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Jacob S. Treating myasthenia gravis beyond the eye clinic. Eye (Lond) 2024:10.1038/s41433-024-03133-x. [PMID: 38789789 DOI: 10.1038/s41433-024-03133-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/17/2024] [Accepted: 05/07/2024] [Indexed: 05/26/2024] Open
Abstract
Myasthenia gravis (MG) is one of the most well characterised autoimmune disorders affecting the neuromuscular junction with autoantibodies targeting the acetylcholine receptor (AChR) complex. The vast majority of patients present with ocular symptoms including double vision and ptosis, but may progress on to develop generalised fatiguable muscle weakness. Severe involvement of the bulbar muscles can lead to dysphagia, dysarthria and breathing difficulties which can progress to myasthenic crisis needing ventilatory support. Given the predominant ocular onset of the disease, it is important that ophthalmologists are aware of the differential diagnosis, investigations and management including evolving therapies. When the disease remains localised to the extraocular muscles (ocular MG) IgG1 and IgG3 antibodies against the AChR (including clustered AChR) are present in nearly 50% of patients. In generalised MG this is seen in nearly 90% patients. Other antibodies include those against muscle specific tyrosine kinase (MuSK) and lipoprotein receptor related protein 4 (LRP4). Even though decremental response on repetitive nerve stimulation is the most well recognised neurophysiological abnormality, single fibre electromyogram (SFEMG) in experienced hands is the most sensitive test which helps in the diagnosis. Initial treatment should be using cholinesterase inhibitors and then proceeding to immunosuppression using corticosteroids and steroid sparing drugs. Patients requiring bulbar muscle support may need rescue therapies including plasma exchange and intravenous immunoglobulin (IVIg). Newer therapeutic targets include those against the B lymphocytes, complement system, neonatal Fc receptors (FcRn) and various other elements of the immune system.
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Affiliation(s)
- Saiju Jacob
- University Hospitals Birmingham, Birmingham, UK.
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
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Tokuyasu D, Suzuki S, Uzawa A, Nagane Y, Masuda M, Konno S, Kubota T, Samukawa M, Sugimoto T, Ishizuchi K, Oyama M, Yasuda M, Akamine H, Onishi Y, Suzuki Y, Kawaguchi N, Minami N, Kimura T, Takahashi MP, Murai H, Utsugisawa K. Real-world experience with eculizumab and switching to ravulizumab for generalized myasthenia gravis. Ann Clin Transl Neurol 2024; 11:1338-1346. [PMID: 38572524 DOI: 10.1002/acn3.52051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 03/01/2024] [Accepted: 03/10/2024] [Indexed: 04/05/2024] Open
Abstract
OBJECTIVE Eculizumab and ravulizumab are complement protein C5 inhibitors, showing efficacy and tolerability for patients with anti-acetylcholine receptor-positive (AChR+) generalized myasthenia gravis (gMG) in phase 3 clinical trials and subsequent analyses. The purpose of the present study was to evaluate the clinical significance of eculizumab and switching to ravulizumab for refractory AChR+ gMG patients in the real-world experience. METHODS Among the database of Japan MG registry survey 2021, we studied AChR+ gMG patients who received eculizumab. We also evaluated these patients who switched from eculizumab to ravulizumab. Responder was defined as an improvement of at least 3 points in MG-ADL. We performed a questionnaire of preference between eculizumab and ravulizumab. RESULTS Among 1,106 patients with AChR+ gMG, 36 patients (3%) received eculizumab (female 78%, mean age 56.0 years). Eculizumab was preferentially used in severe and refractory MG patients. The duration of eculizumab treatment was 35 months on average. MG-ADL improved from 9.4 ± 4.9 to 5.9 ± 5.1, and 25 (70%) of the 36 gMG patients were responders. Postintervention status was markedly improved after the eculizumab treatment. Of 13 patients who did not continue eculizumab, 6 showed insufficiencies. Early onset MG was most effective. However, 15 patients switching from eculizumab to ravulizumab kept favorable response and tolerability. Questionnaire surveys showed preference for ravulizumab over eculizumab. INTERPRETATION Eculizumab and switching to ravulizumab showed to be effective for refractory AChR+ gMG patients in clinical settings.
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Affiliation(s)
- Daiki Tokuyasu
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Shigeaki Suzuki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Akiyuki Uzawa
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yuriko Nagane
- Department of Neurology, Hanamaki General Hospital, Hanamaki, Japan
| | - Masayuki Masuda
- Department of Neurology, Tokyo Medical University, Tokyo, Japan
| | - Shingo Konno
- Department of Neurology, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Tomoya Kubota
- Department of Clinical Laboratory and Biomedical Sciences, Division of Health Sciences, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Makoto Samukawa
- Department of Neurology, Kindai University Faculty of Medicine, Sayama, Japan
| | - Takamichi Sugimoto
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Hiroshima, Japan
| | - Kei Ishizuchi
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Munenori Oyama
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Manato Yasuda
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hiroyuki Akamine
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yosuke Onishi
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yasushi Suzuki
- Department of Neurology, National Hospital Organization Sendai Medical Center, Sendai, Japan
| | - Naoki Kawaguchi
- Department of Neurology, Neurology Chiba Clinic, Chiba, Japan
| | - Naoya Minami
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Sapporo, Japan
| | - Takashi Kimura
- Department of Neurology, Hyogo Medical University, Nishinomiya, Japan
| | - Masanori P Takahashi
- Department of Clinical Laboratory and Biomedical Sciences, Division of Health Sciences, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hiroyuki Murai
- Department of Neurology, International University of Health and Welfare, Narita, Japan
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Ohnari K, Hashimoto T, Iwanaka Y, Ohnari K, Adachi H, Okada K. Dramatic improvement in refractory myasthenia gravis with eculizumab treatment: a case report. J Neurol 2024; 271:2902-2905. [PMID: 38393426 DOI: 10.1007/s00415-024-12245-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/03/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024]
Affiliation(s)
- Kana Ohnari
- Department of Neurology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Tomoyo Hashimoto
- Department of Neurology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan.
| | - Yukio Iwanaka
- Department of Neurology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Keiko Ohnari
- Department of Neurology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Hiroaki Adachi
- Department of Neurology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kazumasa Okada
- Department of Neurology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
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Gutschmidt K, Schoser B. [Myasthenia Gravis - Update]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2024; 92:139-156. [PMID: 38636491 DOI: 10.1055/a-2238-7784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
Myasthenia gravis - still a challenge for sufferers and doctors in 2023. But which therapy is best suited? Our clinically experienced experts have summarized the current guidelines for diagnosis and treatment in order to provide optimal support for those affected. Find out how you can carry out a quick and targeted diagnosis and which treatment options are available to alleviate the course of the disease.
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Fionda L, Rossini E, Lauletta A, Leonardi L, Tufano L, Costanzo R, Marchetti P, Salvetti M, Garibaldi M, Morino S, Antonini G. Eculizumab for myasthenic exacerbation during treatment with immune-checkpoint inhibitors. Neurol Sci 2024; 45:1243-1247. [PMID: 38108913 DOI: 10.1007/s10072-023-07190-0] [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: 09/23/2023] [Accepted: 11/06/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVE To test the complement inhibitor eculizumab in the treatment of MG exacerbation during therapy with the immune-checkpoint inhibitor (ICI) pembrolizumab, avoiding its discontinuation, which could be detrimental to oncologic course. METHODS A 76-year-old male with non-thymomatous generalized anti-AchR + MG (MGFA class IVB), during treatment with pembrolizumab for colorectal cancer, developed a severe myasthenic exacerbation, refractory to steroids and IvIg. Eculizumab was started, without pembrolizumab discontinuation. The patient was prospectively followed using MGFA, MG Activities of Daily Living (MG-ADL), Quantitative MG (QMG), MG Composite (MGC), and MG Quality of Life 15 (MG-QOL-15). RESULTS After an 18-week follow-up, the patient presented a progressive improvement in scores on all scales, achieving a MGFA class IIIB. The percentage improvement was 40% in MG-ADL, 36% in MG Composite, and about 30% in QMG. Bulbar symptoms improved by about 70% in MG-ADL and MG Composite and 40% in QMG. Eculizumab was well tolerated and pembrolizumab regularly continued, with a good control of cancer progression. DISCUSSION Eculizumab potentially offers a mechanism-based treatment of MG in patients under anti-programmed cell death protein 1 (PD-1) agents, without interfering with their mechanism of action and avoiding their discontinuation. Larger case series deserve to be evaluated.
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Affiliation(s)
- Laura Fionda
- Neuromuscular and Rare Disease Centre, Sant'Andrea Hospital, Via di Grottarossa 1035-1039, 00189, Rome, Italy.
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Faculty of Medicine and Psychology., SAPIENZA University of Rome, Via Grottarossa 1035-1039, 00189, Rome, Italy.
| | - Elena Rossini
- Neuromuscular and Rare Disease Centre, Sant'Andrea Hospital, Via di Grottarossa 1035-1039, 00189, Rome, Italy
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Faculty of Medicine and Psychology., SAPIENZA University of Rome, Via Grottarossa 1035-1039, 00189, Rome, Italy
| | - Antonio Lauletta
- Neuromuscular and Rare Disease Centre, Sant'Andrea Hospital, Via di Grottarossa 1035-1039, 00189, Rome, Italy
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Faculty of Medicine and Psychology., SAPIENZA University of Rome, Via Grottarossa 1035-1039, 00189, Rome, Italy
| | - Luca Leonardi
- Neuromuscular and Rare Disease Centre, Sant'Andrea Hospital, Via di Grottarossa 1035-1039, 00189, Rome, Italy
- Neurology Unit, Sant'Andrea Hospital, 00189, Rome, Italy, Via Grottarossa 1035-1039
| | - Laura Tufano
- Neuromuscular and Rare Disease Centre, Sant'Andrea Hospital, Via di Grottarossa 1035-1039, 00189, Rome, Italy
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Faculty of Medicine and Psychology., SAPIENZA University of Rome, Via Grottarossa 1035-1039, 00189, Rome, Italy
| | - Rocco Costanzo
- Neuromuscular and Rare Disease Centre, Sant'Andrea Hospital, Via di Grottarossa 1035-1039, 00189, Rome, Italy
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Faculty of Medicine and Psychology., SAPIENZA University of Rome, Via Grottarossa 1035-1039, 00189, Rome, Italy
| | - Paolo Marchetti
- IRCCS IDI-Istituto Dermopatico dell'Immacolata, 00167, Rome, Italy
| | - Marco Salvetti
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Faculty of Medicine and Psychology., SAPIENZA University of Rome, Via Grottarossa 1035-1039, 00189, Rome, Italy
- Neurology Unit, Sant'Andrea Hospital, 00189, Rome, Italy, Via Grottarossa 1035-1039
| | - Matteo Garibaldi
- Neuromuscular and Rare Disease Centre, Sant'Andrea Hospital, Via di Grottarossa 1035-1039, 00189, Rome, Italy
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Faculty of Medicine and Psychology., SAPIENZA University of Rome, Via Grottarossa 1035-1039, 00189, Rome, Italy
| | - Stefania Morino
- Neuromuscular and Rare Disease Centre, Sant'Andrea Hospital, Via di Grottarossa 1035-1039, 00189, Rome, Italy
- Neurology Unit, Sant'Andrea Hospital, 00189, Rome, Italy, Via Grottarossa 1035-1039
| | - Giovanni Antonini
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Faculty of Medicine and Psychology., SAPIENZA University of Rome, Via Grottarossa 1035-1039, 00189, Rome, Italy
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Peng Y, Yang H, Chen Q, Jin H, Xue YH, Du MQ, Liu S, Yao SY. An angel or a devil? Current view on the role of CD8 + T cells in the pathogenesis of myasthenia gravis. J Transl Med 2024; 22:183. [PMID: 38378668 PMCID: PMC10877804 DOI: 10.1186/s12967-024-04965-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 02/07/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Myasthenia gravis (MG) and the experimental autoimmune MG (EAMG) animal model are characterized by T-cell-induced and B-cell-dominated autoimmune diseases that affect the neuromuscular junction. Several subtypes of CD4+ T cells, including T helper (Th) 17 cells, follicular Th cells, and regulatory T cells (Tregs), contribute to the pathogenesis of MG. However, increasing evidence suggests that CD8+ T cells also play a critical role in the pathogenesis and treatment of MG. MAIN BODY Herein, we review the literature on CD8+ T cells in MG, focusing on their potential effector and regulatory roles, as well as on relevant evidence (peripheral, in situ, cerebrospinal fluid, and under different treatments), T-cell receptor usage, cytokine and chemokine expression, cell marker expression, and Treg, Tc17, CD3+CD8+CD20+ T, and CXCR5+ CD8+ T cells. CONCLUSIONS Further studies on CD8+ T cells in MG are necessary to determine, among others, the real pattern of the Vβ gene usage of autoantigen-specific CD8+ cells in patients with MG, real images of the physiology and function of autoantigen-specific CD8+ cells from MG/EAMG, and the subset of autoantigen-specific CD8+ cells (Tc1, Tc17, and IL-17+IFN-γ+CD8+ T cells). There are many reports of CD20-expressing T (or CD20 + T) and CXCR5+ CD8 T cells on autoimmune diseases, especially on multiple sclerosis and rheumatoid arthritis. Unfortunately, up to now, there has been no report on these T cells on MG, which might be a good direction for future studies.
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Affiliation(s)
- Yong Peng
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China.
- Department of Neurology, The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, 412000, Hunan, China.
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Quan Chen
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China
- Department of Neurology, The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, 412000, Hunan, China
| | - Hong Jin
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China
- Department of Neurology, The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, 412000, Hunan, China
| | - Ya-Hui Xue
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China
- Department of Neurology, The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, 412000, Hunan, China
| | - Miao-Qiao Du
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China
- Department of Neurology, The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, 412000, Hunan, China
| | - Shu Liu
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China
- Department of Neurology, The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, 412000, Hunan, China
| | - Shun-Yu Yao
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China
- Department of Neurology, The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, 412000, Hunan, China
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Iorio R. Myasthenia gravis: the changing treatment landscape in the era of molecular therapies. Nat Rev Neurol 2024; 20:84-98. [PMID: 38191918 DOI: 10.1038/s41582-023-00916-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2023] [Indexed: 01/10/2024]
Abstract
Myasthenia gravis (MG) is an autoimmune disorder that affects the neuromuscular junction, leading to muscle weakness and fatigue. MG is caused by antibodies against the acetylcholine receptor (AChR), the muscle-specific kinase (MuSK) or other AChR-related proteins that are expressed in the postsynaptic muscle membrane. The standard therapeutic approach for MG has relied on acetylcholinesterase inhibitors, corticosteroids and immunosuppressants, which have shown good efficacy in improving MG-related symptoms in most people with the disease; however, these therapies can carry a considerable burden of long-term adverse effects. Moreover, up to 15% of individuals with MG exhibit limited or no response to these standard therapies. The emergence of molecular therapies, including monoclonal antibodies, B cell-depleting agents and chimeric antigen receptor T cell-based therapies, has the potential to revolutionize the MG treatment landscape. This Review provides a comprehensive overview of the progress achieved in molecular therapies for MG associated with AChR antibodies and MuSK antibodies, elucidating both the challenges and the opportunities these therapies present to the field. The latest developments in MG treatment are described, exploring the potential for personalized medicine approaches.
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Affiliation(s)
- Raffaele Iorio
- Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy.
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
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Li X, Chen J, Wang Y, Zheng S, Wan K, Liu X. Registered trials on novel therapies for myasthenia gravis: a cross-sectional study on ClinicalTrials.gov. Sci Rep 2024; 14:2067. [PMID: 38267496 PMCID: PMC10808105 DOI: 10.1038/s41598-024-52539-w] [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: 07/10/2023] [Accepted: 01/19/2024] [Indexed: 01/26/2024] Open
Abstract
Novel biologics in MG therapy research is on the rise. This research aimed to investigate the characteristics of registered trials on novel therapies for myasthenia gravis on ClinicalTrials.gov. This cross-sectional study used a descriptive approach to assess the features of the included trials on ClinicalTrials.gov. We found 62 registered trials from 2007 to 2023 on ClinicalTrials.gov. The results showed a yearly rise in the number of registered trials (r = 0.76, p < 0.001). Following 2017, more industry-sponsored trials were conducted (91.5% [43] vs. 60% [9], p = 0.009), fewer results were released (10.6% [5] vs. 60% [9], p = 0.001), and more trials entered phase 3 (67.4% [31] vs. 20% [2], p = 0.001). The most researched novel medications were neonatal Fc receptor inhibitors (51.2% [21]), complement inhibitors (39.0% [16]), and B cell depletors (14.6% [6]). According to the website's data, the neonatal Fc receptor inhibitors and complement inhibitors were effective in treating myasthenia gravis patients in three trials (NCT03315130, NCT03669588, and NCT00727194). This study provides valuable insights into the profile of registered trials on novel therapies for myasthenia gravis. More clinical studies are needed in the future to prove the value of its application.
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Affiliation(s)
- Xingyue Li
- Department of Neurology, Xiangyang No.1 People's Hospital, Hubei University of Medicine, Xiangyang, China
| | | | | | | | - Kun Wan
- Hubei University of Medicine, Shiyan, China
| | - Xiaodong Liu
- Department of Neurology, Taihe Hospital, Hubei University of Medicine, Shiyan, China.
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Zhou A, Ho S, Vickers A. Eculizumab in myasthenia gravis: A review. Saudi J Ophthalmol 2024; 38:34-40. [PMID: 38628404 PMCID: PMC11016999 DOI: 10.4103/sjopt.sjopt_74_23] [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: 03/31/2023] [Revised: 10/09/2023] [Accepted: 10/10/2023] [Indexed: 04/19/2024] Open
Abstract
Eculizumab, a monoclonal antibody against complement C5, is a novel therapy to treat refractory myasthenia gravis (MG). The present review was undertaken to study the role of eculizumab in MG. This includes the drug's mechanism, pharmacokinetics, clinical trial findings, tolerability, side effects, safety, dosage, administration, and cost. An English-language search for relevant items was undertaken using Embase and PubMed from 1946 to present. Clinical trial registries/databases and websites were also searched for relevant data. Keywords were eculizumab and MG. The present review found 103 articles after initial screening. Current data support eculizumab as an effective, safe, and tolerable drug in cases of refractory MG. However, its cost can prevent it from being widely accessible to a majority of the general population.
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Affiliation(s)
- Avery Zhou
- Kirk Kerkorian School of Medicine, Las Vegas, NV, USA
| | - Sabrina Ho
- Kirk Kerkorian School of Medicine, Las Vegas, NV, USA
| | - Aroucha Vickers
- Department of Neurology, Valley Hospital Medical Center, Las Vegas, NV, USA
- Department of Neuro-Ophthalmology, Las Vegas Neurology Center, Las Vegas, NV, USA
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Vu T, Wiendl H, Katsuno M, Reddel SW, Howard JF. Ravulizumab in Myasthenia Gravis: A Review of the Current Evidence. Neuropsychiatr Dis Treat 2023; 19:2639-2655. [PMID: 38059203 PMCID: PMC10697093 DOI: 10.2147/ndt.s374694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/17/2023] [Indexed: 12/08/2023] Open
Abstract
The terminal complement C5 inhibitor ravulizumab was engineered from the humanized monoclonal antibody eculizumab to have an extended half-life and duration of action. It binds to human terminal complement protein C5, inhibiting its cleavage into C5a and C5b, thus preventing the cascade of events that lead to architectural destruction of the postsynaptic neuromuscular junction membrane by the membrane attack complex, and consequent muscle weakness in patients with anti-acetylcholine receptor (AChR) antibody-positive generalized myasthenia gravis (gMG). The 26-week randomized, placebo-controlled period (RCP) of the phase 3 CHAMPION MG study demonstrated the rapid efficacy of ravulizumab in reducing MG symptoms. Weight-based dosing of ravulizumab every 8 weeks provided sustained efficacy, in terms of patient-reported (Myasthenia Gravis-Activities of Daily Living) and clinician-reported (Quantitative Myasthenia Gravis) endpoints in patients with anti-AChR antibody-positive gMG. Pharmacokinetic and pharmacodynamic analyses showed therapeutic serum ravulizumab concentrations (>175 µg/mL) were achieved immediately after the first dose and were maintained throughout 26 weeks, irrespective of patient body weight; inhibition of serum free C5 was immediate, complete (<0.5 μg/mL), and sustained in all patients. Interim results from the open-label extension (OLE) showed that after 60 weeks, efficacy was maintained in patients continuing on ravulizumab. Rapid and sustained improvements in efficacy, similar to those seen in patients initiating ravulizumab in the RCP, were observed after initiation of ravulizumab treatment in patients who switched from placebo in the RCP to ravulizumab in the OLE. The findings from the RCP and OLE support ravulizumab's favorable safety profile. In conclusion, ravulizumab has a simple weight-based administration and long dosing interval. Its targeted mechanism of action without generalized immunosuppression is reflected in its rapid onset of symptom improvement, sustained efficacy and good safety profile in the treatment of patients with anti-AChR antibody-positive gMG.
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Affiliation(s)
- Tuan Vu
- Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Stephen W Reddel
- Department of Neurology, Concord Hospital, University of Sydney, Sydney, NSW, Australia
| | - James F Howard
- Department of Neurology, The University of North Carolina, Chapel Hill, NC, USA
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Weidmayer SL, Gallagher G. Refractory generalized myasthenia gravis with myasthenic incomplete ophthalmoplegia successfully treated with eculizumab. Am J Ophthalmol Case Rep 2023; 32:101925. [PMID: 37711751 PMCID: PMC10498161 DOI: 10.1016/j.ajoc.2023.101925] [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: 03/21/2023] [Revised: 08/07/2023] [Accepted: 08/24/2023] [Indexed: 09/16/2023] Open
Abstract
Purpose This is a case of myasthenic incomplete ophthalmoplegia mimicking a partial cranial nerve 3 palsy both subjectively and objectively improving after treatment with eculizumab. Observations We chronicle a case of severe generalized myasthenia gravis including myasthenia masquerading as a partial cranial nerve 3 palsy, refractory to pyridostigmine, mycophenolate, prednisone, intravenous immunoglobulin and plasma exchange but responsive to eculizumab. Conclusions and importance This case demonstrates ocular and generalized myasthenia gravis refractory to several other therapies but amenable to eculizumab infusions, suggesting this medication may be of significant value in these difficult cases, and should be further explored for refractory ocular myasthenia gravis.
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Affiliation(s)
- Sara L. Weidmayer
- LTC Charles S. Kettles VA Medical Center, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, United States
- WK Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, 1000 Wall Street, Ann Arbor, MI, United States
| | - Gary Gallagher
- Department of Neurology, University of Michigan, 1500 E. Medical Center Dr #1914, Ann Arbor, MI, United States
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12
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Antozzi C, Mantegazza R. Impact of Ravulizumab on Patient Outcomes and Quality of Life in Generalized Myasthenia Gravis. Patient Relat Outcome Meas 2023; 14:305-312. [PMID: 37876920 PMCID: PMC10590807 DOI: 10.2147/prom.s408175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/21/2023] [Indexed: 10/26/2023] Open
Abstract
Myasthenia gravis (MG) is an autoimmune ion channel disorder in which antibodies to different end-plate antigens impair neuromuscular transmission, ultimately leading to muscle weakness and fatigability. In about 85% of patients with MG, autoantibodies against the acetylcholine receptor (AChR) activate the complement cascade, causing damage to the neuromuscular junction. MG is a chronic disorder for which standard therapies with corticosteroids, immunosuppressive drugs, and immunomodulation with plasma exchange or intravenous immunoglobulins modify the course of the disease, but the residual burden of physical, psychological, and social disability highlights several unmet needs, among these the need for specific, targeted, and well tolerated therapies able to improve the patients' quality of life. Complement inhibition paved the way to precision medicine in MG since, for the first time, a specific therapy targeting a crucial pathogenetic step has been designed, tested, and proven to be effective in a controlled fashion. Ravulizumab represents the first long-acting complement inhibitor approved for treatment of patients with generalized MG, able to provide rapid, complete, and sustained complement inhibition. Ravulizumab improved the MG Activity of Daily Living scale and other clinical parameters up to 26 weeks as shown by the CHAMPION MG trial, and by its open label extension, with the added value of being administered every 8 weeks. The schedule of administration is likely to improve patients' adherence and hence their quality of life. The introduction of complement inhibition will considerably change the traditional therapeutic strategy for MG.
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Affiliation(s)
- Carlo Antozzi
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- Immunotherapy and Apheresis Departmental Unit, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Renato Mantegazza
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
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13
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San PP, Jacob S. Role of complement in myasthenia gravis. Front Neurol 2023; 14:1277596. [PMID: 37869140 PMCID: PMC10585143 DOI: 10.3389/fneur.2023.1277596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/18/2023] [Indexed: 10/24/2023] Open
Abstract
Myasthenia gravis is a prototypic neuroimmune disorder with autoantibodies targeting the acetylcholine receptor complex at the neuromuscular junction. Patients present with mainly ocular muscle weakness and tend to have a generalized muscle weakness later in the clinical course. The weakness can be severe and fatal when bulbar muscles are heavily involved. Acetylcholine receptor antibodies are present in the majority of patients and are of IgG1 and IgG3 subtypes which can activate the complement system. The complement involvement plays a major role in the neuromuscular junction damage and the supporting evidence in the literature is described in this article. Complement therapies were initially studied and approved for paroxysmal nocturnal hemoglobinuria and in the past decade, those have also been studied in myasthenia gravis. The currently available randomized control trial and real-world data on the efficacy and safety of the approved and investigational complement therapies are summarized in this review.
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Affiliation(s)
- Pyae Phyo San
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Saiju Jacob
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
- Department of Neurology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
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14
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Zhang Z, Huang X, Du X, Wang Z, Wang Y, Xu M, Chen X, Yao Q, Yan L, Zhang Y. Plasma C18:0-ceramide is a novel potential biomarker for disease severity in myasthenia gravis. J Neurochem 2023; 165:907-919. [PMID: 37158660 DOI: 10.1111/jnc.15837] [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: 03/02/2023] [Revised: 04/17/2023] [Accepted: 04/20/2023] [Indexed: 05/10/2023]
Abstract
Myasthenia gravis (MG) is an antibody-mediated autoimmune disorder characterized by fluctuation of fatigue and weakness of muscle. Due to the heterogeneity of the course of MG, available biomarkers for prognostic prediction are urgently needed. Ceramide (Cer) was reported to participate in immune regulation and many autoimmune diseases, but its effects on MG remain undefined. This study aimed to investigate the ceramides expression levels in MG patients and their potential as novel biomarkers of disease severity. Levels of plasma ceramides were determined by ultra performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS). Severity of disease was assessed by quantitative MG scores (QMGs), MG-specific activities of daily living scale (MG-ADLs) and 15-item MG quality of Life (MG-QOL15). The concentrations of serum interleukin-1β (IL-1β), IL-6, IL-17A, and IL-21 were determined by enzyme-linked immunosorbent assay (ELISA), and the proportions of circulating memory B cells and plasmablasts were detected by flow-cytometry assay. Four plasma ceramides levels we studied were detected higher in MG patients. And three of them (C16:0-Cer, C18:0-Cer, and C24:0-Cer) were positively associated with QMGs. In addition, receiver operating characteristic (ROC) analysis suggested that plasma ceramides have a good ability of differentiating MG from HCs. Importantly, only C18:0-Cer was shown to be positively associated with the concentration of serum IL and circulating memory B cells, and the decrease in plasma C18:0-Cer paralleled the clinical improvement of patients with MG. All together, our data suggest that ceramides may play an important role in the immunopathological mechanism of MG, and C18:0-Cer has the potential to be a novel biomarker for disease severity in MG.
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Affiliation(s)
- Zhouao Zhang
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xiaoyu Huang
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Xue Du
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Zhouyi Wang
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Yingying Wang
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Mingming Xu
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xiao Chen
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Qian Yao
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Lisha Yan
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Yong Zhang
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
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15
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Meisel A, Annane D, Vu T, Mantegazza R, Katsuno M, Aguzzi R, Frick G, Gault L, Howard JF. Long-term efficacy and safety of ravulizumab in adults with anti-acetylcholine receptor antibody-positive generalized myasthenia gravis: results from the phase 3 CHAMPION MG open-label extension. J Neurol 2023:10.1007/s00415-023-11699-x. [PMID: 37103755 PMCID: PMC10134722 DOI: 10.1007/s00415-023-11699-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 04/28/2023]
Abstract
INTRODUCTION Ravulizumab demonstrated efficacy and an acceptable safety profile versus placebo in the randomized controlled period (RCP) of the phase 3 CHAMPION MG trial in patients with anti-acetylcholine receptor antibody-positive generalized myasthenia gravis. We report an interim analysis of the ongoing open-label extension (OLE) designed to evaluate long-term treatment effects. METHODS Following completion of the 26-week RCP, patients could enter the OLE; patients who received ravulizumab in the RCP continued the drug; patients who previously received placebo switched to ravulizumab. Patients receive body-weight-based maintenance dosing of ravulizumab every 8 weeks. Efficacy endpoints up to 60 weeks included Myasthenia Gravis-Activities of Daily Living (MG-ADL) and Quantitative Myasthenia Gravis (QMG) scores, with least-squares (LS) mean change and 95% confidence intervals (95% CI) reported. RESULTS Long-term efficacy and safety in the OLE were analyzed in 161 and 169 patients, respectively. Improvements in all scores were maintained through 60 weeks in patients who received ravulizumab during the RCP; LS mean change from RCP baseline in MG-ADL score was - 4.0 (95% CI: - 4.8, - 3.1; p < 0.0001). Rapid (within 2 weeks) and sustained improvements occurred in patients previously receiving placebo; LS mean change in MG-ADL score from OLE baseline to Week 60 was - 1.7 (95% CI: - 2.7, - 0.8; p = 0.0007). Similar trends were seen in QMG scores. Ravulizumab treatment was associated with a decreased rate of clinical deterioration events compared with placebo. Ravulizumab was well tolerated; no meningococcal infections were reported. CONCLUSION Findings support the sustained efficacy and long-term safety of ravulizumab, administered every 8 weeks, in adults with anti-acetylcholine receptor antibody-positive generalized myasthenia gravis. CLINICALTRIALS gov identifier: NCT03920293; EudraCT: 2018-003243-39.
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Affiliation(s)
| | | | - Tuan Vu
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | | | | | - Rasha Aguzzi
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
| | - Glen Frick
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
| | - Laura Gault
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
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16
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Nair SS, Jacob S. Novel Immunotherapies for Myasthenia Gravis. Immunotargets Ther 2023; 12:25-45. [PMID: 37038596 PMCID: PMC10082579 DOI: 10.2147/itt.s377056] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 03/03/2023] [Indexed: 04/07/2023] Open
Abstract
Myasthenia gravis (MG), a prototype autoimmune neurological disease, had its therapy centred on corticosteroids, non-steroidal broad-spectrum immunotherapy and cholinesterase inhibitors for several decades. Treatment-refractory MG and long-term toxicities of the medications have been major concerns with the conventional therapies. Advances in the immunology and pathogenesis of MG have ushered in an era of newer therapies which are more specific and efficacious. Complement inhibitors and neonatal Fc receptor blockers target disease-specific pathogenic mechanisms linked to myasthenia and have proven their efficacy in pivotal clinical studies. B cell-depleting agents, specifically rituximab, have also emerged as useful for the treatment of severe MG. Many more biologicals are in the pipeline and in diverse stages of development. This review discusses the evidence for the novel therapies and the specific issues related to their clinical use.
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Affiliation(s)
- Sruthi S Nair
- Department of Neurology, University Hospitals Birmingham, Birmingham, B15 2TH, UK
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Saiju Jacob
- Department of Neurology, University Hospitals Birmingham, Birmingham, B15 2TH, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TT, UK
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17
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Complement Inhibition in Myasthenia Gravis and Neuromyelitis Optica Spectrum Disorder. Can J Neurol Sci 2023; 50:165-173. [PMID: 34895385 DOI: 10.1017/cjn.2021.508] [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: 11/07/2022]
Abstract
The complement system is a tightly controlled signaling network that plays a role in innate immune surveillance. However, abnormal signaling through this pathway contributes to tissue damage in several inflammatory, autoimmune, and degenerative diseases. Myasthenia gravis (MG) and neuromyelitis optica spectrum disorders (NMOSD) have complement dysfunction at the core of pathogenesis, providing a strong rationale for therapeutic targeting of complement components. The purpose of this paper is to briefly review the role of complement activation in the pathogenesis of MG and NMOSD, to discuss the rationale and evidence for complement inhibition as a method to manage these diseases, and to provide a Canadian perspective on the use of complement inhibition therapy through real-world cases of MG and NMOSD.
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18
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Subxiphoid and subcostal arch versus unilateral video-assisted thoracic surgery approaches to thymectomy for myasthenia gravis. Surg Today 2023; 53:12-21. [PMID: 35776206 DOI: 10.1007/s00595-022-02533-4] [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: 07/29/2021] [Accepted: 04/24/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE Thymectomy is an important treatment for myasthenia gravis (MG). We conducted this study to compare the clinical outcomes of the recently introduced subxiphoid and subcostal arch thymectomy (SASAT) approach with those of the standard unilateral video-assisted thoracoscopic surgery (VATS). METHODS We analyzed, retrospectively, the perioperative, and long-term outcomes of 179 consecutive MG patients (age 18-65 years), who underwent SASAT or unilateral VATS-extended thymectomy between July, 2012 and May, 2019. RESULTS All demographic and clinical characteristics were comparable in the two groups. The median surgical time, estimated blood loss, thoracotomy conversion rate, total and chest drainage, and complications did not differ significantly between the groups. The visual analog scale (VAS) score was significantly lower in the SASAT group. Complete stable remission (CSR) was achieved in a significantly larger proportion of the SASAT group patients and was significantly higher in women than in men. The Quantitative MG score was significantly lower in the SASAT group. Patients in the MG Foundation of America Clinical Classification groups I and II achieved better remission rates than those in groups III-V. CONCLUSIONS SASAT is a safe and feasible MG treatment, which may yield better outcomes than unilateral VATS and improve the quality of treatment.
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19
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Jiang F, Su Y, Chang T. Knowledge mapping of global trends for myasthenia gravis development: A bibliometrics analysis. Front Immunol 2023; 14:1132201. [PMID: 36936960 PMCID: PMC10019893 DOI: 10.3389/fimmu.2023.1132201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 02/16/2023] [Indexed: 03/06/2023] Open
Abstract
Background Myasthenia gravis (MG) is an autoimmune disease with acquired neuromuscular junction transmission disorders. In the last two decades, various pathogenesis, application of immunosuppressive agents, and targeted immunotherapy have been significant events. However, extracting the most critical information from complex events is very difficult to guide clinical work. Therefore, we used bibliometrics to summarize and look forward. Methods Science Citation Index Expanded (SCI-E) from the Web of Science Core Collection (WoSCC) database was identified as a source of material for obtaining MG-related articles. Scimago Graphica, CiteSpace, VOSviewer, and bibliometrix were utilized for bibliometric analysis. Knowledge network graphs were constructed and visualized; countries, institutions, authors, journals, references, and keywords were evaluated. In addition, GraphPad Prism and Microsoft Excel 365 were applied for statistical analysis. Results As of October 25, 2022, 9,970 original MG-related articles were used for the bibliometric analysis; the cumulative number of citations to these articles was 236,987, with an H-index of 201. The United States ranked first in terms of the number of publications (2,877) and H-index (134). Oxford has the highest H-index (67), and Udice French Research University has the highest number of publications (319). The author with the highest average number of citations (66.19), publications (151), and H-index (53) was Vincent A. 28 articles have remained in an explosive period of citations. The final screening yielded predictive keywords related to clinical trials and COVID-19. Conclusion We conducted a bibliometric analysis of 9,970 original MG-related articles published between 1966 and 2022. Ultimately, we found that future MG research hotspots include two major parts: (1) studies directly related to MG disease itself: clinical trials of various targeted biological agents; the relationship between biomarkers and therapeutic decisions, pathogenesis and outcome events, ultimately serving individualized management or precision therapy; (2) studies related to MG and COVID-19: different variants of COVID-19 (e.g., Omicron) on MG adverse outcome events; assessment of the safety of different COVID-19 vaccines for different subtypes of MG.
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Affiliation(s)
- Fan Jiang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
- The Second Brigade of Cadet, Basic Medical School, Air Force Military Medical University, Xi’an Shaanxi, China
| | - Yue Su
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Ting Chang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
- *Correspondence: Ting Chang,
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20
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Younger DS. Critical illness-associated weakness and related motor disorders. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:707-777. [PMID: 37562893 DOI: 10.1016/b978-0-323-98818-6.00031-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Weakness of limb and respiratory muscles that occurs in the course of critical illness has become an increasingly common and serious complication of adult and pediatric intensive care unit patients and a cause of prolonged ventilatory support, morbidity, and prolonged hospitalization. Two motor disorders that occur singly or together, namely critical illness polyneuropathy and critical illness myopathy, cause weakness of limb and of breathing muscles, making it difficult to be weaned from ventilatory support, commencing rehabilitation, and extending the length of stay in the intensive care unit, with higher rates of morbidity and mortality. Recovery can take weeks or months and in severe cases, and may be incomplete or absent. Recent findings suggest an improved prognosis of critical illness myopathy compared to polyneuropathy. Prevention and treatment are therefore very important. Its management requires an integrated team approach commencing with neurologic consultation, creatine kinase (CK) measurement, detailed electrodiagnostic, respiratory and neuroimaging studies, and potentially muscle biopsy to elucidate the etiopathogenesis of the weakness in the peripheral and/or central nervous system, for which there may be a variety of causes. These tenets of care are being applied to new cases and survivors of the coronavirus-2 disease pandemic of 2019. This chapter provides an update to the understanding and approach to critical illness motor disorders.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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21
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Suzuki S, Uzawa A, Murai H. Efgartigimod for generalized myasthenia gravis with or without anti-acetylcholine receptor antibodies: a worldwide and Japanese perspective. Expert Rev Clin Immunol 2022; 18:1207-1215. [PMID: 36227228 DOI: 10.1080/1744666x.2022.2136167] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION The management of myasthenia gravis (MG) has been improved due to immunotherapy advances, but 20% of individuals with MG are refractory to the conventional therapy, and the need for novel biological drugs remains. AREA COVERED The Japanese clinical guidelines for MG published in May 2022 include the concept that treatment is often lifelong and should aim to maintain a sufficient quality of life and mental health. We provide an overview of the therapeutic strategy for generalized MG in Japan, in comparison with the international consensus. We summarize the clinical efficacy, safety, and tolerability of efgartigimod, the first approved anti-neonatal Fc receptor inhibitor for MG. A phase III study showed that efgartigimod was well-tolerated and efficacious in patients with generalized MG. EXPERT OPINION Efgartigimod is a promising biological drug for patients with moderate to severe generalized MG with or without anti-acetylcholine receptor antibodies in Japan.
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Affiliation(s)
- Shigeaki Suzuki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Akiyuki Uzawa
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hiroyuki Murai
- Department of Neurology, International University of Health and Welfare, Narita, Japan
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22
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Abstract
PURPOSE OF REVIEW This review summarizes recent insights into the immunopathogenesis of autoimmune myasthenia gravis (MG). Mechanistic understanding is presented according to MG disease subtypes and by leveraging the knowledge gained through the use of immunomodulating biological therapeutics. RECENT FINDINGS The past two years of research on MG have led to a more accurate definition of the mechanisms through which muscle-specific tyrosine kinase (MuSK) autoantibodies induce pathology. Novel insights have also emerged from the collection of stronger evidence on the pathogenic capacity of low-density lipoprotein receptor-related protein 4 autoantibodies. Clinical observations have revealed a new MG phenotype triggered by cancer immunotherapy, but the underlying immunobiology remains undetermined. From a therapeutic perspective, MG patients can now benefit from a wider spectrum of treatment options. Such therapies have uncovered profound differences in clinical responses between and within the acetylcholine receptor and MuSK MG subtypes. Diverse mechanisms of immunopathology between the two subtypes, as well as qualitative nuances in the autoantibody repertoire of each patient, likely underpin the variability in therapeutic outcomes. Although predictive biomarkers of clinical response are lacking, these observations have ignited the development of assays that might assist clinicians in the choice of specific therapeutic strategies. SUMMARY Recent advances in the understanding of autoantibody functionalities are bringing neuroimmunologists closer to a more detailed appreciation of the mechanisms that govern MG pathology. Future investigations on the immunological heterogeneity among MG patients will be key to developing effective, individually tailored therapies.
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Affiliation(s)
- Gianvito Masi
- Department of Neurology, Yale School of Medicine, New Haven, CT 06511 USA
- Department of Immunobiology, Yale School of Medicine, New Haven, CT 06511 USA
| | - Kevin C. O’Connor
- Department of Neurology, Yale School of Medicine, New Haven, CT 06511 USA
- Department of Immunobiology, Yale School of Medicine, New Haven, CT 06511 USA
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23
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Sanderson NSR. Complement and myasthenia gravis. Mol Immunol 2022; 151:11-18. [PMID: 36063582 DOI: 10.1016/j.molimm.2022.08.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/26/2022] [Accepted: 08/28/2022] [Indexed: 11/17/2022]
Abstract
Myasthenia gravis is a neuromuscular disease associated with antibodies against components of the neuromuscular junction, most often against the acetylcholine receptor (AChR). Although several mechanisms have been postulated to explain how these autoantibodies can lead to the pathology of the disease, convincing evidence suggests that destruction of the receptor-bearing postsynaptic membrane by complement membrane attack complex is of central importance. In this review, evidence for the importance of complement, and possible relationships between autoantigen, autoantibodies, complement activation, and the destruction of the membrane are discussed. More recent insights from the results of the complement-inhibiting therapeutic antibody eculizumab are also described, and the mechanisms connecting antibody binding to complement activation are considered from a structural viewpoint.
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24
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Waheed W, Newman E, Aboukhatwa M, Moin M, Tandan R. Practical Management for Use of Eculizumab in the Treatment of Severe, Refractory, Non-Thymomatous, AChR + Generalized Myasthenia Gravis: A Systematic Review. Ther Clin Risk Manag 2022; 18:699-719. [PMID: 35855752 PMCID: PMC9288180 DOI: 10.2147/tcrm.s266031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 07/04/2022] [Indexed: 11/28/2022] Open
Abstract
Myasthenia gravis (MG) is a rare autoimmune disorder caused by specific autoantibodies at the neuromuscular junction. MG is classified by the antigen specificity of these antibodies. Acetylcholine receptor (AChR) antibodies are the most common type (74–88%), followed by anti-muscle specific kinase (MuSK) and other antibodies. While all these antibodies lead to neuromuscular transmission failure, the immuno-pathogenic mechanisms are distinct. Complement activation is a primary driver of AChR antibody-positive MG (AChR+ MG) pathogenesis. This leads to the formation of the membrane attack complex and destruction of AChR receptors and the postsynaptic membrane resulting in impaired neurotransmission and muscle weakness characteristic of MG. Broad-based immune-suppressants like corticosteroids are effective in controlling MG; however, their long-term use can be associated with significant adverse effects. Advances in translational research have led to the development of more directed therapeutic agents that are likely to alter the future of MG treatment. Eculizumab is a humanized monoclonal antibody that inhibits the cleavage of complement protein C5 and is approved for use in generalized MG. In this review, we discuss the pathophysiology of MG; the therapeutic efficacy and tolerability of eculizumab, as well as the practical guidelines for its use in MG; future studies exploring the role of eculizumab in different stages and subtypes of MG subtypes; the optimal duration of therapy and its discontinuation; the characterization of non-responder patients; and the use of biomarkers for monitoring therapy are highlighted. Based on the pathophysiologic mechanisms, emerging therapies and new therapeutic targets are also reviewed.
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Affiliation(s)
- Waqar Waheed
- Department of Neurological Sciences, The University of Vermont and the University of Vermont Medical Center, Burlington, VT, USA
| | - Eric Newman
- Department of Neurological Sciences, The University of Vermont and the University of Vermont Medical Center, Burlington, VT, USA
| | - Marwa Aboukhatwa
- Pharmacotherapy Department, University of Vermont Medical Center, Burlington, VT, USA
| | - Maryam Moin
- Department of Neurology, University of Illinois College of Medicine, Peoria, IL, USA
| | - Rup Tandan
- Department of Neurological Sciences, The University of Vermont and the University of Vermont Medical Center, Burlington, VT, USA
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25
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Suh J, Clarke V, Amato AA, Guidon AC. Safety and outcomes of eculizumab for acetylcholine receptor-positive generalized myasthenia gravis in clinical practice. Muscle Nerve 2022; 66:348-353. [PMID: 35684980 DOI: 10.1002/mus.27656] [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: 02/13/2022] [Revised: 06/02/2022] [Accepted: 06/03/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION/AIMS Safety and outcomes data on eculizumab for generalized myasthenia gravis (gMG) in clinical practice remain limited. Outcomes and concomitant medication use may differ in practice compared with clinical trials. We analyzed the clinical and safety outcomes of patients who received eculizumab at our institutions. METHODS Patients with acetylcholine receptor antibody positive (AChR+) gMG, who received ≥1 dose of eculizumab and had ≥1 follow-up before December 10, 2021, were identified. Data were abstracted by chart review. Outcomes included MG Foundation of America Post Intervention Status (MGFA-PIS), Clinical Classification (MGFA-CC), MG-Activities of Daily Living (MG-ADL), concurrent immunomodulatory therapy use, and adverse events. RESULTS Twelve patients were included. Mean age at eculizumab initiation was 57.4 y (range, 21-77). Eight had refractory MG. Four had history of thymoma and thymectomy. A mean of 3.2 (range, 2-5) immunomodulatory therapies were previously tried. Mean follow-up duration was 18 mo (range, 2-21.6). Clinical improvement occurred rapidly; MGFA-PIS was improved in 80%, and MGFA-CC improved in 83% at 1 mo. Mean MG-ADL decreased from 8.7 to 2.8 at 1 mo, and remained ≤ 3 $$ \le 3 $$ .5 over 1.5 y. Mean daily prednisone dose decreased from 22.5 mg to 7.2 mg at 1.5 y. Five of 7 patients discontinued maintenance IVIG or PLEX. No patients had meningococcal infections and adverse events were mild. DISCUSSION Clinical improvement occurred in most patients after eculizumab initiation, beginning as quickly as 1 mo. Steroids were tapered and maintenance IVIG and PLEX were discontinued in most. Eculizumab had a favorable safety profile even when combined with other immunosuppressants.
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Affiliation(s)
- Joome Suh
- Division of Neuromuscular Medicine, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Virginia Clarke
- Division of Neuromuscular Medicine, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anthony A Amato
- Division of Neuromuscular Medicine, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Amanda C Guidon
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Neuromuscular Medicine, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Vanoli F, Mantegazza R. Antibody Therapies in Autoimmune Neuromuscular Junction Disorders: Approach to Myasthenic Crisis and Chronic Management. Neurotherapeutics 2022; 19:897-910. [PMID: 35165857 PMCID: PMC9294078 DOI: 10.1007/s13311-022-01181-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2022] [Indexed: 02/06/2023] Open
Abstract
Myasthenia gravis (MG) is a neurological autoimmune disorder characterized by muscle weakness and fatigue. It is a B cell-mediated disease caused by pathogenic antibodies directed against various components of the neuromuscular junction (NMJ). Despite the wide range of adverse effects, current treatment is still based on non-specific immunosuppression, particularly on long-term steroid usage. The increasing knowledge regarding the pathogenic mechanisms of MG has however allowed to create more target-specific therapies. A very attractive therapeutic approach is currently offered by monoclonal antibodies (mAbs), given their ability to specifically and effectively target different immunopathological pathways, such as the complement cascade, B cell-related cluster of differentiation (CD) proteins, and the human neonatal Fc receptor (FcRn). Up to now, eculizumab, a C5-directed mAb, has been approved for the treatment of generalized MG (gMG) and efgartigimod, a FcRn inhibitor, has just been approved by the U.S. Food and Drug Administration for the treatment of anti-acetylcholine receptor (AChR) antibody positive gMG. Other mAbs are currently under investigation with encouraging preliminary results, further enriching the new range of therapeutic possibilities for MG. This review article provides an overview of the present status of mAb-based therapies for MG, which offer an exciting promise for better outcomes by setting the basis of a precision medicine approach.
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Affiliation(s)
- Fiammetta Vanoli
- Neuroimmunology and Neuromuscular Disease Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
- Department of Human Neurosciences, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185, Rome, Italy
| | - Renato Mantegazza
- Neuroimmunology and Neuromuscular Disease Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
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McCombe JA, Pittock SJ. Anti-complement Agents for Autoimmune Neurological Disease. Neurotherapeutics 2022; 19:711-728. [PMID: 35553024 PMCID: PMC9294087 DOI: 10.1007/s13311-022-01223-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 01/06/2023] Open
Abstract
In recent years, there has been increasing recognition of the diversity of autoimmune neurological diseases affecting all levels of the nervous system. A growing understanding of disease pathogenesis has enabled us to better target specific elements of the immune system responsible for the cell dysfunction and cell destruction seen in these diseases. This is no better demonstrated than in the development of complement directed therapies for the treatment of complement mediated autoimmune neurological conditions. Herein, we describe the basic elements of the complement cascade, provide an overview of select autoimmune neurological diseases whose pathogenesis is mediated by complement, the effector system of autoantigen bound autoantibodies, and discuss the complement directed therapies trialed in the treatment of these diseases. Several complement-directed therapies have demonstrated benefit in the treatment of autoimmune neurological diseases; we also review the trials resulting in the approval of these therapies for the treatment of AChR Ab-positive myasthenia gravis (MG) and neuromyelitis spectrum disorder. Finally, on the heels of the recent successes described, we discuss possibilities for the future, including additional targeted therapies with greater ease of administration, improved risk profiles, and other possible uses for therapeutics targeting elements of the complement cascade.
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Affiliation(s)
- Jennifer A McCombe
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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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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Song J, Zhao R, Yan C, Luo S, Xi J, Ding P, Li L, Hu W, Zhao C. A Targeted Complement Inhibitor CRIg/FH Protects Against Experimental Autoimmune Myasthenia Gravis in Rats via Immune Modulation. Front Immunol 2022; 13:746068. [PMID: 35154091 PMCID: PMC8825366 DOI: 10.3389/fimmu.2022.746068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 01/04/2022] [Indexed: 11/13/2022] Open
Abstract
Antibody-induced complement activation may cause injury of the neuromuscular junction (NMJ) and is thus considered as a primary pathogenic factor in human myasthenia gravis (MG) and animal models of experimental autoimmune myasthenia gravis (EAMG). In this study, we tested whether CRIg/FH, a targeted complement inhibitor, could attenuate NMJ injury in rat MG models. We first demonstrated that CRIg/FH could inhibit complement-dependent cytotoxicity on human rhabdomyosarcoma TE671 cells induced by MG patient-derived IgG in vitro. Furthermore, we investigated the therapeutic effect of CRIg/FH in a passive and an active EAMG rodent model. In both models, administration of CRIg/FH could significantly reduce the complement-mediated end-plate damage and suppress the development of EAMG. In the active EAMG model, we also found that CRIg/FH treatment remarkably reduced the serum concentration of autoantibodies and of the cytokines including IFN-γ, IL-2, IL-6, and IL-17, and upregulated the percentage of Treg cells in the spleen, which was further verified in vitro. Therefore, our findings indicate that CRIg/FH may hold the potential for the treatment of MG via immune modulation.
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Affiliation(s)
- Jie Song
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China
| | - Rui Zhao
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China
| | - Chong Yan
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China
| | - Sushan Luo
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China
| | - Jianying Xi
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China
| | - Peipei Ding
- Fudan University Shanghai Cancer Center and Institutes of Biomedical Sciences, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ling Li
- Fudan University Shanghai Cancer Center and Institutes of Biomedical Sciences, Shanghai Medical College, Fudan University, Shanghai, China
| | - Weiguo Hu
- Fudan University Shanghai Cancer Center and Institutes of Biomedical Sciences, Shanghai Medical College, Fudan University, Shanghai, China.,Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, China
| | - Chongbo Zhao
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China
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Verschuuren JJGM, Palace J, Murai H, Tannemaat MR, Kaminski HJ, Bril V. Advances and ongoing research in the treatment of autoimmune neuromuscular junction disorders. Lancet Neurol 2022; 21:189-202. [DOI: 10.1016/s1474-4422(21)00463-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 11/16/2021] [Accepted: 12/17/2021] [Indexed: 12/14/2022]
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31
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Gomathy SB, Agarwal A, Vishnu VY. Molecular Therapy in Myasthenia Gravis. Neurology 2022. [DOI: 10.17925/usn.2022.18.1.49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disorder caused by antibodies that act against the myoneural junction. Conventional immunosuppressants such as corticosteroids, azathioprine and mycophenolate are associated with long-term side effects and many patients do not achieve remission and may become refractory. Thus, there is an unmet need for target-specific therapies that act faster, have fewer side effects and lead to stable disease remission. However, many of the novel therapeutic agents being described are not meeting their primary endpoints. We reviewed the current status of novel immunotherapies for MG, their mechanisms of action, along with the side effect profiles. Fast onset of action, sustained disease remission and relatively low frequency of side effects of the new agents are attractive. However, the unknown long-term safety and high cost are precluding factors. Better preclinical studies and more randomized trials are needed before novel agents are routinely employed.
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32
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Tice JA, Touchette DR, Lien PW, Agboola F, Nikitin D, Pearson SD. The effectiveness and value of eculizumab and efgartigimod for generalized myasthenia gravis. J Manag Care Spec Pharm 2021; 28:119-124. [PMID: 34949112 PMCID: PMC10373007 DOI: 10.18553/jmcp.2022.28.1.119] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
DISCLOSURES: Funding for this summary was contributed by Arnold Ventures, The Donaghue Foundation, Harvard Pilgrim Health Care, and Kaiser Foundation Health Plan to the Institute for Clinical and Economic Review (ICER), an independent organization that evaluates the evidence on the value of health care interventions. ICER's annual policy summit is supported by dues from AbbVie, America's Health Insurance Plans, Anthem, Alnylam, AstraZeneca, Biogen, Blue Shield of CA, Boehringer-Ingelheim, Cambia Health Services, CVS, Editas, Evolve Pharmacy, Express Scripts, Genentech/Roche, GlaxoSmithKline, Harvard Pilgrim, Health Care Service Corporation, HealthFirst, Health Partners, Humana, Johnson & Johnson (Janssen), Kaiser Permanente, LEO Pharma, Mallinckrodt, Merck, Novartis, National Pharmaceutical Council, Pfizer, Premera, Prime Therapeutics, Regeneron, Sanofi, Sun Life Financial, uniQure, and United Healthcare. Agboola, Nikitin, and Pearson are employed by ICER. Through their affiliated institutions, Tice, Touchette, and Lien received funding from ICER for the work described in this summary.
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Affiliation(s)
- Jeffrey A Tice
- Division of General Internal Medicine, University of California San Francisco
| | | | - Pei-Wen Lien
- University of Illinois at Chicago College of Pharmacy, Chicago, IL
| | - Foluso Agboola
- Institute for Clinical and Economic Review (ICER), Boston, MA
| | - Dmitriy Nikitin
- Institute for Clinical and Economic Review (ICER), Boston, MA
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Feng X, Song Z, Wu M, Liu Y, Luo S, Zhao C, Zhang W. Efficacy and Safety of Immunotherapies in Refractory Myasthenia Gravis: A Systematic Review and Meta-Analysis. Front Neurol 2021; 12:725700. [PMID: 34925206 PMCID: PMC8672452 DOI: 10.3389/fneur.2021.725700] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 10/25/2021] [Indexed: 01/21/2023] Open
Abstract
Introduction: Approximately 10–20% of patients WITH myasthenia gravis (MG) are refractory to conventional immunotherapies. The purpose of this study was to conduct a systematic review and meta-analysis to explore the optimal therapies for refractory MG. Method: Correlative studies were performed through a search in PubMed, Cochrane Library, and Embase databases. The primary outcome was defined by changes in the quantitative myasthenia gravis score (QMG). Secondary outcomes were defined by the Myasthenia Gravis Activities of Daily Living Scale (MG-ADL), Myasthenia Gravis Foundation of America (MGFA) post intervention status, adverse events, and disease exacerbation after treatment. Result: A total of 16 studies were included with 403 patients with refractory MG on therapies with rituximab, eculizumab, tacrolimus, and cladribine. Therapeutic efficacy of rituximab and eculizumab was identified with an estimated reduction in QMG score (4.158 vs. 6.928) and MG-ADL (4.400 vs. 4.344), respectively. No significant changes were revealed in efficacy or exacerbation density between the two independent therapeutic cohorts. The estimated adverse event density of eculizumab was more significant than that in the rituximab group (1.195 vs. 0.134 per patient-year), while the estimated serious event density was similar. Conclusion: The efficacy and safety of rituximab and eculizumab have been approved in patients with refractory MG. Rituximab had a superior safety profile than eculizumab with a lower incidence of adverse events. Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021236818, identifier CRD42021236818.
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Affiliation(s)
- Xuelin Feng
- Department of Neurology, East Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zubiao Song
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Mengli Wu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yanmei Liu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Sushan Luo
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Chongbo Zhao
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Weixi Zhang
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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34
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Monteleone JPR, Gao X, Kleijn HJ, Bellanti F, Pelto R. Eculizumab Pharmacokinetics and Pharmacodynamics in Patients With Generalized Myasthenia Gravis. Front Neurol 2021; 12:696385. [PMID: 34795626 PMCID: PMC8594444 DOI: 10.3389/fneur.2021.696385] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 08/20/2021] [Indexed: 11/17/2022] Open
Abstract
Objective: To investigate the pharmacokinetics, pharmacodynamics, and exposure-response of the approved 900/1,200 mg dosing regimen for the terminal complement component 5 (C5) inhibitor eculizumab in patients with generalized myasthenia gravis (gMG). Methods: The analysis used data from 62 patients aged ≥ 18 years with anti-acetylcholine receptor (AChR) antibody-positive refractory gMG who received eculizumab during the REGAIN study (ClinicalTrials.gov: NCT01997229). One- and two-compartment population-pharmacokinetic models were evaluated, and the impact of covariates on pharmacokinetic parameters was assessed. Relationships between eculizumab exposure and free C5 concentration, in vitro hemolytic activity, clinical response, and tolerability were characterized. Results: Steady-state serum eculizumab concentrations were achieved by Week 4 and were sustained throughout the 26-week treatment period. The eculizumab pharmacokinetic data were well-described by a two-compartment model with first-order elimination, including effects of body weight on pharmacokinetic parameters and plasma-exchange events on clearance. Complete inhibition of terminal complement was achieved in nearly all patients at the time of trough and peak eculizumab concentrations at all post-dose timepoints assessed (free C5 < 0.5 μg/ml in 92% of patients; in vitro hemolysis < 20% in 87% of patients). Serum eculizumab concentrations of ≥116 μg/ml achieved free C5 concentrations of < 0.5 μg/ml. Clinical efficacy and tolerability were consistent across the eculizumab exposure range. Conclusions: Rigorous, quantitative, model-based exposure-response analysis of serum eculizumab concentration and response data demonstrated that the approved eculizumab dosing (900/1,200 mg) for adults with anti-AChR antibody-positive refractory gMG rapidly achieved complete inhibition of terminal complement activation and provided sustained clinical efficacy across the eculizumab exposure range.
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Affiliation(s)
- Jonathan P. R. Monteleone
- Department of Pharmacometrics, PK/PD M&S, Clinical Development and Translational Sciences, Alexion Pharmaceuticals Inc., Boston, MA, United States
| | - Xiang Gao
- Department of Pharmacometrics, PK/PD M&S, Clinical Development and Translational Sciences, Alexion Pharmaceuticals Inc., Boston, MA, United States
| | | | | | - Ryan Pelto
- Department of Pharmacometrics, PK/PD M&S, Clinical Development and Translational Sciences, Alexion Pharmaceuticals Inc., Boston, MA, United States
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Galtier J, Duval F, Machelart I, Greib C, Lazaro E, Pellegrin J, Viallard J, Tour RP, Rivière E. Myasthenia gravis and paroxysmal nocturnal hemoglobinuria after thymectomy: A rare association. EJHAEM 2021; 2:834-837. [PMID: 35845222 PMCID: PMC9176050 DOI: 10.1002/jha2.244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/20/2021] [Accepted: 05/23/2021] [Indexed: 11/08/2022]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a very rare clonal autoimmune disease manifesting with hemolysis, thrombosis, or bone marrow failure. We present an atypical association of myasthenia gravis, aplastic anemia, and PNH occurring years after thymectomy. While this association might be extremely rare, it may not be coincidental as there is a common pathophysiology between PNH and aplastic anemia, with the latter reported in several thymoma/thymectomy cases. Eculizumab was introduced with good efficacy and without safety concern in our patient, leading to long‐term control of PNH without worsening of myasthenia gravis.
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Affiliation(s)
- Jean Galtier
- Hematology Department Haut‐Leveque Hospital University Hospital Center of Bordeaux Pessac France
| | - Fanny Duval
- Neurology Department Pellegrin Hospital University Hospital Center of Bordeaux Bordeaux France
| | - Irène Machelart
- Internal Medicine and Infectious Diseases Haut‐Leveque Hospital University Hospital Center of Bordeaux Pessac France
| | - Carine Greib
- Internal Medicine and Infectious Diseases Haut‐Leveque Hospital University Hospital Center of Bordeaux Pessac France
| | - Estibaliz Lazaro
- Internal Medicine and Infectious Diseases Haut‐Leveque Hospital University Hospital Center of Bordeaux Pessac France
| | - Jean‐Luc Pellegrin
- Internal Medicine and Infectious Diseases Haut‐Leveque Hospital University Hospital Center of Bordeaux Pessac France
| | - Jean‐François Viallard
- Internal Medicine and Infectious Diseases Haut‐Leveque Hospital University Hospital Center of Bordeaux Pessac France
- INSERM U1034 Pessac Cedex France
| | - Regis Peffault Tour
- Service d'Hématologie Greffe Centre de référence des aplasies médullaires acquises et constitutionnelles Hôpital Saint Louis AP‐HP Paris France
| | - Etienne Rivière
- Internal Medicine and Infectious Diseases Haut‐Leveque Hospital University Hospital Center of Bordeaux Pessac France
- INSERM U1034 Pessac Cedex France
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Siddiqi ZA, Nowak RJ, Mozaffar T, O'Brien F, Yountz M, Patti F. Eculizumab in refractory generalized myasthenia gravis previously treated with rituximab: subgroup analysis of REGAIN and its extension study. Muscle Nerve 2021; 64:662-669. [PMID: 34590717 DOI: 10.1002/mus.27422] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 09/16/2021] [Accepted: 09/16/2021] [Indexed: 12/24/2022]
Abstract
INTRODUCTION/AIMS Individuals with refractory generalized myasthenia gravis (gMG) who have a history of rituximab use and experience persistent symptoms represent a population with unmet treatment needs. The aim of this analysis was to evaluate the efficacy and safety of eculizumab in patients with refractory anti-acetylcholine receptor antibody-positive (AChR+ ) gMG previously treated with rituximab. METHODS This post hoc subgroup analysis of the phase 3 REGAIN study (NCT01997229) and its open-label extension (OLE; NCT02301624) compared baseline characteristics, safety, and response to eculizumab in participants who had previously received rituximab with those who had not. Rituximab use was not permitted within the 6 months before screening or during REGAIN/OLE. RESULTS Of 125 REGAIN participants, 14 had received rituximab previously (7 received placebo and 7 received eculizumab). In the previous-rituximab group, 57% had used at least four other immunosuppressants compared with 16% in the no-previous-rituximab group. Myasthenia Gravis Activities of Daily Living total scores from eculizumab baseline to week 130 of eculizumab treatment improved in both the previous-rituximab and no-previous-rituximab groups (least-squares mean -4.4, standard error of the mean [SEM] 1.0 [n = 9] and least-squares mean -4.6, SEM 0.3 [n = 67], respectively; difference = 0.2, 95% confidence interval -1.88 to 2.22). In addition, in both groups, most patients who were treated with eculizumab for 130 weeks achieved a Myasthenia Gravis Foundation of America post-intervention status of minimal manifestations (66.7% and 65.0%, respectively). The eculizumab safety profile was similar between groups and consistent with its established profile. DISCUSSION Eculizumab is an effective therapy for patients with refractory AChR+ gMG, irrespective of whether they had received rituximab treatment previously.
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Affiliation(s)
- Zaeem A Siddiqi
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Richard J Nowak
- Department of Neurology, Yale University School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Tahseen Mozaffar
- Department of Neurology, University of California Irvine, Orange, California, USA
| | - Fanny O'Brien
- Alexion Pharmaceuticals, Inc., Boston, Massachusetts, USA
| | - Marcus Yountz
- Alexion Pharmaceuticals, Inc., Boston, Massachusetts, USA
| | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies, G.F. Ingrassia, University of Catania, Catania, Italy
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Evoli A, Spagni G, Monte G, Damato V. Heterogeneity in myasthenia gravis: considerations for disease management. Expert Rev Clin Immunol 2021; 17:761-771. [PMID: 34043932 DOI: 10.1080/1744666x.2021.1936500] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Myasthenia gravis is a rare disease of the neuromuscular junction and a prototype of B cell-driven immunopathology. Pathogenic antibodies target post-synaptic transmembrane proteins, most commonly the nicotinic acetylcholine receptor and the muscle-specific tyrosine kinase, inducing end-plate alterations and neuromuscular transmission impairment. Several clinical subtypes are distinct on the basis of associated antibodies, age at symptom onset, thymus pathology, genetic factors, and weakness distribution. These subtypes have distinct pathogenesis that can account for different responses to treatment. Conventional therapy is based on the use of symptomatic agents, steroids, immunosuppressants and thymectomy. Of late, biologics have emerged as effective therapeutic options.Areas covered: In this review, we will discuss the management of myasthenia gravis in relation to its phenotypic and biological heterogeneity, in the light of recent advances in the disease immunopathology, new diagnostic tools, and results of clinical trialsExpert opinion: Clinical management is shaped on serological subtype, and patient age at onset, lifestyle and comorbidities, balancing therapeutic needs and safety. Although reliable biomarkers predictive of clinical and biologic outcome are still lacking, recent developments promise a more effective and safe treatment. Disease subtyping according to serological testing and immunopathology is crucial to the appropriateness of clinical management.
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Affiliation(s)
- Amelia Evoli
- Dipartimento di Neuroscienze, Università Cattolica Del Sacro Cuore, Rome, Italy.,Unità Operativa Complessa di Neurologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Gregorio Spagni
- Dipartimento di Neuroscienze, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Gabriele Monte
- Dipartimento di Neuroscienze, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Valentina Damato
- Dipartimento di Neuroscienze, Università Cattolica Del Sacro Cuore, Rome, Italy
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38
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Suzuki S. Targeted molecular therapy for myasthenia gravis. Lancet Neurol 2021; 20:499-500. [PMID: 34146498 DOI: 10.1016/s1474-4422(21)00173-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 05/19/2021] [Accepted: 05/19/2021] [Indexed: 01/09/2023]
Affiliation(s)
- Shigeaki Suzuki
- Department of Neurology, Keio University School of Medicine, Tokyo 160-8582, Japan.
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39
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Usman U, Chrisman C, Houston D, Haws CC, Wang A, Muley S. The use of eculizumab in ventilator-dependent myasthenia gravis patients. Muscle Nerve 2021; 64:212-215. [PMID: 34008175 DOI: 10.1002/mus.27326] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 05/12/2021] [Accepted: 05/16/2021] [Indexed: 01/13/2023]
Abstract
INTRODUCTION/AIMS Eculizumab has been shown to be efficacious in acetylcholine receptor antibody-positive (AChR+ ) Myasthenia Gravis Foundation of America (MGFA) class II, III, and IV generalized myasthenia gravis (gMG) patients. However, it has not been studied in MGFA class V gMG patients. METHODS We report three AChR+ , refractory, MGFA class V gMG patients treated with eculizumab. MGFA class, MG-Composite (MGC) score and MG Activities of Daily Living (MG-ADL) score were assessed before and after eculizumab. RESULTS Two of three gMG patients, refractory to intravenous immunoglobulin, plasmapheresis, prednisone, and (in one case) rituximab, showed a robust response to eculizumab with marked improvement in MGFA, MG-ADL, and MGC measures. The third patient showed a partial response to eculizumab but remained on noninvasive ventilation and gastrostomy intubation. Patients 1 and 2 achieved minimal manifestation status at week 4 and week 6, respectively, and showed continued improvement on MG-ADL and MGC scores through weeks 55 and 43, respectively, with eculizumab. The third patient showed a partial response at week 10, followed by a slight decline in his MG-ADL score, but noted a slow but an incomplete improvement afterward on MG-ADL and MGC scores, possibly due to delayed eculizumab infusion. DISCUSSION Eculizumab may play a role in the treatment of patients with MGFA class V, refractory gMG. Larger studies are required to provide further evidence.
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Affiliation(s)
- Uzma Usman
- Department of Neurology, Yale University, New Haven, Connecticut, USA
| | - Christina Chrisman
- Department of Neurology, Banner University Medical Centre, Phoenix, AZ, Phoenix, Arizona, USA
| | - Drew Houston
- Department of Neurology, Barrow Neurological Institute. Phoenix. AZ, Phoenix, Arizona, USA
| | - Clara Chow Haws
- Department of Neurology, Phoenix Children Hospital, Phoenix, Arizona, USA
| | - Alan Wang
- Department of Neurology, Banner University Medical Centre, Phoenix, AZ, Phoenix, Arizona, USA
| | - Suraj Muley
- Department of Neurology, Barrow Neurological Institute. Phoenix. AZ, Phoenix, Arizona, USA
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Howard JF, Vissing J, Gilhus NE, Leite MI, Utsugisawa K, Duda PW, Farzaneh-Far R, Murai H, Wiendl H. Zilucoplan: An Investigational Complement C5 Inhibitor for the Treatment of Acetylcholine Receptor Autoantibody-Positive Generalized Myasthenia Gravis. Expert Opin Investig Drugs 2021; 30:483-493. [PMID: 33792453 DOI: 10.1080/13543784.2021.1897567] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Generalized myasthenia gravis (gMG) is an autoimmune disorder in which pathogenic autoantibodies damage the neuromuscular junction, causing disabling or life-threatening muscle weakness. Most treatments nonspecifically inhibit aspects of the immune system, do not directly address the causal mechanisms of tissue damage, and often have side-effect profiles that negatively impact patients. Understanding of the central pathogenic role of the complement cascade in gMG is advancing, and a new complement-targeting treatment is under investigation. AREAS COVERED We provide an overview of gMG etiology, the complement cascade, current treatments, and the investigational gMG therapy zilucoplan. Zilucoplan is a small, subcutaneously administered, macrocyclic peptide that inhibits cleavage of complement component C5 and the subsequent formation of the membrane attack complex. EXPERT OPINION In a randomized, double-blind, placebo-controlled, phase 2 clinical trial, zilucoplan demonstrated clinically meaningful complement inhibition in patients with acetylcholine receptor-positive gMG. Zilucoplan, a first-of-its-kind cyclic peptide targeting C5, appears to be a therapeutic option for the treatment of gMG based on available pharmacokinetic/pharmacodynamic data and phase 1 and 2 efficacy, safety, and tolerability data with limited long-term follow-up. Zilucoplan use earlier in the treatment paradigm would be suitable in this population should phase 3 efficacy and safety data be equally favorable.
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Affiliation(s)
- James F Howard
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - John Vissing
- Department of Clinical Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Nils E Gilhus
- Department of Clinical Medicine, University of Bergen and Haukeland University Hospital, Bergen, Norway
| | - M Isabel Leite
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kimiaki Utsugisawa
- Department of Neurology, Hanamaki General Hospital, Hanamaki, Iwate, Japan
| | | | | | - Hiroyuki Murai
- Department of Neurology, International University of Health and Welfare, Narita, Chiba, Japan
| | - Heinz Wiendl
- Department of Neurology, Institute of Translational Neurology, University of Münster, Münster, Germany
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Nowak RJ, Muppidi S, Beydoun SR, O'Brien FL, Yountz M, Howard JF. Concomitant Immunosuppressive Therapy Use in Eculizumab-Treated Adults With Generalized Myasthenia Gravis During the REGAIN Open-Label Extension Study. Front Neurol 2020; 11:556104. [PMID: 33329303 PMCID: PMC7732596 DOI: 10.3389/fneur.2020.556104] [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: 04/27/2020] [Accepted: 10/06/2020] [Indexed: 12/12/2022] Open
Abstract
Introduction: Chronic, broad-spectrum immunosuppressive therapy (IST) can be associated with side effects in many people with generalized myasthenia gravis (gMG), and treatment guidelines recommend that the IST dose be tapered once patients achieve a stable treatment response. We therefore examined IST use in eculizumab-treated patients with refractory gMG. Methods: The REGAIN open-label extension (OLE) enrolled 117 adults with refractory anti-acetylcholine receptor antibody-positive gMG who had completed the 6-month, randomized, double-blind, placebo-controlled REGAIN study of eculizumab. Eligible patients had received ≥2 ISTs for ≥1 year or ≥1 IST with intravenous immunoglobulin or plasma exchange ≥4 times in 1 year, without symptom control. During REGAIN, changes in concomitant MG therapies were not permitted; during the OLE, they were permitted at the investigators' discretion. Participants received eculizumab 1,200 mg every 2 weeks for up to 4 years; concomitant prednisone and related corticosteroids (PRED), azathioprine (AZA), and mycophenolate mofetil (MMF) use was recorded. Changes in MG Activities of Daily Living and Quantitative MG total scores, MG exacerbations, and adverse events were also recorded. Results: At last OLE assessment, 88.0% (103/117) of participants were using ≥1 IST vs. 98.3% (115/117) at OLE baseline. During the OLE, 76.9% (90/117) of patients experienced a total of 719 IST changes. Almost half of participants [48.7% (57/117)] stopped or decreased ≥1 IST owing to MG symptom improvement, representing 38.9% (280/719) of all changes. In patients who decreased and/or stopped ≥1 IST, mean daily doses of PRED, AZA, and MMF decreased between OLE baseline and last assessment by 60.8% [standard deviation (SD), 28.07; P < 0.0001], 89.1% (SD, 25.77; P < 0.0001), and 56.0% (SD, 32.99; P < 0.0001), respectively. Improved clinical outcomes were observed with eculizumab regardless of IST changes during the OLE, and eculizumab's safety profile was similar in patients who used PRED, AZA, and MMF. Conclusions: Use of ISTs by patients with previously refractory gMG decreased during eculizumab treatment in the REGAIN OLE. Clinical improvements with eculizumab were maintained by patients in all groups, including those who decreased and/or stopped concomitant ISTs. Trial registration:www.clinicaltrials.gov: NCT01997229, NCT02301624.
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Affiliation(s)
- Richard J Nowak
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Srikanth Muppidi
- Department of Neurology and Neurosciences, Stanford University School of Medicine, Stanford, CA, United States
| | - Said R Beydoun
- Department of Neurology, University of Southern California, Los Angeles, CA, United States
| | | | | | - James F Howard
- Department of Neurology, University of North Carolina, Chapel Hill, NC, United States
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