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Koneczny I, Macher S, Hutterer M, Seifert-Held T, Berger-Sieczkowski E, Blaabjerg M, Breu M, Dreyhaupt J, Dutra LA, Erdler M, Fae I, Fischer G, Frommlet F, Heidbreder A, Högl B, Klose V, Klotz S, Liendl H, Nissen MS, Rahimi J, Reinecke R, Ricken G, Stefani A, Süße M, Teive HAG, Weis S, Berger T, Sabater L, Gaig C, Lewerenz J, Höftberger R. HLA dependency and possible clinical relevance of intrathecally synthesized anti-IgLON5 IgG4 in anti-IgLON5 disease. Front Immunol 2024; 15:1376456. [PMID: 38827736 PMCID: PMC11141242 DOI: 10.3389/fimmu.2024.1376456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 04/15/2024] [Indexed: 06/04/2024] Open
Abstract
Background Anti-IgLON5 disease is a rare chronic autoimmune disorder characterized by IgLON5 autoantibodies predominantly of the IgG4 subclass. Distinct pathogenic effects were described for anti-IgLON5 IgG1 and IgG4, however, with uncertain clinical relevance. Methods IgLON5-specific IgG1-4 levels were measured in 46 sera and 20 cerebrospinal fluid (CSF) samples from 13 HLA-subtyped anti-IgLON5 disease patients (six females, seven males) using flow cytometry. Intervals between two consecutive serum or CSF samplings (31 and 10 intervals, respectively) were categorized with regard to the immunomodulatory treatment active at the end of the interval, changes of anti-IgLON5 IgG1 and IgG4 levels, and disease severity. Intrathecal anti-IgLON5 IgG4 synthesis (IS) was assessed using a quantitative method. Results The median age at onset was 66 years (range: 54-75), disease duration 10 years (range: 15-156 months), and follow-up 25 months (range: 0-83). IgLON5-specific IgG4 predominance was observed in 38 of 46 (83%) serum and 11 of 20 (55%) CSF samples. Anti-IgLON5 IgG4 levels prior clinical improvement in CSF but not serum were significantly lower than in those prior stable/progressive disease. Compared to IgLON5 IgG4 levels in serum, CSF levels in HLA-DRB1*10:01 carriers were significantly higher than in non-carriers. Indeed, IgLON5-specific IgG4 IS was demonstrated not only in four of five HLA-DRB1*10:01 carriers but also in one non-carrier. Immunotherapy was associated with decreased anti-IgGLON5 IgG serum levels. In CSF, lower anti-IgLON5 IgG was associated with immunosuppressive treatments used in combination, that is, corticosteroids and/or azathioprine plus intravenous immunoglobulins or rituximab. Conclusion Our findings might indicate that CSF IgLON5-specific IgG4 is frequently produced intrathecally, especially in HLA-DRB1*10:01 carriers. Intrathecally produced IgG4 may be clinically relevant. While many immunotherapies reduce serum IgLON5 IgG levels, more intense immunotherapies induce clinical improvement and may be able to target intrathecally produced anti-IgLON5 IgG. Further studies need to confirm whether anti-IgLON5 IgG4 IS is a suitable prognostic and predictive biomarker in anti-IgLON5 disease.
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Affiliation(s)
- Inga Koneczny
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Stefan Macher
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Markus Hutterer
- Department of Neurology, Johannes Kepler University Linz, Linz, Austria
- Department of Neurology with Stroke Unit and Acute Geriatrics, Saint John of God Hospital Linz, Linz, Austria
| | - Thomas Seifert-Held
- Department of Neurology, Medical University of Graz, Graz, Austria
- Department of Neurology, Landeskrankenhaus (LKH) Murtal, Standort Knittelfeld, Austria
| | | | - Morten Blaabjerg
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Markus Breu
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Jens Dreyhaupt
- Institute for Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | | | - Marcus Erdler
- Department of Neurology and Karl Landsteiner Institute for Neuroimmunological and Neurodegenerative Disorders Klinik Donaustadt, Vienna, Austria
| | - Ingrid Fae
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Gottfried Fischer
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Florian Frommlet
- Center of Medical Data Science, Medical University of Vienna, Vienna, Austria
| | - Anna Heidbreder
- Department of Neurology, Johannes Kepler University Linz, Linz, Austria
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Birgit Högl
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Veronika Klose
- Department of Neurology, University Hospital Ulm, Ulm, Germany
| | - Sigrid Klotz
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Herburg Liendl
- Department of Neurology, Landeskrankenhaus (LKH) Murtal, Standort Knittelfeld, Austria
| | - Mette S. Nissen
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Jasmin Rahimi
- Department of Neurology and Karl Landsteiner Institute for Neuroimmunological and Neurodegenerative Disorders Klinik Donaustadt, Vienna, Austria
| | - Raphael Reinecke
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Gerda Ricken
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Ambra Stefani
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Marie Süße
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Helio A. G. Teive
- Movement Disorders Unit, Neurology Service, Internal Medicine Department, Hospital de Clínicas, Federal University of Paraná, Curitiba, PR, Brazil
| | - Serge Weis
- Division of Neuropathology, Department of Pathology and Molecular Pathology, Johannes Kepler University Linz, Linz, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Lidia Sabater
- Fundació de recerca clínic-Institut d’Investigacions Biomèdiques August Pi i Sunyer (FCRB-IDIBAPS), Caixa Research Institute (CRI), Universitat de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Madrid, Spain
| | - Carles Gaig
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Madrid, Spain
- Department of Neurology, Hospital Clínic, Barcelona, Spain
| | - Jan Lewerenz
- Department of Neurology, University Hospital Ulm, Ulm, Germany
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
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Seyedsadr M, Bang M, McCarthy E, Zhang S, Chen HC, Mohebbi M, Hugo W, Whitmire JK, Lechner MG, Su MA. A pathologically expanded, clonal lineage of IL-21 producing CD4+ T cells drives Inflammatory neuropathy. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.01.07.574553. [PMID: 38260637 PMCID: PMC10802410 DOI: 10.1101/2024.01.07.574553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Inflammatory neuropathies, which include CIDP (chronic inflammatory demyelinating polyneuropathy) and GBS (Guillain Barre Syndrome), result from autoimmune destruction of the peripheral nervous system (PNS) and are characterized by progressive weakness and sensory loss. CD4+ T cells play a key role in the autoimmune destruction of the PNS. Yet, key properties of pathogenic CD4+ T cells remain incompletely understood. Here, we use paired scRNAseq and scTCRseq of peripheral nerves from an inflammatory neuropathy mouse model to identify IL-21 expressing CD4+ T cells that are clonally expanded and multifunctional. These IL-21-expressing CD4+ T cells are comprised of two transcriptionally distinct expanded populations, which express genes associated with Tfh and Tph subsets. Remarkably, TCR clonotypes are shared between these two IL-21-expressing populations, suggesting a common lineage differentiation pathway. Finally, we demonstrate that IL-21 signaling is required for neuropathy development and pathogenic T cell infiltration into peripheral nerves. IL-21 signaling upregulates CXCR6, a chemokine receptor that promotes CD4+ T cell localization in peripheral nerves. Together, these findings point to IL-21 signaling, Tfh/Tph differentiation, and CXCR6-mediated cellular localization as potential therapeutic targets in inflammatory neuropathies.
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Affiliation(s)
- Maryamsadat Seyedsadr
- Department of Microbiology, Immunology, and Molecular Genetics, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | - Madison Bang
- Department of Microbiology, Immunology, and Molecular Genetics, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | - Ethan McCarthy
- Department of Microbiology, Immunology, and Molecular Genetics, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | - Shirley Zhang
- Department of Microbiology, Immunology, and Molecular Genetics, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | - Ho-Chung Chen
- Department of Microbiology, Immunology, and Molecular Genetics, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | - Mahnia Mohebbi
- Department of Microbiology, Immunology, and Molecular Genetics, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | - Willy Hugo
- Department of Medicine, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | | | - Melissa G. Lechner
- Department of Medicine, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | - Maureen A. Su
- Department of Microbiology, Immunology, and Molecular Genetics, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
- Department of Pediatrics, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
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3
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Chen X, Qiu J, Gao Z, Liu B, Zhang C, Yu W, Yang J, Shen Y, Qi L, Yao X, Sun H, Yang X. Myasthenia gravis: Molecular mechanisms and promising therapeutic strategies. Biochem Pharmacol 2023; 218:115872. [PMID: 37865142 DOI: 10.1016/j.bcp.2023.115872] [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: 09/03/2023] [Revised: 10/16/2023] [Accepted: 10/18/2023] [Indexed: 10/23/2023]
Abstract
Myasthenia gravis (MG) is a type of autoimmune disease caused by the blockage of neuromuscular junction transmission owing to the attack of autoantibodies on transmission-related proteins. Related antibodies, such as anti-AChR, anti-MuSK and anti-LRP4 antibodies, can be detected in most patients with MG. Although traditional therapies can control most symptoms, several challenges remain to be addressed, necessitating the development of more effective and safe treatment strategies for MG. With the in-depth exploration on the mechanism and immune targets of MG, effective therapies, especially therapies using biologicals, have been reported recently. Given the important roles of immune cells, cytokines and intercellular interactions in the pathological process of MG, B-cell targeted therapy, T-cell targeted therapy, proteasome inhibitors targeting plasma cell, complement inhibitors, FcRn inhibitors have been developed for the treatment of MG. Although these novel therapies exert good therapeutic effects, they may weaken the immunity and increase the risk of infection in MG patients. This review elaborates on the pathogenesis of MG and discusses the advantages and disadvantages of the strategies of traditional treatment and biologicals. In addition, this review emphasises that combined therapy may have better therapeutic effects and reducing the risk of side effects of treatments, which has great prospects for the treatment of MG. With the deepening of research on immunotherapy targets in MG, novel opportunities and challenges in the treatment of MG will be introduced.
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Affiliation(s)
- Xin Chen
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Department of Neurology, Affiliated Hospital of Nantong University, Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Jiayi Qiu
- Department of Clinical Medicine, Medical College, Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Zihui Gao
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Department of Neurology, Affiliated Hospital of Nantong University, Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Boya Liu
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Department of Neurology, Affiliated Hospital of Nantong University, Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Chen Zhang
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Department of Neurology, Affiliated Hospital of Nantong University, Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Weiran Yu
- Department of Clinical Medicine, Medical College, Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Jiawen Yang
- Department of Clinical Medicine, Medical College, Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Yuntian Shen
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Department of Neurology, Affiliated Hospital of Nantong University, Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Lei Qi
- Department of Emergency Medicine, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Xinlei Yao
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Department of Neurology, Affiliated Hospital of Nantong University, Nantong University, Nantong, Jiangsu Province 226001, PR China.
| | - Hualin Sun
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Department of Neurology, Affiliated Hospital of Nantong University, Nantong University, Nantong, Jiangsu Province 226001, PR China.
| | - Xiaoming Yang
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Department of Neurology, Affiliated Hospital of Nantong University, Nantong University, Nantong, Jiangsu Province 226001, PR China.
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4
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Barrett LD, Ballew M, Ewers E. Hashimoto's Encephalopathy with Use of Intravenous Immunoglobulin as First-Line Therapy. Mil Med 2023; 188:e3276-e3279. [PMID: 37428510 DOI: 10.1093/milmed/usad264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 01/17/2023] [Accepted: 06/30/2023] [Indexed: 07/11/2023] Open
Abstract
Hashimoto's encephalopathy is an uncommon cause of altered mental status in hospitalized patients and is challenging to diagnose, particularly in the presence of other psychiatric comorbidities. Corticosteroids are the primary treatment. Here, we present a patient with history of post-traumatic stress disorder and prior substance abuse admitted with profound altered mental status and agitation requiring admission to the intensive care unit and mechanical ventilation. He was treated with intravenous immunoglobulin (IVIG) instead of the standard steroid course because of concerns for worsening agitation. The patient had improvement with IVIG infusions, returned to a functional state, and has remained on IVIG therapy monthly since the initial episode without any disease recurrence.
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Affiliation(s)
- Laura D Barrett
- Department of Internal Medicine, Fort Belvoir Community Hospital, Fort Belvoir, VA 22060, USA
| | - Matthew Ballew
- Department of Family Medicine, Fort Belvoir Community Hospital, Fort Belvoir, VA 22060, USA
| | - Evan Ewers
- Infectious Disease and Critical Care Medicine, Fort Belvoir Community Hospital, Fort Belvoir, VA 22060, USA
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5
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Shastri A, Al Aiyan A, Kishore U, Farrugia ME. Immune-Mediated Neuropathies: Pathophysiology and Management. Int J Mol Sci 2023; 24:7288. [PMID: 37108447 PMCID: PMC10139406 DOI: 10.3390/ijms24087288] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 03/12/2023] [Accepted: 03/21/2023] [Indexed: 04/29/2023] Open
Abstract
Dysfunction of the immune system can result in damage of the peripheral nervous system. The immunological mechanisms, which include macrophage infiltration, inflammation and proliferation of Schwann cells, result in variable degrees of demyelination and axonal degeneration. Aetiology is diverse and, in some cases, may be precipitated by infection. Various animal models have contributed and helped to elucidate the pathophysiological mechanisms in acute and chronic inflammatory polyradiculoneuropathies (Guillain-Barre Syndrome and chronic inflammatory demyelinating polyradiculoneuropathy, respectively). The presence of specific anti-glycoconjugate antibodies indicates an underlying process of molecular mimicry and sometimes assists in the classification of these disorders, which often merely supports the clinical diagnosis. Now, the electrophysiological presence of conduction blocks is another important factor in characterizing another subgroup of treatable motor neuropathies (multifocal motor neuropathy with conduction block), which is distinct from Lewis-Sumner syndrome (multifocal acquired demyelinating sensory and motor neuropathy) in its response to treatment modalities as well as electrophysiological features. Furthermore, paraneoplastic neuropathies are also immune-mediated and are the result of an immune reaction to tumour cells that express onconeural antigens and mimic molecules expressed on the surface of neurons. The detection of specific paraneoplastic antibodies often assists the clinician in the investigation of an underlying, sometimes specific, malignancy. This review aims to discuss the immunological and pathophysiological mechanisms that are thought to be crucial in the aetiology of dysimmune neuropathies as well as their individual electrophysiological characteristics, their laboratory features and existing treatment options. Here, we aim to present a balance of discussion from these diverse angles that may be helpful in categorizing disease and establishing prognosis.
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Affiliation(s)
- Abhishek Shastri
- Central and North West London NHS Foundation Trust, London NW1 3AX, UK
| | - Ahmad Al Aiyan
- Department of Veterinary Medicine, UAE University, Al Ain P.O. Box 15551, United Arab Emirates
| | - Uday Kishore
- Department of Veterinary Medicine, UAE University, Al Ain P.O. Box 15551, United Arab Emirates
| | - Maria Elena Farrugia
- Department of Neurology, Institute of Neurological Sciences, Southern General Hospital, Glasgow G51 4TF, UK
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6
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Kalita J, Misra UK, Chaudhary SK, Das M, Mishra A, Ranjan A, Kumar M. The outcome of Guillain-Barré syndrome following intravenous immunoglobulin compared to the natural course. Eur J Neurol 2022; 29:3071-3080. [PMID: 35837807 DOI: 10.1111/ene.15500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 06/29/2022] [Accepted: 07/07/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Intravenous immunoglobulin (IVIg) is recommended in Guillain-Barré syndrome (GBS), but its efficacy may vary in different subtypes. We report the outcomes of patients with GBS following IVIg treatment compared to the natural course (NC). We also compare the effect of IVIg treatment in different subtypes of GBS. METHODS From a cohort of 528 GBS, we have extracted 189 patients who received IVIg and compared their outcomes with 199 age and peak disability matched patients who did not receive IVIg, plasmapheresis, or corticosteroid. Disability was assessed using the 0-6 GBS Disability Scale (GBSDS). Clinical and neurophysiological subtypes were recorded. The primary outcome was functional disability at 6-months and was categorized as complete (GBSDS ≤ 1), partial (GBSDS 2-3), and poor (GBSDS > 3). The secondary outcomes were in-hospital death, and duration of hospitalization, and mechanical ventilation (MV). RESULTS In-hospital death (2.6% vs 2%; p = 0.74) and 3-months poor recovery (20.7% vs 18%) were similar in the IVIg and NC group. At 6-months, however, a lesser proportion of patients in IVIg group had poor recovery (2.2% vs 8.3%; p = 0.026). The outcomes of IVIg and NC were compared in 72 AMAN and 256 AIDP patients. IVIg therapy did not alter the outcome in AMAN but resulted in a lesser proportion of poor recovery at 6-months in AIDP (0.8% vs. 6.6%; p = 0.03). CONCLUSION Intravenous immunoglobulin is beneficial in AIDP variants of GBS but not in the AMAN subtype. A customized treatment may be cost-effective till a randomized controlled trial is conducted in AMAN.
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Affiliation(s)
- Jayantee Kalita
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow
| | - Usha K Misra
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow.,Department of Neurology, Apollomedics Super Specialty Hospitals, Lucknow, Uttar Pradesh, India
| | - Sarvesh K Chaudhary
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow
| | - Moromi Das
- Department of Neurology, Guwahati Medical College, Assam, India
| | - Anadi Mishra
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow
| | - Abhay Ranjan
- Department of Neurology, Indira Gandhi Institute of Medical Sciences, Patna, India
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7
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Menon D, Bril V. Pharmacotherapy of Generalized Myasthenia Gravis with Special Emphasis on Newer Biologicals. Drugs 2022; 82:865-887. [PMID: 35639288 PMCID: PMC9152838 DOI: 10.1007/s40265-022-01726-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 11/20/2022]
Abstract
Myasthenia gravis (MG) is a chronic, fluctuating, antibody-mediated autoimmune disorder directed against the post-synaptic neuromuscular junctions of skeletal muscles, resulting in a wide spectrum of manifestations ranging from mild to potentially fatal. Given its unique natural course, designing an ideal trial design for MG has been wrought with difficulties and evidence in favour of several of the conventional agents is weak as per current standards. Despite this, acetylcholinesterases and corticosteroids have remained the cornerstones of treatment for several decades with intravenous immunoglobulins (IVIG) and therapeutic plasma exchange (PLEX) offering rapid treatment response, especially in crises. However, the treatment of MG entails long-term immunosuppression and conventional agents are viable options but take longer to act and have a number of class-specific adverse effects. Advances in immunology, translational medicine and drug development have seen the emergence of several newer biological agents which offer selective, target-specific immunotherapy with fewer side effects and rapid onset of action. Eculizumab is one of the newer agents that belong to the class of complement inhibitors and has been approved for the treatment of refractory general MG. Zilucoplan and ravulizumab are other agents in this group in clinical trials. Neisseria meningitis is a concern with all complement inhibitors, mandating vaccination. Neonatal Fc receptor (FcRn) inhibitors prevent immunoglobulin recycling and cause rapid reduction in antibody levels. Efgartigimod is an FcRn inhibitor recently approved for MG treatment, and rozanolixizumab, nipocalimab and batoclimab are other agents in clinical trial development. Although lacking high quality evidence from randomized clinical trials, clinical experience with the use of anti-CD20 rituximab has led to its use in refractory MG. Among novel targets, interleukin 6 (IL6) inhibitors such as satralizumab are promising and currently undergoing evaluation. Cutting-edge therapies include genetically modifying T cells to recognise chimeric antigen receptors (CAR) and chimeric autoantibody receptors (CAAR). These may offer sustained and long-term remissions, but are still in very early stages of evaluation. Hematopoietic stem cell transplantation (HSCT) allows immune resetting and offers sustained remission, but the induction regimens often involve serious systemic toxicity. While MG treatment is moving beyond conventional agents towards target-specific biologicals, lack of knowledge as to the initiation, maintenance, switching, tapering and long-term safety profile necessitates further research. These concerns and the high financial burden of novel agents may hamper widespread clinical use in the near future.
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Affiliation(s)
- Deepak Menon
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, 5EC-309, Toronto General Hospital, University of Toronto, 200 Elizabeth St, Toronto, M5G 2C4, Canada.
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Rajabally YA. Immunoglobulin and Monoclonal Antibody Therapies in Guillain-Barré Syndrome. Neurotherapeutics 2022; 19:885-896. [PMID: 35648286 PMCID: PMC9159039 DOI: 10.1007/s13311-022-01253-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2022] [Indexed: 12/29/2022] Open
Abstract
Guillain-Barré syndrome (GBS) is an acute autoimmune polyradiculoneuropathy affecting 1-2 subjects per 100,000 every year worldwide. It causes, in its classic form, symmetric weakness in the proximal and distal limb muscles with common involvement of the cranial nerves, particularly facial weakness. Respiratory function is compromised in a case in four. Randomised controlled trials have demonstrated the benefit of therapeutic plasma exchange in hastening time to recovery. Intravenous immunoglobulin was subsequently shown to be as efficacious as plasma exchange in adult subjects. In children, few trials have shown the benefit of intravenous immunoglobulin versus supportive care. Pharmacokinetic studies suggested a relationship between increase in immunoglobulin G level post-infusion and outcome, implying administration of larger doses may be beneficial in subjects with poor prognosis. However, a subsequent trial of a second dose of immunoglobulin in such subjects failed to show improved outcome, while demonstrating a higher risk of thromboembolic side-effects. Monoclonal antibody therapy has more recently been investigated for GBS, after multiple studies in animal models, with different agents and variable postulated mechanisms of action. Eculizumab, a humanised monoclonal antibody against the complement protein C5, was tested in in two randomised, double-blind, placebo-controlled phase 2 trials. Neither showed benefit versus immunoglobulins alone on disability level at 4 weeks, although one study importantly suggested possible, clinically highly relevant, late effects on normalising function. A phase 3 trial is in progress. Preliminary results of a placebo-controlled ongoing study of ANX005, a humanised recombinant antibody against C1q inhibiting the complement cascade, have been promising.
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Affiliation(s)
- Yusuf A Rajabally
- Aston Medical School, Aston University, Birmingham, B4 7ET, UK.
- Inflammatory Neuropathy Clinic, University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham, B15 2TH, UK.
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Koneczny I, Tzartos J, Mané-Damas M, Yilmaz V, Huijbers MG, Lazaridis K, Höftberger R, Tüzün E, Martinez-Martinez P, Tzartos S, Leypoldt F. IgG4 Autoantibodies in Organ-Specific Autoimmunopathies: Reviewing Class Switching, Antibody-Producing Cells, and Specific Immunotherapies. Front Immunol 2022; 13:834342. [PMID: 35401530 PMCID: PMC8986991 DOI: 10.3389/fimmu.2022.834342] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/28/2022] [Indexed: 12/24/2022] Open
Abstract
Organ-specific autoimmunity is often characterized by autoantibodies targeting proteins expressed in the affected tissue. A subgroup of autoimmunopathies has recently emerged that is characterized by predominant autoantibodies of the IgG4 subclass (IgG4-autoimmune diseases; IgG4-AID). This group includes pemphigus vulgaris, thrombotic thrombocytopenic purpura, subtypes of autoimmune encephalitis, inflammatory neuropathies, myasthenia gravis and membranous nephropathy. Although the associated autoantibodies target specific antigens in different organs and thus cause diverse syndromes and diseases, they share surprising similarities in genetic predisposition, disease mechanisms, clinical course and response to therapies. IgG4-AID appear to be distinct from another group of rare immune diseases associated with IgG4, which are the IgG4-related diseases (IgG4-RLD), such as IgG4-related which have distinct clinical and serological properties and are not characterized by antigen-specific IgG4. Importantly, IgG4-AID differ significantly from diseases associated with IgG1 autoantibodies targeting the same organ. This may be due to the unique functional characteristics of IgG4 autoantibodies (e.g. anti-inflammatory and functionally monovalent) that affect how the antibodies cause disease, and the differential response to immunotherapies of the IgG4 producing B cells/plasmablasts. These clinical and pathophysiological clues give important insight in the immunopathogenesis of IgG4-AID. Understanding IgG4 immunobiology is a key step towards the development of novel, IgG4 specific treatments. In this review we therefore summarize current knowledge on IgG4 regulation, the relevance of class switching in the context of health and disease, describe the cellular mechanisms involved in IgG4 production and provide an overview of treatment responses in IgG4-AID.
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Affiliation(s)
- Inga Koneczny
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
- *Correspondence: Inga Koneczny,
| | - John Tzartos
- Neuroimmunology, Tzartos NeuroDiagnostics, Athens, Greece
- 2nd Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Marina Mané-Damas
- Research Group Neuroinflammation and Autoimmunity, Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Vuslat Yilmaz
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Maartje G. Huijbers
- Department of Human Genetics, Leiden University Medical Center, Leiden, Netherlands
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Konstantinos Lazaridis
- Department of Immunology, Laboratory of Immunology, Hellenic Pasteur Institute, Athens, Greece
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Erdem Tüzün
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Pilar Martinez-Martinez
- Research Group Neuroinflammation and Autoimmunity, Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Socrates Tzartos
- Neuroimmunology, Tzartos NeuroDiagnostics, Athens, Greece
- Department of Neurobiology, Hellenic Pasteur Institute, Athens, Greece
| | - Frank Leypoldt
- Neuroimmunology, Institute of Clinical Chemistry and Department of Neurology, UKSH Kiel/Lübeck, Kiel University, Kiel, Germany
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10
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Macher S, Bsteh G, Berger T, Höftberger R. Diagnostic approach and treatment regimens in adult patients suffering from antibody-mediated or paraneoplastic encephalitis. Curr Pharm Des 2022; 28:454-467. [PMID: 35100954 DOI: 10.2174/1381612828666220131093259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 12/17/2021] [Indexed: 11/22/2022]
Abstract
Identification of patients with antibody-mediated encephalitis poses a diagnostic challenge and any delay in that respect will increase the interval until initiation of immunotherapy and may negatively affect the patient´s clinical outcome. Within this review we focus on therapeutic strategies in antibody-mediated encephalitis and propose how to proceed with patients, who are suspected to have encephalitis of unknown origin. We further briefly outline differences in treatment of paraneoplastic and antibody-mediated encephalitis according to its pathomechanisms.
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Affiliation(s)
- Stefan Macher
- Department of Neurology, Medical University of Vienna, Vienna, Austria; 2 Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria; 2 Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria; 2 Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Romana Höftberger
- Department of Neurology, Medical University of Vienna, Vienna, Austria; 2 Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
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11
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Kira JI. Anti-Neurofascin 155 Antibody-Positive Chronic Inflammatory Demyelinating Polyneuropathy/Combined Central and Peripheral Demyelination: Strategies for Diagnosis and Treatment Based on the Disease Mechanism. Front Neurol 2021; 12:665136. [PMID: 34177770 PMCID: PMC8222570 DOI: 10.3389/fneur.2021.665136] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 04/06/2021] [Indexed: 02/02/2023] Open
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is an immune-mediated demyelinating disease of the peripheral nervous system (PNS). A small number of CIDP patients harbors autoantibodies against nodal/paranodal proteins, such as neurofascin 155 (NF155), contactin 1, and contactin-associated protein 1. In most cases, the predominant immunoglobulin (IgG) subclass is IgG4. Node/paranode antibody-positive CIDP demonstrates distinct features compared with antibody-negative CIDP, including a poor response to intravenous immunoglobulin. The neuropathology of biopsied sural nerve shows Schwann cell terminal loop detachment from axons without macrophage infiltration or inflammation. This is partly attributable to IgG4, which blocks protein-protein interactions without inducing inflammation. Anti-NF155 antibody-positive (NF155+) CIDP is unique because of the high frequency of subclinical demyelinating lesions in the central nervous system (CNS). This is probably because NF155 coexists in the PNS and CNS. Such cases showing demyelinating lesions in both the CNS and PNS are now termed combined central and peripheral demyelination (CCPD). NF155+ CIDP/CCPD commonly presents hypertrophy of spinal nerve roots and cranial nerves, such as trigeminal and oculomotor nerves, and extremely high levels of cerebrospinal fluid (CSF) protein, which indicates nerve root inflammation. In the CSF, the CXCL8/IL8, IL13, TNFα, CCL11/eotaxin, CCL2/MCP1, and IFNγ levels are significantly higher and the IL1β, IL1ra, and GCSF levels are significantly lower in NF155+ CIDP than in non-inflammatory neurological diseases. Even compared with anti-NF155 antibody-negative (NF155-) CIDP, the CXCL8/IL8 and IL13 levels are significantly higher and the IL1β and IL1ra levels are significantly lower than those in NF155+ CIDP. Canonical discriminant analysis revealed NF155+ and NF155- CIDP to be separable with IL4, IL10, and IL13, the three most significant discriminators, all of which are required for IgG4 class switching. Therefore, upregulation of both Th2 and Th1 cytokines and downregulation of macrophage-related cytokines are characteristic of NF155+ CIDP, which explains spinal root inflammation and the lack of macrophage infiltration in the sural nerves. All Japanese patients with NF155+ CIDP/CCPD have one of two specific human leukocyte antigen (HLA) haplotypes, which results in a significantly higher prevalence of HLA-DRB1 * 15:01-DQB1 * 06:02 compared with healthy Japanese controls. This indicates an involvement of specific HLA class II molecules and relevant T cells in addition to IgG4 anti-NF155 antibodies in the mechanism underlying IgG4 NF155+ CIDP/CCPD.
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Affiliation(s)
- Jun-Ichi Kira
- Translational Neuroscience Center, Graduate School of Medicine, and School of Pharmacy at Fukuoka, International University of Health and Welfare, Fukuoka, Japan.,Department of Neurology, Brain and Nerve Center, Fukuoka Central Hospital, International University of Health and Welfare, Fukuoka, Japan
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12
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Application of intravenous immunoglobulin (IVIG) to modulate inflammation in critical COVID-19 - A theoretical perspective. Med Hypotheses 2021; 151:110592. [PMID: 33878626 PMCID: PMC8032597 DOI: 10.1016/j.mehy.2021.110592] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 04/01/2021] [Accepted: 04/05/2021] [Indexed: 12/15/2022]
Abstract
COVID-19 is an airway disease that has affected ~125 million people worldwide, caused by a novel coronavirus termed severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), spread through respiratory droplets, direct contact, and aerosol transmission. Although most patients presenting with absent or mild symptoms recover completely, the highest morbidity and mortality rates are seen in the elderly, and patients with comorbidities such as cardiovascular diseases, cancer, immunosuppressive diseases, diabetes, and pre-existing respiratory illnesses. Several therapeutic strategies have been examined, but a wide-ranging therapeutic option for particularly severe cases of COVID-19 remains to be elucidated. Considering the indications presented by COVID-19 patients who present similarly with inflammatory conditions, intravenous immunoglobulin (IVIG) administration has been examined as a possible route to reduce proinflammatory markers such as ESR, CRP and ferritin by reducing inflammation, based on its anti-inflammatory effects as indicated by utilisation of IVIG for numerous other inflammatory conditions. Herein, summarising the recent key clinical evaluations of IVIG administration, we present our hypothesis that administration of IVIG within a specific dosage would be extremely beneficial towards reducing mortality and perhaps even the length of hospitalisation of patients exhibiting severe COVID-19 symptoms.
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13
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Leelayuwatanakul N, Kongpolprom N, Sriprasart T, Phoophiboon V, Thanthitaweewat V, Thawanaphong S, Sirichana W, Chirakalwasan N, Kawkitinarong K, Sittipunt C, Putcharoen O, Paitoonpong L, Suwanpimolkul G, Jantarabenjakul W, Srisawat N, Pachinburavan M. Multimodality treatment in immunocompromised patients with severe COVID-19: the role of IL-6 inhibitor, intravenous immunoglobulin, and haemoperfusion. Respirol Case Rep 2021; 9:e0733. [PMID: 33732466 PMCID: PMC7938208 DOI: 10.1002/rcr2.733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/02/2021] [Accepted: 02/16/2021] [Indexed: 01/08/2023] Open
Abstract
Cytokine release syndrome (CRS) is known to be associated with severe coronavirus disease 2019 (COVID-19). Multiple anti-inflammatory therapies such as tocilizumab, corticosteroids, intravenous immunoglobulin (IVIG), and haemoadsorption or haemoperfusion have been used to combat this life-threatening condition. However, immunocompromised hosts are often omitted from research studies, and knowledge on the clinical efficacy of these therapies in immunocompromised patients is therefore limited. We report two cases of immunocompromised patients with severe COVID-19-related CRS requiring mechanical ventilation who were treated with multimodality treatment consisting of tocilizumab, IVIG, and haemoperfusion. Within 48 h, both patients showed clinical improvement with PaO2:FiO2 ratio and haemodynamic stability. Both survived to discharge. There were no adverse events following these therapies. In conclusion, combined therapeutic modalities, possibly tailored to individual inflammatory profiles, are promising treatment for severe COVID-19 infection in the immunocompromised host. Timely administration of adjunctive therapies that alleviate overwhelming inflammation may provide the best outcome.
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Affiliation(s)
- Nophol Leelayuwatanakul
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of MedicineChulalongkorn UniversityBangkokThailand
| | - Napplika Kongpolprom
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of MedicineChulalongkorn UniversityBangkokThailand
| | - Thitiwat Sriprasart
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of MedicineChulalongkorn UniversityBangkokThailand
| | - Vorakamol Phoophiboon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of MedicineChulalongkorn UniversityBangkokThailand
| | - Vorawut Thanthitaweewat
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of MedicineChulalongkorn UniversityBangkokThailand
| | - Sarita Thawanaphong
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of MedicineChulalongkorn UniversityBangkokThailand
| | - Worawan Sirichana
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of MedicineChulalongkorn UniversityBangkokThailand
| | - Naricha Chirakalwasan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of MedicineChulalongkorn UniversityBangkokThailand
| | - Kamon Kawkitinarong
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of MedicineChulalongkorn UniversityBangkokThailand
| | - Chanchai Sittipunt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of MedicineChulalongkorn UniversityBangkokThailand
| | - Opass Putcharoen
- Division of Infectious Diseases, Department of Medicine, Faculty of MedicineChulalongkorn UniversityBangkokThailand
- Thai Red Cross Emerging Infectious Diseases Clinical CenterKing Chulalongkorn Memorial HospitalBangkokThailand
| | - Leilani Paitoonpong
- Division of Infectious Diseases, Department of Medicine, Faculty of MedicineChulalongkorn UniversityBangkokThailand
- Thai Red Cross Emerging Infectious Diseases Clinical CenterKing Chulalongkorn Memorial HospitalBangkokThailand
| | - Gompol Suwanpimolkul
- Division of Infectious Diseases, Department of Medicine, Faculty of MedicineChulalongkorn UniversityBangkokThailand
- Thai Red Cross Emerging Infectious Diseases Clinical CenterKing Chulalongkorn Memorial HospitalBangkokThailand
| | - Watsamon Jantarabenjakul
- Thai Red Cross Emerging Infectious Diseases Clinical CenterKing Chulalongkorn Memorial HospitalBangkokThailand
- Department of Paediatrics, Faculty of MedicineChulalongkorn UniversityBangkokThailand
| | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of MedicineChulalongkorn UniversityBangkokThailand
| | - Monvasi Pachinburavan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of MedicineChulalongkorn UniversityBangkokThailand
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14
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Practical Aspects of Transitioning from Intravenous to Subcutaneous Immunoglobulin Therapy in Neuromuscular Disorders. Can J Neurol Sci 2021; 49:161-167. [PMID: 33766159 DOI: 10.1017/cjn.2021.56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Recent evidence shows that subcutaneous immunoglobulin (SCIG) is as efficacious as intravenous immunoglobulin (IVIG) and has a better safety profile and acceptance rate among patients with neuromuscular disorders who require maintenance IVIG treatment. Awareness of the practical aspects of patient selection, enrollment, dose calculation, administration, and follow-up would help physicians coordinate a smooth and seamless transition from IVIG to SCIG. SCIG is ideally offered to patients having intolerable side effects during IVIG or wearing-off effect and in those keen for treatment autonomy. The weekly dose of SCIG is calculated by multiplying the maintenance dose of IVIG by the dose adjustment factor and dividing by the interval between IVIG in weeks and is initiated 1 week after the last dose of IVIG. The physician places the order for the SCIG and the clinic nurse or the physician refers the patient to the home care nursing program for further education and training. The necessary supplies are dispatched to the patient who would also collect the SCIG from the transfusion center of the nearest hospital. The patient is educated on assembling and administering the infusion, and home visits are continued until the patient or caregiver is confident. Regular follow-up with the patient is maintained to assess treatment response and side effects if any. With a smooth transition, most patients have excellent tolerance to SCIG and in our experience seldom request switching back to IVIG. Transitioning patients from IVIG to SCIG offers several advantages and thus, in general, is preferable for multiple stakeholders.
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15
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Yang MC, Liu A. Surge of Miller Fisher variant and Guillain-Barré syndrome in two downtown Los Angeles community teaching hospitals. Clin Case Rep 2020; 8:2245-2250. [PMID: 33235769 PMCID: PMC7669403 DOI: 10.1002/ccr3.3132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/27/2020] [Accepted: 06/12/2020] [Indexed: 11/29/2022] Open
Abstract
Guillain-Barré syndrome (GBS) and Miller Fisher variant (MFv) cases spiked threefold in Los Angeles, with a high proportion of MFv cases. MFv is underdiagnosed when accompanying neurological symptoms are mild. This report emphasizes the seasonality of GBS and its relation to ganglioside antibodies.
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Affiliation(s)
- Michael C. Yang
- Department of Internal MedicineAdventist Health White MemorialLos AngelesCAUSA
| | - Antonio Liu
- Department of NeurologyAdventist Health White MemorialLos AngelesCAUSA
- Department of NeurologyCalifornia Hospital Medical CenterLos AngelesCAUSA
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16
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Kuitwaard K, Brusse E, Jacobs BC, Vrancken AFJE, Eftimov F, Notermans NC, van der Kooi AJ, Fokkink WJR, Nieboer D, Lingsma HF, Merkies ISJ, van Doorn PA. Randomized trial of intravenous immunoglobulin maintenance treatment regimens in chronic inflammatory demyelinating polyradiculoneuropathy. Eur J Neurol 2020; 28:286-296. [PMID: 32876962 PMCID: PMC7820989 DOI: 10.1111/ene.14501] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 08/26/2020] [Indexed: 12/28/2022]
Abstract
Background and purpose High peak serum immunoglobulin G (IgG) levels may not be needed for maintenance intravenous immunoglobulin (IVIg) treatment in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and such high levels may cause side effects. More frequent lower dosing may lead to more stable IgG levels and higher trough levels, which might improve efficacy. The aim of this trial is to investigate whether high frequent low dosage IVIg treatment is more effective than low frequent high dosage IVIg treatment. Methods In this randomized placebo‐controlled crossover trial, we included patients with CIDP proven to be IVIg‐dependent and receiving an individually established stable dose and interval of IVIg maintenance treatment. In the control arm, patients received their individual IVIg dose and interval followed by a placebo infusion at half the interval. In the intervention arm, patients received half their individual dose at half the interval. After a wash‐out phase patients crossed over. The primary outcome measure was handgrip strength (assessed using a Martin Vigorimeter). Secondary outcome indicators were health‐related quality of life (36‐item Short‐Form Health Survey), disability (Inflammatory Rasch‐built Overall Disability Scale), fatigue (Rasch‐built Fatigue Severity Scale) and side effects. Results Twenty‐five patients were included and were treated at baseline with individually adjusted dosages of IVIg ranging from 20 to 80 g and intervals ranging from 14 to 35 days. Three participants did not complete the trial; the main analysis was therefore based on the 22 patients completing both treatment periods. There was no significant difference in handgrip strength change from baseline between the two treatment regimens (coefficient −2.71, 95% CI −5.4, 0.01). Furthermore, there were no significant differences in any of the secondary outcomes or side effects. Conclusions More frequent lower dosing does not further improve the efficacy of IVIg in stable IVIg‐dependent CIDP and does not result in fewer side effects.
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Affiliation(s)
- K Kuitwaard
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands.,Department of Neurology, Albert Schweitzer hospital, Dordrecht, The Netherlands
| | - E Brusse
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - B C Jacobs
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands.,Department of Immunology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - A F J E Vrancken
- Department of Neurology, Brain Centre Rudolf Magnus University Medical Centre Utrecht, Utrecht, The Netherlands
| | - F Eftimov
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - N C Notermans
- Department of Neurology, Brain Centre Rudolf Magnus University Medical Centre Utrecht, Utrecht, The Netherlands
| | - A J van der Kooi
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - W-J R Fokkink
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands.,Department of Immunology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - D Nieboer
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - H F Lingsma
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - I S J Merkies
- Department of Neurology, Curaçao Medical Centre Willemstad, Willemstad, Curaçao.,Department of Neurology, School of Medical Health and Neuroscience, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - P A van Doorn
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
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17
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Menon D, Barnett C, Bril V. Novel Treatments in Myasthenia Gravis. Front Neurol 2020; 11:538. [PMID: 32714266 PMCID: PMC7344308 DOI: 10.3389/fneur.2020.00538] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 05/14/2020] [Indexed: 01/08/2023] Open
Abstract
Myasthenia gravis (MG) is the prototypical autoimmune disorder caused by specific autoantibodies at the neuromuscular junction. Broad-based immunotherapies, such as corticosteroids, azathioprine, mycophenolate, tacrolimus, and cyclosporine, have been effective in controlling symptoms of myasthenia. While being effective in a majority of MG patients many of these immunosuppressive agents are associated with long-term side effects, often intolerable for patients, and take several months to be effective. With advances in translational research and drug development capabilities, more directed therapeutic agents that can alter the future of MG treatment have been developed. This review focuses on the aberrant immunological processes in MG, the novel agents that target them along with the clinical evidence for efficacy and safety. These agents include terminal complement C5 inhibitors, Fc receptor inhibitors, B cell depleting agents (anti CD 19 and 20 and B cell activating factor [BAFF)]inhibitors), proteosome inhibitors, T cells and cytokine based therapies (chimeric antigen receptor T [CART-T] cell therapy), autologous stem cell transplantation, and subcutaneous immunoglobulin (SCIG). Most of these new agents have advantages over conventional immunosuppressive treatment (IST) for MG therapy in terms of faster onset of action, favourable side effect profile and the potential for a sustained and long-term remission.
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Affiliation(s)
| | | | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, ON, Canada
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18
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Kolls BJ, O'Keefe YA, Sahgal AK. Autoimmune Encephalitis: NMDA Receptor Encephalitis as an Example of Translational Neuroscience. Neurotherapeutics 2020; 17:404-413. [PMID: 32394329 PMCID: PMC7283418 DOI: 10.1007/s13311-020-00861-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Autoimmune encephalitis (AE) is a group of disorders causing synaptic receptor dysfunction with a broad range of neurological symptoms that has been historically difficult to differentiate clinically. Today, AE represents an excellent example of the rapid determination of the cause of a disease and the ability to identify potential treatments using relatively simple basic science techniques of investigation. Of the number of autoimmune encephalitides identified thus far, one of the best examples of the impact of basic science studies on disease management is NMDA receptor mediated autoimmune encephalitis (NMDAr-AE). In this review, we will provide an overview of the epidemiology of NMDAr-AE, clinical features and treatments, and the basic science tools and techniques that were used to identify the cause, correlate symptoms to underlying pathophysiology, and to understand the mechanism of disease pathology.
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Affiliation(s)
- Brad J Kolls
- Department of Neurology, Duke University School of Medicine, Durham, NC, 27710, USA.
- Brain Injury Translational Research Laboratories, Bryan Research Building, 227F, 311 Research Drive, Durham, NC, 27710, USA.
| | - Yasmin A O'Keefe
- Department of Neurology, Duke University School of Medicine, Durham, NC, 27710, USA
| | - Alok K Sahgal
- Department of Neurology, Duke University School of Medicine, Durham, NC, 27710, USA
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19
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Ogata H, Zhang X, Yamasaki R, Fujii T, Machida A, Morimoto N, Kaida K, Masuda T, Ando Y, Kuwahara M, Kusunoki S, Nakamura Y, Matsushita T, Isobe N, Kira JI. Intrathecal cytokine profile in neuropathy with anti-neurofascin 155 antibody. Ann Clin Transl Neurol 2019; 6:2304-2316. [PMID: 31657126 PMCID: PMC6856599 DOI: 10.1002/acn3.50931] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 09/28/2019] [Accepted: 10/01/2019] [Indexed: 12/27/2022] Open
Abstract
Objective To characterize the CSF cytokine profile in chronic inflammatory demyelinating polyneuropathy (CIDP) patients with IgG4 anti‐neurofascin 155 (NF155) antibodies (NF155+ CIDP) or those lacking anti‐NF155 antibodies (NF155− CIDP). Methods Twenty‐eight CSF cytokines/chemokines/growth factors were measured by multiplexed fluorescent immunoassay in 35 patients with NF155+ CIDP, 36 with NF155− CIDP, and 28 with non‐inflammatory neurological disease (NIND). Results CSF CXCL8/IL‐8, IL‐13, TNF‐α, CCL11/eotaxin, CCL2/MCP‐1, and IFN‐γ were significantly higher, while IL‐1β, IL‐1ra, and G‐CSF were lower, in NF155+ CIDP than in NIND. Compared with NF155− CIDP, CXCL8/IL‐8 and IL‐13 were significantly higher, and IL‐1β, IL‐1ra, and IL‐6 were lower, in NF155+ CIDP. CXCL8/IL‐8, IL‐13, CCL11/eotaxin, CXCL10/IP‐10, CCL3/MIP‐1α, CCL4/MIP‐1β, and TNF‐α levels were positively correlated with markedly elevated CSF protein, while IL‐13, CCL11/eotaxin, and IL‐17 levels were positively correlated with increased CSF cell counts. IL‐13, CXCL8/IL‐8, CCL4/MIP‐1β, CCL3/MIP‐1α, and CCL5/RANTES were decreased by combined immunotherapies in nine NF155+ CIDP patients examined longitudinally. By contrast, NF155− CIDP had significantly increased IFN‐γ compared with NIND, and exhibited positive correlations of IFN‐γ, CXCL10/IP‐10, and CXCL8/IL‐8 with CSF protein. Canonical discriminant analysis of cytokines/chemokines revealed that NF155+ and NF155− CIDP were separable, and that IL‐4, IL‐10, and IL‐13 were the three most significant discriminators. Interpretation Intrathecal upregulation of type 2 helper T (Th2) cell cytokines is characteristic of IgG4 NF155+ CIDP, while type 1 helper T cell cytokines are increased in CIDP regardless of the presence or absence of anti‐NF155 antibodies, suggesting that overproduction of Th2 cell cytokines is unique to NF155+ CIDP.
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Affiliation(s)
- Hidenori Ogata
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Xu Zhang
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Neurology and Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Ryo Yamasaki
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takayuki Fujii
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akira Machida
- Department of Neurology, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Nobutoshi Morimoto
- Department of Neurology, Kagawa Prefectural Central Hospital, Kagawa, Japan
| | - Kenichi Kaida
- Department of Neurology, Anti-aging and Vascular Medicine, National Defense Medical College, Saitama, Japan
| | - Teruaki Masuda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Motoi Kuwahara
- Department of Neurology, School of Medicine, Kinki University, Osaka, Japan
| | - Susumu Kusunoki
- Department of Neurology, School of Medicine, Kinki University, Osaka, Japan
| | - Yuri Nakamura
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takuya Matsushita
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Noriko Isobe
- Department of Neurological Therapeutics, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Jun-Ichi Kira
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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20
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Parker CL, McSweeney MD, Lucas AT, Jacobs TM, Wadsworth D, Zamboni WC, Lai SK. Pretargeted delivery of PEG-coated drug carriers to breast tumors using multivalent, bispecific antibody against polyethylene glycol and HER2. NANOMEDICINE : NANOTECHNOLOGY, BIOLOGY, AND MEDICINE 2019; 21:102076. [PMID: 31394261 PMCID: PMC7224238 DOI: 10.1016/j.nano.2019.102076] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/18/2019] [Accepted: 07/29/2019] [Indexed: 12/19/2022]
Abstract
Pretargeting is an increasingly explored strategy to improve nanoparticle targeting, in which pretargeting molecules that bind both selected epitopes on target cells and nanocarriers are first administered, followed by the drug-loaded nanocarriers. Bispecific antibodies (bsAb) represent a promising class of pretargeting molecules, but how different bsAb formats may impact the efficiency of pretargeting remains poorly understood, in particular Fab valency and Fc receptor (FcR)-binding of bsAb. We found the tetravalent bsAb markedly enhanced PEGylated nanoparticle binding to target HER2+ cells relative to the bivalent bsAb in vitro. Pretargeting with tetravalent bsAb with abrogated FcR binding increased tumor accumulation of PEGylated liposomal doxorubicin (PLD) 3-fold compared to passively targeted PLD alone, and 5-fold vs pretargeting with tetravalent bsAb with normal FcR binding in vivo. Our work demonstrates that multivalency and elimination of FcRn recycling are both important features of pretargeting molecules, and further supports pretargeting as a promising nanoparticle delivery strategy.
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MESH Headings
- Animals
- Antibodies, Bispecific/chemistry
- Antibodies, Bispecific/pharmacology
- Antineoplastic Agents, Immunological/chemistry
- Antineoplastic Agents, Immunological/pharmacology
- Cell Line, Tumor
- Drug Carriers/chemistry
- Drug Carriers/pharmacology
- Female
- Humans
- Mice, Nude
- Neoplasms, Experimental/drug therapy
- Neoplasms, Experimental/metabolism
- Neoplasms, Experimental/pathology
- Polyethylene Glycols/chemistry
- Polyethylene Glycols/pharmacology
- Receptor, ErbB-2/antagonists & inhibitors
- Xenograft Model Antitumor Assays
- omega-Chloroacetophenone
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Affiliation(s)
- Christina L Parker
- Division of Pharmacoengineering and Molecular Pharmaceutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, United States
| | - Morgan D McSweeney
- Division of Pharmacoengineering and Molecular Pharmaceutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, United States
| | - Andrew T Lucas
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, United States; UNC Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, United States; Carolina Center for Nanotechnology Excellence, University of North Carolina at Chapel Hill, United States
| | - Timothy M Jacobs
- Division of Pharmacoengineering and Molecular Pharmaceutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, United States
| | - Daniel Wadsworth
- Division of Pharmacoengineering and Molecular Pharmaceutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, United States
| | - William C Zamboni
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, United States; UNC Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, United States; Carolina Center for Nanotechnology Excellence, University of North Carolina at Chapel Hill, United States
| | - Samuel K Lai
- Division of Pharmacoengineering and Molecular Pharmaceutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, United States; Department of Biomedical Engineering, University of North Carolina at Chapel Hill, United States; Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, United States.
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21
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Abbas A, Rajabally YA. Complications of Immunoglobulin Therapy and Implications for Treatment of Inflammatory Neuropathy: A Review. Curr Drug Saf 2019; 14:3-13. [PMID: 30332974 DOI: 10.2174/1574886313666181017121139] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 10/11/2018] [Accepted: 10/12/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Intravenous Immunoglobulin (IVIg) forms a cornerstone of effective treatment for acute and chronic inflammatory neuropathies, with a class I evidence base in Guillain-Barré Syndrome (GBS), Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) and multifocal motor neuropathy (MMN). It is generally considered to be a safe therapy however there are several recognised complications which are reviewed in this article. DISCUSSION AND CONCLUSION Most adverse events are immediate and mild such as headache, fever and nausea although more serious immediate reactions such as anaphylaxis may rarely occur. Delayed complications are rare but may be serious, including thromboembolic events and acute kidney injury, and these and associated risk factors are also discussed. We emphasise the importance of safe IVIg administration and highlight practical measures to minimise complications of this therapy.
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Affiliation(s)
- Ahmed Abbas
- Department of Neurophysiology, Queen Elizabeth Hospital, University Hospital of Birmingham, Birmingham, United Kingdom
| | - Yusuf A Rajabally
- Department of Neurophysiology, Queen Elizabeth Hospital, University Hospital of Birmingham, Birmingham, United Kingdom.,Department of Neurology, Queen Elizabeth Hospital, University Hospital of Birmingham, Birmingham, United Kingdom.,Department of Aston Brain Centre, Aston University, Birmingham, United Kingdom
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22
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Takahashi H, Okuda S, Tamura M, Kamei S, Aizawa R, Kobayashi T. Prophylactic Treatment with Intravenous Immunoglobulin Attenuates Experimental Optic Neuritis in Mice. Biol Pharm Bull 2019; 42:173-178. [DOI: 10.1248/bpb.b18-00458] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Hiroyuki Takahashi
- Pharmacology Research Department, Teijin Institute for Bio-medical Research, Teijin Pharma Limited
| | | | - Mizuho Tamura
- Pharmacology Research Department, Teijin Institute for Bio-medical Research, Teijin Pharma Limited
| | | | - Reiko Aizawa
- Pharmacology Research Department, Teijin Institute for Bio-medical Research, Teijin Pharma Limited
| | - Tsunefumi Kobayashi
- Pharmacology Research Department, Teijin Institute for Bio-medical Research, Teijin Pharma Limited
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23
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Short-term and long-term effects of immunoadsorption in refractory chronic inflammatory demyelinating polyneuropathy: a prospective study in 17 patients. J Neurol 2018; 265:2906-2915. [DOI: 10.1007/s00415-018-9082-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 10/01/2018] [Accepted: 10/01/2018] [Indexed: 12/25/2022]
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24
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Ulrichts P, Guglietta A, Dreier T, van Bragt T, Hanssens V, Hofman E, Vankerckhoven B, Verheesen P, Ongenae N, Lykhopiy V, Enriquez FJ, Cho J, Ober RJ, Ward ES, de Haard H, Leupin N. Neonatal Fc receptor antagonist efgartigimod safely and sustainably reduces IgGs in humans. J Clin Invest 2018; 128:4372-4386. [PMID: 30040076 DOI: 10.1172/jci97911] [Citation(s) in RCA: 149] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 07/03/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Intravenous Ig (IVIg), plasma exchange, and immunoadsorption are frequently used in the management of severe autoimmune diseases mediated by pathogenic IgG autoantibodies. These approaches modulating IgG levels can, however, be associated with some severe adverse reactions and a substantial burden to patients. Targeting the neonatal Fc receptor (FcRn) presents an innovative and potentially more effective, safer, and more convenient alternative for clearing pathogenic IgGs. METHODS A randomized, double-blind, placebo-controlled first-in-human study was conducted in 62 healthy volunteers to explore single and multiple ascending intravenous doses of the FcRn antagonist efgartigimod. The study objectives were to assess safety, tolerability, pharmacokinetics, pharmacodynamics, and immunogenicity. The findings of this study were compared with the pharmacodynamics profile elicited by efgartigimod in cynomolgus monkeys. RESULTS Efgartigimod treatment resulted in a rapid and specific clearance of serum IgG levels in both cynomolgus monkeys and healthy volunteers. In humans, single administration of efgartigimod reduced IgG levels up to 50%, while multiple dosing further lowered IgGs on average by 75% of baseline levels. Approximately 8 weeks following the last administration, IgG levels returned to baseline. Efgartigimod did not alter the homeostasis of albumin or Igs other than IgG, and no serious adverse events related to efgartigimod infusion were observed. CONCLUSION Antagonizing FcRn using efgartigimod is safe and results in a specific, profound, and sustained reduction of serum IgG levels. These results warrant further evaluation of this therapeutic approach in IgG-driven autoimmune diseases. TRIAL REGISTRATION Clinicaltrials.gov NCT03457649. FUNDING argenx BVBA.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - JunHaeng Cho
- Department of Molecular and Cellular Medicine, Texas A&M University Health Science Center, College Station, Texas, USA
| | - Raimund J Ober
- Department of Molecular and Cellular Medicine, Texas A&M University Health Science Center, College Station, Texas, USA.,Department of Biomedical Engineering, Texas A&M University, College Station, Texas, USA
| | - E Sally Ward
- Department of Molecular and Cellular Medicine, Texas A&M University Health Science Center, College Station, Texas, USA.,Department of Microbial Pathogenesis and Immunology, Texas A&M University Health Science Center, Bryan, Texas, USA
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25
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Tradtrantip L, Felix CM, Spirig R, Morelli AB, Verkman A. Recombinant IgG1 Fc hexamers block cytotoxicity and pathological changes in experimental in vitro and rat models of neuromyelitis optica. Neuropharmacology 2018; 133:345-353. [PMID: 29428821 PMCID: PMC6322534 DOI: 10.1016/j.neuropharm.2018.02.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 01/26/2018] [Accepted: 02/02/2018] [Indexed: 12/17/2022]
Abstract
Intravenous human immunoglobulin G (IVIG) may have therapeutic benefit in neuromyelitis optica spectrum disorders (herein called NMO), in part because of the anti-inflammatory properties of the IgG Fc region. Here, we evaluated recombinant Fc hexamers consisting of the IgM μ-tailpiece fused with the Fc region of human IgG1. In vitro, the Fc hexamers prevented cytotoxicity in aquaporin-4 (AQP4) expressing cells and in rat spinal cord slice cultures exposed to NMO anti-AQP4 autoantibody (AQP4-IgG) and complement, with >500-fold greater potency than IVIG or monomeric Fc fragments. Fc hexamers at low concentration also prevented antibody-dependent cellular cytotoxicity produced by AQP4-IgG and natural killer cells. Serum from rats administered a single intravenous dose of Fc hexamers at 50 mg/kg taken at 8 h did not produce complement-dependent cytotoxicity when added to AQP4-IgG-treated AQP4-expressing cell cultures. In an experimental rat model of NMO produced by intracerebral injection of AQP4-IgG, Fc hexamers at 50 mg/kg administered before and at 12 h after AQP4-IgG fully prevented astrocyte injury, complement activation, inflammation and demyelination. These results support the potential therapeutic utility of recombinant IgG1 Fc hexamers in AQP4-IgG seropositive NMO.
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Affiliation(s)
- Lukmanee Tradtrantip
- Departments of Medicine and Physiology, University of California, San Francisco, CA, USA
| | - Christian M. Felix
- Departments of Medicine and Physiology, University of California, San Francisco, CA, USA
| | | | | | - A.S. Verkman
- Departments of Medicine and Physiology, University of California, San Francisco, CA, USA
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26
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Seijsing J, Yu S, Frejd FY, Höiden-Guthenberg I, Gräslund T. In vivo depletion of serum IgG by an affibody molecule binding the neonatal Fc receptor. Sci Rep 2018; 8:5141. [PMID: 29572538 PMCID: PMC5865129 DOI: 10.1038/s41598-018-23481-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 03/12/2018] [Indexed: 12/28/2022] Open
Abstract
Lowering the total level of Immunoglobulin G (IgG) in circulation is a promising general treatment option for many autoimmune diseases driven by pathogenic autoantibodies. The half-life of IgG in circulation is unusually long as a consequence of its interaction with the neonatal Fc receptor (FcRn), which protects it from lysosomal degradation by cells in contact with blood. Blocking the IgG/FcRn interaction prevents FcRn-mediated rescue, which may lead to increased catabolism and a lowering of the total IgG level. Here, we find that an engineered alternative scaffold protein, an affibody molecule, interacting specifically with FcRn, is able to block the IgG/FcRn interaction in vitro. The affibody molecule (ZFcRn) was expressed alone or as a fusion to an albumin binding domain (ABD), to extend its half-life in circulation, in both cases with retained affinity and blocking potential. Repeated i.v. injections in mice of ZFcRn and ZFcRn-ABD were found to result in an up to 40% reduction of the IgG serum-level after 5 days. Potential applications of ZFcRn as a general treatment modality for autoimmune diseases are discussed.
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Affiliation(s)
- Johan Seijsing
- School of Biotechnology, KTH Royal Institute of Technology, Roslagstullsbacken 21, 11417, Stockholm, Sweden.,Department of Molecular Biosciences, The Wenner-Gren Institute, Stockholm University, Stockholm, Sweden
| | - Shengze Yu
- School of Biotechnology, KTH Royal Institute of Technology, Roslagstullsbacken 21, 11417, Stockholm, Sweden
| | | | | | - Torbjörn Gräslund
- School of Biotechnology, KTH Royal Institute of Technology, Roslagstullsbacken 21, 11417, Stockholm, Sweden.
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27
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Wang Z, Arat S, Magid-Slav M, Brown JR. Meta-analysis of human gene expression in response to Mycobacterium tuberculosis infection reveals potential therapeutic targets. BMC SYSTEMS BIOLOGY 2018; 12:3. [PMID: 29321020 PMCID: PMC5763539 DOI: 10.1186/s12918-017-0524-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 12/22/2017] [Indexed: 01/24/2023]
Abstract
Background With the global emergence of multi-drug resistant strains of Mycobacterium tuberculosis, new strategies to treat tuberculosis are urgently needed such as therapeutics targeting potential human host factors. Results Here we performed a statistical meta-analysis of human gene expression in response to both latent and active pulmonary tuberculosis infections from nine published datasets. We found 1655 genes that were significantly differentially expressed during active tuberculosis infection. In contrast, no gene was significant for latent tuberculosis. Pathway enrichment analysis identified 90 significant canonical human pathways, including several pathways more commonly related to non-infectious diseases such as the LRRK2 pathway in Parkinson’s disease, and PD-1/PD-L1 signaling pathway important for new immuno-oncology therapies. The analysis of human genome-wide association studies datasets revealed tuberculosis-associated genetic variants proximal to several genes in major histocompatibility complex for antigen presentation. We propose several new targets and drug-repurposing opportunities including intravenous immunoglobulin, ion-channel blockers and cancer immuno-therapeutics for development as combination therapeutics with anti-mycobacterial agents. Conclusions Our meta-analysis provides novel insights into host genes and pathways important for tuberculosis and brings forth potential drug repurposing opportunities for host-directed therapies. Electronic supplementary material The online version of this article (doi: 10.1186/s12918-017-0524-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Zhang Wang
- Computational Biology, Target Sciences, GlaxoSmithKline (GSK) R & D, Collegeville, PA, 19426, USA
| | - Seda Arat
- Computational Biology, Target Sciences, GlaxoSmithKline (GSK) R & D, Collegeville, PA, 19426, USA.,Current address: The Jackson Laboratory, Farmington, CT, 06032, USA
| | - Michal Magid-Slav
- Computational Biology, Target Sciences, GlaxoSmithKline (GSK) R & D, Collegeville, PA, 19426, USA.
| | - James R Brown
- Computational Biology, Target Sciences, GlaxoSmithKline (GSK) R & D, Collegeville, PA, 19426, USA.
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28
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Kuitwaard K, Fokkink WJR, Brusse E, Vrancken AFJE, Eftimov F, Notermans NC, van der Kooi AJ, Merkies ISJ, Jacobs BC, van Doorn PA. Maintenance IV immunoglobulin treatment in chronic inflammatory demyelinating polyradiculoneuropathy. J Peripher Nerv Syst 2017; 22:425-432. [PMID: 29092099 DOI: 10.1111/jns.12242] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 10/27/2017] [Accepted: 10/29/2017] [Indexed: 12/27/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) patients treated with intravenous immunoglobulin (IVIg) usually start with a standard dosage of 2 g/kg bodyweight. Only a minority of patients has a sustained improvement, and most require ongoing maintenance treatment. Preferred IVIg regimens, however, vary considerably between doctors and at present it is unknown which is optimal. As there are also large differences in IVIg dosage and interval requirements between patients, optimal IVIg maintenance treatment of CIDP is even more complex. The lack of evidence-based guidelines on how IVIg maintenance treatment should be administered may potentially lead to under- or overtreatment of this expensive therapy. We provide an overview of published practical IVIg maintenance treatment regimens, IVIg maintenance schedules used in randomized controlled trials and one based upon our own long-term experience on how this treatment could be given in CIDP.
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Affiliation(s)
- Krista Kuitwaard
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Neurology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Willem-Jan R Fokkink
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Immunology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Esther Brusse
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Alexander F J E Vrancken
- Department of Neurology, Brain Center Rudolf Magnus University, Medical Center Utrecht, Utrecht, The Netherlands
| | - Filip Eftimov
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Nicolette C Notermans
- Department of Neurology, Brain Center Rudolf Magnus University, Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Ingemar S J Merkies
- Department of Neurology, School of Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Neurology, St. Elisabeth Hospital, Willemstad, Curacao
| | - Bart C Jacobs
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Immunology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Pieter A van Doorn
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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29
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Shin YW, Lee ST, Park KI, Jung KH, Jung KY, Lee SK, Chu K. Treatment strategies for autoimmune encephalitis. Ther Adv Neurol Disord 2017; 11:1756285617722347. [PMID: 29399043 PMCID: PMC5784571 DOI: 10.1177/1756285617722347] [Citation(s) in RCA: 128] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 06/14/2017] [Indexed: 12/13/2022] Open
Abstract
Autoimmune encephalitis is one of the most rapidly growing research topics in neurology. Along with discoveries of novel antibodies associated with the disease, clinical experience and outcomes with diverse immunotherapeutic agents in the treatment of autoimmune encephalitis are accumulating. Retrospective observations indicate that early aggressive treatment is associated with better functional outcomes and fewer relapses. Immune response to first-line immunotherapeutic agents (corticosteroids, intravenous immunoglobulin, plasma exchange, and immunoadsorption) is fair, but approximately half or more of patients are administered second-line immunotherapy (rituximab and cyclophosphamide). A small but significant proportion of patients are refractory to all first- and second-line therapies and require further treatment. Although several investigations have shown promising alternatives, the low absolute number of patients involved necessitates more evidence to establish further treatment strategies. In this review, the agents used for first- and second-line immunotherapy are discussed and recent attempts at finding new treatment options are introduced.
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Affiliation(s)
- Yong-Won Shin
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea Yeongjusi Health Center, Gyeongsangbuk-do, South Korea
| | - Soon-Tae Lee
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyung-Il Park
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Keun-Hwa Jung
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Ki-Young Jung
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Sang Kun Lee
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Kon Chu
- Department of Neurology, Comprehensive Epilepsy Center, Laboratory for Neurotherapeutics, Biomedical Research Institute, Seoul National niversity Hospital, 101, Daehangno, Jongno-gu, Seoul 110-744, South Korea Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
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30
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Wang Q, Xing C, Hao Y, Shi Q, Qi Z, Lv Z, Song Y, Xu P, Feng X, Zhang L, Zhang Y, Wang Y, Yuki N. Memory B cells in Guillain-Barré syndrome. J Neuroimmunol 2017; 305:1-4. [PMID: 28284328 DOI: 10.1016/j.jneuroim.2017.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/31/2016] [Accepted: 01/11/2017] [Indexed: 12/30/2022]
Abstract
IgG autoantibodies against gangliosides show the highest titers at the disease onset of axonal Guillain-Barré syndrome (GBS), in which there are no IgM anti-ganglioside antibodies. We hypothesized that memory B cells take part in the development of producing IgG autoantibodies. In this study, we analyzed the memory B cells in patients with GBS using flow cytometry. There was significantly higher percentage of memory B cells in patients with GBS than the healthy controls. The Spearman correlation analysis demonstrated that increased percentage of memory B cells was positively correlated with the clinical severity of the patients with GBS. Our study provides the evidences that memory B cells may be involved in mechanism of GBS.
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Affiliation(s)
- Qian Wang
- Department of Neurology, Affiliated Hospital of Jining Medical University, Jining, Shandong, PR China
| | - Chunye Xing
- Department of Neurology, Affiliated Hospital of Jining Medical University, Jining, Shandong, PR China
| | - Yanlei Hao
- Department of Neurology, Affiliated Hospital of Jining Medical University, Jining, Shandong, PR China
| | - Qiguang Shi
- Department of Neurology, Affiliated Hospital of Jining Medical University, Jining, Shandong, PR China
| | - Ziyou Qi
- Department of Neurology, Affiliated Hospital of Jining Medical University, Jining, Shandong, PR China
| | - Zhanyun Lv
- Department of Neurology, Affiliated Hospital of Jining Medical University, Jining, Shandong, PR China
| | - Yan Song
- Department of Neurology, Affiliated Hospital of Jining Medical University, Jining, Shandong, PR China
| | - Peng Xu
- Department of Neurology, Affiliated Hospital of Jining Medical University, Jining, Shandong, PR China
| | - Xungang Feng
- Department of Neurology, Affiliated Hospital of Jining Medical University, Jining, Shandong, PR China
| | - Lili Zhang
- Department of Neurology, Affiliated Hospital of Jining Medical University, Jining, Shandong, PR China
| | - Yong Zhang
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, PR China
| | - Yuzhong Wang
- Department of Neurology, Affiliated Hospital of Jining Medical University, Jining, Shandong, PR China.
| | - Nobuhiro Yuki
- Department of Neurology, Mishima Hospital, Niigata, Japan.
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31
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Tavakolpour S, Mirsafaei HS, Delshad S. Management of pemphigus disease in pregnancy. Am J Reprod Immunol 2016; 77. [DOI: 10.1111/aji.12601] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 10/17/2016] [Indexed: 12/16/2022] Open
Affiliation(s)
- Soheil Tavakolpour
- Skin Research Center; Shahid Beheshti University of Medical Sciences; Tehran Iran
- Immunology Research Center; Tehran University of Medical Sciences; Tehran Iran
| | | | - Saeid Delshad
- Medical biology Research Center; Kermanshah University of Medical Sciences; Kermanshah Iran
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32
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Predicting the Response to Intravenous Immunoglobulins in an Animal Model of Chronic Neuritis. PLoS One 2016; 11:e0164099. [PMID: 27711247 PMCID: PMC5053527 DOI: 10.1371/journal.pone.0164099] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 09/20/2016] [Indexed: 11/19/2022] Open
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a disabling autoimmune disorder of the peripheral nervous system (PNS). Intravenous immunoglobulins (IVIg) are effective in CIDP, but the treatment response varies greatly between individual patients. Understanding this interindividual variability and predicting the response to IVIg constitute major clinical challenges in CIDP. We previously established intercellular adhesion molecule (ICAM)-1 deficient non-obese diabetic (NOD) mice as a novel animal model of CIDP. Here, we demonstrate that similar to human CIDP patients, ICAM-1 deficient NOD mice respond to IVIg treatment by clinical and histological measures. Nerve magnetic resonance imaging and histology demonstrated that IVIg ameliorates abnormalities preferentially in distal parts of the sciatic nerve branches. The IVIg treatment response also featured great heterogeneity allowing us to identify IVIg responders and non-responders. An increased production of interleukin (IL)-17 positively predicted IVIg treatment responses. In human sural nerve biopsy sections, high numbers of IL-17 producing cells were associated with younger age and shorter disease duration. Thus, our novel animal model can be utilized to identify prognostic markers of treatment responses in chronic inflammatory neuropathies and we identify IL-17 production as one potential such prognostic marker.
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33
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Rescue effects of intravenous immunoglobulin on optic nerve degeneration in a rat model of neuromyelitis optica. Jpn J Ophthalmol 2016; 60:419-23. [DOI: 10.1007/s10384-016-0454-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 03/23/2016] [Indexed: 02/01/2023]
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34
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Telcharova-Mihaylovska A, Stefanov S, Nikolova I. Kawasaki disease and acute haemolytic anaemia after two IVIG infusions. BIOTECHNOL BIOTEC EQ 2016. [DOI: 10.1080/13102818.2016.1159529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Affiliation(s)
- Albena Telcharova-Mihaylovska
- Clinic of Rheumatology, Pediatric University Hospital SBALDB “Prof. Ivan Mitev”, Medical University of Sofia, Sofia, Bulgaria
| | - Stefan Stefanov
- Clinic of Rheumatology, Pediatric University Hospital SBALDB “Prof. Ivan Mitev”, Medical University of Sofia, Sofia, Bulgaria
| | - Irina Nikolova
- Department of Pharmacology, Pharmacotherapy and Toxicology, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
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Ali N, Rampure R, Malik F, Jafri SIM, Amberker D. Guillain-Barré syndrome occurring synchronously with systemic lupus erythematosus as initial manifestation treated successfully with low-dose cyclophosphamide. J Community Hosp Intern Med Perspect 2016; 6:30689. [PMID: 27124163 PMCID: PMC4848430 DOI: 10.3402/jchimp.v6.30689] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 02/16/2016] [Accepted: 02/26/2016] [Indexed: 11/22/2022] Open
Abstract
Systemic lupus erythematous (SLE) is frequently encountered in clinical practice; a widespread immunological response can involve any organ system, sometimes leading to rare and diagnostically challenging presentations. We describe a 38-year-old female who presented with symmetric numbness and tingling of the hands and feet, and cervical pain. Imaging studies were not diagnostic of any serious underlying pathology. The patient developed ascending paresis involving lower extremities and cranial muscles (dysphagia and facial weakness). Guillain–Barré syndrome (GBS) was diagnosed on the basis of electromyography and lumbar puncture showing albuminocytologic dissociation. Intravenous immunoglobulins (IVIG) were administered for 5 days. Supported by anti-dsDNA antibody, oral ulcers, proteinuria of 0.7 g in 24 h, and neurological manifestation, she was diagnosed with lupus. After completion of IVIG, she received pulse-dose corticosteroids and one dose of low-dose cyclophosphamide. Her neurological symptoms improved and she had complete neurological recovery several months after her initial presentation. Literature search provides evidence of co-occurrence of lupus and GBS occurring mostly later in the course of the disease. However, GBS as initial manifestation of SLE is exceedingly rare and less understood. The association of GBS with lupus is important to recognize for rapid initiation of appropriate therapy and for consideration of immunosuppressive therapy which may affect the outcome.
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Affiliation(s)
- Naveed Ali
- Department of Internal Medicine, Abington Memorial Hospital/Abington-Jefferson Health, Abington, PA, USA;
| | - Ritesh Rampure
- Department of Hospitalist Medicine, Abington Memorial Hospital/Abington-Jefferson Health, Abington, PA, USA
| | - Faizan Malik
- Department of Internal Medicine, Abington Memorial Hospital/Abington-Jefferson Health, Abington, PA, USA
| | - Syed Imran Mustafa Jafri
- Department of Internal Medicine, Abington Memorial Hospital/Abington-Jefferson Health, Abington, PA, USA
| | - Deepa Amberker
- Department of Internal Medicine, Abington Memorial Hospital/Abington-Jefferson Health, Abington, PA, USA
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Freo U, Zara G, Furnari M, Ori C. Postoperative Bilateral Brachial Plexopathy in a Diabetic Patient. PAIN MEDICINE 2016; 17:1962-1965. [PMID: 27084414 DOI: 10.1093/pm/pnw047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Ulderico Freo
- Anesthesiology and Intensive Care, Department of Internal Medicine DIMED, Padua University, Padua, Italy
| | - Gabriella Zara
- Anesthesiology and Intensive Care, Department of Internal Medicine DIMED, Padua University, Padua, Italy
| | - Maurizio Furnari
- Anesthesiology and Intensive Care, Department of Internal Medicine DIMED, Padua University, Padua, Italy
| | - Carlo Ori
- Anesthesiology and Intensive Care, Department of Internal Medicine DIMED, Padua University, Padua, Italy
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Jovanovich E, Karam C. Human immune globulin infusion in the management of multifocal motor neuropathy. Degener Neurol Neuromuscul Dis 2015; 6:1-12. [PMID: 30050363 PMCID: PMC6053084 DOI: 10.2147/dnnd.s96258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Multifocal motor neuropathy (MMN) is a debilitating and rare disease causing profound weakness with minimal to no sensory symptoms. Conduction block is frequently seen on electrodiagnostic testing. An immune-mediated pathology is suspected though the exact underlying pathophysiology has yet to be elucidated. The presence of anti-GM1 ganglioside IgM antibodies coupled with favorable response to intravenous and subcutaneous immunoglobulins supports a complement-mediated mechanism which leads to destruction of nerve tissue with probable predilection to the nodes of Ranvier. High-dose immunoglobulin currently is the only treatment with proven efficacy for MMN patients. Unfortunately, many patients experience decreased responsiveness to immunoglobulins over time, requiring higher and more frequent dosing. In this review, we will focus on the pharmacology, efficacy, safety, and tolerability of intravenous and subcutaneous immune globulin infusion for treatment of MMN.
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Affiliation(s)
| | - Chafic Karam
- Department of Neurology, The University of North Carolina, Chapel Hill, NC, USA,
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Viswanathan S, Wong AH, Quek AM, Yuki N. Intravenous immunoglobulin may reduce relapse frequency in neuromyelitis optica. J Neuroimmunol 2015; 282:92-6. [DOI: 10.1016/j.jneuroim.2015.03.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Revised: 03/24/2015] [Accepted: 03/27/2015] [Indexed: 01/12/2023]
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Léger JM, Guimarães-Costa R, Iancu Ferfoglia R. The pathogenesis of multifocal motor neuropathy and an update on current management options. Ther Adv Neurol Disord 2015; 8:109-22. [PMID: 25941538 PMCID: PMC4409549 DOI: 10.1177/1756285615575269] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Multifocal motor neuropathy (MMN) is a rare and disabling disease. Several experimental studies and clinical data are strongly suggestive of an immune-mediated pathogenesis, although underlying mechanisms in MMN seem to be very specific, mainly because of the presence of IgM anti-GM1 serum antibodies and the dramatic response to intravenous immunoglobulins (IVIg). The origin of antiganglioside antibodies and the way in which they act at the molecular level remain unclear. Several studies have demonstrated the key role of complement activation in the underlying mechanisms of MMN, as well as in animal models of acute motor axonal neuropathy (AMAN). Deposition of the membrane attack complex may disrupt the architecture of the nodes of Ranvier and paranodal areas, causing local disruption of nodal sodium-channel clusters. In patients with MMN, muscle weakness is the consequence of conduction blocks (CB), which leads to secondary axonal degeneration, consequently the aim of the treatment is to reverse CB at early stages of the disease. High-dose immunoglobulin is to date the only therapy which has proven efficacy in MMN patients in providing transient improvement of muscle strength, but long-term follow-up studies show a progressive motor decline. Therefore, other therapies are needed to improve the conduction nerve properties in long-term design. The reduction of complement activation and more generally the gain in paranodal stabilization could be directions for future therapeutic strategies.
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Affiliation(s)
- Jean-Marc Léger
- National Referral Center for rare Neuromuscular Diseases, Institut Hospitalo-Universitaire de Neurosciences, University Hospital Pitié-Salpêtrière and University Pierre et Marie Curie (Paris VI), 47 boulevard de l'Hôpital, 75013 Paris, France
| | - Raquel Guimarães-Costa
- National Referral Center for rare Neuromuscular Diseases, Institut Hospitalo-Universitaire de Neurosciences, University Hospital Pitié-Salpêtrière and University Pierre et Marie Curie (Paris VI), Paris, France
| | - Ruxandra Iancu Ferfoglia
- National Referral Center for rare Neuromuscular Diseases, Institut Hospitalo-Universitaire de Neurosciences, University Hospital Pitié-Salpêtrière and University Pierre et Marie Curie (Paris VI), Paris, France
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Papadopoulos MC, Bennett JL, Verkman AS. Treatment of neuromyelitis optica: state-of-the-art and emerging therapies. Nat Rev Neurol 2014; 10:493-506. [PMID: 25112508 DOI: 10.1038/nrneurol.2014.141] [Citation(s) in RCA: 192] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Neuromyelitis optica (NMO) is an autoimmune disease of the CNS that is characterized by inflammatory demyelinating lesions in the spinal cord and optic nerve, potentially leading to paralysis and blindness. NMO can usually be distinguished from multiple sclerosis (MS) on the basis of seropositivity for IgG antibodies against the astrocytic water channel aquaporin-4 (AQP4). Differentiation from MS is crucial, because some MS treatments can exacerbate NMO. NMO pathogenesis involves AQP4-IgG antibody binding to astrocytic AQP4, which causes complement-dependent cytotoxicity and secondary inflammation with granulocyte and macrophage infiltration, blood-brain barrier disruption and oligodendrocyte injury. Current NMO treatments include general immunosuppressive agents, B-cell depletion, and plasma exchange. Therapeutic strategies targeting complement proteins, the IL-6 receptor, neutrophils, eosinophils and CD19--all initially developed for other indications--are under clinical evaluation for repurposing for NMO. Therapies in the preclinical phase include AQP4-blocking antibodies and AQP4-IgG enzymatic inactivation. Additional, albeit currently theoretical, treatment options include reduction of AQP4 expression, disruption of AQP4 orthogonal arrays, enhancement of complement inhibitor expression, restoration of the blood-brain barrier, and induction of immune tolerance. Despite the many therapeutic options in NMO, no controlled clinical trials in patients with this condition have been conducted to date.
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Affiliation(s)
- Marios C Papadopoulos
- Academic Neurosurgery Unit, St George's, University of London, Room 0.136 Jenner Wing, Cranmer Terrace, Tooting, London SW17 0RE, UK
| | - Jeffrey L Bennett
- Departments of Neurology and Ophthalmology, University of Colorado School of Medicine, Research Complex 2, Mail stop B-182, 12700 East 19th Avenue, Aurora, CO 80045, USA
| | - Alan S Verkman
- Department of Medicine, University of California, San Francisco, Health Science East Tower Room 1246, 513 Parnassus Avenue, San Francisco, CA 94143, USA
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Human immunoglobulin G reduces the pathogenicity of aquaporin-4 autoantibodies in neuromyelitis optica. Exp Neurol 2014; 255:145-53. [PMID: 24636863 DOI: 10.1016/j.expneurol.2014.03.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 02/20/2014] [Accepted: 03/04/2014] [Indexed: 12/14/2022]
Abstract
Neuromyelitis optica (NMO) pathogenesis involves binding of anti-aquaporin-4 (AQP4) autoantibodies (NMO-IgG) present in serum to AQP4 on astrocytes, which causes complement-dependent cytotoxicity (CDC) and antibody-dependent cellular cytotoxicity (ADCC). Human immunoglobulin G (hIgG) is effective for treatment of humorally mediated neurological autoimmune diseases and has been reported to improve disease outcome in a limited number of NMO patients. Here, we investigated hIgG actions on NMO-IgG pathogenicity using an in vivo rat model of NMO and in vitro assays. In rats administered NMO-IgG by intracerebral injection, the size of neuroinflammatory demyelinating lesions was reduced by ~50% when hIgG was administered by intraperitoneal injection to reach levels of 10-25mg/mL in rat serum, comparable with human therapeutic levels. In vitro, hIgG at 10mg/mL reduced by 90% NMO-IgG-mediated CDC following addition of NMO-IgG and human complement to AQP4-expressing cells. The hIgG effect was mainly on the classical complement pathway. hIgG at 10mg/mL also reduced by up to 90% NMO-IgG-mediated ADCC as assayed with human natural killer cells as effector cells. However, hIgG at up to 40mg/mL did not affect AQP4 cell surface expression or its supramolecular assembly in orthogonal arrays of particles, nor did it affect NMO-IgG binding to AQP4. We conclude that hIgG reduces NMO-IgG pathogenicity by inhibition of CDC and ADCC, providing a mechanistic basis to support further clinical evaluation of its therapeutic efficacy in NMO.
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Querol L, Nogales-Gadea G, Rojas-Garcia R, Diaz-Manera J, Pardo J, Ortega-Moreno A, Sedano MJ, Gallardo E, Berciano J, Blesa R, Dalmau J, Illa I. Neurofascin IgG4 antibodies in CIDP associate with disabling tremor and poor response to IVIg. Neurology 2014; 82:879-86. [PMID: 24523485 DOI: 10.1212/wnl.0000000000000205] [Citation(s) in RCA: 230] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To describe the frequency of antibodies against neurofascin in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and the associated clinical features. METHODS Immunocytochemistry was used to identify antibodies to neurofascin 155 (NF155) and 186. Serum reactivity with paranodes and brain tissue was tested with immunohistochemistry of teased-nerve fibers and rat brain. Antibody titers and immunoglobulin (Ig) G isotypes were determined using ELISA. Clinical information was obtained retrospectively. RESULTS Two of 53 patients, but none of 204 controls, had antibodies to NF155 (p = 0.041). The 2 patients with NF155 antibodies developed severe polyradiculoneuropathy with predominant distal weakness that was refractory to IVIg. Eight additional patients with IVIg-refractory CIDP were then identified from a national database; 2 of them with the same clinical features also had NF155 antibodies. Overall, 3 of the 4 patients with NF155 antibodies had a disabling and characteristic tremor (high amplitude, low frequency, postural, and intention). Patients' antibodies reacted with the paranodes in teased-nerve fibers and with the neuropil of rat cerebellum, brain, and brainstem. Anti-NF155 antibodies were predominantly of the IgG4 isotype in all patients. CONCLUSION Patients with CIDP positive for IgG4 NF155 antibodies constitute a specific subgroup with a severe phenotype, poor response to IVIg, and disabling tremor. Autoantibodies against paranodal structures associate with distinct clinical features in CIDP and their identification has diagnostic, prognostic, and therapeutic implications. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that autoantibodies to NF155 identify a CIDP subtype characterized by severe neuropathy, poor response to IVIg, and disabling tremor.
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Affiliation(s)
- Luis Querol
- From the Neuromuscular Diseases Unit (L.Q., G.N.-G., R.R.-G., J.D.-M., E.G., R.B., I.I.), Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona; Centro para la Investigación Biomédica en Red en Enfermedades Neurodegenerativas (L.Q., G.N.-G., R.R.-G., J.D.-M., M.J.S., E.G., J.B., I.I.), CIBERNED, Madrid; Department of Neurology (J.P.), Hospital Clínico de Santiago, Santiago de Compostela; Department of Neurology (A.O.-M.), Hospital Virgen de las Nieves, Granada; Department of Neurology (M.J.S., J.B.), University Hospital Marqués de Valdecilla (IFIMAV) and University of Cantabria; Department of Neurology (J.D.), Hospital Clinic, Universitat de Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona; and Institució Catalana de Recerca i Estudis Avançats (J.D.), Barcelona, Spain
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Niknami M, Wang MX, Nguyen T, Pollard JD. Beneficial effect of a multimerized immunoglobulin Fc in an animal model of inflammatory neuropathy (experimental autoimmune neuritis). J Peripher Nerv Syst 2014; 18:141-52. [PMID: 23781961 DOI: 10.1111/jns5.12022] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Intravenous immunoglobulin (IVIg) is one of the first-line therapies for inflammatory neuropathies. Clinical use of IVIg for these disorders is limited by expense and availability. Here, we investigated a synthetic product alternative to IVIg. The aim of this study was to test the therapeutic efficacy of a novel recombinant polyvalent murine IgG2a Fc compound (stradomer™) in experimental autoimmune neuritis (EAN). Seventy-four Lewis rats were immunized with myelin, randomized into three groups, and were treated with albumin, IVIg, or stradomer at 1% of IVIg dose. Rats were assessed clinically, electrophysiologically, and histologically. The clinical disease severity was evaluated by clinical grading and weight changes. The electrophysiological studies recorded motor conduction velocity (MCV), amplitudes, and latencies of the evoked compound muscle action potential (CMAP) and spinal somatosensory evoked potential. The treatment efficacy of the IVIg and stradomer groups was compared to the albumin (control) group. We demonstrate that stradomer has a similar therapeutic efficacy to human IVIg in EAN. Rats receiving stradomer or IVIg showed significantly lower clinical scores and less prominent weight loss compared with controls. A statistically significant improvement in both MCV and the amplitudes of distal and proximal evoked CMAP was observed in the stradomer and IVIg groups. Finally, treatment with both IVIg and stradomer resulted in statistically less inflammation and demyelinating changes in the sciatic nerve as evidenced by lower histological grade. These results reveal the potential of using fully recombinant multimerized immunoglobulin Fc instead of IVIg for treating inflammatory neuropathies.
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Affiliation(s)
- Marzieh Niknami
- Department of Neurology, Central Clinical School, University of Sydney, Sydney, Australia
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Treatment of chronic inflammatory demyelinating polyneuropathy: from molecular bases to practical considerations. Autoimmune Dis 2014; 2014:201657. [PMID: 24527207 PMCID: PMC3914592 DOI: 10.1155/2014/201657] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 11/13/2013] [Indexed: 02/07/2023] Open
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is an autoimmune disease of the peripheral nervous system, in which both cellular and humoral immune responses are involved. The disease is clinically heterogeneous with some patients displaying pure motor form and others also showing a variable degree of sensory dysfunction; disease evolution may also differ from patient to patient, since monophasic, progressive, and relapsing forms are reported. Underlying such clinical variability there is probably a broad spectrum of molecular dysfunctions that are and will be the target of therapeutic strategies. In this review we first explore the biological bases of current treatments and subsequently we focus on the practical management that must also take into account pharmacoeconomic issues.
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Rajabally YA, Wong SL, Kearney DA. Immunoglobulin G level variations in treated chronic inflammatory demyelinating polyneuropathy: clues for future treatment regimens? J Neurol 2013; 260:2052-6. [PMID: 23645220 DOI: 10.1007/s00415-013-6938-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 04/22/2013] [Accepted: 04/24/2013] [Indexed: 10/26/2022]
Abstract
Intravenous immunoglobulins (IVIg) are effective for treating chronic inflammatory demyelinating polyneuropathy (CIDP), although treatment needs are variable and need to be individualized. Dose and frequency requirements are not currently predictable in advance. In Guillain-Barré syndrome, IVIg interpatient pharmacokinetic variations have been demonstrated in relation to clinical outcome. We studied 15 patients with CIDP following two routine courses of IVIg. IgG levels were assessed pretreatment and 14 days post-treatment. Best clinical response (BCR) was ascertained in each case, predefined, according to individual patients' circumstances, on the 10 m walk, or MRC sum score, or Jamar grip dynamometry. Correlations between IgG level variations, doses administered, weight, body mass index, BCR and infusion interval were determined. Postinfusion rise in IgG levels were correlated in individual patients (p = 0.005), but interpatient variability was high. No correlations were ascertained between IgG level variation and weight, body mass index, BCR, total dose of IVIg administered, or dose of IVIg administered per kilogram per week. There were significant correlations between total dose administered and post-infusion IgG level at 14 days (p = 0.004) and between infusion interval and mean rise in IgG level (p = 0.001) These findings suggest significant variability in IgG metabolism between patients, unrelated to minimal effective dose administered, weight, body mass index or degree of functional improvement. Required frequency of IVIg infusions may, however, importantly relate to patient-specific post-infusion rise in IgG levels hence possibly explaining inter-patient differences in treatment frequency needs. IgG level monitoring may be helpful in establishing optimum treatment regimens in individual cases.
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Affiliation(s)
- Yusuf A Rajabally
- Neuromuscular Clinic, Department of Neurology, University Hospitals of Birmingham, Queen Elizabeth Hospital, Birmingham, B15 2TH, UK.
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Stangel M, Baumann U, Borte M, Fasshauer M, Hensel M, Huscher D, Kirch W, Pittrow D, Reiser M, Gold R. Treatment of Neurological Autoimmune Diseases with Immunoglobulins: First Insights from the Prospective SIGNS Registry. J Clin Immunol 2012; 33 Suppl 1:S67-71. [DOI: 10.1007/s10875-012-9789-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Accepted: 08/28/2012] [Indexed: 10/27/2022]
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Immunoglobulins for primary or secondary immunodeficiency or for immunomodulation in neurological autoimmune diseases: insights from the prospective SIGNS registry. J Public Health (Oxf) 2012. [DOI: 10.1007/s10389-012-0500-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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Jani‐Acsadi A, Lewis RA. Chronic Immune‐Mediated Demyelinating Polyneuropathies. Neuromuscul Disord 2011. [DOI: 10.1002/9781119973331.ch25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Thromboembolic complications of intravenous immunoglobulin therapy in patients with neuropathy: a two-year study. J Neurol Sci 2011; 308:124-7. [PMID: 21679973 DOI: 10.1016/j.jns.2011.05.035] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 05/11/2011] [Accepted: 05/24/2011] [Indexed: 11/23/2022]
Abstract
BACKGROUND The incidence and determinants of thromboembolic complications (TEC) of intravenous immunoglobulin (IVIg) therapy in patients with dysimmune neuropathy are uncertain. METHODS We performed a retrospective study of patients with dysimmune neuropathy seen at our institution and treated with IVIg, over a 24-month period. RESULTS Sixty-two patients were treated with a total of 616 courses of IVIg. TEC occurred in 7 patients. In 5, these occurred within 14 days after IVIg infusion ("early TEC"). Early TEC were significantly more frequent after courses administered to IVIg-naïve patients (3/25 vs. 2/591 courses; p<0.001), but incidences were comparable in newly- vs. previously-treated patients (3/25 vs. 2/44 patients; p=0.34). Early TEC included 2 cases of myocardial infarction, one of acute coronary syndrome, one of deep vein thrombosis (DVT) with pulmonary embolism and one of isolated DVT. Mean dose per course was comparable in affected and unaffected patients (p=0.47), but administration of daily doses ≥ 35 g correlated significantly with occurrence of early TEC (p=0.028). Previous coronary disease (p=0.037) and immobility at time of treatment (p=0.049) were independent predictors of early TEC. Patients with early TEC had significantly more risk factors (p<0.001), and were significantly more likely to have ≥ 4 risk factors (p=0.006), than those without early TEC. CONCLUSION The risk of TEC with IVIg is not negligible in patients with neuropathy. Although higher with a first-ever infusion, the general risk may be comparable in IVIg-naïve and previously-treated patients. Administration of daily doses ≥ 35 g of IVIg may carry a greater risk of early TEC. Coronary disease, immobility at time of treatment, presence of ≥ 4 risk factors, should lead to caution and consideration of alternative treatments.
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