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Lilleker JB, Naddaf E, Saris CGJ, Schmidt J, de Visser M, Weihl CC. 272nd ENMC international workshop: 10 Years of progress - revision of the ENMC 2013 diagnostic criteria for inclusion body myositis and clinical trial readiness. 16-18 June 2023, Hoofddorp, The Netherlands. Neuromuscul Disord 2024; 37:36-51. [PMID: 38522330 DOI: 10.1016/j.nmd.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 02/29/2024] [Accepted: 03/04/2024] [Indexed: 03/26/2024]
Abstract
Since the publication of the 2013 European Neuromuscular Center (ENMC) diagnostic criteria for Inclusion Body Myositis (IBM), several advances have been made regarding IBM epidemiology, pathogenesis, diagnostic tools, and clinical trial readiness. Novel diagnostic tools include muscle imaging techniques such as MRI and ultrasound, and serological testing for cytosolic 5'-nucleotidase-1A antibodies. The 272nd ENMC workshop aimed to develop new diagnostic criteria, discuss clinical outcome measures and clinical trial readiness. The workshop started with patient representatives highlighting several understudied symptoms and the urge for a timely diagnosis. This was followed by presentations from IBM experts highlighting the new developments in the field. This report is composed of two parts, the first part providing new diagnostic criteria on which consensus was achieved. The second part focuses on the use of outcome measures in clinical practice and clinical trials, highlighting current limitations and outlining the goals for future studies.
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Affiliation(s)
- James B Lilleker
- Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, UK; Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester, UK
| | - Elie Naddaf
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Christiaan G J Saris
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jens Schmidt
- Department of Neurology and Pain Treatment, Neuromuscular Center and Center for Translational Medicine, Immanuel Klinik Rüdersdorf, University Hospital of the Brandenburg Medical School MHB, Rüdersdorf bei Berlin, Germany; Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany; Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Marianne de Visser
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Conrad C Weihl
- Neuromuscular Division, Washington University School of Medicine, Saint Louis, MO, USA.
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Guglielmi V, Cheli M, Tonin P, Vattemi G. Sporadic Inclusion Body Myositis at the Crossroads between Muscle Degeneration, Inflammation, and Aging. Int J Mol Sci 2024; 25:2742. [PMID: 38473988 DOI: 10.3390/ijms25052742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/19/2024] [Accepted: 02/22/2024] [Indexed: 03/14/2024] Open
Abstract
Sporadic inclusion body myositis (sIBM) is the most common muscle disease of older people and is clinically characterized by slowly progressive asymmetrical muscle weakness, predominantly affecting the quadriceps, deep finger flexors, and foot extensors. At present, there are no enduring treatments for this relentless disease that eventually leads to severe disability and wheelchair dependency. Although sIBM is considered a rare muscle disorder, its prevalence is certainly higher as the disease is often undiagnosed or misdiagnosed. The histopathological phenotype of sIBM muscle biopsy includes muscle fiber degeneration and endomysial lymphocytic infiltrates that mainly consist of cytotoxic CD8+ T cells surrounding nonnecrotic muscle fibers expressing MHCI. Muscle fiber degeneration is characterized by vacuolization and the accumulation of congophilic misfolded multi-protein aggregates, mainly in their non-vacuolated cytoplasm. Many players have been identified in sIBM pathogenesis, including environmental factors, autoimmunity, abnormalities of protein transcription and processing, the accumulation of several toxic proteins, the impairment of autophagy and the ubiquitin-proteasome system, oxidative and nitrative stress, endoplasmic reticulum stress, myonuclear degeneration, and mitochondrial dysfunction. Aging has also been proposed as a contributor to the disease. However, the interplay between these processes and the primary event that leads to the coexistence of autoimmune and degenerative changes is still under debate. Here, we outline our current understanding of disease pathogenesis, focusing on degenerative mechanisms, and discuss the possible involvement of aging.
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Affiliation(s)
- Valeria Guglielmi
- Cellular and Molecular Biology of Cancer Program, NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037, USA
- Immunity and Pathogenesis Program, Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037, USA
| | - Marta Cheli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy
| | - Paola Tonin
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy
| | - Gaetano Vattemi
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy
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Abstract
PURPOSE OF REVIEW This review provides an overview of the management and treatment landscape of inclusion body myositis (IBM), while highlighting the current challenges and future directions. RECENT FINDINGS IBM is a slowly progressive myopathy that predominantly affects patients over the age of 40, leading to increased morbidity and mortality. Unfortunately, a definitive cure for IBM remains elusive. Various clinical trials targeting inflammatory and some of the noninflammatory pathways have failed. The search for effective disease-modifying treatments faces numerous hurdles including variability in presentation, diagnostic challenges, poor understanding of pathogenesis, scarcity of disease models, a lack of validated outcome measures, and challenges related to clinical trial design. Close monitoring of swallowing and respiratory function, adapting an exercise routine, and addressing mobility issues are the mainstay of management at this time. SUMMARY Addressing the obstacles encountered by patients with IBM and the medical community presents a multitude of challenges. Effectively surmounting these hurdles requires embracing cutting-edge research strategies aimed at enhancing the management and treatment of IBM, while elevating the quality of life for those affected.
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Tavee J, Brannagan TH, Lenihan MW, Muppidi S, Kellermeyer L, D Donofrio P. Updated consensus statement: Intravenous immunoglobulin in the treatment of neuromuscular disorders report of the AANEM ad hoc committee. Muscle Nerve 2023; 68:356-374. [PMID: 37432872 DOI: 10.1002/mus.27922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 06/05/2023] [Indexed: 07/13/2023]
Abstract
Intravenous immune globulin (IVIG) is an immune-modulating biologic therapy that is increasingly being used in neuromuscular disorders despite the paucity of high-quality evidence for various specific diseases. To address this, the AANEM created the 2009 consensus statement to provide guidance on the use of IVIG in neuromuscular disorders. Since then, there have been several randomized controlled trials for IVIG, a new FDA-approved indication for dermatomyositis and a revised classification system for myositis, prompting the AANEM to convene an ad hoc panel to update the existing guidelines.New recommendations based on an updated systemic review of the literature were categorized as Class I-IV. Based on Class I evidence, IVIG is recommended in the treatment of chronic inflammatory demyelinating polyneuropathy, Guillain-Barré Syndrome (GBS) in adults, multifocal motor neuropathy, dermatomyositis, stiff-person syndrome and myasthenia gravis exacerbations but not stable disease. Based on Class II evidence, IVIG is also recommended for Lambert-Eaton myasthenic syndrome and pediatric GBS. In contrast, based on Class I evidence, IVIG is not recommended for inclusion body myositis, post-polio syndrome, IgM paraproteinemic neuropathy and small fiber neuropathy that is idiopathic or associated with tri-sulfated heparin disaccharide or fibroblast growth factor receptor-3 autoantibodies. Although only Class IV evidence exists for IVIG use in necrotizing autoimmune myopathy, it should be considered for anti-hydroxy-3-methyl-glutaryl-coenzyme A reductase myositis given the risk of long-term disability. Insufficient evidence exists for the use of IVIG in Miller-Fisher syndrome, IgG and IgA paraproteinemic neuropathy, autonomic neuropathy, chronic autoimmune neuropathy, polymyositis, idiopathic brachial plexopathy and diabetic lumbosacral radiculoplexopathy.
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Affiliation(s)
- Jinny Tavee
- National Jewish Health, Division of Neurology, Denver, Colorado, USA
| | - Thomas H Brannagan
- Vagelos College of Physicians and Surgeons, Neurological Institute, Columbia University, New York, New York, USA
| | | | - Sri Muppidi
- Stanford Neuroscience Health Center, Palo Alto, California, USA
| | | | - Peter D Donofrio
- Neurology Clinic, Vanderbilt University, Nashville, Tennessee, USA
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Vogt S, Kleefeld F, Preusse C, Arendt G, Bieneck S, Brunn A, Deckert M, Englert B, Goebel HH, Masuhr A, Neuen-Jacob E, Kornblum C, Reimann J, Montagnese F, Schoser B, Stenzel W, Hahn K. Morphological and molecular comparison of HIV-associated and sporadic inclusion body myositis. J Neurol 2023; 270:4434-4443. [PMID: 37280376 PMCID: PMC10243696 DOI: 10.1007/s00415-023-11779-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 06/08/2023]
Abstract
OBJECTIVE The molecular characteristics of sporadic inclusion body myositis (sIBM) have been intensively studied, and specific patterns on the cellular, protein and RNA level have emerged. However, these characteristics have not been studied in the context of HIV-associated IBM (HIV-IBM). In this study, we compared clinical, histopathological, and transcriptomic patterns of sIBM and HIV-IBM. METHODS In this cross-sectional study, we compared patients with HIV-IBM and sIBM based on clinical and morphological features as well as gene expression levels of specific T-cell markers in skeletal muscle biopsy samples. Non-disease individuals served as controls (NDC). Cell counts for immunohistochemistry and gene expression profiles for quantitative PCR were used as primary outcomes. RESULTS 14 muscle biopsy samples (7 HIV-IBM, 7 sIBM) of patients and 6 biopsy samples from NDC were included. Clinically, HIV-IBM patients showed a significantly lower age of onset and a shorter period between symptom onset and muscle biopsy. Histomorphologically, HIV-IBM patients showed no KLRG1+ or CD57+ cells, while the number of PD1+ cells did not differ significantly between the two groups. All markers were shown to be significantly upregulated at gene expression level with no significant difference between the IBM subgroups. CONCLUSION Despite HIV-IBM and sIBM sharing important clinical, histopathological, and transcriptomic signatures, the presence of KLRG1+ cells discriminated sIBM from HIV-IBM. This may be explained by longer disease duration and subsequent T-cell stimulation in sIBM. Thus, the presence of TEMRA cells is characteristic for sIBM, but not a prerequisite for the development of IBM in HIV+ patients.
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Affiliation(s)
- Sinja Vogt
- Department of Neurology, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117, Berlin, Germany
| | - Felix Kleefeld
- Department of Neurology, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117, Berlin, Germany
- BIH Charité Clinician Scientist Program, BIH Biomedical Innovation Academy, Berlin Institute of Health at Charité, Universitätsmedizin Berlin, 10117, Berlin, Germany
| | - Corinna Preusse
- Department of Neuropathology, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117, Berlin, Germany
| | | | - Stefan Bieneck
- Department of Internal Medicine, Rheumatology, Schlosspark-Klinik, 14059, Berlin, Germany
| | - Anna Brunn
- Faculty of Medicine, Institute of Neuropathology, University Hospital Cologne, 50937, Cologne, Germany
| | - Martina Deckert
- Faculty of Medicine, Institute of Neuropathology, University Hospital Cologne, 50937, Cologne, Germany
| | - Benjamin Englert
- Center for Neuropathology and Prion Research, Ludwig-Maximilians University Munich, 81337, Munich, Germany
| | - Hans-Hilmar Goebel
- Department of Neuropathology, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117, Berlin, Germany
| | - Anja Masuhr
- Department of Internal Medicine, Infectiology, Auguste-Viktoria-Klinikum, 12157, Berlin, Germany
| | - Eva Neuen-Jacob
- Department of Neuropathology, University Hospital Düsseldorf, 40225, Düsseldorf, Germany
| | - Cornelia Kornblum
- Department of Neurology, University Hospital Bonn, 53127, Bonn, Germany
| | - Jens Reimann
- Department of Neurology, University Hospital Bonn, 53127, Bonn, Germany
| | - Federica Montagnese
- Department of Neurology, Friedrich-Baur-Institute, University Hospital Munich, 80336, Munich, Germany
| | - Benedikt Schoser
- Department of Neurology, Friedrich-Baur-Institute, University Hospital Munich, 80336, Munich, Germany
| | - Werner Stenzel
- Department of Neuropathology, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117, Berlin, Germany.
| | - Katrin Hahn
- Department of Neurology, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117, Berlin, Germany.
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Abstract
The autoimmune inflammatory myopathies constitute a heterogeneous group of acquired myopathies that have in common the presence of endomysial inflammation and moderate to severe muscle weakness. Based on currently evolved distinct clinical, histologic, immunopathologic, and autoantibody features, these disorders can be best classified as dermatomyositis, necrotizing autoimmune myositis, antisynthetase syndrome-overlap myositis, and inclusion body myositis. Although polymyositis is no longer considered a distinct subset but rather an extinct entity, it is herein described because its clinicopathologic information has provided over many years fundamental information on T-cell-mediated myocytotoxicity, especially in reference to inclusion body myositis. Each inflammatory myopathy subset has distinct immunopathogenesis, prognosis, and response to immunotherapies, necessitating the need to correctly diagnose each subtype from the outset and avoid disease mimics. The paper describes the main clinical characteristics that aid in the diagnosis of each myositis subtype, highlights the distinct features on muscle morphology and immunopathology, elaborates on the potential role of autoantibodies in pathogenesis or diagnosis , and clarifies common uncertainties in reference to putative triggering factors such as statins and viruses including the 2019-coronavirus-2 pandemic. It extensively describes the main autoimmune markers related to autoinvasive myocytotoxic T-cells, activated B-cells, complement, cytokines, and the possible role of innate immunity. The concomitant myodegenerative features seen in inclusion body myositis along with their interrelationship between inflammation and degeneration are specifically emphasized. Finally, practical guidelines on the best therapeutic approaches are summarized based on up-to-date knowledge and controlled studies, highlighting the prospects of future immunotherapies and ongoing controversies.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, United States; Neuroimmunology Unit National and Kapodistrian University of Athens Medical School, Athens, Greece.
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Naddaf E. Inclusion body myositis: Update on the diagnostic and therapeutic landscape. Front Neurol 2022; 13:1020113. [PMID: 36237625 PMCID: PMC9551222 DOI: 10.3389/fneur.2022.1020113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
Inclusion body myositis (IBM) is a progressive muscle disease affecting patients over the age of 40, with distinctive clinical and histopathological features. The typical clinical phenotype is characterized by prominent involvement of deep finger flexors and quadriceps muscles. Less common presentations include isolated dysphagia, asymptomatic hyper-CKemia, and axial or limb weakness beyond the typical pattern. IBM is associated with marked morbidity as majority of patients eventually become wheelchair dependent with limited use of their hands and marked dysphagia. Furthermore, IBM mildly affects longevity with aspiration pneumonia and respiratory complications being the most common cause of death. On muscle biopsy, IBM is characterized by a peculiar combination of endomysial inflammation, rimmed vacuoles, and protein aggregation. These histopathological features are reflective of the complexity of underlying disease mechanisms. No pharmacological treatment is yet available for IBM. Monitoring for swallowing and respiratory complications, exercise, and addressing mobility issues are the mainstay of management. Further research is needed to better understand disease pathogenesis and identify novel therapeutic targets.
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Abstract
Idiopathic inflammatory myopathies (IIMs) represent a heterogeneous group of systemic autoimmune diseases characterized by immune-mediated muscle injury. As insights into pathogenesis of IIM evolve, novel therapeutic strategies have become available to optimize outcomes. Herein, we summarize novel and emerging strategies in the management of dermatomyositis (DM), immunemediated necrotizing myopathy (IMNM), and inclusion body myositis (IBM).
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Affiliation(s)
- Caoilfhionn M Connolly
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lotta Plomp
- Department of Internal Medicine and Clinical Immunology, Pitié Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Julie J Paik
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Yves Allenbach
- Department of Internal Medicine and Clinical Immunology, Pitié Salpêtrière Hospital, Sorbonne University, Paris, France.
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Abstract
Inflammatory myopathies, including polymyositis (PM), dermatomyositis (DM), inclusion body myositis (IBM), necrotizing myopathy (NM), antisynthetase syndrome (ASS) and overlap myositis (OM), in short myositis, are rare diseases. All forms of myositis have progressive muscle weakness in common, with each subtype characterized by different autoantibody profiles, histological findings and extramuscular manifestations. Due to better understanding of the pathogenesis of the muscle inflammation in myositis, new molecular pathways for targeted therapy have been discovered. Current therapies aim at different components of the innate or the adaptive immune response. Additionally, non-inflammatory mechanisms in myositis have come into focus as possible treatment targets. The use of therapeutical antibodies in myositis has been examined in various clinical studies, several of them randomized controlled ones: Depletion of B-cells by rituximab has been established as treatment of refractory myositis. IVIG, an antibody therapy in the wider sense, has now been licensed for DM following a recent positive clinical trial. Negative study results were reported in randomized trials with infliximab, sifalimumab and bimagrumab. Studies on basiliximab and eculizumab are currently underway, and are expected to yield results in a couple of years. Despite some promising results of clinical studies with antibody therapy in myositis, further research is crucial to optimize the treatment for this debilitating disease and to find treatment alternatives for treatment-refractory patients.
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Affiliation(s)
- Rachel Zeng
- Muscle Immunobiology Group, Neuromuscular Center, Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Stefanie Glaubitz
- Muscle Immunobiology Group, Neuromuscular Center, Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Jens Schmidt
- Muscle Immunobiology Group, Neuromuscular Center, Department of Neurology, University Medical Center Göttingen, Göttingen, Germany.
- Department of Neurology and Pain Treatment, Immanuel Klinik Rüdersdorf, University Hospital of the Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany.
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany.
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Dalakas MC. Treatment and Management of Autoimmune Myopathies. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00022-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Piazzi M, Bavelloni A, Cenni V, Faenza I, Blalock WL. Revisiting the Role of GSK3, A Modulator of Innate Immunity, in Idiopathic Inclusion Body Myositis. Cells 2021; 10:cells10113255. [PMID: 34831477 PMCID: PMC8625526 DOI: 10.3390/cells10113255] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/18/2021] [Accepted: 11/19/2021] [Indexed: 12/13/2022] Open
Abstract
Idiopathic or sporadic inclusion body myositis (IBM) is the leading age-related (onset >50 years of age) autoimmune muscular pathology, resulting in significant debilitation in affected individuals. Once viewed as primarily a degenerative disorder, it is now evident that much like several other neuro-muscular degenerative disorders, IBM has a major autoinflammatory component resulting in chronic inflammation-induced muscle destruction. Thus, IBM is now considered primarily an inflammatory pathology. To date, there is no effective treatment for sporadic inclusion body myositis, and little is understood about the pathology at the molecular level, which would offer the best hopes of at least slowing down the degenerative process. Among the previously examined potential molecular players in IBM is glycogen synthase kinase (GSK)-3, whose role in promoting TAU phosphorylation and inclusion bodies in Alzheimer’s disease is well known. This review looks to re-examine the role of GSK3 in IBM, not strictly as a promoter of TAU and Abeta inclusions, but as a novel player in the innate immune system, discussing some of the recent roles discovered for this well-studied kinase in inflammatory-mediated pathology.
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Affiliation(s)
- Manuela Piazzi
- “Luigi Luca Cavalli-Sforza” Istituto di Genetica Molecolare-Consiglio Nazionale delle Ricerche (IGM-CNR), 40136 Bologna, Italy; (M.P.); (V.C.)
- IRCCS, Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Alberto Bavelloni
- Laboratorio di Oncologia Sperimentale, Istituto Ortopedico Rizzoli, 40136 Bologna, Italy;
| | - Vittoria Cenni
- “Luigi Luca Cavalli-Sforza” Istituto di Genetica Molecolare-Consiglio Nazionale delle Ricerche (IGM-CNR), 40136 Bologna, Italy; (M.P.); (V.C.)
- IRCCS, Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Irene Faenza
- Dipartimento di Scienze Biomediche and Neuromotorie, Università di Bologna, 40136 Bologna, Italy;
| | - William L. Blalock
- “Luigi Luca Cavalli-Sforza” Istituto di Genetica Molecolare-Consiglio Nazionale delle Ricerche (IGM-CNR), 40136 Bologna, Italy; (M.P.); (V.C.)
- IRCCS, Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
- Correspondence:
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Zeng R, Glaubitz S, Schmidt J. Inflammatory myopathies: shedding light on promising agents and combination therapies in clinical trials. Expert Opin Investig Drugs 2021; 30:1125-1140. [PMID: 34779311 DOI: 10.1080/13543784.2021.2003776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Due to new insights into the pathogenesis of inflammatory myopathies - in short myositis - and the urgent need for new treatment options in patients who are refractory to standard therapy, multiple novel drugs have been developed and studied in clinical trials. In light of this exciting development, a critical evaluation of the present data is necessary in order to identify the best pathway to future treatment of inflammatory myopathies. AREAS COVERED This review focuses on the current evidence from clinical trials in myositis and encompasses dermatomyositis, polymyositis, necrotizing myopathy, antisynthetase-syndrome, overlap myositis, and inclusion body myositis. The results of studies on new therapeutic agents are summarized, in particular larger cohort studies and randomized trials from recent years. When such data were not available, earlier and smaller representative studies were included instead. EXPERT OPINION Current studies in most myositis subtypes have shown positive effects of novel biologicals such as abatacept, sifalimumab, JAK-Inhibitors as well as known agents such as rituximab, but further studies are needed to confirm these observations. In inclusion body myositis, the eagerly awaited recent therapeutic trials have missed their primary endpoints, except for the phase 2 study with rapamycin, which has demonstrated significant improvements in secondary endpoints. Future trials will also need to focus on combination therapies of multiple immunomodulatory agents.
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Affiliation(s)
- Rachel Zeng
- Muscle Immunobiology Group, Department of Neurology, Neuromuscular Center, University Medical Center Göttingen, Göttingen, Germany
| | - Stefanie Glaubitz
- Muscle Immunobiology Group, Department of Neurology, Neuromuscular Center, University Medical Center Göttingen, Göttingen, Germany
| | - Jens Schmidt
- Muscle Immunobiology Group, Department of Neurology, Neuromuscular Center, University Medical Center Göttingen, Göttingen, Germany.,Department of Neurology and Pain Treatment, University Hospital of the Medical School Brandenburg, Immanuel Klinik Rüdersdorf, Rüdersdorf bei Berlin, Germany.,Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
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Glaubitz S, Zeng R, Rakocevic G, Schmidt J. Update on Myositis Therapy: from Today's Standards to Tomorrow's Possibilities. Curr Pharm Des 2021; 28:863-880. [PMID: 34781868 DOI: 10.2174/1381612827666211115165353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 10/18/2021] [Indexed: 11/22/2022]
Abstract
Inflammatory myopathies, in short, myositis, are heterogeneous disorders that are characterized by inflammation of skeletal muscle and weakness of arms and legs. Research over the past few years has led to a new understanding regarding the pathogenesis of myositis. The new insights include different pathways of the innate and adaptive immune response during the pathogenesis of myositis. The importance of non-inflammatory mechanisms such as cell stress and impaired autophagy has been recently described. New target-specific drugs for myositis have been developed and are currently being tested in clinical trials. In this review, we discuss the mechanisms of action of pharmacological standards in myositis and provide an outlook of future treatment approaches.
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Affiliation(s)
- Stefanie Glaubitz
- Department of Neurology, Muscle Immunobiology Group, Neuromuscular Center, University Medical Center Göttingen, Göttingen. Germany
| | - Rachel Zeng
- Department of Neurology, Muscle Immunobiology Group, Neuromuscular Center, University Medical Center Göttingen, Göttingen. Germany
| | - Goran Rakocevic
- Department of Neurology, Neuromuscular Division, University of Virginia, Charlottesville. United States
| | - Jens Schmidt
- Department of Neurology, Muscle Immunobiology Group, Neuromuscular Center, University Medical Center Göttingen, Göttingen. Germany
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Lucchini M, Maggi L, Pegoraro E, Filosto M, Rodolico C, Antonini G, Garibaldi M, Valentino ML, Siciliano G, Tasca G, De Arcangelis V, De Fino C, Mirabella M. Anti-cN1A Antibodies Are Associated with More Severe Dysphagia in Sporadic Inclusion Body Myositis. Cells 2021; 10:cells10051146. [PMID: 34068623 PMCID: PMC8151681 DOI: 10.3390/cells10051146] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/03/2021] [Accepted: 05/05/2021] [Indexed: 01/15/2023] Open
Abstract
In recent years, an autoantibody directed against the 5'-citosolic nucleotidase1A (cN1A) was identified in the sera of sporadic inclusion body myositis (s-IBM) patients with widely variable sensitivity (33%-76%) and specificity (87%-100%). We assessed the sensitivity/specificity of anti-cN1A antibodies in an Italian cohort of s-IBM patients, searching for a potential correlation with clinical data. We collected clinical data and sera from 62 consecutive s-IBM patients and 62 other inflammatory myopathies patients. Testing for anti-cN1A antibodies was performed using a commercial ELISA. Anti-cN1A antibodies were detected in 23 s-IBM patients, resulting in a sensitivity of 37.1% with a specificity of 96.8%. Positive and negative predictive values were 92.0% and 60.6%, respectively. We did not find significant difference regarding demographic variables, nor quadriceps or finger flexor weakness. Nevertheless, we found that anti-cN1A-positive patients presented significantly lower scores in IBMFRS item 1 (swallowing, p = 0.045) and more frequently reported more severe swallowing problems, expressed as an IBMFRS item 1 score ≤ 2 (p < 0.001). We confirmed the low sensitivity and high specificity of anti-cN1A Ab in s-IBM patients with a high positive predictive value. The presence of anti-CN1A antibodies identified patients with a greater risk of more severe dysphagia.
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Affiliation(s)
- Matteo Lucchini
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy; (G.T.); (V.D.A.); (C.D.F.); (M.M.)
- Department of Neurosciences, Section of Neurology, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
- Correspondence:
| | - Lorenzo Maggi
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milano, Italy;
| | - Elena Pegoraro
- Department of Neurosciences, University of Padova, 35122 Padova, Italy;
| | - Massimiliano Filosto
- Department of Clinical and Experimental Sciences, University of Brescia, NeMO-Brescia Clinical Center for Neuromuscular Diseases, 25121 Brescia, Italy;
| | - Carmelo Rodolico
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy;
| | - Giovanni Antonini
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), School of Medicine and Psychology, Sant’Andrea Hospital, Sapienza University of Rome, 00189 Rome, Italy; (G.A.); (M.G.)
| | - Matteo Garibaldi
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), School of Medicine and Psychology, Sant’Andrea Hospital, Sapienza University of Rome, 00189 Rome, Italy; (G.A.); (M.G.)
| | - Maria Lucia Valentino
- IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy;
- Department of Biomedical and Neuromotor Sciences, University of Bologna, 40126 Bologna, Italy
| | - Gabriele Siciliano
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy;
| | - Giorgio Tasca
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy; (G.T.); (V.D.A.); (C.D.F.); (M.M.)
- Department of Neurosciences, Section of Neurology, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Valeria De Arcangelis
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy; (G.T.); (V.D.A.); (C.D.F.); (M.M.)
| | - Chiara De Fino
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy; (G.T.); (V.D.A.); (C.D.F.); (M.M.)
| | - Massimiliano Mirabella
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy; (G.T.); (V.D.A.); (C.D.F.); (M.M.)
- Department of Neurosciences, Section of Neurology, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
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15
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Schoser B. [Which treatment attempts should be undertaken for inclusion body myositis?]. Z Rheumatol 2021; 80:362-363. [PMID: 33709167 DOI: 10.1007/s00393-021-00984-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Benedikt Schoser
- Friedrich-Baur-Institut, Neurologische Klinik, LMU Klinikum, Ziemssenstr 1, 80336, München, Deutschland.
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16
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Snedden AM, Lilleker JB, Chinoy H. In Pursuit of an Effective Treatment: the Past, Present and Future of Clinical Trials in Inclusion Body Myositis. Curr Treat Options in Rheum 2021; 7:63-81. [DOI: 10.1007/s40674-020-00169-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Abstract
Purpose of review
No clinical trial in sporadic inclusion body myositis (IBM) thus far has shown a clear and sustained therapeutic effect. We review previous trial methodology, explore why results have not translated into clinical practice, and suggest improvements for future IBM trials.
Recent findings
Early trials primarily assessed immunosuppressive medications, with no significant clinical responses observed. Many of these studies had methodological issues, including small participant numbers, nonspecific diagnostic criteria, short treatment and/or assessment periods and insensitive outcome measures. Most recent IBM trials have instead focused on nonimmunosuppressive therapies, but there is mounting evidence supporting a primary autoimmune aetiology, including the discovery of immunosuppression-resistant clones of cytotoxic T cells and anti-CN-1A autoantibodies which could potentially be used to stratify patients into different cohorts. The latest trials have had mixed results. For example, bimagrumab, a myostatin blocker, did not affect the 6-min timed walk distance, whereas sirolimus, a promotor of autophagy, did. Larger studies are planned to evaluate the efficacy of sirolimus and arimoclomol.
Summary
Thus far, no treatment for IBM has demonstrated a definite therapeutic effect, and effective treatment options in clinical practice are lacking. Trial design and ineffective therapies are likely to have contributed to these failures. Identification of potential therapeutic targets should be followed by future studies using a stratified approach and sensitive and relevant outcome measures.
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17
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Bender TTA, Leyens J, Sellin J, Kravchenko D, Conrad R, Mücke M, Seidel MF. Therapeutic options for patients with rare rheumatic diseases: a systematic review and meta-analysis. Orphanet J Rare Dis 2020; 15:308. [PMID: 33129321 PMCID: PMC7603763 DOI: 10.1186/s13023-020-01576-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 10/06/2020] [Indexed: 01/05/2023] Open
Abstract
Background Rare diseases (RDs) in rheumatology as a group have a high prevalence, but randomized controlled trials are hampered by their heterogeneity and low individual prevalence. To survey the current evidence of pharmacotherapies for rare rheumatic diseases, we conducted a systematic review and meta-analysis. Randomized controlled trials (RCTs) of RDs in rheumatology for different pharmaco-interventions were included into this meta-analysis if there were two or more trials investigating the same RD and using the same assessment tools or outcome parameters. The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PUBMED were searched up to April 2nd 2020. The overall objective of this study was to identify RCTs of RDs in rheumatology, evaluate the overall quality of these studies, outline the evidence of pharmacotherapy, and summarize recommended therapeutic regimens. Results We screened 187 publications, and 50 RCTs met our inclusion criteria. In total, we analyzed data of 13 different RDs. We identified several sources of potential bias, such as a lack of description of blinding methods and allocation concealment, as well as small size of the study population. Meta-analysis was possible for 26 studies covering six RDs: Hunter disease, Behçet’s disease, giant cell arteritis, ANCA-associated vasculitis, reactive arthritis, and systemic sclerosis. The pharmacotherapies tested in these studies consisted of immunosuppressants, such as corticosteroids, methotrexate and azathioprine, or biologicals. We found solid evidence for idursulfase as a treatment for Hunter syndrome. In Behçet’s disease, apremilast and IF-α showed promising results with regard to total and partial remission, and Tocilizumab with regard to relapse-free remission in giant cell arteritis. Rituximab, cyclophosphamide, and azathioprine were equally effective in ANCA-associated vasculitis, while mepolizumab improved the efficacy of glucocorticoids. The combination of rifampicin and azithromycin showed promising results in reactive arthritis, while there was no convincing evidence for the efficacy of pharmacotherapy in systemic sclerosis. Conclusion For some diseases such as systemic sclerosis, ANCA-associated vasculitis, or Behcet's disease, higher quality trials were available. These RCTs showed satisfactory efficacies for immunosuppressants or biological drugs, except for systemic sclerosis. More high quality RCTs are urgently warranted for a wide spectrum of RDs in rheumatology.
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Affiliation(s)
- Tim T A Bender
- Center for Rare Diseases Bonn, University Hospital of Bonn, Bonn, Germany
| | - Judith Leyens
- Children's University Hospital of Bonn, Bonn, Germany
| | - Julia Sellin
- Center for Rare Diseases Bonn, University Hospital of Bonn, Bonn, Germany
| | | | - Rupert Conrad
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Bonn, Bonn, Germany.
| | - Martin Mücke
- Center for Rare Diseases Bonn, University Hospital of Bonn, Bonn, Germany.
| | - Matthias F Seidel
- Department of Rheumatology, Hospital Centre Biel-Bienne, Biel, Switzerland.
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18
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Oldroyd AGS, Lilleker JB, Williams J, Chinoy H, Miller JAL. Long‐term strength and functional status in inclusion body myositis and identification of trajectory subgroups. Muscle Nerve 2020; 62:76-82. [PMID: 32134516 PMCID: PMC8629114 DOI: 10.1002/mus.26859] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 02/26/2020] [Accepted: 03/01/2020] [Indexed: 11/08/2022]
Abstract
Introduction Methods Results Discussion See editorial on pages 7–9 in this issue.
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Affiliation(s)
- Alexander G. S. Oldroyd
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre Manchester United Kingdom
- Centre for Musculoskeletal Research, University of Manchester, Manchester Academic Health Science Centre Manchester United Kingdom
- Centre for Epidemiology Versus Arthritis University of Manchester Manchester United Kingdom
- Department of Rheumatology Salford Royal NHS Foundation Trust Salford United Kingdom
| | - James B. Lilleker
- Centre for Musculoskeletal Research, University of Manchester, Manchester Academic Health Science Centre Manchester United Kingdom
- Manchester Centre for Clinical Neurosciences Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre United Kingdom
| | - Jacob Williams
- Manchester Medical School University of Manchester Manchester United Kingdom
| | - Hector Chinoy
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre Manchester United Kingdom
- Centre for Musculoskeletal Research, University of Manchester, Manchester Academic Health Science Centre Manchester United Kingdom
- Department of Rheumatology Salford Royal NHS Foundation Trust Salford United Kingdom
- Manchester Centre for Clinical Neurosciences Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre United Kingdom
| | - James A. L. Miller
- Department of Neurology Royal Victoria Hospitals, The Newcastle upon Tyne Hospitals NHS Foundation Trust Queen Victoria Road, Newcastle United Kingdom
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19
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Abstract
Inclusion body myositis (IBM) is often viewed as an enigmatic disease with uncertain pathogenic mechanisms and confusion around diagnosis, classification and prospects for treatment. Its clinical features (finger flexor and quadriceps weakness) and pathological features (invasion of myofibres by cytotoxic T cells) are unique among muscle diseases. Although IBM T cell autoimmunity has long been recognized, enormous attention has been focused for decades on several biomarkers of myofibre protein aggregates, which are present in <1% of myofibres in patients with IBM. This focus has given rise, together with the relative treatment refractoriness of IBM, to a competing view that IBM is not an autoimmune disease. Findings from the past decade that implicate autoimmunity in IBM include the identification of a circulating autoantibody (anti-cN1A); the absence of any statistically significant genetic risk factor other than the common autoimmune disease 8.1 MHC haplotype in whole-genome sequencing studies; the presence of a marked cytotoxic T cell signature in gene expression studies; and the identification in muscle and blood of large populations of clonal highly differentiated cytotoxic CD8+ T cells that are resistant to many immunotherapies. Mounting evidence that IBM is an autoimmune T cell-mediated disease provides hope that future therapies directed towards depleting these cells could be effective.
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Affiliation(s)
- Steven A Greenberg
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA. .,Children's Hospital Computational Health Informatics Program, Boston Children's Hospital, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA.
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20
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Patwardhan A. The Value of Intravenous Immunoglobulin Therapy in Idiopathic Inflammatory Myositis in the Current Transformed Era of Biologics. Cureus 2020; 12:e7049. [PMID: 32128294 PMCID: PMC7034746 DOI: 10.7759/cureus.7049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 01/29/2020] [Indexed: 12/26/2022] Open
Abstract
The understanding of etiology and pathogenesis of idiopathic immune myositis is fast evolving, and so is the classification of myositis subtypes. The diversity in genetics, major histocompatibility complex expressions, immunohistochemical, and specific and associated autoantibodies not only explains the individual variability in response to therapies but also begs for subtype-specific treatments. With the evolution of the new biological therapies, the treatment of idiopathic immune myositis (IIM) has greatly transformed in recent years. This article appraises the current therapeutic value of intravenous immunoglobulin (IVIg) in idiopathic immune myopathy patients in the era of transformed treatment options. This article argues why the IVIg therapy still retains its value as an unreplaceable treatment option in certain specific subtypes of idiopathic immune myositis patients as well as in certain specific clinical idiopathic immune myositis scenarios.
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21
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Abstract
The myositis syndromes include polymyositis, dermatomyositis (DM), necrotizing myopathy, inclusion body myositis (IBM), antisynthetase syndrome and overlap syndromes with myositis. These syndromes mostly occur in middle-aged patients, while juvenile DM occurs in children and adolescents. Patients mostly show a subacute weakness and myalgia in the upper and lower limbs, the diagnosis is based upon these clinical findings in combination with muscle biopsy results and specific serum autoantibodies. In recent years, research achieved a better understanding about the molecular mechanism underlying the myositis syndromes, as well as disease progress and extramuscular organ manifestations, such as interstitial lung disease and association with neoplasias. Treatment mainly consists of glucocorticosteroids and immunosuppressants. IBM is usually refractory to treatments. This review provides an overview of the current standards of treatment and new treatment options like monoclonal antibodies and new molecular therapies and their first results from clinical trials.
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Affiliation(s)
- Stefanie Glaubitz
- Department of Neurology, Muscle Immunobiology Group, Neuromuscular Center, University Medical Center Göttingen, Göttingen, Germany
| | - Rachel Zeng
- Department of Neurology, Muscle Immunobiology Group, Neuromuscular Center, University Medical Center Göttingen, Göttingen, Germany
| | - Jens Schmidt
- Department of Neurology, Muscle Immunobiology Group, Neuromuscular Center, University Medical Center Göttingen, Robert-Koch-Sr. 40, 37075 Göttingen, Germany
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22
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Furuta M, Furuta N, Nagashima K, Fujita Y, Tsushima Y, Ikeda Y. Differential and quantitative neuroimaging characteristics of inclusion body myositis. J Clin Neurosci 2020; 72:244-51. [PMID: 31839382 DOI: 10.1016/j.jocn.2019.11.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 11/27/2019] [Indexed: 11/23/2022]
Abstract
In clinical settings, it is often difficult to distinguish inclusion body myositis (IBM) from other neuromuscular diseases. In order to clarify clinically useful characteristics for making the differential diagnosis of IBM, we performed clinical, epidemiological, and neuroimaging analyses in patients with various types of neuromuscular disorders. We enrolled 333 patients with myopathy and 12 patients with amyotrophic lateral sclerosis (ALS) who had been hospitalized in our department from January 1, 1979, to December 31, 2018. Among them, 18 patients with IBM, 16 patients with polymyositis (PM), and 12 patients with ALS who showed equivalent severity of muscle weakness in their lower limbs underwent the quantitative neuroimaging analysis using lower limb CT and clinical assessment. Patients with IBM exhibited significantly greater muscular degeneration in the rectus femoris, vastus, sartorius, adductor, anterior calf, and medial gastrocnemius muscles than those with PM or ALS. The ratio of the remaining muscle area of the quadriceps relative to that of the hamstrings and the duration from onset to CT imaging were negatively correlated in patients with IBM, indicating that the anterior thigh muscles were preferentially affected over the posterior muscles. Characteristic muscular degeneration in the lower limbs on CT imaging may aid for making the diagnosis of IBM.
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23
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Mohannak N, Pattison G, Hird K, Needham M. Dysphagia in Patients with Sporadic Inclusion Body Myositis: Management Challenges. Int J Gen Med 2019; 12:465-474. [PMID: 31824189 PMCID: PMC6901064 DOI: 10.2147/ijgm.s198031] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 11/21/2019] [Indexed: 01/14/2023] Open
Abstract
Dysphagia in inclusion body myositis (IBM) is common and associated with increased mortality and morbidity due to aspiration pneumonia, malnutrition and dehydration. There is currently no consensus on treatment of dysphagia in IBM and outcomes are variable depending on timing of intervention, patient preference and available expertise. There is a paucity of research exploring the pathophysiology of dysphagia in IBM and appropriate investigations. Increased knowledge of the aetiopathogenesis is likely to change the approach to treatment as well as improve the quality of life for patients. This review explores the epidemiology and pathophysiology of dysphagia in IBM and the currently available treatment strategies.
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Affiliation(s)
- Nika Mohannak
- School of Medicine, The University of Notre Dame, Fremantle, Western Australia, Australia
| | - Gemma Pattison
- Department of Speech Pathology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Kathryn Hird
- School of Medicine, The University of Notre Dame, Fremantle, Western Australia, Australia
| | - Merrilee Needham
- School of Medicine, The University of Notre Dame, Fremantle, Western Australia, Australia
- Department of Neurology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
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24
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Abstract
Intravenous immunoglobulin (IVIg) is used in the treatment of autoimmune diseases, including immune-mediated central and peripheral nervous system disorders. This article will review the indications, proposed mechanism of actions, and administration of immunoglobulin treatment in various neuropathies, neuromuscular junction disorders, and myopathies. IVIg may have more than one mechanism of action to alter the pathogenesis of underlying neuromuscular disease. IVIg treatment has been used as a first-line treatment in Guillain-Barre syndrome, chronic inflammatory demyelinating polyradiculoneuropathy, multifocal motor neuropathy, and second-line off-label treatment in medically refractory cases of polymyositis, dermatomyositis, and myasthenia gravis. IVIg is a well-tolerated and effective treatment for these neuromuscular diseases. With this review article, we hope to increase clinicians' awareness of the indications and efficiencies of IVIg in a broad spectrum of neuromuscular diseases.
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Affiliation(s)
- Ahmet Z Burakgazi
- Department of Internal Medicine, Neuroscience Section, Virginia Tech Carilion School of Medicine, Carilion Clinic Neurology, Roanoke, VA
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25
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Affiliation(s)
- Mavroudis Ioannis
- Department of Neurology, Leeds General Infirmary, LTHT, Leeds, UK
- Laboratory of Neuropathology and Electron Microscopy, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Petridis Foivos
- Laboratory of Neuropathology and Electron Microscopy, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Third Department of Neurology, G. Papanikolaou General Hospital, Thessaloniki, Greece
| | - Kazis Dimitrios
- Third Department of Neurology, G. Papanikolaou General Hospital, Thessaloniki, Greece
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26
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Abstract
Inclusion body myositis is the most common acquired myopathy after the age of 50. It is characterized by progressive asymmetric weakness predominantly affecting the quadriceps and/or finger flexors. Loss of ambulation and dysphagia are major complications of the disease. Inclusion body myositis can be associated with cytosolic 5'-nucleotidase 1A antibodies. Muscle biopsy usually shows inflammatory cells surrounding and invading non-necrotic muscle fibers, rimmed vacuoles, congophilic inclusions, and protein aggregates. Disease pathogenesis remains poorly understood and consists of an interplay between inflammatory and degenerative pathways. Antigen-driven, clonally restricted, cytotoxic T cells represent a main feature of the inflammatory component, whereas abnormal protein homeostasis with protein misfolding, aggregation, and dysfunctional protein disposal is the hallmark of the degenerative component. Inclusion body myositis remains refractory to treatment. Better understanding of the disease pathogenesis led to the identification of novel therapeutic targets, addressing both the inflammatory and degenerative pathways.
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Affiliation(s)
- Elie Naddaf
- Neuromuscular Medicine Division, Department of Neurology, Mayo Clinic, Rochester, Minnesota, 55905, USA
| | - Richard J Barohn
- Neuromuscular Medicine Division, Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, 66103, USA
| | - Mazen M Dimachkie
- Neuromuscular Medicine Division, Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, 66103, USA.
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27
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Abstract
Inflammatory disorders of the skeletal muscle include polymyositis (PM), dermatomyositis (DM), (immune mediated) necrotizing myopathy (NM), overlap syndrome with myositis (overlap myositis, OM) including anti-synthetase syndrome (ASS), and inclusion body myositis (IBM). Whereas DM occurs in children and adults, all other forms of myositis mostly develop in middle aged individuals. Apart from a slowly progressive, chronic disease course in IBM, patients with myositis typically present with a subacute onset of weakness of arms and legs, often associated with pain and clearly elevated creatine kinase in the serum. PM, DM and most patients with NM and OM usually respond to immunosuppressive therapy, whereas IBM is largely refractory to treatment. The diagnosis of myositis requires careful and combinatorial assessment of (1) clinical symptoms including pattern of weakness and paraclinical tests such as MRI of the muscle and electromyography (EMG), (2) broad analysis of auto-antibodies associated with myositis, and (3) detailed histopathological work-up of a skeletal muscle biopsy. This review provides a comprehensive overview of the current classification, diagnostic pathway, treatment regimen and pathomechanistic understanding of myositis.
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Affiliation(s)
- Jens Schmidt
- Department of Neurology, Muscle Immunobiology Group, Neuromuscular Center, University Medical Center Göttingen, Göttingen, Germany,Correspondence to: Prof. Dr. Jens Schmidt, MD, FEAN, FAAN, Muscle Immunobiology Group, Neuromuscular Center, Department of Neurology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany. Tel.: +49 551 39 22355; Fax: +49 551 39 8405; E-mail:
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28
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Abstract
Idiopathic inflammatory myopathies (IIMs) are heterogeneous disorders that affect the skeletal muscles. Polymyositis, dermatomyositis, and inclusion body myositis are major IIM subsets. Immune-mediated necrotizing myopathy became recognized as a potentially new IIM subset. Since the new classification criteria published by the International Myositis Classification Criteria Project have higher sensitivity and specificity for IIM classification and subclassification than the previous criteria, they should help precise diagnosis. It should be noted that several tests available in current clinical practice, such as electromyography, magnetic resonance imaging, and other myositis-specific autoantibodies than anti-Jo-1 antibodies, were not included in the new criteria. As for treatment, glucocorticoids are used empirically as the first-line treatment despite their various adverse effects. Concomitant treatment with steroid-sparing immunosuppressive agents, including methotrexate, azathioprine, calcineurin inhibitors, mycophenolate mofetil, and cyclophosphamide, reduces successfully initial glucocorticoid doses for the remission induction, the relapse risk during glucocorticoid tapering, and adverse effects of glucocorticoids. Treatment with biologics, including rituximab and abatacept, seems promising in some IIM patients. Multi-target treatment with glucocorticoids and several steroid-sparing immunosuppressive agents is effective in refractory IIM patients. Considering proven steroid-sparing efficacy and tolerability of multi-target treatment in patients with other autoimmune diseases, it should be a good therapeutic option for IIMs.
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Affiliation(s)
- Hirokazu Sasaki
- a Department of Rheumatology, Graduate School of Medical and Dental Sciences , Tokyo Medical and Dental University (TMDU) , Tokyo , Japan
| | - Hitoshi Kohsaka
- a Department of Rheumatology, Graduate School of Medical and Dental Sciences , Tokyo Medical and Dental University (TMDU) , Tokyo , Japan
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29
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Benveniste O. Miosite da corpi inclusi. Neurologia 2018; 18:1-7. [DOI: 10.1016/s1634-7072(18)89405-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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30
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Couture P, Malfatti E, Morau G, Mathian A, Cohen-Aubart F, Nielly H, Amoura Z, Cherin P. Inclusion body myositis and human immunodeficiency virus type 1: A new case report and literature review. Neuromuscul Disord 2018; 28:334-338. [PMID: 29426734 DOI: 10.1016/j.nmd.2018.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 09/22/2017] [Accepted: 01/06/2018] [Indexed: 10/18/2022]
Abstract
Prevalence of muscle disease in human immunodeficiency virus (HIV) infection is less than 1% of patients with acquired immune deficiency syndrome. Sporadic inclusion body myositis (IBM) is observed in a few cases of patients infected by retroviruses such as HIV-1. A Caucasian man was diagnosed with HIV when he was 30 years old. The viral load was undetectable and CD4 cell count was 600/mm3 when the diagnosis of inclusion body myositis was confirmed. Histological findings were typical of IBM. The treatment consisted of immunoglobulin therapy for three years without effect. Twenty-two patients were found in the English and French literature. They are younger than those who suffer from IBM without HIV (median age = 47, range: 30 to 59), and they are mostly men with considerable serum creatine kinase (CK) elevation (median CK level = 1322 IU/L, range: 465 to 10270), most of them were treated with Zidovudine.
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Affiliation(s)
- Priscille Couture
- Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Département de Médecine Interne 2, Centre National de Référence des Maladies Auto-Immunes Systémiques et Rares. Institut E3M. 47-83 Boulevard de l'Hôpital, 75013, Paris, France.
| | - Edoardo Malfatti
- Assistance Publique-Hôpitaux de Paris, Unité de Morphologie Neuromusculaire - Institut de myologie, Hôpital Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Geneviève Morau
- Assistance Publique-Hôpitaux de Paris, Maladie infectieuse et tropicale, Hôpital Bichat Claude Bernard, 46 Rue Henri Huchard, 75018, Paris, France
| | - Alexis Mathian
- Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Département de Médecine Interne 2, Centre National de Référence des Maladies Auto-Immunes Systémiques et Rares. Institut E3M. 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Fleur Cohen-Aubart
- Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Département de Médecine Interne 2, Centre National de Référence des Maladies Auto-Immunes Systémiques et Rares. Institut E3M. 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Hubert Nielly
- Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Département de Médecine Interne 2, Centre National de Référence des Maladies Auto-Immunes Systémiques et Rares. Institut E3M. 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Zahir Amoura
- Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Département de Médecine Interne 2, Centre National de Référence des Maladies Auto-Immunes Systémiques et Rares. Institut E3M. 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Patrick Cherin
- Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Département de Médecine Interne 2, Centre National de Référence des Maladies Auto-Immunes Systémiques et Rares. Institut E3M. 47-83 Boulevard de l'Hôpital, 75013, Paris, France
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Abstract
BACKGROUND Intravenously administered immunoglobulins have multiple modes of action that are anti-inflammatory. They can therefore be beneficial in a number of autoimmune disorders. OBJECTIVE The aim of this article is to analyze and summarize studies on the administration of intravenous immunoglobulins in rheumatological diseases. METHODS A selective search and analysis of the literature was carried out related to the mode of action and efficacy of intravenous immunoglobulins in rheumatological diseases. RESULTS AND CONCLUSION Intravenous immunoglobulins have a broad mode of action and can therefore be beneficial in almost all autoimmune diseases. Conditions in which they are of special benefit include immunothrombopenia (ITP), Kawasaki disease and idiopathic inflammatory myopathies. In rare situations, they may also be indicated in systemic lupus erythematosus (SLE), Sjögren's syndrome and neuropathies, catastrophic antiphospholipid syndrome (APS), scleroderma, antineutrophil cytoplasmic antibody (ANCA) associated vasculitis, pyoderma gangrenosum and scleromyxedema. Severe adverse events are rare. In view of the high costs of the therapy, intravenous immunoglobulins are mostly applied in emergency situations, as salvage therapy when other standard therapies have failed or when severe infections are a contraindication to the administration of immunosuppressants.
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Affiliation(s)
- T Witte
- Klinik für Immunologie und Rheumatologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
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Gallay L, Petiot P. Sporadic inclusion-body myositis: Recent advances and the state of the art in 2016. Rev Neurol (Paris) 2016; 172:581-6. [DOI: 10.1016/j.neurol.2016.07.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 07/29/2016] [Indexed: 02/08/2023]
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Anh-Tu Hoa S, Hudson M. Critical review of the role of intravenous immunoglobulins in idiopathic inflammatory myopathies. Semin Arthritis Rheum 2016; 46:488-508. [PMID: 27908534 DOI: 10.1016/j.semarthrit.2016.07.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 07/20/2016] [Accepted: 07/21/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of this review was to summarize key findings from the literature concerning the therapeutic role of intravenous immunoglobulins (IVIg) in idiopathic inflammatory myopathies (IIM), dissecting the evidence according to disease subtype and treatment indication, and to review the evidence relating to the mechanism of action of IVIg in IIM to ascertain rationale for continued research. METHODS Medline (Ovid) and Pubmed databases were searched from inception to July 2016 using relevant keywords. Original and review articles were retrieved for full-text review. Bibliographies of selected articles were also hand-searched for additional references. Data were summarized qualitatively and in tabular form. RESULTS The efficacy of IVIg in IIM is supported by 3 randomized controlled trials, involving dermatomyositis and polymyositis subjects, in refractory, relapsed, or steroid-dependent disease, as well as part of first-line therapy in elderly dermatomyositis subjects. Other indications for IVIg are supported by uncontrolled evidence only. Limitations of studies include open, uncontrolled or retrospective study designs, small and selected samples, short-term follow-up and ad hoc outcome measures. Despite the limited evidence, there is strong biological plausibility for the role of IVIg in IIM. CONCLUSION Robust, controlled evidence to support the use of IVIg using validated outcome measures is urgently required to guide therapeutic decision-making and maximize outcomes in IIM.
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Affiliation(s)
- Sabrina Anh-Tu Hoa
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada
| | - Marie Hudson
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada; Department of Medicine, Jewish General Hospital, Montreal, Quebec, Canada; Faculty of Medicine, McGill University, Montreal, Quebec, Canada.
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Abstract
Idiopathic inflammatory myopathies (IIM) are a group of chronic, autoimmune conditions affecting primarily the proximal muscles. The most common types are dermatomyositis (DM), polymyositis (PM), necrotizing autoimmune myopathy (NAM), and sporadic inclusion body myositis (sIBM). Patients typically present with sub-acute to chronic onset of proximal weakness manifested by difficulty with rising from a chair, climbing stairs, lifting objects, and combing hair. They are uniquely identified by their clinical presentation consisting of muscular and extramuscular manifestations. Laboratory investigations, including increased serum creatine kinase (CK) and myositis specific antibodies (MSA) may help in differentiating clinical phenotype and to confirm the diagnosis. However, muscle biopsy remains the gold standard for diagnosis. These disorders are potentially treatable with proper diagnosis and initiation of therapy. Goals of treatment are to eliminate inflammation, restore muscle performance, reduce morbidity, and improve quality of life. This review aims to provide a basic diagnostic approach to patients with suspected IIM, summarize current therapeutic strategies, and provide an insight into future prospective therapies.
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Affiliation(s)
- Asma Malik
- Neurology, Saint Louis University, Saint Louis, MO, USA
| | - Ghazala Hayat
- Neurology, Saint Louis University, Saint Louis, MO, USA
| | - Junaid S. Kalia
- Department of Neurology and Neurotherapeutics, The University of Texas Southwestern, Dallas, TX, USA
| | - Miguel A. Guzman
- Department of Pathology, Saint Louis University, Saint Louis, MO, USA
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Barahona Afonso AF, João CM. The Production Processes and Biological Effects of Intravenous Immunoglobulin. Biomolecules 2016; 6:15. [PMID: 27005671 DOI: 10.3390/biom6010015] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 03/01/2016] [Accepted: 03/01/2016] [Indexed: 12/17/2022] Open
Abstract
Immunoglobulin is a highly diverse autologous molecule able to influence immunity in different physiological and diseased situations. Its effect may be visible both in terms of development and function of B and T lymphocytes. Polyclonal immunoglobulin may be used as therapy in many diseases in different circumstances such as primary and secondary hypogammaglobulinemia, recurrent infections, polyneuropathies, cancer, after allogeneic transplantation in the presence of infections and/or GVHD. However, recent studies have broadened the possible uses of polyclonal immunoglobulin showing that it can stimulate certain sub-populations of T cells with effects on T cell proliferation, survival and function in situations of lymphopenia. These results present a novel and considerable impact of intravenous immunoglobulin (IVIg) treatment in situations of severe lymphopenia, a situation that can occur in cancer patients after chemo and radiotherapy treatments. In this review paper the established and experimental role of polyclonal immunoglobulin will be presented and discussed as well as the manufacturing processes involved in their production.
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Abstract
The idiopathic inflammatory myopathies are uncommon and heterogeneous disorders. Their classification is based on distinct clinicopathologic features. Although idiopathic inflammatory myopathies share some similarities, different subtypes may have variable responses to therapy, so it is very important to distinguish the correct subtype. There are few randomised, double blind placebo controlled studies to support the current treatment. High dose corticosteroids continue to be the first-line therapy and other immunosupressive drugs are used in refractory cases, as well as steroid-sparing agents. Some novel therapeutic approaches have emerged as potential treatment including tacrolimus, intravenous immunoglobulin and rituximab, following good outcomes reported in case studies. However, more randomised controlled trials are needed. This review considers the current and the potential future therapies for inflammatory myopathies.
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Affiliation(s)
- Serena Fasano
- a Rheumatology Unit, Department of Clinical and Experimental Medicine , Second University of Naples , Naples , Italy
| | - Sara Custódio Alves
- b Internal Medicine Unit, Department of Medicine , Hospital de Cascais , Cascais , Portugal
| | - David A Isenberg
- c Centre for Rheumatology, Department of Medicine , University College London , London , UK
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Abstract
To investigate the existing evidence on the effectiveness of approaches to treating inclusion body myositis and to assess the methodological quality of this evidence. The Cochrane Controlled Trials Register (CENTRAL), Medline, Embase, Cinahl, Physiotherapy Evidence (Pedro), McMaster and Web of Science databases were searched. The references of identified articles and reviews were also checked for relevancy. The methodological quality was assessed according to the Cochrane Collaboration's domain-based evaluation framework. Of the 331 identified records, 10 were considered relevant for a qualitative analysis. The risk of bias was considered being low for six studies and high for four. Eight studies were randomized controlled trials, and two were controlled clinical trials. In the samples, male gender predominated, and the mean age of the participants varied from 51 to 72 years. The duration of intervention varied from 3 to 17 months. One small trial on the effect of oxandrolone reported a significant positive result. The other trials observed no improvement or insignificant improvement among the participants treated with intravenous immunoglobulin, methotrexate, etanercept or interferon. Thus far, there is no evidence indicating that any specific treatment is the effective in treating inclusion body myositis.
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Affiliation(s)
- M. Saltychev
- Department of Physical and Rehabilitation Medicine; Turku University Hospital and University of Turku; Turku Finland
| | - M. Mikkelsson
- Rehabilitation Centre; Päijät-Häme Central Hospital and University of Tampere; Lahti Finland
| | - K. Laimi
- Department of Physical and Rehabilitation Medicine; Turku University Hospital and University of Turku; Turku Finland
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Abstract
Owing to its anti-inflammatory efficacy in various autoimmune disease conditions, intravenous immunoglobulin (IVIG)-pooled IgG obtained from the plasma of several thousands individuals-has been used for nearly three decades and is proving to be efficient in a growing number of neurological diseases. IVIG therapy has been firmly established for the treatment of Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy, either as first-line therapy or adjunctive treatment. IVIG is also recommended as rescue therapy in patients with worsening myasthenia gravis and is beneficial as a second-line therapy for dermatomyositis and stiff-person syndrome. Subcutaneous rather than intravenous administration of IgG is gaining momentum because of its effectiveness in patients with primary immunodeficiency and the ease with which it can be administered independently from hospital-based infusions. The demand for IVIG therapy is growing, resulting in rising costs and supply shortages. Strategies to replace IVIG with recombinant products have been developed based on proposed mechanisms that confer the anti-inflammatory activity of IVIG, but their efficacy has not been tested in clinical trials. This review covers new developments in the immunobiology and clinical applications of IVIG in neurological diseases.
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Affiliation(s)
- Jan D Lünemann
- Institute of Experimental Immunology, Laboratory of Neuroinflammation, University of Zürich, Winterthurerstrasse 190, Zürich, Switzerland.
- Department of Neurology, University Hospital of Basel, Basel, Switzerland.
| | - Isaak Quast
- Institute of Experimental Immunology, Laboratory of Neuroinflammation, University of Zürich, Winterthurerstrasse 190, Zürich, Switzerland
| | - Marinos C Dalakas
- Neuroimmunology Unit, University of Athens Medical School, Athens, Greece
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
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Abstract
Until recently, the treatment of immune-mediated inflammatory myopathies has largely been empirical with glucocorticoids, steroid-sparing immunosuppressive drugs, and intravenous immunoglobulin. However, a proportion of patients are only partially responsive to these therapies, and there has been a need to consider alternative treatment approaches. In particular, patients with inclusion body myositis are resistant to conventional immunotherapies or show only a transient response, and remain a major challenge. With increasing recognition of the different subtypes of immune-mediated inflammatory myopathies, and improved understanding of their pathogenesis, more targeted treatments are now being trialled. The overall approach to treatment, and novel therapies targeting B cells, T cells, and specific cytokines are discussed in this review.
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Affiliation(s)
- Merrilee Needham
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, 6150, WA, Australia.
- Fiona Stanley Hospital, Murdoch, 6150, WA, Australia.
- West Australian Neuroscience Research Institute, Queen Elizabeth II Medical Centre, Nedlands, 6009, WA, Australia.
| | - Frank L Mastaglia
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, 6150, WA, Australia
- West Australian Neuroscience Research Institute, Queen Elizabeth II Medical Centre, Nedlands, 6009, WA, Australia
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Abstract
INTRODUCTION Inclusion body myositis (IBM) is a slowly progressive degenerative inflammatory disorder affecting both proximal and distal muscles. Immunosuppressive therapies are generally ineffective in the treatment of this disorder, and most patients are resistant to steroid therapy. Some benefits with mild improvement were observed with intravenous immunoglobulin (IVIg), particularly in patients with severe dysphagia. OBJECTIVES The objective of this review was to describe the use of subcutaneous Ig (SCIg) in patients with IBM and to assess its feasibility. RESULTS This report reviews 6 cases of IBM treated with SCIg in clinical practice. All patients had received prior treatments for IBM, including immunosuppressive agents and IVIg. SCIg was administered over a long period of time, ranging from 4.5 to 27 months. No patient discontinued the SCIg because of a treatment-related event or safety issues. The 6 cases showed an improvement in muscle strength and resolution of dysphagia. For 2 patients, this improvement persisted for approximately 12 months. CONCLUSIONS SCIg might be proposed as an alternative therapy to patients with IBM who are resistant to corticoids and immunosuppressive therapies. Our findings suggest that treatment with SCIg (Gammanorm 16.5%, Octapharma AB) is feasible and safe in patients with IBM.
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Affiliation(s)
- Patrick Cherin
- Department of Internal Medicine, Pitié-Salpetrière Hospital Group, Paris, France
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De Paepe B, Zschüntzsch J. Scanning for Therapeutic Targets within the Cytokine Network of Idiopathic Inflammatory Myopathies. Int J Mol Sci 2015; 16:18683-713. [PMID: 26270565 PMCID: PMC4581266 DOI: 10.3390/ijms160818683] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 07/13/2015] [Accepted: 07/15/2015] [Indexed: 12/17/2022] Open
Abstract
The idiopathic inflammatory myopathies (IIM) constitute a heterogeneous group of chronic disorders that include dermatomyositis (DM), polymyositis (PM), sporadic inclusion body myositis (IBM) and necrotizing autoimmune myopathy (NAM). They represent distinct pathological entities that, most often, share predominant inflammation in muscle tissue. Many of the immunopathogenic processes behind the IIM remain poorly understood, but the crucial role of cytokines as essential regulators of the intramuscular build-up of inflammation is undisputed. This review describes the extensive cytokine network within IIM muscle, characterized by strong expression of Tumor Necrosis Factors (TNFα, LTβ, BAFF), Interferons (IFNα/β/γ), Interleukins (IL-1/6/12/15/18/23) and Chemokines (CXCL9/10/11/13, CCL2/3/4/8/19/21). Current therapeutic strategies and the exploration of potential disease modifying agents based on manipulation of the cytokine network are provided. Reported responses to anti-TNFα treatment in IIM are conflicting and new onset DM/PM has been described after administration of anti-TNFα agents to treat other diseases, pointing to the complex effects of TNFα neutralization. Treatment with anti-IFNα has been shown to suppress the IFN type 1 gene signature in DM/PM patients and improve muscle strength. Beneficial effects of anti-IL-1 and anti-IL-6 therapy have also been reported. Cytokine profiling in IIM aids the development of therapeutic strategies and provides approaches to subtype patients for treatment outcome prediction.
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Affiliation(s)
- Boel De Paepe
- Neuromuscular Reference Center, Laboratory for Neuropathology, 10K12E, Ghent University Hospital, 9000 Ghent, Belgium.
| | - Jana Zschüntzsch
- Department of Neurology, University Medical Centre, Göttingen University, 37075 Göttingen, Germany.
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Abstract
BACKGROUND Inclusion body myositis (IBM) is a late-onset inflammatory muscle disease (myopathy) associated with progressive proximal and distal limb muscle atrophy and weakness. Treatment options have attempted to target inflammatory and atrophic features of this condition (for example with immunosuppressive and immunomodulating drugs, anabolic steroids, and antioxidant treatments), although as yet there is no known effective treatment for reversing or minimising the progression of inclusion body myositis. In this review we have considered the benefits, adverse effects, and costs of treatment in targeting cardinal effects of the condition, namely muscle atrophy, weakness, and functional impairment. OBJECTIVES To assess the effects of treatment for IBM. SEARCH METHODS On 7 October 2014 we searched the Cochrane Neuromuscular Disease Group Specialized Register, the Cochrane Central Register for Controlled Trials (CENTRAL), MEDLINE, and EMBASE. Additionally in November 2014 we searched clinical trials registries for ongoing or completed but unpublished trials. SELECTION CRITERIA We considered randomised or quasi-randomised trials, including cross-over trials, of treatment for IBM in adults compared to placebo or any other treatment for inclusion in the review. We specifically excluded people with familial IBM and hereditary inclusion body myopathy, but we included people who had connective tissue and autoimmune diseases associated with IBM, which may or may not be identified in trials. We did not include studies of exercise therapy or dysphagia management, which are topics of other Cochrane systematic reviews. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. MAIN RESULTS The review included 10 trials (249 participants) using different treatment regimens. Seven of the 10 trials assessed single agents, and 3 assessed combined agents. Many of the studies did not present adequate data for the reporting of the primary outcome of the review, which was the percentage change in muscle strength score at six months. Pooled data from two trials of interferon beta-1a (n = 58) identified no important difference in normalised manual muscle strength sum scores from baseline to six months (mean difference (MD) -0.06, 95% CI -0.15 to 0.03) between IFN beta-1a and placebo (moderate-quality evidence). A single trial of methotrexate (MTX) (n = 44) provided moderate-quality evidence that MTX did not arrest or slow disease progression, based on reported percentage change in manual muscle strength sum scores at 12 months. None of the fully published trials were adequately powered to detect a treatment effect. We assessed six of the nine fully published trials as providing very low-quality evidence in relation to the primary outcome measure. Three trials (n = 78) compared intravenous immunoglobulin (combined in one trial with prednisone) to a placebo, but we were unable to perform meta-analysis because of variations in study analysis and presentation of trial data, with no access to the primary data for re-analysis. Other comparisons were also reported in single trials. An open trial of anti-T lymphocyte immunoglobulin (ATG) combined with MTX versus MTX provided very low-quality evidence in favour of the combined therapy, based on percentage change in quantitative muscle strength sum scores at 12 months (MD 12.50%, 95% CI 2.43 to 22.57). Data from trials of oxandrolone versus placebo, azathioprine (AZA) combined with MTX versus MTX, and arimoclomol versus placebo did not allow us to report either normalised or percentage change in muscle strength sum scores. A complete analysis of the effects of arimoclomol is pending data publication. Studies of simvastatin and bimagrumab (BYM338) are ongoing. All analysed trials reported adverse events. Only 1 of the 10 trials interpreted these for statistical significance. None of the trials included prespecified criteria for significant adverse events. AUTHORS' CONCLUSIONS Trials of interferon beta-1a and MTX provided moderate-quality evidence of having no effect on the progression of IBM. Overall trial design limitations including risk of bias, low numbers of participants, and short duration make it difficult to say whether or not any of the drug treatments included in this review were effective. An open trial of ATG combined with MTX versus MTX provided very low-quality evidence in favour of the combined therapy based on the percentage change data given. We were unable to draw conclusions from trials of IVIg, oxandrolone, and AZA plus MTX versus MTX. We need more randomised controlled trials that are larger, of longer duration, and that use fully validated, standardised, and responsive outcome measures.
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Affiliation(s)
- Michael R Rose
- King's College Hospital NHS Foundation TrustDepartment of NeurologyAcademic Neuroscience CentreDenmark HillLondonUKSE5 9RS
| | - Katherine Jones
- King's College Hospital NHS Foundation TrustDepartment of NeurologyAcademic Neuroscience CentreDenmark HillLondonUKSE5 9RS
| | - Kevin Leong
- NHLI, Imperial College LondonICTEM Builiding; 4th FloorHammersmith CampusW12 0HSUK
| | - Maggie C Walter
- Ludwig‐Maximilians‐UniversityDepartment of Neurology, Friedrich‐Baur‐Institute, Laboratory for Molecular MyologyZiemssenstr.1MunichGermany80336
| | - James Miller
- Royal Victoria Infirmaryc/o Department of Neurology, Newcastle upon Tyne Hospitals TrustQueen Victoria RoadNewcastle Upon TyneUKNE1 4LP
| | - Marinos C Dalakas
- Thomas Jefferson UniversityDepartment of Neurology, Sidney Kimmel Medical College901 Walnut Street4th FloorPhiladelphiaPAUSA19107
| | - Ruth Brassington
- National Hospital for Neurology and NeurosurgeryMRC Centre for Neuromuscular DiseasesPO Box 114LondonUKWC1N 3BG
| | - Robert Griggs
- University of RochesterDepartment of Neurology601 Elmwood AvenueRochesterNYUSA14642
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Benveniste O, Stenzel W, Hilton-Jones D, Sandri M, Boyer O, van Engelen BGM. Amyloid deposits and inflammatory infiltrates in sporadic inclusion body myositis: the inflammatory egg comes before the degenerative chicken. Acta Neuropathol 2015; 129:611-24. [PMID: 25579751 PMCID: PMC4405277 DOI: 10.1007/s00401-015-1384-5] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 01/05/2015] [Accepted: 01/06/2015] [Indexed: 11/27/2022]
Abstract
Sporadic inclusion body myositis (sIBM) is the most frequently acquired myopathy in patients over 50 years of age. It is imperative that neurologists and rheumatologists recognize this disorder which may, through clinical and pathological similarities, mimic other myopathies, especially polymyositis. Whereas polymyositis responds to immunosuppressant drug therapy, sIBM responds poorly, if at all. Controversy reigns as to whether sIBM is primarily an inflammatory or a degenerative myopathy, the distinction being vitally important in terms of directing research for effective specific therapies. We review here the pros and the cons for the respective hypotheses. A possible scenario, which our experience leads us to favour, is that sIBM may start with inflammation within muscle. The rush of leukocytes attracted by chemokines and cytokines may induce fibre injury and HLA-I overexpression. If the protein degradation systems are overloaded (possibly due to genetic predisposition, particular HLA-I subtypes or ageing), amyloid and other protein deposits may appear within muscle fibres, reinforcing the myopathic process in a vicious circle.
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Affiliation(s)
- Olivier Benveniste
- Département de Médecine Interne et Immunologie Clinique, Assistance Publique-Hôpitaux de Paris, GH Pitié-Salpêtrière, Université Pierre et Marie Curie, Inserm, U974, DHU I2B, Paris, France,
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Wang J, McQuilten ZK, Wood EM, Aubron C. Intravenous immunoglobulin in critically ill adults: When and what is the evidence? J Crit Care 2015; 30:652.e9-16. [PMID: 25702845 DOI: 10.1016/j.jcrc.2015.01.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 01/20/2015] [Accepted: 01/30/2015] [Indexed: 02/07/2023]
Abstract
Intravenous immunoglobulin (IVIg) use is growing dramatically internationally due to the increasing numbers of acute and chronic conditions that may benefit from IVIg. Patients with conditions that may benefit from IVIg might require intensive care unit (ICU) admission, supporting the need to review IVIg use in the critical care setting. The most common clinical indications for IVIg in adults that may require ICU admission and are commonly supported under clinical practice guidelines are Guillain-Barré syndrome, myasthenia gravis and Lambert-Eaton myasthenic syndrome, inflammatory myopathies, and primary or secondary immunodeficiency diseases complicated by severe bacterial sepsis. Other emerging indications include necrotizing fasciitis, toxic epidermal necrolysis/Stevens-Johnson syndrome, and toxic shock syndrome. The evidence for IVIg use in sepsis and septic shock remains controversial and insufficient to recommend its routine use. Intravenous immunoglobulin is expensive and also carries risks of adverse effects, including common and benign infusion-related reactions, as well as relatively rare and more serious problems, such as thromboembolic events, renal failure, and aseptic meningitis. In this article, we review the literature on conditions requiring ICU admission and IVIg, and we classify them as supported, emerging, or unsupported indications based on the available evidence and guidelines for clinical use of IVIg.
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47
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Miller FW. Management of inflammatory muscle disease. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00150-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Abstract
The use of IVIG to treat a wide variety of immune-driven diseases has grown rapidly, although the mechanism of action is not completely understood. Increasing demand for IVIG coupled with concerns regarding potential transmissible agents has led to worldwide supply shortages. National agencies have therefore produced guidelines for its use, with the latest England and Wales guideline being published in 2011. Due to the rarity of the rheumatic diseases, the evidence for IVIG use has been shown to be lacking in some areas and promising in others. Conditions in which IVIG has been shown to have benefit include ITP, Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathy occurring in the context of rheumatic disease, as well as in SLE, idiopathic inflammatory myopathies and ANCA-associated vasculitides. This review looks at current IVIG use and is designed to be an aid for rheumatologists when considering the use of IVIG in clinical practice.
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Affiliation(s)
- Ben Mulhearn
- Christie NHS Foundation Trust, Arthritis Research UK Epidemiology Unit, Institute of Inflammation and Repair, Manchester Academic Health Sciences Centre, University of Manchester and Kellgren Centre for Rheumatology, NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Ian N Bruce
- Christie NHS Foundation Trust, Arthritis Research UK Epidemiology Unit, Institute of Inflammation and Repair, Manchester Academic Health Sciences Centre, University of Manchester and Kellgren Centre for Rheumatology, NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK Christie NHS Foundation Trust, Arthritis Research UK Epidemiology Unit, Institute of Inflammation and Repair, Manchester Academic Health Sciences Centre, University of Manchester and Kellgren Centre for Rheumatology, NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Amato AA, Sivakumar K, Goyal N, David WS, Salajegheh M, Praestgaard J, Lach-Trifilieff E, Trendelenburg AU, Laurent D, Glass DJ, Roubenoff R, Tseng BS, Greenberg SA. Treatment of sporadic inclusion body myositis with bimagrumab. Neurology 2014; 83:2239-46. [PMID: 25381300 DOI: 10.1212/wnl.0000000000001070] [Citation(s) in RCA: 147] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE To study activin signaling and its blockade in sporadic inclusion body myositis (sIBM) through translational studies and a randomized controlled trial. METHODS We measured transforming growth factor β signaling by SMAD2/3 phosphorylation in muscle biopsies of 50 patients with neuromuscular disease (17 with sIBM). We tested inhibition of activin receptors IIA and IIB (ActRII) in 14 patients with sIBM using one dose of bimagrumab (n = 11) or placebo (n = 3). The primary outcome was the change in right thigh muscle volume by MRI at 8 weeks. Lean body mass, strength, and function were secondary outcomes. Twelve of the patients (10 bimagrumab, 2 placebo) participated in a subsequent 16-week observation phase. RESULTS Muscle SMAD2/3 phosphorylation was higher in sIBM than in other muscle diseases studied (p = 0.003). Eight weeks after dosing, the bimagrumab-treated patients increased thigh muscle volume (right leg +6.5% compared with placebo, p = 0.024; left leg +7.6%, p = 0.009) and lean body mass (+5.7% compared with placebo, p = 0.014). Subsequently, bimagrumab-treated patients had improved 6-minute walking distance, which peaked at 16 weeks (+14.6%, p = 0.008) compared with placebo. There were no serious adverse events; the main adverse events with bimagrumab were mild acne and transient involuntary muscle contractions. CONCLUSIONS Transforming growth factor β superfamily signaling, at least through ActRII, is implicated in the pathophysiology of sIBM. Inhibition of ActRII increased muscle mass and function in this pilot trial, offering a potential novel treatment of sIBM. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that for patients with inclusion body myositis, bimagrumab increases thigh muscle volume at 8 weeks.
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Affiliation(s)
- Anthony A Amato
- From Brigham and Women's Hospital and Harvard Medical School (A.A.A., M.S., S.A.G.), Boston; Boston Children's Hospital (S.A.G.); Harvard-Massachusetts Institute of Technology (S.A.G.), Division of Health Sciences and Technology, Cambridge, MA; Barrow Neurological Institute (K.S.), Phoenix AZ; Massachusetts General Hospital (N.G., W.S.D.), Boston; Novartis Institutes for Biomedical Research (E.L.-T., A.-U.T., D.L., D.J.G., R.R., B.S.T.), Cambridge, MA and Basel, Switzerland; and Novartis Pharmaceuticals Corporation (J.P.), East Hanover, NJ
| | - Kumaraswamy Sivakumar
- From Brigham and Women's Hospital and Harvard Medical School (A.A.A., M.S., S.A.G.), Boston; Boston Children's Hospital (S.A.G.); Harvard-Massachusetts Institute of Technology (S.A.G.), Division of Health Sciences and Technology, Cambridge, MA; Barrow Neurological Institute (K.S.), Phoenix AZ; Massachusetts General Hospital (N.G., W.S.D.), Boston; Novartis Institutes for Biomedical Research (E.L.-T., A.-U.T., D.L., D.J.G., R.R., B.S.T.), Cambridge, MA and Basel, Switzerland; and Novartis Pharmaceuticals Corporation (J.P.), East Hanover, NJ
| | - Namita Goyal
- From Brigham and Women's Hospital and Harvard Medical School (A.A.A., M.S., S.A.G.), Boston; Boston Children's Hospital (S.A.G.); Harvard-Massachusetts Institute of Technology (S.A.G.), Division of Health Sciences and Technology, Cambridge, MA; Barrow Neurological Institute (K.S.), Phoenix AZ; Massachusetts General Hospital (N.G., W.S.D.), Boston; Novartis Institutes for Biomedical Research (E.L.-T., A.-U.T., D.L., D.J.G., R.R., B.S.T.), Cambridge, MA and Basel, Switzerland; and Novartis Pharmaceuticals Corporation (J.P.), East Hanover, NJ
| | - William S David
- From Brigham and Women's Hospital and Harvard Medical School (A.A.A., M.S., S.A.G.), Boston; Boston Children's Hospital (S.A.G.); Harvard-Massachusetts Institute of Technology (S.A.G.), Division of Health Sciences and Technology, Cambridge, MA; Barrow Neurological Institute (K.S.), Phoenix AZ; Massachusetts General Hospital (N.G., W.S.D.), Boston; Novartis Institutes for Biomedical Research (E.L.-T., A.-U.T., D.L., D.J.G., R.R., B.S.T.), Cambridge, MA and Basel, Switzerland; and Novartis Pharmaceuticals Corporation (J.P.), East Hanover, NJ
| | - Mohammad Salajegheh
- From Brigham and Women's Hospital and Harvard Medical School (A.A.A., M.S., S.A.G.), Boston; Boston Children's Hospital (S.A.G.); Harvard-Massachusetts Institute of Technology (S.A.G.), Division of Health Sciences and Technology, Cambridge, MA; Barrow Neurological Institute (K.S.), Phoenix AZ; Massachusetts General Hospital (N.G., W.S.D.), Boston; Novartis Institutes for Biomedical Research (E.L.-T., A.-U.T., D.L., D.J.G., R.R., B.S.T.), Cambridge, MA and Basel, Switzerland; and Novartis Pharmaceuticals Corporation (J.P.), East Hanover, NJ
| | - Jens Praestgaard
- From Brigham and Women's Hospital and Harvard Medical School (A.A.A., M.S., S.A.G.), Boston; Boston Children's Hospital (S.A.G.); Harvard-Massachusetts Institute of Technology (S.A.G.), Division of Health Sciences and Technology, Cambridge, MA; Barrow Neurological Institute (K.S.), Phoenix AZ; Massachusetts General Hospital (N.G., W.S.D.), Boston; Novartis Institutes for Biomedical Research (E.L.-T., A.-U.T., D.L., D.J.G., R.R., B.S.T.), Cambridge, MA and Basel, Switzerland; and Novartis Pharmaceuticals Corporation (J.P.), East Hanover, NJ
| | - Estelle Lach-Trifilieff
- From Brigham and Women's Hospital and Harvard Medical School (A.A.A., M.S., S.A.G.), Boston; Boston Children's Hospital (S.A.G.); Harvard-Massachusetts Institute of Technology (S.A.G.), Division of Health Sciences and Technology, Cambridge, MA; Barrow Neurological Institute (K.S.), Phoenix AZ; Massachusetts General Hospital (N.G., W.S.D.), Boston; Novartis Institutes for Biomedical Research (E.L.-T., A.-U.T., D.L., D.J.G., R.R., B.S.T.), Cambridge, MA and Basel, Switzerland; and Novartis Pharmaceuticals Corporation (J.P.), East Hanover, NJ
| | - Anne-Ulrike Trendelenburg
- From Brigham and Women's Hospital and Harvard Medical School (A.A.A., M.S., S.A.G.), Boston; Boston Children's Hospital (S.A.G.); Harvard-Massachusetts Institute of Technology (S.A.G.), Division of Health Sciences and Technology, Cambridge, MA; Barrow Neurological Institute (K.S.), Phoenix AZ; Massachusetts General Hospital (N.G., W.S.D.), Boston; Novartis Institutes for Biomedical Research (E.L.-T., A.-U.T., D.L., D.J.G., R.R., B.S.T.), Cambridge, MA and Basel, Switzerland; and Novartis Pharmaceuticals Corporation (J.P.), East Hanover, NJ
| | - Didier Laurent
- From Brigham and Women's Hospital and Harvard Medical School (A.A.A., M.S., S.A.G.), Boston; Boston Children's Hospital (S.A.G.); Harvard-Massachusetts Institute of Technology (S.A.G.), Division of Health Sciences and Technology, Cambridge, MA; Barrow Neurological Institute (K.S.), Phoenix AZ; Massachusetts General Hospital (N.G., W.S.D.), Boston; Novartis Institutes for Biomedical Research (E.L.-T., A.-U.T., D.L., D.J.G., R.R., B.S.T.), Cambridge, MA and Basel, Switzerland; and Novartis Pharmaceuticals Corporation (J.P.), East Hanover, NJ
| | - David J Glass
- From Brigham and Women's Hospital and Harvard Medical School (A.A.A., M.S., S.A.G.), Boston; Boston Children's Hospital (S.A.G.); Harvard-Massachusetts Institute of Technology (S.A.G.), Division of Health Sciences and Technology, Cambridge, MA; Barrow Neurological Institute (K.S.), Phoenix AZ; Massachusetts General Hospital (N.G., W.S.D.), Boston; Novartis Institutes for Biomedical Research (E.L.-T., A.-U.T., D.L., D.J.G., R.R., B.S.T.), Cambridge, MA and Basel, Switzerland; and Novartis Pharmaceuticals Corporation (J.P.), East Hanover, NJ
| | - Ronenn Roubenoff
- From Brigham and Women's Hospital and Harvard Medical School (A.A.A., M.S., S.A.G.), Boston; Boston Children's Hospital (S.A.G.); Harvard-Massachusetts Institute of Technology (S.A.G.), Division of Health Sciences and Technology, Cambridge, MA; Barrow Neurological Institute (K.S.), Phoenix AZ; Massachusetts General Hospital (N.G., W.S.D.), Boston; Novartis Institutes for Biomedical Research (E.L.-T., A.-U.T., D.L., D.J.G., R.R., B.S.T.), Cambridge, MA and Basel, Switzerland; and Novartis Pharmaceuticals Corporation (J.P.), East Hanover, NJ
| | - Brian S Tseng
- From Brigham and Women's Hospital and Harvard Medical School (A.A.A., M.S., S.A.G.), Boston; Boston Children's Hospital (S.A.G.); Harvard-Massachusetts Institute of Technology (S.A.G.), Division of Health Sciences and Technology, Cambridge, MA; Barrow Neurological Institute (K.S.), Phoenix AZ; Massachusetts General Hospital (N.G., W.S.D.), Boston; Novartis Institutes for Biomedical Research (E.L.-T., A.-U.T., D.L., D.J.G., R.R., B.S.T.), Cambridge, MA and Basel, Switzerland; and Novartis Pharmaceuticals Corporation (J.P.), East Hanover, NJ.
| | - Steven A Greenberg
- From Brigham and Women's Hospital and Harvard Medical School (A.A.A., M.S., S.A.G.), Boston; Boston Children's Hospital (S.A.G.); Harvard-Massachusetts Institute of Technology (S.A.G.), Division of Health Sciences and Technology, Cambridge, MA; Barrow Neurological Institute (K.S.), Phoenix AZ; Massachusetts General Hospital (N.G., W.S.D.), Boston; Novartis Institutes for Biomedical Research (E.L.-T., A.-U.T., D.L., D.J.G., R.R., B.S.T.), Cambridge, MA and Basel, Switzerland; and Novartis Pharmaceuticals Corporation (J.P.), East Hanover, NJ.
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