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Vesperinas-Castro A, Cortés-Vicente E. Rituximab treatment in myasthenia gravis. Front Neurol 2023; 14:1275533. [PMID: 37849836 PMCID: PMC10577386 DOI: 10.3389/fneur.2023.1275533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 09/11/2023] [Indexed: 10/19/2023] Open
Abstract
Myasthenia gravis (MG) is a chronic autoimmune disease mediated by antibodies against post-synaptic proteins of the neuromuscular junction. Up to 10%-30% of patients are refractory to conventional treatments. For these patients, rituximab has been used off-label in the recent decades. Rituximab is a monoclonal antibody against the CD20 protein that leads to B cell depletion and to the synthesis of new antibody-secreting plasma cells. Although rituximab was created to treat B-cell lymphoma, its use has widely increased to treat autoimmune diseases. In MG, the benefit of rituximab treatment in MuSK-positive patients seems clear, but a high variability in the results of observational studies and even clinical trials has been reported for AChR-positive patients. Moreover, few evidence has been reported in seronegative MG and juvenile MG and some questions about regimen of administration or monitoring strategies, remains open. In this review, we intend to revise the available literature on this topic and resume the current evidence of effectiveness of Rituximab in MG, with special attention to results on every MG subtype, as well as the administration protocols, monitoring strategies and safety profile of the drug.
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Affiliation(s)
- Ana Vesperinas-Castro
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Elena Cortés-Vicente
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
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Ramdas S, Della Marina A, Ryan MM, McWilliam K, Klein A, Jacquier D, Alabaf S, Childs AM, Parasuraman D, Beeson D, Palace J, Jungbluth H. Rituximab in juvenile myasthenia gravis-an international cohort study and literature review. Eur J Paediatr Neurol 2022; 40:5-10. [PMID: 35835035 DOI: 10.1016/j.ejpn.2022.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 06/15/2022] [Accepted: 06/17/2022] [Indexed: 11/16/2022]
Abstract
Juvenile myasthenia gravis (JMG) is a rare, antibody-mediated disorder of the neuromuscular junction. Treatment strategies in JMG are largely informed by adult MG treatments as the pathophysiology is similar. Rituximab is increasingly considered as a treatment option in refractory JMG but has not yet been systematically investigated in this patient group We conducted a retrospective study from five international centres with expertise in paediatric myasthenia. 10 JMG patients treated with rituximab were identified. Following rituximab treatment all patients had a reduction in JMG-related hospital admissions. At 24 month follow up, 6 patients (60%) had achieved complete stable remission or pharmacological remission and 7 patients were able to reduce immunomodulatory treatment(s). The main side-effect was infusion-related reactions (30%) which resolved in all patients with symptomatic treatment. We compared our cohort to previously reported JMG cases treated with rituximab and noted similar response rates but a slightly higher side-effect profile. Rituximab is a safe and effective treatment option in moderate to severe JMG and most patients have an improvement in MG symptoms post treatment.
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Affiliation(s)
- Sithara Ramdas
- MDUK Neuromuscular Centre, Department of Paediatrics, University of Oxford, United Kingdom; Department of Paediatric Neurology, John Radcliffe Hospital, Oxford, United Kingdom.
| | - Adela Della Marina
- Department of Neuropediatrics, Developmental Neurology and Social Pediatrics, Children's Hospital, University of Duisburg-Essen, Germany.
| | - Monique M Ryan
- Neurology Department, Royal Children's Hospital, Melbourne, Australia.
| | - Kenneth McWilliam
- Department of Paediatric Neurology, Royal Hospital for Sick Children, Edinburgh, United Kingdom.
| | - Andrea Klein
- Department of Pediatric Neurology, University Children's Hospital Basel, Basel, Switzerland; University Children's Hospital Bern, Inselspital, Bern, Switzerland.
| | - David Jacquier
- Paediatric Neurology and Neurorehabilitation Unit, Lausanne University Hospital, Lausanne, Switzerland.
| | - Setareh Alabaf
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom.
| | - Anne-Marie Childs
- Department of Paediatric Neurology, Leeds Teaching Hospitals, United Kingdom.
| | - Deepak Parasuraman
- Department of Paediatrics, Heartlands Hospital, Birmingham, United Kingdom.
| | - David Beeson
- Neurosciences Group, Nuffield Department of Clinical Neurosciences, Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom.
| | - Jacqueline Palace
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom.
| | - Heinz Jungbluth
- Department of Paediatric Neurology, Neuromuscular Service, Evelina's Children Hospital, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK; Randall Centre for Cell and Molecular Biophysics, Muscle Signalling Section, FoLSM, King's College, London, UK.
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Molimard A, Gitiaux C, Barnerias C, Audic F, Isapof A, Walther-Louvier U, Cances C, Espil-Taris C, Davion JB, Quijano-Roy S, Grisel C, Chabrol B, Desguerre I. Rituximab Therapy in the Treatment of Juvenile Myasthenia Gravis: The French Experience. Neurology 2022; 98:e2368-e2376. [PMID: 35314497 DOI: 10.1212/wnl.0000000000200288] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 02/10/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Corticosteroids are the first-line immunosuppressants in the management of juvenile myasthenia gravis despite their adverse effects. The place of new immunosuppressive therapies is not clearly defined by the last international consensus held in March 2019, due to the lack of clinical trials. The aim of this study is to describe the use of rituximab, its efficacy and safety in 8 main pediatric centers of the French neuromuscular reference network in order to propose a new place in the therapeutic strategy of juvenile myasthenia gravis. METHOD We conducted a retrospective multicenter study from January 1, 2009 to April 30, 2020, including a large cohort of children with myasthenia gravis in 8 main French pediatric reference centers of the Filnemus network. The type of myasthenia, the different lines of immunosuppressive treatment and the clinical course of the patients were collected. To evaluate the efficacy of rituximab, we studied the clinical course of patients on immunosuppressive therapy. Outcome was defined as the clinical and therapeutic status of patients at the last visit: stable without immunosuppressants, stable with immunosuppressants or unstable. RESULTS We included 74 patients: 18 children with ocular form and 56 children with generalized form. Of the 37 patients who required immunosuppressive therapy, 27 were treated with rituximab. Patients treated with rituximab had a better outcome than patients treated with conventional immunosuppressants (p = 0.006). The use of rituximab as a first-line immunosuppressant showed a better efficacy with a discontinuation of immunosuppressants in 75% of patients (vs. 25%, p=0.04) and resulted cortisone sparing (42% vs. 92%, p=0.03) compared with rituximab treatment as a second or third-line immunosuppression. Rituximab was well tolerated; no adverse effect was observed. CONCLUSION The use of rituximab has increased in France over the last 10 years as first line immunosuppressant. This study suggests a good tolerability and efficacy of rituximab in juvenile myasthenia gravis. Early use appears to improve outcomes and facilitate cortisone-sparing in antibody-positive generalized juvenile myasthenia. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that for children with MG rituximab is effective and well tolerated.
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Affiliation(s)
| | - Cyril Gitiaux
- Centre de Référence des Maladies Neuromusculaires Nord/Ile de France/Est, Service de Neurologie pédiatrique, Hôpital Necker-Enfants Malades, APHP, Paris, France
| | - Christine Barnerias
- Centre de Référence des Maladies Neuromusculaires Nord/Ile de France/Est, Service de Neurologie pédiatrique, Hôpital Necker-Enfants Malades, APHP, Paris, France
| | - Frédérique Audic
- Centre de Référence des Maladies Neuromusculaires de l'enfant PACARARE, Service de Neuropédiatrie, Hôpital Timone Enfants, 264 rue Saint Pierre, 13385, Marseille Cedex 5
| | - Arnaud Isapof
- Centre de Référence des Maladies Neuromusculaires Nord/Ile de France/Est, Service de Neuropédiatrie, Hôpital Trousseau, APHP, Paris, France
| | - Ulrike Walther-Louvier
- Centre de Référence des Maladies Neuromusculaires AOC, Service de Neuropédiatrie CHU Montpellier, Montpellier, France
| | - Claude Cances
- Centre de Référence des Maladies Neuromusculaires AOC, Unité de Neurologie Pédiatrique, Hôpital des Enfants CHU Toulouse, Toulouse, France
| | - Caroline Espil-Taris
- Centre de Référence des Maladies Neuromusculaires AOC, Unité de Neurologie pédiatrique, CHU Pellegrin, Bordeaux, France
| | - Jean-Baptiste Davion
- Centre de référence des maladies neuromusculaires Nord Est Ile de France, CHU de Lille, Lille, France
| | - Susana Quijano-Roy
- Centre de Référence des Maladies Neuromusculaires Nord/Ile de France/Est, Hôpital Raymond Poincaré, APHP, Garches, France
| | - Coraline Grisel
- Service de pédiatrie, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Brigitte Chabrol
- Centre de Référence des Maladies Neuromusculaires de l'enfant PACARARE, Service de Neuropédiatrie, Hôpital Timone Enfants, 264 rue Saint Pierre, 13385, Marseille Cedex 5
| | - Isabelle Desguerre
- Centre de Référence des Maladies Neuromusculaires Nord/Ile de France/Est, Service de Neurologie pédiatrique, Hôpital Necker-Enfants Malades, APHP, Paris, France
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Zingariello CD, Elder ME, Kang PB. Rituximab as Adjunct Maintenance Therapy for Refractory Juvenile Myasthenia Gravis. Pediatr Neurol 2020; 111:40-43. [PMID: 32951658 DOI: 10.1016/j.pediatrneurol.2020.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Juvenile myasthenia gravis is a pediatric autoimmune disorder of the neuromuscular junction associated with substantial morbidity, for which standard therapies are not always efficacious. The objective of our study was to assess the tolerability and efficacy of rituximab use in children with refractory juvenile myasthenia gravis. METHODS We conduced a retrospective cohort study at a single tertiary care referral center to evaluate children with juvenile myasthenia gravis who were treated with rituximab. The clinical status of these participants before and after initiation of rituximab therapy was measured, focusing on numbers of hospital admissions, numbers of immunomodulatory or immunosuppressive medications needed, and Myasthenia Gravis Foundation of America severity class. RESULTS Five children with juvenile myasthenia gravis were ascertained who received rituximab as part of their regimen, four of whom had elevated acetylcholine receptor antibodies and one of whom had elevated muscle-specific kinase antibodies. After initiation of rituximab therapy, all participants experienced reduced numbers of immunomodulatory medications during the follow-up period (mean 11.6 months). Four of the five subjects experienced fewer juvenile myasthenia gravis-related hospital admissions and reduced (improved) Myasthenia Gravis Foundation of America classes, with no subjects having moderate or severe symptoms following treatment with rituximab. No significant adverse events were recorded for any of the participants. CONCLUSION Rituximab was well-tolerated and efficacious in this juvenile myasthenia gravis cohort. The beneficial effect of rituximab was most pronounced in the one participant with muscle-specific kinase antibodies.
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Affiliation(s)
- Carla D Zingariello
- Division of Pediatric Neurology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida
| | - Melissa E Elder
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida
| | - Peter B Kang
- Division of Pediatric Neurology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida; Department of Neurology and Department of Molecular Genetics and Microbiology, University of Florida College of Medicine, Gainesville, Florida.
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O'Connell K, Ramdas S, Palace J. Management of Juvenile Myasthenia Gravis. Front Neurol 2020; 11:743. [PMID: 32793107 PMCID: PMC7393473 DOI: 10.3389/fneur.2020.00743] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/16/2020] [Indexed: 02/06/2023] Open
Abstract
Juvenile Myasthenia Gravis (JMG) is a rare disorder, defined as myasthenia gravis in children younger than 18 years of age. While clinical phenotypes are similar to adults, there are a number of caveats that influence management: broader differential diagnoses; higher rates of spontaneous remission; and the need to initiate appropriate treatment early, to avoid the long-term physical and psychosocial morbidity. Current practice is taken from treatment guidelines for adult MG or individual experience, with considerable variability seen across centers. We discuss our approach to treating JMG, in a large specialist JMG service, and review currently available evidence and highlight potential areas for future research. First-line treatment of generalized JMG is symptomatic management with pyridostigmine, but early use of immunosuppression, where good control is not achieved is important. Oral prednisolone is used as first-line immunosuppression with appropriate prevention and monitoring of side effects. Second-line therapies including azathioprine and mycophenolate may be considered where there is: no response to steroids, inability to wean to a reasonable minimum effective dose or if side-effects are intolerable. Management of ocular JMG is similar, but requires close involvement of ophthalmology in young children to prevent amblyopia. Muscle-specific tyrosine kinase (MuSK)-JMG show a poorer response to pyridostigmine and anecdotal evidence suggests that rituximab should be considered as second-line immunosuppression. Thymectomy is indicated in any patient with a thymoma, and consideration should be given in acetylcholine receptor (AChR) positive JMG allowing time for spontaneous remission. The benefit is less clear in ocular JMG and is not advised in MuSK-JMG. Children experiencing a myasthenic crisis require urgent hospital admission with access to the intensive care unit. PLEX is preferred over IVIG due to rapid onset of action, but this needs to be balanced with feasibility in very young children. Key questions remain in the management of JMG: when to initiate both first- and second-line treatments, choosing between steroid-sparing agents, and determining the optimal dose and treatment duration. We feel that given the rarity of this disease, the establishment of national registries and collaboration across groups will be needed to address these issues and facilitate future drug trials in JMG.
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Affiliation(s)
- Karen O'Connell
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Sithara Ramdas
- Department of Paediatric Neurology, John Radcliffe Hospital, Oxford, United Kingdom
| | - Jacqueline Palace
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
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