Rituximab treatment for myasthenia gravis

Comparison between rituximab treatment for new-onset generalized myasthenia gravis and refractory generalized myasthenia gravis

Brauner S, Eriksson-Dufva A, Hietala MA, et al
JAMA Neurology|August 11, 2020

This study was conducted at Karolinska University Hospital, Stockholm, Sweden. Data was collected on a county-based community sample of 72 patients exposed to rituximab early or later in the myasthenia gravis disease course as well as controls receiving conventional immunotherapy.

Aim: to discover if the response to rituximab differs between patients with new-onset myasthenia gravis vs generalized myasthenia gravis, resistant to treatment, and how does rituximab compare with conventional immunotherapy in these patients?

Findings: In this cohort study, rituximab appeared to perform better if initiated early after onset of generalized symptoms of myasthenia gravis.

Conclusions: Early treatment with rituximab may be associated with improved treatment outcomes and may be considered earlier in the treatment for patients with new-onset generalized myasthenia gravis.

Read the full article on JAMA Neurology


Research into Myositis‐specific autoantibodies

Myositis‐specific autoantibodies and their clinical associations in idiopathic inflammatory myopathies

Wong VTL, So H, Lam TTO, et al
Acta Neurologica Scandinavica|August 11, 2020

This multi‐centered studywas done on adult Chinese patients with idiopathic inflammatory myopathies (IIMs) in regional hospitals in Hong Kong from July 2016 to January 2018. 

Aim: to discover the prevalence of Myositis‐specific autoantibodies (MSAs) and their associated complications in a cohort of patients with idiopathic inflammatory myopathies (IIMs).

Findings: different antibodies were detected. 

ConclusionsMSA testing means patients with IIMs can be divided into subgroups and easier prediction of potentially life‐threatening complications.

Read the full article at Acta Neurologica Scandinavica.

Myositis is an autoimmune disease where the body attacks healthy muscle fibers causing muscle inflammation, and eventually, loss of strength, functionality and mobility. It can be life-threatening when it affects the lungs and heart, but fortunately, there are medications and therapies to effectively treat the condition. ~ Hospital for Special Surgery


Does autoimmune thyroid disease affect rheumatoid arthritis disease activity or response to methotrexate?

                  Does autoimmune thyroid disease affect rheumatoid arthritis disease activity or response to methotrexate?


Objective: To investigate if autoimmune thyroid disease (AITD) impacts rheumatoid arthritis (RA) disease activity or response to methotrexate.
Methods: A nationwide register-based cohort study of 9 004 patients with new-onset RA from the Swedish Rheumatology Quality Register year 2006-2016, with linkage to other nationwide registers to identify comorbidity with AITD defined as thyroxine prescription before RA diagnosis, excluding non-autoimmune causes. We compared RA disease activity using 28-joint Disease Activity Score (DAS28) and its components, and EULAR response, between patients with and without AITD, using logistic regression.
Results: At diagnosis, patient reported outcome measures (PROMs; patient global, Health Assessment Questionnaire Disability Index and pain) but not objective disease activity measures (erythrocyte sedimentation rate and swollen joint count) were significantly higher among RA patients with AITD compared with those without. The level of DAS28 was 5.2 vs 5.1. By contrast, AITD had little influence on EULAR response to methotrexate at 3 months, nor at 6 months. When stratified by age, however, AITD was more common among EULAR non/moderate responders at 3 and 6 months in patients below 45 years resulting in ORs of non/moderate response of 1.44 and 2.75.

Conclusion: At diagnosis, RA patients with concomitant AITD score worse on patient reported but not on objective RA disease activity measures, while DAS28 was only marginally elevated. The overall chance of achieving a EULAR good response at 3 or 6 months remains unaffected, although among a limited subgroup of younger patients, AITD may be a predictor for an inferior primary response.


Major Depressive Disorder Raises Risk of Developing Autoimmune Skin Disease

Major Depressive Disorder and Autoimmune Skin Disease

Patients with major depressive disorder are at increased risk of developing an autoimmune skin disease, according to a 2020 study. 

This large Taiwanese study aimed to investigate the association of major depressive disorder (MDD) with risk of getting a new autoimmune skin disorder (ASD).

Subjects were recruited from the National Health Insurance Research Database in Taiwan: 222,522 patients with MDD and 890,088 matched controls to assess the risk of developing ASDs.
Researchers found an increased risk of ASDs among the patients with MDD compared to the matched controls. 
Analysis showed that MDD patients had a significantly increased risk of developing the following skin conditions all of which have an autoimmune basis:
  • psoriasis 
  • lichen planus  
  • alopecia areata  
  • morphea 
  • autoimmune bullous diseases 
  • hidradenitis suppurativa 
  • vitiligo 
  • lupus erythematosus
  • systemic sclerosis 
  • Sjogren's syndrome 
  • dermatomyositis

Conclusions of the study:

Patients with MDD had an increased risk of developing ASDs as compared to the controls. 
Further studies are needed to better understand the underlying mechanisms.


Scientists Re-wires Immune System to Hinder Attack on Healthy Cells in Autoimmune Diseases

Attack on Healthy Cells in Autoimmune Diseases

Researchers from the University of Birmingham have devised an approach to prevent the body's immune system from recognizing its own proteins, thus preventing an attack on healthy cells in autoimmune disorders.

In their study, the authors analyzed the mechanism of T-cells, which controlled the body's immune function and discovered that they could be manipulated to prevent its attack on its own cells.

For example, with multiple sclerosis, an autoimmune disease involving the brain and spinal cord, the new technique discovered would hinder the body from attacking the Myelin Basic Protection (MBP) by fooling the immune system to perceive the protein as a part of itself.
According to Professor David Wraith, an author of the study from the Institute of Immunology and Immunotherapy, the team's findings have vital connotations for millions of patients suffering from autoimmune conditions that physicians currently find difficult to treat.
Autoimmune diseases are currently treated using immunosuppressive drugs. The problem with this is that they suppress the whole immune system, making the patient prone to cancers and other infections. Trials using antigen therapy in patients with MS and Grave’s disease are ongoing, but results from short-term preliminary clinical trials showed both MS and Graves’ disease patients started to have improved health while the trials lasted. ProfessorDavid Wraith
The findings of the study supported by the Medical Research Council were published in the journal Cell Reports on June 9, 2020.


Remission of Pituitary Autoimmunity Induced by Gluten-Free Diet

Remission of Pituitary Autoimmunity Induced by  Diet

An improvement of some autoimmune diseases associated with celiac disease (CD) has been observed after a gluten-free diet (GFD).

The aim of this study was to evaluate the effect of a gluten-free diet (GFD) on autoimmune pituitary impairment in patients with celiac disease and potential/subclinical lymphocytic hypophysitis (LYH).
Lymphocytic hypophysitis is a condition in which the pituitary gland becomes infiltrated by lymphocytes, resulting in pituitary enlargement and impaired function. NORD
Five-year longitudinal observational study.
Ninety-three newly diagnosed LYH patients (high titer of antipituitary antibodies [APA] and normal or subclinically impaired pituitary function) were enrolled from 2000 to 2013 and grouped as follows: group 1, consisting of 43 patients with LYH + CD, and group 2, consisting of 50 patients with isolated LYH only.
A GFD was started in patients in group 1 after the diagnosis of CD.
Main outcome measures
APA titers and pituitary function were evaluated at the beginning of the study and then yearly for 5 years in both groups. Patients progressing to a clinically overt LYH were excluded from the follow-up.
Complete remission of LYH (disappearance of APA and recovery of pituitary function in patients with previous subclinical hypopituitarism) occurred in 15 patients in group 1 after a GFD (34%) and spontaneously in only 1 patient in group 2 (2%) (P < .001). 
Two patients in group 1 and 25 in group 2 progressed to a clinically overt hypopituitarism and dropped out from the study to receive an appropriate replacement therapy. 
The presence of CD was the only independent predictor of pituitary function recovery (hazard ratio [HR] 0.059, 95% confidence interval [CI] 0.01–0.54, P = .012).
In patients with LYH and CD, a GFD may be able to induce remission of subclinical LYH, or prevent the progression to clinical stage of this disease.

This research was done at the tertiary referral center for immunoendocrinology at the University of Campania “Luigi Vanvitelli” in Naples, Italy.


Remission of Pituitary Autoimmunity Induced by Gluten-Free Diet in Patients With Celiac Disease

Giuseppe Bellastella, Maria Ida Maiorino, Paolo Cirillo, Miriam Longo,Vlenia Pernice, Angela Costantino, Carmen Annunziata, Antonio Bellastella,Katherine Esposito, Annamaria De Bellis
The Journal of Clinical Endocrinology & Metabolism, Volume 105, Issue 7, July 2020, dgz228, https://doi.org/10.1210/clinem/dgz228
Published: 20 May 2020


Autoimmune and coronavirus updates

Autoimmune and coronavirus updates

The information below is based on the latest information and research available as of April 9th, 2020. As you know COVID-19 information changes frequently as new research is done. Please discuss your medications, autoimmune conditions and risk with your healthcare provider.

RISK CALCULATOR: Assessing your risk – rheumatology patients: Some people are more vulnerable to the new coronavirus, COVID-19 than others. If you have an autoimmune condition and/or if you are receiving treatment to control your immune system your risk from COVID-19 is higher. VERSUS ARTHRITIS

DIABETES KNOW YOUR RISK:  There is no evidence to date that people with diabetes are at increased risk of being infected with COVID-19.  However, people with diabetes, especially the elderly, can experience more severe symptoms and are more likely to need hospitalisation if they are infected with COVID-19. DIABETES AUSTRALIA

Young people with type 1 diabetes - Data from Wuhan (China) and Italy has found no evidence that children or young people with type 1 diabetes who develop COVID-19 experience severe symptoms of the disease.

Adults with type 1 diabetes or type 2 diabetes - If you’re living with diabetes and you develop a viral infection, such as COVID-19, it can be harder to treat and you may be at higher risk of serious complications.

Older people with diabetes, and people who have diabetes complications such as heart or kidney disease, may experience more severe symptoms of COVID-19.
COVID-19 & IBD Medication: You probably have questions about your IBD medications and wonder if they increase your risk for contracting SARS-CoV-2 and developing COVID-19. Information at CROHN'S & COLITIS FOUNDATION

LUPUS and (COVID-19) frequently asked questions: It’s important that you emphasize to your friends, colleagues, neighbours, and anyone who might come in frequent contact with you or your environment that lupus puts you at higher risk from infections like coronavirus. This will let them know to be very careful with their own hygiene and health habits to ensure they don’t put you at further risk. LUPUS FOUNDATION OF AMERICA

MULTIPLE SCLEROSIS: Guidance for the use of disease modifying therapies during the COVID-19 pandemic. Information from THE NATIONAL MS SOCIETY (USA)

MYOSITIS: Dr. Rohit Aggarwal, Associate Professor of Medicine, Medical Director, Arthritis and Autoimmunity Center from the University of Pittsburgh, and Chair of The Myositis Association’s Medical Advisory Board recommends that myositis patients, particularly those on immunosuppressive drugs or older than 60 years of age, should take common sense steps and follow CDC recommendations such as frequent hand washing and avoiding sick contacts (including friends or family), avoiding touching your eyes, nose and mouth, covering your cough and sneezes and staying home when you are sick. Dr. Aggarwal also recommends avoiding non-urgent long-distance travel for patients on multiple immunosuppressive medications at this time. THE MYOSITIS ASSOCIATION

CELIAC DISEASE: The Celiac Disease Foundation Medical Advisory Board states that celiac disease patients in general are not considered to be immunocompromised. A small proportion of celiac disease patients with severe malnutrition and weight loss, the rare complication of Type 2 refractory celiac disease, on immunosuppressive medications, or with other serious illnesses, may be at increased risk of severe illness from COVID-19 and should consult with their physicians.

SJOGREN'S SYNDROME: For you, as a Sjögren’s patient, the key is not to panic but to take care of yourself. You are not more susceptible to becoming infected by the coronavirus than others, but if you do get diagnosed as being positive with COVID-19, the complications from COVID-19 may be more severe. Your risk of severe disease may be higher if you have a weakened immune system which may be the case for older people, people with other chronic diseases such as diabetes, cancer, heart, renal or chronic lung disease. Please note though, that not all Sjögren’s patients have compromised immune systems. However, some medications commonly taken by Sjögren’s patients may suppress the immune system, including  Arava (leflunomide), Imuran (azathioprine), cyclophosphamide, methotrexate, prednisone, Solu-Medrol (methylprednisolone), CellCept (Mycophenolate mofetil), and Rituxan (Rituximab). Plaquenil (hydroxychloroquine), on the other hand, does not suppress the immune system. Leslie P. Laing President: Sjögren’s Society of Canada

VASCULITIS: The specific risks of COVID-19 in people with vasculitis are yet to be determined. We suspect our patients are at higher risk of infection due to immunosuppression used to manage vasculitis. So far, we do not know whether the risk differs based on the type of immune-suppressing medication someone is taking. We also do not yet have data on the clinical course of patients with vasculitis who develop infection with COVID-19.
All patients with vasculitis (especially those on treatment) should consider themselves at high risk. They should take all the recommended precautions recommended by the Center for Disease Control (CDC) to minimize exposure. THE VASCULITIS FOUNDATION

CDC’s list of those at high-risk for severe illness from COVID-19 includes:
  • People 65 years or older
  • People who live in a nursing home or long-term care facility
  • People of all ages with underlying medical conditions, especially if they are not well controlled
    • Chronic lung disease or moderate to serve asthma
    • Serious heart conditions
    • Conditions that cause a person to be immunocompromised, including cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune weakening medications
  • Severe obesity (body mass index [BMI of 40 or higher)
  • Diabetes
  • Chronic kidney disease and who are undergoing dialysis
  • Liver disease


Asthma and coronavirus disease - COVID -19


Special precautions to be taken by asthmatics as per CDC recommendations include:
  • The symptoms of asthma need to be kept under control using medications as advised by a physician.
  • The use of inhalers with steroids in them as recommended by physicians is needed.
  • Medications prescribed for asthma control should not be stopped, nor the asthma treatment plan altered without consultation with the physician.
  • An emergency supply of inhalers and asthma medications needs to be ensured by talking to the healthcare providers, pharmacists, and insurers. The CDC recommends that all asthmatics, as well as others with long term ailments, need to have at least 30 days of prescription and non-prescription drugs at home in case they need to be homebound for long periods of time.
  • For asthmatics, all triggers of asthma should be avoided
  • Inhaler use correctly is also important
  • Persons with asthma in the community may cause anxiety, which may act as a trigger for asthma. Steps should be taken to control anxiety and stress during this time.
  • Dust can be a trigger for asthma. During COVID-19 pandemic, cleaning and disinfection of the home could be vital. The CDC recommends that those with asthma should not be the ones involved in cleaning and should be away from the room when cleaning is done.
  • The house should be aired and well ventilated using fans and open doors and windows.
  • Not just in homes of asthmatics, in other homes as well, frequently touched surfaces such as phones, remotes, tables, switches, doorknobs, handles, etc. need to be disinfected with soap and water.
  • In case of symptoms, health care providers need to be contacted immediately.


INFORMATION ABOUT COVID- 19 for those with AUTOIMMUNE DISEASE and other chronic illnesses

The spread of the coronavirus, now called COVID-19, is causing alarm worldwide.
The World Health Organization has declared a global health emergency, and many countries have a rise in confirmed cases.
In the US, the Centers for Disease Control and Prevention (CDC) is advising people to be prepared for disruptions to daily life that will be necessary if the coronavirus spreads within communities.
information about COVID-19 for those with autoimmune disease

As Wuhan has seen the highest number of infections their numbers have been analyzed showing:
  • people over 60 are more at risk.
  • people with other chronic illnesses are more at risk.
Those with other chronic illnesses do worse: There have been approximately 5,000 cases where individuals have reported a known co-morbid medical condition, such as high blood pressure, diabetes, heart disease, chronic lung disease, or cancer. The average mortality rate in these groups is in the 5-10% range, whereas of the 15,000 individuals who reported no other medical conditions, the mortality rate to date has been less than 1%. FORBES
While less than 1 percent of people who were otherwise healthy died from the disease, the fatality rate for people with cardiovascular disease was 10.5 percent. That figure was 7.3 percent for diabetes patients and around 6 percent for those with chronic respiratory disease, hypertension, or cancer.  THE SCIENTIST
It is hard to know the facts in these early days of the conronavirus about the long term prognosis for people with autoimmune disease. My concerns are that many people with autoimmune disease take immunosuppressant medications to manage their symptoms and these can make them more vulnerable to infection generally. Also our bodies are working so hard already, are they going to fight off the coronavirus?


Common corona virus symptoms include:
  • fever 
  • dry cough
  • fatigue
Some people also get:
  • sore throat
  • congested nose
  • nausea and gastrointestinal symptoms
  • shortness of breath
  • flu like aches and pains
THE MAIN PROBLEM WITH THE CORONAVIRUS is that you are contagious when you do not have symptoms. These symptoms generally appear three to four days after exposure but can be up to 27 days later!

According to the WHO, coronaviruses may survive on surfaces for just a few hours or several days, although many factors will influence this, including surface material and weather.
That’s why personal preventive steps like frequently washing hands with soap and water or an alcohol-based hand sanitizer, and wiping down often-touched surfaces with disinfectants or a household cleaning spray, are a good idea. HARVARD HEALTH 

"If you’re sick or you are immune-compromised, avoid places with large numbers of people." UCHealth.

In Australia we have been told by the Health Minister to stop shaking hands when we great people. In France they have been told to stop kissing on the cheek. This is because this disease is so transmissible. The only way to avoid it is to not have any contact with anybody!

Keep up to date on your local health warnings and advice. The main advice at the moment seems to be to wash our hands often, for 20 seconds or more, with soap and water.

CDC provides recommendations on postponing or cancelling travel to certain countries only, at this stage. These travel notices are based on assessment of the potential health risks involved with traveling to a certain area. Their list of travel notices is available here.

Smart Traveller, by the Australian government, provides travel updates on countries and recommendations.

The Institute of Public Health in Norway, says "To prevent infection, people should keep at least one metre away from people with respiratory symptoms and those who are ill should avoid coughing or sneezing directly onto others."
  • Avoid infection by not traveling to epidemic areas. 
  • Infected people should use mouthwash. 
  • Frequent and thorough hand washing and good general hygiene are recommended. 
  • Preventive measures are especially important for people with weakened immune systems. 
  • Immunosuppressants should be considered discontinued among those infected until the infection is over. A vaccine against covid-19 has not yet been developed (as of March 2020). Antibiotics (against bacteria) do not work against viruses. Anti-viral drugs especially for coronavirus are not available (as of March 2020). 
  • In cases where covid-19 causes pneumonia, hospital treatment will often be necessary. Oxygen supplementation and breathing aid, including the use of a respirator may be necessary.
  • People who use immunosuppressive drugs and have no symptoms of infection should continue with their usual treatment during an epidemic. 
  • If signs of infection with fever and other influenza symptoms should occur, a 1-2 week treatment break with the immunosuppressive therapy may be appropriate. However, it assumes that one is not completely dependent on the treatment. Prednisolone and other cortisone preparations should not be terminated abruptly.  Physician and specialist in rheumatic diseases PhD Øyvind Palm 

coronavirus and autoimmune diseases


I personally have 3 autoimmune diseases and other health issues.

I will be avoiding all non essential travel and have sadly postponed an overseas holiday to Asia.

I will be avoiding all large events and gathering places such as universities, the library and the shopping mall.

If I was still working I would be asking to work from home due to my compromised immune system.

I am trying to be my healthiest self by eating well and exercising. I have already added magnesium and Vitamin D supplements to my diet and will now add a daily multivitamin as well and garlic tablets. It can't hurt and it may help fight off infection.

Eating garlic appears to offer the best of both worlds, dampening the over-reactive face of the immune system by suppressing inflammation while boosting protective immunity, for example natural killer cell activity, which our body uses to purge cells that have been stricken by viruses or cancer. In World War II garlic was evidently dubbed ‘Russian Penicillin’ because, after running out of antibiotics, that’s what the Soviet government turned to. Dr Michael Greger at Nutrition Facts
I have asked my doctor for extra scripts of my medications so I can have an adequate supply.

I have put in place a plan with my family regarding what we will be doing if more cases come to our area.

We have checked our medicine chest to make sure all painkillers etc are in supply and not out of date.

We are checking our pantry and making sure we have all our normal food supplies and a few extra so that we do not have to go to the shops as often. Our list includes extra toilet paper, canned food and dry goods such as rice and pasta.
For food, you can just buy two or three weeks’ worth of shelf-stable food that you would eat anyway, and be done; this could include canned food like beans and vegetables, pasta, rice, cereals or oats, oils/fats, nuts and dried fruits. It’s really not that hard because we’re talking two-three weeks, so whatever you get is fine. Zeynep Tufekci is an associate professor at the University of North Carolina School of Information and Library Science, her coronavirus article is at Scientific American.  

I will be updating this page with suggestions as I research them.

I have no medical background but use reliable sources when providing you information and when doing research. Best wishes from Lee Good.

You can check out my website on Autoimmune Disease here.

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