Pearls &amp; Oy-sters: Pembrolizumab-induced myasthenia gravis

AlGaeed, Mohanad; Mukharesh, Loulwah; Heinzelmann, Morgan; Kaminski, Henry J.

doi:10.1212/wnl.0000000000006278

Cited by 24 publications

(7 citation statements)

References 20 publications

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“…Our findings support that irMG has several different clinical features compared with idioMG, which has also been proved by previous studies ( 10 , 11 ). Demographically, the age at diagnosis of irMG was significantly greater than that of patients with idioMG.…”

Section: Discussionsupporting

confidence: 92%

Association Between Clinical Factors and Result of Immune Checkpoint Inhibitor Related Myasthenia Gravis: A Single Center Experience and Systematic Review

et al. 2022

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BackgroundNeurological immune-related adverse events (nirAEs) are rare toxicities of immune-checkpoint inhibitors (ICI). With the increase use of ICIs, incidence of nirAEs is growing, among which ICI related MG (irMG) is causing high fatality rate. Given the limited evidence, data from a large cohort of patients with irMG is needed to aid in recognition and management of this fatal complication.ObjectiveThis study aimed to summarize clinical characteristics of irMG and explore predictors of irMG clinical outcome.MethodsWe summarized our institution's patients who were diagnosed as irMG between Sep 2019 and Oct 2021. We systematically reviewed the literature through Oct 2021 to identify all similar reported patients who met inclusion criteria. As the control group, patients with idiopathic MG were used. We collected data on clinical features, management, and outcomes of both irMG and idioMG cases. Further statistical analysis was conducted.ResultsSixty three irMG patients and 380 idioMG patients were included in the final analysis. For irMG patients, six were from our institution while the rest 57 were from reported cases. The average age of irMG patients is 70.16 years old. Forty three were male. Average time from first ICI injection to symptom onset was 5.500 weeks. Eleven patients had a past history of MG. Higher MGFA classification and higher QMGS rates were observed in irMG patients compared to idioMG patients. For complication, more irMG patients had myositis or myocarditis overlapping compared to idioMG patients. The most commonly used treatment was corticosteroids for both idioMG and irMG. Twenty one patients (35%) with irMG had unfavorable disease outcome. Single variate and multivariate binary logistic regression proved that association with myocarditis, high MGFA classification or QMGS rates at first visit were negatively related to disease outcome in irMG patients.ConclusionirMG is a life-threatening adverse event. irMG has unique clinical manifestations and clinical outcome compared to idioMG. When suspicious, early evaluation of MGFA classification, QMGS rates and myositis/myocarditis evaluation are recommended.

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Section: Discussionsupporting

confidence: 92%

Association Between Clinical Factors and Result of Immune Checkpoint Inhibitor Related Myasthenia Gravis: A Single Center Experience and Systematic Review

et al. 2022

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“…We evaluated articles, including case reports and case series, in English that provided original patient data. Among the 92 articles found on PubMed, 45 articles (49 cases, one case of our own) were included in the review ( Supplementary Table 1 ) ( 2 – 45 ). After reading each article, the cases with several missing data or undetermined causes of mortality were excluded.…”

Section: Methodsmentioning

confidence: 99%

Immune Checkpoint Inhibitor-Induced Myasthenia Gravis

et al. 2020

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The development of immune checkpoint inhibitors (ICIs) has been a major breakthrough in cancer immunotherapy. The increasing use of ICIs has led to the discovery of a broad spectrum of immune-related adverse events (irAEs). Immune-related myasthenia gravis (irMG) is a rare but life-threatening irAE. In this review, the clinical presentations of irMG are described and the risk of irMG-related mortality is examined using information from relevant studies. In 47 reported cases of irMG with clear causes of mortality, irMG appeared to be a distinct category of neuromuscular disorders and differed from classical MG in terms of its demographic patient characteristics, pathogenesis, serology profile, response to treatment, associated complications, and prognosis. Because of the high mortality of irMG, measures to increase the vigilance of medical teams are necessary to ensure the timely identification of the signs of irMG and early treatment, particularly in the early course of ICI therapy. The diagnostic plans should be comprehensive and include the evaluation of other organ systems, such as the dermatological, gastrointestinal, respiratory, neuromuscular, and cardiovascular systems, in addition to the traditional diagnostic tests for MG. Treatment plans should be individualized on the basis of the extent of organ involvement and clinical severity. Additional therapeutic studies on irMG in the future are required to minimize irAE-related mortality and increase the safety of patients with cancer in the ICI era.

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“…Immunotherapy-induced MG is an increasingly recognized and feared complication of ICIs [ 84 , 85 ]. Although MG exacerbation has been reported in patients who have had stable myasthenia during ICIs therapy, ICIs-related MG appears to be primarily new with no previous clinical history of MG [ 29 , 86 ]. The average onset of MG-related symptoms was four weeks (from six days to 16 weeks) of ICIs.…”

Section: Neurotoxic Features Of Immunotherapymentioning

confidence: 99%

Neurotoxicity of Tumor Immunotherapy: The Emergence of Clinical Attention

Zhang

Xue

Yin

et al. 2022

Journal of Oncology

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Tumor immunotherapy brings substantial and long-term clinical benefits that can even cure tumors. However, the accumulation of evidence suggests that immunotherapy also induces severe and complex neurologic immune-related adverse events (ir-AEs) and even leads to immunotherapy-related death, which arouses the concern of clinicians. The timely and accurate identification of neurotoxicity helps clinicians detect and treat these complications early, thereby enhancing treatment efficiency and improving the prognosis of patients. At present, the mechanism of neurotoxicity caused by immunotherapy has not been completely elucidated. This paper mainly reviews the clinical features, pathogenesis, and therapeutic strategies of neurologic ir-AEs.

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Pearls & Oy-sters: Pembrolizumab-induced myasthenia gravis

Cited by 24 publications

References 20 publications

Association Between Clinical Factors and Result of Immune Checkpoint Inhibitor Related Myasthenia Gravis: A Single Center Experience and Systematic Review

Association Between Clinical Factors and Result of Immune Checkpoint Inhibitor Related Myasthenia Gravis: A Single Center Experience and Systematic Review

Immune Checkpoint Inhibitor-Induced Myasthenia Gravis

Neurotoxicity of Tumor Immunotherapy: The Emergence of Clinical Attention

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