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Gasior M, Husain A, Barra ME, Raja SM, MacLeod D, Guptill JT, Vaitkevicius H, Rybak E. Intravenous Ganaxolone: Pharmacokinetics, Pharmacodynamics, Safety, and Tolerability in Healthy Adults. Clin Pharmacol Drug Dev 2024; 13:248-258. [PMID: 38231434 DOI: 10.1002/cpdd.1365] [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: 07/23/2023] [Accepted: 12/04/2023] [Indexed: 01/18/2024]
Abstract
Ganaxolone, a neuroactive steroid anticonvulsant that modulates both synaptic and extrasynaptic γ-aminobutyric acid type A (GABAA ) receptors, is in development for treatment of status epilepticus (SE) and rare epileptic disorders, and has been approved in the United States for treatment of seizures associated with cyclin-dependent kinase-like 5 deficiency disorder in patients ≥2 years old. This phase 1 study in 36 healthy volunteers evaluated the pharmacokinetics, pharmacodynamics, and safety of intravenous ganaxolone administered as a (i) single bolus, (ii) infusion, and (iii) bolus followed by continuous infusion. After a single bolus over 2 minutes (20 mg) or 5 minutes (10 or 30 mg), ganaxolone was detected in plasma with a median Tmax of 5 minutes, whereas a 60-minute infusion (10 or 30 mg) or a bolus (6 mg over 5 minutes) followed by infusion (20 mg/h) for 4 hours achieved a median Tmax of approximately 1 and 3 hours, respectively. Cmax was dose and administration-time dependent, ranging from 73.8 ng/mL (10 mg over 5 minutes) to 1240 ng/mL (30 mg over 5 minutes). Bolus doses above 10 mg of ganaxolone markedly influenced the bispectral index score with a rapid decline; smaller changes occurred on the Modified Observer's Assessment of Alertness/Sedation scale and in quantitative electroencephalogram. Most adverse events were of mild severity, with 2 events of moderate severity; none were reported as serious. No effects on systemic hemodynamics or respiratory functions were reported. Overall, ganaxolone was generally well tolerated at the doses studied and demonstrated pharmacokinetic and pharmacodynamic properties suitable to treat SE.
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Affiliation(s)
| | - Aatif Husain
- Duke University School of Medicine, Durham, NC, USA
| | | | | | | | | | | | - Eva Rybak
- Marinus Pharmaceuticals, Inc., Radnor, PA, USA
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Narayanaswami P, Sanders DB, Thomas L, Thibault D, Blevins J, Desai R, Krueger A, Bibeau K, Liu B, Guptill JT. Comparative effectiveness of azathioprine and mycophenolate mofetil for myasthenia gravis (PROMISE-MG): a prospective cohort study. Lancet Neurol 2024; 23:267-276. [PMID: 38365379 DOI: 10.1016/s1474-4422(24)00028-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 01/01/2024] [Accepted: 01/02/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND Myasthenia gravis is an autoimmune disorder of the neuromuscular junction. Treatment typically includes symptomatic oral cholinesterase inhibitors, immunosuppression, and immunomodulation. In addition to corticosteroids, azathioprine and mycophenolate mofetil are the most frequently used immunosuppressants in North America. We aimed to evaluate the comparative effectiveness of these two drugs, and to assess the effect of the dose and duration of treatment. METHODS We did a prospective cohort study at 19 academic centres in Canada and the USA. We included patients (aged ≥18 years) with autoimmune myasthenia gravis, who were never treated with immunosuppressants. Treating clinicians determined the choice of medication, dose, follow-up intervals, and drug monitoring. Outcome measures and adverse events were recorded at each visit. We assessed two co-primary outcomes. The first was the patient-reported Myasthenia Gravis-Quality of Life 15-revised (MGQOL-15r) score, measured as the mean change from treatment initiation to the follow-up visit with the lowest score. A clinically meaningful reduction (CMR) in MGQOL-15r was defined as a 5-point decrease. The second was a composite clinical outcome of disease improvement (Myasthenia Gravis Foundation of America Post-Intervention Status Minimal Manifestations or better) and low adverse event burden (defined as grade ≤1 Common Terminology Criteria for Adverse Events). We also compared these outcomes in patients receiving an adequate dose and duration of azathioprine (≥2 mg/kg per day for at least 12 months) or mycophenolate mofetil (≥2 g per day for at least 8 months) and a lower dose or shorter duration of these agents. We used propensity score weighting with generalised linear regression models. This study is registered with ClinicalTrials.gov (NCT03490539). FINDINGS Between May 1, 2018, and Aug 31, 2020, 167 patients were enrolled; 85 did not receive azathioprine or mycophenolate mofetil and were excluded. Four were excluded from outcome analyses because they had scores of 0 on an outcome measure at treatment initiation. Of the 78 patients included in analyses, 47 received mycophenolate mofetil (median follow-up 25 months [IQR 13·5-31·5]) and 31 received azathioprine (median follow-up 20 months [IQR 13-30]). The mean change in MG-QOL15r was -10·4 (95% CI -18·9 to -1·3) with mycophenolate mofetil and -6·8 (-17·2 to 3·6) with azathioprine (mean difference -3·3, 95% CI -7·7 to 1·2; p=0·15). 38 (81%) of 47 patients receiving mycophenolate mofetil and 18 (57%) of 31 receiving azathioprine had a CMR in MG-QOL15r (risk difference 24·0%; 95% CI -0·2 to 48·0; p=0·052). The clinical composite outcome was achieved in 22 (47·7%) of 47 patients who received mycophenolate mofetil and nine (28·1%) of 31 who received azathioprine (risk difference 19·6%, 95% CI -4·9 to 44·2; p=0·12). Descriptive analysis did not find a difference in the proportion of patients reaching a CMR in MG-QOL15r between the adequate dose and duration group and the lower dose or shorter duration group. Adverse events occurred in 11 (32%) of 34 patients who received azathioprine and nine (19%) of 48 who received mycophenolate mofetil. The most frequent adverse events were hepatotoxicity with azathioprine (five [15%] of 34) and gastrointestinal disturbances (seven [15%] of 48) with mycophenolate mofetil. There were no study-related deaths. INTERPRETATION More than half of patients treated with azathioprine and mycophenolate mofetil felt their quality of life improved; no difference in clinical outcomes was noted between the two drugs. Adverse events associated with azathioprine were potentially more serious than those with mycophenolate mofetil, although mycophenolate mofetil is teratogenic. Lower than recommended doses of azathioprine might be effective, with reduced dose-dependent adverse events. More comparative effectiveness studies are required to inform treatment choices in myasthenia gravis. FUNDING Patient-Centered Outcomes Research Institute, Myasthenia Gravis Foundation of America.
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Affiliation(s)
| | - Donald B Sanders
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Laine Thomas
- Duke Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | | | | | - Rishi Desai
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA USA
| | - Andrew Krueger
- Accordant Health Services, CVS Health, High Point, NC, USA
| | - Kathie Bibeau
- Myasthenia Gravis Foundation of America, Seattle, WA, USA
| | - Bo Liu
- Duke Department of Statistical Science, Duke University, Durham, NC, USA
| | - Jeffrey T Guptill
- Department of Neurology, Duke University Medical Center, Durham, NC, USA; Argenx US, Boston, MA, USA
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Hughes T, Howard JF, Silvestri NJ, Anderson AEL, Sato M, Suchotliff S, Guptill JT, Phillips G. The economic burden of individuals living with generalized myasthenia gravis and facing social determinants of health challenges. Front Public Health 2023; 11:1247931. [PMID: 37766748 PMCID: PMC10520715 DOI: 10.3389/fpubh.2023.1247931] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023] Open
Abstract
Objective Better understanding the impact of social determinants of health (SDOH) barriers from the patient perspective is crucial to improve holistic patient support in generalized myasthenia gravis (gMG), a rare autoimmune disorder with high disease and treatment burden. The objective of this study was to identify economic challenges experienced by individuals living with gMG and SDOH barriers to better address current unmet needs. Methods Adults (18-75 years) living with gMG and experiencing SDOH barriers in the United States were recruited to a mixed-methods study including qualitative interviews and a web-based quantitative survey. Quotas were implemented to include a balanced spread of baseline demographic categories including insurance type, living environment, and employment status among the study sample. Direct and indirect economic challenges were identified by degree of concern. Results The survey was completed by 38 individuals living with gMG, the majority of whom were enrolled in public insurance and not employed. The most commonly reported major economic concerns were managing funds for emergency care (66%), loss of income (61%), and non-medical expenses (58%), highlighting the diversity of economic challenges. Individuals who were using public insurance plans, living in non-urban environments, and unemployed experienced pronounced challenges around managing non-medical costs and accessing government assistance. Conclusion Both direct and indirect costs were emphasized as major concerns among individuals living with gMG and SDOH barriers. Increasing access to relevant, personalized, and holistic resources, including care management, should be prioritized to improve disease management and outcomes for individuals living with gMG.
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Affiliation(s)
- Tom Hughes
- Argenx US Inc., Boston, MA, United States
| | - James F. Howard
- Department of Neurology, University of North Carolina, Chapel Hill, NC, United States
| | | | | | - Mai Sato
- ZS Associates, New York, NY, United States
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Guptill JT, Benatar M, Granit V, Habib AA, Howard JF, Barnett-Tapia C, Nowak RJ, Lee I, Ruzhansky K, Dimachkie MM, Cutter GR, Kaminski HJ. Addressing Outcome Measure Variability in Myasthenia Gravis Clinical Trials. Neurology 2023; 101:442-451. [PMID: 37076302 PMCID: PMC10491448 DOI: 10.1212/wnl.0000000000207278] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 02/23/2023] [Indexed: 04/21/2023] Open
Abstract
An increasing number of clinical trials are enrolling patients with myasthenia gravis (MG). A lack of standardization in the performance of outcome measures leads to confusion among site research teams and is a source of variability in clinical trial data. MGNet, the NIH-supported Rare Disease Clinical Research Network for MG, views standardization of MG outcome measures as a critical need. To address this issue, a group of experts summarized key outcome measures used in MG clinical trials and a symposium was convened to address issues contributing to outcome measure variability. Consensus recommendations resulted in changes to outcome measure instructions and, in some cases, modifications to specific instruments. Recommended changes were posted for public commentary before finalization. Changes to the MG-Activities of Daily Living, MG-Quality of Life-15r, and MG-Impairment Index were limited to adding details to the administration instructions. Recommendations for proper positioning of participants and how to score items that could not be performed because of non-MG reasons were provided for the MG Composite. The Quantitative MG (QMG) score required the most attention, and changes were made both to the instructions and the performance of certain items resulting in the QMG-Revised. The Postintervention Status was believed to have a limited role in clinical trials, except for the concept of minimal manifestation status. As a next step, training materials and revised source documents, which will be freely available to study teams, will be created and posted on the MGNet website. Further studies are needed to validate changes made to the QMG-Revised.
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Affiliation(s)
- Jeffrey T Guptill
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC.
| | - Michael Benatar
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Volkan Granit
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Ali A Habib
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - James F Howard
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Carolina Barnett-Tapia
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Richard J Nowak
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Ikjae Lee
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Katherine Ruzhansky
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Mazen M Dimachkie
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Gary R Cutter
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Henry J Kaminski
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
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Masi G, Pham MC, Karatz T, Oh S, Payne AS, Nowak RJ, Howard JF, Guptill JT, Juel VC, O'Connor KC. Clinicoserological insights into patients with immune checkpoint inhibitor-induced myasthenia gravis. Ann Clin Transl Neurol 2023; 10:825-831. [PMID: 36924454 PMCID: PMC10187728 DOI: 10.1002/acn3.51761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/01/2023] [Accepted: 03/03/2023] [Indexed: 03/18/2023] Open
Abstract
To compare the immunopathology of immune checkpoint inhibitor-induced myasthenia gravis (ICI-MG) and idiopathic MG, we profiled the respective AChR autoantibody pathogenic properties. Of three ICI-MG patients with AChR autoantibodies, only one showed complement activation and modulation/blocking potency, resembling idiopathic MG. In contrast, AChR autoantibody-mediated effector functions were not detected in the other two patients, questioning the role of their AChR autoantibodies as key mediators of pathology. The contrasting properties of AChR autoantibodies in these cases challenge the accuracy of serological testing in establishing definite ICI-MG diagnoses and underscore the importance of a thorough clinical assessment when evaluating ICI-related adverse events.
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Affiliation(s)
- Gianvito Masi
- Department of Immunobiology, Yale School of Medicine, New Haven, Connecticut, 06511, USA
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, 06511, USA
| | - Minh C Pham
- Department of Immunobiology, Yale School of Medicine, New Haven, Connecticut, 06511, USA
| | - Tabitha Karatz
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, 27710, USA
| | - Sangwook Oh
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, 19104, USA
| | - Aimee S Payne
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, 19104, USA
| | - Richard J Nowak
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, 06511, USA
| | - James F Howard
- Department of Neurology, The University of North Carolina at Chapel Hill, CB#7025, Houpt Building, 170 Manning Drive, Chapel Hill, North Carolina, 27599-7025, USA
| | - Jeffrey T Guptill
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, 27710, USA
| | - Vern C Juel
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, 27710, USA
| | - Kevin C O'Connor
- Department of Immunobiology, Yale School of Medicine, New Haven, Connecticut, 06511, USA
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, 06511, USA
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Sanders DB, Lutz MW, Raja SM, Juel VC, Guptill JT, Hobson-Webb LD, Massey JM. The Duke Myasthenia Gravis Clinic Registry: II. Analysis of outcomes. Muscle Nerve 2023; 67:291-296. [PMID: 36734303 DOI: 10.1002/mus.27794] [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: 06/02/2022] [Revised: 01/25/2023] [Accepted: 01/29/2023] [Indexed: 02/04/2023]
Abstract
INTRODUCTION/AIMS The Duke Myasthenia Gravis (MG) Clinic Registry contains comprehensive physician-derived data on patients with MG seen in the Duke MG Clinic since 1980. The aim of this study was to report outcomes in patients seen in the clinic and treated according to the International Consensus Guidance statements. METHODS This is a retrospective cohort study of patients initially seen after 2000 and followed for at least 2 years in the clinic. Treatment goal (TG) was defined as achieving MGFA post-intervention status of "minimal manifestations" or better; PIS was determined by the treating neurologist. Time-to-event analysis, including Cox proportional hazards modeling, was performed to assess the effect of sex, acetylcholine receptor antibody (AChR-Ab) status, age at disease onset, distribution (ocular vs generalized), thymectomy, and thymoma on the time to achieve TG. RESULTS Among the 367 cohort patients, 72% achieved TG (median time less than 2 years). A greater proportion of patients with AChR-Abs and thymectomy achieved TG and they did so sooner than patients without these antibodies or thymectomy. Otherwise, there were no significant differences in these findings within the tested subgroups. The disease duration at the first Duke Clinic visit was shorter in patients who achieved TG than in those who did not. DISCUSSION These results demonstrate outcomes that can be achieved in patients with MG treated according to the current Consensus Guidance statements. Among other things, they can be used to determine the added value and potential role of new treatment modalities developed since 2018.
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Affiliation(s)
- Donald B Sanders
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Michael W Lutz
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Shruti M Raja
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Vern C Juel
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey T Guptill
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Lisa D Hobson-Webb
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Janice M Massey
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina
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Lodise TP, O’Donnell JN, Balevic S, Liu X, Gu K, George J, Raja S, Guptill JT, Zaharoff S, Schwager N, Fowler VG, Wall A, Wiegand K, Chambers HF. Pharmacokinetics of Ceftazidime-Avibactam in Combination with Aztreonam (COMBINE) in a Phase 1, Open-Label Study of Healthy Adults. Antimicrob Agents Chemother 2022; 66:e0093622. [PMID: 36394326 PMCID: PMC9764983 DOI: 10.1128/aac.00936-22] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 07/08/2022] [Accepted: 10/19/2022] [Indexed: 11/19/2022] Open
Abstract
Scant pharmacokinetic (PK) data are available on ceftazidime-avibactam (CZA) and aztreonam (ATM) in combination, and it is unknown if CZA-ATM exacerbates alanine aminotransferase (ALT)/aspartate aminotransferase (AST) elevations relative to ATM alone. This phase 1 study sought to describe the PK of CZA-ATM and assess the associations between ATM exposures and ALT/AST elevations. Subjects (n = 48) were assigned to one of six cohorts (intermittent infusion [II] CZA, continuous infusion [CI] CZA, II ATM, CI ATM [8 g/daily], II CZA with II ATM [6 g/daily], and II CZA with II ATM [8 g/daily]), and study product(s) were administered for 7 days. A total of 19 subjects (40%) had ALT/AST elevations, and most (89%) occurred in the ATM/CZA-ATM cohorts. Two subjects in the CI ATM cohort experienced severe ALT/AST elevations, which halted the study. All subjects with ALT/AST elevations were asymptomatic with no other signs of liver injury, and all ALT/AST elevations resolved without sequalae after cessation of dosing. In the population PK (PopPK) analyses, CZA-ATM administration reduced total ATM clearance by 16%, had a negligible effect on total ceftazidime clearance, and was not a covariate in the avibactam PopPK model. In the exposure-response analyses, coadministration of CZA-ATM was not found to augment ALT/AST elevations. Modest associations were observed between ATM exposure (maximum concentration of drug in serum [Cmax] and area under the concentration-time curve [AUC]) and ALT/AST elevations in the analysis of subjects in the II ATM/CZA-ATM cohorts. The findings suggest that administration of CZA-ATM reduces ATM clearance but does not exacerbate AST/ALT elevations relative to ATM alone. The results also indicate that CI ATM should be used with caution.
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Affiliation(s)
- Thomas P. Lodise
- Albany College of Pharmacy and Health Sciences, Albany, New York, USA
| | | | - Stephen Balevic
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Xing Liu
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kenan Gu
- Office of Regulatory Affairs (ORA), Division of Microbiology and Infectious Diseases (DMID), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Jomy George
- Office of Regulatory Affairs (ORA), Division of Microbiology and Infectious Diseases (DMID), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Shruti Raja
- Duke Early Phase Clinical Research Unit, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jeffrey T. Guptill
- Duke Early Phase Clinical Research Unit, Duke University School of Medicine, Durham, North Carolina, USA
| | - Smitha Zaharoff
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nyssa Schwager
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Vance G. Fowler
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Henry F. Chambers
- University of California, San Francisco, and San Francisco General Hospital, San Francisco, California, USA
| | - Antibacterial Resistance Leadership Group
- Albany College of Pharmacy and Health Sciences, Albany, New York, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Office of Regulatory Affairs (ORA), Division of Microbiology and Infectious Diseases (DMID), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
- Duke Early Phase Clinical Research Unit, Duke University School of Medicine, Durham, North Carolina, USA
- The Emmes Company, Rockville, Maryland, USA
- University of California, San Francisco, and San Francisco General Hospital, San Francisco, California, USA
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8
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Lodise TP, O’Donnell JN, Raja S, Guptill JT, Zaharoff S, Schwager N, Fowler VG, Beresnev T, Wall A, Wiegand K, Serti Chrisos E, Balevic S, Chambers HF. Safety of Ceftazidime-Avibactam in Combination with Aztreonam (COMBINE) in a Phase I, Open-Label Study in Healthy Adult Volunteers. Antimicrob Agents Chemother 2022; 66:e0093522. [PMID: 36394316 PMCID: PMC9764989 DOI: 10.1128/aac.00935-22] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 07/08/2022] [Accepted: 10/17/2022] [Indexed: 11/19/2022] Open
Abstract
This phase I study evaluated the safety of the optimal ceftazidime-avibactam (CZA) with aztreonam (ATM) regimens identified in hollow fiber infection models of MBL-producing Enterobacterales. Eligible healthy subjects aged 18 to 45 years were assigned to one of six cohorts: 2.5 g CZA over 2 h every 8 h (approved dose), CZA continuous infusion (CI) (7.5 g daily), 2 g ATM over 2 h every 6 h, ATM CI (8 g daily), CZA (approved dose) with 1.5 g ATM over 2 h every 6 h, and CZA (approved dose) with 2 g ATM over 2 h every 6 h. Study drug(s) were administered for 7 days. The most frequently observed adverse events (AEs) were hepatic aminotransferase (ALT/AST) elevations (n = 19 subjects). Seventeen of the 19 subjects with ALT/AST elevations received ATM alone or CZA-ATM. The incidence of ALT/AST elevations was comparable between the ATM-alone and CZA-ATM cohorts. Two subjects in the ATM CI cohort experienced severe ALT/AST elevation AEs. All subjects with ALT/AST elevations were asymptomatic with no other findings suggestive of liver injury. Most other AEs were of mild to moderate severity and were similar across cohorts, except for prolonged prothrombin time (more frequent in CZA-ATM cohorts). These results suggest that CZA-ATM administered as 2-h intermittent infusions is safe and that some caution should be exercised with the use of ATM CI at an ATM dose of 8 g daily. If CZA-ATM is prescribed, clinicians are advised to monitor liver function, hematologic, and coagulation parameters. Future controlled studies are required to better define the safety and efficacy of the CZA-ATM regimens evaluated in this phase I study.
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Affiliation(s)
- Thomas P. Lodise
- Albany College of Pharmacy and Health Sciences, Albany, New York, USA
| | | | - Shruti Raja
- Duke Early Phase Clinical Research Unit, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jeffrey T. Guptill
- Duke Early Phase Clinical Research Unit, Duke University School of Medicine, Durham, North Carolina, USA
| | - Smitha Zaharoff
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nyssa Schwager
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Vance G. Fowler
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Tatiana Beresnev
- Division of Microbiology and Infectious Diseases (DMID), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | | | | | | | - Stephen Balevic
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Henry F. Chambers
- University of California, San Francisco, and San Francisco General Hospital, San Francisco, California, USA
| | - Antibacterial Resistance Leadership Group
- Albany College of Pharmacy and Health Sciences, Albany, New York, USA
- Duke Early Phase Clinical Research Unit, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Division of Microbiology and Infectious Diseases (DMID), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
- The Emmes Company, Rockville, Maryland, USA
- University of California, San Francisco, and San Francisco General Hospital, San Francisco, California, USA
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Guptill JT, Sleasman JW, Steeland S, Sips M, Gelinas D, de Haard H, Azar A, Winthrop KL. Effect of FcRn antagonism on protective antibodies and to vaccines in IgG-mediated autoimmune diseases pemphigus and generalised myasthenia gravis. Autoimmunity 2022; 55:620-631. [PMID: 36036539 DOI: 10.1080/08916934.2022.2104261] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Antagonism of the neonatal Fc receptor (FcRn) by efgartigimod has been studied in several autoimmune diseases mediated by immunoglobulin G (IgG) as a therapeutic approach to remove pathogenic IgGs. Whereas reduction of pathogenic titres has demonstrated efficacy in multiple autoimmune diseases, reducing total IgG could potentially increase infection risk in patients receiving FcRn antagonists. The objective of this study was to analyse the effect of FcRn antagonism with efgartigimod on existing protective antibody titres and the ability to mount an immune response after vaccine challenge. Serum levels of total IgG and protective antibodies against tetanus toxoid (TT), varicella zoster virus (VZV), and pneumococcal capsular polysaccharide (PCP) were measured in all patients enrolled in an open-label trial of efgartigimod for the treatment of pemphigus. Vaccine specific-responses were assessed by measuring changes in IgG titres in patients with generalised myasthenia gravis (gMG) who were treated with efgartigimod and who received influenza, pneumococcal, or coronavirus disease 2019 (COVID-19) vaccines during participation in the double-blind trial ADAPT or open-label extension, ADAPT+ (n = 17). FcRn antagonism reduced levels of protective anti-TT, anti-VZV, and anti-PCP antibodies and total IgG to a similar extent; anti-TT and anti-VZV titres remained above minimally protective thresholds for the majority of patients, (10/12) 83% and (14/15) 93% respectively. Protective antibodies returned to baseline values upon treatment cessation. Antigen-specific IgG responses to influenza, pneumococcal, and COVID-19 immunisation were detected in patients with gMG who received these vaccines while undergoing therapy with efgartigimod. In conclusion, FcRn antagonism with efgartigimod did not hamper generation of IgG responses but did transiently reduce IgG titres of all specificities.
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Affiliation(s)
- Jeffrey T Guptill
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA.,argenx, Ghent, Belgium
| | - John W Sleasman
- Department of Pediatrics, Division of Allergy, Immunology, and Pulmonary Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | | | | | - Antoine Azar
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kevin L Winthrop
- Division of Infectious Disease, Oregon Health and Science University, Portland, Oregon, USA
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10
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Statland JM, Campbell C, Desai U, Karam C, Díaz-Manera J, Guptill JT, Korngut L, Genge A, Tawil RN, Elman L, Joyce NC, Wagner KR, Manousakis G, Amato AA, Butterfield RJ, Shieh PB, Wicklund M, Gamez J, Bodkin C, Pestronk A, Weihl CC, Vilchez-Padilla JJ, Johnson NE, Mathews KD, Miller B, Leneus A, Fowler M, van de Rijn M, Attie KM. Randomized phase 2 study of ACE-083, a muscle-promoting agent, in facioscapulohumeral muscular dystrophy. Muscle Nerve 2022; 66:50-62. [PMID: 35428982 PMCID: PMC9321022 DOI: 10.1002/mus.27558] [Citation(s) in RCA: 1] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 04/07/2022] [Accepted: 04/09/2022] [Indexed: 12/21/2022]
Abstract
Introduction/Aims Facioscapulohumeral muscular dystrophy (FSHD) is a slowly progressive muscular dystrophy without approved therapies. In this study we evaluated whether locally acting ACE‐083 could safely increase muscle volume and improve functional outcomes in adults with FSHD. Methods Participants were at least 18 years old and had FSHD1/FSHD2. Part 1 was open label, ascending dose, assessing safety and tolerability (primary objective). Part 2 was randomized, double‐blind for 6 months, evaluating ACE‐083240 mg/muscle vs placebo injected bilaterally every 3 weeks in the biceps brachii (BB) or tibialis anterior (TA) muscles, followed by 6 months of open label. Magnetic resonance imaging measures included total muscle volume (TMV; primary objective), fat fraction (FF), and contractile muscle volume (CMV). Functional measures included 6‐minute walk test, 10‐meter walk/run, and 4‐stair climb (TA group), and performance of upper limb midlevel/elbow score (BB group). Strength, patient‐reported outcomes (PROs), and safety were also evaluated. Results Parts 1 and 2 enrolled 37 and 58 participants, respectively. Among 55 participants evaluable in Part 2, the least‐squares mean (90% confidence interval, analysis of covariance) treatment difference for TMV was 16.4% (9.8%‐23.0%) in the BB group (P < .0001) and 9.5% (3.2%‐15.9%) in the TA group (P = .01). CMV increased significantly in the BB and TA groups and FF decreased in the TA group. There were no consistent improvements in functional or PRO measures in either group. The most common adverse events were mild or moderate injection‐site reactions. Discussion Significant increases in TMV with ACE‐083 vs placebo did not result in consistent functional or PRO improvements with up to 12 months of treatment.
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Affiliation(s)
- Jeffrey M Statland
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Craig Campbell
- Department of Pediatrics and Clinical Neurological Sciences, University of Western Ontario, London, Ontario, Canada
| | - Urvi Desai
- Carolinas MDA Care Center, Atrium Health, Charlotte, North Carolina, USA
| | - Chafic Karam
- Neuromuscular Division, Oregon Health & Science University, Portland, Oregon, USA
| | - Jordi Díaz-Manera
- Neuromuscular Diseases Unit, Neurology Department, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain.,Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Enfermedades Raras, Madrid, Spain.,John Walton Muscular Dystrophy Research Centre, Newcastle University Translational and Clinical Research Institute, Newcastle, UK
| | - Jeffrey T Guptill
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Angela Genge
- Montreal Neurological Institute, Montreal, Quebec, Canada
| | - Rabi N Tawil
- University of Rochester School of Medicine, Rochester, New York, USA
| | - Lauren Elman
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nanette C Joyce
- University of California Davis Medical Center, Davis, California, USA
| | - Kathryn R Wagner
- Johns Hopkins School of Medicine, Kennedy Krieger Institute, Baltimore, Maryland, USA
| | - Georgios Manousakis
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Russell J Butterfield
- Departments of Neurology and Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Perry B Shieh
- University of California Los Angeles, Los Angeles, California, USA
| | | | - Josep Gamez
- Department of Medicine, GMA Clinic, European Reference Network on Rare Neuromuscular Diseases (ERN EURO-NMD) and Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Cynthia Bodkin
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Alan Pestronk
- Washington University School of Medicine, St. Louis, Missouri, USA
| | - Conrad C Weihl
- Washington University School of Medicine, St. Louis, Missouri, USA
| | - Juan J Vilchez-Padilla
- Hospital UIP La Fe, Neuromuscular Reference Centre, Valencia, Spain.,Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Enfermedades Raras, Madrid, Spain
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11
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Masi G, Li Y, Karatz T, Pham MC, Oxendine SR, Nowak RJ, Guptill JT, O'Connor KC. The clinical need for clustered AChR cell-based assay testing of seronegative MG. J Neuroimmunol 2022; 367:577850. [PMID: 35366559 PMCID: PMC9106915 DOI: 10.1016/j.jneuroim.2022.577850] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 03/11/2022] [Accepted: 03/23/2022] [Indexed: 12/31/2022]
Abstract
Trial eligibility in myasthenia gravis (MG) remains largely dependent on a positive autoantibody serostatus. This significantly hinders seronegative MG (SNMG) patients from receiving potentially beneficial new treatments. In a subset of SNMG patients, acetylcholine receptor (AChR) autoantibodies are detectable by a clustered AChR cell-based assay (CBA). Of 99 SNMG patients from two academic U.S. centers, 18 (18.2%) tested positive by this assay. Autoantibody positivity was further validated in 17/18 patients. In a complementary experiment, circulating AChR-specific B cells were identified in a CBA-positive SNMG patient. These findings corroborate the clinical need for clustered AChR CBA testing when evaluating SNMG patients.
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Affiliation(s)
- Gianvito Masi
- Department of Neurology, Yale School of Medicine, New Haven, CT 06511, USA; Department of Immunobiology, Yale School of Medicine, New Haven, CT 06511, USA
| | - Yingkai Li
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, NC 27710, USA
| | - Tabitha Karatz
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, NC 27710, USA
| | - Minh C Pham
- Department of Immunobiology, Yale School of Medicine, New Haven, CT 06511, USA
| | - Seneca R Oxendine
- Department of Neurology, Yale School of Medicine, New Haven, CT 06511, USA; Department of Immunobiology, Yale School of Medicine, New Haven, CT 06511, USA
| | - Richard J Nowak
- Department of Neurology, Yale School of Medicine, New Haven, CT 06511, USA
| | - Jeffrey T Guptill
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, NC 27710, USA; Duke Clinical Research Institute, Durham, NC 27710, USA
| | - Kevin C O'Connor
- Department of Neurology, Yale School of Medicine, New Haven, CT 06511, USA; Department of Immunobiology, Yale School of Medicine, New Haven, CT 06511, USA.
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12
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Rumsey JW, Lorance C, Jackson M, Sasserath T, McAleer CW, Long CJ, Goswami A, Russo MA, Raja SM, Gable KL, Emmett D, Hobson-Webb LD, Chopra M, Howard JF, Guptill JT, Storek MJ, Alonso-Alonso M, Atassi N, Panicker S, Parry G, Hammond T, Hickman JJ. Classical Complement Pathway Inhibition in a "Human-On-A-Chip" Model of Autoimmune Demyelinating Neuropathies. Adv Ther (Weinh) 2022; 5:2200030. [PMID: 36211621 PMCID: PMC9540753 DOI: 10.1002/adtp.202200030] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 02/14/2022] [Indexed: 07/21/2023]
Abstract
Chronic autoimmune demyelinating neuropathies are a group of rare neuromuscular disorders with complex, poorly characterized etiology. Here we describe a phenotypic, human-on-a-chip (HoaC) electrical conduction model of two rare autoimmune demyelinating neuropathies, chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy (MMN), and explore the efficacy of TNT005, a monoclonal antibody inhibitor of the classical complement pathway. Patient sera was shown to contain anti-GM1 IgM and IgG antibodies capable of binding to human primary Schwann cells and induced pluripotent stem cell derived motoneurons. Patient autoantibody binding was sufficient to activate the classical complement pathway resulting in detection of C3b and C5b-9 deposits. A HoaC model, using a microelectrode array with directed axonal outgrowth over the electrodes treated with patient sera, exhibited reductions in motoneuron action potential frequency and conduction velocity. TNT005 rescued the serum-induced complement deposition and functional deficits while treatment with an isotype control antibody had no rescue effect. These data indicate that complement activation by CIDP and MMN patient serum is sufficient to mimic neurophysiological features of each disease and that complement inhibition with TNT005 was sufficient to rescue these pathological effects and provide efficacy data included in an investigational new drug application, demonstrating the model's translational potential.
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Affiliation(s)
- John W Rumsey
- Hesperos, Inc., 12501 Research Parkway, Suite 100, Orlando, FL 32826
| | - Case Lorance
- Hesperos, Inc., 12501 Research Parkway, Suite 100, Orlando, FL 32826
| | - Max Jackson
- Hesperos, Inc., 12501 Research Parkway, Suite 100, Orlando, FL 32826
| | - Trevor Sasserath
- Hesperos, Inc., 12501 Research Parkway, Suite 100, Orlando, FL 32826
| | | | | | - Arindom Goswami
- NanoScience Technology Center, University of Central Florida, Orlando, Florida, USA
| | - Melissa A Russo
- Division of Neuromuscular Disease, Department of Neurology, Duke University Medical Center, Box 3403, Durham, NC, USA
| | - Shruti M Raja
- Division of Neuromuscular Disease, Department of Neurology, Duke University Medical Center, Box 3403, Durham, NC, USA
| | - Karissa L Gable
- Division of Neuromuscular Disease, Department of Neurology, Duke University Medical Center, Box 3403, Durham, NC, USA
| | - Doug Emmett
- Division of Neuromuscular Disease, Department of Neurology, Duke University Medical Center, Box 3403, Durham, NC, USA
| | - Lisa D Hobson-Webb
- Division of Neuromuscular Disease, Department of Neurology, Duke University Medical Center, Box 3403, Durham, NC, USA
| | - Manisha Chopra
- Department of Neurology, The University of North Carolina - Chapel Hill, School of Medicine, Chapel Hill, NC, USA
| | - James F Howard
- Department of Neurology, The University of North Carolina - Chapel Hill, School of Medicine, Chapel Hill, NC, USA
| | - Jeffrey T Guptill
- Division of Neuromuscular Disease, Department of Neurology, Duke University Medical Center, Box 3403, Durham, NC, USA
| | - Michael J Storek
- Sanofi, Immunology and Inflammation, 225 2 Ave, Waltham, MA, 02451 USA
| | | | - Nazem Atassi
- Sanofi, Neurology Early Development, 50 Binney Street, Cambridge, MA, 02142 USA
| | - Sandip Panicker
- Bioverativ, a Sanofi company, 225 2 Ave, Waltham, MA, 02451 USA
| | - Graham Parry
- Bioverativ, a Sanofi company, 225 2 Ave, Waltham, MA, 02451 USA
| | - Timothy Hammond
- Sanofi, Neurological Diseases, 49 New York Ave, Framingham, MA, 01701 USA
| | - James J Hickman
- Hesperos, Inc., 12501 Research Parkway, Suite 100, Orlando, FL 32826
- NanoScience Technology Center, University of Central Florida, Orlando, Florida, USA
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13
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Balevic SJ, Raja SM, Randell R, Deye GA, Conrad T, Nakamura A, Peyton DH, Shotwell S, Liebman K, Cohen-Wolkowiez M, Guptill JT. Adverse Reactions in a Phase 1 Trial of the Anti-Malarial DM1157: An Example of Pharmacokinetic Modeling and Simulation Guiding Clinical Trial Decisions. Infect Dis Ther 2022; 11:841-852. [PMID: 35184256 PMCID: PMC8960550 DOI: 10.1007/s40121-022-00605-z] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 01/31/2022] [Indexed: 11/12/2022] Open
Abstract
Introduction There is an urgent need to develop new drugs to treat malaria due to increasing resistance to first-line therapeutics targeting the causative organism, Plasmodium falciparum (P. falciparum). One drug candidate is DM1157, a small molecule that inhibits the formation of hemozoin, which protects P. falciparum from heme toxicity. We describe a first-in-human, phase 1 trial of DM1157 in healthy adult volunteers that was halted early because of significant toxicity. Methods Adverse events were summarized using descriptive statistics. We used pharmacokinetic modeling to quantitatively assess whether the DM1157 exposure needed for P. falciparum inhibition was achievable at safe doses. Results We found that there was no dose where both the safety and efficacy target were simultaneously achieved; conversely, the model predicted that 27 mg was the highest dosage at which patients would consistently maintain safe exposure with multiple dosing. By pre-defining dose escalation stopping rules and conducting an interim pharmacokinetic/pharmacodynamic analysis, we determined that the study would be unable to safely achieve a dosage needed to observe an anti-malarial effect, thereby providing strong rationale to halt the study. Conclusion This study provides an important example of the risks and challenges of conducting early phase research as well as the role of modeling and simulation to optimize participant safety (ClinicalTrials.gov, NCT03490162). Supplementary Information The online version contains supplementary material available at 10.1007/s40121-022-00605-z.
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14
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Punga AR, Maddison P, Heckmann JM, Guptill JT, Evoli A. Epidemiology, diagnostics, and biomarkers of autoimmune neuromuscular junction disorders. Lancet Neurol 2022; 21:176-188. [DOI: 10.1016/s1474-4422(21)00297-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/18/2021] [Accepted: 08/25/2021] [Indexed: 12/14/2022]
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15
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Narayanaswami P, Sanders DB, Bibeau K, Krueger A, Venitz J, Guptill JT. Identifying a patient-centered outcome measure for a comparative effectiveness treatment trial in myasthenia gravis. Muscle Nerve 2021; 65:75-81. [PMID: 34687458 DOI: 10.1002/mus.27443] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 11/09/2022]
Abstract
INTRODUCTION/AIMS Data regarding the comparative effectiveness of myasthenia gravis (MG) treatments is not available. We used patient input to identify a patient-centered outcome measure (PCOM) for PROMISE-MG, a comparative effectiveness trial of MG treatments. METHODS First, a questionnaire survey was administered to 58 people with MG at the patient meeting of the Myasthenia Gravis Foundation of America (MGFA), evaluating the impact of MG-related symptoms and MG treatments on patients' lives. Second, an online focus group of 13 patients with MG was conducted. Third, a potential outcome measure was selected. Fourth, the selected PCOM was evaluated by patients to assess how completely and accurately it captured their experiences with MG. RESULTS The patient survey showed that limb weakness had the most impact on patients' lives. Weight gain, mood swings, insomnia, and diarrhea were the most bothersome treatment side effects. Avoiding hospitalization was very important. Focus group participants reported fatigue as one of the most bothersome symptoms and differentiated it from myasthenic weakness. They defined an ideal treatment as having minimal or no side effects and an 80% improvement in symptoms. DISCUSSION Based on patient input, the 15-item Myasthenia Gravis Quality of Life-Revised (MG-QOL15R) scale, a validated patient-reported outcome measure (PRO), was selected as the primary PCOM for PROMISE-MG. Avoiding hospitalization and having minimal to no treatment adverse effects were selected as additional outcome measures. The patient-centeredness of a PRO depends on the context of a study: PROs should be evaluated for appropriateness as a PCOM for every study.
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Affiliation(s)
- Pushpa Narayanaswami
- Department of Neurology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA
| | - Donald B Sanders
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Kathie Bibeau
- Myasthenia Gravis Foundation of America, Seattle, Washington, USA
| | - Andrew Krueger
- Accordant Health Services, Greensboro, North Carolina, USA
| | - Jurgen Venitz
- Department of Pharmaceutics, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA
| | - Jeffrey T Guptill
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
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Harada Y, Guptill JT. Management/Treatment of Lambert-Eaton Myasthenic Syndrome. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00690-4] [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: 10/20/2022]
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17
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Li Y, Yi JS, Howard JF, Chopra M, Russo MA, Guptill JT. Cellular changes in eculizumab early responders with generalized myasthenia gravis. Clin Immunol 2021; 231:108830. [PMID: 34450290 DOI: 10.1016/j.clim.2021.108830] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 04/12/2021] [Revised: 08/19/2021] [Accepted: 08/19/2021] [Indexed: 11/19/2022]
Abstract
Eculizumab (ECU), a C5 complement inhibitor, is approved to treat acetylcholine receptor autoantibody positive generalized myasthenia gravis (AChR MG). The clinical effect of ECU relies on inhibition of the terminal complement complex; however, the effect of ECU on lymphocytes is largely unknown. We evaluated innate and adaptive immunity among AChR MG patients (N = 3) before ECU and ≥3 months later while on stable therapy, and found reduced activation markers in memory CD4+ T cell subsets, increased regulatory T cell populations, and reduced frequencies of CXCR5+HLA-DR+CCR7+ Tfh subsets and CD11b+ migratory memory B cells. We observed increases within CD8+ T cell subsets that were terminally differentiated and senescent. Our data suggest complement inhibition with ECU modulates the adaptive immunity in patients with MG, consistent with preclinical data showing changes in complement-mediated signaling by T- and antigen-presenting cells. These findings extend our understanding of ECU's mechanism of action when treating patients with MG.
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Affiliation(s)
- Yingkai Li
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - John S Yi
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - James F Howard
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Manisha Chopra
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Melissa A Russo
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey T Guptill
- Department of Neurology, Duke University Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
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18
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Raja SM, Guptill JT, McConnell A, Al-Khalidi HR, Hartwig MG, Klapper JA. Perioperative Outcomes of Thymectomy in Myasthenia Gravis: A Thoracic Surgery Database Analysis. Ann Thorac Surg 2021; 113:904-910. [PMID: 34339670 DOI: 10.1016/j.athoracsur.2021.06.071] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 05/22/2021] [Accepted: 06/25/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND There is clinical equipoise regarding the perioperative and long-term outcomes of autoimmune myasthenia gravis (MG) patients undergoing open vs minimally invasive thymectomy, particularly for non-thymomatous MG. This analysis utilizes multicenter, real-world clinical evidence to assess perioperative complications of open and minimally invasive thymectomy techniques in MG patients. METHODS Thymectomy cases 2009-2019 in MG patients were identified in the Society of Thoracic Surgeons General Thoracic Surgery Database. Thymectomies were grouped by surgical technique: transthoracic (TT), transcervical (TC), video-assisted thoracoscopic surgery (VATS), or Robotic VATS (RVATS). Multivariable logistic regression models assessed the association between surgical technique and perioperative complications. RESULTS Analysis of non-thymomatous cases (n=1,725) revealed VATS (OR 0.44, CI 0.23-0.83), RVATS (0.73, 0.48-1.26) and TC (0.19, 0.06-0.62) had lower odds of perioperative complications than TT thymectomies. VATS (2.29, 0.63-8.30) and RVATS (4.08, 1.21-3.78) thymectomies had higher odds of perioperative complications than TC. Analysis of thymomatous cases (n=311) found no significant difference in the odds of perioperative complications in TT vs minimally invasive (VATS/RVATS) procedures. The proportion of RVATS procedures increased from 6.43% to 44.27% while TT (56.43% to 34.35%) and TC (19.29% to 6.87%) thymectomies decreased. CONCLUSIONS Minimally invasive and TC thymectomies have fewer perioperative complications than TT when performed for non-thymomatous MG. Minimally invasive procedures are increasingly performed for both non-thymomatous and thymomatous disease. There is a nationwide shift towards minimally invasive procedures, even for thymoma resections. Long-term neurological outcome data are needed to determine whether a reduced perioperative risk for minimally invasive thymectomies translates to improved MG outcomes.
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Affiliation(s)
- Shruti M Raja
- Department of Neurology, Division of Neuromuscular Medicine, Duke University Medical Center.
| | - Jeffrey T Guptill
- Department of Neurology, Division of Neuromuscular Medicine, Duke University Medical Center
| | - Alec McConnell
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine
| | - Hussein R Al-Khalidi
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine
| | - Matthew G Hartwig
- Department of Surgery, Division of Cardiothoracic Surgery, Duke University Medical Center
| | - Jacob A Klapper
- Department of Surgery, Division of Cardiothoracic Surgery, Duke University Medical Center
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19
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Guidon AC, Muppidi S, Nowak RJ, Guptill JT, Hehir MK, Ruzhansky K, Burton LB, Post D, Cutter G, Conwit R, Mejia NI, Kaminski HJ, Howard JF. Telemedicine visits in myasthenia gravis: Expert guidance and the Myasthenia Gravis Core Exam (MG-CE). Muscle Nerve 2021; 64:270-276. [PMID: 33959997 DOI: 10.1002/mus.27260] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 07/30/2020] [Revised: 04/26/2021] [Accepted: 05/04/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION/AIMS Telemedicine may be particularly well-suited for myasthenia gravis (MG) due to the disorder's need for specialized care, its hallmark fluctuating muscle weakness, and the potential for increased risk of virus exposure among patients with MG during the coronavirus disease 2019 (COVID-19) pandemic during in-person clinical visits. A disease-specific telemedicine physical examination to reflect myasthenic weakness does not currently exist. METHODS This paper outlines step-by-step guidance on the fundamentals of a telemedicine assessment for MG. The Myasthenia Gravis Core Exam (MG-CE) is introduced as a MG-specific, telemedicine, physical examination, which contains eight components (ptosis, diplopia, facial strength, bulbar strength, dysarthria, single breath count, arm strength, and sit to stand) and takes approximately 10 minutes to complete. RESULTS Pre-visit preparation, remote ascertainment of patient-reported outcome scales and visit documentation are also addressed. DISCUSSION Additional knowledge gaps in telemedicine specific to MG care are identified for future investigation.
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Affiliation(s)
- Amanda C Guidon
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Srikanth Muppidi
- Department of Neurology, Stanford University Hospital, Palo Alto, California, USA
| | - Richard J Nowak
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jeffrey T Guptill
- Department of Neurology, Duke University, Durham, North Carolina, USA
| | - Michael K Hehir
- Department of Neurological Sciences, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Katherine Ruzhansky
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Leeann B Burton
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David Post
- Department of Neurology, Stanford University Hospital, Palo Alto, California, USA
| | - Gary Cutter
- Department of Biostatistics, University of Alabama, Birmingham, Alabama, USA
| | - Robin Conwit
- Division of Clinical Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, NINDS, Rockville, Maryland, USA
| | - Nicte I Mejia
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Henry J Kaminski
- Department of Neurology, George Washington University Medical Center, Washington, District of Columbia, USA
| | - James F Howard
- Department of Neurology, The University of North Carolina, Chapel Hill, North Carolina, USA
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20
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Guidon AC, Burton LB, Chwalisz BK, Hillis J, Schaller TH, Amato AA, Betof Warner A, Brastianos PK, Cho TA, Clardy SL, Cohen JV, Dietrich J, Dougan M, Doughty CT, Dubey D, Gelfand JM, Guptill JT, Johnson DB, Juel VC, Kadish R, Kolb N, LeBoeuf NR, Linnoila J, Mammen AL, Martinez-Lage M, Mooradian MJ, Naidoo J, Neilan TG, Reardon DA, Rubin KM, Santomasso BD, Sullivan RJ, Wang N, Woodman K, Zubiri L, Louv WC, Reynolds KL. Consensus disease definitions for neurologic immune-related adverse events of immune checkpoint inhibitors. J Immunother Cancer 2021; 9:e002890. [PMID: 34281989 PMCID: PMC8291304 DOI: 10.1136/jitc-2021-002890] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2021] [Indexed: 12/12/2022] Open
Abstract
Expanding the US Food and Drug Administration-approved indications for immune checkpoint inhibitors in patients with cancer has resulted in therapeutic success and immune-related adverse events (irAEs). Neurologic irAEs (irAE-Ns) have an incidence of 1%-12% and a high fatality rate relative to other irAEs. Lack of standardized disease definitions and accurate phenotyping leads to syndrome misclassification and impedes development of evidence-based treatments and translational research. The objective of this study was to develop consensus guidance for an approach to irAE-Ns including disease definitions and severity grading. A working group of four neurologists drafted irAE-N consensus guidance and definitions, which were reviewed by the multidisciplinary Neuro irAE Disease Definition Panel including oncologists and irAE experts. A modified Delphi consensus process was used, with two rounds of anonymous ratings by panelists and two meetings to discuss areas of controversy. Panelists rated content for usability, appropriateness and accuracy on 9-point scales in electronic surveys and provided free text comments. Aggregated survey responses were incorporated into revised definitions. Consensus was based on numeric ratings using the RAND/University of California Los Angeles (UCLA) Appropriateness Method with prespecified definitions. 27 panelists from 15 academic medical centers voted on a total of 53 rating scales (6 general guidance, 24 central and 18 peripheral nervous system disease definition components, 3 severity criteria and 2 clinical trial adjudication statements); of these, 77% (41/53) received first round consensus. After revisions, all items received second round consensus. Consensus definitions were achieved for seven core disorders: irMeningitis, irEncephalitis, irDemyelinating disease, irVasculitis, irNeuropathy, irNeuromuscular junction disorders and irMyopathy. For each disorder, six descriptors of diagnostic components are used: disease subtype, diagnostic certainty, severity, autoantibody association, exacerbation of pre-existing disease or de novo presentation, and presence or absence of concurrent irAE(s). These disease definitions standardize irAE-N classification. Diagnostic certainty is not always directly linked to certainty to treat as an irAE-N (ie, one might treat events in the probable or possible category). Given consensus on accuracy and usability from a representative panel group, we anticipate that the definitions will be used broadly across clinical and research settings.
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Affiliation(s)
- Amanda C Guidon
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuromuscular Medicine, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Leeann B Burton
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuromuscular Medicine, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Bart K Chwalisz
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuroimmunology and Neuroinfectious Disease, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - James Hillis
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuroimmunology and Neuroinfectious Disease, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Anthony A Amato
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuromuscular Medicine, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Allison Betof Warner
- Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Priscilla K Brastianos
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Tracey A Cho
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Stacey L Clardy
- Department of Neurology, University of Utah, Salt Lake CIty, UT, USA
| | - Justine V Cohen
- Division of Oncology, Department of Medicine, University of Pennsylvania, PA, USA
| | - Jorg Dietrich
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Dougan
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher T Doughty
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuromuscular Medicine, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Divyanshu Dubey
- Departments of Neurology and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Jeffrey T Guptill
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
- Division of Neuromuscular Medicine, Duke University, Durham, NC, USA
| | - Douglas B Johnson
- Division of Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Vern C Juel
- Division of Neuromuscular Medicine, Duke University, Durham, NC, USA
| | - Robert Kadish
- Department of Neurology, University of Utah, Salt Lake CIty, UT, USA
| | - Noah Kolb
- Division of Neuromuscular Medicine, Department of Neurology, University of Vermont, Burlington, VT, USA
| | - Nicole R LeBoeuf
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Dermatology, Center for Cutaneous Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Jenny Linnoila
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuroimmunology and Neuroinfectious Disease, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andrew L Mammen
- Muscle Disease Unit, Laboratory of Muscle Stem Cells and Gene Regulation, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Maria Martinez-Lage
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuropathology, Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Meghan J Mooradian
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jarushka Naidoo
- Medical Oncology, Department of Medicine, Beaumont Hospital Dublin and RCSI University of Health Sciences, Dublin, Ireland
- Upper Aerodigestive Division, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center/Johns Hopkins University, Baltimore, MD, USA
| | - Tomas G Neilan
- Harvard Medical School, Boston, Massachusetts, USA
- Cardio-oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - David A Reardon
- Harvard Medical School, Boston, Massachusetts, USA
- Center for Neuro-oncology, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Krista M Rubin
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Bianca D Santomasso
- Department of Neurology, Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ryan J Sullivan
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Nancy Wang
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Karin Woodman
- Section of Cancer Neurology, Department of Neuro-Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Leyre Zubiri
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Kerry L Reynolds
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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21
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Li Y, Yi JS, Russo MA, Rosa-Bray M, Weinhold KJ, Guptill JT. Normative dataset for plasma cytokines in healthy human adults. Data Brief 2021; 35:106857. [PMID: 33665253 PMCID: PMC7900339 DOI: 10.1016/j.dib.2021.106857] [Citation(s) in RCA: 4] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 01/11/2023] Open
Abstract
We determined normative data for plasma cytokines established from a cohort of 126 carefully screened healthy adults aged 18 to 64 years. Participants were enrolled to ensure an even age and sex distribution and to include at least 30% non-Caucasians. Plasma cytokines for 18 analytes were tested by multiplex immunoassay. The data are presented by age cohort (18-29 years, 30-39, 40-49, and 50-66), as well as by sex and racial background. This dataset complements published normative ranges of cellular subsets generated by comprehensive polychromatic flow cytometry analysis of the healthy human immune system [1]. These data are available to researchers and have value as a reference range for research involving peripheral cytokines.
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Affiliation(s)
- Yingkai Li
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, 915 S. LaSalle St. Ext.; Box 2926, SORF Building; Room 124, Durham, NC 27710, United States
| | - John S. Yi
- Department of Surgery, Duke University School of Medicine, Durham, NC 27710, United States
| | - Melissa A. Russo
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, 915 S. LaSalle St. Ext.; Box 2926, SORF Building; Room 124, Durham, NC 27710, United States
| | | | - Kent J. Weinhold
- Department of Surgery, Duke University School of Medicine, Durham, NC 27710, United States
| | - Jeffrey T. Guptill
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, 915 S. LaSalle St. Ext.; Box 2926, SORF Building; Room 124, Durham, NC 27710, United States
- Duke Clinical Research Institute, Durham, NC 27710, United States
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22
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Guptill JT, Barfield R, Chan C, Russo MA, Emmett D, Raja S, Massey JM, Juel VC, Hobson-Webb LD, Gable KL, Gonzalez N, Hammett A, Howard JF, Chopra M, Kaminski HJ, Siddiqi ZA, Migdal M, Yi JS. Reduced plasmablast frequency is associated with seronegative myasthenia gravis. Muscle Nerve 2020; 63:577-585. [PMID: 33294984 DOI: 10.1002/mus.27140] [Citation(s) in RCA: 2] [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: 05/29/2020] [Revised: 12/01/2020] [Accepted: 12/06/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The immunopathology of autoimmune seronegative myasthenia gravis (SN MG) is poorly understood. Our objective was to determine immune profiles associated with a diagnosis of SN MG. METHODS We performed high-dimensional flow cytometry on blood samples from SN MG patients (N = 68), healthy controls (N = 46), and acetylcholine receptor antibody (AChR+) MG patients (N = 27). We compared 12 immune cell subsets in SN MG to controls using logistic modeling via a discovery-replication design. An exploratory analysis fit a multinomial model comparing AChR+ MG and controls to SN MG. RESULTS An increase in CD19+ CD20- CD38hi plasmablast frequencies was associated with lower odds of being a SN MG case in both the discovery and replication analyses (discovery P-value = .0003, replication P-value = .0021). Interleukin (IL) -21 producing helper T cell frequencies were associated with a diagnosis of AChR+ MG (P = .004). CONCLUSIONS Reduced plasmablast frequencies are strongly associated with a SN MG diagnosis and may be a useful diagnostic biomarker in the future.
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Affiliation(s)
- Jeffrey T Guptill
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Richard Barfield
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Cliburn Chan
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Melissa A Russo
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Doug Emmett
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Shruti Raja
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Janice M Massey
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Vern C Juel
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Lisa D Hobson-Webb
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Karissa L Gable
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Natalia Gonzalez
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Alex Hammett
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - James F Howard
- Neuromuscular Disorders Section, Department of Neurology, The University of North Carolina, Chapel Hill, North Carolina, USA
| | - Manisha Chopra
- Neuromuscular Disorders Section, Department of Neurology, The University of North Carolina, Chapel Hill, North Carolina, USA
| | - Henry J Kaminski
- Department of Neurology, George Washington University, Washington, District of Columbia, USA
| | - Zaeem A Siddiqi
- Division of Neurology, University of Alberta, Edmonton, Alberta, Canada
| | - Mattingly Migdal
- The University of North Carolina, Chapel Hill, North Carolina, USA
| | - John S Yi
- Division of Surgical Sciences, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
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23
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Li Y, Emmett CD, Cobbaert M, Sanders DB, Juel VC, Hobson-Webb LD, Massey JM, Gable KL, Raja SM, Gonzalez NL, Guptill JT. Knowledge and perceptions of the COVID-19 pandemic among patients with myasthenia gravis. Muscle Nerve 2020; 63:357-364. [PMID: 33280141 DOI: 10.1002/mus.27130] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 06/25/2020] [Revised: 11/25/2020] [Accepted: 11/27/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients with myasthenia gravis (MG) may be particularly vulnerable during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic due to risk of worsening disease during infection, potential adverse impacts of coronavirus disease 2019 (COVID-19) treatments on neuromuscular transmission, and a limited ability to fight off infection related to immunosuppressive treatments. Our goal is to understand how patients are experiencing the COVID-19 pandemic, including where they receive relevant information, how it has affected medical care, and what measures they use to protect themselves. METHODS This is a prospective online survey study at large academic practice. All patients with a neuromuscular junction disorder diagnosis code in the Duke Health System were invited to participate. RESULTS One thousand eight hundred and forty eight patients were approached to participate and 75 completed the survey between 16 April 2020 and 28 May 2020. The most frequently used information sources were non-presidential federal government (75%), state government (57%), local healthcare provider (37%), and television news (36%). Non-presidential federal government (80%), local healthcare providers (55%), state government (33%), and patient support organizations (29%) were considered the most trusted information sources. Thirty-three (44%) of survey responders had attended a telemedicine visit. Patients were taking recommended precautions during the pandemic and remained very concerned (69%) about COVID-19. Generalized Anxiety Disorder-7 scores were moderate-severe in 20% of responders. CONCLUSIONS Healthcare providers, the government, and patient organizations play a critical role in communicating with the MG patient community. Use of targeted messaging strategies by these groups to convey accurate information may increase effectiveness and lead to more informed patients with reduced anxiety.
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Affiliation(s)
- Yingkai Li
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - C Douglas Emmett
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Marjan Cobbaert
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Donald B Sanders
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Vern C Juel
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Lisa D Hobson-Webb
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Janice M Massey
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Karissa L Gable
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Shruti M Raja
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Natalia L Gonzalez
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Jeffrey T Guptill
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA
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24
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Muppidi S, Guptill JT, Jacob S, Li Y, Farrugia ME, Guidon AC, Tavee JO, Kaminski H, Howard JF, Cutter G, Wiendl H, Maas MB, Illa I, Mantegazza R, Murai H, Utsugisawa K, Nowak RJ. COVID-19-associated risks and effects in myasthenia gravis (CARE-MG). Lancet Neurol 2020; 19:970-971. [PMID: 33212055 PMCID: PMC7837033 DOI: 10.1016/s1474-4422(20)30413-0] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 10/12/2020] [Accepted: 10/27/2020] [Indexed: 12/28/2022]
Affiliation(s)
- Srikanth Muppidi
- Department of Neurology, Stanford Medical Center, Stanford, CA 94304, USA.
| | - Jeffrey T Guptill
- Duke University School of Medicine, Duke University, Durham, NC, USA
| | - Saiju Jacob
- Department of Neurology and Institute of Immunology and Immunotherapy, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Yingkai Li
- Duke University School of Medicine, Duke University, Durham, NC, USA
| | - Maria E Farrugia
- Neurology Department, Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK
| | - Amanda C Guidon
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Jinny O Tavee
- The Ken and Ruth Davee Department of Neurology, Northwestern University, Chicago, IL, USA
| | - Henry Kaminski
- Department of Neurology, The George Washington University, Washington, DC, USA
| | - James F Howard
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA
| | - Gary Cutter
- Department of Biostatistics, School of Public Health, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Matthew B Maas
- The Ken and Ruth Davee Department of Neurology, Northwestern University, Chicago, IL, USA
| | - Isabel Illa
- Department of Neurology, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
| | | | - Hiroyuki Murai
- Neuroimmunology and Neuromuscular Diseases Unit, International University of Health and Welfare, Narita, Japan
| | | | - Richard J Nowak
- Yale University School of Medicine, Yale University, New Haven, CT, USA
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Sanders DB, Raja SM, Guptill JT, Hobson‐Webb LD, Juel VC, Massey JM. The
D
uke myasthenia gravis clinic registry:
I
.
D
escription and demographics. Muscle Nerve 2020; 63:209-216. [DOI: 10.1002/mus.27120] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/12/2020] [Accepted: 11/13/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Donald B. Sanders
- Neuromuscular Division, Department of Neurology Duke University Medical Center Durham North Carolina USA
| | - Shruti M. Raja
- Neuromuscular Division, Department of Neurology Duke University Medical Center Durham North Carolina USA
| | - Jeffrey T. Guptill
- Neuromuscular Division, Department of Neurology Duke University Medical Center Durham North Carolina USA
| | - Lisa D. Hobson‐Webb
- Neuromuscular Division, Department of Neurology Duke University Medical Center Durham North Carolina USA
| | - Vern C. Juel
- Neuromuscular Division, Department of Neurology Duke University Medical Center Durham North Carolina USA
| | - Janice M. Massey
- Neuromuscular Division, Department of Neurology Duke University Medical Center Durham North Carolina USA
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26
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Van Eldik LJ, Roy SM, Guptill JT. First‐in‐human studies of MW01‐6‐189WH, a brain‐penetrant, anti‐neuroinflammatory, small molecule drug candidate: Phase 1 safety, tolerability, pharmacokinetic, and pharmacodynamic studies in healthy adult volunteers. Alzheimers Dement 2020. [DOI: 10.1002/alz.041208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Linda J. Van Eldik
- Sanders‐Brown Center on Aging Lexington KY USA
- University of Kentucky Lexington KY USA
| | | | - Jeffrey T. Guptill
- Duke University Durham NC USA
- Duke Early Phase Clinical Research Unit Durham NC USA
- Duke Clinical Research Institute Durham NC USA
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27
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Li Y, Guptill JT, Russo MA, Howard JF, Massey JM, Juel VC, Hobson-Webb LD, Emmett D, Chopra M, Raja S, Liu W, Yi JS. Imbalance in T follicular helper cells producing IL-17 promotes pro-inflammatory responses in MuSK antibody positive myasthenia gravis. J Neuroimmunol 2020; 345:577279. [PMID: 32497931 DOI: 10.1016/j.jneuroim.2020.577279] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 03/04/2020] [Revised: 05/08/2020] [Accepted: 05/24/2020] [Indexed: 12/14/2022]
Abstract
A detailed understanding of the role of Tfh cells in MuSK-antibody positive myasthenia gravis (MuSK-MG) is lacking. We characterized phenotype and function of Tfh cells in MuSK-MG patients and controls. We found similar overall Tfh and follicular regulatory (Tfr) T cell frequencies in MuSK-MG and healthy controls, but MuSK-MG patients exhibited higher frequencies of Tfh17 cells and a higher ratio of Tfh:Tfr cells. These results suggest imbalanced Tfh cell regulation, further supported by increased frequencies of CD4 T cells co-producing IL-21/IL-17 and IL-17/IFN-γ, and increased Tfh-supported IgG production. These results support a role for Tfh cell dysregulation in MuSK-MG immunopathology.
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Affiliation(s)
- Yingkai Li
- Department of Neurology, Duke University Medical Center, Durham, NC, USA; Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jeffrey T Guptill
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Melissa A Russo
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - James F Howard
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Janice M Massey
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Vern C Juel
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Lisa D Hobson-Webb
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Doug Emmett
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Manisha Chopra
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Shruti Raja
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Weibin Liu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - John S Yi
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.
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28
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Van Eldik LJ, Sawaki L, Bowen K, Laskowitz DT, Noveck RJ, Hauser B, Jordan L, Spears TG, Wu H, Watt K, Raja S, Roy SM, Watterson DM, Guptill JT. First-in-Human Studies of MW01-6-189WH, a Brain-Penetrant, Antineuroinflammatory Small-Molecule Drug Candidate: Phase 1 Safety, Tolerability, Pharmacokinetic, and Pharmacodynamic Studies in Healthy Adult Volunteers. Clin Pharmacol Drug Dev 2020; 10:131-143. [PMID: 32255549 PMCID: PMC7541708 DOI: 10.1002/cpdd.795] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 02/18/2020] [Indexed: 11/18/2022]
Abstract
MW01‐6‐189WH (MW189) is a novel central nervous system–penetrant small‐molecule drug candidate that selectively attenuates stressor‐induced proinflammatory cytokine overproduction and is efficacious in intracerebral hemorrhage and traumatic brain injury animal models. We report first‐in‐human, randomized, double‐blind, placebo‐controlled phase 1 studies to evaluate the safety, tolerability, and pharmacokinetics (PK) of single and multiple ascending intravenous doses of MW189 in healthy adult volunteers. MW189 was safe and well tolerated in single and multiple doses up to 0.25 mg/kg, with no clinically significant concerns. The most common drug‐related treatment‐emergent adverse event was infusion‐site reactions, likely related to drug solution acidity. No clinically concerning changes were seen in vital signs, electrocardiograms, physical or neurological examinations, or safety laboratory results. PK analysis showed dose‐proportional increases in plasma concentrations of MW189 after single or multiple doses, with approximately linear kinetics and no significant drug accumulation. Steady state was achieved by dose 3 for all dosing cohorts. A pilot pharmacodynamic study administering low‐dose endotoxin to induce a systemic inflammatory response was done to evaluate the effects of a single intravenous dose of MW189 on plasma cytokine levels. MW189 treatment resulted in lower levels of the proinflammatory cytokine TNF‐α and higher levels of the anti‐inflammatory cytokine IL‐10 compared with placebo treatment. The outcomes are consistent with the pharmacological mechanism of MW189. Overall, the safety profile, PK properties, and pharmacodynamic effect support further development of MW189 for patients with acute brain injury.
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Affiliation(s)
- Linda J. Van Eldik
- Sanders‐Brown Center on AgingUniversity of KentuckyLexingtonKentuckyUSA
- Department of NeuroscienceUniversity of KentuckyLexingtonKentuckyUSA
- Spinal Cord and Brain Injury Research CenterUniversity of KentuckyLexingtonKentuckyUSA
| | - Lumy Sawaki
- Department of Physical Medicine & RehabilitationUniversity of KentuckyLexingtonKentuckyUSA
| | - Karen Bowen
- Bluegrass Research Consultants, Inc.VersaillesKentuckyUSA
| | - Daniel T. Laskowitz
- Department of NeurologyDuke UniversityDurhamNorth CarolinaUSA
- Duke Clinical Research InstituteDurhamNorth CarolinaUSA
| | | | - Byron Hauser
- Duke Early Phase Clinical Research UnitDurhamNorth CarolinaUSA
| | - Lynn Jordan
- Duke Early Phase Clinical Research UnitDurhamNorth CarolinaUSA
| | | | - Huali Wu
- Duke Clinical Research InstituteDurhamNorth CarolinaUSA
| | - Kevin Watt
- Duke Clinical Research InstituteDurhamNorth CarolinaUSA
| | - Shruti Raja
- Department of NeurologyDuke UniversityDurhamNorth CarolinaUSA
- Duke Early Phase Clinical Research UnitDurhamNorth CarolinaUSA
| | | | | | - Jeffrey T. Guptill
- Department of NeurologyDuke UniversityDurhamNorth CarolinaUSA
- Duke Clinical Research InstituteDurhamNorth CarolinaUSA
- Duke Early Phase Clinical Research UnitDurhamNorth CarolinaUSA
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29
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Abstract
Myasthenia gravis is an autoimmune disease in which immunoglobulin G (IgG) autoantibodies are formed against the nicotinic acetylcholine receptor (AChR) or other components of the neuromuscular junction. Though effective treatments are currently available, many commonly used therapies have important limitations and alternative therapeutic options are needed for patients. A novel treatment approach currently in clinical trials for myasthenia gravis targets the neonatal Fc receptor (FcRn). This receptor plays a central role in prolonging the half–life of IgG molecules. The primary function of FcRn is salvage of IgG and albumin from lysosomal degradation through the recycling and transcytosis of IgG within cells. Antagonism of this receptor causes IgG catabolism, resulting in reduced overall IgG and pathogenic autoantibody levels. This treatment approach is particularly intriguing as it does not result in widespread immune suppression, in contrast to many therapies in routine clinical use. Experience with plasma exchange and emerging phase 2 clinical trial data of FcRn antagonists provide proof of concept for IgG lowering in myasthenia gravis. Here we review the IgG lifecycle and the relevance of IgG lowering to myasthenia gravis treatment and summarize the available data on FcRn targeted therapeutics in clinical trials for myasthenia gravis.
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Affiliation(s)
- Karissa L Gable
- Department of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - Jeffrey T Guptill
- Department of Neurology, Duke University School of Medicine, Durham, NC, United States.,Duke Clinical Research Institute, Durham, NC, United States
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30
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Yi JS, Russo MA, Raja S, Massey JM, Juel VC, Shin J, Hobson-Webb LD, Gable K, Guptill JT. Inhibition of the transcription factor ROR-γ reduces pathogenic Th17 cells in acetylcholine receptor antibody positive myasthenia gravis. Exp Neurol 2019; 325:113146. [PMID: 31838097 DOI: 10.1016/j.expneurol.2019.113146] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 08/12/2019] [Revised: 11/27/2019] [Accepted: 12/10/2019] [Indexed: 12/25/2022]
Abstract
IL-17 producing CD4 T cells (Th17) cells increase significantly with disease severity in myasthenia gravis (MG) patients. To suppress the generation of Th17 cells, we examined the effect of inhibiting retinoic acid receptor-related-orphan-receptor-C (RORγ), a Th17-specific transcription factor critical for differentiation. RORγ inhibition profoundly reduced Th17 cell frequencies, including IFN-γ and IL-17 co-producing pathogenic Th17 cells. Other T helper subsets were not affected. In parallel, CD8 T cell subsets producing IL-17 and IL-17/IFN-γ were increased in MG patients and inhibited by the RORγ inhibitor. These findings provide rationale for exploration of targeted Th17 therapies, including ROR-γ inhibitors, to treat MG patients.
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Affiliation(s)
- John S Yi
- Division of Surgical Sciences, Department of Surgery, Duke University Medical Center, 915 S., LaSalle Street, Box 2926, Durham, NC 27710, USA.
| | - Melissa A Russo
- Neuromuscular Section, Department of Neurology, Duke University Medical Center, Box 3403, Durham, NC 27710, USA
| | - Shruti Raja
- Neuromuscular Section, Department of Neurology, Duke University Medical Center, Box 3403, Durham, NC 27710, USA
| | - Janice M Massey
- Neuromuscular Section, Department of Neurology, Duke University Medical Center, Box 3403, Durham, NC 27710, USA
| | - Vern C Juel
- Neuromuscular Section, Department of Neurology, Duke University Medical Center, Box 3403, Durham, NC 27710, USA
| | - Jay Shin
- Duke University, Durham, NC 27710, USA
| | - Lisa D Hobson-Webb
- Neuromuscular Section, Department of Neurology, Duke University Medical Center, Box 3403, Durham, NC 27710, USA
| | - Karissa Gable
- Neuromuscular Section, Department of Neurology, Duke University Medical Center, Box 3403, Durham, NC 27710, USA
| | - Jeffrey T Guptill
- Neuromuscular Section, Department of Neurology, Duke University Medical Center, Box 3403, Durham, NC 27710, USA
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31
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Yi JS, Rosa-Bray M, Staats J, Zakroysky P, Chan C, Russo MA, Dumbauld C, White S, Gierman T, Weinhold KJ, Guptill JT. Establishment of normative ranges of the healthy human immune system with comprehensive polychromatic flow cytometry profiling. PLoS One 2019; 14:e0225512. [PMID: 31825961 PMCID: PMC6905525 DOI: 10.1371/journal.pone.0225512] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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: 08/05/2019] [Accepted: 11/06/2019] [Indexed: 12/12/2022] Open
Abstract
Existing normative flow cytometry data have several limitations including small sample sizes, incompletely described study populations, variable flow cytometry methodology, and limited depth for defining lymphocyte subpopulations. To overcome these issues, we defined high-dimensional flow cytometry reference ranges for the healthy human immune system using Human Immunology Project Consortium methodologies after carefully screening 127 subjects deemed healthy through clinical and laboratory testing. We enrolled subjects in the following age cohorts: 18–29 years, 30–39, 40–49, and 50–66 and enrolled cohorts to ensure an even gender distribution and at least 30% non-Caucasians. From peripheral blood mononuclear cells, flow cytometry reference ranges were defined for >50 immune subsets including T-cell (activation, maturation, T follicular helper and regulatory T cell), B-cell, and innate cells. We also developed a web tool for visualization of the dataset and download of raw data. This dataset provides the immunology community with a resource to compare and extract data from rigorously characterized healthy subjects across age groups, gender and race.
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Affiliation(s)
- John S Yi
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
| | | | - Janet Staats
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
| | - Pearl Zakroysky
- Duke Clinical Research Institute, Durham, NC, United States of America
| | - Cliburn Chan
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, United States of America
| | - Melissa A Russo
- Department of Neurology, Duke University School of Medicine, Durham, NC, United States of America
| | - Chelsae Dumbauld
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
| | - Scott White
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
| | - Todd Gierman
- Biomat USA-Grifols Plasma Operations, United States of America
| | - Kent J Weinhold
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
| | - Jeffrey T Guptill
- Duke Clinical Research Institute, Durham, NC, United States of America.,Department of Neurology, Duke University School of Medicine, Durham, NC, United States of America
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32
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Raja SM, Howard JF, Juel VC, Massey JM, Chopra M, Guptill JT. Clinical outcome measures following plasma exchange for MG exacerbation. Ann Clin Transl Neurol 2019; 6:2114-2119. [PMID: 31560178 PMCID: PMC6801175 DOI: 10.1002/acn3.50901] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 07/18/2019] [Revised: 08/29/2019] [Accepted: 09/01/2019] [Indexed: 11/10/2022] Open
Abstract
Our objective is to report longitudinal results of the MG‐ADL, MG‐Composite, MG‐MMT, and MG‐QoL15 in an open‐label trial of therapeutic plasma exchange in myasthenia gravis. Ten MG patients experiencing exacerbation had assessments prior to, immediately following, and at selected time points post‐TPE. Changes from baseline to 2 weeks post‐TPE were: MG‐ADL median −5.0, P < 0.0033, MG‐QoL15 median −13.0, P < 0.001, MG‐MMT median −10.0, P < 0.0001, and MG‐Composite median −10.0, P < 0.005. TPE produced a rapid, clinically significant change in all instruments, indicating these outcome measures are robust endpoints for clinical trials of rapidly efficacious MG therapies.
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Affiliation(s)
- Shruti M Raja
- Division of Neuromuscular Medicine, Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - James F Howard
- Neuromuscular Disease Section, Department of Neurology, The University of North Carolina, Chapel Hill, North Carolina
| | - Vern C Juel
- Division of Neuromuscular Medicine, Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Janice M Massey
- Division of Neuromuscular Medicine, Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Manisha Chopra
- Neuromuscular Disease Section, Department of Neurology, The University of North Carolina, Chapel Hill, North Carolina
| | - Jeffrey T Guptill
- Division of Neuromuscular Medicine, Department of Neurology, Duke University Medical Center, Durham, North Carolina.,Neurosciences Medicine, Duke Clinical Research Institute, Durham, North Carolina
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33
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Raja SM, Sanders DB, Juel VC, Harati Y, Smith AG, Pascuzzi R, Richman DP, Wu A, Aleš KL, Jacobus LR, Jacobus DP, Guptill JT. Validation of the triple timed up-and-go test in Lambert-Eaton myasthenia. Muscle Nerve 2019; 60:292-298. [PMID: 31269226 DOI: 10.1002/mus.26625] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 12/11/2018] [Revised: 06/27/2019] [Accepted: 06/29/2019] [Indexed: 12/22/2022]
Abstract
INTRODUCTION There are no validated, practical, and quantitative measures of disease severity in Lambert-Eaton myasthenia (LEM). METHODS Data from the Effectiveness of 3,4-Diaminopyridine in Lambert-Eaton Myasthenic Syndrome (DAPPER) trial were analyzed to assess triple timed up-and-go (3TUG) reproducibility and relationships between 3TUG times and other measures of LEM severity. RESULTS The coverage probability technique showed ≥0.90 probability for an acceptable 3TUG difference of ≤0.2, indicating that it is reproducible in LEM patients. The correlation between 3TUG times and lower extremity function scores was significant in subjects who continued and in those who were withdrawn from 3,4-diaminopyridine free base. Worsening patient-reported Weakness Self-Assessment Scale and Investigator Assessment of Treatment Effect scores corresponded with prolongation of 3TUG times. DISCUSSION The 3TUG is reproducible, demonstrates construct validity for assessment of lower extremity function in LEM patients, and correlates with changes in patient and physician assessments. These findings, along with prior reliability studies, indicate 3TUG is a valid measure of disease severity in LEM.
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Affiliation(s)
- Shruti M Raja
- Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Donald B Sanders
- Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Vern C Juel
- Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Yadollah Harati
- Department of Neurology, Baylor College of Medicine, Houston, Texas
| | - A Gordon Smith
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Robert Pascuzzi
- Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana
| | - David P Richman
- Department of Neurology, University of California Davis Medical Center, Sacramento, California
| | - Angie Wu
- Center for Predictive Modeling, Duke Clinical Research Institute, Durham, North Carolina
| | - Kathy L Aleš
- Jacobus Pharmaceutical Company, Princeton, New Jersey
| | | | | | - Jeffrey T Guptill
- Department of Neurology, Duke University Medical Center, Durham, North Carolina.,Neurosciences Medicine, Duke Clinical Research Institute, Durham, North Carolina
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34
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Guptill JT, Runken MC, Eaddy M, Lunacsek O, Fuldeore RM. Treatment Patterns and Costs of Chronic Inflammatory Demyelinating Polyneuropathy: A Claims Database Analysis. Am Health Drug Benefits 2019; 12:127-135. [PMID: 31346365 PMCID: PMC6611518] [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] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 01/28/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Corticosteroids, plasma exchange, and intravenous immunoglobulin (IVIG) have been standard-of-care treatments for chronic inflammatory demyelinating polyneuropathy (CIDP) for more than 2 decades. Despite guideline recommendations for best clinical practices, heterogeneity in patient presentation and the course of treatment for CIDP remains. There is limited literature regarding the real-world treatment patterns of and costs associated with CIDP. OBJECTIVE To analyze and describe the real-world treatment patterns of and economic burden associated with CIDP. METHODS This retrospective cohort study evaluated the treatment patterns and CIDP-related healthcare costs over a 2-year follow-up period for patients with newly diagnosed CIDP who had commercial insurance, using claims data from the IMS LifeLink PharMetrics Plus Claims database between 2009 through 2014. Treatment-naïve patients with newly diagnosed CIDP were evaluated for 2 years postdiagnosis, which captured the treatments used and the resource utilization. The patients were defined as receiving active CIDP therapy (ie, IVIG, immunosuppressants, oral or intravenous steroids, or plasma exchange) or active surveillance. RESULTS Of the 525 patients identified with newly diagnosed CIDP, 55.2% of patients were prescribed only steroid therapy, and 25.3% of patients were prescribed an IVIG therapy during the 2-year follow-up. The median time to the initial treatment was shortest for patients receiving plasma exchange alone (0.03 months) or in combination with a steroid (0.03 months), followed by IVIG plus another therapy (0.53 months), and then IVIG alone (0.71 months). Initiating therapy with steroids alone took the longest mean time (6.51 months) to start the treatment. The median length of time to receive therapy was longest for the steroid plus plasma exchange cohort (21.8 months), followed by the steroid plus immunosuppressant cohort (10.1 months), and the 2 IVIG cohorts (9.04 months for IVIG alone and 9.82 months for IVIG plus another therapy). The mean total CIDP-specific 2-year follow-up costs were highest for the cohort that received IVIG alone ($119,928) or with an additional therapy ($133,334) and lowest for patients who received active surveillance ($3723) or steroids alone ($3101). CONCLUSIONS Steroid therapy was initiated later and resulted in a shorter duration of treatment than other treatment options for patients with CIDP, which may reflect diagnostic uncertainty, disease severity or remission, therapeutic challenge to determine diagnosis, or the side-effect profile of steroids. The use of steroids alone was the most common prescribed treatment for CIDP. Further research is needed to understand the rationale for treatment decisions in this patient population and their potential impact on patients and health plans.
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Affiliation(s)
- Jeffrey T Guptill
- Associate Professor of Neurology, Duke Clinical Research Institute, Duke University, Durham, NC
| | - M Chris Runken
- Senior Director Global HEOR, Grifols SSNA, Research Triangle Park, NC
| | - Michael Eaddy
- Vice President, Scientific Consulting, Xcenda, Palm Harbor, FL
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35
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Cowart D, Venuti RP, Lynch K, Guptill JT, Noveck RJ, Foo SY. A Phase 1 Randomized Study of Single Intravenous Infusions of the Novel Nitroxyl Donor BMS-986231 in Healthy Volunteers. J Clin Pharmacol 2019; 59:717-730. [PMID: 30703258 PMCID: PMC6519195 DOI: 10.1002/jcph.1364] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 06/07/2018] [Accepted: 11/21/2018] [Indexed: 12/25/2022]
Abstract
Nitroxyl (HNO) is a reactive nitrogen molecule that has potential therapeutic benefits for patients with acute heart failure. The results of the first‐in‐human study for BMS‐986231, a novel HNO donor, are reported. The aim of this sequential cohort study was to evaluate the safety, tolerability, and pharmacokinetic profile of BMS‐986231 after 24‐ and 48‐hour intravenous infusions in healthy volunteers. Eighty subjects were randomized and dosed. Seven cohorts (stratum A) received BMS‐986231 0.1, 0.33, 1, 3, 5, 10, and 15 μg/kg/min or placebo, infused over 24 hours. An additional cohort (stratum B) received 10 μg/kg/min or placebo, infused over 48 hours. Adverse events (AEs) were reported for 30 days after completion of infusion. Blood/urine samples were collected at regular intervals; other parameters (blood pressure, heart rate/rhythm, cardiac index) were also assessed. Headaches were the most commonly reported drug‐related AE (48%) in those who received BMS‐986231, although their severity was reduced by hydration. No other significant drug‐related AEs were noted. BMS‐986231 was associated with dose‐dependent and well‐tolerated reductions in systolic and diastolic blood pressure versus baseline; cardiac index, as measured noninvasively, was increased. BMS‐986231 had no clinically significant effect on heart rate/rhythm or laboratory parameters. Its mean elimination half‐life was 0.7‐2.5 hours. BMS‐986231 was safe and well‐tolerated for up to 24 hours (15 μg/kg/min) or 48 hours (10 μg/kg/min), with a favorable hemodynamic profile observed. Ongoing studies continue to evaluate the potential benefit of BMS‐986231 in patients with acute heart failure.
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Affiliation(s)
| | | | - Kim Lynch
- Duke Early Phase Clinical Research Unit, Durham, NC, USA
| | | | | | - Shi Yin Foo
- Cardioxyl Pharmaceuticals, Inc., Chapel Hill, NC, USA
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36
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Guptill JT, Runken MC, Eaddy M, Lunacsek OE, Fuldeore RM, Blanchette CM, Zacherle E, Noone JM. Two comparative assessments of intravenous immunoglobulin therapy switching patterns in the treatment of chronic inflammatory demyelinating polyneuropathy in the US. Patient Prefer Adherence 2019; 13:649-655. [PMID: 31118588 PMCID: PMC6503323 DOI: 10.2147/ppa.s185852] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 03/01/2019] [Indexed: 11/29/2022] Open
Abstract
Purpose: For chronic inflammatory demyelinating polyneuropathy (CIDP) patients, each branded intravenous immunoglobulin (IVIG) treatment differs in production processes, virus elimination, formulation, and composition. Given the limited availability of real-world data comparing IVIGs for CIDP, this study evaluated switching patterns between IVIG products in 2 separate retrospective databases. Patients and methods: Two independent analytic teams retrospectively evaluated IVIG treatment-naïve patients with an ICD diagnosis code for CIDP. Study 1 used integrated healthcare claims from IMS LifeLink PharMetrics Plus™ and Study 2 used the Truven MarketScan® Database. All analyses were descriptive, with outcomes assessed during the 2-year post-index period. Results: One-quarter of IVIG patients switched therapies within the 2-year study period. In both studies, switching rates were lowest for IVIG-G (Gamunex®-C) (Study 1: 9.8%, Study 2: 8.9%), followed by IVIG-F (Flebogamma®) (Study 1: 25.0%, Study 2: 18.2%), and highest for IVIG-other (Octagam®/Gammaplex®) (Study 1: 50.0%, Study 2: 33.3%). When patients were switched, most switched to IVIG-G (Study 1: 51.6%, Study 2: 54.3%). Conclusion: The small proportion of CIDP switchers in 2 independent studies suggests that IVIG therapy is generally well tolerated. However, differences existed in switch rates for different IVIG products. The reason for low switching rates could not be assessed in this study; therefore, further studies are required to detect possible relevant differences in effectiveness and tolerability.
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Affiliation(s)
| | - M Chris Runken
- Grifols SSNA, Research Triangle Park, Durham, NC, USA
- Correspondence: M Chris RunkenGrifols SSNA, Research Triangle Park, 79 TW Alexander Way, Building 4101-3125, Durham, NC27709, USATel +1 919 316 6343Email
| | | | | | | | - Christopher M Blanchette
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC, USA
| | - Emily Zacherle
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC, USA
| | - Joshua M Noone
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC, USA
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Sabre L, Guptill JT, Russo M, Juel VC, Massey JM, Howard JF, Hobson-Webb LD, Punga AR. Circulating microRNA plasma profile in MuSK+ myasthenia gravis. J Neuroimmunol 2018; 325:87-91. [PMID: 30316681 PMCID: PMC6240475 DOI: 10.1016/j.jneuroim.2018.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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: 08/13/2018] [Revised: 10/03/2018] [Accepted: 10/04/2018] [Indexed: 12/11/2022]
Abstract
Muscle-specific tyrosine kinase antibody positive myasthenia gravis (MuSK+ MG) is an immunological subtype with distinctive pathogenic mechanisms and clinical features. The aim of this study was to analyze the circulating plasma microRNA profile of patients with MuSK+ MG. From the discovery cohort miR-210-3p, miR-324-3p and miR-328-3p were further analyzed in the validation cohort. We found a distinct plasma profile of miR-210-3p and miR-324-3p that were significantly decreased in MuSK+ MG patients compared to healthy controls (4.1 ± 1.4 vs 5.1 ± 1.4, p = .006 and 4.7 ± 1.0 vs 5.4 ± 1.3, p = .02). These findings reveal a distinct plasma miRNA profile in MuSK+ MG.
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Affiliation(s)
- Liis Sabre
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Uppsala, Sweden
| | | | - Melissa Russo
- Department of Neurology, Duke University, Durham, USA
| | - Vern C Juel
- Department of Neurology, Duke University, Durham, USA
| | | | - James F Howard
- Department of Neurology, University of North Carolina - Chapel Hill, Chapel Hill, USA
| | | | - Anna Rostedt Punga
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Uppsala, Sweden.
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Li Y, Guptill JT, Russo MA, Massey JM, Juel VC, Hobson-Webb LD, Howard JF, Chopra M, Liu W, Yi JS. Tacrolimus inhibits Th1 and Th17 responses in MuSK-antibody positive myasthenia gravis patients. Exp Neurol 2018; 312:43-50. [PMID: 30472069 DOI: 10.1016/j.expneurol.2018.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 08/20/2018] [Revised: 10/25/2018] [Accepted: 11/22/2018] [Indexed: 12/17/2022]
Abstract
Muscle specific tyrosine kinase antibody positive myasthenia gravis (MuSK- MG) is characterized by autoantibodies against the MuSK protein of the neuromuscular junction resulting in weakness of bulbar and proximal muscles. We previously demonstrated that patients with MuSK-MG have increased pro-inflammatory Th1 and Th17 responses. Tacrolimus, an immunosuppressant used in AChR-MG and transplantation patients, inhibits T cell responses through interference with IL-2 transcription. The therapeutic efficacy and immunological effect of tacrolimus in MuSK-MG is unclear. In the current study we examined the proliferation, phenotype and cytokine production of CD4+ and CD8+ T cells in peripheral blood mononuclear cells of MuSK-MG following a 3-day in vitro culture with or without tacrolimus. We determined that tacrolimus profoundly suppressed CD4 and CD8 T cell proliferation and significantly suppressed Th1 and Th17 responses, as demonstrated by a reduced frequency of IFN-γ, IL-2, and IL-17 producing CD4 T cells and reduced frequencies of IFN-γ and IL-2 producing CD8 T cells. Tacrolimus also inhibits pathogenic Th17 cells coproducing IL-17 and IFN-γ. In addition, tacrolimus suppressed follicular T helper cell (Tfh) and regulatory T helper cell (Treg) subsets. These findings provide preliminary support for tacrolimus as a potential alternative immunosuppressive therapy for MuSK-MG.
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Affiliation(s)
- Yingkai Li
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jeffrey T Guptill
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Melissa A Russo
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Janice M Massey
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Vern C Juel
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Lisa D Hobson-Webb
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - James F Howard
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Manisha Chopra
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Weibin Liu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - John S Yi
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.
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Shakhnovich V, Brian Smith P, Guptill JT, James LP, Collier DN, Wu H, Livingston CE, Zhao J, Kearns GL, Cohen-Wolkowiez M. A Population-Based Pharmacokinetic Model Approach to Pantoprazole Dosing for Obese Children and Adolescents. Paediatr Drugs 2018; 20:483-495. [PMID: 30097906 PMCID: PMC6178956 DOI: 10.1007/s40272-018-0305-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND AIMS Pharmacokinetic data for proton pump inhibitors (PPIs), acid-suppression drugs commonly prescribed to children, are lacking for obese children who are at greatest risk for acid-related disease. In a recent multi-center investigation, we demonstrated decreased, total body weight adjusted, apparent clearance (CL/F) of the PPI pantoprazole for obese children compared with their non-obese peers. Subsequently, we developed a population-based pharmacokinetic (PopPK) model to characterize pantoprazole disposition and evaluated appropriate pantoprazole dosing strategies for obese pediatric patients, using simulation. METHODS Pharmacokinetic data from the only prospective study of PPIs in obese children (aged 6-17 years; n = 40) included 273 pantoprazole and 256 pantoprazole-sulfone plasma concentrations, after single oral-dose administration, and were used for pantoprazole model development and covariate analysis (NONMEM®). Model evaluation was performed via bootstrapping and predictive checks, and the final model was applied to simulate systemic pantoprazole exposures for common dosing scenarios. RESULTS A two-compartment PopPK model, which included CYP2C19 genotype and total body weight, provided the best fit. Resultant, typical, weight-normalized pantoprazole parameter estimates were different than previously reported for children or adults, with significantly reduced pantoprazole CL/F for obese children. Of the dosing scenarios evaluated, the weight-tiered approach, approved by the US Food and Drug Administration, achieved pantoprazole exposures [area under the curve (AUC0-∞)] within ranges previously reported as therapeutic, without over- or under-prediction for obese children. CONCLUSIONS Our data argue against empiric dose escalation of PPIs for obese children and support current FDA-approved pediatric weight-tiered dosing for pantoprazole; however, 3- to 5-fold inter-individual variability in pantoprazole AUC0-∞ remained using this dosing approach.
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Affiliation(s)
- Valentina Shakhnovich
- The Children's Mercy Hospital, Kansas City, MO, USA.
- University of Missouri-Kansas City School of Medicine, Kansas City, USA.
| | | | | | | | | | - Huali Wu
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - Jian Zhao
- The Emmes Corporation, Rockville, MD, USA
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40
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Ku LC, Hornik CP, Beechinor RJ, Chamberlain JM, Guptill JT, Harper B, Capparelli EV, Martz K, Anand R, Cohen-Wolkowiez M, Gonzalez D. Population Pharmacokinetics and Exploratory Exposure-Response Relationships of Diazepam in Children Treated for Status Epilepticus. CPT Pharmacometrics Syst Pharmacol 2018; 7:718-727. [PMID: 30267478 PMCID: PMC6263663 DOI: 10.1002/psp4.12349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 10/08/2018] [Indexed: 11/19/2022]
Abstract
Diazepam is labeled for status epilepticus (SE) in children, but there are limited data characterizing its disposition in pediatric patients. We developed a population pharmacokinetic (PK) model of i.v. diazepam in children with SE. We evaluated relationships between PK parameters and both safety and efficacy, and simulated exposures using dosing regimens from the product label and clinical practice. The model was developed using prospective data from a pediatric clinical trial comparing diazepam to lorazepam for treatment of SE. Altogether, 87 patients aged ≥ 3 months to < 18 years contributed 162 diazepam concentrations. Diazepam PKs were well characterized by a two‐compartment model scaled by body size. No significant or clinically important relationships were observed between diazepam PKs and safety or efficacy. Simulations demonstrated that, compared with label dosing, the study dose (0.2 mg/kg i.v., maximum 8 mg) resulted in greater frequency in rapidly achieving the target therapeutic range of 200–600 ng/mL.
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Affiliation(s)
- Lawrence C Ku
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA.,Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Christoph P Hornik
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA.,Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ryan J Beechinor
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - James M Chamberlain
- Division of Emergency Medicine, Children's National Medical Center, Washington, DC, USA
| | - Jeffrey T Guptill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Barrie Harper
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Edmund V Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, California, USA
| | | | | | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA.,Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Shakhnovich V, Smith PB, Guptill JT, James LP, Collier DN, Wu H, Livingston CE, Zhao J, Kearns GL. Obese Children Require Lower Doses of Pantoprazole Than Nonobese Peers to Achieve Equal Systemic Drug Exposures. J Pediatr 2018; 193:102-108.e1. [PMID: 29389444 PMCID: PMC5806153 DOI: 10.1016/j.jpeds.2017.10.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 10/04/2017] [Accepted: 10/11/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess appropriate pantoprazole dosing for obese children, we conducted a prospective pharmacokinetics (PK) investigation of pantoprazole in obese children, a patient population that is traditionally excluded from clinical trials. STUDY DESIGN A total of 41 obese children (6-17 years of age), genotyped for CYP2C19 variants *2, *3, *4, and *17, received a single oral dose of pantoprazole, ~1.2 mg/kg lean body weight (LBW), with LBW calculated via a validated formula. Ten post-dose pantoprazole plasma concentrations were measured, and PK variables generated via noncompartmental methods (WinNonlin). Linear and nonlinear regression analyses and analyses of variance were used to explore obesity, age, and CYP2C19 genotype contribution to pantoprazole PK. PK variables of interest were compared with historic nonobese peers treated with pantoprazole. RESULTS Independent of genotype, when normalized to dose per kg total body weight, pantoprazole apparent clearance and apparent volume of distribution were significantly lower (P < .05) and systemic exposure significantly higher (P < .01) in obese vs nonobese children. When normalized per kg LBW, these differences were not evident in children ≥12 years of age and markedly reduced in children <12 years of age. CONCLUSIONS LBW dosing of pantoprazole led to pantoprazole PK similar to nonobese peers. Additional factors, other than body size (eg, age-related changes in CYP2C19 activity), appear to affect pantoprazole PK in children <12 years of age. TRIAL REGISTRATION ClinicalTrials.gov: NCT02186652.
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Affiliation(s)
- Valentina Shakhnovich
- Divisions of Gastroenterology & Clinical Pharmacology, Toxicology and Therapeutic Innovation, The Children's Mercy Hospital, Kansas City, MO.
| | - P Brian Smith
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Duke Clinical Research Institute, Durham, NC
| | - Jeffrey T Guptill
- Department of Neurology, Division of Neuromuscular Medicine, Duke Clinical Research Institute, Durham, NC
| | - Laura P James
- Department of Pediatrics, University of Arkansas for Medical Sciences Section of Clinical Pharmacology and Toxicology, Arkansas Children's Hospital, Little Rock, AR
| | - David N Collier
- Department of Pediatrics and Center for Health Disparities, Division of General Pediatrics, East Carolina University, Greenville, NC
| | - Huali Wu
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Duke Clinical Research Institute, Durham, NC
| | | | - Jian Zhao
- The Emmes Statistical Group, Rockville, MD
| | - Gregory L Kearns
- Department of Pediatrics, University of Arkansas for Medical Sciences Section of Clinical Pharmacology and Toxicology, Arkansas Children's Hospital, Little Rock, AR
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Guptill JT, Raja S, Sanders DB, Narayanaswami P. Comparative effectiveness clinical trials to advance treatment of myasthenia gravis. Ann N Y Acad Sci 2018; 1413:69-75. [PMID: 29377158 DOI: 10.1111/nyas.13582] [Citation(s) in RCA: 2] [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: 10/03/2017] [Revised: 11/20/2017] [Accepted: 11/27/2017] [Indexed: 12/15/2022]
Abstract
Myasthenia gravis (MG) presents many challenges for establishing treatment efficacy through clinical trials. Among these are the rarity and heterogeneity of the disease, spontaneous fluctuations, prolonged latency to effect for many immunosuppressive drugs, and the uncertain generalizability of results from randomized controlled trials (RCTs). Prospective observational study designs may overcome some of these limitations, but attention is required to ensure that internal validity is not compromised. Observational comparative effectiveness research (CER) utilizes data obtained during routine clinical care to evaluate the effectiveness of interventions in real-life practice conditions, thereby improving generalizability to the clinic. Compared with RCTs, observational CER studies may be less resource intensive and costly. Recent advances that have improved the feasibility of CER studies for MG are (1) the development of MG common data elements, (2) the publication of international consensus guidance for MG treatment, and (3) the development of a web-based REDCap database that can be shared and adapted to standardize data collection. This infrastructure could be used for multisite comparisons of commonly used therapies and provides longitudinal information on patient- and clinician-centered MG outcome measures. A challenge is to design studies that address the potential limitations of observational trials, such as confounding and selection and information bias.
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Affiliation(s)
- Jeffrey T Guptill
- Department of Neurology, Duke University, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina
| | - Shruti Raja
- Department of Neurology, Duke University, Durham, North Carolina
| | - Donald B Sanders
- Department of Neurology, Duke University, Durham, North Carolina
| | - Pushpa Narayanaswami
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Abstract
Myasthenia gravis (MG) is an archetypal autoimmune disease. The pathology is characterized by autoantibodies to the acetylcholine receptor (AChR) in most patients or to muscle-specific tyrosine kinase (MuSK) in others and to a growing number of other postsynaptic proteins in smaller subsets. A decrease in the number of functional AChRs or functional interruption of the AChR within the muscle end plate of the neuromuscular junction is caused by pathogenic autoantibodies. Although the molecular immunology underpinning the pathology is well understood, much remains to be learned about the cellular immunology contributing to the production of autoantibodies. This Review documents research concerning the immunopathology of MG, bringing together evidence principally from human studies with an emphasis on the role of adaptive immunity and B cells in particular. Proposed mechanisms for autoimmunity, which take into account that different types of MG may incorporate divergent immunopathology, are offered. Muscle Nerve 57: 172-184, 2018.
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Affiliation(s)
- John S Yi
- Division of Surgical Sciences, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Jeffrey T Guptill
- Department of Neurology, Neuromuscular Section, Duke University Medical Center, Durham, North Carolina, USA
| | - Panos Stathopoulos
- Department of Neurology, Yale School of Medicine, Room 353J, 300 George Street, New Haven, Connecticut, 06511, USA
| | - Richard J Nowak
- Department of Neurology, Yale School of Medicine, Room 353J, 300 George Street, New Haven, Connecticut, 06511, USA
| | - Kevin C O'Connor
- Department of Neurology, Yale School of Medicine, Room 353J, 300 George Street, New Haven, Connecticut, 06511, USA
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Thakkar N, Guptill JT, Aleš K, Jacobus D, Jacobus L, Peloquin C, Cohen‐Wolkowiez M, Gonzalez D. Population Pharmacokinetics/Pharmacodynamics of 3,4-Diaminopyridine Free Base in Patients With Lambert-Eaton Myasthenia. CPT Pharmacometrics Syst Pharmacol 2017; 6:625-634. [PMID: 28623849 PMCID: PMC5613184 DOI: 10.1002/psp4.12218] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 05/26/2017] [Accepted: 06/04/2017] [Indexed: 11/24/2022] Open
Abstract
Lambert-Eaton myasthenia (LEM) is a rare autoimmune disorder associated with debilitating muscle weakness. There are limited treatment options and 3,4-diaminopyridine (3,4-DAP) free base is an investigational orphan drug used to treat LEM-related weakness. We performed a population pharmacokinetic/pharmacodynamic (PK/PD) analysis using 3,4-DAP and metabolite concentrations collected from a phase II study in patients with LEM. The Triple Timed Up & Go (3TUG) assessment, which measures lower extremity weakness, was the primary outcome measure. A total of 1,270 PK samples (49 patients) and 1,091 3TUG data points (32 randomized patients) were included in the PK/PD analysis. A two-compartment and one-compartment model for parent and metabolite, respectively, described the PK data well. Body weight and serum creatinine partially explained the variability in clearance for the final PK model. A fractional inhibitory maximum effect (Emax ) model characterized the exposure-response relationship well. The PK/PD model was applied to identify a suggested dosing approach for 3,4-DAP free base.
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Affiliation(s)
- Nilay Thakkar
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of PharmacyUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | | | - Kathy Aleš
- Jacobus Pharmaceutical Company, Inc.PlainsboroNew JerseyUSA
| | - David Jacobus
- Jacobus Pharmaceutical Company, Inc.PlainsboroNew JerseyUSA
| | - Laura Jacobus
- Jacobus Pharmaceutical Company, Inc.PlainsboroNew JerseyUSA
| | - Charles Peloquin
- College of Pharmacy and Emerging Pathogens InstituteUniversity of FloridaGainesvilleFloridaUSA
| | | | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of PharmacyUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
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Gonzalez D, Chamberlain JM, Guptill JT, Cohen-Wolkowiez M, Harper B, Zhao J, Capparelli EV. Population Pharmacokinetics and Exploratory Pharmacodynamics of Lorazepam in Pediatric Status Epilepticus. Clin Pharmacokinet 2017; 56:941-951. [PMID: 27943220 PMCID: PMC5466505 DOI: 10.1007/s40262-016-0486-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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] [Indexed: 11/29/2022]
Abstract
BACKGROUND Lorazepam is one of the preferred agents used for intravenous treatment of status epilepticus (SE). We combined data from two pediatric clinical trials to characterize the population pharmacokinetics of intravenous lorazepam in infants and children aged 3 months to 17 years with active SE or a history of SE. METHODS We developed a population pharmacokinetic model for lorazepam using the NONMEM software. We then assessed exploratory exposure-response relationships using the overall efficacy and safety study endpoints, and performed dosing simulations. RESULTS A total of 145 patients contributed 439 pharmacokinetic samples. The median (range) age and dose were 5.4 years (0.3-17.8) and 0.10 mg/kg (0.02-0.18), respectively. A two-compartment pharmacokinetic model with allometric scaling described the data well. In addition to total body weight (WT), younger age was associated with slightly higher weight-normalized clearance (CL). The following relationships characterized the typical values for the central compartment volume (V1), CL, peripheral compartment volume (V2), and intercompartmental CL (Q), using individual subject WT (kg) and age (years): V1 (L) = 0.879*WT; CL (L/h) = 0.115*(Age/4.7)0.133*WT0.75; V2 (L) = 0.542*V1; Q (L/h) = 1.45*WT0.75. No pharmacokinetic parameters were associated with clinical outcomes. Simulations suggest uniform pediatric dosing (0.1 mg/kg, to a maximum of 4 mg) can be used to achieve concentrations of 50-100 ng/mL in children with SE, which have been previously associated with effective seizure control. CONCLUSIONS The population pharmacokinetics of lorazepam were successfully described using a sparse sampling approach and a two-compartment model in pediatric patients with active SE.
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Affiliation(s)
- Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - James M Chamberlain
- Division of Emergency Medicine, Children's National Medical Center, Washington, DC, USA
| | - Jeffrey T Guptill
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | | | - Jian Zhao
- Emmes Corporation, Rockville, MD, USA
| | - Edmund V Capparelli
- Department of Pediatrics and Skaggs School of Pharmacy, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA, 92093-0831, USA.
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Sanders DB, Guptill JT, Aleš KL, Hobson-Webb LD, Jacobus DP, Mahmood R, Massey JM, Pittman MM, Prather K, Raja SM, Yow E, Juel VC. Reliability of the triple-timed up-and-go test. Muscle Nerve 2017; 57:136-139. [PMID: 28545168 DOI: 10.1002/mus.25700] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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: 11/21/2016] [Revised: 05/21/2017] [Accepted: 05/21/2017] [Indexed: 11/09/2022]
Abstract
INTRODUCTION We report the reliability of a new measure, the triple-timed up-and-go (3TUG) test, for assessing clinical function in patients with Lambert-Eaton myasthenia (LEM). METHODS Intrarater reproducibility and interrater agreement of the 3TUG test were assessed in 25 control participants, 24 patients with non-LEM neuromuscular disease, and 12 patients with LEM. The coverage probability (CP) method was the primary measure of reproducibility and agreement. The a priori acceptable range was < 20% difference in 3TUG test times and a CP ≥0.90 confirmed agreement. RESULTS CP values > 0.90 for intrarater and interrater tests confirmed acceptable reproducibility and agreement for all groups. DISCUSSION The 3TUG test is a quick, noninvasive, and reproducible measure that is easy to perform, measures clinically important weakness in LEM patients, and requires little training. Additional evaluation in a larger number of LEM patients is in progress to validate the 3TUG test as a clinical measure in LEM. Muscle Nerve 57: 136-139, 2017.
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Affiliation(s)
- Donald B Sanders
- Neuromuscular Section, Department of Neurology, Duke University Medical Center, Box 3403, Durham, North Carolina, 27710, USA
| | - Jeffrey T Guptill
- Neuromuscular Section, Department of Neurology, Duke University Medical Center, Box 3403, Durham, North Carolina, 27710, USA
| | - Kathy L Aleš
- Jacobus Pharmaceutical Company, Princeton, New Jersey, USA
| | - Lisa D Hobson-Webb
- Neuromuscular Section, Department of Neurology, Duke University Medical Center, Box 3403, Durham, North Carolina, 27710, USA
| | | | - Riaz Mahmood
- Campbell University School of Osteopathic Medicine, Lillington, North Carolina, USA
| | - Janice M Massey
- Neuromuscular Section, Department of Neurology, Duke University Medical Center, Box 3403, Durham, North Carolina, 27710, USA
| | - Melissa M Pittman
- Neuromuscular Section, Department of Neurology, Duke University Medical Center, Box 3403, Durham, North Carolina, 27710, USA
| | - Kristi Prather
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Shruti M Raja
- Neuromuscular Section, Department of Neurology, Duke University Medical Center, Box 3403, Durham, North Carolina, 27710, USA
| | - Eric Yow
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Vern C Juel
- Neuromuscular Section, Department of Neurology, Duke University Medical Center, Box 3403, Durham, North Carolina, 27710, USA
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47
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Juel VC, Sanders DB, Hobson-Webb LD, Massey JM, Guptill JT, O'Brien F, Wang JJ, Howard JF. Marked clinical and jitter improvement after eculizumab in refractory myasthenia. Muscle Nerve 2017; 56:E16-E18. [PMID: 28214342 DOI: 10.1002/mus.25620] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 02/08/2017] [Accepted: 02/14/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Vern C Juel
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Donald B Sanders
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Lisa D Hobson-Webb
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Janice M Massey
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Jeffrey T Guptill
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Fanny O'Brien
- Department of Clinical Research, Alexion Pharmaceuticals, Cheshire, Connecticut, USA.,Department Global Medical Affairs, Alexion Pharmaceuticals, Cheshire, Connecticut, USA
| | - Jing Jing Wang
- Department of Clinical Research, Alexion Pharmaceuticals, Cheshire, Connecticut, USA.,Department Global Medical Affairs, Alexion Pharmaceuticals, Cheshire, Connecticut, USA
| | - James F Howard
- Department of Neurology, University of North Carolina, Chapel Hill, North Carolina, USA
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Yi JS, Russo MA, Massey JM, Juel V, Hobson-Webb LD, Gable K, Raja SM, Balderson K, Weinhold KJ, Guptill JT. B10 Cell Frequencies and Suppressive Capacity in Myasthenia Gravis Are Associated with Disease Severity. Front Neurol 2017; 8:34. [PMID: 28239367 PMCID: PMC5301008 DOI: 10.3389/fneur.2017.00034] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [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: 12/23/2016] [Accepted: 01/24/2017] [Indexed: 01/01/2023] Open
Abstract
Myasthenia gravis (MG) is a T cell-dependent, B cell-mediated disease. The mechanisms for loss of self-tolerance in this disease are not well understood, and recently described regulatory B cell (Breg) subsets have not been thoroughly investigated. B10 cells are a subset of Bregs identified by the production of the immunosuppressive cytokine, interleukin-10 (IL-10). B10 cells are known to strongly inhibit B- and T-cell inflammatory responses in animal models and are implicated in human autoimmunity. In this study, we examined quantitative and qualitative aspects of B10 cells in acetylcholine receptor autoantibody positive MG (AChR-MG) patients and healthy controls. We observed reduced B10 cell frequencies in AChR-MG patients, which inversely correlated with disease severity. Disease severity also affected the function of B10 cells, as B10 cells in the moderate/severe group of MG patients were less effective in suppressing CD4 T-cell proliferation. These results suggest that B10 cell frequencies may be a useful biomarker of disease severity, and therapeutics designed to restore B10 cell frequencies could hold promise as a treatment for this disease through restoration of self-tolerance.
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Affiliation(s)
- John S Yi
- Division of Surgical Sciences, Department of Surgery, Duke University Medical Center , Durham, NC , USA
| | - Melissa A Russo
- Department of Neurology, Neuromuscular Section, Duke University Medical Center , Durham, NC , USA
| | - Janice M Massey
- Department of Neurology, Neuromuscular Section, Duke University Medical Center , Durham, NC , USA
| | - Vern Juel
- Department of Neurology, Neuromuscular Section, Duke University Medical Center , Durham, NC , USA
| | - Lisa D Hobson-Webb
- Department of Neurology, Neuromuscular Section, Duke University Medical Center , Durham, NC , USA
| | - Karissa Gable
- Department of Neurology, Neuromuscular Section, Duke University Medical Center , Durham, NC , USA
| | - Shruti M Raja
- Department of Neurology, Neuromuscular Section, Duke University Medical Center , Durham, NC , USA
| | - Kristina Balderson
- Department of Neurology, Neuromuscular Section, Duke University Medical Center , Durham, NC , USA
| | - Kent J Weinhold
- Division of Surgical Sciences, Department of Surgery, Duke University Medical Center , Durham, NC , USA
| | - Jeffrey T Guptill
- Department of Neurology, Neuromuscular Section, Duke University Medical Center , Durham, NC , USA
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Ericson JE, Zimmerman KO, Gonzalez D, Melloni C, Guptill JT, Hill KD, Wu H, Cohen-Wolkowiez M. A Systematic Literature Review Approach to Estimate the Therapeutic Index of Selected Immunosuppressant Drugs After Renal Transplantation. Ther Drug Monit 2017; 39:13-20. [PMID: 28081041 PMCID: PMC5235278 DOI: 10.1097/ftd.0000000000000364] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [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] [Indexed: 01/05/2023]
Abstract
BACKGROUND Drugs that exhibit close margins between therapeutic and toxic blood concentrations are considered to have a narrow therapeutic index (NTI). The Food and Drug Administration has proposed that NTI drugs should have more stringent bioequivalence standards for approval of generic formulations. However, many immunosuppressant drugs do not have a well-defined therapeutic index (TI). METHODS We sought to determine whether safety, efficacy, and pharmacokinetic data obtained from the medical literature through a comprehensive literature search could be used to estimate the TI of cyclosporine, tacrolimus, and sirolimus. In this analysis, we considered TI ≤2 as a criterion to define a drug as having an NTI. RESULTS Published literature indicates that cyclosporine has a TI of 2-3, which falls just short of our criteria to be classified as having an NTI. We found sirolimus and tacrolimus to have a therapeutic range of 5-12 ng/mL and of 5-20 ng/mL, respectively, but were unable to calculate the TI. CONCLUSIONS Although the current literature does not provide a clear indication that these drugs have an NTI, the routine use of therapeutic drug monitoring in clinical practice suggests that more stringent testing of their pharmacokinetic and pharmacodynamic properties should be performed before the approval of generic formulations.
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Affiliation(s)
- Jessica E. Ericson
- Departments of Pediatrics, Pennsylvania State University, Hershey, PA
- Duke Clinical Research Institute, Durham, NC
| | - Kanecia O. Zimmerman
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | | | - Kevin D. Hill
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
| | - Huali Wu
- Duke Clinical Research Institute, Durham, NC
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
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Guptill JT, Raja SM, Boakye-Agyeman F, Noveck R, Ramey S, Tu TM, Laskowitz DT. Phase 1 Randomized, Double-Blind, Placebo-Controlled Study to Determine the Safety, Tolerability, and Pharmacokinetics of a Single Escalating Dose and Repeated Doses of CN-105 in Healthy Adult Subjects. J Clin Pharmacol 2016; 57:770-776. [PMID: 27990643 DOI: 10.1002/jcph.853] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [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: 09/26/2016] [Accepted: 11/10/2016] [Indexed: 11/11/2022]
Abstract
Spontaneous intracranial hemorrhage (ICH) remains a devastating stroke subtype, affecting as many as 80,000 people annually in the United States and associated with extremely high mortality. In the absence of any pharmacological interventions demonstrated to improve outcome, care for patients with ICH remains largely supportive. Thus, despite advances in the understanding of ICH and brain injury, there remains an unmet need for interventions that improve neurologic recovery and outcomes. Recent research suggesting inflammation and APOE genotype play a role in modifying neurologic outcome after brain injury has led to the development of an APOE-derived peptide agent (CN-105). Preclinical studies have demonstrated that CN-105 effectively downregulates the inflammatory response in acute brain injury, including ICH. Following Investigational New Drug (IND) enabling studies in murine models, this first-in-human single escalating dose and multiple dose placebo-controlled clinical trial was performed to define the safety and pharmacokinetics (PK) of CN-105. A total of 48 subjects (12 control, 36 active) were randomized in this study; all subjects completed the study. No significant safety issues were identified with both dosing regimens, and PK analysis revealed linearity without significant drug accumulation. The median half-life in the terminal elimination phase of CN-105 following a single or repeated dosing regimen did not change (approximately 3.6 hours). With the PK and preliminary safety of CN-105 established, the drug is now poised to begin first-in-disease phase 2 clinical trials in patients with ICH who urgently need new therapeutic options.
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Affiliation(s)
- Jeffrey T Guptill
- Department of Neurology, Duke University, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Shruti M Raja
- Department of Neurology, Duke University, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | | | | | - Sarah Ramey
- Duke Clinical Research Institute, Durham, NC, USA
| | - Tian Ming Tu
- SingHealth, National Neuroscience Institute, Singapore, Republic of Singapore
| | - Daniel T Laskowitz
- Department of Neurology, Duke University, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
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