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Cree BAC, Kim HJ, Weinshenker BG, Pittock SJ, Wingerchuk DM, Fujihara K, Paul F, Cutter GR, Marignier R, Green AJ, Aktas O, Hartung HP, She D, Rees W, Smith M, Cimbora D, Katz E, Bennett JL. Safety and efficacy of inebilizumab for the treatment of neuromyelitis optica spectrum disorder: end-of-study results from the open-label period of the N-MOmentum trial. Lancet Neurol 2024; 23:588-602. [PMID: 38760098 DOI: 10.1016/s1474-4422(24)00077-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/12/2024] [Accepted: 02/13/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Inebilizumab, an anti-CD19 B-cell-depleting antibody, demonstrated safety and efficacy in neuromyelitis optica spectrum disorder in the randomised controlled period of the N-MOmentum trial. Here, end-of-study data, including the randomised controlled period and open-label extension period, are reported. METHODS In the double-blind, randomised, placebo-controlled, phase 2/3 N-MOmentum trial, adults aged 18 years and older with an neuromyelitis optica spectrum disorder diagnosis, Expanded Disability Status Scale score of 8·0 or less, and history of either at least one acute inflammatory attack requiring rescue therapy in the past year or two attacks requiring rescue therapy in the past 2 years, were recruited from 81 outpatient specialty clinics or hospitals in 24 countries. Eligible participants were randomly assigned (3:1), using a central interactive voice system or interactive web response system, and a permuted block randomisation scheme (block size of 4), to receive intravenous inebilizumab (300 mg) or identical placebo on days 1 and 15 of the randomised period, which lasted up to 197 days. Participants and all study staff were masked to treatment assignment. The primary endpoint of the randomised period of the trial was time to onset of adjudicated neuromyelitis optica spectrum disorder attack on or before day 197. Participants in the randomised controlled period who had an adjudicated attack, completed 197 days in the study, or were in the randomised controlled period when enrolment stopped, could voluntarily enter the open-label period. In the open-label period, participants either initiated inebilizumab if assigned placebo (receiving 300 mg on days 1 and 15 of the open-label period) or continued treatment if assigned inebilizumab (receiving 300 mg on day 1 and placebo on day 15, to maintain B-cell depletion and masking of the randomised controlled period). All participants subsequently received inebilizumab 300 mg every 6 months for a minimum of 2 years. The end-of-study analysis endpoints were time to adjudicated attack and annualised attack rate (assessed in all participants who received inebilizumab at any point during the randomised controlled period or open-label period [any inebilizumab population] and the aquaporin-4 [AQP4]-IgG seropositive subgroup [any inebilizumab-AQP4-IgG seropositive population]) and safety outcomes (in all participants who were exposed to inebilizumab, analysed as-treated). This study is registered with ClinicalTrials.gov, NCT02200770, and is now complete. FINDINGS Between Jan 6, 2015, and Sept 24, 2018, 467 individuals were screened, 231 were randomly assigned, and 230 received at least one dose of inebilizumab (n=174) or placebo (n=56). Between May 19, 2015, and Nov 8, 2018, 165 (95%) of 174 participants in the inebilizumab group and 51 (91%) of 56 in the placebo group entered the open-label period (mean age 42·9 years [SD 12·4], 197 [91%] of 216 were female, 19 [9%] were male, 115 [53%] were White, 45 [21%] were Asian, 19 [9%] were American Indian or Alaskan Native, and 19 [9%] were Black or African American). As of data cutoff for this end of study analysis (Dec 18, 2020; median exposure 1178 days [IQR 856-1538], total exposure of 730 person-years) 225 participants formed the any inebilizumab population, and 208 (92%) participants were AQP4-IgG seropositive. Overall, 63 adjudicated neuromyelitis optica spectrum disorder attacks occurred in 47 (21%) of 225 treated participants (60 attacks occurred in 44 [21%] of 208 in the AQP4-IgG seropositive subgroup); 40 (63%) of 63 attacks occurred in 34 (15%) of 225 treated participants during the first year of treatment. Of individuals who had an adjudicated attack while receiving inebilizumab, 36 (77%) of 47 were subsequently attack-free at the end of 4 years. Annualised attack rates decreased year-on-year, with end-of-study adjusted annualised attack rates being similar in the any inebilizumab-AQP4-IgG seropositive subgroup (0·097 [95% CI 0·070-0·14]) and any inebilizumab populations (0·092 [0·067-0·13]). Overall, 208 (92%) of 225 participants who received any inebilizumab had at least one treatment-emergent adverse event, the most frequent of which were urinary tract infection (59 [26%]), nasopharyngitis (47 [21%]), and arthralgia (39 [17%]). Infection rates did not increase over 4 years. Three (1%) of 225 participants in the any inebilizumab population died during the open-label period (one each due to a CNS event of unknown cause and pneumonia, respiratory insufficiency resulting from an neuromyelitis optica spectrum disorder attack and viral pneumonia related to COVID-19), all of which were deemed to be unrelated to treatment. INTERPRETATION Data from the end-of-study analysis of the N-MOmentum trial showed continued and sustained clinical benefits of long-term inebilizumab treatment in individuals with neuromyelitis optica spectrum disorder, which supports the role of inebilizumab as a CD19+ B-cell-depleting therapy in neuromyelitis optica spectrum disorder. FUNDING MedImmune and Viela Bio/Horizon Therapeutics, now part of Amgen.
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Affiliation(s)
- Bruce A C Cree
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA.
| | - Ho Jin Kim
- Research Institute and Hospital of National Cancer Center, Goyang, South Korea
| | | | - Sean J Pittock
- Center for MS and Autoimmune Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Kazuo Fujihara
- Department of Multiple Sclerosis Therapeutics, Fukushima Medical University, Fukushima, Japan; Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan
| | - Friedemann Paul
- Experimental and Clinical Research Center, Max Delbrück Center for Molecular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Gary R Cutter
- Department of Biostatistics, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Romain Marignier
- Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuroinflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
| | - Ari J Green
- Department of Ophthalmology, UCSF Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Orhan Aktas
- Department of Neurology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; Brain and Mind Center, University of Sydney, Sydney, NSW, Australia; Department of Neurology, Medical University of Vienna, Vienna, Austria; Department of Neurology, Palacký University Olomouc, Olomouc, Czech Republic
| | - Dewei She
- Horizon Therapeutics/Amgen, Deerfield, IL, USA
| | | | | | | | | | - Jeffrey L Bennett
- Departments of Neurology and Ophthalmology, Programs in Neuroscience and Immunology, University of Colorado School of Medicine, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
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Jacob S. Treating myasthenia gravis beyond the eye clinic. Eye (Lond) 2024:10.1038/s41433-024-03133-x. [PMID: 38789789 DOI: 10.1038/s41433-024-03133-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/17/2024] [Accepted: 05/07/2024] [Indexed: 05/26/2024] Open
Abstract
Myasthenia gravis (MG) is one of the most well characterised autoimmune disorders affecting the neuromuscular junction with autoantibodies targeting the acetylcholine receptor (AChR) complex. The vast majority of patients present with ocular symptoms including double vision and ptosis, but may progress on to develop generalised fatiguable muscle weakness. Severe involvement of the bulbar muscles can lead to dysphagia, dysarthria and breathing difficulties which can progress to myasthenic crisis needing ventilatory support. Given the predominant ocular onset of the disease, it is important that ophthalmologists are aware of the differential diagnosis, investigations and management including evolving therapies. When the disease remains localised to the extraocular muscles (ocular MG) IgG1 and IgG3 antibodies against the AChR (including clustered AChR) are present in nearly 50% of patients. In generalised MG this is seen in nearly 90% patients. Other antibodies include those against muscle specific tyrosine kinase (MuSK) and lipoprotein receptor related protein 4 (LRP4). Even though decremental response on repetitive nerve stimulation is the most well recognised neurophysiological abnormality, single fibre electromyogram (SFEMG) in experienced hands is the most sensitive test which helps in the diagnosis. Initial treatment should be using cholinesterase inhibitors and then proceeding to immunosuppression using corticosteroids and steroid sparing drugs. Patients requiring bulbar muscle support may need rescue therapies including plasma exchange and intravenous immunoglobulin (IVIg). Newer therapeutic targets include those against the B lymphocytes, complement system, neonatal Fc receptors (FcRn) and various other elements of the immune system.
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Affiliation(s)
- Saiju Jacob
- University Hospitals Birmingham, Birmingham, UK.
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
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Al-Hawary SIS, Jasim SA, Hjazi A, Ullah H, Bansal P, Deorari M, Sapaev IB, Ami AA, Mohmmed KH, Abosaoda MK. A new perspective on therapies involving B-cell depletion in autoimmune diseases. Mol Biol Rep 2024; 51:629. [PMID: 38717637 DOI: 10.1007/s11033-024-09575-6] [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: 03/26/2024] [Accepted: 04/22/2024] [Indexed: 06/30/2024]
Abstract
It has been rediscovered in the last fifteen years that B-cells play an active role in autoimmune etiology rather than just being spectators. The clinical success of B-cell depletion therapies (BCDTs) has contributed to this. BCDTs, including those that target CD20, CD19, and BAFF, were first developed to eradicate malignant B-cells. These days, they treat autoimmune conditions like multiple sclerosis and systemic lupus erythematosus. Particular surprises have resulted from the use of BCDTs in autoimmune diseases. For example, even in cases where BCDT is used to treat the condition, its effects on antibody-secreting plasma cells and antibody levels are restricted, even though these cells are regarded to play a detrimental pathogenic role in autoimmune diseases. In this Review, we provide an update on our knowledge of the biology of B-cells, examine the outcomes of clinical studies employing BCDT for autoimmune reasons, talk about potential explanations for the drug's mode of action, and make predictions about future approaches to targeting B-cells other than depletion.
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Affiliation(s)
| | | | - Ahmed Hjazi
- Department of Medical Laboratory, College of Applied Medical Sciences, Prince Sattam Bin Abdulaziz University, 11942, Al-Kharj, Saudi Arabia
| | - Himayat Ullah
- College of Medicine, Shaqra University, 15526, Shaqra, Saudi Arabia.
| | - Pooja Bansal
- Department of Biotechnology and Genetics, Jain (Deemed-to-Be) University, Bengaluru, Karnataka, 560069, India
- Department of Allied Healthcare and Sciences, Vivekananda Global University, Jaipur, Rajasthan, 303012, India
| | - Mahamedha Deorari
- Uttaranchal Institute of Pharmaceutical Sciences, Uttaranchal University, Dehradun, India
| | - I B Sapaev
- Tashkent Institute of Irrigation and Agricultural Mechanization Engineers National Research University, Tashkent, Uzbekistan
- Scientific Researcher, Western Caspian University, Baku, Azerbaijan
| | - Ahmed Ali Ami
- Department of Medical Laboratories Technology, Al-Nisour University College, Baghdad, Iraq
| | | | - Munther Kadhim Abosaoda
- College of Pharmacy, The Islamic University, Najaf, Iraq
- College of Pharmacy, The Islamic University of Al Diwaniyah, Al Diwaniyah, Iraq
- College of Pharmacy, The Islamic University of Babylon, Hillah, Iraq
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Shang H, Shen X, Yu X, Zhang J, Jia Y, Gao F. B-cell targeted therapies in autoimmune encephalitis: mechanisms, clinical applications, and therapeutic potential. Front Immunol 2024; 15:1368275. [PMID: 38562943 PMCID: PMC10982343 DOI: 10.3389/fimmu.2024.1368275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 03/04/2024] [Indexed: 04/04/2024] Open
Abstract
Autoimmune encephalitis (AE) broadly refers to inflammation of the brain parenchyma mediated by autoimmune mechanisms. In most patients with AE, autoantibodies against neuronal cell surface antigens are produced by B-cells and induce neuronal dysfunction through various mechanisms, ultimately leading to disease progression. In recent years, B-cell targeted therapies, including monoclonal antibody (mAb) therapy and chimeric antigen receptor T-cell (CAR-T) therapy, have been widely used in autoimmune diseases. These therapies decrease autoantibody levels in patients and have shown favorable results. This review summarizes the mechanisms underlying these two B-cell targeted therapies and discusses their clinical applications and therapeutic potential in AE. Our research provides clinicians with more treatment options for AE patients whose conventional treatments are not effective.
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Affiliation(s)
- Haodong Shang
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, Henan, China
- BGI College, Zhengzhou University, Zhengzhou, Henan, China
| | - Xinru Shen
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, Henan, China
- BGI College, Zhengzhou University, Zhengzhou, Henan, China
| | - Xiaoxiao Yu
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, Henan, China
- BGI College, Zhengzhou University, Zhengzhou, Henan, China
| | - Jing Zhang
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, Henan, China
- BGI College, Zhengzhou University, Zhengzhou, Henan, China
| | - Yongliang Jia
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, Henan, China
- BGI College, Zhengzhou University, Zhengzhou, Henan, China
| | - Feng Gao
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, Henan, China
- BGI College, Zhengzhou University, Zhengzhou, Henan, China
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Carlson AK, Amin M, Cohen JA. Drugs Targeting CD20 in Multiple Sclerosis: Pharmacology, Efficacy, Safety, and Tolerability. Drugs 2024; 84:285-304. [PMID: 38480630 PMCID: PMC10982103 DOI: 10.1007/s40265-024-02011-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2024] [Indexed: 04/02/2024]
Abstract
Currently, there are four monoclonal antibodies (mAbs) that target the cluster of differentiation (CD) 20 receptor available to treat multiple sclerosis (MS): rituximab, ocrelizumab, ofatumumab, and ublituximab. B-cell depletion therapy has changed the therapeutic landscape of MS through robust efficacy on clinical manifestations and MRI lesion activity, and the currently available anti-CD20 mAb therapies for use in MS are a cornerstone of highly effective disease-modifying treatment. Ocrelizumab is currently the only therapy with regulatory approval for primary progressive MS. There are currently few data regarding the relative efficacy of these therapies, though several clinical trials are ongoing. Safety concerns applicable to this class of therapeutics relate primarily to immunogenicity and mechanism of action, and include infusion-related or injection-related reactions, development of hypogammaglobulinemia (leading to increased infection and malignancy risk), and decreased vaccine response. Exploration of alternative dose/dosing schedules might be an effective strategy for mitigating these risks. Future development of biosimilar medications might make these therapies more readily available. Although anti-CD20 mAb therapies have led to significant improvements in disease outcomes, CNS-penetrant therapies are still needed to more effectively address the compartmentalized inflammation thought to play an important role in disability progression.
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Affiliation(s)
- Alise K Carlson
- Mellen Center, Neurologic Institute, Cleveland Clinic, 9500 Euclid Ave U10, Cleveland, OH, 44195, USA
| | - Moein Amin
- Mellen Center, Neurologic Institute, Cleveland Clinic, 9500 Euclid Ave U10, Cleveland, OH, 44195, USA
| | - Jeffrey A Cohen
- Mellen Center, Neurologic Institute, Cleveland Clinic, 9500 Euclid Ave U10, Cleveland, OH, 44195, USA.
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Wemlinger SM, Cambier JC. Therapeutic tactics for targeting B lymphocytes in autoimmunity and cancer. Eur J Immunol 2024; 54:e2249947. [PMID: 37816494 DOI: 10.1002/eji.202249947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 10/05/2023] [Accepted: 10/09/2023] [Indexed: 10/12/2023]
Abstract
B lymphocytes have become a very popular therapeutic target in a number of autoimmune indications due to their newly appreciated roles, and approachability, in these diseases. Many of the therapies now applied in autoimmunity were initially developed to deplete malignant B cells. These strategies have also been found to benefit patients suffering from such autoimmune diseases as multiple sclerosis, type I diabetes, systemic lupus erythematosus, and rheumatoid arthritis, to name a few. These observations have supported the expansion of research addressing the mechanistic contributions of B cells in these diseases, as well as blossoming of therapeutics that target them. This review seeks to summarize cutting-edge modalities for targeting B cells, including monoclonal antibodies, bispecific antibodies, antibody-drug conjugates, chimeric antigen receptor-T cells, and small molecule inhibitors. Efforts to refine B-cell targeted therapy to eliminate only pathogenic autoreactive cells will be addressed as well as the potential for future B-cell-based cellular therapeutics. Finally, we also address approaches that seek to silence B-cell function without depletion.
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Affiliation(s)
- Scott M Wemlinger
- Department of Immunology and Microbiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - John C Cambier
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, Colorado, USA
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Tannemaat MR, Huijbers MG, Verschuuren JJGM. Myasthenia gravis-Pathophysiology, diagnosis, and treatment. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:283-305. [PMID: 38494283 DOI: 10.1016/b978-0-12-823912-4.00026-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Myasthenia gravis (MG) is an autoimmune disease characterized by dysfunction of the neuromuscular junction resulting in skeletal muscle weakness. It is equally prevalent in males and females, but debuts at a younger age in females and at an older age in males. Ptosis, diplopia, facial bulbar weakness, and limb weakness are the most common symptoms. MG can be classified based on the presence of serum autoantibodies. Acetylcholine receptor (AChR) antibodies are found in 80%-85% of patients, muscle-specific kinase (MuSK) antibodies in 5%-8%, and <1% may have low-density lipoprotein receptor-related protein 4 (Lrp4) antibodies. Approximately 10% of patients are seronegative for antibodies binding the known disease-related antigens. In patients with AChR MG, 10%-20% have a thymoma, which is usually detected at the onset of the disease. Important differences between clinical presentation, treatment responsiveness, and disease mechanisms have been observed between these different serologic MG classes. Besides the typical clinical features and serologic testing, the diagnosis can be established with additional tests, including repetitive nerve stimulation, single fiber EMG, and the ice pack test. Treatment options for MG consist of symptomatic treatment (such as pyridostigmine), immunosuppressive treatment, or thymectomy. Despite the treatment with symptomatic drugs, steroid-sparing immunosuppressants, intravenous immunoglobulins, plasmapheresis, and thymectomy, a large proportion of patients remain chronically dependent on corticosteroids (CS). In the past decade, the number of treatment options for MG has considerably increased. Advances in the understanding of the pathophysiology have led to new treatment options targeting B or T cells, the complement cascade, the neonatal Fc receptor or cytokines. In the future, these new treatments are likely to reduce the chronic use of CS, diminish side effects, and decrease the number of patients with refractory disease.
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Affiliation(s)
- Martijn R Tannemaat
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Maartje G Huijbers
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands; Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
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Kim HJ, Aktas O, Patterson KR, Korff S, Kunchok A, Bennett JL, Weinshenker BG, Paul F, Hartung H, Cimbora D, Smith MA, Mittereder N, Rees WA, She D, Cree BAC. Inebilizumab reduces neuromyelitis optica spectrum disorder risk independent of FCGR3A polymorphism. Ann Clin Transl Neurol 2023; 10:2413-2420. [PMID: 37804003 PMCID: PMC10723240 DOI: 10.1002/acn3.51911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/24/2023] [Accepted: 09/13/2023] [Indexed: 10/08/2023] Open
Abstract
Inebilizumab, a humanized, glycoengineered, IgG1 monoclonal antibody that depletes CD19+ B-cells, is approved to treat aquaporin 4 (AQP4) IgG-seropositive neuromyelitis optica spectrum disorder (NMOSD). Inebilizumab is afucosylated and engineered for enhanced affinity to Fc receptor III-A (FCGR3A) receptors on natural killer cells to maximize antibody-dependent cellular cytotoxicity. Previously, the F allele polymorphism at amino acid 158 of the FCGR3A gene (F158) was shown to decrease IgG-binding affinity and reduce rituximab (anti-CD20) efficacy for NMOSD attack prevention. In contrast, our current findings from inebilizumab-treated NMOSD patients indicate similar clinical outcomes between those with F158 and V158 allele genotypes.
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Affiliation(s)
- Ho Jin Kim
- Department of NeurologyResearch Institute and Hospital of National Cancer CenterGoyangSouth Korea
| | - Orhan Aktas
- Medical FacultyHeinrich Heine University DüsseldorfDüsseldorfGermany
| | | | | | - Amy Kunchok
- Department of NeurologyMellen Center for Multiple Sclerosis, Cleveland ClinicOhioClevelandUSA
| | - Jeffrey L. Bennett
- Department of Neurology, Programs in Neuroscience and ImmunologyUniversity of Colorado School of Medicine, Anschutz Medical CampusColoradoAuroraUSA
| | | | - Friedemann Paul
- Experimental and Clinical Research Center, Max Delbrück Center for Molecular Medicine and CharitéUniversitätsmedizin Berlin, Corporate Member of Freie Universitat Berlin and Humboldt‐Universitat zu BerlinBerlinGermany
| | - Hans‐Peter Hartung
- Medical FacultyHeinrich Heine University DüsseldorfDüsseldorfGermany
- Brain and Mind CentreUniversity of SydneyNew South WalesSydneyAustralia
- Department of NeurologyMedical University ViennaViennaAustria
- Department of NeurologyPalacky University in OlomoucOlomoucCzech Republic
| | | | | | | | | | - Dewei She
- Horizon TherapeuticsIllinoisDeerfieldUSA
| | - Bruce A. C. Cree
- Department of Neurology, UCSF Weill Institute for NeurosciencesUniversity of California San FranciscoCaliforniaSan FranciscoUSA
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Golfinopoulou R, Giudicelli V, Manso T, Kossida S. Delving into Molecular Pathways: Analyzing the Mechanisms of Action of Monoclonal Antibodies Integrated in IMGT/mAb-DB for Myasthenia Gravis. Vaccines (Basel) 2023; 11:1756. [PMID: 38140161 PMCID: PMC10747390 DOI: 10.3390/vaccines11121756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/20/2023] [Accepted: 11/22/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Myasthenia Gravis (MG) is a rare autoimmune disease presenting with auto-antibodies that affect the neuromuscular junction. In addition to symptomatic treatment options, novel therapeutics include monoclonal antibodies (mAbs). IMGT®, the international ImMunoGeneTics information system®, extends the characterization of therapeutic antibodies with a systematic description of their mechanisms of action (MOA) and makes them available through its database for mAbs and fusion proteins, IMGT/mAb-DB. METHODS Using available literature data combined with amino acid sequence analyses from mAbs managed in IMGT/2Dstructure-DB, the IMGT® protein database, biocuration allowed us to define in a standardized way descriptions of MOAs of mAbs that target molecules towards MG treatment. RESULTS New therapeutic targets include FcRn and molecules such as CD38, CD40, CD19, MS4A1, and interleukin-6 receptor. A standardized graphical representation of the MOAs of selected mAbs was created and integrated within IMGT/mAb-DB. The main mechanisms involved in these mAbs are either blocking or neutralizing. Therapies directed to B cell depletion and plasma cells have a blocking MOA with an immunosuppressant effect along with Fc-effector function (MS4A1, CD38) or FcγRIIb engager effect (CD19). Monoclonal antibodies targeting the complement also have a blocking MOA with a complement inhibitor effect, and treatments targeting T cells have a blocking MOA with an immunosuppressant effect (CD40) and Fc-effector function (IL6R). On the other hand, FcRn antagonists present a neutralizing MOA with an FcRn inhibitor effect. CONCLUSION The MOA of each new mAb needs to be considered in association with the immunopathogenesis of each of the subtypes of MG in order to integrate the new mAbs as a viable and safe option in the therapy decision process. In IMGT/mAb-DB, mAbs for MG are characterized by their sequence, domains, and chains, and their MOA is described.
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Affiliation(s)
- Rebecca Golfinopoulou
- IMGT, The International ImMunoGeneTics Information System, National Center for Scientific Research (CNRS), Institute of Human Genetics (IGH), University of Montpellier (UM), 34090 Montpellier, France; (R.G.); (V.G.)
- Department of Biotechnology, School of Applied Biology and Biotechnology, Agricultural University of Athens, 11855 Athens, Greece
| | - Véronique Giudicelli
- IMGT, The International ImMunoGeneTics Information System, National Center for Scientific Research (CNRS), Institute of Human Genetics (IGH), University of Montpellier (UM), 34090 Montpellier, France; (R.G.); (V.G.)
| | - Taciana Manso
- IMGT, The International ImMunoGeneTics Information System, National Center for Scientific Research (CNRS), Institute of Human Genetics (IGH), University of Montpellier (UM), 34090 Montpellier, France; (R.G.); (V.G.)
| | - Sofia Kossida
- IMGT, The International ImMunoGeneTics Information System, National Center for Scientific Research (CNRS), Institute of Human Genetics (IGH), University of Montpellier (UM), 34090 Montpellier, France; (R.G.); (V.G.)
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Fujihara K, Kim HJ, Saida T, Misu T, Nagano Y, Totsuka N, Iizuka M, Kido S, Terata R, Okumura K, Hirota S, Cree BAC. Efficacy and safety of inebilizumab in Asian participants with neuromyelitis optica spectrum disorder: Subgroup analyses of the N-MOmentum study. Mult Scler Relat Disord 2023; 79:104938. [PMID: 37769428 DOI: 10.1016/j.msard.2023.104938] [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: 03/30/2023] [Revised: 07/26/2023] [Accepted: 08/12/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Inebilizumab, an anti-CD19 B cell-depleting antibody, reduced the risk of a neuromyelitis optica spectrum disorder (NMOSD) attack, disability worsening, magnetic resonance imaging (MRI) lesion activity, and disease-related hospitalizations in participants with NMOSD in the N-MOmentum study (NCT02200770). However, the efficacy and safety outcomes of inebilizumab specific to an Asian population were not fully reported. Therefore, subgroup analyses of the N-MOmentum study were conducted post hoc to evaluate the efficacy and safety of inebilizumab in Asian participants with NMOSD. METHODS The N-MOmentum study was a multicenter, double-blind, randomized, placebo-controlled phase 2/3 trial with an open-label extension period (OLP). In the subgroup analyses, data from Asian participants from the N-MOmentum study were compared with those of non-Asian participants. Eligible participants were randomly allocated (3:1) to receive 300 mg intravenous (IV) inebilizumab or placebo on Days 1 and 15. Participants who had an NMOSD attack or completed the randomized controlled period (RCP) could enter the OLP, where they received inebilizumab for ≥2 years. All participants who entered the OLP received inebilizumab 300 mg IV every 6 months. RESULTS Overall, 230 participants received treatment (174 received inebilizumab and 56 received placebo), of whom 47 were Asian (39 received inebilizumab and 8 received placebo). Baseline characteristics were similar between the Asian and non-Asian subgroups, except for disease duration, annualized relapse rate prior to randomization in this study, and previous maintenance therapy. In the Asian subgroup, the risk of NMOSD attacks was reduced with inebilizumab versus placebo (hazard ratio, 0.202) and the attack-free rate at 28 weeks was 82.1% with inebilizumab versus 37.5% with placebo, in the 6-month RCP. NMOSD attack rates were comparable between the Asian and non-Asian subgroups. In the Asian subgroup, the rates of Expanded Disability Status Scale worsening from baseline, active MRI lesions, and disease-related hospitalizations tended to be lower in the inebilizumab group than in the placebo group; similar results were shown in the non-Asian subgroup. For long-term efficacy and safety (RCP and OLP), the annualized adjudicated NMOSD attack rate in Asian participants treated with inebilizumab was reduced (0.096) compared with that at baseline (1.04), with a mean follow-up period of inebilizumab treatment of 3.38 years, which was consistent with the results in the non-Asian subgroup. The risk of NMOSD attack decreased with prolonged duration of treatment in both the inebilizumab/inebilizumab and placebo/inebilizumab groups in the Asian and non-Asian subgroups. The incidence of treatment-emergent adverse events (TEAEs) was similar between the Asian and non-Asian subgroups. In the Asian and non-Asian subgroups, 15.2% and 35.2% of participants, respectively, had at least one serious TEAE and/or Grade ≥3 TEAE during long-term therapy. No deaths occurred in the Asian subgroup whereas three deaths occurred in the non-Asian subgroup. CONCLUSION Inebilizumab reduced the risk of an NMOSD attack, progression of disability, MRI lesion activity, and disease-related hospitalizations in Asian participants with NMOSD. The efficacy of inebilizumab in reducing NMOSD attacks continued without any unexpected safety signals or concerns during long-term use in Asian participants.
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Affiliation(s)
- Kazuo Fujihara
- Department of Multiple Sclerosis Therapeutics, Fukushima Medical University, 1 Hikariga-oka, Fukushima 960-1295, Japan.
| | - Ho Jin Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang 10408, Republic of Korea.
| | - Takahiko Saida
- Department of Neurology, Kyoto Min-iren Chuo Hospital, Nishinokyokasuga-cho, Nakagyo-ku, Kyoto 604-8463, Japan
| | - Tatsuro Misu
- Department of Neurology, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Yoshito Nagano
- Medical Affairs Department, Mitsubishi Tanabe Pharma Corporation, 3-2-10 Dosho-machi, Chuo-ku, Osaka 541-8505, Japan
| | - Naoko Totsuka
- Clinical Research & Development II Department, Mitsubishi Tanabe Pharma Corporation, 1-1-1 Marunouchi, Chiyoda-ku, Tokyo 100-8205, Japan
| | - Masato Iizuka
- Data Science Department, Mitsubishi Tanabe Pharma Corporation, 1-1-1 Marunouchi, Chiyoda-ku, Tokyo 100-8205, Japan
| | - Shinsuke Kido
- Clinical Research & Development II Department, Mitsubishi Tanabe Pharma Corporation, 1-1-1 Marunouchi, Chiyoda-ku, Tokyo 100-8205, Japan
| | - Ryuuji Terata
- Clinical Research & Development II Department, Mitsubishi Tanabe Pharma Corporation, 1-1-1 Marunouchi, Chiyoda-ku, Tokyo 100-8205, Japan
| | - Kyoko Okumura
- Global Pharmacovigilance Department, Mitsubishi Tanabe Pharma Corporation, 3-2-10 Dosho-machi, Chuo-ku, Osaka 541-8505, Japan
| | - Shinya Hirota
- Medical Intelligence Department, Mitsubishi Tanabe Pharma Corporation, 3-2-10 Dosho-machi, Chuo-ku, Osaka 541-8505, Japan
| | - Bruce A C Cree
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, 675 Nelson Rising Lane, Box 3206, San Francisco, CA 94158, United States
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11
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Monson N, Smith C, Greenberg H, Plumb P, Guzman A, Tse K, Chen D, Zhang W, Morgan M, Speed H, Powell C, Batra S, Cowell L, Christley S, Vernino S, Blackburn K, Greenberg B. VH2+ Antigen-Experienced B Cells in the Cerebrospinal Fluid Are Expanded and Enriched in Pediatric Anti-NMDA Receptor Encephalitis. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2023; 211:1332-1339. [PMID: 37712756 PMCID: PMC10593502 DOI: 10.4049/jimmunol.2300156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 08/17/2023] [Indexed: 09/16/2023]
Abstract
Pediatric and adult autoimmune encephalitis (AE) are often associated with Abs to the NR1 subunit of the N-methyl-d-aspartate (NMDA) receptor (NMDAR). Very little is known regarding the cerebrospinal fluid humoral immune profile and Ab genetics associated with pediatric anti-NMDAR-AE. Using a combination of cellular, molecular, and immunogenetics tools, we collected cerebrospinal fluid from pediatric subjects and generated 1) flow cytometry data to calculate the frequency of B cell subtypes in the cerebrospinal fluid of pediatric subjects with anti-NMDAR-AE and controls, 2) a panel of recombinant human Abs from a pediatric case of anti-NMDAR-AE that was refractory to treatment, and 3) a detailed analysis of the Ab genes that bound the NR1 subunit of the NMDAR. Ag-experienced B cells including memory cells, plasmablasts, and Ab-secreting cells were expanded in the pediatric anti-NMDAR-AE cohort, but not in the controls. These Ag-experienced B cells in the cerebrospinal fluid of a pediatric case of NMDAR-AE that was refractory to treatment had expanded use of variable H chain family 2 (VH2) genes with high somatic hypermutation that all bound to the NR1 subunit of the NMDAR. A CDR3 motif was identified in this refractory case that likely drove early stage activation and expansion of naive B cells to Ab-secreting cells, facilitating autoimmunity associated with pediatric anti-NMDAR-AE through the production of Abs that bind NR1. These features of humoral immune responses in the cerebrospinal fluid of pediatric anti-NMDAR-AE patients may be relevant for clinical diagnosis and treatment.
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Affiliation(s)
- Nancy Monson
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX
- Department of Immunology, UT Southwestern Medical Center, Dallas, TX
| | - Chad Smith
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX
| | - Hannah Greenberg
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX
| | - Patricia Plumb
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX
| | - Alyssa Guzman
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX
| | - Key Tse
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX
| | - Ding Chen
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX
| | - Wei Zhang
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX
| | - Miles Morgan
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX
| | - Haley Speed
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX
| | - Craig Powell
- Department of Neurobiology, Civitan International Research Center, University of Alabama Marnix E. Heersink School of Medicine, Birmingham, AL
| | - Sushobhna Batra
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX
| | - Lindsay Cowell
- Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Scott Christley
- Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Steve Vernino
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX
| | - Kyle Blackburn
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX
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12
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Yong HYF, Burton JM. A Clinical Approach to Existing and Emerging Therapeutics in Neuromyelitis Optica Spectrum Disorder. Curr Neurol Neurosci Rep 2023; 23:489-506. [PMID: 37540387 DOI: 10.1007/s11910-023-01287-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2023] [Indexed: 08/05/2023]
Abstract
PURPOSE OF REVIEW Neuromyelitis optica spectrum disorder (NMOSD) is a rare but highly disabling disease of the central nervous system. Unlike multiple sclerosis, disability in NMOSD occurs secondary to relapses that, not uncommonly, lead to blindness, paralysis, and death. Recently, newer, targeted immunotherapies have been trialed and are now in the treatment arsenal. We have endeavoured to evaluate the current state of NMOSD therapeutics. RECENT FINDINGS This review provides a pragmatic evaluation of recent clinical trials and post-marketing data for rituximab, inebilizumab, satralizumab, eculizumab, and ravalizumab, contrasted to older agents. We also review contemporary issues such as treatment in the context of SARS-CoV2 infection and pregnancy. There has been a dramatic shift in NMOSD morbidity and mortality with earlier and improved disease recognition, diagnostic accuracy, and the advent of more effective, targeted therapies. Choosing a maintenance therapy remains nuanced depending on patient factors and accessibility. With over 100 putative agents in trials, disease-free survival is now a realistic goal for NMOSD patients.
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Affiliation(s)
- Heather Y F Yong
- Division of Neurology, Department of Clinical Neurosciences, University of Calgary, Cummings School of Medicine, Calgary, AB, Canada
| | - Jodie M Burton
- Division of Neurology, Department of Clinical Neurosciences, University of Calgary, Cummings School of Medicine, Calgary, AB, Canada.
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.
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13
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Leite MI, Panahloo Z, Harrison N, Palace J. A systematic literature review to examine the considerations around pregnancy in women of child-bearing age with myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) or aquaporin 4 neuromyelitis optica spectrum disorder (AQP4+ NMOSD). Mult Scler Relat Disord 2023; 75:104760. [PMID: 37224631 DOI: 10.1016/j.msard.2023.104760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 05/04/2023] [Accepted: 05/09/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Aquaporin-4 antibody positive (AQP4+) neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) are rare autoimmune diseases with overlapping phenotypes. Understanding their clinical manifestation prior to, during and after pregnancy may influence the management of women of child-bearing age (WOCBA) with these diseases. METHODS This systematic review identified relevant MEDLINE-indexed publications dated between 01 January 2011 and 01 November 2021, and congress materials from key conferences between 01 January 2019 and 01 November 2021. These were manually assessed for relevance to AQP4+ NMOSD and/or MOGAD in WOCBA, with selected data extracted and considered. RESULTS In total, 107 articles were retrieved and reviewed for relevancy, including 65 clinical studies. Limited evidence was found regarding a conclusive impact of either disease on female fertility, sexual function or menarche, and impact on maternal outcomes requires further investigation in both conditions to establish risk for pre-eclampsia, gestational diabetes and other complications relative to the general population. Collated data for pregnancy outcomes show clear risks in AQP4+ NMOSD to healthy delivery and a rise in annualised relapse rate postpartum that may require adaptation of treatment regimens. Disease activity appears to be attenuated during pregnancy in MOGAD patients with an increased risk of relapse during the postpartum months, but strong conclusions cannot be made due to a paucity of available data. CONCLUSIONS This review brings together the literature on AQP4+ NMOSD and MOGAD in WOCBA. The potential impact of pregnancy and the postpartum period on disease activity suggest a proactive management strategy early on may improve maternal and infant outcomes, but more clinical data are needed, particularly for MOGAD.
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Affiliation(s)
- M Isabel Leite
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK.
| | | | | | - Jacqueline Palace
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK
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14
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Nair SS, Jacob S. Novel Immunotherapies for Myasthenia Gravis. Immunotargets Ther 2023; 12:25-45. [PMID: 37038596 PMCID: PMC10082579 DOI: 10.2147/itt.s377056] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 03/03/2023] [Indexed: 04/07/2023] Open
Abstract
Myasthenia gravis (MG), a prototype autoimmune neurological disease, had its therapy centred on corticosteroids, non-steroidal broad-spectrum immunotherapy and cholinesterase inhibitors for several decades. Treatment-refractory MG and long-term toxicities of the medications have been major concerns with the conventional therapies. Advances in the immunology and pathogenesis of MG have ushered in an era of newer therapies which are more specific and efficacious. Complement inhibitors and neonatal Fc receptor blockers target disease-specific pathogenic mechanisms linked to myasthenia and have proven their efficacy in pivotal clinical studies. B cell-depleting agents, specifically rituximab, have also emerged as useful for the treatment of severe MG. Many more biologicals are in the pipeline and in diverse stages of development. This review discusses the evidence for the novel therapies and the specific issues related to their clinical use.
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Affiliation(s)
- Sruthi S Nair
- Department of Neurology, University Hospitals Birmingham, Birmingham, B15 2TH, UK
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Saiju Jacob
- Department of Neurology, University Hospitals Birmingham, Birmingham, B15 2TH, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TT, UK
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15
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Barreras P, Vasileiou ES, Filippatou AG, Fitzgerald KC, Levy M, Pardo CA, Newsome SD, Mowry EM, Calabresi PA, Sotirchos ES. Long-term Effectiveness and Safety of Rituximab in Neuromyelitis Optica Spectrum Disorder and MOG Antibody Disease. Neurology 2022; 99:e2504-e2516. [PMID: 36240094 PMCID: PMC9728038 DOI: 10.1212/wnl.0000000000201260] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 08/01/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Rituximab is used widely for relapse prevention in neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein (MOG)-IgG-associated disease (MOGAD); however, data regarding the effectiveness and safety of long-term rituximab use in these conditions are limited. In this study, we sought to evaluate long-term clinical outcomes in patients with aquaporin-4 IgG-seropositive (AQP4-IgG+) NMOSD and MOGAD treated with rituximab. METHODS We performed a retrospective chart review of patients with AQP4-IgG+ NMOSD or MOGAD followed at the Johns Hopkins Neuromyelitis Optica Clinic and included patients who had received at least 1 dose of rituximab. RESULTS We identified 111 patients with NMOSD and 23 patients with MOGAD who fulfilled the inclusion criteria. The median duration of rituximab treatment for the patients with NMOSD was 3.7 years (range: 0.5-13.2 years) and for the patients with MOGAD was 2.1 years (range: 0.5-7.0 years). The annualized relapse rate (ARR) decreased after rituximab initiation in both NMOSD (median ARR: pretreatment 1.1, posttreatment 0; p < 0.001) and MOGAD (median ARR: pretreatment 1.9, posttreatment 0.3; p = 0.002). Relapses on rituximab occurred in 31 patients with NMOSD (28%) and 14 patients with MOGAD (61%). The majority of NMOSD treatment failures (37/48 relapses; 77%) occurred either within the initial 6 months after starting rituximab (n = 13 relapses) or in the setting of delayed/missed rituximab doses and/or peripheral B-cell reconstitution (n = 24 relapses), whereas in MOGAD, these circumstances were present in a smaller proportion of treatment failures (19/35 relapses; 54%). The risk of relapse on rituximab was greater for patients with MOGAD compared with patients with NMOSD (hazard ratio: 2.8, 95% CI: 1.5-5.2, p = 0.001). Infections requiring hospitalization occurred in 13% and immunoglobulin G (IgG) hypogammaglobulinemia in 17% of patients. The median rituximab treatment duration before IgG hypogammaglobulinemia onset was 5.4 years (interquartile range: 3.8-7.7 years). DISCUSSION Rituximab treatment is associated with the reduced annualized relapse rate in AQP4-IgG-seropositive NMOSD, especially in the absence of gaps in treatment and/or B-cell reconstitution. In MOGAD, although a reduction in relapses was observed after initiation of rituximab, this association appeared to be less robust than in AQP4-IgG-seropositive NMOSD. Severe infections and hypogammaglobulinemia occurred in a significant proportion of patients, highlighting the need for close monitoring of infectious complications. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that rituximab decreases the annualized relapse rate in AQP4-IgG-seropositive NMOSD and MOGAD.
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Affiliation(s)
- Paula Barreras
- From the Department of Neurology (P.B., E.S.V., A.G.F., K.C.F., C.A.P., S.D.N., E.M.M.C.R., P.A.C., E.S.S.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (M.L.), Harvard University, Boston, MA
| | - Eleni S Vasileiou
- From the Department of Neurology (P.B., E.S.V., A.G.F., K.C.F., C.A.P., S.D.N., E.M.M.C.R., P.A.C., E.S.S.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (M.L.), Harvard University, Boston, MA
| | - Angeliki G Filippatou
- From the Department of Neurology (P.B., E.S.V., A.G.F., K.C.F., C.A.P., S.D.N., E.M.M.C.R., P.A.C., E.S.S.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (M.L.), Harvard University, Boston, MA
| | - Kathryn C Fitzgerald
- From the Department of Neurology (P.B., E.S.V., A.G.F., K.C.F., C.A.P., S.D.N., E.M.M.C.R., P.A.C., E.S.S.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (M.L.), Harvard University, Boston, MA
| | - Michael Levy
- From the Department of Neurology (P.B., E.S.V., A.G.F., K.C.F., C.A.P., S.D.N., E.M.M.C.R., P.A.C., E.S.S.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (M.L.), Harvard University, Boston, MA
| | - Carlos A Pardo
- From the Department of Neurology (P.B., E.S.V., A.G.F., K.C.F., C.A.P., S.D.N., E.M.M.C.R., P.A.C., E.S.S.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (M.L.), Harvard University, Boston, MA
| | - Scott D Newsome
- From the Department of Neurology (P.B., E.S.V., A.G.F., K.C.F., C.A.P., S.D.N., E.M.M.C.R., P.A.C., E.S.S.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (M.L.), Harvard University, Boston, MA
| | - Ellen M Mowry
- From the Department of Neurology (P.B., E.S.V., A.G.F., K.C.F., C.A.P., S.D.N., E.M.M.C.R., P.A.C., E.S.S.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (M.L.), Harvard University, Boston, MA
| | - Peter A Calabresi
- From the Department of Neurology (P.B., E.S.V., A.G.F., K.C.F., C.A.P., S.D.N., E.M.M.C.R., P.A.C., E.S.S.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (M.L.), Harvard University, Boston, MA
| | - Elias S Sotirchos
- From the Department of Neurology (P.B., E.S.V., A.G.F., K.C.F., C.A.P., S.D.N., E.M.M.C.R., P.A.C., E.S.S.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (M.L.), Harvard University, Boston, MA.
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16
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Barreras P, Vasileiou ES, Filippatou AG, Fitzgerald KC, Levy M, Pardo CA, Newsome SD, Mowry EM, Calabresi PA, Sotirchos ES. Long-term Effectiveness and Safety of Rituximab in Neuromyelitis Optica Spectrum Disorder and MOG Antibody Disease. Neurology 2022; 99:e2504-e2516. [PMID: 36240094 PMCID: PMC9728038 DOI: 10.1212/wnl.0000000000201260 10.1212/wnl.0000000000201260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 08/01/2022] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Rituximab is used widely for relapse prevention in neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein (MOG)-IgG-associated disease (MOGAD); however, data regarding the effectiveness and safety of long-term rituximab use in these conditions are limited. In this study, we sought to evaluate long-term clinical outcomes in patients with aquaporin-4 IgG-seropositive (AQP4-IgG+) NMOSD and MOGAD treated with rituximab. METHODS We performed a retrospective chart review of patients with AQP4-IgG+ NMOSD or MOGAD followed at the Johns Hopkins Neuromyelitis Optica Clinic and included patients who had received at least 1 dose of rituximab. RESULTS We identified 111 patients with NMOSD and 23 patients with MOGAD who fulfilled the inclusion criteria. The median duration of rituximab treatment for the patients with NMOSD was 3.7 years (range: 0.5-13.2 years) and for the patients with MOGAD was 2.1 years (range: 0.5-7.0 years). The annualized relapse rate (ARR) decreased after rituximab initiation in both NMOSD (median ARR: pretreatment 1.1, posttreatment 0; p < 0.001) and MOGAD (median ARR: pretreatment 1.9, posttreatment 0.3; p = 0.002). Relapses on rituximab occurred in 31 patients with NMOSD (28%) and 14 patients with MOGAD (61%). The majority of NMOSD treatment failures (37/48 relapses; 77%) occurred either within the initial 6 months after starting rituximab (n = 13 relapses) or in the setting of delayed/missed rituximab doses and/or peripheral B-cell reconstitution (n = 24 relapses), whereas in MOGAD, these circumstances were present in a smaller proportion of treatment failures (19/35 relapses; 54%). The risk of relapse on rituximab was greater for patients with MOGAD compared with patients with NMOSD (hazard ratio: 2.8, 95% CI: 1.5-5.2, p = 0.001). Infections requiring hospitalization occurred in 13% and immunoglobulin G (IgG) hypogammaglobulinemia in 17% of patients. The median rituximab treatment duration before IgG hypogammaglobulinemia onset was 5.4 years (interquartile range: 3.8-7.7 years). DISCUSSION Rituximab treatment is associated with the reduced annualized relapse rate in AQP4-IgG-seropositive NMOSD, especially in the absence of gaps in treatment and/or B-cell reconstitution. In MOGAD, although a reduction in relapses was observed after initiation of rituximab, this association appeared to be less robust than in AQP4-IgG-seropositive NMOSD. Severe infections and hypogammaglobulinemia occurred in a significant proportion of patients, highlighting the need for close monitoring of infectious complications. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that rituximab decreases the annualized relapse rate in AQP4-IgG-seropositive NMOSD and MOGAD.
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Affiliation(s)
- Paula Barreras
- From the Department of Neurology (P.B., E.S.V., A.G.F., K.C.F., C.A.P., S.D.N., E.M.M.C.R., P.A.C., E.S.S.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (M.L.), Harvard University, Boston, MA
| | - Eleni S Vasileiou
- From the Department of Neurology (P.B., E.S.V., A.G.F., K.C.F., C.A.P., S.D.N., E.M.M.C.R., P.A.C., E.S.S.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (M.L.), Harvard University, Boston, MA
| | - Angeliki G Filippatou
- From the Department of Neurology (P.B., E.S.V., A.G.F., K.C.F., C.A.P., S.D.N., E.M.M.C.R., P.A.C., E.S.S.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (M.L.), Harvard University, Boston, MA
| | - Kathryn C Fitzgerald
- From the Department of Neurology (P.B., E.S.V., A.G.F., K.C.F., C.A.P., S.D.N., E.M.M.C.R., P.A.C., E.S.S.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (M.L.), Harvard University, Boston, MA
| | - Michael Levy
- From the Department of Neurology (P.B., E.S.V., A.G.F., K.C.F., C.A.P., S.D.N., E.M.M.C.R., P.A.C., E.S.S.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (M.L.), Harvard University, Boston, MA
| | - Carlos A Pardo
- From the Department of Neurology (P.B., E.S.V., A.G.F., K.C.F., C.A.P., S.D.N., E.M.M.C.R., P.A.C., E.S.S.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (M.L.), Harvard University, Boston, MA
| | - Scott D Newsome
- From the Department of Neurology (P.B., E.S.V., A.G.F., K.C.F., C.A.P., S.D.N., E.M.M.C.R., P.A.C., E.S.S.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (M.L.), Harvard University, Boston, MA
| | - Ellen M Mowry
- From the Department of Neurology (P.B., E.S.V., A.G.F., K.C.F., C.A.P., S.D.N., E.M.M.C.R., P.A.C., E.S.S.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (M.L.), Harvard University, Boston, MA
| | - Peter A Calabresi
- From the Department of Neurology (P.B., E.S.V., A.G.F., K.C.F., C.A.P., S.D.N., E.M.M.C.R., P.A.C., E.S.S.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (M.L.), Harvard University, Boston, MA
| | - Elias S Sotirchos
- From the Department of Neurology (P.B., E.S.V., A.G.F., K.C.F., C.A.P., S.D.N., E.M.M.C.R., P.A.C., E.S.S.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (M.L.), Harvard University, Boston, MA.
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17
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Sánchez-Tejerina D, Sotoca J, Llaurado A, López-Diego V, Juntas-Morales R, Salvado M. New Targeted Agents in Myasthenia Gravis and Future Therapeutic Strategies. J Clin Med 2022; 11:6394. [PMID: 36362622 PMCID: PMC9658349 DOI: 10.3390/jcm11216394] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 08/22/2023] Open
Abstract
Myasthenia gravis (MG) is a chronic autoimmune disease for which multiple immunomodulatory therapies are available. Nevertheless, MG has a significant impact on patient quality of life. In recent years, experts' main efforts have focused on optimizing treatment strategies, since disease burden is considerably affected by their safety and tolerability profiles, especially in patients with refractory phenotypes. This article aims to offer neurologists caring for MG patients an overview of the most innovative targeted drugs specifically designed for this disease and summarizes the recent literature and more recent evidence on agents targeting B cells and plasmablasts, complement inhibitors, and neonatal fragment crystallizable receptor (FcRn) antagonists. Positive clinical trial results have been reported, and other studies are ongoing. Finally, we briefly discuss how the introduction of these novel targeted immunological therapies in a changing management paradigm would affect not only clinical outcomes, disease burden, safety, and tolerability, but also health spending in a condition that is increasingly managed based on a patient-centred model.
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Affiliation(s)
| | | | | | | | | | - Maria Salvado
- Clinic of Neuromuscular Disorders and Rare Diseases, Neurology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Research Institute, European Reference Network for Neuromuscular and Rare Diseases EURO-NMD, 08035 Barcelona, Spain
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18
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Abstract
Inebilizumab (Uplizna®) is a recently approved monoclonal antibody for use in adults with neuromyelitis optica spectrum disorder (NMOSD) who are anti-aquaporin-4 (AQP4) antibody seropositive. Inebilizumab targets the B cell antigen CD19 and effectively depletes circulating B cells, thus suppressing inflammatory NMOSD attacks that are potentially disabling or life-threatening. It is approved as an intravenous infusion in several countries. In the pivotal phase 2/3 N-MOmentum trial, inebilizumab reduced the risk of NMOSD attacks compared with placebo, including in AQP4-antibody seropositive patients. Inebilizumab also significantly reduced the risk of disability score worsening, the number of NMOSD-related hospitalisations and MRI lesion count, but had no significant effect on low-contrast binocular vision. The treatment effect on relapse risk and disability scores was sustained in inebilizumab-treated patients for ≥ 4 years during the open-label extension. Inebilizumab was generally well tolerated, with the most common adverse events being urinary tract infection and arthralgia. Thus, inebilizumab is an effective treatment option for adults with AQP4-antibody seropositive NMOSD.
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Affiliation(s)
- Tina Nie
- Springer Nature, Mairangi Bay, Private Bag 65901, Auckland, 0754, New Zealand.
| | - Hannah A Blair
- Springer Nature, Mairangi Bay, Private Bag 65901, Auckland, 0754, New Zealand
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19
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Neuromyelitis Optica Spectrum Disorder: From Basic Research to Clinical Perspectives. Int J Mol Sci 2022; 23:ijms23147908. [PMID: 35887254 PMCID: PMC9323454 DOI: 10.3390/ijms23147908] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/08/2022] [Accepted: 07/15/2022] [Indexed: 02/05/2023] Open
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is an inflammatory disease of the central nervous system characterized by relapses and autoimmunity caused by antibodies against the astrocyte water channel protein aquaporin-4. Over the past decade, there have been significant advances in the biologic knowledge of NMOSD, which resulted in the IDENTIFICATION of variable disease phenotypes, biomarkers, and complex inflammatory cascades involved in disease pathogenesis. Ongoing clinical trials are looking at new treatments targeting NMOSD relapses. This review aims to provide an update on recent studies regarding issues related to NMOSD, including the pathophysiology of the disease, the potential use of serum and cerebrospinal fluid cytokines as disease biomarkers, the clinical utilization of ocular coherence tomography, and the comparison of different animal models of NMOSD.
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20
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Abstract
Multiple sclerosis (MS) is a chronic autoimmune demyelinating disease of the central nervous system (CNS) that often progresses to severe disability. Previous studies have highlighted the role of T cells in disease pathophysiology; however, the success of B-cell-targeted therapies has led to an increased interest in how B cells contribute to disease immunopathology. In this review, we summarize evidence of B-cell involvement in MS disease mechanisms, starting with pathology and moving on to review aspects of B cell immunobiology potentially relevant to MS. We describe current theories of critical B cell contributions to the inflammatory CNS milieu in MS, namely (i) production of autoantibodies, (ii) antigen presentation, (iii) production of proinflammatory cytokines (bystander activation), and (iv) EBV involvement. In the second part of the review, we summarize medications that have targeted B cells in patients with MS and their current position in the therapeutic armamentarium based on clinical trials and real-world data. Covered therapeutic strategies include the targeting of surface molecules such as CD20 (rituximab, ocrelizumab, ofatumumab, ublituximab) and CD19 (inebilizumab), and molecules necessary for B-cell activation such as B cell activating factor (BAFF) (belimumab) and Bruton's Tyrosine Kinase (BTK) (evobrutinib). We finally discuss the use of B-cell-targeted therapeutics in pregnancy.
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21
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Jan Z, Mollazadeh S, Abnous K, Taghdisi SM, Danesh A, Ramezani M, Alibolandi M. Targeted Delivery Platforms for the Treatment of Multiple Sclerosis. Mol Pharm 2022; 19:1952-1976. [PMID: 35501974 DOI: 10.1021/acs.molpharmaceut.1c00892] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Multiple sclerosis (MS) is a neurodegenerative condition of the central nervous system (CNS) that presents with varying levels of disability in patients, displaying the significance of timely and effective management of this complication. Though several treatments have been developed to protect nerves, comprehensive improvement of MS is still considered an essential bottleneck. Therefore, the development of innovative treatment methods for MS is one of the core research areas. In this regard, nanoscale platforms can offer practical and ideal approaches to the diagnosis and treatment of various diseases, especially immunological disorders such as MS, to improve the effectiveness of conventional therapies. It should be noted that there is significant progress in the development of neuroprotective strategies through the implementation of various nanoparticles, monoclonal antibodies, peptides, and aptamers. In this study, we summarize different particle systems as well as targeted therapies, such as antibodies, peptides, nucleic acids, and engineered cells for the treatment of MS, and discuss their potential in the treatment of MS in the preclinical and clinical stages. Future advances in targeted delivery of medical supplies may offer new strategies for complete recovery as well as practical treatment of progressive forms of MS.
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Affiliation(s)
- Zeinab Jan
- Department of Pharmaceutical Biotechnology, School of Pharmacy, Mashhad University of Medical Science, 7GJP+VPQ Mashhad, Iran
| | - Samaneh Mollazadeh
- Natural Products and Medicinal Plants Research Center, North Khorasan University of Medical Sciences, F82C+G8V Bojnurd, Iran
| | - Khalil Abnous
- Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, 7GJP+VPQ Mashhad, Iran
| | - Seyed Mohammad Taghdisi
- Targeted Drug Delivery Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, 7GJP+VPQ Mashhad, Iran
| | - Abolghasem Danesh
- Department of Pharmaceutical Biotechnology, School of Pharmacy, Mashhad University of Medical Science, 7GJP+VPQ Mashhad, Iran
| | - Mohammad Ramezani
- Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, 7GJP+VPQ Mashhad, Iran
| | - Mona Alibolandi
- Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, 7GJP+VPQ Mashhad, Iran
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22
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B cells in autoimmune hepatitis: bystanders or central players? Semin Immunopathol 2022; 44:411-427. [PMID: 35488094 PMCID: PMC9256567 DOI: 10.1007/s00281-022-00937-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/07/2022] [Indexed: 02/07/2023]
Abstract
B cells are central for the adaptive immune system to mount successful immune responses not only as antibody producers but also as regulators of cellular immunity. These multifaceted features are also reflected in autoimmunity where autoreactive B cells can fuel disease by production of cytotoxic autoantibodies, presentation of autoantigens to autoreactive T cells, and secretion of cytokines and chemokines that either promote detrimental immune activation or impair regulatory T and B cells. The role of B cells and autoantibodies in autoimmune hepatitis (AIH) have been controversially discussed, with typical autoantibodies and hypergammaglobulinemia indicating a key role, while strong HLA class II association suggests T cells as key players. In this review, we summarize current knowledge on B cells in AIH and how different B cell subpopulations may drive AIH progression beyond autoantibodies. We also discuss recent findings of B cell-directed therapies in AIH.
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23
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Duong SL, Prüss H. Paraneoplastic Autoimmune Neurological Syndromes and the Role of Immune Checkpoint Inhibitors. Neurotherapeutics 2022; 19:848-863. [PMID: 35043373 PMCID: PMC9294109 DOI: 10.1007/s13311-022-01184-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2022] [Indexed: 12/14/2022] Open
Abstract
The introduction of immune checkpoint inhibitors (ICIs) in oncologic therapies has led to a paradigm shift in cancer treatment. ICIs have increased the overall survival in patients with malignant melanoma, small-cell lung cancer, and many other tumor entities. Despite their clinical benefits, these novel cancer immunotherapies can induce neurological immune-related adverse events (irAEs). Such immune-mediated complications can manifest within the spectrum of paraneoplastic neurological syndromes (PNSs). PNSs are rare immune-mediated complications of systemic cancers that can involve every aspect of the nervous system. The emergence of PNSs with ICI treatment opens further pathways to study the complex immunopathological interplay of cancer immunity, cross-reactive neurological autoimmune phenomena, and effects of ICIs on the immune system. ICI-induced PNSs comprise a diverse antibody repertoire and phenotypic spectrum with severe and life-threatening disease progression in some cases. Timely diagnosis and urgent interventions are pivotal for a favorable neurologic and oncologic outcome. This review focuses on the pathogenesis of cancer immunotherapy and the disruption of immune tolerance in PNSs and provides an overview of the most pertinent clinical manifestations and principles of diagnostic and therapeutic managements in light of the expected increase in PNSs due to the widespread use of ICIs in clinical practice. This review further discusses potential and evolving concepts of therapeutic monoclonal antibodies for the treatment of PNSs.
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Affiliation(s)
- Sophie L Duong
- Department of Neurology and Experimental Neurology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE) Berlin, 10117, Berlin, Germany
| | - Harald Prüss
- Department of Neurology and Experimental Neurology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
- German Center for Neurodegenerative Diseases (DZNE) Berlin, 10117, Berlin, Germany.
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24
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Cai H, Zhou R, Jiang F, Zeng Q, Yang H. Vaccination in neuromyelitis optica spectrum disorders: Friend or enemy? Mult Scler Relat Disord 2022; 58:103394. [PMID: 35216775 DOI: 10.1016/j.msard.2021.103394] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/26/2021] [Accepted: 11/08/2021] [Indexed: 12/11/2022]
Abstract
Neuromyelitis optica spectrum disorders (NMOSDs) are uncommon antibody-mediated autoimmune diseases of the central nervous system (CNS), mainly occurring in optic nerves and spinal cord, which can cause visual impairment, paralysis, and occasionally bulbar dysfunction. Such neurological deficits can adversely affect pulmonary functions and increase complicated infection risk. Besides, most NMOSD patients undergo immunosuppressive therapy. All these factors make NMOSD patients the potential high-risk group under the current pandemic of coronavirus disease 2019 (COVID-19). Meanwhile, COVID-19 infection has already been demonstrated as a risk factor for NMOSD relapses. This review discusses the basic immunology of vaccination and common problems, including immunogenicity, safety, and efficacy of vaccination on NMOSD patients. Additionally, we offered vaccination recommendations, health care and treatment advice for NMOSD patients under the background of COVID-19.
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Affiliation(s)
- Haobing Cai
- Department of Neurology, Xiangya Hospital, Central South University, Changsha410008, China
| | - Ran Zhou
- Department of Neurology, Xiangya Hospital, Central South University, Changsha410008, China
| | - Fei Jiang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha410008, China
| | - Qiuming Zeng
- Department of Neurology, Xiangya Hospital, Central South University, Changsha410008, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha410008, China.
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25
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Yang J, Liu X. Immunotherapy for Refractory Autoimmune Encephalitis. Front Immunol 2022; 12:790962. [PMID: 34975890 PMCID: PMC8716621 DOI: 10.3389/fimmu.2021.790962] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/02/2021] [Indexed: 12/20/2022] Open
Abstract
Autoimmune encephalitis (AE) is an immune-mediated disease involving the central nervous system, usually caused by antigen-antibody reactions. With the advent of autoantibody-associated diseases, AE has become a hot research frontier in neuroimmunology. The first-line conventional treatments of autoimmune encephalitis consist of steroids, intravenous immunoglobulin (IVIG), plasma exchange (PLEX), and second-line therapy includes rituximab. Despite considerable research and expanding clinical experience, current treatments are still ineffective for a significant number of patients. Although there is no clear consensus, clinical trial evidence limited, and the level of evidence for some of the drugs based on single reports, third-line therapy is a viable alternative for refractory encephalitis patients. With the current rapid research progress, a breakthrough in the treatment of AE is critical. This article aims to review the third-line therapy for refractory AE
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Affiliation(s)
- Jiawei Yang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xueyan Liu
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
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26
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Abstract
PURPOSE Our understanding of thyroid-associated ophthalmopathy (TAO, A.K.A Graves' orbitopathy, thyroid eye disease) has advanced substantially, since one of us (TJS) wrote the 2010 update on TAO, appearing in this journal. METHODS PubMed was searched for relevant articles. RESULTS Recent insights have resulted from important studies conducted by many different laboratory groups around the World. A clearer understanding of autoimmune diseases in general and TAO specifically emerged from the use of improved research methodologies. Several key concepts have matured over the past decade. Among them, those arising from the refinement of mouse models of TAO, early stage investigation into restoring immune tolerance in Graves' disease, and a hard-won acknowledgement that the insulin-like growth factor-I receptor (IGF-IR) might play a critical role in the development of TAO, stand out as important. The therapeutic inhibition of IGF-IR has blossomed into an effective and safe medical treatment. Teprotumumab, a β-arrestin biased agonist monoclonal antibody inhibitor of IGF-IR has been studied in two multicenter, double-masked, placebo-controlled clinical trials demonstrated both effectiveness and a promising safety profile in moderate-to-severe, active TAO. Those studies led to the approval by the US FDA of teprotumumab, currently marketed as Tepezza for TAO. We have also learned far more about the putative role that CD34+ fibrocytes and their derivatives, CD34+ orbital fibroblasts, play in TAO. CONCLUSION The past decade has been filled with substantial scientific advances that should provide the necessary springboard for continually accelerating discovery over the next 10 years and beyond.
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Affiliation(s)
- E J Neag
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, Brehm Tower, 1000 Wall Street, Ann Arbor, MI, 48105, USA
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan Medical School, Ann Arbor, MI, 48105, USA
- Michigan State University College of Osteopathic Medicine, East Lansing, MI, USA
| | - T J Smith
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, Brehm Tower, 1000 Wall Street, Ann Arbor, MI, 48105, USA.
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan Medical School, Ann Arbor, MI, 48105, USA.
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27
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Verschuuren JJGM, Palace J, Murai H, Tannemaat MR, Kaminski HJ, Bril V. Advances and ongoing research in the treatment of autoimmune neuromuscular junction disorders. Lancet Neurol 2022; 21:189-202. [DOI: 10.1016/s1474-4422(21)00463-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 11/16/2021] [Accepted: 12/17/2021] [Indexed: 12/14/2022]
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Wang J, Yang J, Kopeček J. Nanomedicines in B cell-targeting therapies. Acta Biomater 2022; 137:1-19. [PMID: 34687954 PMCID: PMC8678319 DOI: 10.1016/j.actbio.2021.10.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 09/29/2021] [Accepted: 10/14/2021] [Indexed: 02/08/2023]
Abstract
B cells play multiple roles in immune responses related to autoimmune diseases as well as different types of cancers. As such, strategies focused on B cell targeting attracted wide interest and developed intensively. There are several common mechanisms various B cell targeting therapies have relied on, including direct B cell depletion, modulation of B cell antigen receptor (BCR) signaling, targeting B cell survival factors, targeting the B cell and T cell costimulation, and immune checkpoint blockade. Nanocarriers, used as drug delivery vehicles, possess numerous advantages to low molecular weight drugs, reducing drug toxicity, enhancing blood circulation time, as well as augmenting targeting efficacy and improving therapeutic effect. Herein, we review the commonly used targets involved in B cell targeting approaches and the utilization of various nanocarriers as B cell-targeted delivery vehicles. STATEMENT OF SIGNIFICANCE: As B cells are engaged significantly in the development of many kinds of diseases, utilization of nanomedicines in B cell depletion therapies have been rapidly developed. Although numerous studies focused on B cell targeting have already been done, there are still various potential receptors awaiting further investigation. This review summarizes the most relevant studies that utilized nanotechnologies associated with different B cell depletion approaches, providing a useful tool for selection of receptors, agents and/or nanocarriers matching specific diseases. Along with uncovering new targets in the function map of B cells, there will be a growing number of candidates that can benefit from nanoscale drug delivery.
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Affiliation(s)
- Jiawei Wang
- Center for Controlled Chemical Delivery, University of Utah, Salt Lake City, UT, United States; Department of Pharmaceutics and Pharmaceutical Chemistry, University of Utah, Salt Lake City, UT, United States
| | - Jiyuan Yang
- Center for Controlled Chemical Delivery, University of Utah, Salt Lake City, UT, United States; Department of Pharmaceutics and Pharmaceutical Chemistry, University of Utah, Salt Lake City, UT, United States
| | - Jindřich Kopeček
- Center for Controlled Chemical Delivery, University of Utah, Salt Lake City, UT, United States; Department of Pharmaceutics and Pharmaceutical Chemistry, University of Utah, Salt Lake City, UT, United States; Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, United States.
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29
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Rensel M, Zabeti A, Mealy MA, Cimbora D, She D, Drappa J, Katz E. Long-term efficacy and safety of inebilizumab in neuromyelitis optica spectrum disorder: Analysis of aquaporin-4-immunoglobulin G-seropositive participants taking inebilizumab for ⩾4 years in the N-MOmentum trial. Mult Scler 2021; 28:925-932. [PMID: 34595983 PMCID: PMC9024030 DOI: 10.1177/13524585211047223] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background: Efficacy and safety of inebilizumab for treatment of neuromyelitis optica spectrum disorder in adults seropositive for aquaporin-4 (AQP4)–immunoglobulin (Ig) G were demonstrated in the 28-week randomized controlled period of the N-MOmentum study. Objective: To assess efficacy and safety of long-term inebilizumab treatment. Methods: Post hoc analysis was performed in 75 AQP4–IgG–seropositive participants receiving inebilizumab for ⩾4 years in the randomized controlled period and open-label extension of the N-MOmentum study. Results: Eighteen attacks occurred in 13 participants during inebilizumab treatment (annualized attack rate, 0.052 attacks/person-year). Twelve attacks occurred during the first year of treatment, and two each occurred in years 2–4. Disability scores remained stable throughout ⩾4 years of treatment. Inebilizumab was well tolerated, with two (2.7%) serious treatment-emergent adverse events related to inebilizumab and no deaths. Immunoglobulin G levels decreased over time; however, correlation between severe infections and low IgG levels could not be determined because of their small numbers. Conclusion: These results from the N-MOmentum study continue to support use of inebilizumab for treatment of neuromyelitis optica spectrum disorder. Furthermore, the findings suggest that efficacy of inebilizumab may be enhanced after the first year of treatment, warranting additional long-term investigation.
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Affiliation(s)
- Mary Rensel
- Mellen Center for Multiple Sclerosis, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.,Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, USA
| | - Aram Zabeti
- University of Cincinnati, Cincinnati, OH, USA
| | - Maureen A Mealy
- Horizon Therapeutics plc, Deerfield, IL, USA; (known as Viela Bio at the time of study conduct)
| | - Daniel Cimbora
- Horizon Therapeutics plc, Deerfield, IL, USA; (known as Viela Bio at the time of study conduct)
| | - Dewei She
- Horizon Therapeutics plc, Deerfield, IL, USA; (known as Viela Bio at the time of study conduct)
| | - Jorn Drappa
- Horizon Therapeutics plc, Deerfield, IL, USA; (known as Viela Bio at the time of study conduct)
| | - Eliezer Katz
- Horizon Therapeutics plc, Deerfield, IL, USA; (known as Viela Bio at the time of study conduct)
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30
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J Tullman M, Zabeti A, Vuocolo S, Dinh Q. Inebilizumab for treatment of neuromyelitis optica spectrum disorder. Neurodegener Dis Manag 2021; 11:341-352. [PMID: 34486379 DOI: 10.2217/nmt-2021-0017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is a rare autoimmune disease characterized by recurrent optic neuritis and transverse myelitis often resulting in severe disability. Anti-AQP4-immunoglobulin G (IgG) is a pathogenic product of CD19-positive plasma cells found in most, but not all, individuals with NMOSD and is associated with immune-mediated neurologic injury. Inebilizumab, an afucosylated humanized IgG1κ, anti-CD19 monoclonal antibody, may target pathogenic CD19-expressing B cells. In a Phase II/III trial, inebilizumab significantly reduced the proportion of participants experiencing an NMOSD attack and was well tolerated versus placebo. Fewer treated participants had worsening disability than those receiving placebo. Inebilizumab was approved in 2020 by the US FDA for treatment of anti-AQP4 antibody positive NMOSD.
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Affiliation(s)
- Mark J Tullman
- The MS Center for Innovations in Care, St. Louis, MO 63131, USA
| | - Aram Zabeti
- University of Cincinnati Gardner Neuroscience Institute, Cincinnati, OH 45219, USA
| | | | - Quinn Dinh
- Horizon Therapeutics plc, Deerfield, IL 60015, USA
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31
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Levy M, Mealy MA. B-Cell Targeted Treatments for Neuromyelitis Optica Spectrum Disorder: A Focus on CD19 and CD20. Immunotargets Ther 2021; 10:325-331. [PMID: 34447723 PMCID: PMC8384424 DOI: 10.2147/itt.s255722] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/10/2021] [Indexed: 12/02/2022] Open
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is a rare relapsing autoimmune disease of the central nervous system that preferentially targets the optic nerves and spinal cord, leading to visual loss and impaired mobility. Until 2019, no medications were FDA-approved for NMOSD treatment, and standard of care was based on mostly empiric and retrospective data. Therapies that target B cells emerged as a treatment strategy due to their fundamental role in disease pathogenesis. We explore different monoclonal antibodies directed at either CD20+ or CD19+ B cells that may have utilization in the treatment of NMOSD, discussing what is known regarding their efficacy and safety.
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Affiliation(s)
- Michael Levy
- Department of Neurology, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA
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32
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Margoni M, Preziosa P, Filippi M, Rocca MA. Anti-CD20 therapies for multiple sclerosis: current status and future perspectives. J Neurol 2021; 269:1316-1334. [PMID: 34382120 PMCID: PMC8356891 DOI: 10.1007/s00415-021-10744-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 12/26/2022]
Abstract
Multiple sclerosis (MS) is a chronic inflammatory, demyelinating and neurodegenerative disease affecting the central nervous system (CNS), often characterized by the accumulation of irreversible clinical disability over time. During last years, there has been a dramatic evolution in several key concepts of immune pathophysiology of MS and in the treatment of this disease. The demonstration of the strong efficacy and good safety profile of selective B-cell-depleting therapies (such as anti-CD20 monoclonal antibodies) has significantly expanded the therapeutic scenario for both relapsing and progressive MS patients with the identification of a new therapeutic target. The key role of B cells in triggering MS disease has been also pointed out, determining a shift from the traditional view of MS activity as largely being ‘T-cell mediated’ to the notion that MS-related pathological processes involve bi-directional interactions between several immune cell types, including B cells, both in the periphery and in the CNS. This review provides an updated overview of the involvement of B cells in the immune pathophysiology and pathology of MS. We summarize the rationale regarding the use of anti-CD20 therapies and the results of the main randomized controlled trials and observational studies investigating the efficacy and safety profile of rituximab, ocrelizumab, ofatumumab and ublituximab. Suggestions regarding vaccinations and management of MS patients during COVID-19 pandemic with anti-CD20 therapies are also discussed. Finally, therapies under investigation and future perspectives of anti-CD20 therapies are taken into consideration.
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Affiliation(s)
- Monica Margoni
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Multiple Sclerosis Center of the Veneto Region, Department of Neurosciences, University Hospital-School of Medicine, Padua, Italy
| | - Paolo Preziosa
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, 20132, Milan, Italy
| | - Maria A Rocca
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy. .,Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy. .,Vita-Salute San Raffaele University, 20132, Milan, Italy.
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Abstract
Inebilizumab (Uplizna™; inebilizumab-cdon in the USA) is a humanised anti-CD19 monoclonal antibody being developed by Viela Bio for the treatment of a range of autoimmune diseases associated with CD19-expressing B cells. Inebilizumab targets and depletes CD19-expressing B cells through antibody-dependent cell-mediated cytotoxicity. In June 2020, inebilizumab received its first global approval in the USA for the treatment of neuromyelitis optica spectrum disorder (NMOSD) in adult patients who are seropositive for immunoglobulin G autoantibodies against aquaporin-4 (AQP4-IgG). The drug is also undergoing clinical evaluation for kidney transplant desensitization, myasthenia gravis, and IgG4-related disease. This article summarizes the milestones in the development of inebilizumab leading to this first approval for the treatment of AQP4-IgG seropositive NMOSD.
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Affiliation(s)
- James E Frampton
- Springer Nature, Mairangi Bay, Private Bag 65901, Auckland, 0754, New Zealand.
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DiSano KD, Gilli F, Pachner AR. Memory B Cells in Multiple Sclerosis: Emerging Players in Disease Pathogenesis. Front Immunol 2021; 12:676686. [PMID: 34168647 PMCID: PMC8217754 DOI: 10.3389/fimmu.2021.676686] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 05/11/2021] [Indexed: 11/25/2022] Open
Abstract
Multiple Sclerosis (MS) is an inflammatory demyelinating disease of the central nervous system. Once thought to be primarily driven by T cells, B cells are emerging as central players in MS immunopathogenesis. Interest in multiple B cell phenotypes in MS expanded following the efficacy of B cell-depleting agents targeting CD20 in relapsing-remitting MS and inflammatory primary progressive MS patients. Interestingly, these therapies primarily target non-antibody secreting cells. Emerging studies seek to explore B cell functions beyond antibody-mediated roles, including cytokine production, antigen presentation, and ectopic follicle-like aggregate formation. Importantly, memory B cells (Bmem) are rising as a key B cell phenotype to investigate in MS due to their antigen-experience, increased lifespan, and rapid response to stimulation. Bmem display diverse effector functions including cytokine production, antigen presentation, and serving as antigen-experienced precursors to antibody-secreting cells. In this review, we explore the cellular and molecular processes involved in Bmem development, Bmem phenotypes, and effector functions. We then examine how these concepts may be applied to the potential role(s) of Bmem in MS pathogenesis. We investigate Bmem both within the periphery and inside the CNS compartment, focusing on Bmem phenotypes and proposed functions in MS and its animal models. Finally, we review how current immunomodulatory therapies, including B cell-directed therapies and other immunomodulatory therapies, modify Bmem and how this knowledge may be harnessed to direct therapeutic strategies in MS.
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Affiliation(s)
- Krista D. DiSano
- Department of Neurology, Geisel School of Medicine & Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
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35
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Tugizova M, Vlahovic L, Tomczak A, Wetzel NS, Han MH. New Therapeutic Landscape in Neuromyelitis Optica. Curr Treat Options Neurol 2021; 23:13. [PMID: 33814893 PMCID: PMC8008025 DOI: 10.1007/s11940-021-00667-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2021] [Indexed: 12/11/2022]
Abstract
Purpose of review This review discusses the current treatment trends and emerging therapeutic landscape for patients with neuromyelitis optica spectrum disorder (NMOSD). Recent findings Conventional immune suppressive therapies, such as B cell depletion, have been used for long-term treatment. However, the availability of recent FDA-approved and investigational drugs has made therapeutic choices for NMOSD more complex. Summary Recent randomized clinical trials have shown that eculizumab, inebilizumab, and satralizumab are efficacious therapies for AQP4 seropositive NMOSD. These therapies may not have the same benefit in patients with seronegative NMOSD, including MOG-associated disease, and further investigation is required in this population. Reliable biomarkers to guide therapy decisions are urgently needed. There is a plethora of promising investigational therapies currently in the pipeline with exciting and novel mechanisms of action.
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Affiliation(s)
- Madina Tugizova
- Department of Neurology, Division of Neuroimmunology, Stanford University, 1201 Welch Road, MSLS p212, Stanford, CA 94305 USA.,Multiple Sclerosis Center, Stanford Hospital and Clinics, Palo Alto, CA USA
| | - Luka Vlahovic
- Department of Neurology, Creighton University School of Medicine, Omaha, NE USA
| | - Anna Tomczak
- Department of Neurology, Division of Neuroimmunology, Stanford University, 1201 Welch Road, MSLS p212, Stanford, CA 94305 USA.,Multiple Sclerosis Center, Stanford Hospital and Clinics, Palo Alto, CA USA
| | - Nora Sandrine Wetzel
- Department of Neurology, Division of Neuroimmunology, Stanford University, 1201 Welch Road, MSLS p212, Stanford, CA 94305 USA.,Faculty of Medicine, University of Zurich, Zürich, Switzerland
| | - May Htwe Han
- Department of Neurology, Division of Neuroimmunology, Stanford University, 1201 Welch Road, MSLS p212, Stanford, CA 94305 USA.,Multiple Sclerosis Center, Stanford Hospital and Clinics, Palo Alto, CA USA
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36
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Aktas O, Smith MA, Rees WA, Bennett JL, She D, Katz E, Cree BAC. Serum Glial Fibrillary Acidic Protein: A Neuromyelitis Optica Spectrum Disorder Biomarker. Ann Neurol 2021; 89:895-910. [PMID: 33724534 PMCID: PMC8252046 DOI: 10.1002/ana.26067] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 12/27/2022]
Abstract
Objective Blood tests to monitor disease activity, attack severity, or treatment impact in neuromyelitis optica spectrum disorder (NMOSD) have not been developed. This study investigated the relationship between serum glial fibrillary acidic protein (sGFAP) concentration and NMOSD activity and assessed the impact of inebilizumab treatment. Methods N‐MOmentum was a prospective, multicenter, double‐blind, placebo‐controlled, randomized clinical trial in adults with NMOSD. sGFAP levels were measured by single‐molecule arrays (SIMOA) in 1,260 serial and attack‐related samples from 215 N‐MOmentum participants (92% aquaporin 4‐immunoglobulin G‐seropositive) and in control samples (from healthy donors and patients with relapsing–remitting multiple sclerosis). Results At baseline, 62 participants (29%) exhibited high sGFAP concentrations (≥170 pg/ml; ≥2 standard deviations above healthy donor mean concentration) and were more likely to experience an adjudicated attack than participants with lower baseline concentrations (hazard ratio [95% confidence interval], 3.09 [1.6–6.1], p = 0.001). Median (interquartile range [IQR]) concentrations increased within 1 week of an attack (baseline: 168.4, IQR = 128.9–449.7 pg/ml; attack: 2,160.1, IQR = 302.7–9,455.0 pg/ml, p = 0.0015) and correlated with attack severity (median fold change from baseline [FC], minor attacks: 1.06, IQR = 0.9–7.4; major attacks: 34.32, IQR = 8.7–107.5, p = 0.023). This attack‐related increase in sGFAP occurred primarily in placebo‐treated participants (FC: 20.2, IQR = 4.4–98.3, p = 0.001) and was not observed in inebilizumab‐treated participants (FC: 1.1, IQR = 0.8–24.6, p > 0.05). Five participants (28%) with elevated baseline sGFAP reported neurological symptoms leading to nonadjudicated attack assessments. Interpretation Serum GFAP may serve as a biomarker of NMOSD activity, attack risk, and treatment effects. ANN NEUROL 2021;89:895–910
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Affiliation(s)
- Orhan Aktas
- Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | | | | | - Jeffrey L Bennett
- School of Medicine, Anschutz Medical Campus, University of Colorado, Aurora, CO
| | | | | | - Bruce A C Cree
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA
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Romeo AR. Recent advances in the treatment of neuromyelitis optica spectrum disorders. Curr Opin Rheumatol 2021; 33:233-239. [PMID: 33741809 DOI: 10.1097/bor.0000000000000791] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review examines recently published randomized placebo-controlled trials for the treatment of neuromyelitis optica spectrum disorders (NMOSD). RECENT FINDINGS Until recently, treatments for NMOSD were used-off label and had not been subjected to randomized placebo-controlled trials. Increased understanding of the pathophysiology of NMOSD, particularly aquaporin-4-IgG seropositive NMOSD, lead to the investigation of eculizumab, inebilizumab, and satralizumab for maintenance therapy. Eculizumab inhibits the cleavage of the terminal complement protein C5, inebilizumab depletes immune cells of B-lymphocyte lineage, and satralizumab inhibits interleukin-6 receptors. International, phase 3, randomized, placebo-controlled trials have demonstrated that each of these therapies reduces the risk of NMOSD relapse. In some cases, the studied therapies were administered in conjunction with other immunosuppressants. Each therapy has important safety considerations, notably risk of meningococcal infection with eculizumab and risks of infection and hypogammaglobulinemia with inebilizumab. Reviewing trial design highlights future areas of inquiry for the treatment of NMOSD. SUMMARY Eculizumab, inebilizumab, and satralizumab are effective maintenance therapies approved for the treatment of AQP-4 seropositive NMOSD.
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Affiliation(s)
- Andrew R Romeo
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
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38
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Waliszewska-Prosół M, Chojdak-Łukasiewicz J, Budrewicz S, Pokryszko-Dragan A. Neuromyelitis Optica Spectrum Disorder Treatment-Current and Future Prospects. Int J Mol Sci 2021; 22:ijms22062801. [PMID: 33802046 PMCID: PMC7998461 DOI: 10.3390/ijms22062801] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/07/2021] [Accepted: 03/09/2021] [Indexed: 12/16/2022] Open
Abstract
Neuromyelitis optica (NMO) is an immune-mediated demyelinative disorder of the central nervous system affecting mainly the optical nerves and the spinal cord. The recurrent course of the disease, with exacerbations and incomplete remissions, causes accumulating disability, which has a profound impact upon patients’ quality of life. The discovery of antibodies against aquaporin 4 (AQP4) and their leading role in NMO etiology and the formulation of diagnostic criteria have improved appropriate recognition of the disease. In recent years, there has been rapid progress in understanding the background of NMO, leading to an increasing range of treatment options. On the basis of a review of the relevant literature, the authors present currently available therapeutic strategies for NMO as well as ongoing research in this field, with reference to key points of immune-mediated processes involved in the background of the disease.
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Wang T, Wang B, Zeng Z, Li H, Zhang F, Ruan X, Wang C, Guo S. Efficacy and safety of bortezomib in rituximab-resistant anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis as well as the clinical characteristics: An observational study. J Neuroimmunol 2021; 354:577527. [PMID: 33652303 DOI: 10.1016/j.jneuroim.2021.577527] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/18/2021] [Accepted: 02/18/2021] [Indexed: 01/15/2023]
Abstract
Treatment resistance leads to physiological, psychological, and economical effects among patients with anti-N-methyl d-aspartate receptor (anti-NMDAR) encephalitis, and the clinical and immune characteristics of these patients remain to be described. According to our clinical experience, bortezomib may be effective due to its plasma-cells depletion ability. Herein, the clinical presentations and immune parameters, including B cell and antibody secreting cell (ASC) abundance, of 5 enrolled treatment-resistant patients are described. When compared with 5 treatment-sensitive cases, the patients had serious clinical presentations but comparable B cells and ASCs. After receiving bortezomib, the ASC count and anti-NMDAR antibody titers decreased effectively. All 5 patients had a favorable prognosis (mRS ≤ 2) with a median follow-up of 31 months without severe side effects or relapse.
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Affiliation(s)
- Tingting Wang
- Department of Neurology, Shandong Provincial Hospital affiliated to Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Baojie Wang
- Department of Neurology, Shandong Provincial ENT Hospital Affiliated to Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Ziling Zeng
- Department of Neurology, Shandong Provincial Hospital affiliated to Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Honghao Li
- Department of Neurology, Shandong Provincial Hospital affiliated to Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Fusheng Zhang
- Department of Neurology, Shandong Provincial Hospital affiliated to Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Xiyun Ruan
- Department of Neurology, Shandong Provincial Hospital affiliated to Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Chunjuan Wang
- Department of Neurology, Shandong Provincial Hospital affiliated to Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, Shandong, China.
| | - Shougang Guo
- Department of Neurology, Shandong Provincial Hospital affiliated to Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; Department of Neurology, Shandong Provincial Hospital affiliated to Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, Shandong, China.
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40
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Susa KJ, Rawson S, Kruse AC, Blacklow SC. Cryo-EM structure of the B cell co-receptor CD19 bound to the tetraspanin CD81. Science 2021; 371:300-305. [PMID: 33446559 DOI: 10.1126/science.abd9836] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 12/09/2020] [Indexed: 12/12/2022]
Abstract
Signaling through the CD19-CD81 co-receptor complex, in combination with the B cell receptor, is a critical determinant of B cell development and activation. It is unknown how CD81 engages CD19 to enable co-receptor function. Here, we report a 3.8-angstrom structure of the CD19-CD81 complex bound to a therapeutic antigen-binding fragment, determined by cryo-electron microscopy (cryo-EM). The structure includes both the extracellular domains and the transmembrane helices of the complex, revealing a contact interface between the ectodomains that drives complex formation. Upon binding to CD19, CD81 opens its ectodomain to expose a hydrophobic CD19-binding surface and reorganizes its transmembrane helices to occlude a cholesterol binding pocket present in the apoprotein. Our data reveal the structural basis for CD19-CD81 complex assembly, providing a foundation for rational design of therapies for B cell dysfunction.
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Affiliation(s)
- Katherine J Susa
- Department of Biological Chemistry and Molecular Pharmacology, Blavatnik Institute, Harvard Medical School, Boston, MA 02115, USA
| | - Shaun Rawson
- Department of Biological Chemistry and Molecular Pharmacology, Blavatnik Institute, Harvard Medical School, Boston, MA 02115, USA
| | - Andrew C Kruse
- Department of Biological Chemistry and Molecular Pharmacology, Blavatnik Institute, Harvard Medical School, Boston, MA 02115, USA.
| | - Stephen C Blacklow
- Department of Biological Chemistry and Molecular Pharmacology, Blavatnik Institute, Harvard Medical School, Boston, MA 02115, USA. .,Department of Cancer Biology, Dana-Farber Cancer Institute, Boston, MA 02215, USA
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41
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B Cells and Antibodies as Targets of Therapeutic Intervention in Neuromyelitis Optica Spectrum Disorders. Pharmaceuticals (Basel) 2021; 14:ph14010037. [PMID: 33419217 PMCID: PMC7825598 DOI: 10.3390/ph14010037] [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: 12/10/2020] [Revised: 01/02/2021] [Accepted: 01/03/2021] [Indexed: 12/11/2022] Open
Abstract
The first description of neuromyelitis optica by Eugène Devic and Fernand Gault dates back to the 19th century, but only the discovery of aquaporin-4 autoantibodies in a major subset of affected patients in 2004 led to a fundamentally revised disease concept: Neuromyelits optica spectrum disorders (NMOSD) are now considered autoantibody-mediated autoimmune diseases, bringing the pivotal pathogenetic role of B cells and plasma cells into focus. Not long ago, there was no approved medication for this deleterious disease and off-label therapies were the only treatment options for affected patients. Within the last years, there has been a tremendous development of novel therapies with diverse treatment strategies: immunosuppression, B cell depletion, complement factor antagonism and interleukin-6 receptor blockage were shown to be effective and promising therapeutic interventions. This has led to the long-expected official approval of eculizumab in 2019 and inebilizumab in 2020. In this article, we review current pathogenetic concepts in NMOSD with a focus on the role of B cells and autoantibodies as major contributors to the propagation of these diseases. Lastly, by highlighting promising experimental and future treatment options, we aim to round up the current state of knowledge on the therapeutic arsenal in NMOSD.
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Sell J, Haselmann H, Hallermann S, Hust M, Geis C. Autoimmune encephalitis: novel therapeutic targets at the preclinical level. Expert Opin Ther Targets 2020; 25:37-47. [PMID: 33233983 DOI: 10.1080/14728222.2021.1856370] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Antibody-mediated encephalitides (AE) with pathogenic autoantibodies (aAB) against neuronal surface antigens are a growing group of diseases characterized by antineuronal autoimmunity in the brain. AE patients typically present with rapidly progressive encephalitis and characteristic disease symptoms dependent on the target antigen. Current treatment consists of an escalating immunotherapy strategy including plasma exchange, steroid application, and B cell depletion. AREAS COVERED For this review, we searched Medline database and google scholar with inclusive dates from 2000. We summarize current treatment strategies and present novel therapeutic approaches of target-specific interventions at the pre-clinical level as well as immunotherapy directed at antibody-induced pathology. Treatment options include modulation of target proteins, intervention with downstream pathways, antibody modification, and depletion of antibody-secreting cells. EXPERT OPINION Although current therapies in AE are effective in many patients, recovery is often prolonged and relapses as well as persistent deficits can occur. Specific immunotherapy together with supportive target-specific therapy may provide faster control of severe symptoms, shorten the disease course, and lead to long-lasting disease stability. Among the various novel therapeutic approaches, modulation of targeted receptors by small molecules crossing the blood-brain barrier as well as prevention of aAB binding is of particular interest.
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Affiliation(s)
- Josefine Sell
- Section Translational Neuroimmunology, Department of Neurology, Jena University Hospital , Jena, Germany
| | - Holger Haselmann
- Section Translational Neuroimmunology, Department of Neurology, Jena University Hospital , Jena, Germany
| | - Stefan Hallermann
- Carl-Ludwig-Institute for Physiology, Medical Faculty, Leipzig University , Leipzig, Germany
| | - Michael Hust
- Department Biotechnology, Technische Universität Braunschweig, Institute for Biochemistry, Biotechnology and Bioinformatics , Braunschweig, Germany
| | - Christian Geis
- Section Translational Neuroimmunology, Department of Neurology, Jena University Hospital , Jena, Germany
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Graf J, Mares J, Barnett M, Aktas O, Albrecht P, Zamvil SS, Hartung HP. Targeting B cells to modify MS, NMOSD, and MOGAD: Part 2. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 8:8/1/e919. [PMID: 33411674 PMCID: PMC8063618 DOI: 10.1212/nxi.0000000000000919] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/11/2020] [Indexed: 12/15/2022]
Abstract
Ocrelizumab, rituximab, ofatumumab, ublituximab, inebilizumab, and evobrutinib
are immunotherapies that target various B cell–related proteins. Most of
these treatments have proven efficacy in relapsing and progressive forms of MS
and neuromyelitis optica spectrum disease (NMOSD) or are in advanced stages of
clinical development. Currently, ocrelizumab and inebilizumab are licensed for
treatment of MS and NMOSD, respectively. This part of the review focuses on
monoclonal antibody B cell–depleting strategies in NMOSD and the emerging
related myelin oligodendrocyte glycoprotein (MOG) immunoglobulin
G–associated disease (MOGAD). Case series and phase 2/3 studies in these
inflammatory disorders are assessed. The safety profile of long-term B-cell
depletion in MS, NMOSD, and MOGAD will be highlighted. Finally implications of
the current coronavirus disease 2019 pandemic on the management of patients with
these disorders and the use of B cell–depleting agents will be
discussed.
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Affiliation(s)
- Jonas Graf
- From the Department of Neurology (J.G., O.A., P.A., H.-P.H.), University Hospital, Medical Faculty Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (J.M.), Palacky University, Olomouc, Czech Republic; Department of Neurology, Brain and Mind Centre (M.B., H.-P.H.), Department of Neurology, University of Sydney, New South Wales, Australia; and Department of Neurology (S.S.Z.), UCSF Weill Institute of Neurosciences, University of California at San Francisco
| | - Jan Mares
- From the Department of Neurology (J.G., O.A., P.A., H.-P.H.), University Hospital, Medical Faculty Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (J.M.), Palacky University, Olomouc, Czech Republic; Department of Neurology, Brain and Mind Centre (M.B., H.-P.H.), Department of Neurology, University of Sydney, New South Wales, Australia; and Department of Neurology (S.S.Z.), UCSF Weill Institute of Neurosciences, University of California at San Francisco
| | - Michael Barnett
- From the Department of Neurology (J.G., O.A., P.A., H.-P.H.), University Hospital, Medical Faculty Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (J.M.), Palacky University, Olomouc, Czech Republic; Department of Neurology, Brain and Mind Centre (M.B., H.-P.H.), Department of Neurology, University of Sydney, New South Wales, Australia; and Department of Neurology (S.S.Z.), UCSF Weill Institute of Neurosciences, University of California at San Francisco
| | - Orhan Aktas
- From the Department of Neurology (J.G., O.A., P.A., H.-P.H.), University Hospital, Medical Faculty Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (J.M.), Palacky University, Olomouc, Czech Republic; Department of Neurology, Brain and Mind Centre (M.B., H.-P.H.), Department of Neurology, University of Sydney, New South Wales, Australia; and Department of Neurology (S.S.Z.), UCSF Weill Institute of Neurosciences, University of California at San Francisco
| | - Philipp Albrecht
- From the Department of Neurology (J.G., O.A., P.A., H.-P.H.), University Hospital, Medical Faculty Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (J.M.), Palacky University, Olomouc, Czech Republic; Department of Neurology, Brain and Mind Centre (M.B., H.-P.H.), Department of Neurology, University of Sydney, New South Wales, Australia; and Department of Neurology (S.S.Z.), UCSF Weill Institute of Neurosciences, University of California at San Francisco
| | - Scott S Zamvil
- From the Department of Neurology (J.G., O.A., P.A., H.-P.H.), University Hospital, Medical Faculty Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (J.M.), Palacky University, Olomouc, Czech Republic; Department of Neurology, Brain and Mind Centre (M.B., H.-P.H.), Department of Neurology, University of Sydney, New South Wales, Australia; and Department of Neurology (S.S.Z.), UCSF Weill Institute of Neurosciences, University of California at San Francisco
| | - Hans-Peter Hartung
- From the Department of Neurology (J.G., O.A., P.A., H.-P.H.), University Hospital, Medical Faculty Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (J.M.), Palacky University, Olomouc, Czech Republic; Department of Neurology, Brain and Mind Centre (M.B., H.-P.H.), Department of Neurology, University of Sydney, New South Wales, Australia; and Department of Neurology (S.S.Z.), UCSF Weill Institute of Neurosciences, University of California at San Francisco.
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Xie Q, Sun M, Sun J, Zheng T, Wang M. New progress in the treatment of neuromyelitis optica spectrum disorder with monoclonal antibodies (Review). Exp Ther Med 2020; 21:148. [PMID: 33456515 DOI: 10.3892/etm.2020.9579] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 11/27/2020] [Indexed: 12/14/2022] Open
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is a group of immune-mediated inflammatory demyelinating diseases mainly affecting the central nervous system. It is characterized by high risk of relapse and progression to disability. The frequent recurrences of neuromyelitis optica spectrum disorder often exacerbate the neurological dysfunction and severely affect the patient's quality of life. Conventional treatments for neuromyelitis optica spectrum disorder, including acute treatment and sequential therapy, aim to decrease the degree of disability and recurrences. In recent years, new monoclonal antibodies have yielded encouraging results. The present review discusses the research status and recent progress in the treatment of NMOSD with monoclonal antibodies.
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Affiliation(s)
- Qinfang Xie
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, Gansu 730030, P.R. China
| | - Mengjiao Sun
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, Gansu 730030, P.R. China
| | - Jing Sun
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, Gansu 730030, P.R. China
| | - Ting Zheng
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, Gansu 730030, P.R. China
| | - Manxia Wang
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, Gansu 730030, P.R. China
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45
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Holmøy T, Høglund RA, Illes Z, Myhr KM, Torkildsen Ø. Recent progress in maintenance treatment of neuromyelitis optica spectrum disorder. J Neurol 2020; 268:4522-4536. [PMID: 33011853 PMCID: PMC8563615 DOI: 10.1007/s00415-020-10235-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/16/2020] [Accepted: 09/17/2020] [Indexed: 02/07/2023]
Abstract
Background Treatment of neuromyelitis optica spectrum disorder (NMOSD) has so far been based on retrospective case series. The results of six randomized clinical trials including five different monoclonal antibodies targeting four molecules and three distinct pathophysiological pathways have recently been published. Methods Literature search on clinical trials and case studies in NMOSD up to July 10. 2020. Results We review mechanism of action, efficacy and side effects, and consequences for reproductive health from traditional immunosuppressants and monoclonal antibodies including rituximab, inebilizumab, eculizumab, tocilizumab and satralizumab. Conclusion In NMOSD patients with antibodies against aquaporin 4, monoclonal antibodies that deplete B cells (rituximab and inebilizumab) or interfere with interleukin 6 signaling (tocilizumab and satralizumab) or complement activation (eculizumab) have superior efficacy compared to placebo. Tocilizumab and rituximab were also superior to azathioprine in head-to-head studies. Rituximab, tocilizumab and to some extent eculizumab have well-known safety profiles for other inflammatory diseases, and rituximab and azathioprine may be safe during pregnancy.
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Affiliation(s)
- Trygve Holmøy
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Rune Alexander Høglund
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Zsolt Illes
- Department of Neurology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Kjell-Morten Myhr
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
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Abstract
Myasthenia gravis (MG) is an autoimmune, neuromuscular disorder that produces disabling weakness through a compromise of neuromuscular transmission. The disease fulfills strict criteria of an antibody-mediated disease. Close to 90% of patients have antibodies directed towards the nicotinic acetylcholine receptor (AChR) on the post-synaptic surface of skeletal muscle and another 5% to the muscle-specific kinase, which is involved in concentrating the AChR to the muscle surface of the neuromuscular junction. Conventional treatments of intravenous immunoglobulin and plasma exchange reduce autoantibody levels to produce their therapeutic effect, while prednisone and immunosuppressives do so by moderating autoantibody production. None of these treatments were specifically developed for MG and have a range of adverse effects. The extensive advances in monoclonal antibody technology allowing specific modulation of biological pathways has led to a tremendous increase in the potential treatment options. For MG, monoclonal antibody therapeutics target the effector mechanism of complement inhibition and the reduction of antibody levels by FcRn inhibition. Antibodies directed against CD20 and signaling pathways, which support lymphocyte activity, have been used to reduce autoantibody production. Thus far, only eculizumab, an antibody against C5, has reached the clinic. We review the present status of monoclonal antibody-based treatments for MG that have entered human testing and offer the promise to transform treatment of MG.
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Affiliation(s)
- Sawsan Alabbad
- Department of Neurology, George Washington University, 2150 Pennsylvania Avenue NW, Washington, DC, 20008, USA
| | - Mohanad AlGaeed
- Department of Neurology, George Washington University, 2150 Pennsylvania Avenue NW, Washington, DC, 20008, USA
| | - Patricia Sikorski
- Department of Neurology, George Washington University, 2150 Pennsylvania Avenue NW, Washington, DC, 20008, USA
| | - Henry J Kaminski
- Department of Neurology, George Washington University, 2150 Pennsylvania Avenue NW, Washington, DC, 20008, USA.
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47
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Stevens MY, Cropper HC, Lucot KL, Chaney AM, Lechtenberg KJ, Jackson IM, Buckwalter MS, James ML. Development of a CD19 PET tracer for detecting B cells in a mouse model of multiple sclerosis. J Neuroinflammation 2020; 17:275. [PMID: 32948198 PMCID: PMC7501720 DOI: 10.1186/s12974-020-01880-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/23/2020] [Indexed: 01/11/2023] Open
Abstract
Background B cells play a central role in multiple sclerosis (MS) through production of injurious antibodies, secretion of pro-inflammatory cytokines, and antigen presentation. The therapeutic success of monoclonal antibodies (mAbs) targeting B cells in some but not all individuals suffering from MS highlights the need for a method to stratify patients and monitor response to treatments in real-time. Herein, we describe the development of the first CD19 positron emission tomography (PET) tracer, and its evaluation in a rodent model of MS, experimental autoimmune encephalomyelitis (EAE). Methods Female C57BL/6 J mice were induced with EAE through immunization with myelin oligodendrocyte glycoprotein (MOG1–125). PET imaging of naïve and EAE mice was performed 19 h after administration of [64Cu]CD19-mAb. Thereafter, radioactivity in organs of interest was determined by gamma counting, followed by ex vivo autoradiography of central nervous system (CNS) tissues. Anti-CD45R (B220) immunostaining of brain tissue from EAE and naïve mice was also conducted. Results Radiolabelling of DOTA-conjugated CD19-mAb with 64Cu was achieved with a radiochemical purity of 99% and molar activity of 2 GBq/μmol. Quantitation of CD19 PET images revealed significantly higher tracer binding in whole brain of EAE compared to naïve mice (2.02 ± 0.092 vs. 1.68 ± 0.06 percentage of injected dose per gram, % ID/g, p = 0.0173). PET findings were confirmed by ex vivo gamma counting of perfused brain tissue (0.22 ± 0.020 vs. 0.12 ± 0.003 % ID/g, p = 0.0010). Moreover, ex vivo autoradiography of brain sections corresponded with PET imaging results and the spatial distribution of B cells observed in B220 immunohistochemistry—providing further evidence that [64Cu]CD19-mAb enables visualization of B cell infiltration into the CNS of EAE mice. Conclusion CD19-PET imaging can be used to detect elevated levels of B cells in the CNS of EAE mice, and has the potential to impact the way we study, monitor, and treat clinical MS.
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Affiliation(s)
- Marc Y Stevens
- Department of Radiology, Molecular Imaging Program at Stanford, 1201 Welch Rd, Stanford, CA, 94305, USA
| | - Haley C Cropper
- Department of Radiology, Molecular Imaging Program at Stanford, 1201 Welch Rd, Stanford, CA, 94305, USA
| | | | - Aisling M Chaney
- Department of Radiology, Molecular Imaging Program at Stanford, 1201 Welch Rd, Stanford, CA, 94305, USA
| | - Kendra J Lechtenberg
- Department of Neurology & Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Isaac M Jackson
- Department of Radiology, Molecular Imaging Program at Stanford, 1201 Welch Rd, Stanford, CA, 94305, USA
| | - Marion S Buckwalter
- Department of Neurology & Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Michelle L James
- Department of Radiology, Molecular Imaging Program at Stanford, 1201 Welch Rd, Stanford, CA, 94305, USA. .,Department of Neurology & Neurological Sciences, Stanford University, Stanford, CA, USA.
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48
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Mallah K, Couch C, Borucki DM, Toutonji A, Alshareef M, Tomlinson S. Anti-inflammatory and Neuroprotective Agents in Clinical Trials for CNS Disease and Injury: Where Do We Go From Here? Front Immunol 2020; 11:2021. [PMID: 33013859 PMCID: PMC7513624 DOI: 10.3389/fimmu.2020.02021] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/27/2020] [Indexed: 02/06/2023] Open
Abstract
Neurological disorders are major contributors to death and disability worldwide. The pathology of injuries and disease processes includes a cascade of events that often involve molecular and cellular components of the immune system and their interaction with cells and structures within the central nervous system. Because of this, there has been great interest in developing neuroprotective therapeutic approaches that target neuroinflammatory pathways. Several neuroprotective anti-inflammatory agents have been investigated in clinical trials for a variety of neurological diseases and injuries, but to date the results from the great majority of these trials has been disappointing. There nevertheless remains great interest in the development of neuroprotective strategies in this arena. With this in mind, the complement system is being increasingly discussed as an attractive therapeutic target for treating brain injury and neurodegenerative conditions, due to emerging data supporting a pivotal role for complement in promoting multiple downstream activities that promote neuroinflammation and degeneration. As we move forward in testing additional neuroprotective and immune-modulating agents, we believe it will be useful to review past trials and discuss potential factors that may have contributed to failure, which will assist with future agent selection and trial design, including for complement inhibitors. In this context, we also discuss inhibition of the complement system as a potential neuroprotective strategy for neuropathologies of the central nervous system.
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Affiliation(s)
- Khalil Mallah
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, SC, United States
| | - Christine Couch
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, SC, United States
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, SC, United States
| | - Davis M. Borucki
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, SC, United States
- Department of Neurosciences, Medical University of South Carolina, Charleston, SC, United States
- Medical Scientist Training Program, Medical University of South Carolina, Charleston, SC, United States
| | - Amer Toutonji
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, SC, United States
- Department of Neurosciences, Medical University of South Carolina, Charleston, SC, United States
- Medical Scientist Training Program, Medical University of South Carolina, Charleston, SC, United States
| | - Mohammed Alshareef
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, SC, United States
- Department of Neurological Surgery, Medical University of South Carolina, Charleston, SC, United States
| | - Stephen Tomlinson
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, SC, United States
- Ralph Johnson VA Medical Center, Charleston, SC, United States
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Differential Effects of MS Therapeutics on B Cells-Implications for Their Use and Failure in AQP4-Positive NMOSD Patients. Int J Mol Sci 2020; 21:ijms21145021. [PMID: 32708663 PMCID: PMC7404039 DOI: 10.3390/ijms21145021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/11/2020] [Accepted: 07/13/2020] [Indexed: 12/25/2022] Open
Abstract
B cells are considered major contributors to multiple sclerosis (MS) pathophysiology. While lately approved disease-modifying drugs like ocrelizumab deplete B cells directly, most MS medications were not primarily designed to target B cells. Here, we review the current understanding how approved MS medications affect peripheral B lymphocytes in humans. These highly contrasting effects are of substantial importance when considering these drugs as therapy for neuromyelitis optica spectrum disorders (NMOSD), a frequent differential diagnosis to MS, which is considered being a primarily B cell- and antibody-driven diseases. Data indicates that MS medications, which deplete B cells or induce an anti-inflammatory phenotype of the remaining ones, were effective and safe in aquaporin-4 antibody positive NMOSD. In contrast, drugs such as natalizumab and interferon-β, which lead to activation and accumulation of B cells in the peripheral blood, lack efficacy or even induce catastrophic disease activity in NMOSD. Hence, we conclude that the differential effect of MS drugs on B cells is one potential parameter determining the therapeutic efficacy or failure in antibody-dependent diseases like seropositive NMOSD.
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50
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Afzali S, Salehi S, Shahi A, Amirzargar A. B cell modulation strategies in the improvement of transplantation outcomes. Mol Immunol 2020; 125:140-150. [PMID: 32682148 DOI: 10.1016/j.molimm.2020.06.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/19/2020] [Accepted: 06/30/2020] [Indexed: 01/03/2023]
Abstract
Successful transplantation outcome is the final goal in most end stage and nonfunctional organs; however, despite using different therapeutic strategies, antibody-mediated rejection is still a big obstacle. B cells have a key role in transplant rejection by several functions, such as antibody production, antigen presenting, contribution in T cell activation, forming the germinal center, and tertiary lymphoid organs. Therefore, B cells modulation seems to be very crucial in transplant outcome. A double-edged sword function is considered for B cells during transplantation; On the one hand, antibody production against the transplanted organ induces antibody-mediated rejection. On the other hand, IL10 production by regulatory B (Breg) cells induces graft tolerance. Nowadays, several monoclonal antibodies (mAb) are available for B cell modulation that are routinely used in transplant recipients, among which rituximab (anti-CD20 mAb) act in eliminating B cells. However, there are some other monoclonal antibodies, such as epratuzumab and Inotuzumab ozogamicin (IO), which exert anti-CD22 activity, resulting in disruption of B cell functions and induction of tolerance in autoimmune disease or B cell malignancies; that notwithstanding, these mAbs have not yet been tried in transplantation. In this review, we focus on different methods for modulating the activity of B cells as well as induction of Breg cells, aiming to prevent the allograft rejection.
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Affiliation(s)
- Shima Afzali
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran; Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Saeedeh Salehi
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Abbas Shahi
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Aliakbar Amirzargar
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
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