be more vigilant while prescribing patients with chelating drugs like D-penicillamine with regular monitoring of the new symptoms and keeping a very low threshold for the suspicion of myasthenia gravis. Keywords d-penicillamine; myasthenia gravis; pyridostigmine; Wilson's disease.
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Affiliation(s)
- Lekhjung Thapa
- Department of Neurology, National Neuro Center, Maharajgunj, Chakrapath, Kathmandu, Nepal,Correspondence: Dr Lekhjung Thapa, Department of Neurology, National Neuro Centre, Maharajgunj, Kathmandu, Nepal. , Phone: +977-9749370390
| | - Monika Thapa
- Department of Neurology, National Neuro Center, Maharajgunj, Chakrapath, Kathmandu, Nepal
| | - Suman Bhattarai
- Department of Neurology, National Neuro Center, Maharajgunj, Chakrapath, Kathmandu, Nepal
| | - Abhishek Man Shrestha
- Department of Neurology, National Neuro Center, Maharajgunj, Chakrapath, Kathmandu, Nepal
| | - Nooma Sharma
- Department of Neurology, National Neuro Center, Maharajgunj, Chakrapath, Kathmandu, Nepal
| | - Nilshan Rai
- KIST Medical College and Teaching Hospital, Imadol, Lalitpur, Nepal
| | - Merina Pokharel
- Department of Neurology, National Neuro Center, Maharajgunj, Chakrapath, Kathmandu, Nepal
| | - Raju Paudel
- Department of Neurology, National Neuro Center, Maharajgunj, Chakrapath, Kathmandu, Nepal
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