Telitacicept following plasma exchange in the treatment of subjects with recurrent neuromyelitis optica spectrum disorders: A single‐center, single‐arm, open‐label study

Effects of telitacicept in SLE patients with antiphospholipid antibody positivity: a retrospective self-controlled case series

OBJECTIVES

Antiphospholipid antibody (aPL) is closely related to the manifestation of antiphospholipid syndrome (APS) and an increased risk of thrombosis in systemic lupus erythematosus (SLE) patients. Telitacicept is a new dual B cell inhibitor which has been approved in China to treat SLE, but its application in APS or aPL-positive patients is still lacking. This study aimed to observe the effects of telitacicept in SLE patients with aPL positivity.

METHODS

It is a retrospective self-controlled case series study on SLE patients with aPL positivity who received telitacicept at a Chinese medical center during June 2021 to March 2023. Demographical information, clinical and immunological characteristics, and aPL profiles were gleaned from the electronic medical records system, and response of aPL profiles to telitacicept treatment was analyzed.

RESULTS

Sixteen SLE patients were included. Eight of them were definite APS, and the other eight patients were aPL carriers. After 6 months of telitacicept administration, significant improvements were observed in parameters representing SLE disease activity, including SLEDAI-2 K, anti-dsDNA antibody levels, and complement levels. Meanwhile, we observed significant decreases in aPL levels that had not been previously reported. LAC normalized ratios significantly decreased from baseline after telitacicept treatment for 6 months (dRVVT: 1.86 (1.24, 2.80) vs. 1.44 (1.11, 1.94), P = 007; SCT: 1.76 (1.28, 3.23) vs. 1.36 (1.06, 2.01), P = 0.010). The titer of aCL IgG decreased from 196.6 (54.58, 328.85) to 90.20 (15.6, 202.20) CU, and anti-β2GPI IgG decreased from 828.70 (51.60, 2490.80) to 211.10 (18.40, 422.50) CU after 6 months of telitacicept treatment (P-value 0.005 and 0.013, respectively). Interestingly, a rebound tendency in aPL titers was observed after telitacicept withdrawal. No thrombosis events or pregnancy morbidities occurred, and no serious adverse events or death happened during treatment.

CONCLUSIONS

Telitacicept may be an effective and safe option for patients with persistent aPL. Further well-designed prospective cohort studies are needed to confirm these findings. Key Points • Telitacicept is effective to lower aPL titers and promote aPL seroconversion, which may provide potential for the application of telitacicept in APS by reducing aPL-related events. • No thrombosis events and serious adverse events happened in aPL-positive patients during telitacicept treatment.

Advances in the treatment of neuromyelitis optic spectrum disorder

Neuromyelitis optic spectrum disorder (NMOSD) is a rare autoimmune disease characterized by recurrent episodes and severe debilitation. It primarily involves the central nervous system and is associated with the presence of aquaporin-4 antibodies. Effective management of NMOSD necessitates long-term therapeutic strategies that focus on alleviating symptoms during acute episodes and preventing relapse. In recent years, the approval of emerging biologics targeting B cells, interleukin-6 receptors, and the complement pathway has marked a transformative development in NMOSD treatment. This article provides a comprehensive review of therapeutic advances in NMOSD, integrating the current literature to serve as a theoretical basis for clinical decision-making of NMOSD patients.

Telitacicept: A New Therapy for the Treatment of Optic Neuromyelitis Spectrum Disease Associated with Other Autoimmune Disorders

Neuromyelitis optica spectrum disorders (NMOSD) are primarily autoimmune diseases mediated by B cells and AQP4-IgG antibodies, typically affecting the optic nerves and spinal cord, and are characterised by high relapse rates and significant disability. We present two cases of NMOSD patients who also had systemic lupus erythematosus (SLE), with one case additionally complicated by myasthenia gravis (MG). Both patients initially received first-line treatment with corticosteroids; however, no clinical improvement was observed; As a result, the treatment was switched to the dual-target biologic agent, Telitacicept. Following the administration of Telitacicept, both patients demonstrated significant improvements in clinical symptoms, daily functional abilities, and imaging findings. This report highlights the successful use of Telitacicept in treating NMOSD complicated by other autoimmune diseases, which may serve as an important reference for the management of NMOSD.

Advances in maintenance therapies for neuromyelitis optica spectrum disorders: A new era of targeted drugs

BACKGROUND

Neuromyelitis optica spectrum disorder (NMOSD) is a rare inflammatory demyelinating disease of the central nervous system, mainly affecting the optic nerve and spinal cord, with a high rate of recurrence and disability. The spectrum of possibilities for NMOSD maintenance therapies has increased recently due to the development of novel medications based on a deeper understanding of its pathogenesis.

METHODS

Clinical and preclinical advances in NMOSD maintenance therapies were searched in PubMed up until July 20, 2024.

RESULTS

We reviewed the treatment options including approved monoclonal antibodies, clinical trial drugs, and preclinical targets. Both randomized clinical trials and real-word studies have evaluated the safety and efficacy of monoclonal antibodies against complement, IL-6 receptor and B cells. Drugs in the early stage of clinical trials are mainly focused on small molecule targeted drugs and cell-based therapies. Additionally, preclinical studies aimed to explore new targets, such as aquaporin blocking antibodies, based on experiences in cell cultures and animal models.

CONCLUSIONS

From biologics to small molecules and cells, researchers have endeavored to provide better medical care for NMOSD patients. With the emergence of more and more targeted drugs, it is anticipated that the treatment of NMOSD will enter a new era.

Acute neuromyelitis optica spectrum disorder patients' clinical analysis of disability-related biomarkers

BACKGROUND

The clinical features of neuromyelitis optica spectrum disorder (NMOSD) predominantly include optic neuritis and myelitis, among other symptoms. A greater level of disability during the acute phase typically suggests an unfavorable prognosis. Nevertheless, the clinical biomarkers that impact the severity of disability in NMOSD remain unclear.

METHODS

We analyzed 41 NMOSD patients and 41 normal controls to identify biomarkers associated with the disease. NMOSD patients were categorized into two groups based on their Expanded Disability Status Scale(EDSS) score: mild to moderate disability (EDSS < 4) and severe disability (EDSS ≥ 4). Correlation and ROC analyses were conducted on various biomarkers, including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio(MLR), cerebrospinal fluid (CSF)/serum albumin quotient(QAlb), CSF/blood immunoglobulin G quotient (QIgG), CSF/blood immunoglobulin A quotient (QIgA), CSF/blood immunoglobulin M quotient (QIgM), to identify markers linked to disability severity and confirm their independence.

RESULTS

Significant differences in blood NLR, PLR, and MLR were found between NMOSD patients and normal controls (P < 0.01) in biomarker comparison analysis. Significant variations in QAlb, QIgG, QIgA, QIgM, and PLR were noted between the two groups of NMOSD patients stratified by disability severity. A correlation analysis revealed a positive association between QAlb, QIgG, QIgA, QIgM, PLR, and EDSS scores. Levels of QAlb, QIgG, QIgA, QIgM, and PLR were found to be effective indicators of NMOSD severity in Receiver Operating Characteristic (ROC) analysis (P < 0.01). Multifactor regression analysis confirmed the independence of PLR in assessing disease severity (P < 0.01).

CONCLUSION

1. QAlb, QIgG, QIgA, QIgM, and PLR have demonstrated efficacy as biomarkers for assessing the severity of NMOSD; 2. PLR has shown promise as a standalone indicator for evaluating disease severity in patients with NMOSD.

Successful treatment of refractory systemic lupus erythematosus-associated immune thrombocytopenia with drug-induced liver injury with telitacicept: a case report and review

Immune thrombocytopenia(ITP)is a common clinical manifestation of systemic lupus erythematosus(SLE). Drug therapy includes glucocorticoids(GCs),disease-modifying anti-rheumatic drugs (DMARDs) and biologics. Refractory thrombocytopenia can be life-threatening, and the use of effective medications plays a crucial role in disease improvement. Here, we report a case of ITP secondary to SLE. The use of dexamethasone(DEX), cyclosporine A(CsA), and hetrombopag resulted in drug-induced liver injury. Subsequently, telitacicept was chosen and successfully controlled the patient's condition. It suggests that telitacicept may be a new treatment option for refractory SLE-ITP.

Successful sequential therapy with rituximab and telitacicept in refractory Anti-NMDA receptor encephalitis and MOG-associated demyelination: a case report and literature review

Clinical management of the rare and complex overlapping syndrome of MOG-antibody disease and anti-NMDAR encephalitis (MNOS), which has an uncertain pathogenesis and a high risk of recurrence, is highly challenging. We describe the case of a 19 years-old female patient, who first complained of headache, fever, and irritability. After that, she experienced frequent seizures and mood disorders. The diagnosis of MNOS was verified through antibody tests and imaging. For the patient, intravenous immunoglobulin and high-dose methylprednisolone were effective as first-line immunotherapy. Long-term immunotherapy with oral prednisone and mycophenolate mofetil was used to prevent relapses. However, over six years, the patient had five relapses when the mycophenolate mofetil dosage was reduced. The patient's condition stabilized after taking rituximab as second-line immunotherapy, with less than 1% of total lymphocytes being CD19+ cells. Eleven months later, the plasmablast ratio increased, and patients experienced new symptoms such as bilateral optic neuritis. After that, the patient got telitacicept injections regularly for 13 months, during which time her symptoms subsided, and there were no adverse effects or relapses. This case suggests that telitacicept may be a viable adjunct or sequential therapy option for the depletion of B cells in MNOS.

The effectiveness of telitacicept in patients with systemic lupus erythematosus: A retrospective, real-world study

OBJECTIVE

Despite some study demonstrated the effectiveness of telitacicept in patients with systemic lupus erythematosus (SLE), a noticeable gap exists in real-world data. This study aimed to examine the effectiveness and safety of telitacicept in patients with SLE in the real-world.

METHOD

This retrospective study enrolled patients with SLE at the Tangdu Hospital from January 2022 to January 2023. These patients were administered telitacicept at 80 mg or 160 mg dosage. The observed outcomes were changes in the SLE Responder Index 4 (SRI-4), disease activity, renal function, and immunological indicators.

RESULT

Sixty-one patients were enrolled, with 60 patients completed the 24-week follow-up, and 30 completed the 52-week. The SRI-4 response rates at 4, 12, 24, and 52 weeks were 52.5%, 67.2%, 75.4%, and 80.0%, respectively. No statistically differences were observed in the SRI-4 response rates between the 80 mg and 160 mg doses at any of the time points (all p > 0.05). By 52 weeks, the Safety of Estrogens in Lupus Erythematosus National Assessment-SLE Disease Activity Index scores were significant decreased from baseline (p < 0.001), and complement 3 and 4 levels (p = 0.001), albumin levels (p = 0.004), and the overall change in glucocorticoid dosage (p < 0.001) were all significantly increased, with all showing significant changes over time (p < 0.001). During the study, 3 (4.9%) patients experienced infection, and 1 (1.6%) developed an allergy at the injection site.

CONCLUSION

Telitacicept exhibited a highly effective and favorable safety in patients with SLE, with improved renal and hematological manifestations and facilitated a reduction in glucocorticoid medication usage.

Successful treatment of generalized myasthenia gravis with telitacicept: a Chinese case series and literature review

Background

Despite existing treatments of generalized myasthenia gravis (gMG), there remains a need for more effective therapies with fewer side effects. Telitacicept, targeting B lymphocyte stimulator (BLyS) and a proliferation-inducing ligand (APRIL), emerges as a potential novel therapy for gMG.

Case presentation

In our study, four patients with gMG to standard treatments underwent an 8-week course of telitacicept monotherapy. Post-treatment, all patients exhibited satisfactory improvements. The Myasthenia Gravis Foundation of America Quantitative Myasthenia Gravis (MGFA-QMG) scores, 15-item Myasthenia Gravis Quality of Life (MGQOL-15) scores, and MG-associated Activities of Daily Living (MG-ADL) scores showed a marked reduction, indicating decreased disease severity and enhanced quality of life. Additionally, immunological assessments revealed a decrease in CD19+B lymphocyte counts and acetylcholine receptor (AChR) antibodies. Only one patient reported a mild, transient injection reaction.

Conclusion

Favorable clinical improvement and mild adverse events for gMG in treated with telitacicept were observed. However, larger-scale and longer-term studies are necessary to confirm these results and fully establish the role of telitacicept in the treatment of gMG.

The Latest Progress in the Application of Telitacicept in Autoimmune Diseases

Introduction

Humoral immunity plays a key role in the pathogenesis of autoimmune diseases, and B-lymphocyte activating factor (BAFF) and a proliferation-inducing ligand (APRIL) are essential for the maintenance of B-lymphocyte reservoirs and humoral immunity. In March 2021, telitacicept, the world's first dual target three-channel biologic, was approved in China for the treatment of SLE and is currently in clinical trials exploring multiple indications for other autoimmune diseases.

Areas Covered

This article summarizes the mechanism of action, pharmacokinetics, and clinical efficacy of telitacicept for the treatment of multiple autoimmune diseases.

Expert Opinion

So far, the efficacy and safety of telitacicept in autoimmune diseases have been fully demonstrated in clinical practice. There are still many unresolved issues regarding the timing of initiation and discontinuation, still needs to be evaluated in future studies.

The emerging role of BLyS/APRIL in autoimmune diseases: Biological characteristics, functions, and therapeutic potential

Autoimmune diseases (AIDs) are common diseases in the world. Some cases are difficult to cure and can only delay the progression of the diseases. The B lymphocyte stimulator (BLyS)/a proliferation-inducing ligand (APRIL) plays an important role in B cell homeostasis, regulation of both innate and adaptive immune responses. After binding to their receptors, BLyS/APRIL primarily affects the survival and development of marginal, transitional, and mature B cells. Of note, elevated BLyS/APRIL is seen in many AIDs, such as systemic lupus erythematosus, rheumatoid arthritis, immunoglobulin A nephropathy, etc. Moreover, there is evidence that blocking these two cytokines can control the number of serum autoantibodies, promote the depletion of B lymphocytes, inhibit the activation of T cells and dendritic lymphocytes, and reduce inflammatory stress. Currently, some clinical studies are underway targeting BLyS/APRIL inhibitors for the treatment of AIDs. However, due to the scattered knowledge on the relationship between BLyS/APRIL and AIDs, it is necessary to sort out the existing data. Therefore, in this review, we describe the basic biological characteristics and functions of BLyS/APRIL in AIDs, summarize the potential clinical applications of related inhibitors, especially monoclonal antibodies and recombinant fusion proteins targeting BLyS/APRIL in AIDs, and also outline promising research directions.

Telitacicept: A novel horizon in targeting autoimmunity and rheumatic diseases

BLyS and APRIL have the capability to bind to B cells within the body, allowing these cells to evade elimination when they should naturally be removed. While BLyS primarily plays a role in B cell development and maturation, APRIL is linked to B cell activation and the secretion of antibodies. Thus, in theory, inhibiting BLyS or APRIL could diminish the population of aberrant B cells that contribute to SLE and reduce disease activity in patients. Telitacicept functions by binding to and neutralizing the activities of both BLyS and APRIL, thus hindering the maturation and survival of plasma cells and fully developed B cells. The design of telitacicept is distinctive; it is not a monoclonal antibody but a TACI-Fc fusion protein generated through recombinant DNA technology. This fusion involves merging gene segments of the TACI protein, which can target BLyS/APRIL simultaneously, with the Fc gene segment of the human IgG protein. The TACI-Fc fusion protein exhibits the combined characteristics of both proteins. Currently utilized for autoimmune disease treatment, telitacicept is undergoing clinical investigations globally to assess its efficacy in managing various autoimmune conditions. This review consolidates information on the mechanistic actions, dosing regimens, pharmacokinetics, efficacy, and safety profile of telitacicept-a dual-targeted biological agent. It integrates findings from prior experiments and pharmacokinetic analyses in the treatment of RA and SLE, striving to offer a comprehensive overview of telitacicept's research advancements.

Efficacy and safety of telitacicept in patients with lupus nephritis: a single-center, real-world retrospective study

BACKGROUND

Telitacicept, an innovative drug used for the treatment of systemic lupus erythematosus (SLE), can effectively control disease progression and achieve favorable outcomes. While case reports have mentioned the use of Telitacicept in lupus nephritis (LN) treatment, its safety and efficacy in treating patients with LN have not been explored. Therefore, in this study, we aimed to evaluate the safety and efficacy of Telitacicept in managing patients with LN.

METHODS

In a single-center, real-world retrospective study, 30 LN patients with poor response or adverse reactions to conventional glucocorticoids at our Hospital were enrolled to receive Telitacicept. Patients were administered 160 mg of Telitacicept subcutaneously once a week for at least 24 weeks in addition to standard treatment. We assessed the SLE responder index-4 (SRI-4) at the beginning and the end of the treatment period, measured laboratory test indicators at 3, 6, and 9 months, and observed the occurrence of adverse events in these patients.

RESULTS

The SRI-4 response rate was 86.67% (n = 26), with a significantly lower systemic lupus erythematosus disease activity index (SLEDAI) score compared to the baseline. Post Telitacicept treatment, glucocorticoid intake of patients with LN significantly reduced from 50 (IQR:40, 51.25) at baseline to 10 (IQR:5,10) at the endpoint (Z = - 6.547, p < 0.001). Patients with LN showed significantly improved urine occult blood levels after Telitacicept therapy. While the complement (C3 and C4) contents increased, immunoglobulins (IgG, IgA and IgM) reduced markedly (p < 0.001). The negative rate of dsDNA reached 26.67% and adverse events were alleviated post treatment. Only two cases of LN-related adverse reactions were reported, including herpes and infectious fever, respectively. Telitacicept primarily serves as an agent for the induction of remission therapy, with an attainment of complete remission rate standing at a commendable 73.3%.

CONCLUSIONS

Telitacicept treatment reduced disease severity in patients with LN. The initial clinical trial provided supportive evidence for the effectiveness and safety of Telitacicept as a viable treatment option for LN, allowing a reduction in the daily glucocorticoid intake while maintaining a good safety profile, and improving hypocomplementation in LN management.

Effectiveness and safety of telitacicept for refractory generalized myasthenia gravis: a retrospective study

Background

Refractory generalized myasthenia gravis (GMG) remains a substantial therapeutic challenge. Telitacicept, a recombinant human B-lymphocyte stimulator receptor-antibody fusion protein, holds promise for interrupting the immunopathology of this condition.

Objectives

This study retrospectively assessed the effectiveness and safety of telitacicept in patients with refractory GMG.

Design

A single-center retrospective study.

Methods

Patients with refractory GMG receiving telitacicept (160 mg/week or biweekly) from January to September in 2023 were included. We assessed effectiveness using Myasthenia Gravis Foundation of America post-intervention status (MGFA-PIS), myasthenia gravis treatment status and intensity (MGSTI), quantitative myasthenia gravis (QMG), and MG-activity of daily living (ADL) scores, alongside reductions in prednisone dosage at 3- and 6-month intervals. Safety profiles were also evaluated.

Results

Sixteen patients with MGFA class II-V refractory GMG were included, with eight females and eight males. All patients were followed up for at least 3 months, and 11 patients reached 6 months follow-up. At the 3-month evaluation, 75% (12/16) demonstrated clinical improvement with MGFA-PIS. One patient achieved pharmacological remission, two attained minimal manifestation status, and nine showed functional improvement; three remained unchanged, and one deteriorated. By the 6-month visit, 90.1% (10/11) sustained significant symptomatic improvement. MGSTI scores and prednisone dosages significantly reduced at both follow-ups (p < 0.05). MG-ADL and QMG scores showed marked improvement at 6 months (p < 0.05). The treatment was well tolerated, with no severe adverse events such as allergy or infection reported.

Conclusion

Our exploratory investigation suggests that telitacicept is a feasible and well-tolerated add-on therapy for refractory GMG, offering valuable clinical evidence for this novel treatment option.

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

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.

Case Report: Telitacicept in treating a patient with NF155+ autoimmune nodopathy: a successful attempt to manage recurrent elevated sero-anti-NF155 antibodies

This report presents a case of a neurofascin-155 (NF155)+ autoimmune nodopathy (AN) patient who exhibited resistance to conventional treatments but responded positively to telitacicept therapy. Telitacicept, a dual inhibitor of B lymphocyte stimulator (BLyS) and A proliferation-inducing ligand (APRIL), suppressed the development and survival of plasma cells and mature B cells. The patient's unique clinical features were consistent with NF155+ AN, showing limited response to standard treatments like rituximab and a recurrent significant increase in anti-NF155 antibody titers. Administering telitacicept (160mg, ih) led to an improvement in clinical symptoms, inflammatory neuropathy cause and treatment (INCAT) scale and inflammatory Rasch-built overall disability scale (I-RODS), and stabilized anti-NF155 antibody levels without a rebound. This case demonstrates telitacicept as a potential novel therapy for NF155+ AN, particularly when conventional treatments fail. Further investigation into its safety, efficacy, dosage, and treatment cycle in NF155+ AN is warranted.

Case report: Successful treatment of refractory membranous nephropathy with telitacicept

Despite various treatment methods, the remission rate of membranous nephropathy remains limited. Refractory membranous nephropathy especially lacks effective treatment plans. Telitacicept achieves comprehensive inhibition of CD20-positive B cells, plasma cells, and T cells, thereby bringing new hope to the treatment of membranous nephropathy and refractory membranous nephropathy. Here, we report a case of a 46-year-old man with membranous nephropathy. Although the combined treatment with glucocorticoid, tacrolimus, mycophenolate mofetil, cyclophosphamide, and rituximab was not successful, the patient achieved complete remission of urinary protein after glucocorticoid combined with telitacicept. This is the first report on the application of telitacicept in the treatment of membranous nephropathy, especially refractory membranous nephropathy. The application of telitacicept in the treatment of membranous nephropathy deserves further attention.

B cell targeted therapies in inflammatory autoimmune disease of the central nervous system

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.