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Chan F, Hardy TA, Malik S, Ramanathan S, Riminton DS, Reddel SW. Induction cyclophosphamide with maintenance immunosuppression in high-risk myasthenia gravis: long-term follow-up and safety profile. J Neurol Neurosurg Psychiatry 2024:jnnp-2023-333189. [PMID: 38964847 DOI: 10.1136/jnnp-2023-333189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 04/10/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Patients with refractory or high-risk myasthenia gravis (MG) respond poorly to conventional immunosuppressive therapy, requiring rescue therapies and often experiencing treatment toxicity. Rescue and injectable therapies do not induce remission and require repetitive administration leading to significant constraints on patients and the healthcare system. This long-term follow-up study demonstrates cyclophosphamide as a rapidly effective and safe treatment in patients with refractory or high-risk MG. METHODS Retrospective cohort study of MG patients treated with cyclophosphamide between January 2000 and June 2022 conducted at a quaternary neuroimmunology clinic in New South Wales, Australia. RESULTS 31 patients were treated: mean age of 64 years; median follow-up 3.6 years (5 months to 11 years); 94% seropositive to acetylcholine receptor (AChR) antibodies and 45% had thymoma. A reduced intensity cyclophosphamide induction protocol followed by oral antiproliferative maintenance is described.Median myasthenia gravis composite scores reduced by >50% after the third cycle of cyclophosphamide. Complete cessation of prednisolone was possible in 11 patients while 20 remained on prednisolone with a median daily dose of 5 mg. Plasma exchange was ceased in 62% of patients and intravenous immunoglobulin ceased in 55%. Cyclophosphamide was generally well tolerated with mild cytopenias. There were no malignancies or cases of haemorrhagic cystitis. CONCLUSION We describe a large cohort of high-risk MG patients treated with cyclophosphamide in a retrospective single-clinic cohort. We suggest cyclophosphamide should be considered for rapid remission induction, corticosteroid reduction and long-term freedom from recurrent injectable therapies in selected patients, typically those with AChR antibodies.
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Affiliation(s)
- Fiona Chan
- Queen Elizabeth Hospital, Birmingham, UK
| | - Todd A Hardy
- Department of Neurology, Concord Hospital, Concord, New South Wales, Australia
| | - Sameer Malik
- Department of Immunology, Concord Hospital, Concord, New South Wales, Australia
| | - Sudarshini Ramanathan
- Department of Neurology, Concord Hospital, Concord, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - D Sean Riminton
- Department of Immunology, Concord Hospital, Concord, New South Wales, Australia
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Ren J, Wang J, Liu R, Jin Y, Guo J, Yao Y, Luo J, Hao H, Gao F. Long-Term Efficacy and Safety of Low-Dose Rituximab in Patients with Refractory Myasthenia Gravis. Eur Neurol 2023; 86:387-394. [PMID: 37778340 DOI: 10.1159/000534336] [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: 04/20/2023] [Accepted: 09/26/2023] [Indexed: 10/03/2023]
Abstract
INTRODUCTION Rituximab is a monoclonal chimeric antibody against CD20+ B cells. We aimed to assess the long-term efficacy and safety of CD20+ B cell-guided treatment with low-dose rituximab in refractory myasthenia gravis patients. METHODS Patients with refractory myasthenia gravis treated with rituximab for more than 2 years were included. Rituximab was administered when CD20+ B cells were greater than 1%. We analysed the efficacy of rituximab, treatment interval, side effects, prognosis, and treatment course. RESULTS A total of 22 patients were included. All patients received 2-12 doses of rituximab, and the median follow-up time was 48.5 months. The scores of the Myasthenia Gravis Activities of Daily Living and Myasthenia Gravis Composite were significantly lower than those at baseline (p < 0.05). MGFA-PIS was significantly improved in 21 (95.45%) patients and 14 (63.64%) patients have reached MGFA-PIS minimal manifestations. The average daily dose of prednisone and pyridostigmine bromide and the proportion of immunosuppressants were significantly lower (p < 0.05). Seven patients suffered from 14 worsenings. Eight patients terminated rituximab due to good efficacy. Most patients tolerated rituximab well, although 1 patient had opportunistic infection and hypogammaglobulinemia, 1 patient had an intracranial mass. CONCLUSION Long-term CD20+ B-cell-guided low-dose rituximab showed good efficacy and tolerance in patients with refractory myasthenia gravis.
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Affiliation(s)
- Jingru Ren
- Department of Neurology, Peking University First Hospital, Beijing, China,
| | - Jianchun Wang
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Ran Liu
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Yunyi Jin
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Jing Guo
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Yan Yao
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Jingjing Luo
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Hongjun Hao
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Feng Gao
- Department of Neurology, Peking University First Hospital, Beijing, China
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Vakrakou AG, Karachaliou E, Chroni E, Zouvelou V, Tzanetakos D, Salakou S, Papadopoulou M, Tzartos S, Voumvourakis K, Kilidireas C, Giannopoulos S, Tsivgoulis G, Tzartos J. Immunotherapies in MuSK-positive Myasthenia Gravis; an IgG4 antibody-mediated disease. Front Immunol 2023; 14:1212757. [PMID: 37564637 PMCID: PMC10410455 DOI: 10.3389/fimmu.2023.1212757] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/05/2023] [Indexed: 08/12/2023] Open
Abstract
Muscle-specific kinase (MuSK) Myasthenia Gravis (MG) represents a prototypical antibody-mediated disease characterized by predominantly focal muscle weakness (neck, facial, and bulbar muscles) and fatigability. The pathogenic antibodies mostly belong to the immunoglobulin subclass (Ig)G4, a feature which attributes them their specific properties and pathogenic profile. On the other hand, acetylcholine receptor (AChR) MG, the most prevalent form of MG, is characterized by immunoglobulin (Ig)G1 and IgG3 antibodies to the AChR. IgG4 class autoantibodies are impotent to fix complement and only weakly bind Fc-receptors expressed on immune cells and exert their pathogenicity via interfering with the interaction between their targets and binding partners (e.g. between MuSK and LRP4). Cardinal differences between AChR and MuSK-MG are the thymus involvement (not prominent in MuSK-MG), the distinct HLA alleles, and core immunopathological patterns of pathology in neuromuscular junction, structure, and function. In MuSK-MG, classical treatment options are usually less effective (e.g. IVIG) with the need for prolonged and high doses of steroids difficult to be tapered to control symptoms. Exceptional clinical response to plasmapheresis and rituximab has been particularly observed in these patients. Reduction of antibody titers follows the clinical efficacy of anti-CD20 therapies, a feature implying the role of short-lived plasma cells (SLPB) in autoantibody production. Novel therapeutic monoclonal against B cells at different stages of their maturation (like plasmablasts), or against molecules involved in B cell activation, represent promising therapeutic targets. A revolution in autoantibody-mediated diseases is pharmacological interference with the neonatal Fc receptor, leading to a rapid reduction of circulating IgGs (including autoantibodies), an approach already suitable for AChR-MG and promising for MuSK-MG. New precision medicine approaches involve Chimeric autoantibody receptor T (CAAR-T) cells that are engineered to target antigen-specific B cells in MuSK-MG and represent a milestone in the development of targeted immunotherapies. This review aims to provide a detailed update on the pathomechanisms involved in MuSK-MG (cellular and humoral aberrations), fostering the understanding of the latest indications regarding the efficacy of different treatment strategies.
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Affiliation(s)
- Aigli G. Vakrakou
- First Department of Neurology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleni Karachaliou
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Elisabeth Chroni
- Department of Neurology, School of Medicine, University of Patras, Patras, Greece
| | - Vasiliki Zouvelou
- First Department of Neurology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Tzanetakos
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Stavroula Salakou
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Marianna Papadopoulou
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Department of Physiotherapy, University of West Attica, Athens, Greece
| | - Socrates Tzartos
- Tzartos NeuroDiagnostics, Athens, Greece
- Department of Neurobiology, Hellenic Pasteur Institute, Athens, Greece
- Department of Pharmacy, University of Patras, Patras, Greece
| | - Konstantinos Voumvourakis
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Constantinos Kilidireas
- First Department of Neurology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, Henry Dunant Hospital Center, Athens, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, United States
| | - John Tzartos
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Long-Term Remission With Low-Dose Rituximab in Myasthenia Gravis: A Retrospective Study. J Clin Neuromuscul Dis 2022; 24:18-25. [PMID: 36005470 DOI: 10.1097/cnd.0000000000000420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJETIVE Rituximab (RTX) is a therapeutic option, for patients with myasthenia gravis (MG) not responding to conventional immunosuppressive treatment. In this cohort, we evaluated long-term efficacy of RTX in the treatment of refractory generalized MG. METHODS A retrospective study was performed in adult patients with refractory generalized MG and at least 24 months of follow-up, between January/2015 and October/2021. The Myasthenia Gravis Status and Treatment Intensity Score was used to assess outcomes, and CD19/CD20+ B-cell counts were monitored. RESULTS Sixteen patients with MG (8 antiacetylcholine receptor+ and 8 muscle-specific antikinase+; mean age 45.5 ± 16.2 years) treated with low-dose RTX protocols were included. CD19/CD20 levels remained undetectable 12 months after induction, and no new relapses were observed during follow-up. CONCLUSIONS Low-dose RTX infusions were sufficient to achieve undetectable CD19/20 cell counts and sustained clinical remission. In low and middle-income countries, the impact of low-dose RTX therapy represents a paradigm shift in decision-making for long-term treatment.
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Shivaram S, Nagappa M, Varghese N, Seshagiri DV, Duble S, Siddappa SA, Hesarur N, Sinha S, Taly AB. Rituximab in Myasthenia Gravis- Experience from a Low- and Middle-Income Country (LMIC) Setting. Neurol India 2022; 70:1931-1941. [PMID: 36352590 DOI: 10.4103/0028-3886.359277] [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] [Indexed: 06/16/2023]
Abstract
BACKGROUND Myasthenia gravis (MG) is an immune-mediated disorder of the neuromuscular junction. About 10% are refractory to immunosuppressive therapy. AIMS To analyze the response of patients with generalized MG to rituximab. METHODS AND MATERIALS A retrospective review of patients with MG who received rituximab was carried out (n = 13, M:F = 6:7, mean age: 44.84 ± 15.73 years). Myasthenia Gravis Foundation of America (MGFA), MGFA post-intervention status (MGFA-PIS), and Myasthenia Gravis Status and Treatment Intensity (MGSTI) were assessed before and after rituximab. RESULTS The duration of MG was 104.07 ± 92.25 months. Before rituximab, the MGFA was IIA/IIB/IIIA/IIIB/IVB/V in 1/1/2/6/2/1 patients and MGSTI was four in eight patients and six in three patients. The mean duration of follow up was 20.92 ± 14.06 months (range, 4 to 42 months). Dose reduction or discontinuation of cholinesterase inhibitors could be achieved 12 patients. Complete stable remission (CSR) and pharmacologic remission (PR) were achieved in one and four patients respectively and five patients had minimal manifestations. Most patients attained level 0, 1 or 2 MGSTI at last follow up. No rituximab infusion-related adverse events were noted. Three patients had exacerbation of MG between one to five weeks after rituximab administration. Three patients died, one each due to a cardiac event unrelated to MG or treatment, complications related to myasthenic crisis, and coronavirus disease. CONCLUSIONS Rituximab was effective in bringing about remission in MG and can be considered as a first-line agent. However, it has to be administered under close supervision as some patients develop exacerbation of MG akin to steroid-induced worsening.
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Affiliation(s)
- Sumanth Shivaram
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Madhu Nagappa
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Nibu Varghese
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Doniparthi V Seshagiri
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Shishir Duble
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | | | - Nagabushan Hesarur
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Sanjib Sinha
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Arun B Taly
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
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Alhaidar MK, Abumurad S, Soliven B, Rezania K. Current Treatment of Myasthenia Gravis. J Clin Med 2022; 11:jcm11061597. [PMID: 35329925 PMCID: PMC8950430 DOI: 10.3390/jcm11061597] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 02/04/2023] Open
Abstract
Myasthenia gravis (MG) is the most extensively studied antibody-mediated disease in humans. Substantial progress has been made in the treatment of MG in the last century, resulting in a change of its natural course from a disease with poor prognosis with a high mortality rate in the early 20th century to a treatable condition with a large proportion of patients attaining very good disease control. This review summarizes the current treatment options for MG, including non-immunosuppressive and immunosuppressive treatments, as well as thymectomy and targeted immunomodulatory drugs.
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7
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Zografou C, Vakrakou AG, Stathopoulos P. Short- and Long-Lived Autoantibody-Secreting Cells in Autoimmune Neurological Disorders. Front Immunol 2021; 12:686466. [PMID: 34220839 PMCID: PMC8248361 DOI: 10.3389/fimmu.2021.686466] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/28/2021] [Indexed: 12/24/2022] Open
Abstract
As B cells differentiate into antibody-secreting cells (ASCs), short-lived plasmablasts (SLPBs) are produced by a primary extrafollicular response, followed by the generation of memory B cells and long-lived plasma cells (LLPCs) in germinal centers (GCs). Generation of IgG4 antibodies is T helper type 2 (Th2) and IL-4, -13, and -10-driven and can occur parallel to IgE, in response to chronic stimulation by allergens and helminths. Although IgG4 antibodies are non-crosslinking and have limited ability to mobilize complement and cellular cytotoxicity, when self-tolerance is lost, they can disrupt ligand-receptor binding and cause a wide range of autoimmune disorders including neurological autoimmunity. In myasthenia gravis with predominantly IgG4 autoantibodies against muscle-specific kinase (MuSK), it has been observed that one-time CD20+ B cell depletion with rituximab commonly leads to long-term remission and a marked reduction in autoantibody titer, pointing to a short-lived nature of autoantibody-secreting cells. This is also observed in other predominantly IgG4 autoantibody-mediated neurological disorders, such as chronic inflammatory demyelinating polyneuropathy and autoimmune encephalitis with autoantibodies against the Ranvier paranode and juxtaparanode, respectively, and extends beyond neurological autoimmunity as well. Although IgG1 autoantibody-mediated neurological disorders can also respond well to rituximab induction therapy in combination with an autoantibody titer drop, remission tends to be less long-lasting and cases where titers are refractory tend to occur more often than in IgG4 autoimmunity. Moreover, presence of GC-like structures in the thymus of myasthenic patients with predominantly IgG1 autoantibodies against the acetylcholine receptor and in ovarian teratomas of autoimmune encephalitis patients with predominantly IgG1 autoantibodies against the N‐methyl‐d‐aspartate receptor (NMDAR) confers increased the ability to generate LLPCs. Here, we review available information on the short-and long-lived nature of ASCs in IgG1 and IgG4 autoantibody-mediated neurological disorders and highlight common mechanisms as well as differences, all of which can inform therapeutic strategies and personalized medical approaches.
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Affiliation(s)
- C Zografou
- Institute of Neuropathology, University of Zurich, Zurich, Switzerland
| | - A G Vakrakou
- First Department of Neurology, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - P Stathopoulos
- First Department of Neurology, National and Kapodistrian University of Athens Medical School, Athens, Greece
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8
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Ruetsch-Chelli C, Bresch S, Seitz-Polski B, Rosenthal A, Desnuelle C, Cohen M, Brglez V, Ticchioni M, Lebrun-Frenay C. Memory B Cells Predict Relapse in Rituximab-Treated Myasthenia Gravis. Neurotherapeutics 2021; 18:938-948. [PMID: 33768513 PMCID: PMC8423951 DOI: 10.1007/s13311-021-01006-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2020] [Indexed: 12/11/2022] Open
Abstract
Myasthenia gravis can be efficiently treated with rituximab but there is no consensus regarding administration and dose schedules in this indication. No marker has yet been described to predict the clinical relapse of patients. Our objective was to identify the B cell subpopulations predicting clinical relapse in patients suffering from generalized myasthenia gravis and treated with rituximab. Clinical and biological data of 34 patients followed between 2016 and 2019 were prospectively collected every 3 months. Using multiparameter flow cytometry, we assessed the percentage in leucocytes of lymphocytes and several B cell subpopulations measured in residual disease conditions. CD19+ were also measured in non-residual disease conditions. Clinical examinations were performed by neurologists using the Osserman score. Clinical relapse occurred in 14 patients (41%). No patients required ICU or ventilatory assistance. The mean improvement of the Osserman score was 17.18 (3-45) after the first rituximab treatment (p < 0.0001). The mean delay between the first rituximab maintenance cycle and clinical relapse was 386.8 days. At the time of relapse, CD27+ increased (p = 0.0006) with AUC = 0.7654, while CD19+ did not. At a threshold of 0.01%, the sensitivity and specificity of CD19+CD27+ were 75.8% and 72.8%, respectively, and the positive and negative predictive values were 28.0% and 95.6%, respectively. The percentage of memory B cells in whole blood cells can accurately predict clinical relapse in myasthenia gravis patients treated with rituximab. This monitoring allows physicians to tailor rituximab administration and to decrease the number of infusions over time.
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Affiliation(s)
- Caroline Ruetsch-Chelli
- Laboratoire d'Immunologie, CHU de Nice, Université Côte d'Azur, Nice, France
- Centre Méditerranéen de Médecine Moléculaire (C3M), INSERM U1065, Université Côte d'Azur, Nice Côte d'Azur University, Archet Hospital, 151, route Saint-Antoine de Ginestière CS 23079 -, 06202, Nice, France
- Unité de Recherche Clinique de la Côte d'Azur (UR2CA), Université Côte d'Azur, Nice, France
| | - Saskia Bresch
- Service de Neurologie, Pasteur2, CHU de Nice, Université Côte d'Azur, Nice, France
| | - Barbara Seitz-Polski
- Laboratoire d'Immunologie, CHU de Nice, Université Côte d'Azur, Nice, France
- Unité de Recherche Clinique de la Côte d'Azur (UR2CA), Université Côte d'Azur, Nice, France
| | | | - Claude Desnuelle
- Service de Neurologie, Pasteur2, CHU de Nice, Université Côte d'Azur, Nice, France
| | - Mikael Cohen
- Service de Neurologie, Pasteur2, CHU de Nice, Université Côte d'Azur, Nice, France
- Unité de Recherche Clinique de la Côte d'Azur (UR2CA), Université Côte d'Azur, Nice, France
| | - Vesna Brglez
- Unité de Recherche Clinique de la Côte d'Azur (UR2CA), Université Côte d'Azur, Nice, France
| | - Michel Ticchioni
- Laboratoire d'Immunologie, CHU de Nice, Université Côte d'Azur, Nice, France
- Centre Méditerranéen de Médecine Moléculaire (C3M), INSERM U1065, Université Côte d'Azur, Nice Côte d'Azur University, Archet Hospital, 151, route Saint-Antoine de Ginestière CS 23079 -, 06202, Nice, France
| | - Christine Lebrun-Frenay
- Service de Neurologie, Pasteur2, CHU de Nice, Université Côte d'Azur, Nice, France.
- Unité de Recherche Clinique de la Côte d'Azur (UR2CA), Université Côte d'Azur, Nice, France.
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Zhang C, Bu B, Yang H, Wang L, Liu W, Duan RS, Zhang M, Zeng P, Du C, Yang L, Shi FD. Immunotherapy choice and maintenance for generalized myasthenia gravis in China. CNS Neurosci Ther 2020; 26:1241-1254. [PMID: 33103369 PMCID: PMC7702233 DOI: 10.1111/cns.13468] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 09/19/2020] [Accepted: 09/21/2020] [Indexed: 12/12/2022] Open
Abstract
Aims To compare long‐term efficacy and safety of immunotherapeutic strategies as maintenance to prevent disease relapses of generalized myasthenia gravis (MG) in real‐world settings. Methods This is a retrospective cohort study on generalized MG conducted in seven major neurological centers across China. Eligible participants were patients with generalized MG who were under minimal manifestation status or better. Main outcome measures were probability of patients free of relapses and causes of drug discontinuation. Results Among 1064 patients enrolled, the median (interquartile range) age was 50.3 (37.0‐62.5) years and 641 (60.2%) were women. Disease relapse was significantly lower for rituximab (6.1%) compared with all the other monotherapies (hazard ratio [HR] = 0.18, 95% confidence interval [CI] 0.06 to 0.56, P = .0030). As combination therapies, tacrolimus in combination with corticosteroids reduced risk of disease relapses compared with azathioprine with corticosteroids (HR = 0.45, 95% CI 0.25 to 0.81, P = .0077) or mycophenolate mofetil with corticosteroids (HR = 0.32, 95% CI 0.15 to 0.67, P = .0020). Otherwise, lower‐dose corticosteroids or azathioprine as monotherapy significantly increased risk of disease relapses (HR = 2.78, 95% CI 1.94 to 3.99, P < .0001; HR = 2.14, 95% CI 1.42 to 3.23, P = .0003, respectively). The proportion of discontinuation was lowest in patients with rituximab (20.4%) as monotherapy and tacrolimus with corticosteroids (23.6%). Overall, combination treatment of immunosuppressants with corticosteroids had a lower rate of discontinuation compared with corresponding monotherapy (HR = 0.51, 95% CI 0.36 to 0.71, P < .0001). Conclusions Rituximab as monotherapy and tacrolimus with corticosteroids displayed better clinical efficacy as well as drug maintenance to prevent disease relapses in patients with generalized MG.
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Affiliation(s)
- Chao Zhang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, China.,National Clinical Research Center for Neurological Diseases of China, Jing-Jin Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bitao Bu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Lihua Wang
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Weibin Liu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Rui-Sheng Duan
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Meini Zhang
- Department of Neurology, The First Hospital of Shanxi Medical University, Taiyuan, China
| | - Pei Zeng
- National Clinical Research Center for Neurological Diseases of China, Jing-Jin Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chen Du
- National Clinical Research Center for Neurological Diseases of China, Jing-Jin Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Li Yang
- National Clinical Research Center for Neurological Diseases of China, Jing-Jin Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fu-Dong Shi
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, China.,National Clinical Research Center for Neurological Diseases of China, Jing-Jin Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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10
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Hehir MK, Li Y. Rituximab for late onset myasthenia gravis: Evidence mounting but deliberations continue. Muscle Nerve 2020; 62:297-299. [DOI: 10.1002/mus.26998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/02/2020] [Accepted: 06/07/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Michael K. Hehir
- Department of Neurological SciencesUniversity of Vermont Larner College of Medicine Burlington Vermont USA
| | - Yuebing Li
- Neuromuscular Center, Department of NeurologyCleveland Clinic Cleveland Ohio USA
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Dos Santos A, Noury J‐B, Genestet S, Nadaj‐Pakleza A, Cassereau J, Baron C, Videt D, Michel L, Pereon Y, Wiertlewski S, Magot A. Efficacy and safety of rituximab in myasthenia gravis: a French multicentre real‐life study. Eur J Neurol 2020; 27:2277-2285. [DOI: 10.1111/ene.14391] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/26/2020] [Accepted: 06/03/2020] [Indexed: 12/30/2022]
Affiliation(s)
- A. Dos Santos
- Department of Neurology University Hospital of Nantes Nantes France
| | - J. ‐B. Noury
- Reference Centre for Neuromuscular Diseases AOC University Hospital of Brest Brest France
| | - S. Genestet
- Reference Centre for Neuromuscular Diseases AOC University Hospital of Brest Brest France
| | - A. Nadaj‐Pakleza
- Reference Centre for Neuromuscular Diseases University Hospital of Strasbourg Strasbourg France
| | - J. Cassereau
- Reference Centre for Neuromuscular Diseases AOC University Hospital of Angers Angers France
| | - C. Baron
- Department of Clinical Neurophysiology University Hospital of Poitiers Poitiers France
| | - D. Videt
- Department of Neurology Centre Hospitalier Bretagne Atlantique Vannes France
| | - L. Michel
- Department of Neurology University Hospital of Rennes Rennes France
| | - Y. Pereon
- Reference Centre for Neuromuscular Diseases AOC University Hospital of Nantes Nantes France
| | - S. Wiertlewski
- Department of Neurology University Hospital of Nantes Nantes France
| | - A. Magot
- Reference Centre for Neuromuscular Diseases AOC University Hospital of Nantes Nantes France
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12
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Litchman T, Roy B, Kumar A, Sharma A, Njike V, Nowak RJ. Differential response to rituximab in anti-AChR and anti-MuSK positive myasthenia gravis patients: a single-center retrospective study. J Neurol Sci 2020; 411:116690. [PMID: 32028072 DOI: 10.1016/j.jns.2020.116690] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 12/20/2019] [Accepted: 01/17/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND B-cell targeted therapy with rituximab has shown durable response in treating refractory myasthenia gravis (MG). This study compares the response to rituximab between patients with acetylcholine receptor autoantibody positive (AChR+) and muscle-specific kinase autoantibody positive (MuSK+) MG. METHODS This retrospective study included 33 patients with either AChR+ or MuSK+ MG who were treated with rituximab from 05/31/2003 to 05/31/2017. Pretreatment and post-treatment immunotherapy regimens, clinical symptoms, and examination findings were evaluated. RESULTS Median MGFA Class of II at baseline improved to an asymptomatic median classification at 12-months and last follow-up (p-values <.001) post-rituximab. Improvement in MGFA class was not significantly different between the groups. Twenty-one patients achieved clinical remission (12/17 AChR+, 9/16 MuSK+) with time to remission of 441.4 ± 336.6 days for AChR+ versus 230 ± 180.8 days for MuSK+ patients (p-value 0.049). The mean prednisone dosage requirement decreased significantly in both groups post-rituximab. AChR+ patients required more hospitalizations for exacerbation post-rituximab (p-value 0.046). CONCLUSION Rituximab treatment response is observed in both AChR+ and MuSK+ patients supporting the role of B cell depletion in the management of MG. While there was no significant difference between these groups in terms of clinical improvement, symptom-free state, and prednisone burden, MuSK+ MG patients may experience greater benefits, including earlier time to remission, fewer exacerbations and hospitalizations post-treatment.
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Affiliation(s)
- Tess Litchman
- Yale School of Medicine, Department of Neurology, New Haven, CT, USA
| | - Bhaskar Roy
- Yale School of Medicine, Department of Neurology, New Haven, CT, USA
| | - Aditya Kumar
- Yale School of Medicine, Department of Neurology, New Haven, CT, USA
| | - Aditi Sharma
- Yale School of Medicine, Department of Neurology, New Haven, CT, USA
| | - Valentine Njike
- Griffin Hospital-Derby, Yale University Prevention Research Center, Derby, CT, USA
| | - Richard J Nowak
- Yale School of Medicine, Department of Neurology, New Haven, CT, USA.
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Lu J, Zhong H, Jing S, Wang L, Xi J, Lu J, Zhou L, Zhao C. Low-dose rituximab every 6 months for the treatment of acetylcholine receptor-positive refractory generalized myasthenia gravis. Muscle Nerve 2020; 61:311-315. [PMID: 31875994 DOI: 10.1002/mus.26790] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 12/17/2019] [Accepted: 12/20/2019] [Indexed: 12/31/2022]
Abstract
INTRODUCTION In this prospective, open-label study we explore the effectiveness of low-dose rituximab every 6 months in treating refractory generalized myasthenia gravis (GMG). METHODS Twelve patients with acetylcholine receptor (AChR)-positive refractory GMG were enrolled for the study. The primary endpoint was the change in quantitative myasthenia gravis (QMG) score from baseline to the study end. Secondary endpoints included changes in manual muscle testing (MMT), MG-Related Activities of Daily Living (MG-ADL), and 15-item Quality-of-Life (MGQOL-15) scores, as well as prednisolone reduction. RESULTS MG decreased from 18.25 ± 4.03 to 8.42 ± 3.99 (P = .0001), MMT from 27.50 ± 17.78 to 4.58 ± 4.34 (P = .0001), ADL from 8.50 ± 2.84 to 1.17 ± 1.27 (P < .0001), MGQOL-15 from 37.25 ± 13.78 to 17.50 ± 9.73 (P = .0015), and prednisolone dose from 29.38 ± 11.92 mg/day to 8.86 ± 1.88 mg/day (P ≤ .01). DISCUSSION Low-dose rituximab every 6 months is effective in treating refractory GMG patients.
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Affiliation(s)
- Jun Lu
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Huahua Zhong
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Sisi Jing
- Department of Neurology, Jing'an District Centre Hospital of Shanghai, Fudan University, Shanghai, China
| | - Liang Wang
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jianying Xi
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jiahong Lu
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Lei Zhou
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Chongbo Zhao
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
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Beer R, Blum S. Overview of new developments in mysthenia gravis therapy. ADVANCES IN CLINICAL NEUROSCIENCE & REHABILITATION 2020. [DOI: 10.47795/mqnw5770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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15
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Maintenance immunosuppression in myasthenia gravis, an update. J Neurol Sci 2019; 410:116648. [PMID: 31901719 DOI: 10.1016/j.jns.2019.116648] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/25/2019] [Accepted: 12/24/2019] [Indexed: 01/08/2023]
Abstract
Therapies for myasthenia gravis (MG) include symptomatic and immunosuppressive/immunomodulatory treatment. Options for immunosuppression include corticosteroids, azathioprine, mycophenolate mofetil, cyclosporine, tacrolimus, methotrexate, rituximab, cyclophosphamide, eculizumab, intravenous immunoglobulin, subcutaneous immunoglobulin, plasmapheresis, and thymectomy. The practical aspects of long-term immunosuppressive therapy in MG are critically reviewed in this article. Application of one or more of these specific therapies is guided based on known efficacy, adverse effect profile, particular disease subtype and severity, and patient co-morbidities.
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