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Rajabally YA. Chronic Inflammatory Demyelinating Polyradiculoneuropathy: Current Therapeutic Approaches and Future Outlooks. Immunotargets Ther 2024; 13:99-110. [PMID: 38435981 PMCID: PMC10906673 DOI: 10.2147/itt.s388151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 02/02/2024] [Indexed: 03/05/2024] Open
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a treatable autoimmune disorder, for which different treatment options are available. Current first-line evidence-based therapies for CIDP include intravenous and subcutaneous immunoglobulins, corticosteroids and plasma exchanges. Despite lack of evidence, cyclophosphamide, rituximab and mycophenolate mofetil are commonly used in circumstances of refractoriness and, more debatably, of perceived overdependence on first-line therapies. Rituximab is currently the object of a randomized controlled trial for CIDP. Based on case series, and although rarely considered, haematopoietic autologous stem cell transplants may be effective in refractory disease, with low mortality and high remission rates. A new therapeutic option has appeared with efgartigimod, a neonatal Fc receptor blocker, recently shown to significantly lower relapse rate versus placebo, after withdrawal from previous immunotherapy. Other neonatal Fc receptor blockers, nipocalimab and batoclimab, are under study. The C1 complement-inhibitor SAR445088, acting in the proximal portion of the classical complement system, is currently the subject of a new study in treatment-responsive, refractory and treatment-naïve subjects. Finally, Bruton Tyrosine Kinase inhibitors, which exert anti-B cell effects, may represent another future research avenue. The widening of the therapeutic armamentarium enhances the need for improved evaluation of treatment effects and reliable biomarkers in CIDP.
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Affiliation(s)
- Yusuf A Rajabally
- Inflammatory Neuropathy Clinic, Department of Neurology, University Hospitals Birmingham, Birmingham, B15 2TH, United Kingdom
- Aston Medical School, Aston University, Birmingham, United Kingdom
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2
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van Doorn IN, Eftimov F, Wieske L, van Schaik IN, Verhamme C. Challenges in the Early Diagnosis and Treatment of Chronic Inflammatory Demyelinating Polyradiculoneuropathy in Adults: Current Perspectives. Ther Clin Risk Manag 2024; 20:111-126. [PMID: 38375075 PMCID: PMC10875175 DOI: 10.2147/tcrm.s360249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/14/2024] [Indexed: 02/21/2024] Open
Abstract
Diagnosing Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) poses numerous challenges. The heterogeneous presentations of CIDP variants, its mimics, and the complexity of interpreting electrodiagnostic criteria are just a few of the many reasons for misdiagnoses. Early recognition and treatment are important to reduce the risk of irreversible axonal damage, which may lead to permanent disability. The diagnosis of CIDP is based on a combination of clinical symptoms, nerve conduction study findings that indicate demyelination, and other supportive criteria. In 2021, the European Academy of Neurology (EAN) and the Peripheral Nerve Society (PNS) published a revision on the most widely adopted guideline on the diagnosis and treatment of CIDP. This updated guideline now includes clinical and electrodiagnostic criteria for CIDP variants (previously termed atypical CIDP), updated supportive criteria, and sensory criteria as an integral part of the electrodiagnostic criteria. Due to its many rules and exceptions, this guideline is complex and misinterpretation of nerve conduction study findings remain common. CIDP is treatable with intravenous immunoglobulins, corticosteroids, and plasma exchange. The choice of therapy should be tailored to the individual patient's situation, taking into account the severity of symptoms, potential side effects, patient autonomy, and past treatments. Treatment responses should be evaluated as objectively as possible using disability and impairment scales. Applying these outcome measures consistently in clinical practice aids in recognizing the effectiveness (or lack thereof) of a treatment and facilitates timely consideration of alternative diagnoses or treatments. This review provides an overview of the current perspectives on the diagnostic process and first-line treatments for managing the disease.
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Affiliation(s)
- Iris N van Doorn
- Department of Neurology and Clinical Neurophysiology, Amsterdam Neuroscience and University of Amsterdam, Amsterdam UMC, location AMC, the Netherlands
| | - Filip Eftimov
- Department of Neurology and Clinical Neurophysiology, Amsterdam Neuroscience and University of Amsterdam, Amsterdam UMC, location AMC, the Netherlands
| | - Luuk Wieske
- Department of Neurology and Clinical Neurophysiology, Amsterdam Neuroscience and University of Amsterdam, Amsterdam UMC, location AMC, the Netherlands
- Department of Clinical Neurophysiology, Sint Antonius Hospital, Nieuwegein, the Netherlands
| | - Ivo N van Schaik
- Department of Neurology and Clinical Neurophysiology, Amsterdam Neuroscience and University of Amsterdam, Amsterdam UMC, location AMC, the Netherlands
- Sanquin Blood Supply Foundation, Amsterdam, the Netherlands
| | - Camiel Verhamme
- Department of Neurology and Clinical Neurophysiology, Amsterdam Neuroscience and University of Amsterdam, Amsterdam UMC, location AMC, the Netherlands
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3
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McCombe PA, Hardy TA, Nona RJ, Greer JM. Sex differences in Guillain Barré syndrome, chronic inflammatory demyelinating polyradiculoneuropathy and experimental autoimmune neuritis. Front Immunol 2022; 13:1038411. [PMID: 36569912 PMCID: PMC9780466 DOI: 10.3389/fimmu.2022.1038411] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/24/2022] [Indexed: 12/13/2022] Open
Abstract
Guillain Barré syndrome (GBS) and its variants, and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP and its variants, are regarded as immune mediated neuropathies. Unlike in many autoimmune disorders, GBS and CIDP are more common in males than females. Sex is not a clear predictor of outcome. Experimental autoimmune neuritis (EAN) is an animal model of these diseases, but there are no studies of the effects of sex in EAN. The pathogenesis of GBS and CIDP involves immune response to non-protein antigens, antigen presentation through non-conventional T cells and, in CIDP with nodopathy, IgG4 antibody responses to antigens. There are some reported sex differences in some of these elements of the immune system and we speculate that these sex differences could contribute to the male predominance of these diseases, and suggest that sex differences in peripheral nerves is a topic worthy of further study.
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Affiliation(s)
- Pamela A. McCombe
- Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia,*Correspondence: Pamela A. McCombe,
| | - Todd A. Hardy
- Department of Neurology, Concord Hospital, University of Sydney, Sydney, NSW, Australia,Brain & Mind Centre, University of Sydney, Sydney, NSW, Australia
| | - Robert J. Nona
- Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Judith M. Greer
- Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
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4
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Determinants of Outcome in Chronic Inflammatory Demyelinating Polyneuropathy: A Longitudinal Study. J Clin Neuromuscul Dis 2021; 23:111-112. [PMID: 34808655 DOI: 10.1097/cnd.0000000000000351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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5
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Bus SRM, Wieske L, Keddie S, van Schaik IN, Eftimov F. Subcutaneous immunoglobulin for chronic inflammatory demyelinating polyradiculoneuropathy. Hippokratia 2021. [DOI: 10.1002/14651858.cd014542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Sander RM Bus
- Department of Neurology, Amsterdam Neuroscience; Amsterdam UMC, University of Amsterdam; Amsterdam Netherlands
| | - Luuk Wieske
- Department of Neurology, Amsterdam Neuroscience; Amsterdam UMC, University of Amsterdam; Amsterdam Netherlands
| | - Stephen Keddie
- Faculty of Brain Sciences; Institute of Neurology; London UK
| | - Ivo N van Schaik
- Department of Neurology, Amsterdam Neuroscience; Amsterdam University Medical Centers, location AMC, University of Amsterdam; Amsterdam Netherlands
| | - Filip Eftimov
- Department of Neurology, Amsterdam Neuroscience; Amsterdam UMC, University of Amsterdam; Amsterdam Netherlands
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6
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Farrugia A, Bansal M, Marjanovic I. Estimation of the latent therapeutic demand for immunoglobulin therapies in autoimmune neuropathies in the United States. Vox Sang 2021; 117:208-219. [PMID: 34110626 DOI: 10.1111/vox.13134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 05/03/2021] [Accepted: 05/04/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES The use of immunoglobulin (IG) solutions as an immunomodulatory therapy in certain neurological conditions has become an established modality and represents a significant proportion of total IG use. The estimation of the evidence-based potential demand designated as the latent therapeutic demand (LTD) for IG in these diseases is required for adequate planning of the plasma supply required to manufacture the product. MATERIALS AND METHODS The diseases studied included chronic inflammatory demyelinating polyneuropathy (CIDP), Guillain-Barré syndrome (GBS) and multifocal motor neuropathy (MMN). The LTD for IG was assessed using a decision analysis model, using Microsoft Excel. The model analysed the epidemiological and clinical factors contributing to IG usage. One-way sensitivity analysis and probabilistic sensitivity analysis derived the LTD in grams per 1000 inhabitants. The key variables included the treatment schedule and the prevalence of the disease. RESULTS The model estimates that an average annual IG demand and standard deviation for CIDP, GBS and MMN in the United States is 83.05 ± 24.5, 6.1 ± 3.2 and 36.1 ± 25.5 g/1000 inhabitants, respectively. CONCLUSION Together with previous work on the LTD for IG in immunodeficiencies, these results indicate that current IG usage reflects the estimated LTD for the main indications for IG in the United States The wide range of LTD found in all these studies emphasizes the need for more precise assessment of the underlying variables, particularly disease prevalence and dosage. Further studies on other indications such as secondary immunodeficiencies will augment these results and will assist in guiding demand planning for IG use and plasma collection in the United States and inform blood policy in other countries.
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Affiliation(s)
- Albert Farrugia
- Faculty of Medicine and Health Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Megha Bansal
- Private Consultant, Health Economics and Outcomes Research
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7
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Burt RK, Tappenden P, Balabanov R, Han X, Quigley K, Snowden JA, Sharrack B. The Cost Effectiveness of Immunoglobulin vs. Hematopoietic Stem Cell Transplantation for CIDP. Front Neurol 2021; 12:645263. [PMID: 33828522 PMCID: PMC8019941 DOI: 10.3389/fneur.2021.645263] [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: 01/14/2021] [Accepted: 02/22/2021] [Indexed: 12/22/2022] Open
Abstract
Background: Intravenous immunoglobulin (IVIG) is effective as standard first line therapy for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), but some patients remain dependent on its long-term use. Recently, we have reported that autologous non-myeloablative hematopoietic stem cell transplantation (HSCT) is an effective second line therapy for CIDP. Objectives: To compare the cost of chronic IVIG vs. autologous HSCT (a one-time therapy), we collected data on patients with CIDP undergoing HSCT between 2017 and 2019. This was compared with published literature on the costs and efficacy defined by the Inflammatory Neuropathy Cause And Treatment (INCAT) disability score, Medical Research Council (MRC) sum score, hand grip strength, and SF-36 quality of life (QOL) for CIDP. Methods: Between 2017 and 2019, nineteen patients with chronic CIDP (mean disease treatment duration prior to HSCT of 6 years) underwent autologous HSCT with mean cost of $108,577 per patient (range $56,327-277,119, standard deviation $53,092). After HSCT, 80% of patients remain IVIG and immune treatment free for up to 5 years. In comparison, published cost of IVIG treatment in the USA for an average CIDP patient exceeds $136,000 per year. Despite remaining treatment free, HSCT demonstrated greater improvement in efficacy compared to immunoglobulins. Recommendations: Given the long-term treatment-free remission and better outcome measurements, autologous HSCT is more cost effective than long-term IVIG treatment in patients with chronic CIDP. However, costs will depend on patient selection, the HSCT regimen, and regional variations. Further analysis of the health economics, i.e., cost/outcome ratio, of HSCT as therapy for chronically IVIG dependent CIDP is warranted.
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Affiliation(s)
- Richard K. Burt
- Division of Immunotherapy, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Paul Tappenden
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Roumen Balabanov
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Xiaoqiang Han
- Division of Immunotherapy, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Kathleen Quigley
- Division of Immunotherapy, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - John A. Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, University of Sheffield, Sheffield, United Kingdom
| | - Basil Sharrack
- Academic Department of Neuroscience and Sheffield, NIHR Translational Neuroscience BRC, Sheffield Teaching Hospitals NHS Foundation Trust, University of Sheffield, Sheffield, United Kingdom
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8
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Gable KL, Hobson-Webb LD. The axonal Z-score: Can electrodiagnostic testing find a new role in chronic inflammatory demyelinating polyneuropathy? Clin Neurophysiol 2021; 132:998-999. [PMID: 33663936 DOI: 10.1016/j.clinph.2021.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 02/04/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Karissa L Gable
- Department of Neurology/Neuromuscular Division, Duke University, Durham, NC, USA
| | - Lisa D Hobson-Webb
- Department of Neurology/Neuromuscular Division, Duke University, Durham, NC, USA.
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9
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Kuitwaard K, Brusse E, Jacobs BC, Vrancken AFJE, Eftimov F, Notermans NC, van der Kooi AJ, Fokkink WJR, Nieboer D, Lingsma HF, Merkies ISJ, van Doorn PA. Randomized trial of intravenous immunoglobulin maintenance treatment regimens in chronic inflammatory demyelinating polyradiculoneuropathy. Eur J Neurol 2020; 28:286-296. [PMID: 32876962 PMCID: PMC7820989 DOI: 10.1111/ene.14501] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 08/26/2020] [Indexed: 12/28/2022]
Abstract
Background and purpose High peak serum immunoglobulin G (IgG) levels may not be needed for maintenance intravenous immunoglobulin (IVIg) treatment in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and such high levels may cause side effects. More frequent lower dosing may lead to more stable IgG levels and higher trough levels, which might improve efficacy. The aim of this trial is to investigate whether high frequent low dosage IVIg treatment is more effective than low frequent high dosage IVIg treatment. Methods In this randomized placebo‐controlled crossover trial, we included patients with CIDP proven to be IVIg‐dependent and receiving an individually established stable dose and interval of IVIg maintenance treatment. In the control arm, patients received their individual IVIg dose and interval followed by a placebo infusion at half the interval. In the intervention arm, patients received half their individual dose at half the interval. After a wash‐out phase patients crossed over. The primary outcome measure was handgrip strength (assessed using a Martin Vigorimeter). Secondary outcome indicators were health‐related quality of life (36‐item Short‐Form Health Survey), disability (Inflammatory Rasch‐built Overall Disability Scale), fatigue (Rasch‐built Fatigue Severity Scale) and side effects. Results Twenty‐five patients were included and were treated at baseline with individually adjusted dosages of IVIg ranging from 20 to 80 g and intervals ranging from 14 to 35 days. Three participants did not complete the trial; the main analysis was therefore based on the 22 patients completing both treatment periods. There was no significant difference in handgrip strength change from baseline between the two treatment regimens (coefficient −2.71, 95% CI −5.4, 0.01). Furthermore, there were no significant differences in any of the secondary outcomes or side effects. Conclusions More frequent lower dosing does not further improve the efficacy of IVIg in stable IVIg‐dependent CIDP and does not result in fewer side effects.
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Affiliation(s)
- K Kuitwaard
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands.,Department of Neurology, Albert Schweitzer hospital, Dordrecht, The Netherlands
| | - E Brusse
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - B C Jacobs
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands.,Department of Immunology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - A F J E Vrancken
- Department of Neurology, Brain Centre Rudolf Magnus University Medical Centre Utrecht, Utrecht, The Netherlands
| | - F Eftimov
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - N C Notermans
- Department of Neurology, Brain Centre Rudolf Magnus University Medical Centre Utrecht, Utrecht, The Netherlands
| | - A J van der Kooi
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - W-J R Fokkink
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands.,Department of Immunology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - D Nieboer
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - H F Lingsma
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - I S J Merkies
- Department of Neurology, Curaçao Medical Centre Willemstad, Willemstad, Curaçao.,Department of Neurology, School of Medical Health and Neuroscience, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - P A van Doorn
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
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10
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Hematopoietic stem cell transplantation for chronic inflammatory demyelinating polyradiculoneuropathy. J Neurol 2020; 267:3378-3391. [DOI: 10.1007/s00415-020-10010-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/15/2020] [Accepted: 06/18/2020] [Indexed: 01/23/2023]
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11
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Querol L, Crabtree M, Herepath M, Priedane E, Viejo Viejo I, Agush S, Sommerer P. Systematic literature review of burden of illness in chronic inflammatory demyelinating polyneuropathy (CIDP). J Neurol 2020; 268:3706-3716. [PMID: 32583051 PMCID: PMC8463372 DOI: 10.1007/s00415-020-09998-8] [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: 03/19/2020] [Revised: 06/10/2020] [Accepted: 06/12/2020] [Indexed: 12/13/2022]
Abstract
Background Chronic inflammatory demyelinating polyneuropathy (CIDP) is a rare neurological disorder characterised by muscle weakness and impaired sensory function. The present study provides a comprehensive literature review of the burden of illness of CIDP. Methods Systematic literature search of PubMed, Embase, and key conferences in May 2019. Search terms identified studies on the epidemiology, humanistic burden, current treatment, and economic burden of CIDP published since 2009 in English. Results Forty-five full texts and nineteen conference proceedings were identified on the epidemiology (n = 9), humanistic burden (n = 7), current treatment (n = 40), and economic burden (n = 8) of CIDP. Epidemiological studies showed incidence and prevalence of 0.2–1.6 and 0.8–8.9 per 100,000, respectively, depending on geography and diagnostic criteria. Humanistic burden studies revealed that patients experienced physical and psychosocial burden, including impaired physical function, pain and depression. Publications on current treatments reported on six main types of therapy: intravenous immunoglobulins, subcutaneous immunoglobulins, corticosteroids, plasma exchange, immunosuppressants, and immunomodulators. Treatments may be burdensome, due to adverse events and reduced independence caused by treatment administration setting. In Germany, UK, France, and the US, CIDP economic burden was driven by direct costs of treatment and hospitalisation. CIDP was associated with indirect costs driven by impaired productivity. Conclusions This first systematic review of CIDP burden of illness demonstrates the high physical and psychosocial burden of this rare disease. Future research is required to fully characterise the burden of CIDP, and to understand how appropriate treatment can mitigate burden for patients and healthcare systems. Electronic supplementary material The online version of this article (10.1007/s00415-020-09998-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Luis Querol
- Institut de Recerca Biomèdica Sant Pau, Barcelona, Spain.
| | | | - M Herepath
- Optimal Access Life Science Consulting Limited, Swansea, UK
| | | | | | - S Agush
- Huron Consulting Group, London, UK
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12
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Pegat A, Boisseau W, Maisonobe T, Debs R, Lenglet T, Psimaras D, Azoulay-Cayla A, Fournier E, Viala K. Motor chronic inflammatory demyelinating polyneuropathy (CIDP) in 17 patients: Clinical characteristics, electrophysiological study, and response to treatment. J Peripher Nerv Syst 2020; 25:162-170. [PMID: 32364302 DOI: 10.1111/jns.12380] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 04/29/2020] [Accepted: 04/29/2020] [Indexed: 12/14/2022]
Abstract
Motor chronic inflammatory demyelinating polyneuropathy (CIDP) is a rare and poorly described subtype of CIDP. We aimed to study their clinical and electrophysiological characteristics and response to treatment. From a prospective database of CIDP patients, we included patients with definite or probable CIDP with motor signs and without sensory signs/symptoms at diagnosis. Patients were considered to have pure motor CIDP (PM-CIDP) if sensory conductions were normal or to have motor predominant CIDP (MPred-CIDP) if ≥2 sensory nerve action potential amplitudes were abnormal. Among the 700 patients with CIDP, 17 (2%) were included (PM-CIDP n = 7, MPred-CIDP n = 10); 71% were male, median age at onset was 48 years (range: 13-76 years), 47% had an associated inflammatory or infectious disease or neoplasia. At the more severe disease stage, 94% of patients had upper and lower limb weakness, with distal and proximal weakness in 4 limbs for 56% of them. Three-quarters (75%) responded to intravenous immunoglobulins (IVIg) and four of five patients to corticosteroids including three of three patients with MPred-CIDP. The most frequent conduction abnormalities were conduction blocks (CB, 82%) and F-wave abnormalities (88%). During follow up, 4 of 10 MPred-CIDP patients developed mild sensory symptoms; none with PM-CIDP did so. Patients with PM-CIDP had poorer outcome (median ONLS: 4; range: 22-5) compared to MPred-CIDP (2, range: 0-4; P = .03) at last follow up. This study found a progressive clinical course in the majority of patients with motor CIDP as well as frequent associated diseases, CB, and F-wave abnormalities. Corticosteroids might be considered as a therapeutic option in resistant IVIg patients with MPred-CIDP.
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Affiliation(s)
- Antoine Pegat
- Service de neurologie C pathologies neuromusculaires, service d'explorations fonctionnelles neurologiques, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France.,Département de Neurophysiologie Clinique, Hôpital Pitié Salpêtrière, Assistance publique-Hôpitaux de Paris, Paris, France
| | - William Boisseau
- Département de Neurophysiologie Clinique, Hôpital Pitié Salpêtrière, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Thierry Maisonobe
- Département de Neurophysiologie Clinique, Hôpital Pitié Salpêtrière, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Rabab Debs
- Département de Neurophysiologie Clinique, Hôpital Pitié Salpêtrière, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Timothée Lenglet
- Département de Neurophysiologie Clinique, Hôpital Pitié Salpêtrière, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Dimitri Psimaras
- Département de Neurophysiologie Clinique, Hôpital Pitié Salpêtrière, Assistance publique-Hôpitaux de Paris, Paris, France.,Service de Neurologie 2-Mazarin, Hôpital Pitié Salpêtrière, Assistance publique-Hôpitaux de Paris, Paris, France.,Université Pierre et Marie Curie Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS 975, Inserm U 975, CNRS, UMR 7225, Paris, France
| | - Arièle Azoulay-Cayla
- Département de Neurophysiologie Clinique, Hôpital Pitié Salpêtrière, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Emmanuel Fournier
- Département de Neurophysiologie Clinique, Hôpital Pitié Salpêtrière, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Karine Viala
- Département de Neurophysiologie Clinique, Hôpital Pitié Salpêtrière, Assistance publique-Hôpitaux de Paris, Paris, France
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13
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Al‐Zuhairy A, Sindrup SH, Andersen H, Jakobsen J. A population‐based study of long‐term outcome in treated chronic inflammatory demyelinating polyneuropathy. Muscle Nerve 2020; 61:316-324. [DOI: 10.1002/mus.26772] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 11/26/2019] [Accepted: 11/28/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Ali Al‐Zuhairy
- Department of NeurologyCopenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Søren H. Sindrup
- Department of NeurologyOdense University Hospital Odense Denmark
| | - Henning Andersen
- Department of NeurologyAarhus University Hospital Aarhus Denmark
| | - Johannes Jakobsen
- Department of NeurologyCopenhagen University Hospital Rigshospitalet Copenhagen Denmark
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14
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Lawley A, Seri S, Rajabally YA. Motor unit number index (MUNIX) in chronic inflammatory demyelinating polyneuropathy: A potential role in monitoring response to intravenous immunoglobulins. Clin Neurophysiol 2019; 130:1743-1749. [DOI: 10.1016/j.clinph.2019.06.231] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 05/30/2019] [Accepted: 06/28/2019] [Indexed: 02/07/2023]
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15
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Hartung H, Mallick R, Bril V, Lewis RA, Sobue G, Lawo J, Mielke O, Durn BL, Cornblath DR, Merkies ISJ, van Schaik IN. Patient‐reported outcomes with subcutaneous immunoglobulin in chronic inflammatory demyelinating polyneuropathy: the PATH study. Eur J Neurol 2019; 27:196-203. [DOI: 10.1111/ene.14056] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 08/05/2019] [Indexed: 11/26/2022]
Affiliation(s)
- H.‐P. Hartung
- Department of Neurology UKD and Center for Neurology and Neuropsychiatry LVR Klinikum Medical Faculty Heinrich Heine University Düsseldorf Germany
| | | | - V. Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases Division of Neurology Department of Medicine University Health Network University of Toronto Toronto Canada
- Institute for Research and Medical Consultations Imam Abdulrahman Bin Faisal University Dammam Saudi Arabia
| | - R. A. Lewis
- Department of Neurology Cedars‐Sinai Medical Center Los Angeles CA USA
| | - G. Sobue
- Department of Neurology Nagoya University Graduate School of Medicine Nagoya Japan
| | | | | | | | - D. R. Cornblath
- Department of Neurology Johns Hopkins University School of Medicine Baltimore MD USA
| | - I. S. J. Merkies
- Department of Neurology Maastricht University Medical Center Maastricht The Netherlands
- Department of Neurology St Elizabeth Hospital Willemstad Curacao
| | - I. N. van Schaik
- Department of Neurology Amsterdam University Medical Centres University of Amsterdam Amsterdam The Netherlands
- Spaarne Gasthuis Haarlem The Netherlands
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16
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Abstract
Intravenous immunoglobulin (IVIg) is used in the treatment of autoimmune diseases, including immune-mediated central and peripheral nervous system disorders. This article will review the indications, proposed mechanism of actions, and administration of immunoglobulin treatment in various neuropathies, neuromuscular junction disorders, and myopathies. IVIg may have more than one mechanism of action to alter the pathogenesis of underlying neuromuscular disease. IVIg treatment has been used as a first-line treatment in Guillain-Barre syndrome, chronic inflammatory demyelinating polyradiculoneuropathy, multifocal motor neuropathy, and second-line off-label treatment in medically refractory cases of polymyositis, dermatomyositis, and myasthenia gravis. IVIg is a well-tolerated and effective treatment for these neuromuscular diseases. With this review article, we hope to increase clinicians' awareness of the indications and efficiencies of IVIg in a broad spectrum of neuromuscular diseases.
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Affiliation(s)
- Ahmet Z Burakgazi
- Department of Internal Medicine, Neuroscience Section, Virginia Tech Carilion School of Medicine, Carilion Clinic Neurology, Roanoke, VA
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17
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Belmokhtar C, Lozeron P, Adams D, Franques J, Lacour A, Godet E, Bataille M, Dubourg O, Angibaud G, Delmont E, Bouhour F, Corcia P, Pouget J. Efficacy and Safety of Octagam® in Patients With Chronic Inflammatory Demyelinating Polyneuropathy. Neurol Ther 2019; 8:69-78. [PMID: 30903535 PMCID: PMC6534624 DOI: 10.1007/s40120-019-0132-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Indexed: 12/02/2022] Open
Abstract
Introduction Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a debilitating autoimmune neuropathy that is treated with intravenous immunoglobulin (IVIG). The aim of this retrospective study was to investigate the efficacy and safety of the sucrose-free IVIG Octagam® (Octapharma AG, Lachen, Switzerland) in patients with CIDP. Methods Data from 47 patients who received at least one dose of Octagam were collected from the records of 11 centres in France. Efficacy was assessed using Overall Neuropathy Limitation Scale (ONLS). Safety was evaluated using adverse event rates. Results Data from 24 patients who were IVIG naïve (n = 11) or had stopped IVIG ≥ 12 weeks before initiation of Octagam therapy (washout group; n = 13) were included in the efficacy analysis. At 4 months post-initiation of Octagam treatment, 41.7% of patients had improved their functional status (decrease of ≥ 1 ONLS score) with a significant change in the ONLS score from baseline (– 0.42; p = 0.04; signed test). Functional status was reduced in only two patients: one patient in the IVIG-naïve group and one patient in the IVIG-washout group. All 47 patients were included in the safety analysis, which showed that Octagam was well tolerated, with a frequency of 0.04 adverse events per Octagam course. The most common adverse drug reaction was headache. Conclusions These real-life results are consistent with the efficacy and safety of IVIG reported in randomised controlled studies. A long-term prospective study of Octagam in patients with CIDP is warranted. Funding Octapharma, France SAS.
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Affiliation(s)
- Chafké Belmokhtar
- Octapharma SAS, 62 bis Avenue André Morizet, Boulogne-Billancourt, 92100, Paris, France.
| | - Pierre Lozeron
- Lariboisiere University Hospital, 2 Rue Ambroise Paré, 75010, Paris, France
| | - David Adams
- INSERM UMR115 and Kremlin Bicetre University Hospital, Assistance Publique-Hôpitaux de Paris (APHP), 78 Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Jérôme Franques
- La Timone University Hospital,, Assistance Publique-Hôpitaux de Marseilles (APHM), 264 rue Saint Pierre, 13005, Marseille, France
| | - Arnaud Lacour
- Lille University Hospital, Avenue Oscar Lambret, 59000, Lille, France
| | - Etienne Godet
- Bon-Secours Hospital, 1 Place Philippe de Vigneulles, 57000, Metz, France
| | - Mathieu Bataille
- Caen University Hospital, Avenue de La Côte de Nacre, 14003, Caen, France
| | - Odile Dubourg
- Pitié-Salpêtrière University Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Gilles Angibaud
- Pont de Chaume Clinic, 330 Avenue Marcel Unal, 82000, Montauban, France
| | - Emilien Delmont
- Nice University Hospital, 4 Avenue Reine Victoria, 06003, Nice Cedex 1, France
| | - Françoise Bouhour
- Pierre Wertheimer Hospital, 59 Boulevard Pinel, 69677, Lyon-Bron, France
| | - Philippe Corcia
- Tours University Hospital, 2 Boulevard Tonnellé, 37000, Tours, France
| | - Jean Pouget
- La Timone University Hospital,, Assistance Publique-Hôpitaux de Marseilles (APHM), 264 rue Saint Pierre, 13005, Marseille, France
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18
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Roux T, Debs R, Maisonobe T, Lenglet T, Delorme C, Louapre C, Leblond V, Viala K. Rituximab in chronic inflammatory demyelinating polyradiculoneuropathy with associated diseases. J Peripher Nerv Syst 2018; 23:235-240. [PMID: 30203907 DOI: 10.1111/jns.12287] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 09/03/2018] [Accepted: 09/06/2018] [Indexed: 11/29/2022]
Abstract
We aimed to analyse the response to rituximab in a cohort of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) patients with associated disorders. We conducted a clinical and electrophysiological retrospective monocentric study in 28 CIDP patients. Response to rituximab was defined as (a) a five-point increase in the Medical Research Council sum score or a one-point decrease in the Overall Neuropathy Limitations Scale score, compared to the score at the first rituximab infusion, or (b) the discontinuation of, or reduced need for, the last treatments before rituximab initiation. Twenty-one patients (75%) were responders to rituximab. The median time before response was 6 months (1-10 months). Only two patients needed to be treated again during a median follow-up of 2.0 years (0.75-9 years). Interestingly, the response rate was good in patients with associated autoimmune disease (5/8) and similar to the response rate observed in patients with a haematological disease (16/20) (P = 0.63). A shorter disease duration was associated with a better clinical response to rituximab (odds ratio 0.81, P = 0.025) and the response rate was better (P = 0.05) in common forms (83.3%) than in sensory forms (42.9%). No major adverse events were recorded. Rituximab is efficacious in CIDP patients with haematological or autoimmune disease. It improves clinical response and decreases dependence on first-line treatments.
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Affiliation(s)
- Thomas Roux
- Department of Clinical Neurophysiology, APHP, Pitié-Salpêtrière Hospital, Paris, France
| | - Rabab Debs
- Department of Clinical Neurophysiology, APHP, Pitié-Salpêtrière Hospital, Paris, France.,Medical School, Pierre et Marie Curie University-Paris VI, Paris, France
| | - Thierry Maisonobe
- Department of Clinical Neurophysiology, APHP, Pitié-Salpêtrière Hospital, Paris, France.,Medical School, Pierre et Marie Curie University-Paris VI, Paris, France
| | - Timothée Lenglet
- Department of Clinical Neurophysiology, APHP, Pitié-Salpêtrière Hospital, Paris, France.,Medical School, Pierre et Marie Curie University-Paris VI, Paris, France
| | - Cécile Delorme
- Department of Clinical Neurophysiology, APHP, Pitié-Salpêtrière Hospital, Paris, France.,Medical School, Pierre et Marie Curie University-Paris VI, Paris, France
| | - Céline Louapre
- Department of Neurology, APHP, Pitié-Salpêtrière Hospital, Paris, France
| | - Véronique Leblond
- Department of Haematology, APHP, Pitié-Salpêtrière Hospital, Paris, France
| | - Karine Viala
- Department of Clinical Neurophysiology, APHP, Pitié-Salpêtrière Hospital, Paris, France.,Medical School, Pierre et Marie Curie University-Paris VI, Paris, France
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19
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Corticosteroids in chronic inflammatory demyelinating polyneuropathy : A retrospective, multicentre study, comparing efficacy and safety of daily prednisolone, pulsed dexamethasone, and pulsed intravenous methylprednisolone. J Neurol 2018; 265:2052-2059. [PMID: 29968199 PMCID: PMC6132640 DOI: 10.1007/s00415-018-8948-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 06/14/2018] [Accepted: 06/18/2018] [Indexed: 12/22/2022]
Abstract
Background Chronic inflammatory demyelinating polyneuropathy (CIDP) can be treated with corticosteroids or intravenous immunoglobulins. Various corticosteroid regimens are currently used in CIDP, but it is unknown whether they are equally efficacious. In this retrospective study, we compared efficacy and safety of three corticosteroid regimens in CIDP patients. Methods We included treatment naïve patients that fulfilled the EFNS/PNS criteria for CIDP. Patients were treated with corticosteroids according to the local protocol of three CIDP expertise centres. Corticosteroid regimens consisted of daily oral prednisolone, pulsed oral dexamethasone, or pulsed intravenous methylprednisolone. Outcomes were number of responders to treatment, remission rate of treatment responders, overall probability of 5-year remission, and the occurrence of adverse events. Results A total of 125 patients were included. Sixty-seven (54%) patients received daily prednisone or prednisolone, 37 (30%) pulsed dexamethasone, and 21 (17%) pulsed intravenous methylprednisolone. Overall, 60% (95% CI 51–69%) responded to corticosteroids, with no significant difference between the three treatment regimens (p = 0.56). From the 75 responders, 61% (95% CI 50–73%) remained in remission, during a median follow-up of 55 months (range 1–197 months). The probability of responders reaching 5-year remission was 55% (95% Cl 44–70%), with no difference between the three groups. Adverse events leading to a change in treatment occurred in ten patients (8%). Two patients had a serious adverse event. Conclusion Corticosteroids lead to improvement in 60% of patients and to remission in 61% of treatment responders. There were no differences between treatment modalities in terms of efficacy and safety.
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20
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Cirillo G, Todisco V, Tedeschi G. Long-term neurophysiological and clinical response in patients with chronic inflammatory demyelinating polyradiculoneuropathy treated with subcutaneous immunoglobulin. Clin Neurophysiol 2018; 129:967-973. [DOI: 10.1016/j.clinph.2018.01.070] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 12/22/2017] [Accepted: 01/21/2018] [Indexed: 11/30/2022]
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21
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Wietek S. Octagam ® for chronic inflammatory demyelinating polyneuropathy: results from three observational studies. Neurodegener Dis Manag 2018. [PMID: 29517417 PMCID: PMC6190209 DOI: 10.2217/nmt-2018-0006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To present data from three studies of a Post-Authorization Safety Surveillance (PASS) program for the subset of patients receiving Octagam® 5% or 10% for chronic inflammatory demyelinating polyneuropathy (CIDP). Methods: Data on patients with CIDP treated with Octagam were analyzed to assess its safety and tolerability. Results: Of 2314 patients included in the studies, 58 patients (mean age: 64.6 years) received Octagam for CIDP, mean dose of which was 0.8 g/kg bodyweight/course. 81% of observations for clinical appearance since last observation were assessed as stable and 16.6% showed an improved clinical appearance with treatment. Adverse drug reactions were rare (<0.7% of infusions). Conclusion: Octagam was effective and well-tolerated in patients with CIDP.
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Affiliation(s)
- Stefan Wietek
- Octapharma Pharmazeutika Produktionsges.m.b.H., Global Medical & Scientific Affairs, Vienna, Austria
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22
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Adrichem ME, Eftimov F, van Schaik IN. Intravenous immunoglobulin treatment in chronic inflammatory demyelinating polyradiculoneuropathy, a time to start and a time to stop. J Peripher Nerv Syst 2018; 21:121-7. [PMID: 27241239 DOI: 10.1111/jns.12176] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 05/25/2016] [Accepted: 05/27/2016] [Indexed: 12/27/2022]
Abstract
Intravenous immunoglobulin (IVIg) is often used as preferred treatment in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Several studies highlighted the short-term efficacy of IVIg for CIDP yet many patients need maintenance therapy. Notwithstanding the fact IVIg has been used for over 30 years in CIDP, there is only limited evidence to guide dosage and interval during maintenance treatment. The variation in disease course, lack of biomarkers, and fear of deterioration after stopping IVIg makes long-term treatment challenging. Recent studies suggest a proportion of patients receive unnecessary IVIg maintenance treatment. This review provides an overview of the use of IVIg for CIDP treatment, focusing on evidence for long-term IVIg use.
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Affiliation(s)
- Max E Adrichem
- Department of Neurology, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Filip Eftimov
- Department of Neurology, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Ivo N van Schaik
- Department of Neurology, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
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23
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Kolb NA, Trevino CR, Waheed W, Sobhani F, Landry KK, Thomas AA, Hehir M. Neuromuscular complications of immune checkpoint inhibitor therapy. Muscle Nerve 2018; 58:10-22. [PMID: 29342325 DOI: 10.1002/mus.26070] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 01/10/2018] [Accepted: 01/14/2018] [Indexed: 12/31/2022]
Abstract
Immune checkpoint inhibitor (ICPI) therapy unleashes the body's natural immune system to fight cancer. ICPIs improve overall cancer survival, however, the unbridling of the immune system may induce a variety of immune-related adverse events. Neuromuscular immune complications are rare but they can be severe. Myasthenia gravis and inflammatory neuropathy are the most common neuromuscular adverse events but a variety of others including inflammatory myopathy are reported. The pathophysiologic mechanism of these autoimmune disorders may differ from that of non-ICPI-related immune diseases. Accordingly, while the optimal treatment for ICPI-related neuromuscular disorders generally follows a traditional paradigm, there are important novel considerations in selecting appropriate immunosuppressive therapy. This review presents 2 new cases, a summary of neuromuscular ICPI complications, and an approach to the diagnosis and treatment of these disorders. Muscle Nerve, 2018.
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Affiliation(s)
- Noah A Kolb
- Department of Neurological Sciences, University of Vermont, Burlington, Vermont, USA
| | | | - Waqar Waheed
- Department of Neurological Sciences, University of Vermont, Burlington, Vermont, USA
| | - Fatemeh Sobhani
- Department of Neurological Sciences, University of Vermont, Burlington, Vermont, USA
| | - Kara K Landry
- Department of Medicine, University of Vermont Medical Center, 1 South Prospect Street, MS 405AR2, Burlington, Vermont, 05401, USA
| | - Alissa A Thomas
- Department of Neurological Sciences, University of Vermont, Burlington, Vermont, USA
| | - Mike Hehir
- Department of Neurological Sciences, University of Vermont, Burlington, Vermont, USA
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24
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Kuitwaard K, Fokkink WJR, Brusse E, Vrancken AFJE, Eftimov F, Notermans NC, van der Kooi AJ, Merkies ISJ, Jacobs BC, van Doorn PA. Maintenance IV immunoglobulin treatment in chronic inflammatory demyelinating polyradiculoneuropathy. J Peripher Nerv Syst 2017; 22:425-432. [PMID: 29092099 DOI: 10.1111/jns.12242] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 10/27/2017] [Accepted: 10/29/2017] [Indexed: 12/27/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) patients treated with intravenous immunoglobulin (IVIg) usually start with a standard dosage of 2 g/kg bodyweight. Only a minority of patients has a sustained improvement, and most require ongoing maintenance treatment. Preferred IVIg regimens, however, vary considerably between doctors and at present it is unknown which is optimal. As there are also large differences in IVIg dosage and interval requirements between patients, optimal IVIg maintenance treatment of CIDP is even more complex. The lack of evidence-based guidelines on how IVIg maintenance treatment should be administered may potentially lead to under- or overtreatment of this expensive therapy. We provide an overview of published practical IVIg maintenance treatment regimens, IVIg maintenance schedules used in randomized controlled trials and one based upon our own long-term experience on how this treatment could be given in CIDP.
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Affiliation(s)
- Krista Kuitwaard
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Neurology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Willem-Jan R Fokkink
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Immunology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Esther Brusse
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Alexander F J E Vrancken
- Department of Neurology, Brain Center Rudolf Magnus University, Medical Center Utrecht, Utrecht, The Netherlands
| | - Filip Eftimov
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Nicolette C Notermans
- Department of Neurology, Brain Center Rudolf Magnus University, Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Ingemar S J Merkies
- Department of Neurology, School of Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Neurology, St. Elisabeth Hospital, Willemstad, Curacao
| | - Bart C Jacobs
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Immunology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Pieter A van Doorn
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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25
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Kuitwaard K, Fokkink WJR, Brusse E, Vrancken AFJE, Eftimov F, Notermans NC, van der Kooi AJ, Merkies ISJ, Jacobs BC, van Doorn PA. Protocol of a dose response trial of IV immunoglobulin in chronic inflammatory demyelinating polyradiculoneuropathy (DRIP study). J Peripher Nerv Syst 2017; 23:5-10. [PMID: 29119642 DOI: 10.1111/jns.12244] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 11/03/2017] [Indexed: 11/30/2022]
Abstract
High peak levels of serum IgG may not be needed for maintenance treatment of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) with intravenous immunoglobulin (IVIg). More frequent dosing of IVIg leads to more stable IgG levels and higher trough levels which may be related with improved clinical efficacy. More frequent lower dosing leads to lower peak levels and may induce less systemic side-effects. The DRIP study is a double-blind randomized controlled cross-over intervention study. CIDP patients ≥18 years old, proven IVIg dependent and receiving an individually established but stable maintenance dose and interval of IVIg (Kiovig) can be included. One group (A) will be treated with their normal dosage and interval of IVIg and receive a placebo (albumin 0.5%) infusion in between their regular IVIg infusions, for a total of four infusions. The other group (B) will be treated with half their normal IVIg dosage (with the same volume of placebo to maintain the total volume) at half their interval (double their frequency) for four infusions. After a wash-out phase (2 infusions), patients will cross-over to the other treatment group. During the study the total dose of IVIg administered will remain unchanged as before start of the trial. The main objective is to investigate whether high frequent low dosage IVIg treatment is more effective than low frequent high dosage IVIg treatment as maintenance treatment for CIDP. Hand grip strength, as measured by the Martin Vigorimeter, will be used as the primary outcome measure. Secondary objective is to investigate whether high frequent low dosage of IVIg results in less adverse events compared to low frequent high dosage treatment. The DRIP study is currently ongoing and the protocol is presented.
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Affiliation(s)
- Krista Kuitwaard
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Neurology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Willem-Jan R Fokkink
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Esther Brusse
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Alexander F J E Vrancken
- Department of Neurology, Brain Center Rudolf Magnus University Medical Center Utrecht, Utrecht, The Netherlands
| | - Filip Eftimov
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Nicolette C Notermans
- Department of Neurology, Brain Center Rudolf Magnus University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Ingemar S J Merkies
- Department of Neurology, School of Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Neurology, St. Elisabeth Hospital, Willemstad, Curaçao
| | - Bart C Jacobs
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Pieter A van Doorn
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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26
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Kuwabara S, Mori M, Misawa S, Suzuki M, Nishiyama K, Mutoh T, Doi S, Kokubun N, Kamijo M, Yoshikawa H, Abe K, Nishida Y, Okada K, Sekiguchi K, Sakamoto K, Kusunoki S, Sobue G, Kaji R. Intravenous immunoglobulin for maintenance treatment of chronic inflammatory demyelinating polyneuropathy: a multicentre, open-label, 52-week phase III trial. J Neurol Neurosurg Psychiatry 2017; 88:832-838. [PMID: 28768822 PMCID: PMC5629934 DOI: 10.1136/jnnp-2017-316427] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 06/14/2017] [Accepted: 06/19/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Short-term efficacy of induction therapy with intravenous immunoglobulin (Ig) in patients with chronic inflammatory demyelinating polyneuropathy (CIDP) is well established. However, data of previous studies on maintenance therapy were limited up to 24-week treatment period. We aimed to investigate the efficacy and safety of longer-term intravenous Ig therapy for 52 weeks. METHODS This study was an open-label phase 3 clinical trial conducted in 49 Japanese tertiary centres. 49 patients with CIDP who fulfilled diagnostic criteria were included. After an induction intravenous Ig therapy (0.4 g/kg/day for five consecutive days), maintenance dose intravenous Ig (1.0 g/kg) was given every 3 weeks for up to 52 weeks. The primary outcome measures were the responder rate at week 28 and relapse rate at week 52. The response and relapse were defined with the adjusted Inflammatory Neuropathy Cause and Treatment scale. RESULTS At week 28, the responder rate was 77.6% (38/49 patients; 95% CI 63% to 88%), and the 38 responders continued the maintenance therapy. At week 52, 4 of the 38 (10.5%) had a relapse (95% CI 3% to 25%). During 52 weeks, 34 (69.4%) of the 49 enrolled patients had a maintained improvement. Adverse events were reported in 94% of the patients; two patients (66-year-old and 76-year-old men with hypertension or diabetes) developed cerebral infarction (lacunar infarct with good recovery), and the other adverse effects were mild and resolved by the end of the study period. CONCLUSIONS Maintenance treatment with 1.0 g/kg intravenous Ig every 3 weeks is an efficacious therapy for patients with CIDP, and approximately 70% of them had a sustained remission for 52 weeks. Thrombotic complications should be carefully monitored, particularly in elderly patients with vascular risk factors. TRIAL REGISTRATION NUMBER ClinicalTrials.gov (NCT01824251).
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Affiliation(s)
- Satoshi Kuwabara
- Department of Neurology, Chiba University Hospital, Chiba, Japan
| | - Masahiro Mori
- Department of Neurology, Chiba University Hospital, Chiba, Japan
| | - Sonoko Misawa
- Department of Neurology, Chiba University Hospital, Chiba, Japan
| | - Miki Suzuki
- Department of Neurology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazutoshi Nishiyama
- Department of Neurology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Tatsuro Mutoh
- Department of Neurology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Shizuki Doi
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Sapporo, Japan
| | - Norito Kokubun
- Department of Neurology, Dokkyo Medical University, Tochigi, Japan
| | - Mikiko Kamijo
- Department of Neurology, Chubu Rosai Hospital, Nagoya, Japan
| | - Hiroo Yoshikawa
- Division of Neurology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Koji Abe
- Department of Neurology, Okayama University School of Medicine, Okayama, Japan
| | | | - Kazumasa Okada
- Department of Neurology, University of Occupational and Environmental Health School of Medicine, Kitakyushu, Japan
| | - Kenji Sekiguchi
- Division of Neurology, Kobe University Graduate School of Medicine, Kobe, Japan
| | | | - Susumu Kusunoki
- Department of Neurology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Gen Sobue
- Department of Neurology, Nagoya University School of Medicine, Nagoya, Japan
| | - Ryuji Kaji
- Department of Neurology, Tokushima University School of Medicine, Tokushima, Japan
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27
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Early predictive factors of disability in CIDP. J Neurol 2017; 264:1939-1944. [PMID: 28770373 DOI: 10.1007/s00415-017-8578-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 07/19/2017] [Accepted: 07/24/2017] [Indexed: 01/03/2023]
Abstract
The objective of this study was to identify early clinical, biochemical and electrophysiological prognostic factors of disability in CIDP. We evaluated a dataset from 60 CIDP patients that included sex, age of onset, type of onset, phenotype, disease duration, response to treatment, disability at the time of diagnosis assessed using the modified Rankin Scale (baseline mRS), cerebrospinal fluid protein levels and electrophysiological data. All patients had clinical assessment of disability through the mRS within the last 6 months (last mRS) before enrollment in the study. Stepwise forward logistic regression model was applied to evaluate the impact of clinical, biochemical and electrophysiological parameters on the last mRS, considered as binary outcome (absence or presence of severe disability, i.e., <4/≥4 mRS). Moreover, we used Spearman's rank correlation coefficient to evaluate the relationship between disease duration and last mRS. We observed a significant relationship between last mRS and baseline mRS [p = 0.015, z = 2.44, OR 5.15 (CI 1.38-19.22)] and age of onset [p = 0.017, z = 2.39, OR 1.13 (CI 1.02-1.27) per additional year of age of onset]. There was no correlation between disease duration and last mRS. Our data suggest that a worse clinical status at the beginning of disease and an older age at onset may be negative prognostic factors of long-term disability independent from disease duration.
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Fokkink W, Koch B, Ramakers C, van Doorn PA, van Gelder T, Jacobs BC. Pharmacokinetics and Pharmacodynamics of Intravenous Immunoglobulin G Maintenance Therapy in Chronic Immune-mediated Neuropathies. Clin Pharmacol Ther 2017; 102:709-716. [PMID: 28378901 DOI: 10.1002/cpt.693] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 03/08/2017] [Accepted: 03/13/2017] [Indexed: 11/08/2022]
Abstract
The regimen for IVIg maintenance treatment varies considerably between patients with chronic immune-mediated neuropathies. Although it is widely recognized that treatment regimens should be improved, detailed pharmacokinetics (PK) of IVIg have not yet been established. We aimed to determine the PK of IVIg maintenance treatment in patients with clinically stable, treatment-dependent, chronic immune-mediated neuropathy. Patients received a median IVIg dose of 30 g (range, 15-70 g) every 14 days (range, 7-28 days) resulting in high IgG peak levels (median, 25.9 g/L; range, 16.7-41.0 g/L) and trough levels (median, 16.1 g/L; range, 9.7-23.6 g/L). IgG PK parameters, including half-life (median, 23.1 days; range, 11-60 days), were constant during subsequent courses in the same patients, but varied considerably between patients. The IgG levels at 1 week after infusion correlated with grip strength. These results provide insight into the PK of IVIg maintenance treatment in patients with chronic immune-mediated neuropathies.
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Affiliation(s)
- Wjr Fokkink
- Department of Immunology, Erasmus MC, University Medical Center Rotterdam, The Netherlands.,Department of Neurology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Bcp Koch
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Crb Ramakers
- Department of Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - P A van Doorn
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - T van Gelder
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - B C Jacobs
- Department of Immunology, Erasmus MC, University Medical Center Rotterdam, The Netherlands.,Department of Neurology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
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Ellrichmann G, Gold R, Ayzenberg I, Yoon MS, Schneider-Gold C. Two years' long-term follow up in chronic inflammatory demyelinating polyradiculoneuropathy: efficacy of intravenous immunoglobulin treatment. Ther Adv Neurol Disord 2016; 10:91-101. [PMID: 28382108 DOI: 10.1177/1756285616679369] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Administration of intravenous immunoglobulins (IVIgs) is established for long-term treatment of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Prevention of secondary axonal loss going along with permanent clinical disability and muscular atrophy is a major aim in CIDP therapy. To assess long-term clinical efficacy of IVIg treatment despite heterogenous disease course and variable complaints reported by the patients, long-term electrophysiological monitoring was performed for systematic evaluation of therapeutic efficacy of IVIg. METHODS A total of 21 patients with CIDP treated with IVIg 1 g/kg bodyweight every 3-6 weeks were examined electrophysiologically every 12 months over a period of 2 years. RESULTS Assessment of clinical symptoms, using the Inflammatory Neuropathy Cause and Treatment (INCAT) and Hughes functional grading score (F-score) revealed improvement of motor and sensory symptoms over a period of 2 years. As electrophysiological results remained stable, IVIg treatment seems to be suitable to prevent axonal loss in CIDP. CONCLUSIONS This study confirms efficacy of IVIg as firstline therapy in CIDP. Doses and frequency of IVIg application should be adapted based on clinical evaluation and analysis of long-term electrophysiological findings.
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Affiliation(s)
- Gisa Ellrichmann
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, D-44791 Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Germany
| | - Ilya Ayzenberg
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Germany
| | - Min-Suk Yoon
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Germany
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Expression of brain-derived neurotrophic factor in astrocytes - Beneficial effects of glatiramer acetate in the R6/2 and YAC128 mouse models of Huntington's disease. Exp Neurol 2016; 285:12-23. [PMID: 27587303 DOI: 10.1016/j.expneurol.2016.08.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 07/31/2016] [Accepted: 08/21/2016] [Indexed: 12/18/2022]
Abstract
Glatiramer acetate (GA) is a FDA-approved drug which is licensed for the treatment of relapsing-remitting multiple sclerosis and which may exert neuroprotective effects via brain-derived neurotrophic factor (BDNF). In this study, we investigate effects of GA on BDNF expression especially in astrocytes in vitro and in vivo in brains of R6/2 and YAC128 transgenic mouse models of Huntington's disease (HD) where a pathogenic role of astroglial cells has recently been shown. We show that GA increases the expression of functionally active BDNF in astrocyte culture and in astrocytes of GA treated HD mice. In the brains of these mice, GA decreases neurodegeneration and restores BDNF levels. The beneficial effect of GA in R6/2 mice also comprises reduced weight loss and prolonged life span and, for both models, also improved motor performance. Further studies with this safe and effective drug in HD are warranted.
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Abstract
PURPOSE OF REVIEW Autoimmune disorders of the peripheral nerves are diverse and heterogeneous. T cells, macrophages, and autoantibodies have been implicated in their pathogenesis. Autoantibodies to peripheral nerve molecules seem to play a role not only in the pathogenesis but provide diagnostic, prognostic, and therapeutic help. We review the state of the art and most relevant recent findings regarding autoantibodies in chronic inflammatory neuropathies, focusing on their clinical utility. RECENT FINDINGS Research on autoantibodies in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) has received a recent boost with the description of antibodies against proteins of the node of Ranvier. Antibodies of the IgG4 isotype targeting the paranodal proteins contactin-1 (CNTN1) and neurofascin-155 (NF155) define specific CIDP subtypes and have diagnostic and prognostic implications. In multifocal motor neuropathy, anti-GM1 production is restricted to very few B-cell clones that could be the target of therapies aimed to remove or inactivate them. Moreover, novel ELISA and glycoarray techniques combining GM1 and galactocerebroside gangliosides improved the sensitivity of autoantibody detection. Detailed clinical and paraclinical features, including autoantibody reactivity patters, of autoimmune syndromes affecting simultaneously the central and peripheral nervous systems, are also described. SUMMARY The heterogeneity of chronic inflammatory neuropathies is being unraveled with the description of specific autoantibodies and their association with small disease subtypes. The recently described paranodal autoantibodies anti-CNTN1 and NF155 have direct clinical value and seem to determine response to treatment. Further studies are needed to fully understand the primary contribution of the antibodies to the pathophysiology of the immune neuropathies.
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Goyal NA, Cash TM, Alam U, Enam S, Tierney P, Araujo N, Mozaffar FH, Pestronk A, Mozaffar T. Seropositivity for NT5c1A antibody in sporadic inclusion body myositis predicts more severe motor, bulbar and respiratory involvement. J Neurol Neurosurg Psychiatry 2016; 87:373-8. [PMID: 25857661 PMCID: PMC6192256 DOI: 10.1136/jnnp-2014-310008] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 03/19/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To explore phenotypic differences between individuals with sporadic inclusion body myositis (sIBM) who are seropositive for the NT5c1A antibody compared with those who are seronegative. METHODS Cross-sectional clinical, serological and functional analysis in 25 consecutive participants with sIBM. RESULTS All participants met criteria for clinically defined or probable sIBM. 18 of 25 participants with sIBM (72%) were seropositive for the NT5c1A antibody. No differences between median age and duration of illness between the two groups were seen. Females have higher odds of being seropositive (OR=2.30). Participants with seropositive sIBM took significantly longer to get up and stand (p=0.012). There were no significant differences between the two groups in terms of distance covered on a 6 min walk. Seropositive participants were more likely to require assistive devices such as a walker or wheelchair for mobility (OR=23.00; p=0.007). A number of secondary (exploratory) outcomes were assessed. NT5c1A seropositive sIBM cases had lower total Medical Research Council (MRC) sum score and MRC sum score on the right (p=0.03 and 0.02, respectively). Participants with the NT5c1A antibody were significantly more likely to have symptoms of dysphagia (OR=10.67; p=0.03) and reduced forced vital capacity (p=0.005). Facial weakness occurred in 50% of seropositive participants while it was only seen in 14% of seronegative participants. CONCLUSIONS Even though the small sample size limits definite conclusions, our cross-sectional study showed seropositivity to the NT5c1A antibody is associated with greater motor and functional disability in sIBM. The study also suggests more prominent bulbar, facial and respiratory involvement in individuals positive for NT5c1A antibodies.
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Affiliation(s)
- N A Goyal
- Department of Neurology, University of California, Irvine, California, USA
| | - T M Cash
- Department of Neurology, University of California, Irvine, California, USA
| | - U Alam
- Department of Neurology, University of California, Irvine, California, USA
| | - S Enam
- Department of Neurology, University of California, Irvine, California, USA
| | - P Tierney
- Department of Neurology, University of California, Irvine, California, USA
| | - N Araujo
- Department of Neurology, University of California, Irvine, California, USA
| | - F H Mozaffar
- Department of Neurology, University of California, Irvine, California, USA
| | - A Pestronk
- Department of Neurology, Washington University, St. Louis, Missouri, USA Department of Pathology, Washington University, St. Louis, Missouri, USA
| | - T Mozaffar
- Department of Neurology, University of California, Irvine, California, USA Department of Orthopaedic Surgery, University of California, Irvine, California, USA
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Kleyman I, Brannagan TH. Treatment of chronic inflammatory demyelinating polyneuropathy. Curr Neurol Neurosci Rep 2016; 15:47. [PMID: 26008811 DOI: 10.1007/s11910-015-0563-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is one of the acquired demyelinating neuropathies and is considered to be immune mediated. Diagnosis is typically based on clinical history, neurologic examination, electrophysiologic studies, CSF studies, and pathologic examination. Early diagnosis and treatment is important to prevent irreversible axonal loss and optimize improvement in function. The first-line agents for treatment are intravenous immunoglobulin (IVIg), corticosteroids, and plasmapheresis, which have all been demonstrated to be effective in controlled studies. Studies have not shown a significant difference between these three treatments, and the initial choice of therapy is often based on availability, cost, ease of administration, and side effect profile. If patients do not respond to one of these agents, they may respond to one of the others and sometimes in combination. If the first-line agents are not effective, chemotherapeutic or immunosuppressive agents may be considered. There are limited controlled studies of these modalities, and they are often used in conjunction with a first-line treatment. The majority of patients require long-term therapy to maintain a response and to prevent relapse.
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Affiliation(s)
- Inna Kleyman
- Peripheral Neuropathy Center, Neurological Institute, Columbia University, College of Physicians and Surgeons, 710 W 168th St, box 163, New York, NY, 10032, USA,
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Devaux JJ, Miura Y, Fukami Y, Inoue T, Manso C, Belghazi M, Sekiguchi K, Kokubun N, Ichikawa H, Wong AHY, Yuki N. Neurofascin-155 IgG4 in chronic inflammatory demyelinating polyneuropathy. Neurology 2016; 86:800-7. [PMID: 26843559 PMCID: PMC4793783 DOI: 10.1212/wnl.0000000000002418] [Citation(s) in RCA: 179] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 10/01/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We report the clinical and serologic features of Japanese patients with chronic inflammatory demyelinating polyneuropathy (CIDP) displaying anti-neurofascin-155 (NF155) immunoglobulin G4 (IgG4) antibodies. METHODS In sera from 533 patients with CIDP, anti-NF155 IgG4 antibodies were detected by ELISA. Binding of IgG antibodies to central and peripheral nerves was tested. RESULTS Anti-NF155 IgG4 antibodies were identified in 38 patients (7%) with CIDP, but not in disease controls or normal participants. These patients were younger at onset as compared to 100 anti-NF155-negative patients with CIDP. Twenty-eight patients (74%) presented with sensory ataxia, 16 (42%) showed tremor, 5 (13%) presented with cerebellar ataxia associated with nystagmus, 3 (8%) had demyelinating lesions in the CNS, and 20 of 25 (80%) had poor response to IV immunoglobulin. The clinical features of the antibody-positive patients were statistically more frequent as compared to negative patients with CIDP (n = 100). Anti-NF155 IgG antibodies targeted similarly central and peripheral paranodes. CONCLUSION Anti-NF155 IgG4 antibodies were associated with a subgroup of patients with CIDP showing a younger age at onset, ataxia, tremor, CNS demyelination, and a poor response to IV immunoglobulin. The autoantibodies may serve as a biomarker to improve patients' diagnosis and guide treatments.
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Affiliation(s)
- Jérôme J Devaux
- From Aix-Marseille Université (J.J.D., C.M., M.B.), CNRS, CRN2M-UMR 7286, Marseille, France; Departments of Medicine (Y.M., Y.F., T.I., A.H.Y.W., N.Y.) and Physiology (N.Y.), Yong Loo Lin School of Medicine, National University of Singapore; Brain and Mind Centre (N.Y.), University of Sydney, Australia; Division of Neurology (K.S.), Kobe University Graduate School of Medicine; Department of Neurology (N.K.), Dokkyo Medical University, Tochigi; and Department of Neurology (H.I.), Brain Nerve Center, Showa University Fujigaoka Hospital, Tokyo, Japan
| | - Yumako Miura
- From Aix-Marseille Université (J.J.D., C.M., M.B.), CNRS, CRN2M-UMR 7286, Marseille, France; Departments of Medicine (Y.M., Y.F., T.I., A.H.Y.W., N.Y.) and Physiology (N.Y.), Yong Loo Lin School of Medicine, National University of Singapore; Brain and Mind Centre (N.Y.), University of Sydney, Australia; Division of Neurology (K.S.), Kobe University Graduate School of Medicine; Department of Neurology (N.K.), Dokkyo Medical University, Tochigi; and Department of Neurology (H.I.), Brain Nerve Center, Showa University Fujigaoka Hospital, Tokyo, Japan
| | - Yuki Fukami
- From Aix-Marseille Université (J.J.D., C.M., M.B.), CNRS, CRN2M-UMR 7286, Marseille, France; Departments of Medicine (Y.M., Y.F., T.I., A.H.Y.W., N.Y.) and Physiology (N.Y.), Yong Loo Lin School of Medicine, National University of Singapore; Brain and Mind Centre (N.Y.), University of Sydney, Australia; Division of Neurology (K.S.), Kobe University Graduate School of Medicine; Department of Neurology (N.K.), Dokkyo Medical University, Tochigi; and Department of Neurology (H.I.), Brain Nerve Center, Showa University Fujigaoka Hospital, Tokyo, Japan
| | - Takayuki Inoue
- From Aix-Marseille Université (J.J.D., C.M., M.B.), CNRS, CRN2M-UMR 7286, Marseille, France; Departments of Medicine (Y.M., Y.F., T.I., A.H.Y.W., N.Y.) and Physiology (N.Y.), Yong Loo Lin School of Medicine, National University of Singapore; Brain and Mind Centre (N.Y.), University of Sydney, Australia; Division of Neurology (K.S.), Kobe University Graduate School of Medicine; Department of Neurology (N.K.), Dokkyo Medical University, Tochigi; and Department of Neurology (H.I.), Brain Nerve Center, Showa University Fujigaoka Hospital, Tokyo, Japan
| | - Constance Manso
- From Aix-Marseille Université (J.J.D., C.M., M.B.), CNRS, CRN2M-UMR 7286, Marseille, France; Departments of Medicine (Y.M., Y.F., T.I., A.H.Y.W., N.Y.) and Physiology (N.Y.), Yong Loo Lin School of Medicine, National University of Singapore; Brain and Mind Centre (N.Y.), University of Sydney, Australia; Division of Neurology (K.S.), Kobe University Graduate School of Medicine; Department of Neurology (N.K.), Dokkyo Medical University, Tochigi; and Department of Neurology (H.I.), Brain Nerve Center, Showa University Fujigaoka Hospital, Tokyo, Japan
| | - Maya Belghazi
- From Aix-Marseille Université (J.J.D., C.M., M.B.), CNRS, CRN2M-UMR 7286, Marseille, France; Departments of Medicine (Y.M., Y.F., T.I., A.H.Y.W., N.Y.) and Physiology (N.Y.), Yong Loo Lin School of Medicine, National University of Singapore; Brain and Mind Centre (N.Y.), University of Sydney, Australia; Division of Neurology (K.S.), Kobe University Graduate School of Medicine; Department of Neurology (N.K.), Dokkyo Medical University, Tochigi; and Department of Neurology (H.I.), Brain Nerve Center, Showa University Fujigaoka Hospital, Tokyo, Japan
| | - Kenji Sekiguchi
- From Aix-Marseille Université (J.J.D., C.M., M.B.), CNRS, CRN2M-UMR 7286, Marseille, France; Departments of Medicine (Y.M., Y.F., T.I., A.H.Y.W., N.Y.) and Physiology (N.Y.), Yong Loo Lin School of Medicine, National University of Singapore; Brain and Mind Centre (N.Y.), University of Sydney, Australia; Division of Neurology (K.S.), Kobe University Graduate School of Medicine; Department of Neurology (N.K.), Dokkyo Medical University, Tochigi; and Department of Neurology (H.I.), Brain Nerve Center, Showa University Fujigaoka Hospital, Tokyo, Japan
| | - Norito Kokubun
- From Aix-Marseille Université (J.J.D., C.M., M.B.), CNRS, CRN2M-UMR 7286, Marseille, France; Departments of Medicine (Y.M., Y.F., T.I., A.H.Y.W., N.Y.) and Physiology (N.Y.), Yong Loo Lin School of Medicine, National University of Singapore; Brain and Mind Centre (N.Y.), University of Sydney, Australia; Division of Neurology (K.S.), Kobe University Graduate School of Medicine; Department of Neurology (N.K.), Dokkyo Medical University, Tochigi; and Department of Neurology (H.I.), Brain Nerve Center, Showa University Fujigaoka Hospital, Tokyo, Japan
| | - Hiroo Ichikawa
- From Aix-Marseille Université (J.J.D., C.M., M.B.), CNRS, CRN2M-UMR 7286, Marseille, France; Departments of Medicine (Y.M., Y.F., T.I., A.H.Y.W., N.Y.) and Physiology (N.Y.), Yong Loo Lin School of Medicine, National University of Singapore; Brain and Mind Centre (N.Y.), University of Sydney, Australia; Division of Neurology (K.S.), Kobe University Graduate School of Medicine; Department of Neurology (N.K.), Dokkyo Medical University, Tochigi; and Department of Neurology (H.I.), Brain Nerve Center, Showa University Fujigaoka Hospital, Tokyo, Japan
| | - Anna Hiu Yi Wong
- From Aix-Marseille Université (J.J.D., C.M., M.B.), CNRS, CRN2M-UMR 7286, Marseille, France; Departments of Medicine (Y.M., Y.F., T.I., A.H.Y.W., N.Y.) and Physiology (N.Y.), Yong Loo Lin School of Medicine, National University of Singapore; Brain and Mind Centre (N.Y.), University of Sydney, Australia; Division of Neurology (K.S.), Kobe University Graduate School of Medicine; Department of Neurology (N.K.), Dokkyo Medical University, Tochigi; and Department of Neurology (H.I.), Brain Nerve Center, Showa University Fujigaoka Hospital, Tokyo, Japan
| | - Nobuhiro Yuki
- From Aix-Marseille Université (J.J.D., C.M., M.B.), CNRS, CRN2M-UMR 7286, Marseille, France; Departments of Medicine (Y.M., Y.F., T.I., A.H.Y.W., N.Y.) and Physiology (N.Y.), Yong Loo Lin School of Medicine, National University of Singapore; Brain and Mind Centre (N.Y.), University of Sydney, Australia; Division of Neurology (K.S.), Kobe University Graduate School of Medicine; Department of Neurology (N.K.), Dokkyo Medical University, Tochigi; and Department of Neurology (H.I.), Brain Nerve Center, Showa University Fujigaoka Hospital, Tokyo, Japan.
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Rajabally YA. Long-term immunoglobulin therapy for chronic inflammatory demyelinating polyradiculoneuropathy. Muscle Nerve 2015; 51:657-61. [PMID: 25556954 DOI: 10.1002/mus.24554] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2014] [Indexed: 12/24/2022]
Abstract
Immunoglobulins are an effective but expensive treatment for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Although the goal is to improve function, use of functional scales to monitor therapy is not widespread. Limited recent evidence suggests that doses lower than those used traditionally may be as effective. There are no proven correlations of effective dose with weight, disease severity, or duration. The clinical course of CIDP is heterogeneous and includes monophasic forms and complete remissions. Careful monitoring of immunoglobulin use is necessary to avoid overtreatment. Definitive evidence for immunoglobulin superiority over steroids is lacking. Although latest trial evidence favors immunoglobulins over steroids, the latter may result in higher remission rates and longer remission periods. This article addresses the appropriateness of first-line, high-dose immunoglobulin treatment for CIDP and reviews important clinical questions regarding the need for long-term therapy protocols, adequate monitoring, treatment withdrawal, and consideration of corticosteroids as an alternative to immunoglobulin therapy.
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Affiliation(s)
- Yusuf A Rajabally
- Regional Neuromuscular Clinic, Queen Elizabeth Neurosciences Centre, University Hospitals of Birmingham, Birmingham, B15, 2WB, UK
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Vallat JM, Mathis S, Ghorab K, Milor MA, Richard L, Magy L. Natalizumab as a Disease-Modifying Therapy in Chronic Inflammatory Demyelinating Polyneuropathy - A Report of Three Cases. Eur Neurol 2015; 73:294-302. [DOI: 10.1159/000381767] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 03/15/2015] [Indexed: 11/19/2022]
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Yoon MS. Use of immunoglobulin (Ig) in peripheral neuropathies. Impact of Ig on remission rates: comparison of intravenous immunoglobulin and subcutaneous immunoglobulin. Clin Exp Immunol 2014; 178 Suppl 1:25-6. [PMID: 25546750 DOI: 10.1111/cei.12499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- M-S Yoon
- Department of Neurology, St Josef Hospital Bochum, Ruhr University Bochum, Bochum, Germany
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Rabin M, Mutlu G, Stojkovic T, Maisonobe T, Lenglet T, Fournier E, Bouche P, Léger JM, Viala K. Chronic inflammatory demyelinating polyradiculoneuropathy: search for factors associated with treatment dependence or successful withdrawal. J Neurol Neurosurg Psychiatry 2014; 85:901-6. [PMID: 24309269 DOI: 10.1136/jnnp-2013-306105] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND About 40% of responders to treatment for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) remain treatment dependent and have a relapse if treatment is interrupted. OBJECTIVE To look for factors associated with treatment dependence or successful withdrawal in CIDP patients. METHODS We retrospectively studied 70 responder CIDP patients comprising 34 patients who remained treatment dependent (treatment-dependent group) and 36 patients whose treatment could be discontinued (treatment withdrawal group). Clinical, biological, electrophysiological and therapeutic features were compared between these groups. RESULTS A multifocal deficit was more frequent in the treatment-dependent group (35%) than in the treatment withdrawal group (8%) (p<0.01). The most frequent effective treatment was intravenous immunoglobulin (IVIG) for the treatment-dependent group (79%). In this group, more patients were resistant to corticosteroids in first-line therapy (93%) than in the treatment withdrawal group (40%) (p=0.002). The delay to effective treatment was significantly shorter for the treatment withdrawal group than for the treatment-dependent group (mean 11.1 vs 31.2 months; p<0.01). The rate of successful withdrawal was lower with IVIG (29%) than with corticosteroids (83%) (p<0.001). CONCLUSIONS When compared with the treatment withdrawal group, the treatment-dependent group was more frequently responsive to IVIG, more frequently resistant to corticosteroids in first-line treatment, had a longer delay to effective treatment and was more likely to present a multifocal deficit. The rate of successful withdrawal seems to be higher with corticosteroids, but a prospective study with a long-term follow-up is needed to confirm these features.
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Affiliation(s)
- Magalie Rabin
- Département de Neurophysiologie Clinique, Groupe Hospitalier Pitié-Salpêtrière Paris, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France
| | - Gurkam Mutlu
- Groupe Hospitalier Pitié-Salpêtrière Paris, Service d'urgence cérébrovasculaire Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France
| | - Tanya Stojkovic
- Département de Neurophysiologie Clinique, Groupe Hospitalier Pitié-Salpêtrière Paris, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France Groupe Hospitalier Pitié-Salpêtrière Paris, Centre de Référence des Pathologies Neuromusculaires Paris Est, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France
| | - Thierry Maisonobe
- Département de Neurophysiologie Clinique, Groupe Hospitalier Pitié-Salpêtrière Paris, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France Centre diagnostique et thérapeutique des neuropathies périphériques, Département de Neurophysiologie et Service de Neurologie 1, Groupe Hospitalier Pitié-Salpêtriére Paris, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France Département de Neuropathologie R Escourolle, Groupe Hospitalier Pitié-Salpêtrière Paris, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France
| | - Timothée Lenglet
- Département de Neurophysiologie Clinique, Groupe Hospitalier Pitié-Salpêtrière Paris, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France Centre diagnostique et thérapeutique des neuropathies périphériques, Département de Neurophysiologie et Service de Neurologie 1, Groupe Hospitalier Pitié-Salpêtriére Paris, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France
| | - Emmanuel Fournier
- Département de Neurophysiologie Clinique, Groupe Hospitalier Pitié-Salpêtrière Paris, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France Groupe Hospitalier Pitié-Salpêtrière Paris, Centre de Référence des Pathologies Neuromusculaires Paris Est, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France Centre diagnostique et thérapeutique des neuropathies périphériques, Département de Neurophysiologie et Service de Neurologie 1, Groupe Hospitalier Pitié-Salpêtriére Paris, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France
| | - Pierre Bouche
- Département de Neurophysiologie Clinique, Groupe Hospitalier Pitié-Salpêtrière Paris, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France
| | - Jean-Marc Léger
- Groupe Hospitalier Pitié-Salpêtrière Paris, Centre de Référence des Pathologies Neuromusculaires Paris Est, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France
| | - Karine Viala
- Département de Neurophysiologie Clinique, Groupe Hospitalier Pitié-Salpêtrière Paris, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France Centre diagnostique et thérapeutique des neuropathies périphériques, Département de Neurophysiologie et Service de Neurologie 1, Groupe Hospitalier Pitié-Salpêtriére Paris, Université Pierre et Marie Curie-Paris VI, AP-HP, Paris, France
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Abstract
Chronic neuropathies are operationally classified as primarily demyelinating or axonal, on the basis of electrodiagnostic or pathological criteria. Demyelinating neuropathies are further classified as hereditary or acquired-this distinction is important, because the acquired neuropathies are immune-mediated and, thus, amenable to treatment. The acquired chronic demyelinating neuropathies include chronic inflammatory demyelinating polyneuropathy (CIDP), neuropathy associated with monoclonal IgM antibodies to myelin-associated glycoprotein (MAG; anti-MAG neuropathy), multifocal motor neuropathy (MMN), and POEMS syndrome. They have characteristic--though overlapping--clinical presentations, are mediated by distinct immune mechanisms, and respond to different therapies. CIDP is the default diagnosis if the neuropathy is demyelinating and no other cause is found. Anti-MAG neuropathy is diagnosed on the basis of the presence of anti-MAG antibodies, MMN is characterized by multifocal weakness and motor conduction blocks, and POEMS syndrome is associated with IgG or IgA λ-type monoclonal gammopathy and osteosclerotic myeloma. The correct diagnosis, however, can be difficult to make in patients with atypical or overlapping presentations, or nondefinitive laboratory studies. First-line treatments include intravenous immunoglobulin (IVIg), corticosteroids or plasmapheresis for CIDP; IVIg for MMN; rituximab for anti-MAG neuropathy; and irradiation or chemotherapy for POEMS syndrome. A correct diagnosis is required for choosing the appropriate treatment, with the aim of preventing progressive neuropathy.
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Affiliation(s)
- Norman Latov
- Department of Neurology and Neuroscience, Weill Medical College of Cornell University, 1305 York Avenue, Suite 217, New York, NY 10021, USA
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Querol L, Nogales-Gadea G, Rojas-Garcia R, Diaz-Manera J, Pardo J, Ortega-Moreno A, Sedano MJ, Gallardo E, Berciano J, Blesa R, Dalmau J, Illa I. Neurofascin IgG4 antibodies in CIDP associate with disabling tremor and poor response to IVIg. Neurology 2014; 82:879-86. [PMID: 24523485 DOI: 10.1212/wnl.0000000000000205] [Citation(s) in RCA: 230] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To describe the frequency of antibodies against neurofascin in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and the associated clinical features. METHODS Immunocytochemistry was used to identify antibodies to neurofascin 155 (NF155) and 186. Serum reactivity with paranodes and brain tissue was tested with immunohistochemistry of teased-nerve fibers and rat brain. Antibody titers and immunoglobulin (Ig) G isotypes were determined using ELISA. Clinical information was obtained retrospectively. RESULTS Two of 53 patients, but none of 204 controls, had antibodies to NF155 (p = 0.041). The 2 patients with NF155 antibodies developed severe polyradiculoneuropathy with predominant distal weakness that was refractory to IVIg. Eight additional patients with IVIg-refractory CIDP were then identified from a national database; 2 of them with the same clinical features also had NF155 antibodies. Overall, 3 of the 4 patients with NF155 antibodies had a disabling and characteristic tremor (high amplitude, low frequency, postural, and intention). Patients' antibodies reacted with the paranodes in teased-nerve fibers and with the neuropil of rat cerebellum, brain, and brainstem. Anti-NF155 antibodies were predominantly of the IgG4 isotype in all patients. CONCLUSION Patients with CIDP positive for IgG4 NF155 antibodies constitute a specific subgroup with a severe phenotype, poor response to IVIg, and disabling tremor. Autoantibodies against paranodal structures associate with distinct clinical features in CIDP and their identification has diagnostic, prognostic, and therapeutic implications. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that autoantibodies to NF155 identify a CIDP subtype characterized by severe neuropathy, poor response to IVIg, and disabling tremor.
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Affiliation(s)
- Luis Querol
- From the Neuromuscular Diseases Unit (L.Q., G.N.-G., R.R.-G., J.D.-M., E.G., R.B., I.I.), Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona; Centro para la Investigación Biomédica en Red en Enfermedades Neurodegenerativas (L.Q., G.N.-G., R.R.-G., J.D.-M., M.J.S., E.G., J.B., I.I.), CIBERNED, Madrid; Department of Neurology (J.P.), Hospital Clínico de Santiago, Santiago de Compostela; Department of Neurology (A.O.-M.), Hospital Virgen de las Nieves, Granada; Department of Neurology (M.J.S., J.B.), University Hospital Marqués de Valdecilla (IFIMAV) and University of Cantabria; Department of Neurology (J.D.), Hospital Clinic, Universitat de Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona; and Institució Catalana de Recerca i Estudis Avançats (J.D.), Barcelona, Spain
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Treatment of chronic inflammatory demyelinating polyneuropathy: from molecular bases to practical considerations. Autoimmune Dis 2014; 2014:201657. [PMID: 24527207 PMCID: PMC3914592 DOI: 10.1155/2014/201657] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 11/13/2013] [Indexed: 02/07/2023] Open
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is an autoimmune disease of the peripheral nervous system, in which both cellular and humoral immune responses are involved. The disease is clinically heterogeneous with some patients displaying pure motor form and others also showing a variable degree of sensory dysfunction; disease evolution may also differ from patient to patient, since monophasic, progressive, and relapsing forms are reported. Underlying such clinical variability there is probably a broad spectrum of molecular dysfunctions that are and will be the target of therapeutic strategies. In this review we first explore the biological bases of current treatments and subsequently we focus on the practical management that must also take into account pharmacoeconomic issues.
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