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Kümpfel T, Giglhuber K, Aktas O, Ayzenberg I, Bellmann-Strobl J, Häußler V, Havla J, Hellwig K, Hümmert MW, Jarius S, Kleiter I, Klotz L, Krumbholz M, Paul F, Ringelstein M, Ruprecht K, Senel M, Stellmann JP, Bergh FT, Trebst C, Tumani H, Warnke C, Wildemann B, Berthele A. Update on the diagnosis and treatment of neuromyelitis optica spectrum disorders (NMOSD) - revised recommendations of the Neuromyelitis Optica Study Group (NEMOS). Part II: Attack therapy and long-term management. J Neurol 2024; 271:141-176. [PMID: 37676297 PMCID: PMC10770020 DOI: 10.1007/s00415-023-11910-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/27/2023] [Accepted: 07/27/2023] [Indexed: 09/08/2023]
Abstract
This manuscript presents practical recommendations for managing acute attacks and implementing preventive immunotherapies for neuromyelitis optica spectrum disorders (NMOSD), a rare autoimmune disease that causes severe inflammation in the central nervous system (CNS), primarily affecting the optic nerves, spinal cord, and brainstem. The pillars of NMOSD therapy are attack treatment and attack prevention to minimize the accrual of neurological disability. Aquaporin-4 immunoglobulin G antibodies (AQP4-IgG) are a diagnostic marker of the disease and play a significant role in its pathogenicity. Recent advances in understanding NMOSD have led to the development of new therapies and the completion of randomized controlled trials. Four preventive immunotherapies have now been approved for AQP4-IgG-positive NMOSD in many regions of the world: eculizumab, ravulizumab - most recently-, inebilizumab, and satralizumab. These new drugs may potentially substitute rituximab and classical immunosuppressive therapies, which were as yet the mainstay of treatment for both, AQP4-IgG-positive and -negative NMOSD. Here, the Neuromyelitis Optica Study Group (NEMOS) provides an overview of the current state of knowledge on NMOSD treatments and offers statements and practical recommendations on the therapy management and use of all available immunotherapies for this disease. Unmet needs and AQP4-IgG-negative NMOSD are also discussed. The recommendations were developed using a Delphi-based consensus method among the core author group and at expert discussions at NEMOS meetings.
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Affiliation(s)
- Tania Kümpfel
- Institute of Clinical Neuroimmunology, LMU Hospital, Ludwig-Maximilians-Universität München, Munich, Germany.
| | - Katrin Giglhuber
- Department of Neurology, School of Medicine, Technical University Munich, Klinikum Rechts der Isar, Munich, Germany
| | - Orhan Aktas
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Ilya Ayzenberg
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Judith Bellmann-Strobl
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Experimental and Clinical Research Center, a cooperation between the Max Delbrück Center for Molecular Medicine in the Helmholtz Association and Charité-Universitätsmedizin Berlin, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
- NeuroCure Clinical Research Center, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, and Berlin Institute of Health, and Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Vivien Häußler
- Department of Neurology and Institute of Neuroimmunology and MS (INIMS), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joachim Havla
- Institute of Clinical Neuroimmunology, LMU Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Martin W Hümmert
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Sven Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Ingo Kleiter
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
- Marianne-Strauß-Klinik, Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Luisa Klotz
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Markus Krumbholz
- Department of Neurology and Pain Treatment, Immanuel Klinik Rüdersdorf, University Hospital of the Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
- Department of Neurology & Stroke, University Hospital of Tübingen, Tübingen, Germany
| | - Friedemann Paul
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Experimental and Clinical Research Center, a cooperation between the Max Delbrück Center for Molecular Medicine in the Helmholtz Association and Charité-Universitätsmedizin Berlin, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
- NeuroCure Clinical Research Center, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, and Berlin Institute of Health, and Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Marius Ringelstein
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Neurology, Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Klemens Ruprecht
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Makbule Senel
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Jan-Patrick Stellmann
- Department of Neurology and Institute of Neuroimmunology and MS (INIMS), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- APHM, Hopital de la Timone, CEMEREM, Marseille, France
- Aix Marseille University, CNRS, CRMBM, Marseille, France
| | | | - Corinna Trebst
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | | | - Clemens Warnke
- Department of Neurology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Brigitte Wildemann
- Marianne-Strauß-Klinik, Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Achim Berthele
- Department of Neurology, School of Medicine, Technical University Munich, Klinikum Rechts der Isar, Munich, Germany.
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Siriratnam P, Huda S, Butzkueven H, van der Walt A, Jokubaitis V, Monif M. A comprehensive review of the advances in neuromyelitis optica spectrum disorder. Autoimmun Rev 2023; 22:103465. [PMID: 37852514 DOI: 10.1016/j.autrev.2023.103465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/13/2023] [Indexed: 10/20/2023]
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is a rare relapsing neuroinflammatory autoimmune astrocytopathy, with a predilection for the optic nerves and spinal cord. Most cases are characterised by aquaporin-4-antibody positivity and have a relapsing disease course, which is associated with accrual of disability. Although the prognosis in NMOSD has improved markedly over the past few years owing to advances in diagnosis and therapeutics, it remains a severe disease. In this article, we review the evolution of our understanding of NMOSD, its pathogenesis, clinical features, disease course, treatment options and associated symptoms. We also address the gaps in knowledge and areas for future research focus.
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Affiliation(s)
- Pakeeran Siriratnam
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Saif Huda
- Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Anneke van der Walt
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Vilija Jokubaitis
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Mastura Monif
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Health, Melbourne, Victoria, Australia; Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia.
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Yong HYF, Burton JM. A Clinical Approach to Existing and Emerging Therapeutics in Neuromyelitis Optica Spectrum Disorder. Curr Neurol Neurosci Rep 2023; 23:489-506. [PMID: 37540387 DOI: 10.1007/s11910-023-01287-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2023] [Indexed: 08/05/2023]
Abstract
PURPOSE OF REVIEW Neuromyelitis optica spectrum disorder (NMOSD) is a rare but highly disabling disease of the central nervous system. Unlike multiple sclerosis, disability in NMOSD occurs secondary to relapses that, not uncommonly, lead to blindness, paralysis, and death. Recently, newer, targeted immunotherapies have been trialed and are now in the treatment arsenal. We have endeavoured to evaluate the current state of NMOSD therapeutics. RECENT FINDINGS This review provides a pragmatic evaluation of recent clinical trials and post-marketing data for rituximab, inebilizumab, satralizumab, eculizumab, and ravalizumab, contrasted to older agents. We also review contemporary issues such as treatment in the context of SARS-CoV2 infection and pregnancy. There has been a dramatic shift in NMOSD morbidity and mortality with earlier and improved disease recognition, diagnostic accuracy, and the advent of more effective, targeted therapies. Choosing a maintenance therapy remains nuanced depending on patient factors and accessibility. With over 100 putative agents in trials, disease-free survival is now a realistic goal for NMOSD patients.
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Affiliation(s)
- Heather Y F Yong
- Division of Neurology, Department of Clinical Neurosciences, University of Calgary, Cummings School of Medicine, Calgary, AB, Canada
| | - Jodie M Burton
- Division of Neurology, Department of Clinical Neurosciences, University of Calgary, Cummings School of Medicine, Calgary, AB, Canada.
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.
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Jakimovski D, Weinstock-Guttman B, Zivadinov R. Ublituximab-xiiy as a treatment option for relapsing multiple sclerosis. Expert Rev Neurother 2023; 23:1053-1061. [PMID: 37842819 DOI: 10.1080/14737175.2023.2268842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/05/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION B cell depletion has been established as an efficacious anti-inflammatory therapy in people with relapsing forms of multiple sclerosis (MS). Ublituximab (ublituximab-xiiy) is the latest approved chimeric glycoengineered anti-CD20 monoclonal antibody (mAb) for the treatment of relapsing forms of MS. AREAS COVERED In this narrative review, the authors explore the safety and effectiveness of data derived from the Phase 2 and Phase 3 ublituximab trials and from their respective post-hoc analyses. Moreover, they consider the similarities and differences between the currently available anti-CD20 antibodies for treatment of relapsing MS. Lastly, the authors discuss the role and place of ublituximab in the current disease modifying therapy landscape. EXPERT OPINION Ublituximab is a rapid-acting and effective anti-inflammatory option as a treatment in people with relapsing MS that significantly reduced the annualized relapse rate and MRI-based disease activity. When compared to the Phase III trials of the other two anti-CD20 mAbs (ocrelizumab and ofatumumab), ublituximab did not result with reduction of 3 or 6-month confirmed disability progression. These differences may be attributed to the overall low rate of progression in both the ublituximab and the active comparator teriflunomide arm. Future data from open-label extensions are warranted. There was no significant reduction of ublituximab on whole-brain atrophy compared to teriflunomide.
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Affiliation(s)
- Dejan Jakimovski
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Bianca Weinstock-Guttman
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Center for Biomedical Imaging at the Clinical Translational Science Institute, University at Buffalo, State University of New York, Buffalo, NY, USA
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Furman MJ, Meuth SG, Albrecht P, Dietrich M, Blum H, Mares J, Milo R, Hartung HP. B cell targeted therapies in inflammatory autoimmune disease of the central nervous system. Front Immunol 2023; 14:1129906. [PMID: 36969208 PMCID: PMC10034856 DOI: 10.3389/fimmu.2023.1129906] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/23/2023] [Indexed: 03/11/2023] Open
Abstract
Cumulative evidence along several lines indicates that B cells play an important role in the pathological course of multiple sclerosis (MS), neuromyelitisoptica spectrum disorders (NMOSD) and related CNS diseases. This has prompted extensive research in exploring the utility of targeting B cells to contain disease activity in these disorders. In this review, we first recapitulate the development of B cells from their origin in the bone marrow to their migration to the periphery, including the expression of therapy-relevant surface immunoglobulin isotypes. Not only the ability of B cells to produce cytokines and immunoglobulins seems to be essential in driving neuroinflammation, but also their regulatory functions strongly impact pathobiology. We then critically assess studies of B cell depleting therapies, including CD20 and CD19 targeting monoclonal antibodies, as well as the new class of B cell modulating substances, Bruton´s tyrosinekinase (BTK) inhibitors, in MS, NMOSD and MOGAD.
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Affiliation(s)
- Moritz J. Furman
- Department of Neurology, Heinrich-Heine University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Sven G. Meuth
- Department of Neurology, Heinrich-Heine University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Philipp Albrecht
- Department of Neurology, Heinrich-Heine University Düsseldorf, Medical Faculty, Düsseldorf, Germany
- Department of Neurology, Maria Hilf Clinic, Moenchengladbach, Germany
| | - Michael Dietrich
- Department of Neurology, Heinrich-Heine University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Heike Blum
- Department of Neurology, Heinrich-Heine University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Jan Mares
- Department of Neurology, Palacky University in Olomouc, Olomouc, Czechia
| | - Ron Milo
- Department of Neurology, Barzilai Medical Center, Ashkelon, Israel
| | - Hans-Peter Hartung
- Department of Neurology, Heinrich-Heine University Düsseldorf, Medical Faculty, Düsseldorf, Germany
- Department of Neurology, Palacky University in Olomouc, Olomouc, Czechia
- Brain and Mind Center, Medical Faculty, The University of Sydney, Sydney, NSW, Australia
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Cutler C, Azab MA, Lucke-Wold B, Khan M, Henson JC, Gill AS, Alt JA, Karsy M. Systematic Review of Treatment Options and Therapeutic Responses for Lesions of the Sella and Orbit: Evidence-Based Recommendations. World Neurosurg 2023; 173:136-145.e30. [PMID: 36639102 DOI: 10.1016/j.wneu.2022.12.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/26/2022] [Accepted: 12/26/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Inflammatory pathologies of the sella and orbit are rare but require prompt diagnosis to initiate effective treatment. Because uniform recommendations for treatment are currently lacking, we performed an evidence-based review to identify recommendations. METHODS We performed a literature search of the PubMed, Embase, and Web of Science databases to identify papers evaluating treatment of inflammatory pathologies of the sella and orbit. We used PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to define recommendations, specifically examining aggregated sample sizes, disease-specific patient follow-up, and clinical trials focused on inflammatory diseases of the sella and orbit. RESULTS A total of 169 studies were included and organized by disease pathology. Treatments for various pathologies were recorded. Treatment options included surgery, radiation, steroids, targeted treatments, immunomodulators, intravenous immune globulin, and plasmapheresis. Steroids were the most often employed treatment, second-line management options and timing varied. Pathological diagnosis was highly associated with treatment used. Most evidence were level 3 without available control groups, except for 13 trials in neuromyelitis optica with level 1 or 2 evidence. CONCLUSIONS This is the first evidence-based review to provide recommendations on specific treatments for pathologies of the orbit and sella. The reported data may be useful to help guide randomized clinical trials and provide resource for clinical management decisions based on the available evidence.
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Affiliation(s)
- Christopher Cutler
- Chicago Medical School at Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Mohammed A Azab
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Majid Khan
- Reno School of Medicine, University of Nevada, Reno, Nevada, USA
| | - J Curran Henson
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Amarbir S Gill
- Division of Otolaryngology, Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Jeremiah A Alt
- Division of Otolaryngology, Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Michael Karsy
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA.
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Kim W, Kim HJ. An update on biologic treatments for neuromyelitis optica spectrum disorder. Expert Rev Clin Immunol 2023; 19:111-121. [PMID: 36414430 DOI: 10.1080/1744666x.2023.2151441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune disease of the central nervous system mediated by antibodies targeting the aquaporin-4 (AQP4) water channel expressed on astrocytes. The binding of specific antibodies to AQP4 causes complement-dependent cytotoxicity, leading to inflammation and demyelination. Several recent phase 2 and 3 randomized placebo-controlled trials showed the efficacy and safety of monoclonal antibody therapies targeting B-cells, interleukin-6 receptor, and complement. AREAS COVERED Current biologic treatments for NMOSD and developments therein, and unresolved issues in NMOSD treatment. EXPERT OPINION New biologic treatments demonstrate high efficacy and good safety for patients with AQP4-IgG-positive NMOSD. The optimal therapeutics for seronegative NMOSD, pediatric patients, and female patients who are pregnant or wish to be are unclear, and further research is needed. Also, real-world studies of new biological agents and the data on the durability of their beneficial effects and their long-term safety are required. Effective rescue therapy for an acute attack is critical given permanent disability in NMOSD is attack-related, and biologic agents that treat acute attack are emerging. If such treatments are to become widely applied, studies on the most cost-effective treatment strategies are needed.
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Affiliation(s)
- Woojun Kim
- Department of Neurology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ho Jin Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, Korea
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Wang Y, Zhong X, Wang H, Peng Y, Shi F, Jia D, Yang H, Zeng Q, Quan C, ZhangBao J, Lee M, Qi J, Chen X, Qiu W. Batoclimab as an add-on therapy in neuromyelitis optica spectrum disorder patients with acute attacks. Eur J Neurol 2023; 30:195-203. [PMID: 36087008 DOI: 10.1111/ene.15561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 07/13/2022] [Accepted: 09/04/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND PURPOSE Neuromyelitis optica spectrum disorder (NMOSD) is a severe neurological inflammatory disease mainly caused by pathogenic aquaporin-4 antibodies (AQP4-IgG). The safety and efficacy of the neonatal Fc receptor antagonist batoclimab addition to conventional intravenous methylprednisolone pulse (IVMP) therapy in patients with NMOSD acute attacks was assessed. METHODS In an open-label, dose-escalation phase 1b study, NMOSD patients with acute myelitis and/or optic neuritis received four doses of weekly subcutaneous injections of either 340 mg or 680 mg batoclimab with concurrent IVMP and were followed up for 27 weeks. The primary end-points were safety and tolerability. Secondary end-points included pharmacodynamics and efficacy, with key efficacy assessment at week 4. RESULTS In total nine NMOSD patients were enrolled, including two and seven in the 340 and 680 mg groups. Five patients had acute myelitis, while the remaining four had unilateral optic neuritis. Batoclimab add-on therapy had an overall good safety profile without serious adverse events. In the 680 mg group, mean immunoglobulin G (IgG) reached its maximum reduction at the last dose (day 22). In the meantime, AQP4-IgG was undetectable in six of seven subjects whose baseline AQP4-IgG titers ranged from 1:32 to 1:320. Expanded Disability Status Scale score was reduced by 1.3 ± 0.4 at week 4 (2.7 ± 1.3) compared with baseline (4.0 ± 1.0). CONCLUSIONS Batoclimab add-on therapy to IVMP is safe and tolerated in patients with NMOSD. Preliminary evidence suggests a beneficial neurological effect. A randomized controlled trial would be needed to prove the efficacy.
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Affiliation(s)
- Yuge Wang
- Department of Neurology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xiaonan Zhong
- Department of Neurology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Honghao Wang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yu Peng
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Fudong Shi
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
| | - Dongmei Jia
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Qiuming Zeng
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Chao Quan
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jingzi ZhangBao
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | | | - Jun Qi
- Harbour BioMed, Shanghai, China
| | | | - Wei Qiu
- Department of Neurology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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Wingerchuk DM, Weinshenker BG, McCormick D, Barron S, Simone L, Jarzylo L. Aligning payer and provider strategies with the latest evidence to optimize clinical outcomes for patients with neuromyelitis optica spectrum disorder. J Manag Care Spec Pharm 2022; 28:S3-S27. [DOI: 10.18553/jmcp.2022.28.12-a.s1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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10
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Xu X, Xie L, Wei L, Li M, Wang H, Zhou H, Sun M, Yang M, Xu Q, Yang K, Wei S. Efficacy and safety of monoclonal antibodies in neuromyelitis optica spectrum disorders: A survival meta-analysis of randomized controlled trials. ADVANCES IN OPHTHALMOLOGY PRACTICE AND RESEARCH 2022; 2:100064. [PMID: 37846287 PMCID: PMC10577852 DOI: 10.1016/j.aopr.2022.100064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/30/2022] [Accepted: 05/15/2022] [Indexed: 10/18/2023]
Abstract
Background Monoclonal antibodies such as rituximab (RTX), eculizumab, inebilizumab, satralizumab, and tocilizumab have been found to be effective therapies for neuromyelitis optica spectrum disease (NMOSD) in several clinical randomized controlled trials. Objective The purpose of this meta-analysis of randomized controlled trials was to assess the efficacy and safety of monoclonal antibodies in the treatment of NMOSD. Methods We searched the following databases for relevant English language literature from the establishment of the database to June 2021: PubMed, Embase, Cohorane Library, the Central Register of Controlled Trials (CENTRAL), and Web of Science. Randomized controlled trials of monoclonal antibodies were the targets of the review. Results We included seven trials containing 775 patients (485 in the monoclonal antibody group and 290 in the control group). Patients in the monoclonal group (HR 0.24, 95% CI: 0.14 to 0.40, P < 0.00001), as well as patients with seropositive AQP4-IgG (HR 0.18, 95% CI: 0.11 to 0.29, P < 0.00001), both had a higher free recurrence rate than that in the control group. In the first year (HR 0.25, 95% CI: 0.09 to 0.71, P = 0.009) and the second year (HR 0.32, 95% CI: 0.13 to 0.81, P = 0.02), no relapses were documented. The average changes of the expanded disability status scale (EDSS) score decreased by 0.29 (95% CI: -0.09 to 0.51, P = 0.005). Upper respiratory tract infection (OR 1.52, 95% CI: 0.76 to 3.04, P = 0.24), urinary tract infection(OR 0.79, 95% CI: 0.51 to 1.21, P = 0.27), and headache (OR 1.30, 95% CI: 0.78 to 2.17, P = 0.31) were three most frequent adverse reactions. Conclusions Monoclonal antibodies are particularly effective treatments in avoiding recurrence for NMOSD patients, according to this meta-analysis. The associated adverse responses are not significantly different from those seen with traditional immunosuppressants.
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Affiliation(s)
- Xintong Xu
- Medical School of Chinese PLA, Beijing, China
- Department of Ophthalmology, Chinese PLA General Hospital, Beijing, China
| | - Lindan Xie
- Department of Ophthalmology, Chinese PLA General Hospital, Beijing, China
| | - Lili Wei
- Evidence-Based Medicine Center, Lanzhou University, Lanzhou, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
- Gansu Medical Guideline Technology Center, Lanzhou University, Lanzhou, China
| | - Meixuan Li
- Evidence-Based Medicine Center, Lanzhou University, Lanzhou, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
- Gansu Medical Guideline Technology Center, Lanzhou University, Lanzhou, China
| | - Hao Wang
- Department of Ophthalmology, Lanzhou University Second Hospital, Lanzhou, China
| | - Huanfen Zhou
- Department of Ophthalmology, Chinese PLA General Hospital, Beijing, China
| | - Mingming Sun
- Department of Ophthalmology, Chinese PLA General Hospital, Beijing, China
| | - Mo Yang
- Department of Ophthalmology, Chinese PLA General Hospital, Beijing, China
| | - Quangang Xu
- Department of Ophthalmology, Chinese PLA General Hospital, Beijing, China
| | - Kehu Yang
- Evidence-Based Medicine Center, Lanzhou University, Lanzhou, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
- Gansu Medical Guideline Technology Center, Lanzhou University, Lanzhou, China
| | - Shihui Wei
- Department of Ophthalmology, Chinese PLA General Hospital, Beijing, China
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Chen TX, Fan YT, Peng BW. Distinct mechanisms underlying therapeutic potentials of CD20 in neurological and neuromuscular disease. Pharmacol Ther 2022; 238:108180. [DOI: 10.1016/j.pharmthera.2022.108180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/16/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
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12
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Mariottini A, Muraro PA, Lünemann JD. Antibody-mediated cell depletion therapies in multiple sclerosis. Front Immunol 2022; 13:953649. [PMID: 36172350 PMCID: PMC9511140 DOI: 10.3389/fimmu.2022.953649] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 07/29/2022] [Indexed: 11/30/2022] Open
Abstract
Development of disease-modifying therapies including monoclonal antibody (mAb)-based therapeutics for the treatment of multiple sclerosis (MS) has been extremely successful over the past decades. Most of the mAb-based therapies approved for MS deplete immune cell subsets and act through activation of cellular Fc-gamma receptors expressed by cytotoxic lymphocytes and phagocytes, resulting in antibody-dependent cellular cytotoxicity or by initiation of complement-mediated cytotoxicity. The therapeutic goal is to eliminate pathogenic immune cell components and to potentially foster the reconstitution of a new and healthy immune system. Ab-mediated immune cell depletion therapies include the CD52-targeting mAb alemtuzumab, CD20-specific therapeutics, and new Ab-based treatments which are currently being developed and tested in clinical trials. Here, we review recent developments in effector mechanisms and clinical applications of Ab-based cell depletion therapies, compare their immunological and clinical effects with the prototypic immune reconstitution treatment strategy, autologous hematopoietic stem cell transplantation, and discuss their potential to restore immunological tolerance and to achieve durable remission in people with MS.
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Affiliation(s)
- Alice Mariottini
- Department of Brain Sciences, Imperial College London, London, United Kingdom
- Department of Neurosciences, Drug and Child Health, University of Florence, Florence, Italy
| | - Paolo A. Muraro
- Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Jan D. Lünemann
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
- *Correspondence: Jan D. Lünemann,
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13
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Petzold A, Fraser CL, Abegg M, Alroughani R, Alshowaeir D, Alvarenga R, Andris C, Asgari N, Barnett Y, Battistella R, Behbehani R, Berger T, Bikbov MM, Biotti D, Biousse V, Boschi A, Brazdil M, Brezhnev A, Calabresi PA, Cordonnier M, Costello F, Cruz FM, Cunha LP, Daoudi S, Deschamps R, de Seze J, Diem R, Etemadifar M, Flores-Rivera J, Fonseca P, Frederiksen J, Frohman E, Frohman T, Tilikete CF, Fujihara K, Gálvez A, Gouider R, Gracia F, Grigoriadis N, Guajardo JM, Habek M, Hawlina M, Martínez-Lapiscina EH, Hooker J, Hor JY, Howlett W, Huang-Link Y, Idrissova Z, Illes Z, Jancic J, Jindahra P, Karussis D, Kerty E, Kim HJ, Lagrèze W, Leocani L, Levin N, Liskova P, Liu Y, Maiga Y, Marignier R, McGuigan C, Meira D, Merle H, Monteiro MLR, Moodley A, Moura F, Muñoz S, Mustafa S, Nakashima I, Noval S, Oehninger C, Ogun O, Omoti A, Pandit L, Paul F, Rebolleda G, Reddel S, Rejdak K, Rejdak R, Rodriguez-Morales AJ, Rougier MB, Sa MJ, Sanchez-Dalmau B, Saylor D, Shatriah I, Siva A, Stiebel-Kalish H, Szatmary G, Ta L, Tenembaum S, Tran H, Trufanov Y, van Pesch V, Wang AG, Wattjes MP, Willoughby E, Zakaria M, Zvornicanin J, Balcer L, Plant GT. Diagnosis and classification of optic neuritis. Lancet Neurol 2022; 21:1120-1134. [PMID: 36179757 DOI: 10.1016/s1474-4422(22)00200-9] [Citation(s) in RCA: 62] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 03/16/2022] [Accepted: 04/20/2022] [Indexed: 11/28/2022]
Abstract
There is no consensus regarding the classification of optic neuritis, and precise diagnostic criteria are not available. This reality means that the diagnosis of disorders that have optic neuritis as the first manifestation can be challenging. Accurate diagnosis of optic neuritis at presentation can facilitate the timely treatment of individuals with multiple sclerosis, neuromyelitis optica spectrum disorder, or myelin oligodendrocyte glycoprotein antibody-associated disease. Epidemiological data show that, cumulatively, optic neuritis is most frequently caused by many conditions other than multiple sclerosis. Worldwide, the cause and management of optic neuritis varies with geographical location, treatment availability, and ethnic background. We have developed diagnostic criteria for optic neuritis and a classification of optic neuritis subgroups. Our diagnostic criteria are based on clinical features that permit a diagnosis of possible optic neuritis; further paraclinical tests, utilising brain, orbital, and retinal imaging, together with antibody and other protein biomarker data, can lead to a diagnosis of definite optic neuritis. Paraclinical tests can also be applied retrospectively on stored samples and historical brain or retinal scans, which will be useful for future validation studies. Our criteria have the potential to reduce the risk of misdiagnosis, provide information on optic neuritis disease course that can guide future treatment trial design, and enable physicians to judge the likelihood of a need for long-term pharmacological management, which might differ according to optic neuritis subgroups.
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14
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Treatment and Relapse Prevention of Typical and Atypical Optic Neuritis. Int J Mol Sci 2022; 23:ijms23179769. [PMID: 36077167 PMCID: PMC9456305 DOI: 10.3390/ijms23179769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 12/02/2022] Open
Abstract
Optic neuritis (ON) is an inflammatory condition involving the optic nerve. Several important typical and atypical ON variants are now recognized. Typical ON has a more favorable prognosis; it can be idiopathic or represent an early manifestation of demyelinating diseases, mostly multiple sclerosis (MS). The atypical spectrum includes entities such as antibody-driven ON associated with neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody disease (MOGAD), chronic/relapsing inflammatory optic neuropathy (CRION), and sarcoidosis-associated ON. Appropriate and timely diagnosis is essential to rapidly decide on the appropriate treatment, maximize visual recovery, and minimize recurrences. This review paper aims at presenting the currently available state-of-the-art treatment strategies for typical and atypical ON, both in the acute phase and in the long-term. Moreover, emerging therapeutic approaches and novel steps in the direction of achieving remyelination are discussed.
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15
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Lotan I, Levy M. New treatment perspectives for acute relapses in neuromyelitis optica spectrum disorder. Transfus Med Rev 2022; 36:230-232. [DOI: 10.1016/j.tmrv.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 06/20/2022] [Accepted: 06/21/2022] [Indexed: 10/15/2022]
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16
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Abstract
PURPOSE OF REVIEW This article reviews the cardinal clinical features, distinct immunopathology, current diagnostic criteria, relapse-related risk factors, emerging biomarkers, and evolving treatment strategies pertaining to neuromyelitis optica spectrum disorders (NMOSD). RECENT FINDINGS The discovery of the pathogenic aquaporin-4 (AQP4)-IgG autoantibody and characterization of NMOSD as an autoimmune astrocytopathy have spearheaded the identification of key immunologic therapeutic targets in this disease, including but not limited to the complement system, the interleukin 6 (IL-6) receptor, and B cells. Accordingly, four recent randomized controlled trials have demonstrated the efficacy of three new NMOSD therapies, namely eculizumab, satralizumab, and inebilizumab. SUMMARY Currently, NMOSD poses both diagnostic and treatment challenges. It is debated whether individuals who are seropositive for myelin oligodendrocyte glycoprotein (MOG)-IgG belong within the neuromyelitis optica spectrum. This discussion is fueled by disparities in treatment responses between patients who are AQP4-IgG seropositive and seronegative, suggesting different immunopathologic mechanisms may govern these conditions. As our understanding regarding the immune pathophysiology of NMOSD expands, emerging biomarkers, including serum neurofilament light chain and glial fibrillary acidic protein (GFAP), may facilitate earlier relapse detection and inform long-term treatment decisions. Future research focal points should include strategies to optimize relapse management, restorative treatments that augment neurologic recovery, and practical solutions that promote equitable access to approved therapies for all patients with NMOSD.
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17
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Pathomechanisms in demyelination and astrocytopathy: autoantibodies to AQP4, MOG, GFAP, GRP78 and beyond. Curr Opin Neurol 2022; 35:427-435. [PMID: 35674086 DOI: 10.1097/wco.0000000000001052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight the recently emerging pathomechanisms of diseases associated with autoantibodies to AQP4, MOG, GFAP, GRP78 and further novel targets. We discuss novel biomarkers and therapeutic approaches. RECENT FINDINGS Although complement-mediated cytotoxicity (CDC) is regarded as the major effector mechanism for AQP4-IgG in neuromyelitis optica spectrum disorders (NMOSD), recent studies helped to understand the relevance of complement-independent effector mechanisms. For MOG-IgG mediated diseases the role of CDC is less clear. MOG-IgG may trigger a tightly controlled FcR and BTK-driven microglia proliferative response in MOG-antibody-associated diseases. Differences of antibody-mediated tissue damage may reflect differential response to therapy. In addition, antibodies to GFAP, GRP78 and further novel targets have been implicated in demyelination and astrocytopathy. SUMMARY Elucidating the whole spectrum of effector functions in diseases mediated by AQP4-IgG and MOG-IgG and understanding the role of additional novel autoantibodies involved in demyelination and astrocytopathy may guide further novel treatment decisions.
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18
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Abstract
Multiple sclerosis (MS) is a chronic autoimmune demyelinating disease of the central nervous system (CNS) that often progresses to severe disability. Previous studies have highlighted the role of T cells in disease pathophysiology; however, the success of B-cell-targeted therapies has led to an increased interest in how B cells contribute to disease immunopathology. In this review, we summarize evidence of B-cell involvement in MS disease mechanisms, starting with pathology and moving on to review aspects of B cell immunobiology potentially relevant to MS. We describe current theories of critical B cell contributions to the inflammatory CNS milieu in MS, namely (i) production of autoantibodies, (ii) antigen presentation, (iii) production of proinflammatory cytokines (bystander activation), and (iv) EBV involvement. In the second part of the review, we summarize medications that have targeted B cells in patients with MS and their current position in the therapeutic armamentarium based on clinical trials and real-world data. Covered therapeutic strategies include the targeting of surface molecules such as CD20 (rituximab, ocrelizumab, ofatumumab, ublituximab) and CD19 (inebilizumab), and molecules necessary for B-cell activation such as B cell activating factor (BAFF) (belimumab) and Bruton's Tyrosine Kinase (BTK) (evobrutinib). We finally discuss the use of B-cell-targeted therapeutics in pregnancy.
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19
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Kaegi C, Wuest B, Crowley C, Boyman O. Systematic Review of Safety and Efficacy of Second- and Third-Generation CD20-Targeting Biologics in Treating Immune-Mediated Disorders. Front Immunol 2022; 12:788830. [PMID: 35185862 PMCID: PMC8847774 DOI: 10.3389/fimmu.2021.788830] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 12/17/2021] [Indexed: 12/16/2022] Open
Abstract
Background B cells can contribute to immune-mediated disorders. Targeting CD20 has proved to be efficacious in several B cell-mediated immunopathologies, as illustrated by the use of rituximab, the first anti-CD20 monoclonal antibody (mAb). Following rituximab, second- and third-generation anti-CD20 mAbs have been developed and tried in immune-mediated diseases, including obinutuzumab, ocrelizumab, ofatumumab, ublituximab, and veltuzumab. However, their safety and efficacy has not been systematically reviewed. Objective To evaluate safety and efficacy of obinutuzumab, ocrelizumab, ofatumumab, ublituximab, and veltuzumab for the treatment of immune-mediated disorders compared to placebo, conventional treatment or other biologics. Methods The PRISMA checklist guided the reporting of the data. We searched the PubMed database between 4 October 2016 and 22 July 2021 concentrating on immune-mediated disorders. Results The literature search identified 2220 articles. After screening titles and abstracts against the inclusion and exclusion criteria and assessing full texts, 27 articles were finally included in a narrative synthesis. Conclusions Obinutuzumab has shown promising results in a case series of patients with phospholipase A2 receptor-associated membranous nephropathy and mixed results in systemic lupus erythematosus. Ocrelizumab has been approved for the use in patients with relapsing-remitting multiple sclerosis and primary progressive multiple sclerosis. Ocrelizumab was also tested in patients with rheumatoid arthritis, demonstrating promising results, and in systemic lupus erythematosus, revealing mixed results; however, in these conditions, its use was associated with increased risk of serious infections. Ofatumumab received approval for treating patients with relapsing-remitting multiple sclerosis. Moreover, ofatumumab showed promising results in patients with anti-neutrophil cytoplasmic antibody-associated vasculitis, rheumatoid arthritis, and systemic lupus erythematosus, as well as mixed results in phospholipase A2 receptor-associated membranous nephropathy. Ublituximab was assessed in relapsing-remitting multiple sclerosis and neuromyelitis optica spectrum disorder, with promising results, however, the included number of patients was too small to conclude. Veltuzumab was tested in patients with immune thrombocytopenia resulting in improved platelet counts. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, identifier CRD4201913421.
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Affiliation(s)
- Celine Kaegi
- Department of Immunology, University Hospital Zurich, Zurich, Switzerland
| | - Benjamin Wuest
- Department of Immunology, University Hospital Zurich, Zurich, Switzerland
| | - Catherine Crowley
- Department of Immunology, University Hospital Zurich, Zurich, Switzerland
| | - Onur Boyman
- Department of Immunology, University Hospital Zurich, Zurich, Switzerland.,Faculty of Medicine, University of Zurich, Zurich, Switzerland
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20
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Redenbaugh V, Flanagan EP. Monoclonal Antibody Therapies Beyond Complement for NMOSD and MOGAD. Neurotherapeutics 2022; 19:808-822. [PMID: 35267170 PMCID: PMC9294102 DOI: 10.1007/s13311-022-01206-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 01/09/2023] Open
Abstract
Aquaporin-4 (AQP4)-IgG seropositive neuromyelitis optica spectrum disorders (AQP4-IgG seropositive NMOSD) and myelin oligodendrocyte glycoprotein (MOG)-IgG-associated disease (MOGAD) are inflammatory demyelinating disorders distinct from each other and from multiple sclerosis (MS).While anti-CD20 treatments can be used to treat MS and AQP4-IgG seropositive NMOSD, some MS medications are ineffective or could exacerbate AQP4-IgG seropositive NMOSD including beta-interferons, natalizumab, and fingolimod. AQP4-IgG seropositive NMOSD has a relapsing course in most cases, and preventative maintenance treatments should be started after the initial attack. Rituximab, eculizumab, inebilizumab, and satralizumab all have class 1 evidence for use in AQP4-IgG seropositive NMOSD, and the latter three have been approved by the US Food and Drug Administration (FDA). MOGAD is much more likely to be monophasic than AQP4-IgG seropositive NMOSD, and preventative therapy is usually reserved for those who have had a disease relapse. There is a lack of any class 1 evidence for MOGAD preventative treatment. Observational benefit has been suggested from oral immunosuppressants, intravenous immunoglobulin (IVIg), rituximab, and tocilizumab. Randomized placebo-controlled trials are urgently needed in this area.
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Affiliation(s)
- Vyanka Redenbaugh
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN, 55905, USA
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN, 55905, USA.
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, 55905, USA.
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21
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Carnero Contentti E, López PA, Rojas JI. Emerging drugs for the acute treatment of relapses in adult neuromyelitis optica spectrum disorder patients. Expert Opin Emerg Drugs 2022; 27:91-98. [PMID: 35341428 DOI: 10.1080/14728214.2022.2059463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Neuromyelitis optica spectrum disorders (NMOSD) are rare but often devastating neuroinflammatory autoimmune diseases of the central nervous system. Acute treatment is critically important and it should be initiated early and aggressively, as relapses result in severe residual disability. Acute treatments are still based on clinical experience and observational studies. The most commonly used treatments are steroids and plasmapheresis. Several new treatments to improve management and recovery after relapses in NMOSD are currently under investigation. AREAS COVERED : This review discusses current and the most recent advances in active development of phase II/III clinical trials for acute treatment options and therapeutic strategies that can help management improvement of NMOSD during a relapse. These treatments include bevacizumab, ublituximab and HBM9161. EXPERT OPINION NMOSD relapses require prompt evaluation and timely treatment to restore function and mitigate disability. Timing is critical. Plasmapheresis showed better outcomes in terms of recovery when compared to high-dose intravenous methylprednisolone alone. Some groups suggest that plasmapheresis could be considered as an initial treatment approach in different clinical scenarios due to its higher effectiveness. Future research and/or real-world data will establish the advantages and disadvantages of these new treatments and define the appropriate patient profile.
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Affiliation(s)
| | - Pablo A López
- Neuroimmunology Unit, Department of Neuroscience, Hospital Aleman, Buenos Aires, Argentina
| | - Juan I Rojas
- Centro de Esclerosis Múltiple de Buenos Aires (CEMBA), Buenos Aires, Argentina.,Servicio de Neurología, Hospital Universitario de CEMIC, Buenos Aires, Argentina
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22
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Ruck T, Nimmerjahn F, Wiendl H, Lünemann JD. Next generation antibody-based therapies in neurology. Brain 2021; 145:1229-1241. [PMID: 34928330 DOI: 10.1093/brain/awab465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/04/2021] [Accepted: 11/25/2021] [Indexed: 11/13/2022] Open
Abstract
Antibody (Ab)-based therapeutics are now standard in the treatment of neuroinflammatory diseases, and the spectrum of neurological diseases targeted by those approaches continues to grow. The efficacy of Ab-based drug-platforms is largely determined by the specificity-conferring antigen-binding fragment (Fab) and the crystallizable fragment (Fc) driving antibody function. The latter provides specific instructions to the immune system by interacting with cellular Fc receptors and complement components. Extensive engineering efforts enabled tuning of Fc functions to modulate effector functions and to prolong or reduce Ab serum half-lives. Technologies that improve bioavailability of Ab-based treatment platforms within the central nervous system parenchyma are being developed and could invigorate drug discovery for a number of brain diseases for which current therapeutic options are limited. These powerful approaches are currently being tested in clinical trials or have been successfully translated into the clinic. Here, we review recent developments in the design and implementation of Ab-based treatment modalities in neurological diseases.
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Affiliation(s)
- Tobias Ruck
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, 48149 Münster, Germany.,Department of Neurology, Heinrich-Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Falk Nimmerjahn
- Department of Biology, Division of Genetics, University of Erlangen-Nuremberg, 91058 Erlangen, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, 48149 Münster, Germany
| | - Jan D Lünemann
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, 48149 Münster, Germany
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23
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Carnero Contentti E, Correale J. Neuromyelitis optica spectrum disorders: from pathophysiology to therapeutic strategies. J Neuroinflammation 2021; 18:208. [PMID: 34530847 PMCID: PMC8444436 DOI: 10.1186/s12974-021-02249-1] [Citation(s) in RCA: 101] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 08/24/2021] [Indexed: 02/08/2023] Open
Abstract
Neuromyelitis optica (NMO) is a chronic inflammatory autoimmune disease of the central nervous system (CNS) characterized by acute optic neuritis (ON) and transverse myelitis (TM). NMO is caused by a pathogenic serum IgG antibody against the water channel aquoporin 4 (AQP4) in the majority of patients. AQP4-antibody (AQP4-ab) presence is highly specific, and differentiates NMO from multiple sclerosis. It binds to AQP4 channels on astrocytes, triggering activation of the classical complement cascade, causing granulocyte, eosinophil, and lymphocyte infiltration, culminating in injury first to astrocyte, then oligodendrocytes followed by demyelination and neuronal loss. NMO spectrum disorder (NMOSD) has recently been defined and stratified based on AQP4-ab serology status. Most NMOSD patients experience severe relapses leading to permanent neurologic disability, making suppression of relapse frequency and severity, the primary objective in disease management. The most common treatments used for relapses are steroids and plasma exchange.Currently, long-term NMOSD relapse prevention includes off-label use of immunosuppressants, particularly rituximab. In the last 2 years however, three pivotal clinical trials have expanded the spectrum of drugs available for NMOSD patients. Phase III studies have shown significant relapse reduction compared to placebo in AQP4-ab-positive patients treated with satralizumab, an interleukin-6 receptor (IL-6R) inhibitor, inebilizumab, an antibody against CD19+ B cells; and eculizumab, an antibody blocking the C5 component of complement. In light of the new evidence on NMOSD pathophysiology and of preliminary results from ongoing trials with new drugs, we present this descriptive review, highlighting promising treatment modalities as well as auspicious preclinical and clinical studies.
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24
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Levy M, Mealy MA. B-Cell Targeted Treatments for Neuromyelitis Optica Spectrum Disorder: A Focus on CD19 and CD20. Immunotargets Ther 2021; 10:325-331. [PMID: 34447723 PMCID: PMC8384424 DOI: 10.2147/itt.s255722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/10/2021] [Indexed: 12/02/2022] Open
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is a rare relapsing autoimmune disease of the central nervous system that preferentially targets the optic nerves and spinal cord, leading to visual loss and impaired mobility. Until 2019, no medications were FDA-approved for NMOSD treatment, and standard of care was based on mostly empiric and retrospective data. Therapies that target B cells emerged as a treatment strategy due to their fundamental role in disease pathogenesis. We explore different monoclonal antibodies directed at either CD20+ or CD19+ B cells that may have utilization in the treatment of NMOSD, discussing what is known regarding their efficacy and safety.
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Affiliation(s)
- Michael Levy
- Department of Neurology, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA
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25
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Cacciaguerra L, Tortorella P, Rocca MA, Filippi M. Targeting Neuromyelitis Optica Pathogenesis: Results from Randomized Controlled Trials of Biologics. Neurotherapeutics 2021; 18:1623-1636. [PMID: 33909234 PMCID: PMC8608970 DOI: 10.1007/s13311-021-01055-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2021] [Indexed: 02/04/2023] Open
Abstract
Advances in neuromyelitis optica spectrum disorder pathogenesis have allowed the development of targeted drugs. These treatments act on core elements of the disease, including the pro-inflammatory IL-6 pathway (tocilizumab and satralizumab), B cells (rituximab and inebilizumab), and complement (eculizumab). According to recent phase II-III trials, biologics significantly reduced the risk of relapses in aquaporin-4-seropositive patients, whereas results were less striking in the small cohorts of aquaporin-4-seronegative patients. Most adverse events were mild to moderate, with systemic symptoms (headache, arthralgia) or infections (upper respiratory and urinary tracts) being most commonly reported.
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Affiliation(s)
- Laura Cacciaguerra
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | | | - Maria A Rocca
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.
- Vita-Salute San Raffaele University, Milan, Italy.
- Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.
- Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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26
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Tugizova M, Vlahovic L, Tomczak A, Wetzel NS, Han MH. New Therapeutic Landscape in Neuromyelitis Optica. Curr Treat Options Neurol 2021; 23:13. [PMID: 33814893 PMCID: PMC8008025 DOI: 10.1007/s11940-021-00667-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2021] [Indexed: 12/11/2022]
Abstract
Purpose of review This review discusses the current treatment trends and emerging therapeutic landscape for patients with neuromyelitis optica spectrum disorder (NMOSD). Recent findings Conventional immune suppressive therapies, such as B cell depletion, have been used for long-term treatment. However, the availability of recent FDA-approved and investigational drugs has made therapeutic choices for NMOSD more complex. Summary Recent randomized clinical trials have shown that eculizumab, inebilizumab, and satralizumab are efficacious therapies for AQP4 seropositive NMOSD. These therapies may not have the same benefit in patients with seronegative NMOSD, including MOG-associated disease, and further investigation is required in this population. Reliable biomarkers to guide therapy decisions are urgently needed. There is a plethora of promising investigational therapies currently in the pipeline with exciting and novel mechanisms of action.
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Affiliation(s)
- Madina Tugizova
- Department of Neurology, Division of Neuroimmunology, Stanford University, 1201 Welch Road, MSLS p212, Stanford, CA 94305 USA.,Multiple Sclerosis Center, Stanford Hospital and Clinics, Palo Alto, CA USA
| | - Luka Vlahovic
- Department of Neurology, Creighton University School of Medicine, Omaha, NE USA
| | - Anna Tomczak
- Department of Neurology, Division of Neuroimmunology, Stanford University, 1201 Welch Road, MSLS p212, Stanford, CA 94305 USA.,Multiple Sclerosis Center, Stanford Hospital and Clinics, Palo Alto, CA USA
| | - Nora Sandrine Wetzel
- Department of Neurology, Division of Neuroimmunology, Stanford University, 1201 Welch Road, MSLS p212, Stanford, CA 94305 USA.,Faculty of Medicine, University of Zurich, Zürich, Switzerland
| | - May Htwe Han
- Department of Neurology, Division of Neuroimmunology, Stanford University, 1201 Welch Road, MSLS p212, Stanford, CA 94305 USA.,Multiple Sclerosis Center, Stanford Hospital and Clinics, Palo Alto, CA USA
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27
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Held F, Klein AK, Berthele A. Drug Treatment of Neuromyelitis Optica Spectrum Disorders: Out with the Old, in with the New? Immunotargets Ther 2021; 10:87-101. [PMID: 33777853 PMCID: PMC7989551 DOI: 10.2147/itt.s287652] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 02/16/2021] [Indexed: 12/11/2022] Open
Abstract
Introduction Neuromyelitis optica spectrum disorders (NMOSD) are rare neuroinflammatory demyelinating diseases of the CNS, mainly affecting optic nerves, spinal cord and brainstem regions. The diagnosis depends on clinical symptoms, MRI findings and the detection of autoantibodies against the water channel aquaporin 4 (AQP4-Ab). This autoantibody is particularly important for diagnostic sensitivity and specificity and further sets the course for major therapeutic decisions. Due to a relapsing course with the accumulation of disability, relapse prevention by immunotherapy is crucial in NMOSD. Until recently, disease-modifying agents specific to NMOSD were not available, and patients were treated with various immunosuppressive drugs and regimens - with variable success. Fortunately, since 2019, three new therapeutic antibodies have entered the market. Areas Covered We aim to shortly summarise the pathogenesis and biological targets for acute and preventive therapy of adult NMOSD. We will focus on conventional immunotherapies and the recently approved novel biological drugs satralizumab, eculizumab and inebilizumab, and conclude with a brief outlook on future therapeutic approaches. Expert Opinion Although satralizumab, eculizumab and inebilizumab are a breakthrough concerning short-term efficacy, important questions on their future use remain open. There is no data from head-to-head comparisons, and data on long-term safety and efficacy of the new medicines are pending. Whether any of the biologics are efficacious in AQP4-Ab negative NMOSD patients is not yet known – as is how they will succeed in non-responders to conventional immunotherapies. Further, (autoimmune) comorbidities, affordability, and market availability of drugs may be decisive factors for choosing treatments in the near future. We are fortunate to have these new drugs available now, but they will not immediately supersede established off-label drugs in this indication. It is still too early to definitively revise the treatment algorithms for NMOSD - although we are probably on the way.
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Affiliation(s)
- Friederike Held
- Department of Neurology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Ana-Katharina Klein
- Department of Neurology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Achim Berthele
- Department of Neurology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
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B Cells and Antibodies as Targets of Therapeutic Intervention in Neuromyelitis Optica Spectrum Disorders. Pharmaceuticals (Basel) 2021; 14:ph14010037. [PMID: 33419217 PMCID: PMC7825598 DOI: 10.3390/ph14010037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/02/2021] [Accepted: 01/03/2021] [Indexed: 12/11/2022] Open
Abstract
The first description of neuromyelitis optica by Eugène Devic and Fernand Gault dates back to the 19th century, but only the discovery of aquaporin-4 autoantibodies in a major subset of affected patients in 2004 led to a fundamentally revised disease concept: Neuromyelits optica spectrum disorders (NMOSD) are now considered autoantibody-mediated autoimmune diseases, bringing the pivotal pathogenetic role of B cells and plasma cells into focus. Not long ago, there was no approved medication for this deleterious disease and off-label therapies were the only treatment options for affected patients. Within the last years, there has been a tremendous development of novel therapies with diverse treatment strategies: immunosuppression, B cell depletion, complement factor antagonism and interleukin-6 receptor blockage were shown to be effective and promising therapeutic interventions. This has led to the long-expected official approval of eculizumab in 2019 and inebilizumab in 2020. In this article, we review current pathogenetic concepts in NMOSD with a focus on the role of B cells and autoantibodies as major contributors to the propagation of these diseases. Lastly, by highlighting promising experimental and future treatment options, we aim to round up the current state of knowledge on the therapeutic arsenal in NMOSD.
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Graf J, Mares J, Barnett M, Aktas O, Albrecht P, Zamvil SS, Hartung HP. Targeting B cells to modify MS, NMOSD, and MOGAD: Part 2. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 8:8/1/e919. [PMID: 33411674 PMCID: PMC8063618 DOI: 10.1212/nxi.0000000000000919] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/11/2020] [Indexed: 12/15/2022]
Abstract
Ocrelizumab, rituximab, ofatumumab, ublituximab, inebilizumab, and evobrutinib
are immunotherapies that target various B cell–related proteins. Most of
these treatments have proven efficacy in relapsing and progressive forms of MS
and neuromyelitis optica spectrum disease (NMOSD) or are in advanced stages of
clinical development. Currently, ocrelizumab and inebilizumab are licensed for
treatment of MS and NMOSD, respectively. This part of the review focuses on
monoclonal antibody B cell–depleting strategies in NMOSD and the emerging
related myelin oligodendrocyte glycoprotein (MOG) immunoglobulin
G–associated disease (MOGAD). Case series and phase 2/3 studies in these
inflammatory disorders are assessed. The safety profile of long-term B-cell
depletion in MS, NMOSD, and MOGAD will be highlighted. Finally implications of
the current coronavirus disease 2019 pandemic on the management of patients with
these disorders and the use of B cell–depleting agents will be
discussed.
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Affiliation(s)
- Jonas Graf
- From the Department of Neurology (J.G., O.A., P.A., H.-P.H.), University Hospital, Medical Faculty Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (J.M.), Palacky University, Olomouc, Czech Republic; Department of Neurology, Brain and Mind Centre (M.B., H.-P.H.), Department of Neurology, University of Sydney, New South Wales, Australia; and Department of Neurology (S.S.Z.), UCSF Weill Institute of Neurosciences, University of California at San Francisco
| | - Jan Mares
- From the Department of Neurology (J.G., O.A., P.A., H.-P.H.), University Hospital, Medical Faculty Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (J.M.), Palacky University, Olomouc, Czech Republic; Department of Neurology, Brain and Mind Centre (M.B., H.-P.H.), Department of Neurology, University of Sydney, New South Wales, Australia; and Department of Neurology (S.S.Z.), UCSF Weill Institute of Neurosciences, University of California at San Francisco
| | - Michael Barnett
- From the Department of Neurology (J.G., O.A., P.A., H.-P.H.), University Hospital, Medical Faculty Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (J.M.), Palacky University, Olomouc, Czech Republic; Department of Neurology, Brain and Mind Centre (M.B., H.-P.H.), Department of Neurology, University of Sydney, New South Wales, Australia; and Department of Neurology (S.S.Z.), UCSF Weill Institute of Neurosciences, University of California at San Francisco
| | - Orhan Aktas
- From the Department of Neurology (J.G., O.A., P.A., H.-P.H.), University Hospital, Medical Faculty Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (J.M.), Palacky University, Olomouc, Czech Republic; Department of Neurology, Brain and Mind Centre (M.B., H.-P.H.), Department of Neurology, University of Sydney, New South Wales, Australia; and Department of Neurology (S.S.Z.), UCSF Weill Institute of Neurosciences, University of California at San Francisco
| | - Philipp Albrecht
- From the Department of Neurology (J.G., O.A., P.A., H.-P.H.), University Hospital, Medical Faculty Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (J.M.), Palacky University, Olomouc, Czech Republic; Department of Neurology, Brain and Mind Centre (M.B., H.-P.H.), Department of Neurology, University of Sydney, New South Wales, Australia; and Department of Neurology (S.S.Z.), UCSF Weill Institute of Neurosciences, University of California at San Francisco
| | - Scott S Zamvil
- From the Department of Neurology (J.G., O.A., P.A., H.-P.H.), University Hospital, Medical Faculty Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (J.M.), Palacky University, Olomouc, Czech Republic; Department of Neurology, Brain and Mind Centre (M.B., H.-P.H.), Department of Neurology, University of Sydney, New South Wales, Australia; and Department of Neurology (S.S.Z.), UCSF Weill Institute of Neurosciences, University of California at San Francisco
| | - Hans-Peter Hartung
- From the Department of Neurology (J.G., O.A., P.A., H.-P.H.), University Hospital, Medical Faculty Heinrich Heine University, Düsseldorf, Germany; Department of Neurology (J.M.), Palacky University, Olomouc, Czech Republic; Department of Neurology, Brain and Mind Centre (M.B., H.-P.H.), Department of Neurology, University of Sydney, New South Wales, Australia; and Department of Neurology (S.S.Z.), UCSF Weill Institute of Neurosciences, University of California at San Francisco.
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Xie Q, Sun M, Sun J, Zheng T, Wang M. New progress in the treatment of neuromyelitis optica spectrum disorder with monoclonal antibodies (Review). Exp Ther Med 2020; 21:148. [PMID: 33456515 DOI: 10.3892/etm.2020.9579] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 11/27/2020] [Indexed: 12/14/2022] Open
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is a group of immune-mediated inflammatory demyelinating diseases mainly affecting the central nervous system. It is characterized by high risk of relapse and progression to disability. The frequent recurrences of neuromyelitis optica spectrum disorder often exacerbate the neurological dysfunction and severely affect the patient's quality of life. Conventional treatments for neuromyelitis optica spectrum disorder, including acute treatment and sequential therapy, aim to decrease the degree of disability and recurrences. In recent years, new monoclonal antibodies have yielded encouraging results. The present review discusses the research status and recent progress in the treatment of NMOSD with monoclonal antibodies.
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Affiliation(s)
- Qinfang Xie
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, Gansu 730030, P.R. China
| | - Mengjiao Sun
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, Gansu 730030, P.R. China
| | - Jing Sun
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, Gansu 730030, P.R. China
| | - Ting Zheng
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, Gansu 730030, P.R. China
| | - Manxia Wang
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, Gansu 730030, P.R. China
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Abstract
PURPOSE OF REVIEW Neuromyelitis optica spectrum disorder is an autoimmune disease that causes optic neuritis and transverse myelitis. Attacks can cause severe neurological damage leading to blindness and paralysis. Understanding of the immunopathogenesis of this disease has led to major breakthroughs in diagnosis and treatment. In the past 18 months, three successful phase 3 clinical trials have been published using targeted approaches to preventing relapses. RECENT FINDINGS Updates in epidemiology, imaging, quality of life and treatment for acute relapse and prevention have been published in the past 18 months. Epidemiology studies are distinguishing patients based on their antigen specificity for aquaporin-4 and myelin oligodendrocyte glycoprotein, which are increasingly recognized as separate immunological conditions. Imaging by MRI and optical coherence tomography continue to be developed as tools to distinguish neuromyelitis optica spectrum disorders (NMOSD) from other diseases. This is especially relevant as the recent clinical trials showed differences in response between aquaporin-4 seropositive and seronegative patients. The three drugs that were tested for prevention of NMOSD relapses were eculizumab, inebilizumab, and satralizumab. All of the trials were worldwide, placebo-controlled, double-masked studies that demonstrated a clear benefit with each approach. SUMMARY Recent research in NMOSD has resulted in improved diagnosis and approved treatments.
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Affiliation(s)
- Kathryn Holroyd
- Harvard BWH Mass General Residency Program, Brigham and Women’s Hospital, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Giovanna Manzano
- Harvard BWH Mass General Residency Program, Brigham and Women’s Hospital, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael Levy
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Kosiyakul P, Songwisit S, Ungprasert P, Siritho S, Prayoonwiwat N, Jitprapaikulsan J. Effect of plasma exchange in neuromyelitis optica spectrum disorder: A systematic review and meta-analysis. Ann Clin Transl Neurol 2020; 7:2094-2102. [PMID: 32956562 PMCID: PMC7664276 DOI: 10.1002/acn3.51203] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/07/2020] [Accepted: 07/26/2020] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To conduct systematic review and meta-analysis for the efficacy of therapeutic plasma exchange (TPE) for neuromyelitis optica spectrum disorder (NMOSD) with an acute attack. METHODS Systematic review was performed using EMBASE and OVID/Medline database. The eligible studies must be the studies of NMOSD patients treated with TPE during the acute phase. They must report treatment outcomes using either Expanded Disability Status Scale (EDSS) or visual acuity (VA) before and after the therapy. Pooled mean difference (MD) was then calculated by combining MDs of each study using the random-effects model. RESULTS Fifteen studies were identified; eleven with 241 NMOSD patients reported EDSS outcome and four studies with 103 NMOSD reported visual outcomes. The meta-analysis demonstrated a significantly decreased in EDSS after TPE treatment for NMOSD with an acute attack with the pooled MD of 0.83 (95% CI, 0.26-1.40; I2 69%) comparing pretreatment to immediate posttreatment and 2.13 (95% CI, 1.55-2.70; I2 31%) comparing pretreatment to posttreatment at 6 months to 1-year follow-up. Unfortunately, only one of the four studies evaluating visual outcomes reported standard deviation in association with mean LogMAR; therefore, the meta-analysis cannot be conducted. Nonetheless, all studies consistently demonstrated the benefit of TPE with improved VA and/or LogMAR after treatment. INTERPRETATION This systematic review and meta-analysis showed the benefit of TPE during the NMOSD attack with a significantly improved disability status immediately after treatment and during follow-up.
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Affiliation(s)
- Punchika Kosiyakul
- Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sakdipat Songwisit
- Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Patompong Ungprasert
- Clinical Epidemiology Unit, Department of Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Department of Rheumatic & Immunologic Diseases, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sasitorn Siritho
- Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Bumrungrad Hospital, Bangkok, Thailand
| | - Naraporn Prayoonwiwat
- Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jiraporn Jitprapaikulsan
- Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Mallah K, Couch C, Borucki DM, Toutonji A, Alshareef M, Tomlinson S. Anti-inflammatory and Neuroprotective Agents in Clinical Trials for CNS Disease and Injury: Where Do We Go From Here? Front Immunol 2020; 11:2021. [PMID: 33013859 PMCID: PMC7513624 DOI: 10.3389/fimmu.2020.02021] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/27/2020] [Indexed: 02/06/2023] Open
Abstract
Neurological disorders are major contributors to death and disability worldwide. The pathology of injuries and disease processes includes a cascade of events that often involve molecular and cellular components of the immune system and their interaction with cells and structures within the central nervous system. Because of this, there has been great interest in developing neuroprotective therapeutic approaches that target neuroinflammatory pathways. Several neuroprotective anti-inflammatory agents have been investigated in clinical trials for a variety of neurological diseases and injuries, but to date the results from the great majority of these trials has been disappointing. There nevertheless remains great interest in the development of neuroprotective strategies in this arena. With this in mind, the complement system is being increasingly discussed as an attractive therapeutic target for treating brain injury and neurodegenerative conditions, due to emerging data supporting a pivotal role for complement in promoting multiple downstream activities that promote neuroinflammation and degeneration. As we move forward in testing additional neuroprotective and immune-modulating agents, we believe it will be useful to review past trials and discuss potential factors that may have contributed to failure, which will assist with future agent selection and trial design, including for complement inhibitors. In this context, we also discuss inhibition of the complement system as a potential neuroprotective strategy for neuropathologies of the central nervous system.
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Affiliation(s)
- Khalil Mallah
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, SC, United States
| | - Christine Couch
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, SC, United States
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, SC, United States
| | - Davis M. Borucki
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, SC, United States
- Department of Neurosciences, Medical University of South Carolina, Charleston, SC, United States
- Medical Scientist Training Program, Medical University of South Carolina, Charleston, SC, United States
| | - Amer Toutonji
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, SC, United States
- Department of Neurosciences, Medical University of South Carolina, Charleston, SC, United States
- Medical Scientist Training Program, Medical University of South Carolina, Charleston, SC, United States
| | - Mohammed Alshareef
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, SC, United States
- Department of Neurological Surgery, Medical University of South Carolina, Charleston, SC, United States
| | - Stephen Tomlinson
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, SC, United States
- Ralph Johnson VA Medical Center, Charleston, SC, United States
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Ma X, Kermode AG, Hu X, Qiu W. NMOSD acute attack: Understanding, treatment and innovative treatment prospect. J Neuroimmunol 2020; 348:577387. [PMID: 32987231 DOI: 10.1016/j.jneuroim.2020.577387] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/25/2020] [Accepted: 09/05/2020] [Indexed: 01/09/2023]
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is a group of severe inflammatory demyelinating disorders of the central nervous system that involves the optic nerve and spinal cord. Currently the therapeutic options for an acute attack in NMOSD are limited and rarely characterized in clinical studies. This review discussed the overall characteristics of acute attack of NMOSD, related risk factor, prognosis and management. Considering the huge unmet needs and the emergence of new therapeutic targets, we also reviewed innovative treatments that might alleviate attack damage, along with the challenges to evaluate new drug for acute attack in NMOSD.
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Affiliation(s)
- Xiaoyu Ma
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Allan G Kermode
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China; Centre for Neuromuscular and Neurological Disorders, University of Western Australia, Perth, WA, Australia; Department of Neurology, Sir Charles Gairdner Hospital, Queen Elizabeth II Medical Centre, Perth, WA, Australia; Institute of Immunology and Infectious Diseases, Murdoch University, Perth, WA, Australia
| | - Xueqiang Hu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wei Qiu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
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35
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Duchow A, Paul F, Bellmann-Strobl J. Current and emerging biologics for the treatment of neuromyelitis optica spectrum disorders. Expert Opin Biol Ther 2020; 20:1061-1072. [DOI: 10.1080/14712598.2020.1749259] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Ankelien Duchow
- Neurocure Clinical Research Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Experimental and Clinical Research Center, Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health and Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Friedemann Paul
- Neurocure Clinical Research Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Experimental and Clinical Research Center, Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health and Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Judith Bellmann-Strobl
- Neurocure Clinical Research Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Experimental and Clinical Research Center, Charité - Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health and Max Delbrück Center for Molecular Medicine, Berlin, Germany
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Kim W, Kim HJ. Monoclonal Antibody Therapies for Multiple Sclerosis and Neuromyelitis Optica Spectrum Disorder. J Clin Neurol 2020; 16:355-368. [PMID: 32657055 PMCID: PMC7354979 DOI: 10.3988/jcn.2020.16.3.355] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 12/01/2019] [Accepted: 12/02/2019] [Indexed: 12/21/2022] Open
Abstract
Considerable progress has been made in treatments for multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) over the last several decades. However, the present treatments do not show satisfactory efficacy or safety in a considerable proportion of patients, who experience relapse or disability progression despite receiving treatment and suffer from side effects, which can be severe. Improvements in the understanding of the pathophysiologies of MS and NMOSD have led to numerous therapeutic approaches being proposed and developed. Monoclonal antibodies (mAbs) are receiving increasing attention because of their specificity of action and likelihood of high efficacy with fewer side effects. Many mAbs have been evaluated, and some have been approved for MS or NMOSD treatment. This article reviews the use of mAbs for treating MS and NMOSD, including summarizing their mechanisms of action, efficacy, and safety profiles.
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Affiliation(s)
- Woojun Kim
- Department of Neurology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ho Jin Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, Korea.
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