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Michels RE, Peters ML, Schiffers KM, Bouma PA, Hengstman GI, van Munster CE, Zeinstra E, Voer GD, Krol M. A Delphi panel on treatment of high disease activity relapsing remitting multiple sclerosis in the Netherlands. J Comp Eff Res 2020; 10:93-100. [PMID: 33275036 DOI: 10.2217/cer-2020-0140] [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: 11/21/2022] Open
Abstract
Aim: To gain insight into current treatment and barriers to optimal treatment for high disease activity relapsing remitting multiple sclerosis (MS) in the Netherlands. Materials & methods: A two-round Delphi panel using an online questionnaire was conducted. Seven MS neurologists from diverse locations in the Netherlands were invited to participate. Result: Out of the seven MS neurologists, five completed both questionnaire rounds. Conclusion: Effectiveness and side effects along with patient's lesion load were the most important factors for choosing a disease modifying therapy (DMTs). Respondents felt restricted to optimally treat their patients due to reimbursement restrictions for certain disease modifying therapies, although agreed that satisfactory treatment options are currently available. The answers show consensus between the participating MS neurologists with high certainty of answers.
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Affiliation(s)
- Renée E Michels
- Department of Real World & Analytics Solutions, IQVIA, Herikerbergweg 314, 1101 CT, Amsterdam, The Netherlands
| | - Michel L Peters
- Department of Real World & Analytics Solutions, IQVIA, Herikerbergweg 314, 1101 CT, Amsterdam, The Netherlands
| | - Krijn Mh Schiffers
- Merck B.V., an affiliate of Merck KGaA, Darmstadt, Germany, Tupolevlaan 61, 1119 NW, Schiphol-Rijk, The Netherlands
| | - Paul A Bouma
- Department of Neurology, Tergooi Ziekenhuis, van Riebeeckweg 212, 1213 XZ, Hilversum, The Netherlands
| | - Gerald Id Hengstman
- Department of Neurology, Catharina Ziekenhuis, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - Caspar Ep van Munster
- Department of Neurology, Amphia Ziekenhuis, Molengracht 21, 4818 CK, Breda, The Netherlands
| | - Esther Zeinstra
- Department of Neurology, Isala, Hoogeveenseweg 38, 7943 KA, Meppel, The Netherlands
| | - Gert De Voer
- Merck B.V., an affiliate of Merck KGaA, Darmstadt, Germany, Tupolevlaan 61, 1119 NW, Schiphol-Rijk, The Netherlands
| | - Marieke Krol
- Department of Real World & Analytics Solutions, IQVIA, Herikerbergweg 314, 1101 CT, Amsterdam, The Netherlands
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2
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Schulte-Mecklenbeck A, Bhatia U, Schneider-Hohendorf T, Schwab N, Wiendl H, Gross CC. Analysis of Lymphocyte Extravasation Using an In Vitro Model of the Human Blood-brain Barrier. J Vis Exp 2017. [PMID: 28448020 DOI: 10.3791/55390] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Lymphocyte extravasation into the central nervous system (CNS) is critical for immune surveillance. Disease-related alterations of lymphocyte extravasation might result in pathophysiological changes in the CNS. Thus, investigation of lymphocyte migration into the CNS is important to understand inflammatory CNS diseases and to develop new therapy approaches. Here we present an in vitro model of the human blood-brain barrier to study lymphocyte extravasation. Human brain microvascular endothelial cells (HBMEC) are confluently grown on a porous polyethylene terephthalate transwell insert to mimic the endothelium of the blood-brain barrier. Barrier function is validated by zonula occludens immunohistochemistry, transendothelial electrical resistance (TEER) measurements as well as analysis of evans blue permeation. This model allows investigation of the diapedesis of rare lymphocyte subsets such as CD56brightCD16dim/- NK cells. Furthermore, the effects of other cells, cytokines and chemokines, disease-related alterations, and distinct treatment regimens on the migratory capacity of lymphocytes can be studied. Finally, the impact of inflammatory stimuli as well as different treatment regimens on the endothelial barrier can be analyzed.
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Affiliation(s)
| | - Urvashi Bhatia
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster
| | | | - Nicholas Schwab
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster
| | - Catharina C Gross
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster;
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3
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Leist TP, Comi G, Cree BAC, Coyle PK, Freedman MS, Hartung HP, Vermersch P, Casset-Semanaz F, Scaramozza M. Effect of oral cladribine on time to conversion to clinically definite multiple sclerosis in patients with a first demyelinating event (ORACLE MS): a phase 3 randomised trial. Lancet Neurol 2014; 13:257-67. [DOI: 10.1016/s1474-4422(14)70005-5] [Citation(s) in RCA: 143] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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4
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Yang JF, Tao HQ, Liu YM, Zhan XX, Liu Y, Wang XY, Wang JH, Mu LL, Yang LL, Gao ZM, Kong QF, Wang GY, Han JH, Sun B, Li HL. Characterization of the interaction between astrocytes and encephalitogenic lymphocytes during the development of experimental autoimmune encephalitomyelitis (EAE) in mice. Clin Exp Immunol 2013; 170:254-65. [PMID: 23121666 DOI: 10.1111/j.1365-2249.2012.04661.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The nature of pathogenic mechanisms associated with the development of multiple sclerosis (MS) have long been debated. However, limited research was conducted to define the interplay between infiltrating lymphocytes and resident cells of the central nervous system (CNS). Data presented in this report describe a novel role for astrocyte-mediated alterations to myelin oligodendrocyte glycoprotein (MOG)(35-55) -specific lymphocyte responses, elicited during the development of experimental autoimmune encephalitomyelitis (EAE). In-vitro studies demonstrated that astrocytes inhibited the proliferation and interferon (IFN)-γ, interleukin (IL)-4, IL-17 and transforming growth factor (TGF)-β secretion levels of MOG(35-55) -specific lymphocytes, an effect that could be ameliorated by astrocyte IL-27 neutralization. However, when astrocytes were pretreated with IFN-γ, they could promote the proliferation and secretion levels of MOG(35-55) -specific lymphocytes, coinciding with apparent expression of major histocompatibility complex (MHC)-II on astrocytes themselves. Quantitative polymerase chain reaction (qPCR) demonstrated that production of IL-27 in the spinal cord was at its highest during the initial phases. Conversely, production of IFN-γ in the spinal cord was highest during the peak phase. Quantitative analysis of MHC-II expression in the spinal cord showed that there was a positive correlation between MHC-II expression and IFN-γ production. In addition, astrocyte MHC-II expression levels correlated positively with IFN-γ production in the spinal cord. These findings suggested that astrocytes might function as both inhibitors and promoters of EAE. Astrocytes prevented MOG(35-55) -specific lymphocyte function by secreting IL-27 during the initial phases of EAE. Then, in the presence of higher IFN-γ levels in the spinal cord, astrocytes were converted into antigen-presenting cells. This conversion might promote the progression of pathological damage and result in a peak of EAE severity.
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Affiliation(s)
- J F Yang
- Department of Neurobiology, Harbin Medical University Provincial Key Lab of Neurobiology, Harbin Medical University, Harbin, China
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5
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Pharmacogenomic update on multiple sclerosis: a focus on actual and new therapeutic strategies. THE PHARMACOGENOMICS JOURNAL 2012; 12:453-61. [PMID: 23044601 DOI: 10.1038/tpj.2012.41] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Multiple sclerosis (MS) is an inflammatory and demyelinating disease of central nervous system comprising several subtypes. Pharmacological treatment involves only few drugs. Among these, interferon beta (IFN-β) and glatiramer acetate were the most used. Although evidence supports the efficacy of these agents in treating MS symptoms, actual studies allowed to introduce new innovative drugs in clinical practice. Applying pharmacogenetic approach to MS, IFN-β and several other immune pathways were abundantly investigated. Numerous reports identified some promising therapy markers but only few markers have emerged as clinically useful. This may be partially due to differences in clinical and methodological criteria in the studies. Indeed, responder and non-responder definitions lack standardized clinical definition. The goal of this review is to treat advances in research on the pharmacogenetic markers of MS drugs and to highlight possible correlations between type of responses and genetic profile, with regard to clinical and methodological discrepancies in the studies.
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6
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Awad AM, Stüve O. Immunopathogenesis of multiple sclerosis: new insights and therapeutic implications. Continuum (Minneap Minn) 2012; 16:166-80. [PMID: 22810604 DOI: 10.1212/01.con.0000389940.92283.aa] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Multiple sclerosis (MS) is an inflammatory, demyelinating, and neurodegenerative disorder of the CNS. The etiology of MS remains unknown. However, it is well established that immune dysregulation plays a critical role in the neuropathogenesis of this disorder. In this review, we discuss the current hypotheses concerning the complex cellular and molecular interactions involved in the immunopathogenesis of MS. Although CD4 T lymphocytes have long been considered the critical cellular factor in the immunopathology of MS, the role of other cell types has also recently been investigated. It appears that the spatial distribution of CD4 and CD8 cells in MS lesions is distinct. Yet another T-lymphocyte subset, γ/δ T cells, can be detected in very early MS lesions. The prevalent dogma suggests that CD4 helper T (TH) type 1 cells release cytokines and inflammatory mediators that cause tissue damage, while CD4 TH2 cells might be involved in modulation of these effects. However, a mounting body of evidence suggests that additional T-cell subsets, including TH17 cells, CD8 effector T cells, and CD4 CD25 regulatory T cells, also affect disease activity. In addition, clinical and paraclinical data are accumulating on the prominent role of B lymphocytes and other antigen-presenting cells in MS neuropathogenesis. Given these observations, new therapeutic interventions for MS will need to focus on resetting multiple components of the immune system.
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7
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The TASK1 channel inhibitor A293 shows efficacy in a mouse model of multiple sclerosis. Exp Neurol 2012; 238:149-55. [PMID: 22960185 DOI: 10.1016/j.expneurol.2012.08.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Revised: 08/14/2012] [Accepted: 08/21/2012] [Indexed: 01/26/2023]
Abstract
The two-pore domain potassium channel TASK1 (KCNK3) has recently emerged as an important modulator in autoimmune CNS inflammation. Previously, it was shown that T lymphocytes obtained from TASK1(-/-) mice display impaired T cell effector functions and that TASK1(-/-) mice show a significantly reduced disease severity in myelin oligodendrocyte glycoprotein (MOG(35-55)) peptide induced experimental autoimmune encephalomyelitis (EAE), an animal model of multiple sclerosis. We here evaluate a potent and specific TASK1 channel inhibitor, A293, which caused a dose-dependent reduction of T cell effector functions (cytokine production and proliferation). This effect was abolished in CD4(+) T cells from TASK1(-/-) mice but not in cells from TASK3(-/-) mice. In electrophysiological measurements, A293 application induced a significant reduction of the outward current of wildtype T lymphocytes, while there was no effect in TASK1(-/-) cells. Preventive and therapeutic application of A293 significantly ameliorated the EAE disease course in wildtype mice while it had no significant effect in TASK1(-/-) mice and was still partly effective in TASK3(-/-) mice. In summary, our findings support the concept of TASK1 as an attractive drug target for autoimmune disorders.
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8
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Summerday NM, Brown SJ, Allington DR, Rivey MP. Vitamin D and multiple sclerosis: review of a possible association. J Pharm Pract 2012; 25:75-84. [PMID: 21987526 DOI: 10.1177/0897190011421839] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There has been growing interest in determining environmental risk factors that may play a role in the development or progression of multiple sclerosis (MS). Epidemiological evidence and data from human and animal studies have shown an association between low serum vitamin D levels and an increased incidence of MS and that supplementation with vitamin D may protect against MS development and/or disease relapses. The most appropriate vitamin D dosage for patients with MS is unclear, but investigator shave proposed that serum vitamin D concentrations between 75 and 100 nmol/L (30-40 ng/mL) are optimal to achieve favor able clinical outcomes. Vitamin D supplemented in doses up to 3000 International Units (IU) daily may be necessary to achieve these levels in many patients, and doses of 500 to 800 IU daily appear to be necessary to maintain desired serum vitamin D levels.Short-term supplementation with doses up to 40 000 IU daily has been found to be safe. However, larger and longer clinical studies are needed to assess whether a true relationship exists between serum vitamin D concentrations and MS and to determine a safe and effective amount of vitamin D supplementation.
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Hayes KC. Impact of extended-release dalfampridine on walking ability in patients with multiple sclerosis. Neuropsychiatr Dis Treat 2011; 7:229-39. [PMID: 21573085 PMCID: PMC3090287 DOI: 10.2147/ndt.s10469] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Indexed: 11/23/2022] Open
Abstract
Dalfampridine extended release (ER) 10 mg is an oral tablet form of the potassium (K(+)) channel-blocking compounded dalfampridine, also known as fampridine, and chemically 4-aminopyridine or 4-AP, which received regulatory approval in the United States for the treatment of walking in patients with multiple sclerosis (MS) in January 2010. Two pivotal Phase 3 clinical trials demonstrated significant improvements in walking in patients with the four primary forms of MS following administration of dalfampridine ER tablets 10 mg twice daily. The drug is thought to act by restoring conduction in focally demyelinated axons and by enhancing neurotransmission, thereby leading to improved neurological function. This review describes how dalfampridine represents a new pharmacotherapeutic approach to the clinical management of mobility impairment. It describes the mechanism of action and chemistry of dalfampridine ER, its pharmacokinetics, tolerability, and side effects, and the outcomes of multicenter trials showing its efficacy in improving walking speed. Clinician and patient global assessments, as well as patient self-assessment of the impact of MS on their gait disability, confirm clinically relevant benefit from the therapy. Patients tolerate the drug well and their improvement in terms of household and community ambulation, inferred from analysis of pooled data from several studies, is likely to translate into benefits in the performance of instrumental activities of daily living and a reduction in the neuropsychiatric burden of disease.
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Affiliation(s)
- Keith C Hayes
- Department of Physical Medicine and Rehabilitation, The University of Western Ontario, London, ON, Canada
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10
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Ion channels in autoimmune neurodegeneration. FEBS Lett 2011; 585:3836-42. [DOI: 10.1016/j.febslet.2011.03.065] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Revised: 03/26/2011] [Accepted: 03/28/2011] [Indexed: 11/23/2022]
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11
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Giovannoni G, Cook S, Rammohan K, Rieckmann P, Sørensen PS, Vermersch P, Hamlett A, Viglietta V, Greenberg S. Sustained disease-activity-free status in patients with relapsing-remitting multiple sclerosis treated with cladribine tablets in the CLARITY study: a post-hoc and subgroup analysis. Lancet Neurol 2011; 10:329-37. [DOI: 10.1016/s1474-4422(11)70023-0] [Citation(s) in RCA: 148] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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12
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Meuth SG, Bittner S, Ulzheimer JC, Kleinschnitz C, Kieseier BC, Wiendl H. Therapeutic approaches to multiple sclerosis: an update on failed, interrupted, or inconclusive trials of neuroprotective and alternative treatment strategies. BioDrugs 2010; 24:317-30. [PMID: 20795753 DOI: 10.2165/11537190-000000000-00000] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Currently approved multiple sclerosis (MS) therapeutics have a mainly anti-inflammatory mode of action. However, a number of promising clinical trials have been initiated that either focus on neuroprotection or follow completely different treatment strategies. So far, all of these clinical trials have failed to show efficacy or had to be halted prematurely because of unexpected adverse events. Some others show results that are of unknown significance with regard to a reliable assessment of true efficacy versus safety. For example, trials addressing the highly promising sodium channel blockers are under close observation because of potential adverse effects after drug withdrawal. Previously failed therapeutic approaches in MS have indicated that there are discrepancies between the theoretical expectations and practical outcomes of different compounds. Learning from these failures helps to optimize future study designs and to reduce risks to patients. This review summarizes trials on MS treatments since 2001 that failed or were interrupted, attempts to analyze the underlying reasons for failure, and discusses the implications for our current view of MS pathogenesis, clinical practice, and the design of future studies. In order to maintain clarity, this review focuses on neuroprotective and various other treatment strategies. Clinical trials addressing anti-inflammatory research strategies are presented elsewhere.
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Affiliation(s)
- Sven G Meuth
- Department of Neurology, University of Wuerzburg, Wuerzburg, Germany
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Barten LJ, Allington DR, Procacci KA, Rivey MP. New approaches in the management of multiple sclerosis. DRUG DESIGN DEVELOPMENT AND THERAPY 2010; 4:343-66. [PMID: 21151622 PMCID: PMC2998807 DOI: 10.2147/dddt.s9331] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Multiple sclerosis (MS) is a central nervous system chronic inflammatory disease that is characterized by an extensive and complex immune response. Scientific advances have occurred in immunology, pathophysiology, and diagnostic and clinical assessment tools, and recent discovery of unique therapeutic targets has spurred numerous Phase II and Phase III clinical trials. Reductions in MS relapse rates and improvements in T2 or gadolinium-enhancing lesion burdens have been reported from Phase III trials that include fingolimod, alemtuzumab, cladribine, and rituximab. Promising Phase II trial data exist for teriflunomide, daclizumab, laquinimod, and fumarate. The optimism created by these favorable findings must be tempered with evaluation of the adverse effect profile produced by these new agents. Given the discovery of progressive multifocal leukoencephalopathy with the use of natalizumab, ongoing vigilance for rare and life-threatening reactions due to new agents should be paramount. Patients with MS often experience difficulty with ambulation, spasticity, and cognition. Recent clinical trial data from two Phase III dalfampridine-SR trials indicate certain patients receive benefits in ambulation. This article provides an overview of data from clinical trials of newer agents of potential benefit in MS.
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Affiliation(s)
- Laurie J Barten
- The University of Montana and Community Medical Center, Missoula, MT, USA
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14
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Bittner S, Budde T, Wiendl H, Meuth SG. From the background to the spotlight: TASK channels in pathological conditions. Brain Pathol 2010; 20:999-1009. [PMID: 20529081 PMCID: PMC8094868 DOI: 10.1111/j.1750-3639.2010.00407.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Accepted: 04/13/2010] [Indexed: 01/10/2023] Open
Abstract
TWIK-related acid-sensitive potassium channels (TASK1-3) belong to the family of two-pore domain (K(2P) ) potassium channels. Emerging knowledge about an involvement of TASK channels in cancer development, inflammation, ischemia and epilepsy puts the spotlight on a leading role of TASK channels under these conditions. TASK3 has been especially linked to cancer development. The pro-oncogenic potential of TASK3 could be shown in cell lines and in various tumor entities. Pathophysiological hallmarks in solid tumors (e.g. low pH and oxygen deprivation) regulate TASK3 channels. These conditions can also be found in (autoimmune) inflammation. Inhibition of TASK1,2,3 leads to a reduction of T cell effector function. It could be demonstrated that TASK1(-/-) mice are protected from experimental autoimmune inflammation while the same animals display increased infarct volumes after cerebral ischemia. Furthermore, TASK channels have both an anti-epileptic as well as a pro-epileptic potential. The relative contribution of these opposing influences depends on their cell type-specific expression and the conditions of the cellular environment. This indicates that TASK channels are per se neither protective nor detrimental but their functional impact depends on the "pathophysiological" scenario. Based on these findings TASK channels have evolved from "mere background" channels to key modulators in pathophysiological conditions.
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Affiliation(s)
- Stefan Bittner
- Department of Neurology, University of Wuerzburg, Wuerzburg, Germany
| | - Thomas Budde
- Institute of Physiology I, Westfaelische Wilhelms‐University Muenster, Muenster, Germany
| | - Heinz Wiendl
- Department of Neurology—Inflammatory disorders of the nervous system and neurooncology, University of Muenster, Muenster, Germany
| | - Sven G. Meuth
- Department of Neurology, University of Wuerzburg, Wuerzburg, Germany
- Department of Neurology—Inflammatory disorders of the nervous system and neurooncology, University of Muenster, Muenster, Germany
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Interferon-beta treatment normalises the inhibitory effect of serum from multiple sclerosis patients on oligodendrocyte progenitor proliferation. Neurosci Lett 2010; 485:107-11. [DOI: 10.1016/j.neulet.2010.08.075] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2010] [Revised: 08/25/2010] [Accepted: 08/25/2010] [Indexed: 11/21/2022]
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Ulzheimer JC, Meuth SG, Bittner S, Kleinschnitz C, Kieseier BC, Wiendl H. Therapeutic approaches to multiple sclerosis: an update on failed, interrupted, or inconclusive trials of immunomodulatory treatment strategies. BioDrugs 2010; 24:249-74. [PMID: 20623991 DOI: 10.2165/11537160-000000000-00000] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Multiple sclerosis (MS) continues to be a therapeutic challenge, and much effort is being made to develop new and more effective immune therapies. Particularly in the past decade, neuroimmunologic research has delivered new and highly effective therapeutic options, as seen in the growing number of immunotherapeutic agents and biologics in development. However, numerous promising clinical trials have failed to show efficacy or have had to be halted prematurely because of unexpected adverse events. Some others have shown results that are of unknown significance with regard to a reliable assessment of true efficacy versus safety. For example, studies of the highly innovative monoclonal antibodies that selectively target immunologic effector molecules have not only revealed the impressive efficacy of such treatments, they have also raised serious concerns about the safety profiles of these antibodies. These results add a new dimension to the estimation of risk-benefit ratios regarding acute or long-term adverse effects. Therapeutic approaches that have previously failed in MS have indicated that there are discrepancies between theoretical expectations and practical outcomes of different compounds. Learning from these defeats helps to optimize future study designs and to reduce the risks to patients. This review summarizes trials on MS treatments since 2001 that failed or were interrupted, attempts to analyze the underlying reasons for failure, and discusses the implications for our current view of MS pathogenesis, clinical practice, and design of future studies. In order to maintain clarity, this review focuses on anti-inflammatory therapies and does not include studies on already approved and effective disease-modifying therapies, albeit used in distinct administration routes or under different paradigms. Neuroprotective and alternative treatment strategies are presented elsewhere.
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Giovannoni G, Comi G, Cook S, Rammohan K, Rieckmann P, Soelberg Sørensen P, Vermersch P, Chang P, Hamlett A, Musch B, Greenberg SJ. A placebo-controlled trial of oral cladribine for relapsing multiple sclerosis. N Engl J Med 2010; 362:416-26. [PMID: 20089960 DOI: 10.1056/nejmoa0902533] [Citation(s) in RCA: 646] [Impact Index Per Article: 46.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cladribine provides immunomodulation through selective targeting of lymphocyte subtypes. We report the results of a 96-week phase 3 trial of a short-course oral tablet therapy in patients with relapsing-remitting multiple sclerosis. METHODS We randomly assigned 1326 patients in an approximate 1:1:1 ratio to receive one of two cumulative doses of cladribine tablets (either 3.5 mg or 5.25 mg per kilogram of body weight) or matching placebo, given in two or four short courses for the first 48 weeks, then in two short courses starting at week 48 and week 52 (for a total of 8 to 20 days per year). The primary end point was the rate of relapse at 96 weeks. RESULTS Among patients who received cladribine tablets (either 3.5 mg or 5.25 mg per kilogram), there was a significantly lower annualized rate of relapse than in the placebo group (0.14 and 0.15, respectively, vs. 0.33; P<0.001 for both comparisons), a higher relapse-free rate (79.7% and 78.9%, respectively, vs. 60.9%; P<0.001 for both comparisons), a lower risk of 3-month sustained progression of disability (hazard ratio for the 3.5-mg group, 0.67; 95% confidence interval [CI], 0.48 to 0.93; P=0.02; and hazard ratio for the 5.25-mg group, 0.69; 95% CI, 0.49 to 0.96; P=0.03), and significant reductions in the brain lesion count on magnetic resonance imaging (MRI) (P<0.001 for all comparisons). Adverse events that were more frequent in the cladribine groups included lymphocytopenia (21.6% in the 3.5-mg group and 31.5% in the 5.25-mg group, vs. 1.8%) and herpes zoster (8 patients and 12 patients, respectively, vs. no patients). CONCLUSIONS Treatment with cladribine tablets significantly reduced relapse rates, the risk of disability progression, and MRI measures of disease activity at 96 weeks. The benefits need to be weighed against the risks. (ClinicalTrials.gov number, NCT00213135.)
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Affiliation(s)
- Gavin Giovannoni
- Queen Mary University London, the Blizard Institute of Cell and Molecular Science, Barts and the London School of Medicine and Dentistry, London, United Kingdom.
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Update on inflammation, neurodegeneration, and immunoregulation in multiple sclerosis: therapeutic implications. Clin Neuropharmacol 2009; 32:121-32. [PMID: 19483479 DOI: 10.1097/wnf.0b013e3181880359] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Multiple sclerosis (MS) is an inflammatory, demyelinating, and neurodegenerative disease of the central nervous system of uncertain etiology. There is consensus that a dysregulated immune system plays a critical role in the pathogenesis of MS; therefore, we aim to summarize current hypotheses concerning the complex cellular and molecular interactions involved in the immunopathology of MS. Although CD4+ T lymphocytes have long been implicated in the immunopathology of MS, the role of other T-cell subtypes has been recognized. CD4+ and CD8+ cells have been isolated from different locations within MS lesions and gamma/delta T cells have been isolated from early MS lesions. The prevalent dogma has been that CD4+ TH1 cells release cytokines and mediators of inflammation that may cause tissue damage, although CD4+ TH2 cells may be involved in modulation of these effects. Recent evidence, however, suggests that additional T-cell subsets play a prominent role in MS immunopathology: TH17 cells, CD8+ effector T cells, and CD4+CD25+ regulatory T cells. In addition, laboratory and clinical data are accumulating on the prominent role of B lymphocytes and antigen-presenting cells in MS pathogenesis. On the basis of these observations, new therapeutic approaches for MS will need to focus on resetting multiple components of the immune system.
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Bittner S, Meuth SG, Göbel K, Melzer N, Herrmann AM, Simon OJ, Weishaupt A, Budde T, Bayliss DA, Bendszus M, Wiendl H. TASK1 modulates inflammation and neurodegeneration in autoimmune inflammation of the central nervous system. ACTA ACUST UNITED AC 2009; 132:2501-16. [PMID: 19570851 DOI: 10.1093/brain/awp163] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
We provide evidence that TWIK-related acid-sensitive potassium channel 1 (TASK1), a member of the family of two-pore domain potassium channels relevant for setting the resting membrane potential and balancing neuronal excitability that is expressed on T cells and neurons, is a key modulator of T cell immunity and neurodegeneration in autoimmune central nervous system inflammation. After induction of experimental autoimmune encephalomyelitis, an experimental model mimicking multiple sclerosis, TASK1(-/-) mice showed a significantly reduced clinical severity and markedly reduced axonal degeneration compared with wild-type controls. T cells from TASK1(-/-) mice displayed impaired T cell proliferation and cytokine production, while the immune repertoire is otherwise normal. In addition to these effects on systemic T cell responses, TASK1 exhibits an independent neuroprotective effect which was demonstrated using both a model of acutely prepared brain slices cocultured with activated T cells as well as in vitro cultivation experiments with isolated optic nerves. Anandamide, an endogenous cannabinoid and inhibitor of TASK channels, reduced outward currents and inhibited effector functions of T cells (IFN-gamma production and proliferation); an effect completely abrogated in TASK1(-/-) mice. Accordingly, preventive blockade of TASK1 significantly ameliorated experimental autoimmune encephalomyelitis after immunization. Therapeutic application of anandamide significantly reduced disease severity and was capable of lowering progressive loss of brain parenchymal volume as assessed by magnetic resonance imaging. These data support the identification and characterization of TASK1 as potential molecular target for the therapy of inflammatory and degenerative central nervous system disorders.
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Affiliation(s)
- Stefan Bittner
- University of Wuerzburg, Department of Neurology, Josef-Schneider-Str. 11, 97080 Wuerzburg, Germany
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Abstract
Immunotherapy for multiple sclerosis (MS) has developed extremely successfully during the past decade and a number of new strategies were developed for the treatment of the disease. Examples include therapeutic strategies targeting leukocyte differentiation molecules, costimulatory molecules, anti-adhesion molecules, chemotaxis, novel immunomodulators, autologous stem cell transplantation, anti-infectious therapies and strategies for neuroprotection, neurorepair and remyelination. Here we describe examples of monoclonal antibodies, a novel immunosuppressant and interesting neuroprotective strategies.
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Affiliation(s)
- Sven G Meuth
- Universität Würzburg, Klinik und Poliklinik für Neurologie, Josef-Schneider Str. 11, 97080 Würzburg, Germany.
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Stenner MP, Waschbisch A, Buck D, Doerck S, Einsele H, Toyka KV, Wiendl H. Effects of natalizumab treatment on Foxp3+ T regulatory cells. PLoS One 2008; 3:e3319. [PMID: 18836525 PMCID: PMC2553177 DOI: 10.1371/journal.pone.0003319] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2008] [Accepted: 09/09/2008] [Indexed: 01/24/2023] Open
Abstract
Background Natalizumab, a monoclonal humanized antibody targeting the alpha-4 chain of very late activation antigen 4 (VLA-4) exerts impressive therapeutic effects in patients with relapsing-remitting multiple sclerosis. Our objective was to study impacts of Natalizumab therapy on Foxp3+ T regulatory cells (Tregs) in multiple sclerosis (MS) patients. Methodology A combined approach of in vitro and ex vivo experiments using T cells isolated from the peripheral blood of healthy donors and Natalizumab treated MS patients was chosen. We determined binding of Natalizumab and its effects on the frequency, transmigratory behaviour and suppressive function of Tregs. Principal Findings Binding of Natalizumab and expression of CD49d (alpha-4 chain of VLA-4) differed between non-regulatory and regulatory cells. Albeit Foxp3+ Tregs had lower levels of CD49d, Natalizumab blocked the transmigration of Foxp3+ Tregs similar to non-regulatory T cells. The frequency of peripheral blood Tregs was unaffected by Natalizumab treatment. Natalizumab does not alter the suppressive capacity of CD4+CD25highCD127lowFoxp3+ Tregs under in vitro conditions. Furthermore, the impaired function of Tregs in MS patients is not restored by Natalizumab treatment. Conclusions We provide a first detailed analysis of Natalizumab effects on the regulatory T cell population. Our prospective study shows that Foxp3+ Tregs express lower levels of VLA-4 and bind less Natalizumab. We further the understanding of the mechanisms of action of Natalizumab by demonstrating that unlike other immunomodulatory drugs the beneficial therapeutic effects of the monoclonal antibody are largely independent of alterations in Treg frequency or function.
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Affiliation(s)
| | - Anne Waschbisch
- Department of Neurology, Julius-Maximilians University, Wuerzburg, Germany
| | - Dorothea Buck
- Department of Neurology, Julius-Maximilians University, Wuerzburg, Germany
| | - Sebastian Doerck
- Department of Neurology, Julius-Maximilians University, Wuerzburg, Germany
| | - Hermann Einsele
- Department of Internal Medicine II, Julius-Maximilians University, Wuerzburg, Germany
| | - Klaus V. Toyka
- Department of Neurology, Julius-Maximilians University, Wuerzburg, Germany
| | - Heinz Wiendl
- Department of Neurology, Julius-Maximilians University, Wuerzburg, Germany
- * E-mail:
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Melzer N, Meuth SG, Torres-Salazar D, Bittner S, Zozulya AL, Weidenfeller C, Kotsiari A, Stangel M, Fahlke C, Wiendl H. A beta-lactam antibiotic dampens excitotoxic inflammatory CNS damage in a mouse model of multiple sclerosis. PLoS One 2008; 3:e3149. [PMID: 18773080 PMCID: PMC2522272 DOI: 10.1371/journal.pone.0003149] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2008] [Accepted: 08/15/2008] [Indexed: 01/01/2023] Open
Abstract
In multiple sclerosis (MS) and its animal model experimental autoimmune encephalomyelitis (EAE), impairment of glial “Excitatory Amino Acid Transporters” (EAATs) together with an excess glutamate-release by invading immune cells causes excitotoxic damage of the central nervous system (CNS). In order to identify pathways to dampen excitotoxic inflammatory CNS damage, we assessed the effects of a β-lactam antibiotic, ceftriaxone, reported to enhance expression of glial EAAT2, in “Myelin Oligodendrocyte Glycoprotein” (MOG)-induced EAE. Ceftriaxone profoundly ameliorated the clinical course of murine MOG-induced EAE both under preventive and therapeutic regimens. However, ceftriaxone had impact neither on EAAT2 protein expression levels in several brain areas, nor on the radioactive glutamate uptake capacity in a mixed primary glial cell-culture and the glutamate-induced uptake currents in a mammalian cell line mediated by EAAT2. Moreover, the clinical effect of ceftriaxone was preserved in the presence of the EAAT2-specific transport inhibitor, dihydrokainate, while dihydrokainate alone caused an aggravated EAE course. This demonstrates the need for sufficient glial glutamate uptake upon an excitotoxic autoimmune inflammatory challenge of the CNS and a molecular target of ceftriaxone other than the glutamate transporter. Ceftriaxone treatment indirectly hampered T cell proliferation and proinflammatory INFγ and IL17 secretion through modulation of myelin-antigen presentation by antigen-presenting cells (APCs) e.g. dendritic cells (DCs) and reduced T cell migration into the CNS in vivo. Taken together, we demonstrate, that a β-lactam antibiotic attenuates disease course and severity in a model of autoimmune CNS inflammation. The mechanisms are reduction of T cell activation by modulation of cellular antigen-presentation and impairment of antigen-specific T cell migration into the CNS rather than or modulation of central glutamate homeostasis.
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Affiliation(s)
- Nico Melzer
- Department of Neurology, University of Würzburg, Würzburg, Germany
- * E-mail: (NM); (HW)
| | - Sven G. Meuth
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - Delany Torres-Salazar
- Department of Neurophysiology, Medizinische Hochschule Hannover, Hannover, Germany
- Department of Neurobiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Stefan Bittner
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - Alla L. Zozulya
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | | | - Alexandra Kotsiari
- Department of Neurology, Medizinische Hochschule Hannover, Hannover, Germany
| | - Martin Stangel
- Department of Neurology, Medizinische Hochschule Hannover, Hannover, Germany
| | - Christoph Fahlke
- Department of Neurophysiology, Medizinische Hochschule Hannover, Hannover, Germany
| | - Heinz Wiendl
- Department of Neurology, University of Würzburg, Würzburg, Germany
- * E-mail: (NM); (HW)
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Meuth SG, Bittner S, Meuth P, Simon OJ, Budde T, Wiendl H. TWIK-related acid-sensitive K+ channel 1 (TASK1) and TASK3 critically influence T lymphocyte effector functions. J Biol Chem 2008; 283:14559-70. [PMID: 18375952 DOI: 10.1074/jbc.m800637200] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Two major K(+) channels are expressed in T cells, (i) the voltage-dependent K(V)1.3 channel and (ii) the Ca(2+)-activated K(+) channel KCa 3.1 (IKCa channel). Both critically influence T cell effector functions in vitro and animal models in vivo. Here we identify and characterize TWIK-related acid-sensitive potassium channel 1 (TASK1) and TASK3 as an important third K(+) conductance on T lymphocytes. T lymphocytes constitutively express TASK1 and -3 protein. Application of semi-selective TASK blockers resulted in a significant reduction of cytokine production and cell proliferation. Interference with TASK channels on CD3(+) T cells revealed a dose-dependent reduction ( approximately 40%) of an outward current in patch clamp recordings indicative of TASK channels, a finding confirmed by computational modeling. In vivo relevance of our findings was addressed in an experimental model of multiple sclerosis, adoptive transfer experimental autoimmune encephalomyelitis. Pretreatment of myelin basic protein-specific encephalitogenic T lymphocytes with TASK modulators was associated with significant amelioration of the disease course in Lewis rats. These data introduce K(2)P channels as novel potassium conductance on T lymphocytes critically influencing T cell effector function and identify a possible molecular target for immunomodulation in T cell-mediated autoimmune disorders.
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Affiliation(s)
- Sven G Meuth
- Department of Neurology, University of Wuerzburg, Wuerzburg, Germany.
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Multiple sclerosis therapy: An update on recently finished trials. J Neurol 2007; 254:1473-90. [DOI: 10.1007/s00415-007-0684-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2007] [Revised: 06/14/2007] [Accepted: 06/19/2007] [Indexed: 10/22/2022]
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Brambrink AM, Kirsch JR. Perioperative care of patients with neuromuscular disease and dysfunction. Anesthesiol Clin 2007; 25:483-509, viii-ix. [PMID: 17884705 DOI: 10.1016/j.anclin.2007.05.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
A variety of different pathologies result in disease phenotypes that are summarized as neuromuscular diseases because they share commonalty in their clinical consequences for the patient: a progressive weakening of the skeletal muscles. Distinct caution and appropriate changes to the anesthetic plan are advised when care is provided during the perioperative period. The choice of anesthetic technique, anesthetic drugs, and neuromuscular blockade always depends on the type of neuromuscular disease and the surgical procedure planned. A clear diagnosis of the underlying disease and sufficient knowledge and understanding of the pathophysiology are of paramount importance to the practitioner and guide optimal perioperative management of affected patients.
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Affiliation(s)
- Ansgar M Brambrink
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Sciences University, 3181 Sam Jackson Park Road, Portland, OR 97239-3098, USA.
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Kieseier BC, Wiendl H, Hemmer B, Hartung HP. Treatment and treatment trials in multiple sclerosis. Curr Opin Neurol 2007; 20:286-93. [PMID: 17495622 DOI: 10.1097/wco.0b013e3281568b80] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW This review focuses on advances in current and novel treatment approaches in multiple sclerosis. RECENT FINDINGS New therapeutic approaches in multiple sclerosis are emerging. Orally available treatment strategies are more acceptable for patients and may improve adherence to therapy. An oral formulation of glatiramer acetate failed to demonstrate efficacy in a clinical trial, but other promising compounds are on the horizon, such as FTY720. Advances are currently being made in use of therapeutic monoclonal antibodies that specifically target key molecules involved in the immunopathogenesis of multiple sclerosis. Natalizumab directed against the adhesion molecule very late antigen-4 represents the first specific antibody to be added to our therapeutic armamentarium for multiple sclerosis. Further evidence that immunomodulation should be initiated as early as possible has been reported. SUMMARY Treatment of multiple sclerosis has changed dramatically over the past decade. Enhanced understanding of the immunopathological processes that underlie the disease, advances in biotechnology and development of powerful magnetic resonance imaging technologies, together with improvements in clinical trial design have led to a variety of valuable therapeutic approaches, which are currently being studied in detail.
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Affiliation(s)
- Bernd C Kieseier
- Department of Neurology, Heinrich-Heine-University, Duesseldorf, Germany
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Abstract
This review summarizes the current knowledge on the significance of human leukocyte antigen G (HLA-G) in the nervous system under physiologic and pathologic conditions. The central nervous system (CNS) has classically been viewed as an immune-privileged organ. Immune reactions triggered by, or directed against, CNS structures proceed along specific pathways. The expression and the functioning of the immune-tolerogenic major histocompatibility complex (MHC) molecule HLA-G have revealed novel insights into the endogenous immune-regulatory mechanisms exerted by resident cells within the nervous system, as well as how migrating immune cells contribute to this under pathologic conditions. HLA-G has been evidenced in certain neurologic disorders, including those of autoimmune, infectious, and neoplastic origin. This review compiles the current state of knowledge: how HLA-G is considered to be operative at different levels of the respective pathogenetic cascades of neurologic disorders. These findings are relevant both from a pathogenetic as well as from a therapeutic viewpoint.
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Affiliation(s)
- Heinz Wiendl
- Department of Neurology, Bayerische Julius-Maximilians-Universität Würzburg, Würzburg, Germany.
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