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Eckstein A, Stöhr M, Görtz GE, Gulbins A, Möller L, Fuehrer-Sakel D, Oeverhaus M. Current Therapeutic Approaches for Graves' Orbitopathy - are Targeted Therapies the Future? Klin Monbl Augenheilkd 2024; 241:48-68. [PMID: 37799096 DOI: 10.1055/a-2186-5548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Graves' orbitopathy is an autoimmune disease of the orbit that most frequently occurs with Graves' hyperthyroidism. The occurrence of autoantibodies directed against the TSH receptor (TRAb) is of central importance for the diagnosis and pathogenesis. These autoantibodies are mostly stimulating, and induce uncontrolled hyperthyroidism and tissue remodelling in the orbit and more or less pronounced inflammation. Consequently, patients suffer to a variable extent from periocular swelling, exophthalmos, and fibrosis of the eye muscles and thus restrictive motility impairment with double vision. In recent decades, therapeutic approaches have mainly comprised immunosuppressive treatments and antithyroid drug therapy for hyperthyroidism to inhibit thyroid hormone production. With the recognition that TRAb also activates an important growth factor receptor, IGF1R (insulin-like growth factor 1 receptor), biological agents have been developed. Teprotumumab (an inhibitory IGF1R antibody) has already been approved in the USA and the therapeutic effects are enormous, especially with regard to the reduction of exophthalmos. Side effects are to be considered, especially hyperglycaemia and hearing loss. It is not yet clear whether the autoimmune reaction (development of the TRAb/attraction of immunocompetent cells) is also influenced by anti-IGF1R inhibiting agents. Recurrences after therapy show that the inhibition of antibody development must be included in the therapeutic concept, especially in severe cases.
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Affiliation(s)
- Anja Eckstein
- Klinik für Augenheilkunde, Universitätsklinikum Essen, Deutschland
| | - Mareile Stöhr
- Klinik für Augenheilkunde, Universitätsklinikum Essen, Deutschland
| | - Gina-Eva Görtz
- Labor für Molekulare Augenheilkunde, Universität Duisburg-Essen, Duisburg, Deutschland
| | - Anne Gulbins
- Labor für Molekulare Augenheilkunde, Universität Duisburg-Essen, Duisburg, Deutschland
| | - Lars Möller
- Klinik für Endokrinologie, Diabetologie und Stoffwechsel, Universitätsklinikum Essen, Deutschland
| | - Dagmar Fuehrer-Sakel
- Klinik für Endokrinologie, Diabetologie und Stoffwechsel, Universitätsklinikum Essen, Deutschland
| | - Michael Oeverhaus
- Klinik für Augenheilkunde, Universitätsklinikum Essen, Deutschland
- Gemeinschaftspraxis Dres. Oeverhaus & Weiß, Rietberg, Deutschland
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Cieplińska K, Niedziela E, Kowalska A. Immunological Processes in the Orbit and Indications for Current and Potential Drug Targets. J Clin Med 2023; 13:72. [PMID: 38202079 PMCID: PMC10780108 DOI: 10.3390/jcm13010072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 12/17/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
Thyroid eye disease (TED) is an extrathyroidal manifestation of Graves' disease (GD). Similar to GD, TED is caused by an autoimmune response. TED is an autoimmune inflammatory disorder of the orbit and periorbital tissues, characterized by upper eyelid retraction, swelling, redness, conjunctivitis, and bulging eyes. The pathophysiology of TED is complex, with the infiltration of activated T lymphocytes and activation of orbital fibroblasts (OFs) and autoantibodies against the common autoantigen of thyroid and orbital tissues. Better understanding of the multifactorial pathogenesis of TED contributes to the development of more effective therapies. In this review, we present current and potential drug targets. The ideal treatment should slow progression of the disease with as little interference with patient immunity as possible. In the future, TED treatment will target the immune mechanism involved in the disease and will be based on a strategy of restoring tolerance to autoantigens.
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Affiliation(s)
| | - Emilia Niedziela
- Collegium Medicum, Jan Kochanowski University in Kielce, 25-317 Kielce, Poland; (E.N.); (A.K.)
- Department of Endocrinology, Holy Cross Cancer Center, 25-734 Kielce, Poland
| | - Aldona Kowalska
- Collegium Medicum, Jan Kochanowski University in Kielce, 25-317 Kielce, Poland; (E.N.); (A.K.)
- Department of Endocrinology, Holy Cross Cancer Center, 25-734 Kielce, Poland
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Quintanilla-Dieck L. The management of pediatric Graves' disease. Curr Opin Otolaryngol Head Neck Surg 2023; 31:419-423. [PMID: 37820281 DOI: 10.1097/moo.0000000000000933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
PURPOSE OF REVIEW Graves' disease (GD) constitutes a significant proportion of thyroid disorders seen during childhood. Several specialties may be closely involved in the management of pediatric patients with GD and emerging research in each field contributes to variations in the approach over time. Here we review the recent literature on the management of the disease, with the hope that this can be a valuable resource for treating specialists who need to be continuously updated on new data obtained in relevant fields. RECENT FINDINGS Genetic, postinfectious and environmental factors may play a role in the immunological pathophysiology of GD. Research performed during the COVID-19 pandemic supports that viral-induced immune dysregulation may be a possible trigger for the disease. The various current treatment options all have positive and negative factors to consider. Antithyroidal drug therapy (ATD) is generally recommended as the initial treatment, although remission rates are only 20-30% at 2 years and 75% at 9 years. Unfortunately, about half of patients will relapse within 1 year of discontinuing therapy. Radioactive iodine therapy (RAI) is an effective treatment option and can be considered in certain pediatric patients. There continues to be no definitive evidence that the doses used for GD lead to a higher risk of cancer. Surgical treatment via thyroidectomy is effective and safe when performed by a high-volume surgeon. Recent studies show improvement in quality-of-life after surgery in adolescents and young adults. Future medical treatment options for GD currently being studied include antigen-specific immunotherapy and monoclonal antibodies. SUMMARY Although the future holds promising new therapeutic options for autoimmune diseases including GD, the current choices continue to be ATD, usually first-line, and definitive treatments including RAI and surgery. While all three offer the possibility of remission or cure, drug therapy and RAI have a possibility of relapse. Risks of each approach should be broached in detail with patients and their families, and the nuances of treating this disease specifically in children should be familiar to all treating providers.
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Affiliation(s)
- Lourdes Quintanilla-Dieck
- Department of Otolaryngology Head & Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
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Hansen M, Cheever A, Weber KS, O’Neill KL. Characterizing the Interplay of Lymphocytes in Graves' Disease. Int J Mol Sci 2023; 24:6835. [PMID: 37047805 PMCID: PMC10094834 DOI: 10.3390/ijms24076835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/31/2023] [Accepted: 04/04/2023] [Indexed: 04/09/2023] Open
Abstract
Graves' disease (GD) is a thyroid-specific autoimmune disease with a high prevalence worldwide. The disease is primarily mediated by B cells, which produce autoantibodies against the thyroid-stimulating hormone receptor (TSHR), chronically stimulating it and leading to high levels of thyroid hormones in the body. Interest in characterizing the immune response in GD has motivated many phenotyping studies. The immunophenotype of the cells involved and the interplay between them and their secreted factors are crucial to understanding disease progression and future treatment options. T cell populations are markedly distinct, including increased levels of Th17 and follicular helper T cells (Tfh), while Treg cells appear to be impaired. Some B cells subsets are autoreactive, and anti-TSHR antibodies are the key disease-causing outcome of this interplay. Though some consensus across phenotyping studies will be discussed here, there are also complexities that are yet to be resolved. A better understanding of the immunophenotype of Graves' disease can lead to improved treatment strategies and novel drug targets.
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Affiliation(s)
| | | | | | - Kim L. O’Neill
- Department of Microbiology and Molecular Biology, Brigham Young University, Provo, UT 84602, USA; (M.H.); (A.C.); (K.S.W.)
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Zala A, Thomas R. Antigen-specific immunotherapy to restore antigen-specific tolerance in Type 1 diabetes and Graves' disease. Clin Exp Immunol 2023; 211:164-175. [PMID: 36545825 PMCID: PMC10019129 DOI: 10.1093/cei/uxac115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 10/23/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
Type 1 diabetes and Graves' disease are chronic autoimmune conditions, characterized by a dysregulated immune response. In Type 1 diabetes, there is beta cell destruction and subsequent insulin deficiency whereas in Graves' disease, there is unregulated excessive thyroid hormone production. Both diseases result in significant psychosocial, physiological, and emotional burden. There are associated risks of diabetic ketoacidosis and hypoglycaemia in Type 1 diabetes and risks of thyrotoxicosis and orbitopathy in Graves' disease. Advances in the understanding of the immunopathogenesis and response to immunotherapy in Type 1 diabetes and Graves' disease have facilitated the introduction of targeted therapies to induce self-tolerance, and subsequently, the potential to induce long-term remission if effective. We explore current research surrounding the use of antigen-specific immunotherapies, with a focus on human studies, in Type 1 diabetes and Graves' disease including protein-based, peptide-based, dendritic-cell-based, and nanoparticle-based immunotherapies, including discussion of factors to be considered when translating immunotherapies to clinical practice.
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Affiliation(s)
- Aakansha Zala
- Frazer Institute, The University of Queensland, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Ranjeny Thomas
- Correspondence: Ranjeny Thomas, Frazer Institute, The University of Queensland.
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Oeverhaus M, Stöhr M, Möller L, Führer D, Eckstein A. [Graves' orbitopathy: Current concepts for medical treatment]. Laryngorhinootologie 2023; 102:177-185. [PMID: 36858060 DOI: 10.1055/a-1861-7315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
BACKGROUND The therapy of severe manifestations of Graves' orbitopathy (GO) is still a challenge and requires good interdisciplinary cooperation. It is especially important to use stage-adapted anti-inflammatory therapy to avoid irreversible damage. MATERIAL AND METHODS Discussion of the latest results of multicentre randomised therapy studies on anti-inflammatory treatments for Graves' orbitopathy, as well as new therapeutic concepts. RESULTS Mild cases of GO can be treated with only selenium supplementation and a watchful waiting strategy. In the moderate-to-severe active form of GO, primary therapy consists of i. v. steroids (cumulative 4-5 g) in combination with orbital irradiation in patients with impaired motility. In patients with insufficient therapeutic response after 6 weeks, treatment should be switched to other immunosuppressive agents. In severe sight-threatening disease, bony orbital decompression is usually necessary. As basic research has improved our understanding of the underlying pathophysiology of GO, it has been possible to develop targeted therapies for GO. Teprotumumab, an IGF-1 receptor antibody, was effective in treating GO patients in a phase III trial and should soon be awarded approval for Europe. CONCLUSION The current therapy concept for Graves' orbitopathy is as follows: first anti-inflammatory therapy then surgical correction of the permanent defects. This may soon be modified, due to the use of targeted therapies.
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Affiliation(s)
- Michael Oeverhaus
- Klinik für Augenheilkunde, Universitatsklinikum Essen, Essen, Germany
| | - Mareile Stöhr
- Klinik für Augenheilkunde, Universitatsklinikum Essen, Essen, Germany
| | - Lars Möller
- Klinik für Endokrinologie, Universitatsklinikum Essen, Essen, Germany
| | - Dagmar Führer
- Klinik für Endokrinologie, Universitatsklinikum Essen, Essen, Germany
| | - Anja Eckstein
- Klinik für Augenheilkunde, Universitatsklinikum Essen, Essen, Germany
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Radziszewski M, Kuś A, Bednarczuk T. Genotype-phenotype correlations in Graves' disease. Best Pract Res Clin Endocrinol Metab 2023; 37:101745. [PMID: 36828713 DOI: 10.1016/j.beem.2023.101745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Graves' disease (GD) is a heterogeneous autoimmune disease affecting with varying degrees of severity the thyroid gland, orbital tissues and skin. The pathogenesis of GD involves a complex interplay between multiple genetic, environmental and endogenous factors. Although the genetic predisposition to GD is well established, the significance of genotype-phenotype correlations and the role of epigenetic modifications in the disease pathogenesis remains largely unknown. In this review, we provide an up-to-date overview of genotype-phenotype correlations and summarize possible clinical implications of genetic and epigenetic markers in GD patients. We will specifically discuss the association of genetic markers and epigenetic modifications with age of GD onset, severity of Graves' hyperthyroidism and the development of clinically evident Graves' orbitopathy.
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Affiliation(s)
- Mikołaj Radziszewski
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland.
| | - Aleksander Kuś
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland.
| | - Tomasz Bednarczuk
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland.
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Abstract
INTRODUCTION The thionamide anti-thyroid drugs namely carbimazole, methimazole, and propylthiouracil, have been the predominant therapy modality for Graves' hyperthyroidism for over 60 years. Although these agents have proven efficacy and favorable side-effect profiles, non-thionamide alternatives are occasionally indicated in patients who are intolerant or unresponsive to thionamides alone. This review examines the available non-thionamide drug options for the control of Graves' hyperthyroidism and summarizes their clinical utility, efficacy, and limitations. AREAS COVERED We reviewed existing literature on mechanisms, therapeutic utility, and side-effect profiles of non-thionamide anti-thyroid drugs. Established non-thionamide agents act on various phases of the synthesis, release, and metabolism of thyroid hormones and comprise historical agents such as iodine compounds and potassium perchlorate as well as drug repurposing candidates like lithium, glucocorticoids, beta-blockers, and cholestyramine. Novel experimental agents in development target key players in Graves' disease pathogenesis including B-cell depletors (Rituximab), CD40 blockers (Iscalimab), TSH-receptor antagonists, blocking antibodies, and immune-modifying peptides. EXPERT OPINION Non-thionamide anti-thyroid drugs are useful alternatives in Graves' hyperthyroidism and more clinical trials are needed to establish their safety and long-term efficacy in hyperthyroidism control. Ultimately, the promise for a cure will lie in novel approaches that target the well-established immunopathogenesis of Graves' disease.
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Affiliation(s)
- Aliya Ruslan
- Endocrine and Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, CF47 9DT, UK
| | - Onyebuchi E Okosieme
- Endocrine and Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, CF47 9DT, UK
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
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Burch HB, Perros P, Bednarczuk T, Cooper DS, Dolman PJ, Leung AM, Mombaerts I, Salvi M, Stan MN. Management of Thyroid Eye Disease: A Consensus Statement by the American Thyroid Association and the European Thyroid Association. Thyroid 2022; 32:1439-1470. [PMID: 36480280 PMCID: PMC9807259 DOI: 10.1089/thy.2022.0251] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Thyroid eye disease (TED) remains challenging for clinicians to evaluate and manage. Novel therapies have recently emerged, and their specific roles are still being determined. Most patients with TED develop eye manifestations while being treated for hyperthyroidism and under the care of endocrinologists. Endocrinologists, therefore, have a key role in diagnosis, initial management, and selection of patients who require referral to specialist care. Given that the need for guidance to endocrinologists charged with meeting the needs of patients with TED transcends national borders, and to maximize an international exchange of knowledge and practices, the American Thyroid Association and European Thyroid Association joined forces to produce this consensus statement.
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Affiliation(s)
- Henry B. Burch
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Endocrinology Division, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Address correspondence to: Henry B. Burch, MD, National Institute of Diabetes and Digestive and Kidney Diseases, Division of Diabetes, Endocrinology, & Metabolic Diseases, National Institutes of Health, 6707 Democracy Blvd, Room 5053, Bethesda, MD 20892-0001, USA
| | - Petros Perros
- Department of Endocrinology, Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Tomasz Bednarczuk
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - David S. Cooper
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Peter J. Dolman
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, Canada
| | - Angela M. Leung
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, UCLA David Geffen School of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Ilse Mombaerts
- Department of Ophthalmology, University Hospitals Leuven, Leuven, Belgium
| | - Mario Salvi
- Department of Clinical and Community Services, Graves' Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Milan, Italy
| | - Marius N. Stan
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, Minnesota, USA
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Wong TWC, Wong MYS. Remission in pediatric Graves' disease treated with antithyroid drug and the risk factors associated with relapse. Ann Pediatr Endocrinol Metab 2022; 27:308-314. [PMID: 36567464 PMCID: PMC9816462 DOI: 10.6065/apem.2244038.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 09/20/2022] [Indexed: 12/27/2022] Open
Abstract
PURPOSE To evaluate the characteristics and frequency of remission in pediatric patients with Graves' disease (GD) treated with antithyroid drug (ATD) and to identify factors that may be associated with relapse. METHODS Medical records of patients younger than 19 years who presented to the Department of Pediatrics of Queen Elizabeth Hospital Hong Kong with newly diagnosed GD from 1st January 2007 to 31st December 2017 were retrospectively reviewed. Remission was defined as euthyroidism for 12 months or more after discontinuation of ATD treatment and no relapses during the follow-up period. Patients who successfully achieved remission were compared to those who suffered relapse. Factors that may predict occurrence of relapse after ATD treatments were studied, and their odds ratios (ORs) were calculated. RESULTS A total of 101 patients was included in this study. Eighty-one patients completed one course of ATD. Eighteen patients (17.8%) successfully achieved remission, and 58 patients (57.4%) experienced relapse after discontinuation of ATD. The remission group received a significantly longer course of ATD therapy than the relapse group (median, 28 months; interquartile range [IQR], 18-48 months in remission group vs. median, 21 months; IQR, 17-26; p=0.024). The OR for relapse was 0.971 (95% confidence interval [CI], 0.946-0.997) in univariate analysis and remained significant after adjustments in the multivariate regression model (OR, 0.961; 95% CI, 0.933-0.989; p=0.008). CONCLUSION The remission rate in pediatric patients with GD treated with ATD was low. A longer ATD course was associated with a greater chance of remission in this population.
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Affiliation(s)
- Tsz Wai Catherine Wong
- Department of Paediatrics, Queen Elizabeth Hospital Hong Kong, Hong Kong, Hong Kong,Address for correspondence: Tsz Wai Catherine Wong Department of Paediatrics, Queen Elizabeth Hospital, 30 Gascoigne Road, Jordan, Hong Kong
| | - Man Yee Shirley Wong
- Department of Paediatrics, Queen Elizabeth Hospital Hong Kong, Hong Kong, Hong Kong
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Burch HB, Perros P, Bednarczuk T, Cooper DS, Dolman PJ, Leung AM, Mombaerts I, Salvi M, Stan MN. Management of thyroid eye disease: a Consensus Statement by the American Thyroid Association and the European Thyroid Association. Eur Thyroid J 2022; 11:e220189. [PMID: 36479875 PMCID: PMC9727317 DOI: 10.1530/etj-22-0189] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 10/19/2022] [Indexed: 11/30/2022] Open
Abstract
Thyroid eye disease (TED) remains challenging for clinicians to evaluate and manage. Novel therapies have recently emerged, and their specific roles are still being determined. Most patients with TED develop eye manifestations while being treated for hyperthyroidism and under the care of endocrinologists. Endocrinologists, therefore, have a key role in diagnosis, initial management, and selection of patients who require referral to specialist care. Given that the need for guidance to endocrinologists charged with meeting the needs of patients with TED transcends national borders, and to maximize an international exchange of knowledge and practices, the American Thyroid Association and European Thyroid Association joined forces to produce this Consensus Statement.
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Affiliation(s)
- Henry B Burch
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Endocrinology Division, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Petros Perros
- Department of Endocrinology, Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Tomasz Bednarczuk
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - David S Cooper
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Peter J Dolman
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, Canada
| | - Angela M Leung
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, UCLA David Geffen School of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Ilse Mombaerts
- Department of Ophthalmology, University Hospitals Leuven, Leuven, Belgium
| | - Mario Salvi
- Department of Clinical and Community Services, Graves’ Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Milan, Italy
| | - Marius N Stan
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, Minnesota, USA
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12
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Abstract
Graves disease (GD) is the most common cause of hyperthyroidism, accounting for more than 90% of cases in Korea. Patients with GD are treated with any of the following: antithyroid drugs (ATDs), radioactive iodine (RAI) therapy, or thyroidectomy. Most patients begin treatment with ATDs, and clinical guidelines suggest that the appropriate treatment period is 12 to 18 months. While RAI treatment and surgery manage thyrotoxicosis by destroying or removing thyroid tissue, ATDs control thyrotoxicosis by inhibiting thyroid hormone synthesis and preserving the thyroid gland. Although ATDs efficiently control thyrotoxicosis symptoms, they do not correct the main etiology of GD; therefore, frequent relapses can follow. Recently, a large amount of data has been collected on long-term ATDs for GD, and low-dose methimazole (MMZ) is expected to be a good option for remission. For the long-term management of recurrent GD, it is important to induce remission by evaluating the patient's drug response, stopping ATDs at an appropriate time, and actively switching to surgery or RAI therapy, if indicated. Continuing drug treatment for an extended time is now encouraged in patients with a high possibility of remission with low-dose MMZ. It is also important to pay attention to the quality of life of the patients. This review aimed to summarize the appropriate treatment methods and timing of treatment transition in patients who relapsed several times while receiving treatment for GD.
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Affiliation(s)
- Hyo-Jeong Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Nowon Eulji University Hospital, Eulji University School of Medicine, Seoul, Korea,Corresponding author: Hyo-Jeong Kim, MD, PhD Thyroid-Endocrine Center, Nowon Eulji University Hospital, Annex, 1st floor, 68 Hangeulbiseok-ro, Nowon-gu, Seoul 01830, Korea Tel: +82-2-970-8558 • Fax: +82-2-970-8878 • E-mail:
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13
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Abstract
Graves' orbitopathy (GO) is an orbital autoimmune disorder and the main extrathyroidal manifestation of Graves' disease, the most common cause of hyperthyroidism. GO affects about 30% of Graves' patients, although fewer than 10% have severe forms requiring immunosuppressive treatments. Management of GO requires a multidisciplinary approach. Medical therapies for active moderate-to-severe forms of GO (traditionally, high-dose glucocorticoids) often provide unsatisfactory results, and subsequently surgeries are often needed to cure residual manifestations. The aim of this review is to provide an updated overview of current concepts regarding the epidemiology, pathogenesis, assessment, and treatment of GO, and to present emerging targeted therapies and therapeutic perspectives. Original articles, clinical trials, systematic reviews, and meta-analyses from 1980 to 2021 were searched using the following terms: Graves' disease, Graves' orbitopathy, thyroid eye disease, glucocorticoids, orbital radiotherapy, rituximab, cyclosporine, azathioprine, teprotumumab, TSH-receptor antibody, smoking, hyperthyroidism, hypothyroidism, thyroidectomy, radioactive iodine, and antithyroid drugs. Recent studies suggest a secular trend toward a milder phenotype of GO. Standardized assessment at a thyroid eye clinic allows for a better general management plan. Treatment of active moderate-to-severe forms of GO still relies in most cases on high-dose systemic-mainly intravenous-glucocorticoids as monotherapy or in combination with other therapies-such as mycophenolate, cyclosporine, azathioprine, or orbital radiotherapy-but novel biological agents-including teprotumumab, rituximab, and tocilizumab-have achieved encouraging results.
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Affiliation(s)
- Luigi Bartalena
- Department of Medicine and SurgeryUniversity of InsubriaVareseItaly
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Abstract
CONTEXT Thyroid eye disease (TED), a vision-threatening and disfiguring autoimmune process, has thwarted our efforts to understand its pathogenesis and develop effective and safe treatments. Recent scientific advances have facilitated improved treatment options. OBJECTIVE Review historically remote and recent advances in understanding TED. DESIGN/SETTING/PARTICIPANTS PubMed was scanned using search terms including thyroid-associated ophthalmopathy, thyroid eye disease, Graves' orbitopathy, autoimmune thyroid disease, and orbital inflammation. MAIN OUTCOME MEASURES Strength of scientific evidence, size, scope, and controls of clinical trials/observations. RESULTS Glucocorticoid steroids are widely prescribed systemic medical therapy. They can lessen inflammation-related manifestations of TED but fail to reliably reduce proptosis and diplopia, 2 major causes of morbidity. Other current therapies include mycophenolate, rituximab (anti-CD20 B cell-depleting monoclonal antibody), tocilizumab (interleukin-6 receptor antagonist), and teprotumumab (IGF-I receptor inhibitor). Several new therapeutic approaches have been proposed including targeting prostaglandin receptors, vascular endothelial growth factor, mTOR, and cholesterol pathways. Of potentially greater long-term importance are attempts to restore immune tolerance. CONCLUSION Despite their current wide use, steroids may no longer enjoy first-tier status for TED as more effective and better tolerated medical options become available. Multiple current and emerging therapies, the rationales for which are rooted in theoretical and experimental science, promise better options. These include teprotumumab, rituximab, and tocilizumab. Restoration of immune tolerance could ultimately become the most effective and safe medical management for TED.
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Affiliation(s)
- Terry J Smith
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48105, USA
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15
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Lazaridis K, Fernandez-Santoscoy M, Baltatzidou V, Andersson JO, Christison R, Grünberg J, Tzartos S, Löwenadler B, Fribert C. A Recombinant Acetylcholine Receptor α1 Subunit Extracellular Domain Is a Promising New Drug Candidate for Treatment Of Myasthenia Gravis. Front Immunol 2022; 13:809106. [PMID: 35720339 PMCID: PMC9204200 DOI: 10.3389/fimmu.2022.809106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 04/21/2022] [Indexed: 12/03/2022] Open
Abstract
Background and Aims Myasthenia gravis (MG) is a T-cell dependent antibody-mediated autoimmune disease in which the nicotinic acetylcholine receptor (AChR) is the major autoantigen, comprising several T and B cell auto-epitopes. We hypothesized that an efficacious drug candidate for antigen-specific therapy in MG should comprise a broad range of these auto-epitopes and be administered in a noninflammatory and tolerogenic context. Methods We used a soluble mutated form of the extracellular domain of the α1 chain of the AChR (α1-ECDm), which represents the major portion of auto-epitopes involved in MG, and investigated, in a well-characterized rat model of experimental autoimmune myasthenia gravis (EAMG) whether its intravenous administration could safely and efficiently treat the autoimmune disease. Results We demonstrated that intravenous administration of α1-ECDm abrogates established EAMG, in a dose and time dependent manner, as assessed by clinical symptoms, body weight, and compound muscle action potential (CMAP) decrement. Importantly, the effect was more pronounced compared to drugs representing current standard of care for MG. The protein had a short plasma half-life, most of what could be recovered was sequestered in the liver, kidneys and spleen. Further, we did not observe any signs of toxicity or intolerability in animals treated with α1-ECDm. Conclusion We conclude that intravenous treatment with α1-ECDm is safe and effective in suppressing EAMG. α1-ECDm is in preclinical development as a promising new drug candidate for MG.
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Affiliation(s)
| | | | | | | | | | | | - Socrates Tzartos
- Department of Neurobiology, Hellenic Pasteur Institute, Athens, Greece.,Tzartos NeuroDiagnostics, Athens, Greece
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16
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Furmaniak J, Sanders J, Sanders P, Li Y, Rees Smith B. TSH receptor specific monoclonal autoantibody K1-70 TM targeting of the TSH receptor in subjects with Graves' disease and Graves' orbitopathy-Results from a phase I clinical trial. Clin Endocrinol (Oxf) 2022; 96:878-887. [PMID: 35088429 PMCID: PMC9305464 DOI: 10.1111/cen.14681] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/24/2022] [Accepted: 01/26/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES In Graves' disease (GD), autoantibodies to the thyroid stimulating hormone receptor (TSHR) cause hyperthyroidism. The condition is often associated with eye signs including proptosis, oedema, and diplopia (collectively termed Graves' orbitopathy [GO]). The safety profile of K1-70TM (a human monoclonal TSHR specific autoantibody, which blocks ligand binding and stimulation of the receptor) in patients with GD was evaluated in a phase I clinical trial. PATIENTS AND STUDY DESIGN Eighteen GD patients stable on antithyroid drug medication received a single intramuscular (IM) or intravenous (IV) dose of K1-70TM during an open label phase I ascending dose, safety, tolerability, pharmacokinetic and pharmacodynamic (PD) study. Immunogenic effects of K1-70TM were also determined. RESULTS K1-70TM was well-tolerated in all subjects at all doses and no significant immunogenic response was observed. There were no deaths or serious adverse events. Increased systemic exposure to K1-70TM was observed following a change to IV dosing, indicating this was the correct dosage route. Expected PD effects occurred after a single IM dose of 25 mg or single IV dose of 50 mg or 150 mg with fT3, fT4, and TSH levels progressing into hypothyroid ranges. There were also clinically significant improvements in symptoms of both GD (reduced tremor, improved sleep, improved mental focus, reduced toilet urgency) and GO (reduced exophthalmos measurements, reduced photosensitivity). CONCLUSIONS K1-70TM was safe, well tolerated and produced the expected PD effects with no immunogenic responses. It shows considerable promise as a new drug to block the actions of thyroid stimulators on the TSHR.
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Affiliation(s)
- Jadwiga Furmaniak
- AV7 Limited, FIRS Laboratories, Parc Ty GlasCardiffUK
- RSR Limited, FIRS Laboratories, Parc Ty GlasCardiffUK
| | - Jane Sanders
- AV7 Limited, FIRS Laboratories, Parc Ty GlasCardiffUK
- RSR Limited, FIRS Laboratories, Parc Ty GlasCardiffUK
| | - Paul Sanders
- RSR Limited, FIRS Laboratories, Parc Ty GlasCardiffUK
| | - Yang Li
- RSR Limited, FIRS Laboratories, Parc Ty GlasCardiffUK
| | - Bernard Rees Smith
- AV7 Limited, FIRS Laboratories, Parc Ty GlasCardiffUK
- RSR Limited, FIRS Laboratories, Parc Ty GlasCardiffUK
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17
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Bartalena L, Piantanida E, Gallo D, Ippolito S, Tanda ML. Management of Graves' hyperthyroidism: present and future. Expert Rev Endocrinol Metab 2022; 17:153-166. [PMID: 35287535 DOI: 10.1080/17446651.2022.2052044] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 03/08/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Graves' disease (GD) is an autoimmune disorder due to loss of tolerance to the thyrotropin receptor (TSHR) and ultimately caused by stimulatory TSHR antibodies (TSHR-Ab). GD may be associated with extrathyroidal manifestations, mainly Graves' orbitopathy. Treatment of GD relies on antithyroid drugs (ATDs), radioactive iodine (RAI), thyroidectomy. The major ATD limitation is the high recurrence rate after treatment. The major drawback of RAI and thyroidectomy is the inevitable development of permanent hypothyroidism. AREAS COVERED Original articles, clinical trials, systematic reviews, meta-analyses from 1980 to 2021 were searched using the following terms: Graves' disease, management of Graves' disease, antithyroid drugs, radioactive iodine, thyroidectomy, Graves' orbitopathy, thyroid-eye disease. EXPERT OPINION ATDs are the first-line treatment worldwide, are overall safe and usually given for 18-24 months, long-term treatment may decrease relapses. RAI is safe, although associated with a low risk of GO progression, particularly in smokers. Thyroidectomy requires skilled and high-volume surgeons. Patients play a central role in the choice of treatment within a shared decision-making process. Results from targeted therapies acting on different steps of the autoimmune process, including iscalimab, ATX-GD-59, rituximab, blocking TSHR-Ab, small molecules acting as antagonists of the TSHR, are preliminary or preclinical, but promising in medium-to-long perspective.
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Affiliation(s)
- Luigi Bartalena
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Eliana Piantanida
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Daniela Gallo
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Silvia Ippolito
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Maria Laura Tanda
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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18
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Zhou H, Muller I, Chong KKL, Ludgate M, Fang S. Editorial: Mechanisms and Novel Therapies in Graves' Orbitopathy: Current Update. Front Endocrinol (Lausanne) 2022; 13:902591. [PMID: 35574000 PMCID: PMC9098824 DOI: 10.3389/fendo.2022.902591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 03/23/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Huifang Zhou
- Department of Ophthalmology, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
- *Correspondence: Huifang Zhou, ; Sijie Fang,
| | - Ilaria Muller
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Department of Endocrinology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Division of Infection and Immunity, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Kelvin Kam-Lung Chong
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Marian Ludgate
- Division of Infection and Immunity, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Sijie Fang
- Department of Ophthalmology, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
- *Correspondence: Huifang Zhou, ; Sijie Fang,
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19
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Elia G, Fallahi P, Ragusa F, Paparo SR, Mazzi V, Benvenga S, Antonelli A, Ferrari SM. Precision Medicine in Graves' Disease and Ophthalmopathy. Front Pharmacol 2021; 12:754386. [PMID: 34776972 PMCID: PMC8581657 DOI: 10.3389/fphar.2021.754386] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/12/2021] [Indexed: 02/02/2023] Open
Abstract
Graves’ disease (GD) is a condition caused by an autoimmune process involving the thyroid gland, whose main outcome is hyperthyroidism. TSAb start the autoimmune process stimulating the overproduction of thyroid hormones. In addition, TSAb can stimulate TSH-R expressed in fibroblasts and orbital pre-adipocytes leading to the manifestation of Graves’ ophtalmopathy (GO). Also, autoantibodies directed against IGF-1R have an important role in immune-pathogenesis of GO. Fundamental is the role played by cytokines (IFN-γ, TNF-α, Il-6), and Th1 chemokines in the immune-pathogenesis of both disorders, particularly in the active phase. Novel discoveries in the field led to the investigation of promising therapies, such as immune-therapies towards specific antigens (for example against TSH-R), aiming in restoring the immune tolerance versus the immune dominant epitopes associated with autoimmunity in GD. Moreover, Etanercept (that blocks the TNF-mediated inflammatory responses), TCZ (that acts against the IL-6 receptor), and RTX (that acts against CD20) have proven to be useful and safe therapeutic options in refractory GO treatment. Furthermore, teprotumumab (a human monoclonal anti-IGF-1R blocking antibody), have been revealed effective in the treatment of patients with moderate-severe GO and it is now approved for GO therapy in United States. Molecules able to act as antagonists of CXCR3, or to block CXCL10, are also under study. More extensive researches are needed to deepen out these drugs as well as to identify new targeted and effective therapies, that will permit a more precise identification of GD, or GO, patients able to respond to specific targeted therapies.
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Affiliation(s)
- Giusy Elia
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Poupak Fallahi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Francesca Ragusa
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Valeria Mazzi
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.,Master Program on Childhood, Adolescent and Women's Endocrine Health, University of Messina, Messina, Italy.,Interdepartmental Program of Molecular and Clinical Endocrinology and Women's Endocrine Health, University Hospital, A.O.U. Policlinico G. Martino, Messina, Italy
| | - Alessandro Antonelli
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
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20
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Schurgers E, Wraith DC. Induction of Tolerance to Therapeutic Proteins With Antigen-Processing Independent T Cell Epitopes: Controlling Immune Responses to Biologics. Front Immunol 2021; 12:742695. [PMID: 34567009 PMCID: PMC8459012 DOI: 10.3389/fimmu.2021.742695] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 08/18/2021] [Indexed: 11/28/2022] Open
Abstract
The immune response to exogenous proteins can overcome the therapeutic benefits of immunotherapies and hamper the treatment of protein replacement therapies. One clear example of this is haemophilia A resulting from deleterious mutations in the FVIII gene. Replacement with serum derived or recombinant FVIII protein can cause anti-drug antibodies in 20-50% of individuals treated. The resulting inhibitor antibodies override the benefit of treatment and, at best, make life unpredictable for those treated. The only way to overcome the inhibitor issue is to reinstate immunological tolerance to the administered protein. Here we compare the various approaches that have been tested and focus on the use of antigen-processing independent T cell epitopes (apitopes) for tolerance induction. Apitopes are readily designed from any protein whether this is derived from a clotting factor, enzyme replacement therapy, gene therapy or therapeutic antibody.
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Affiliation(s)
| | - David C Wraith
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
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21
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Meehan GR, Thomas R, Al Khabouri S, Wehr P, Hilkens CM, Wraith DC, Sieghart D, Bonelli M, Nagy G, Garside P, Tough DF, Lewis HD, Brewer JM. Preclinical models of arthritis for studying immunotherapy and immune tolerance. Ann Rheum Dis 2021; 80:1268-1277. [PMID: 34380700 PMCID: PMC8458054 DOI: 10.1136/annrheumdis-2021-220043] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 06/27/2021] [Indexed: 02/06/2023]
Abstract
Increasingly earlier identification of individuals at high risk of rheumatoid arthritis (RA) (eg, with autoantibodies and mild symptoms) improves the feasibility of preventing or curing disease. The use of antigen-specific immunotherapies to reinstate immunological self-tolerance represent a highly attractive strategy due to their potential to induce disease resolution, in contrast to existing approaches that require long-term treatment of underlying symptoms. Preclinical animal models have been used to understand disease mechanisms and to evaluate novel immunotherapeutic approaches. However, models are required to understand critical processes supporting disease development such as the breach of self-tolerance that triggers autoimmunity and the progression from asymptomatic autoimmunity to joint pain and bone loss. These models would also be useful in evaluating the response to treatment in the pre-RA period. This review proposes that focusing on immune processes contributing to initial disease induction rather than end-stage pathological consequences is essential to allow development and evaluation of novel immunotherapies for early intervention. We will describe and critique existing models in arthritis and the broader field of autoimmunity that may fulfil these criteria. We will also identify key gaps in our ability to study these processes in animal models, to highlight where further research should be targeted.
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Affiliation(s)
- Gavin R Meehan
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Ranjeny Thomas
- University of Queensland Diamantina Institute, The University of Queensland, Woolloongabba, Queensland, Australia
| | - Shaima Al Khabouri
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Center for Molecular Medicine, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Pascale Wehr
- University of Queensland Diamantina Institute, The University of Queensland, Woolloongabba, Queensland, Australia
| | - Catharien Mu Hilkens
- Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - David C Wraith
- Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Daniela Sieghart
- Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Michael Bonelli
- Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - György Nagy
- Department of Rheumatology & Clinical Immunology, Semmelweis University, Budapest, Hungary.,Department of Genetics, Cell and Immunobiology, Semmelweis University, Budapest, Hungary
| | - Paul Garside
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - David F Tough
- GlaxoSmithKline Research and Development, Stevenage, Hertfordshire, UK
| | - Huw D Lewis
- GlaxoSmithKline Research and Development, Stevenage, Hertfordshire, UK
| | - James M Brewer
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
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22
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Abstract
The excess thyroid hormone secretion that characterises Graves' disease (GD) is generated when stimulatory antibodies bind to the thyroid stimulating hormone receptor on the follicular cell of the thyroid gland.This underlying mechanism cannot easily be abolished and the mainstay of Graves' disease (GD) management in the young remains thionamide anti-thyroid drug (ATD). Unfortunately, GD will usually recur after a 2 or 3 year course of ATD, even when the stimulatory antibody titres have fallen. The diagnosis of GD therefore usually signals the start of a lengthy period of out-patient assessments and associated venepuncture. Careful, more protracted administration of ATD may increase the likelihood of longer-term remission and reduce the likelihood of the patient developing ATD side-effects. An understanding of how best to use ATD and an awareness of the less well-known consequences of GD and its' treatment - such as excessive weight-gain and long-term hypothyroidism - are also of fundamental importance.Recent clinical studies have shed light on how best to manage the young patient with GD and the associated new information will help to answer some of the questions posed by the young person and their family at diagnosis. This new knowledge is the focus of this article about ATD therapy in the young.
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Affiliation(s)
- Tim Cheetham
- Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK. .,Department of Paediatric Endocrinology, Royal Victoria Infirmary, Great North Children's Hospital, Newcastle upon Tyne, NE1 4LP, UK.
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23
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Wraith DC, Krishna MT. Peptide allergen-specific immunotherapy for allergic airway diseases-State of the art. Clin Exp Allergy 2021; 51:751-769. [PMID: 33529435 DOI: 10.1111/cea.13840] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 01/24/2021] [Accepted: 01/28/2021] [Indexed: 12/13/2022]
Abstract
Allergen-specific immunotherapy (AIT) is the only means of altering the natural immunological course of allergic diseases and achieving long-term remission. Pharmacological measures are able to suppress the immune response and/or ameliorate the symptoms but there is a risk of relapse soon after these measures are withdrawn. Current AIT approaches depend on the administration of intact allergens, often comprising crude extracts of the allergen. We propose that the challenges arising from current approaches, including the risk of serious side-effects, burdensome duration of treatment, poor compliance and high cost, are overcome by application of peptides based on CD4+ T cell epitopes rather than whole allergens. Here we describe evolving approaches, summarize clinical trials involving peptide AIT in allergic rhinitis and asthma, discuss the putative mechanisms involved in their action, address gaps in evidence and propose future directions for research and clinical development.
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Affiliation(s)
- David C Wraith
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Mamidipudi T Krishna
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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24
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Smith TJ. Teprotumumab in Thyroid-Associated Ophthalmopathy: Rationale for Therapeutic Insulin-Like Growth Factor-I Receptor Inhibition. J Neuroophthalmol 2020; 40:74-83. [PMID: 32040069 DOI: 10.1097/WNO.0000000000000890] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Thyroid-associated ophthalmopathy (TAO) is an autoimmune component of Graves' disease for which no currently available medical therapy provides reliable and safe benefit. Based on insights generated experimentally over the past several decades, the insulin-like growth factor-I receptor (IGF-IR) has been implicated in the pathogenesis of TAO. Furthermore, an IGF-IR inhibitor, teprotumumab, has emerged from 2 clinical trials as a promising treatment for active, moderate to severe TAO. This brief review intends to provide an overview of the rationale underlying the development of teprotumumab for this disease. It is possible that teprotumumab will soon take its place in our therapeutic armamentarium for active TAO.
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25
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Richardson N, Wraith DC. Advancement of antigen-specific immunotherapy: knowledge transfer between allergy and autoimmunity. Immunotherapy Advances 2021; 1:ltab009. [PMID: 35919740 PMCID: PMC9327121 DOI: 10.1093/immadv/ltab009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/28/2021] [Accepted: 05/21/2021] [Indexed: 12/11/2022] Open
Abstract
Targeted restoration of immunological tolerance to self-antigens or innocuous environmental allergens represents the ultimate aim of treatment options in autoimmune and allergic disease. Antigen-specific immunotherapy (ASI) is the only intervention that has proven disease-modifying efficacy as evidenced by induction of long-term remission in a number of allergic conditions. Mounting evidence is now indicating that specific targeting of pathogenic T cells in autoinflammatory and autoimmune settings enables effective restoration of immune homeostasis between effector and regulatory cells and alters the immunological course of disease. Here, we discuss the key lessons learned during the development of antigen-specific immunotherapies and how these can be applied to inform future interventions. Armed with this knowledge and current high-throughput technology to track immune cell phenotype and function, it may no longer be a matter of ‘if’ but ‘when’ this ultimate aim of targeted tolerance restoration is realised.
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Affiliation(s)
- Naomi Richardson
- Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - David Cameron Wraith
- Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
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26
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Bevington SL, Ng STH, Britton GJ, Keane P, Wraith DC, Cockerill PN. Chromatin Priming Renders T Cell Tolerance-Associated Genes Sensitive to Activation below the Signaling Threshold for Immune Response Genes. Cell Rep 2021; 31:107748. [PMID: 32521273 PMCID: PMC7296351 DOI: 10.1016/j.celrep.2020.107748] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/20/2020] [Accepted: 05/18/2020] [Indexed: 12/13/2022] Open
Abstract
Immunological homeostasis in T cells is maintained by a tightly regulated signaling and transcriptional network. Full engagement of effector T cells occurs only when signaling exceeds a critical threshold that enables induction of immune response genes carrying an epigenetic memory of prior activation. Here we investigate the underlying mechanisms causing the suppression of normal immune responses when T cells are rendered anergic by tolerance induction. By performing an integrated analysis of signaling, epigenetic modifications, and gene expression, we demonstrate that immunological tolerance is established when both signaling to and chromatin priming of immune response genes are weakened. In parallel, chromatin priming of immune-repressive genes becomes boosted, rendering them sensitive to low levels of signaling below the threshold needed to activate immune response genes. Our study reveals how repeated exposure to antigens causes an altered epigenetic state leading to T cell anergy and tolerance, representing a basis for treating auto-immune diseases. Activation of immune response genes is suppressed in tolerant T cells Epigenetic priming of repressive genes is boosted when tolerance is established Inhibitory receptor genes have a lower threshold of activation in tolerant cells Induction of tolerance by peptides points toward a therapy for multiple sclerosis
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Affiliation(s)
- Sarah L Bevington
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Sky T H Ng
- Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Graham J Britton
- Precision Immunology Institute and Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Peter Keane
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - David C Wraith
- Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK.
| | - Peter N Cockerill
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK.
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27
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Streeter HB, Wraith DC. Manipulating antigen presentation for antigen-specific immunotherapy of autoimmune diseases. Curr Opin Immunol 2021; 70:75-81. [PMID: 33878516 PMCID: PMC8376632 DOI: 10.1016/j.coi.2021.03.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/26/2021] [Accepted: 03/28/2021] [Indexed: 12/14/2022]
Abstract
Specific immunotherapy is the ‘holy grail’ for treatment of autoimmunity. Antigens are delivered by either direct or indirect presentation mechanisms. Liver APC and steady state DC mediate distinct forms of immune regulation. Tr1 cell induction involves epigenetic modification of tolerance associated genes. Trials reveal that antigen-specific immunotherapy can control autoimmune diseases.
Current treatments for autoimmune diseases do not address the immune pathology underlying their initiation and progression and too often rely on non-specific immunosuppressive drugs for control of symptoms. Antigen-specific immunotherapy aims to induce tolerance selectively among the cells causing the disease while leaving the rest of the adaptive immune system capable of protecting against infectious diseases and cancers. Here we describe how novel approaches for antigen-specific immunotherapy are designed to manipulate antigen presentation and promote tolerance to specific self-antigens. This analysis points to liver antigen presenting cells, targeted by carrier particles, and steady-state dendritic cells, to which antigen-processing independent T-cell epitopes (apitopes) bind directly, as the principal targets for antigen-specific immunotherapy. Delivery of antigens to these cells holds great promise for effective control of this rapidly expanding group of diseases.
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Affiliation(s)
- Heather B Streeter
- Institute of Immunology and Immunotherapy, University of Birmingham, B15 2TT, United Kingdom
| | - David C Wraith
- Institute of Immunology and Immunotherapy, University of Birmingham, B15 2TT, United Kingdom.
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28
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Shepard ER, Wegner A, Hill EV, Burton BR, Aerts S, Schurgers E, Hoedemaekers B, Ng STH, Streeter HB, Jansson L, Wraith DC. The Mechanism of Action of Antigen Processing Independent T Cell Epitopes Designed for Immunotherapy of Autoimmune Diseases. Front Immunol 2021; 12:654201. [PMID: 33936079 PMCID: PMC8079784 DOI: 10.3389/fimmu.2021.654201] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/23/2021] [Indexed: 12/20/2022] Open
Abstract
Immunotherapy with antigen-processing independent T cell epitopes (apitopes) targeting autoreactive CD4+ T cells has translated to the clinic and been shown to modulate progression of both Graves’ disease and multiple sclerosis. The model apitope (Ac1-9[4Y]) renders antigen-specific T cells anergic while repeated administration induces both Tr1 and Foxp3+ regulatory cells. Here we address why CD4+ T cell epitopes should be designed as apitopes to induce tolerance and define the antigen presenting cells that they target in vivo. Furthermore, we reveal the impact of treatment with apitopes on CD4+ T cell signaling, the generation of IL-10-secreting regulatory cells and the systemic migration of these cells. Taken together these findings reveal how apitopes induce tolerance and thereby mediate antigen-specific immunotherapy of autoimmune diseases.
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Affiliation(s)
- Ella R Shepard
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
| | - Anja Wegner
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
| | - Elaine V Hill
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
| | - Bronwen R Burton
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
| | - Sarah Aerts
- Apitope International NV, Diepenbeek, Belgium
| | | | | | - Sky T H Ng
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Heather B Streeter
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | | | - David C Wraith
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
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Cui X, Huang M, Wang S, Zhao N, Huang T, Wang Z, Qiao J, Wang S, Shan Z, Teng W, Li Y. Circulating Exosomes From Patients With Graves' Disease Induce an Inflammatory Immune Response. Endocrinology 2021; 162:6046189. [PMID: 33367747 DOI: 10.1210/endocr/bqaa236] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Indexed: 12/14/2022]
Abstract
Exosomes are extracellular vesicles that can participate in autoimmune diseases. The purpose of this study was to explore whether circulating exosomes are involved in Graves' disease (GD) pathogenesis. In this study, serum exosomes were extracted from 26 healthy controls (HC-EXO), 26 GD patients (GD-EXO), and 7 Graves' ophthalmopathy patients (GO-EXO). For each group, the total protein content was detected, and thyrotropin receptor, insulin-like growth factor 1 receptor (IGF-1R), heat shock protein 60 (HSP60), and cluster of differentiation (CD) 63 expression were analyzed by Western blotting (WB). Healthy volunteer-derived peripheral blood mononuclear cells (PBMCs) and HC-EXO or GD-EXO were cocultured for 24 h, and immunofluorescence was used to observe the locations of the exosomes and toll-like receptor (TLR) 2/3. CD11c+TLR2+ and CD11c+TLR3+ cell percentages were determined by flow cytometry. Myeloid differentiation factor 88 (MyD88), toll/interleukin (IL)-1 receptor domain-containing adaptor inducing interferon-β (TRIF) and p-P65 expression were analyzed by WB. IL-6 and IL-1β supernatant levels were detected using enzyme-linked immunosorbent assay. The results showed that the total protein concentration was similar among GD-EXO, GO-EXO, and HC-EXO. IGF-1R and HSP60 expression was significantly higher in GD-EXO and GO-EXO than in HC-EXO. After coculturing PBMCs with GD-EXO or HC-EXO for 24 h, GD-EXO could bind to TLR2/3. GD-EXO significantly increased CD11c+TLR2+ and CD11c+TLR3+ cell percentages; MyD88, TRIF, and p-P65 protein expression; and IL-6 and IL-1β levels. In conclusion, we first demonstrated that GD-EXO and GO-EXO highly expressed IGF-1R and HSP60. GD-EXO may induce an inflammatory response through the TLR/NF-κB signaling pathway and be involved in the pathogenesis of GD.
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Affiliation(s)
- Xuejiao Cui
- Department of Endocrinology and Metabolism, Institute of Endocrinology, The First Hospital of China Medical University, Shenyang, China
- Department of Endocrinology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Mingshi Huang
- Department of Endocrinology and Metabolism, Institute of Endocrinology, The First Hospital of China Medical University, Shenyang, China
| | - Shiwei Wang
- Department of Endocrinology and Metabolism, Institute of Endocrinology, The First Hospital of China Medical University, Shenyang, China
| | - Na Zhao
- Department of Endocrinology and Metabolism, Institute of Endocrinology, The First Hospital of China Medical University, Shenyang, China
| | - Ting Huang
- Department of Endocrinology and Metabolism, Institute of Endocrinology, The First Hospital of China Medical University, Shenyang, China
| | - Zhenzhen Wang
- Department of Endocrinology and Metabolism, Institute of Endocrinology, The First Hospital of China Medical University, Shenyang, China
| | - Jing Qiao
- Department of Endocrinology and Metabolism, Institute of Endocrinology, The First Hospital of China Medical University, Shenyang, China
| | - Shuo Wang
- Department of Endocrinology and Metabolism, Institute of Endocrinology, The First Hospital of China Medical University, Shenyang, China
| | - Zhongyan Shan
- Department of Endocrinology and Metabolism, Institute of Endocrinology, The First Hospital of China Medical University, Shenyang, China
| | - Weiping Teng
- Department of Endocrinology and Metabolism, Institute of Endocrinology, The First Hospital of China Medical University, Shenyang, China
| | - Yushu Li
- Department of Endocrinology and Metabolism, Institute of Endocrinology, The First Hospital of China Medical University, Shenyang, China
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Abstract
BACKGROUND The therapy of severe manifestations of Graves' orbitopathy (GO) is still a challenge and requires good interdisciplinary cooperation. It is especially important to use stage-adapted anti-inflammatory therapy to avoid irreversible damage. MATERIAL AND METHODS Discussion of the latest results of multicentre randomised therapy studies on anti-inflammatory treatments for Graves' orbitopathy, as well as new therapeutic concepts. RESULTS Mild cases of GO can be treated with only selenium supplementation and a watchful waiting strategy. In the moderate-to-severe active form of GO, primary therapy consists of i. v. steroids (cumulative 4 - 5 g) in combination with orbital irradiation in patients with impaired motility. In patients with insufficient therapeutic response after 6 weeks, treatment should be switched to other immunosuppressive agents. In severe sight-threatening disease, bony orbital decompression is usually necessary. As basic research has improved our understanding of the underlying pathophysiology of GO, it has been possible to develop targeted therapies for GO. Teprotumumab, an IGF-1 receptor antibody, was effective in treating GO patients in a phase III trial and should soon be awarded approval for Europe. CONCLUSION The current therapy concept for Graves' orbitopathy is as follows: first anti-inflammatory therapy then surgical correction of the permanent defects. This may soon be modified, due to the use of targeted therapies.
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Affiliation(s)
| | - Mareile Stöhr
- Klinik für Augenheilkunde, Universitätsklinikum Essen, Deutschland
| | - Lars Möller
- Klinik für Augenheilkunde, Universitätsklinikum Essen, Deutschland
| | - Dagmar Führer
- Klinik für Augenheilkunde, Universitätsklinikum Essen, Deutschland
| | - Anja Eckstein
- Klinik für Augenheilkunde, Universitätsklinikum Essen, Deutschland
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Abstract
Graves' orbitopathy (GO), also known as thyroid-associated ophthalmopathy, is the most common ocular abnormality of Graves' disease. It is a disfiguring, invalidating, and potentially blinding orbital disease mediated by an interlocking and complicated immune network. Self-reactive T cells directly against thyroid-stimulating hormone receptor-bearing orbital fibroblasts contribute to autoimmune inflammation and tissue remodeling in GO orbital connective tissues. To date, T helper (Th) 1 (cytotoxic leaning) and Th2 (antibody leaning) cell subsets and an emerging role of Th17 (fibrotic leaning) cells have been implicated in GO pathogenesis. The potential feedback loops between orbital native residential CD34- fibroblasts, CD34+ infiltrating fibrocytes, and effector T cells may affect the T cell subset bias and the skewed pattern of cytokine production in the orbit, thereby determining the outcomes of GO autoimmune reactions. Characterization of the T cell subsets that drive GO and the cytokines they express may significantly advance our understanding of orbital autoimmunity and the development of promising therapeutic strategies against pathological T cells.
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Affiliation(s)
- Sijie Fang
- Department of Ophthalmology, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
- Shanghai Institute of Immunology, Shanghai JiaoTong University School of Medicine, Shanghai, China
- Department of Immunology and Microbiology, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Yi Lu
- Department of Ophthalmology, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
- Shanghai Institute of Immunology, Shanghai JiaoTong University School of Medicine, Shanghai, China
- Department of Immunology and Microbiology, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Yazhuo Huang
- Department of Ophthalmology, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
- Shanghai Institute of Immunology, Shanghai JiaoTong University School of Medicine, Shanghai, China
- Department of Immunology and Microbiology, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Huifang Zhou
- Department of Ophthalmology, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
- *Correspondence: Xianqun Fan, ; Huifang Zhou,
| | - Xianqun Fan
- Department of Ophthalmology, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
- *Correspondence: Xianqun Fan, ; Huifang Zhou,
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Abstract
Graves' hyperthyroidism is characterized by the presence of autoantibodies that stimulate the thyroid-stimulating hormone receptor (TSHR), resulting in uncontrolled secretion of excessive thyroid hormone. Conventional treatments, including antithyroid medication, radioiodine, or surgery have remained largely unchanged for the past 70 years and either lack efficacy for many patients, or result in lifelong thyroid hormone replacement therapy, in the case of the latter 2 options. The demand for new therapeutic options, combined with greater insight into basic immunobiology, has led to the emergence of novel approaches to treat Graves' hyperthyroidism. The current therapies under investigation include biologics, small molecules, and peptide immunomodulation. There is a growing focus on TSHR-specific treatment modalities, which carry the advantage of eliciting a specific, targeted approach, with the aim of avoiding disruption of the functioning immune system. These therapies present a new opportunity to supersede the inadequate treatments currently available for some Graves' patients, offering hope of successful restoration of euthyroidism without the need for ongoing therapy. Several of these therapeutic options have the potential to translate into clinical practice in the near future. This review provides a comprehensive summary of the recent advances and various stages of development of the novel therapeutic approaches to treat Graves' hyperthyroidism.
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Affiliation(s)
- Laura C Lane
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK.,Endocrine unit, Royal Victoria Infirmary, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK.,Department of Paediatric Endocrinology, The Great North Children's Hospital, Newcastle-upon-Tyne, UK
| | - Tim D Cheetham
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK.,Department of Paediatric Endocrinology, The Great North Children's Hospital, Newcastle-upon-Tyne, UK
| | - Petros Perros
- Endocrine unit, Royal Victoria Infirmary, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Simon H S Pearce
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK.,Endocrine unit, Royal Victoria Infirmary, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
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Abstract
Autoimmune thyroid-stimulating antibodies are activating the thyrotropin receptor (TSHR) in both the thyroid and the eye, but different molecular mechanisms are induced in both organs, leading to Graves' disease (GD) and Graves' orbitopathy (GO), respectively. Therapy with anti-thyroid drugs to reduce hyperthyroidism (GD) by suppressing the biosynthesis of thyroid hormones has only an indirect effect on GO, since it does not causally address pathogenic TSHR activation itself. GO is thus very difficult to treat. The activated TSHR but also the cross-interacting insulin-like growth factor 1 receptor (IGF-1R) contribute to this issue. The TSHR is a heptahelical G-protein-coupled receptor, whereas the IGF-1R is a receptor tyrosine kinase. Despite these fundamental structural differences, both receptors are phosphorylated by G-protein receptor kinases, which enables β-arrestin binding. Arrestins mediate receptor internalization and also activate the mitogen-activated protein kinase pathway. Moreover, emerging results suggest that arrestin plays a critical role in the cross-interaction of the TSHR and the IGF-1R either in their common signaling pathway and/or during an indirect or potential TSHR/IGF-1R interaction. In this review, novel pharmacological strategies with allosteric small-molecule modulators to treat GO and GD on the level of the TSHR and/or the TSHR/IGF-1R cross-interaction will be discussed. Moreover, monoclonal antibody approaches targeting the TSHR or the IGF-1R and thereby preventing activation of either receptor will be presented. Another chapter addresses the immunomodulation to treat GO using TSHR-derived peptides targeting the human leukocyte antigen DR isotope (HLA-DR), which is a feasible approach to tackle GO, since HLA-DR and TSHR are overexpressed in orbital tissues of GO patients.
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Affiliation(s)
- Gerd Krause
- Structural Biology, Leibniz-Forschungsinstitut für molekulare Pharmakologie (FMP), Berlin, Germany
- *Gerd Krause, Structural Biology, Leibniz-Forschungsinstitut für molekulare Pharmakologie (FMP), Robert Rössle Strasse 10, DE–13125 Berlin (Germany),
| | - Anja Eckstein
- Department of Ophthalmology, University Hospital Essen, Essen, Germany
| | - Ralf Schülein
- Protein Trafficking, Leibniz-Forschungsinstitut für molekulare Pharmakologie (FMP), Berlin, Germany
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Lee ACH, Kahaly GJ. Novel Approaches for Immunosuppression in Graves' Hyperthyroidism and Associated Orbitopathy. Eur Thyroid J 2020; 9:17-30. [PMID: 33511082 PMCID: PMC7802437 DOI: 10.1159/000508789] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/18/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Both Graves' hyperthyroidism (GH) and Graves' orbitopathy (GO) are associated with significant adverse health consequences. All conventional treatment options have limitations regarding efficacy and safety. Most importantly, they do not specifically address the underlying immunological mechanisms. We aim to review the latest development of treatment approaches in these two closely related disorders. SUMMARY Immunotherapies of GH have recently demonstrated clinical efficacy in preliminary studies. They include ATX-GD-59, an antigen-specific immunotherapy which restores immune tolerance to the thyrotropin receptor; iscalimab, an anti-CD40 monoclonal antibody which blocks the CD40-CD154 costimulatory pathway in B-T cell interaction; and K1-70, a thyrotropin receptor-blocking monoclonal antibody. Novel treatment strategies have also become available in GO. Mycophenolate significantly increased the overall response rate combined with standard glucocorticoid (GC) treatment compared to GC monotherapy. Tocilizumab, an anti-interleukin 6 receptor monoclonal antibody, displayed strong anti-inflammatory action in GC-resistant cases. Teprotumumab, an anti-insulin-like growth factor 1 receptor monoclonal antibody, resulted in remarkable improvement in terms of disease activity, proptosis, and diplopia. Further, rituximab appears to be useful in active disease of recent onset without impending dysthyroid optic neuropathy. KEY MESSAGES Therapeutic advances will continue to optimize our management of GH and associated orbitopathy in an effective and safe manner.
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Affiliation(s)
- Alan Chun Hong Lee
- Division of Endocrinology and Metabolism, Department of Medicine, Queen Mary Hospital, Hong Kong, China
- Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - George J. Kahaly
- Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
- *George J. Kahaly, Department of Medicine I, Johannes Gutenberg University Medical Center, Langenbeckstraße 1, DE–55131 Mainz (Germany),
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Abstract
CONTEXT Invited update on the management of systemic autoimmune Graves disease (GD) and associated Graves orbitopathy (GO). EVIDENCE ACQUISITION Guidelines, pertinent original articles, systemic reviews, and meta-analyses. EVIDENCE SYNTHESIS Thyrotropin receptor antibodies (TSH-R-Abs), foremost the stimulatory TSH-R-Abs, are a specific biomarker for GD. Their measurement assists in the differential diagnosis of hyperthyroidism and offers accurate and rapid diagnosis of GD. Thyroid ultrasound is a sensitive imaging tool for GD. Worldwide, thionamides are the favored treatment (12-18 months) of newly diagnosed GD, with methimazole (MMI) as the preferred drug. Patients with persistently high TSH-R-Abs and/or persistent hyperthyroidism at 18 months, or with a relapse after completing a course of MMI, can opt for a definitive therapy with radioactive iodine (RAI) or total thyroidectomy (TX). Continued long-term, low-dose MMI administration is a valuable and safe alternative. Patient choice, both at initial presentation of GD and at recurrence, should be emphasized. Propylthiouracil is preferred to MMI during the first trimester of pregnancy. TX is best performed by a high-volume thyroid surgeon. RAI should be avoided in GD patients with active GO, especially in smokers. Recently, a promising therapy with an anti-insulin-like growth factor-1 monoclonal antibody for patients with active/severe GO was approved by the Food and Drug Administration. COVID-19 infection is a risk factor for poorly controlled hyperthyroidism, which contributes to the infection-related mortality risk. If GO is not severe, systemic steroid treatment should be postponed during COVID-19 while local treatment and preventive measures are offered. CONCLUSIONS A clear trend towards serological diagnosis and medical treatment of GD has emerged.
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Affiliation(s)
- George J Kahaly
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
- Correspondence and Reprint Requests: George J. Kahaly, MD, PhD, JGU Medical Center, Mainz 55101, Germany. E-mail:
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36
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Abstract
Graves' disease (GD) is an autoimmune disease caused in part by thyroid-stimulating antibodies (TSAbs) that activate the thyroid-stimulating hormone receptor (TSHR). In Graves' hyperthyroidism (GH), TSAbs cause persistent stimulation of thyroid cells leading to continuous thyroid hormone synthesis and secretion. Thyroid eye disease (TED), also called Graves' orbitopathy, is an orbital manifestation of GD. We review the important roles of the TSHR and the insulin-like growth factor 1 receptor (IGF-1R) in the pathogenesis of TED and discuss a model of TSHR/IGF-1R crosstalk that considers two pathways initiated by TSAb activation of TSHR in the eye, an IGF-1R-independent and an IGF-1R-dependent signaling pathway leading to hyaluronan (HA) secretion in orbital fibroblasts. We discuss current and future therapeutic approaches targeting the IGF-1R and TSHR. Teprotumumab, a human monoclonal anti-IGF-1R-blocking antibody, has been approved as an effective treatment in patients with TED. However, as the TSHR seems to be the primary target for TSAbs in patients with GD, future therapeutic interventions directly targeting the TSHR, e.g. blocking antibodies and small molecule antagonists, are being developed and have the advantage to inhibit the IGF-1R-independent as well as the IGF-1R-dependent component of TSAb-induced HA secretion. Antigen-specific immunotherapies using TSHR peptides to reduce serum TSHR antibodies are being developed also. These TSHR-targeted strategies also have the potential to treat both GH and TED with the same drug. We propose that combination therapy targeting TSHR and IGF-1R may be an effective and better tolerated treatment strategy for TED.
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Affiliation(s)
| | | | - Marvin C. Gershengorn
- *Marvin C. Gershengorn, 50 South Dr., Building 50, Room 4134, Bethesda, MD 20892 (USA),
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Nel HJ, Malmström V, Wraith DC, Thomas R. Autoantigens in rheumatoid arthritis and the potential for antigen-specific tolerising immunotherapy. Lancet Rheumatol 2020; 2:e712-e723. [PMID: 38279365 DOI: 10.1016/s2665-9913(20)30344-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/19/2020] [Accepted: 09/03/2020] [Indexed: 02/07/2023]
Abstract
Autoimmune diseases, including rheumatoid arthritis, develop and persist due to impaired immune self-tolerance, which has evolved to regulate inflammatory responses to injury or infection. After diagnosis, patients rarely achieve drug-free remission, and although at-risk individuals can be identified with genotyping, antibody tests, and symptoms, rheumatoid arthritis cannot yet be successfully prevented. Precision medicine is increasingly offering solutions to diseases that were previously considered to be incurable, and immunotherapy has begun to achieve this aim in cancer. Comparatively, modulating autoantigen-specific immune responses with immunotherapy for the cure of autoimmune diseases is at a relatively immature stage. Current treatments using non-specific immune or inflammatory suppression increase susceptibility to infection, and are rarely curative. However, early stage clinical trials suggesting that immunotherapy might allow extended duration of remission and even prevention of progression to disease suggest modulating tolerance in rheumatoid arthritis could be a promising opportunity for therapy.
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Affiliation(s)
- Hendrik J Nel
- University of Queensland Diamantina Institute, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Vivianne Malmström
- Division of Rheumatology, Department of Medicine, Center for Molecular Medicine, Karolinska Institutet and Karolinska University Hospital Solna, Stockholm, Sweden
| | - David C Wraith
- Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Ranjeny Thomas
- University of Queensland Diamantina Institute, Princess Alexandra Hospital, Woolloongabba, QLD, Australia.
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Stanway JA, Isaacs JD. Tolerance-inducing medicines in autoimmunity: rheumatology and beyond. Lancet Rheumatol 2020; 2:e565-e575. [PMID: 38273619 DOI: 10.1016/s2665-9913(20)30100-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 04/09/2020] [Accepted: 04/09/2020] [Indexed: 12/14/2022]
Abstract
Autoimmunity is currently managed with generalised immunosuppression, which is associated with serious side-effects such as infection and cancer. An ideal treatment strategy would be to induce immune tolerance-ie, to reprogramme the immune system to stop recognising the host itself as a threat. Drug-free remission should follow such an intervention, representing a change in the approach to the treatment of autoimmune disease. Tolerance induction is achievable in animal models of autoimmunity but translation to the clinic has been slow. Nonetheless, progress has been made-eg, restoration of therapeutic responsiveness and drug-free remission have been achieved with stem cell transplantation in refractory autoimmunity, and significant delays in onset of type 1 diabetes in individuals at high risk have been achieved following a brief treatment with anti-CD3 monoclonal antibody. In the future, antigen-specific interventions should provide highly targeted, personalised approaches, avoiding generalised immunosuppression entirely. Such trials have already started, using both direct autoantigenic peptide administration, cellular therapies, and other modalities. In this Series paper, we discuss the history of immune tolerance induction with a focus on rheumatological disease while also highlighting essential data from other specialties. We propose key unanswered questions, which will be covered in other papers in this Series.
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Affiliation(s)
- James A Stanway
- National Institute for Health Research, Northern Deanery, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - John D Isaacs
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; Musculoskeletal Unit, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK.
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39
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Oftedal BE, Wolff ASB. New era of therapy for endocrine autoimmune disorders. Scand J Immunol 2020; 92:e12961. [PMID: 32853446 DOI: 10.1111/sji.12961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/10/2020] [Accepted: 08/19/2020] [Indexed: 12/24/2022]
Abstract
The new era of immune and reconstitution therapy of autoimmune disorders is ongoing. However, endocrine autoimmune diseases comprise a group of elaborating pathologies where the development of new treatment strategies remains slow. Substitution of the missing hormones is still standard practice, taking care of the devastating symptoms but not the cause of disease. As our knowledge of the genetic contribution to the aetiology of endocrine disorders increases and early diagnostic tools are available, it is now possible to identify persons at risk before they acquire full-blown disease. This review summarizes current knowledge and treatment of endocrine autoimmune disorders, focusing on type 1 diabetes, Addison's disease, autoimmune thyroid diseases and primary ovarian insufficiency. We explore which new therapies might be used in the different stages of the disease, focus on legalized therapy and elaborate on the ongoing clinical studies for these diseases and the research front, before hypothesizing on the way ahead.
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Affiliation(s)
- Bergithe E Oftedal
- Department of Clinical Science, University of Bergen, Bergen, Norway.,KG Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
| | - Anette S B Wolff
- Department of Clinical Science, University of Bergen, Bergen, Norway.,KG Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
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40
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Abstract
Immune tolerance is defined by an active state of immune system unresponsiveness to foreign and self-antigens. Loss of immune tolerance to self-antigens and the resulting overexpression of autoantibodies can lead to tissue injury and development of various autoimmune diseases. In drug development, the goal of newly emerging immune tolerance therapies is to treat autoimmune disorders by restoring the immunoregulatory capacity of the immune system. Development of immune tolerance targets is initiated with the establishment of pharmacological efficacy in relevant disease animal models, followed by their stepwise translation to humans. This review discusses the major challenges to developing tolerance inducing pharmaceutical drugs, including the selection of appropriate disease models to establish efficacy, adequate, and acceptable in vitro and in vivo safety assessments, relevant biomarkers of human safety and efficacy, and finally, some regulatory guidelines to successfully develop immune tolerance therapeutics. [Box: see text].
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Affiliation(s)
- Zaher A Radi
- Pfizer Worldwide Research, Development and Medical, 2253Pfizer Inc, Cambridge, MA, USA
| | - Thomas A Wynn
- Pfizer Worldwide Research, Development and Medical, 2253Pfizer Inc, Cambridge, MA, USA
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41
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Abstract
The liver is a critical organ in controlling immune tolerance. In particular, it is now clear that targeting antigens for presentation by antigen presenting cells in the liver can induce immune tolerance to either autoantigens from the liver itself or tissues outside of the liver. Here we review immune mechanisms active within the liver that contribute both to the control of infectious diseases and tolerance to self-antigens. Despite its extraordinary capacity for tolerance induction, the liver remains a target organ for autoimmune diseases. In this review, we compare and contrast known autoimmune diseases of the liver. Currently patients tend to receive strong immunosuppressive treatments and, in many cases, these treatments are associated with deleterious side effects, including a significantly higher risk of infection and associated health complications. We propose that, in future, antigen-specific immunotherapies are adopted for treatment of liver autoimmune diseases in order to avoid such adverse effects. We describe various therapeutic approaches that either are in or close to the clinic, highlight their mechanism of action and assess their suitability for treatment of autoimmune liver diseases.
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Affiliation(s)
| | | | - David C. Wraith
- Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
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42
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Abstract
Graves' disease (GD) is an autoimmune disease that primarily affects the thyroid gland. It is the most common cause of hyperthyroidism and occurs at all ages but especially in women of reproductive age. Graves' hyperthyroidism is caused by autoantibodies to the thyroid-stimulating hormone receptor (TSHR) that act as agonists and induce excessive thyroid hormone secretion, releasing the thyroid gland from pituitary control. TSHR autoantibodies also underlie Graves' orbitopathy (GO) and pretibial myxoedema. Additionally, the pathophysiology of GO (and likely pretibial myxoedema) involves the synergism of insulin-like growth factor 1 receptor (IGF1R) with TSHR autoantibodies, causing retro-orbital tissue expansion and inflammation. Although the aetiology of GD remains unknown, evidence indicates a strong genetic component combined with random potential environmental insults in an immunologically susceptible individual. The treatment of GD has not changed substantially for many years and remains a choice between antithyroid drugs, radioiodine or surgery. However, antithyroid drug use can cause drug-induced embryopathy in pregnancy, radioiodine therapy can exacerbate GO and surgery can result in hypoparathyroidism or laryngeal nerve damage. Therefore, future studies should focus on improved drug management, and a number of important advances are on the horizon.
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Affiliation(s)
- Terry F Davies
- Thyroid Research Laboratory, Icahn School of Medicine at Mount Sinai, New York, NY, USA. .,James J. Peters VA Medical Center, New York, NY, USA. .,Mount Sinai Thyroid Center, Mount Sinai Downtown at Union Sq, New York, NY, USA.
| | - Stig Andersen
- Department of Geriatric and Internal Medicine and Arctic Health Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Rauf Latif
- Thyroid Research Laboratory, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,James J. Peters VA Medical Center, New York, NY, USA
| | - Yuji Nagayama
- Department of Molecular Medicine, Atomic Bomb Disease Institute, Nagasaki University, Nagasaki, Japan
| | - Giuseppe Barbesino
- Thyroid Unit, Division of Endocrinology, Massachusetts General Hospital, Boston, MA, USA
| | - Maria Brito
- Mount Sinai Thyroid Center, Mount Sinai Downtown at Union Sq, New York, NY, USA
| | - Anja K Eckstein
- Department of Ophthalmology, University Duisburg Essen, Essen, Germany
| | - Alex Stagnaro-Green
- Departments of Medicine, Obstetrics and Gynecology and Medical Education, University of Illinois College of Medicine at Rockford, Rockford, IL, USA
| | - George J Kahaly
- Department of Medicine I, Johannes Gutenberg University Medical Centre, Mainz, Germany
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43
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Abstract
Graves' disease (GD) is an autoimmune condition with the appearance of anti-TSH receptor (TSHR) autoantibodies in the serum. The consequence is the development of hyperthyroidism in most of the patients. In addition, in the most severe cases, patients can develop orbitopathy (GO), achropachy and dermopathy. The central role of the TSHR for the disease pathology has been well accepted. Therefore immunization against the TSHR is pivotal for the creation of in vivo models for the disease. However, TSHR is well preserved among the species and therefore the immune system is highly tolerant. Many differing attempts have been performed to break tolerance and to create a proper animal model in the last decades. The most successful have been achieved by introducing the human TSHR extracellular domain into the body, either by injection of plasmid or adenoviruses. Currently available models develop the whole spectrum of Graves' disease-autoimmune thyroid disease and orbitopathy and are suitable to study disease pathogenesis and to perform treatment studies. In recent publications new immunomodulatory therapies have been assessed and also diseaseprevention by inducing tolerance using small cyclic peptides from the antigenic region of the extracellular subunit of the TSHR.
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Affiliation(s)
- A Eckstein
- Department of Ophthalmology, Medical Faculty, University Duisburg-Essen, Essen, Germany.
| | - S Philipp
- Laboratory of Molecular Ophthalmology, Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - G Goertz
- Laboratory of Molecular Ophthalmology, Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - J P Banga
- Laboratory of Molecular Ophthalmology, Medical Faculty, University Duisburg-Essen, Essen, Germany
- Emeritus Professor, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - U Berchner-Pfannschmidt
- Laboratory of Molecular Ophthalmology, Medical Faculty, University Duisburg-Essen, Essen, Germany
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Francis N, Francis T, Lazarus JH, Okosieme OE. Current controversies in the management of Graves' hyperthyroidism. Expert Rev Endocrinol Metab 2020; 15:159-169. [PMID: 32315207 DOI: 10.1080/17446651.2020.1754192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 04/07/2020] [Indexed: 12/12/2022]
Abstract
Introduction: The management of Graves' disease centers on the use of effective and well-established therapies, namely thionamide antithyroid drugs, radioactive iodine, and thyroidectomy. Optimal treatment strategies are however controversial and vary significantly across centers.Areas covered: This review addresses specific controversies in Graves' disease management including the choice of primary therapy, the approach to women planning pregnancy, and optimal strategies for antithyroid drug and radioiodine therapy.Expert opinion: Important considerations in choosing therapy include treatment efficacy, adverse effects, patient convenience, and resource settings. Recent data suggest that early and effective control of hyperthyroidism is key to improving cardiovascular morbidity and mortality. Studies addressing cancer risk in radioiodine-treated patients face methodological challenges and require clarification in appropriately designed studies. Remission rates with antithyroid drugs are comparable when thionamides are used alone (titration-regimen) or in combination with levothyroxine (block and replace) and can be optimized by extending treatment for at least 12-18 months. Fixed and calculated radioiodine activity regimens are both effective but entail a trade-off between convenience and precision in the administered activity. Optimal preconception strategies are still evolving but ablative treatment in advance of pregnancy offers the most pragmatic means of reducing adverse effects of hyperthyroidism in subsequent pregnancy.
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Affiliation(s)
- Niroshan Francis
- Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK
| | - Thanuya Francis
- Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK
| | - John H Lazarus
- Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, UK
| | - Onyebuchi E Okosieme
- Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK
- Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, UK
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Griffin JD, Song JY, Sestak JO, DeKosky BJ, Berkland CJ. Linking autoantigen properties to mechanisms of immunity. Adv Drug Deliv Rev 2020; 165-166:105-116. [PMID: 32325104 PMCID: PMC7572523 DOI: 10.1016/j.addr.2020.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 04/13/2020] [Accepted: 04/17/2020] [Indexed: 02/06/2023]
Abstract
Antigen-specific immunotherapies (ASIT) present compelling potential for introducing precision to the treatment of autoimmune diseases where nonspecific, global immunosuppression is currently the only treatment option. Central to ASIT design is the delivery of autoantigen, which parallels allergy desensitization approaches. Clinical success in tolerizing allergen-specific responses spans longer than a century, but autoimmune ASITs have yet to see an FDA-approved breakthrough. Allergens and autoantigens differ substantially in physicochemical properties, and these discrepancies influence the nature of their interactions with the immune system. Approved allergen-specific immunotherapies are typically administered as water soluble, neutrally charged protein fractions from 10 to 70 kDa. Conversely, autoantigens are native proteins that exhibit wide-ranging sizes, solubilities, and charges that render them susceptible to immunogenicity. To translate the success of allergen hyposensitization to ASIT, delivery strategies may be necessary to effectively format autoantigens, guide biodistribution, and engage appropriate immune mechanisms.
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Affiliation(s)
- J Daniel Griffin
- Bioengineering Graduate Program, University of Kansas, Lawrence, KS, United States of America; Department of Pharmaceutical Chemistry, University of Kansas, Lawrence, KS, United States of America
| | - Jimmy Y Song
- Department of Pharmaceutical Chemistry, University of Kansas, Lawrence, KS, United States of America; Bioengineering Graduate Program, University of Kansas, Lawrence, KS, United States of America
| | - Joshua O Sestak
- Department of Pharmaceutical Chemistry, University of Kansas, Lawrence, KS, United States of America; Orion BioScience, Inc, Omaha, NE, United States of America
| | - Brandon J DeKosky
- Bioengineering Graduate Program, University of Kansas, Lawrence, KS, United States of America; Department of Pharmaceutical Chemistry, University of Kansas, Lawrence, KS, United States of America; Department of Chemical and Petroleum Engineering, University of Kansas, Lawrence, KS, United States of America
| | - Cory J Berkland
- Bioengineering Graduate Program, University of Kansas, Lawrence, KS, United States of America; Department of Pharmaceutical Chemistry, University of Kansas, Lawrence, KS, United States of America; Department of Chemical and Petroleum Engineering, University of Kansas, Lawrence, KS, United States of America.
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Kahaly GJ, Stan MN, Frommer L, Gergely P, Colin L, Amer A, Schuhmann I, Espie P, Rush JS, Basson C, He Y. A Novel Anti-CD40 Monoclonal Antibody, Iscalimab, for Control of Graves Hyperthyroidism-A Proof-of-Concept Trial. J Clin Endocrinol Metab 2020; 105:5568230. [PMID: 31512728 DOI: 10.1210/clinem/dgz013] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 09/02/2019] [Indexed: 02/02/2023]
Abstract
CONTEXT The CD40-CD154 co-stimulatory pathway plays an important role in the pathogenesis of Graves disease (GD) by promoting autoreactive B-cell activation. OBJECTIVE Evaluate efficacy and safety of a human, blocking, nondepleting anti-CD40 monoclonal antibody, iscalimab, in hyperthyroid patients with GD. DESIGN Open-label, phase II proof-of-concept study. SETTING Multicenter. PATIENTS Fifteen with GD. INTERVENTION Patients received 5 doses of iscalimab at 10 mg/kg intravenously over 12 weeks. MAIN OUTCOME MEASURES Thyroid-related hormones and autoantibodies, plasma soluble CD40, free CD40 on B cells, soluble CXCL13, pharmacokinetics, and safety were assessed. RESULTS The iscalimab intervention resulted in complete CD40 engagement for up to 20 weeks. A clinical response and biochemical euthyroidism was observed in 7 of 15 (47%) patients. Free and total triiodothyronine and thyroxine normalized in 7 patients who did not receive any rescue medication with antithyroid drugs (ATD), and 2/15 (13.3%) showed normal thyrotropin. Six (40%) patients required ATD. Four of 7 responders relapsed after treatment completion. Serum concentrations of thyrotropin receptor autoantibodies (TSH-R-Ab) significantly declined in all patients (mean 15.3 IU/L vs 4.0 IU/L, 66% reduction; P < 0.001) and TSH-R-Ab levels normalized in 4 (27%). Thyroperoxidase and thyroglobulin autoantibodies significantly decreased in responders. Iscalimab rapidly reduced serum CXCL13 concentrations (P < 0.001). Twelve (80.0%) patients reported at least 1 adverse event (AE). All treatment-related AE were mild or moderate and resolved by end of the study. CONCLUSION Iscalimab was generally safe and clinically effective in a subgroup of hyperthyroid GD patients. The potential therapeutic benefit of iscalimab should be further tested.
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Affiliation(s)
- George J Kahaly
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - Marius Nicolae Stan
- Division of Endocrinology, Diabetes & Metabolism, Mayo Clinic, Rochester, Minnesota
| | - Lara Frommer
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | | | - Laurence Colin
- Novartis Institute for Biomedical Research, Massachusetts
| | - Ahmed Amer
- One Health Plaza, East Hanover, New Jersey
| | | | | | | | - Craig Basson
- Novartis Institute for Biomedical Research, Massachusetts
| | - Yanling He
- Novartis Institute for Biomedical Research, Massachusetts
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47
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Abstract
Introduction: First-line treatment for most young people with Graves' disease (GD) will include the administration of a thionamide antithyroid medication (ATD); Carbimazole (CBZ), Methimazole (MMZ), or rarely, propylthiouracil (PTU). GD is a challenge for families and clinicians because the likelihood of remission following a course of ATD is lower in young people when compared to adults, yet the risk of adverse events is higher. An overall consensus regarding the optimal ATD treatment regimen is lacking; how ATD are prescribed, for how long and how the associated risk of adverse events is managed varies between clinicians, units and nations. This partly reflects clinician and family uncertainty regarding outcomes.Areas covered: This review will focus on some of the key articles published in the field of thionamide ATD in children. It will highlight key issues that need to be discussed with families as well as addressing the approach and controversies in the treatment of GD. This article does not reflect a formal systematic review of the literature.Expert opinion: New strategies in areas such as immunomodulation may see the development of new antithyroid drug treatments that, either in isolation or in combination with thionamide therapy, may increase the likelihood of long-term remission.
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Affiliation(s)
- Laura C Lane
- Translational and Clinical Research Institute, Newcastle University, Newcastle-Upon-Tyne, UK
- Department of Paediatric Endocrinology, The Great North Children's Hospital, Newcastle-Upon-Tyne, UK
| | - Tim Cheetham
- Translational and Clinical Research Institute, Newcastle University, Newcastle-Upon-Tyne, UK
- Department of Paediatric Endocrinology, The Great North Children's Hospital, Newcastle-Upon-Tyne, UK
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48
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Krieger CC, Neumann S, Gershengorn MC. TSH/IGF1 receptor crosstalk: Mechanism and clinical implications. Pharmacol Ther 2020; 209:107502. [PMID: 32061922 DOI: 10.1016/j.pharmthera.2020.107502] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 02/05/2020] [Indexed: 02/07/2023]
Abstract
Increasing evidence of interdependence between G protein-coupled receptors and receptor tyrosine kinase signaling pathways has prompted reevaluation of crosstalk between these receptors in disease and therapy. Investigations into thyroid-stimulating hormone (TSH) and insulin-like growth factor 1 (IGF1) receptor crosstalk, and its application to the clinic have in particular shown recent progress. In this review, we summarize current insights into the mechanism of TSH/IGF1 receptor crosstalk. We discuss evidence that crosstalk is one of the underlying causes of TSHR-based disease and the feasibility of using combinations of TSH receptor and IGF1 receptor antagonists to increase the therapeutic index for the treatment of Graves' hyperthyroidism and Graves' ophthalmopathy.
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Abstract
Receptor autoimmunity is one of the ways in which autoimmune diseases appear in humans. Graves' disease, myasthenia gravis, idiopathic membranous nephropathy, and autoimmune acute encephalitis are the major autoimmune diseases belonging to this particular group. Receptor autoimmune disease are dependent on the presence of autoantibodies directed against cell-surface antigens, namely TSH receptor in thyrocytes, acetylcholine receptor in neuromuscular junction, phospholipase 2 receptor in podocytes, and NMDA receptor in cortical neurons. In this article we outline the distinctive features of receptor autoimmunity and the specific relationship between the autoimmunology laboratory and the presence/concentration of autoantibodies. Some immunological features distinguish receptor autoimmunity. Anti-receptor autoantibody pathologies are considered T cell-dependent, B-cell-mediated autoimmune disorders: the knowledge about the presence of circulating and/or localized autoantibodies to target organs and identification of autoantigens involved in the autoimmune reaction is of paramount importance. Due to the close correlation between the concentration of anti-receptor autoantibodies, the autoimmune target of some cell-surface receptors and the intensity of symptoms, the measurement of these immunoglobulins has become central to diagnose autoimmune diseases in all affected patients, not just in clinically dubious cases. The measurement of autoantibodies is also relevant for differential diagnosis of autoimmune and non-autoimmune forms with similar symptoms. From the methodological point of view, quantitative immunoassay methods of measurement should be preferred over semi-quantitative ones, for the capacity of the first class of methods to define precisely the reference ranges and decision levels overcoming the measurement uncertainty of semi-quantitative methods.
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Affiliation(s)
- Renato Tozzoli
- Laboratory of Clinical Pathology, S. Maria degli Angeli Hospital, and Consultant Endocrinologist, San Giorgio Clinics, Pordenone, Italy.
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Antonelli A, Fallahi P, Elia G, Ragusa F, Paparo SR, Ruffilli I, Patrizio A, Gonnella D, Giusti C, Virili C, Centanni M, Shoenfeld Y, Ferrari SM. Graves' disease: Clinical manifestations, immune pathogenesis (cytokines and chemokines) and therapy. Best Pract Res Clin Endocrinol Metab 2020; 34:101388. [PMID: 32059832 DOI: 10.1016/j.beem.2020.101388] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Graves' disease (GD) is characterized by thyrotoxicosis, caused by the presence of circulating thyroid stimulating antibodies (TSAb), that are determinant also in the pathogenesis of its extrathyroidal manifestations [Graves' ophthalmopathy (GO), pretibial myxedema]. T helper (Th)1 immune response prevails in the immune-pathogenesis of GD and GO, during the active phase, when Th1 chemokines, and their (C-X-C)R3 receptor, play a key role. In GD, the existing treatments are not ideal for hyperthyroidism (long-term remission with anti-thyroid-drugs only in 50% of patients; while radioiodine and surgery cause hypothyroidism). In GD, antigen-specific therapy has been recently published, with the induction of T cell tolerance via an immunization by TSH-R peptides. In GO, rituximab and drugs targeting cytokines have been evaluated. Furthermore, teprotumumab (a human monoclonal anti-IGF-1R blocking antibody) showed to be very effective in GO patients. Further researches are necessary to identify novel effective therapies targeting GD, or GO.
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Affiliation(s)
- Alessandro Antonelli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| | - Poupak Fallahi
- Department of Translational Research and of New Technologies in Medicine and Surgery, University of Pisa, 56126, Pisa, Italy.
| | - Giusy Elia
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| | - Francesca Ragusa
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| | | | - Ilaria Ruffilli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| | - Armando Patrizio
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| | - Debora Gonnella
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| | - Claudia Giusti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| | - Camilla Virili
- Sapienza University of Rome, 9311, Medicosurgical Sciences and Biotechnologies, C.so della Repubblica 79, Latina, 04100, Italy.
| | - Marco Centanni
- Sapienza University of Rome, 9311, Medicosurgical Sciences and Biotechnologies, C.so della Repubblica 79, Latina, 04100, Italy; ASL Latina, 217138, Endocrinology Unit, Latina, Lazio, Italy.
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Russia.
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