Am J Med Genet C Semin Med Genet 2012;160C:40C49. remained LT, versus 5/37 HSAT (maximum 51,200C409,600), 7/37 SIT (12,800C51,000), and 23/37 LT FXIa-IN-1 (200C12,800) among comparators. Conclusions: Results of TLD-MTX co-initiated with rhGAA are motivating and merit a larger longitudinal study. pathogenic variants; their Rabbit Polyclonal to DSG2 immune systems identify ERT as foreign and, as a result, form clinically important levels of anti-rhGAA IgG antibodies.10 CRIM-negative patients account for ~25C32% of all patients with IOPD,11,12 and are likely to have a poor clinical outcome when treated with ERT alone. In contrast, CRIM-positive individuals have some residual native enzyme, whether functional or non-functional, 10 and are more likely to develop lower anti-rhGAA IgG titers or none.13 Inside a retrospective analysis by Banugaria et al,13 39% (9 of 23) CRIM-positive IOPD individuals treated with ERT had high anti-rhGAA IgG antibody titers, FXIa-IN-1 and their clinical results were poor, much like CRIM-negative individuals; therefore it was founded that antibody status affects ERT response. At present, you will find no predictive factors to determine which CRIM-positive FXIa-IN-1 individuals will develop HSAT or sustained intermediate titers (SIT; defined as titers of 12,800 and 51,200 within the first 12 months on rhGAA). Immune tolerance induction (ITI) protocols have been established as an approach to minimize the development of anti-rhGAA IgG antibodies and maintain low or absent antibody titers over time. Protocols for ITI using numerous immunomodulating drugs have been analyzed for prophylaxis to preempt immune response in ERT-na?ve individuals14C16 and for therapy to decrease existing anti-rhGAA antibodies in ERT-treated individuals with already established immune reactions.14,15,17,18 However, studies in FXIa-IN-1 the largest quantity of CRIM-negative individuals na?ve to ERT therapy have prophylactically combined rituximab and methotrexate (e.g. one course of rituximab 375 mg/m2 IV weekly four times; methotrexate 0.4 mg/kg SC every 2 weeks), with or without intravenous immunoglobulin, in attempts to preempt an immune response.14,15,17 In the past, there was no success in individuals with an entrenched immune response and antibody titers persisted after multiple immune modulating treatment regimens.19,20 Addition of the plasma cell-targeting agent bortezomib21 or additional therapies in individuals with established HSAT offers proven successful in minimizing antibody titers, yet required long term immunosuppression arising from the use of maintenance doses of rituximab and methotrexate along with bortezomib.18,22 A short course of prophylactic ITI in CRIM-negative FXIa-IN-1 IOPD individuals offers improved clinical results as compared with ERT monotherapy by preempting the development of HSAT and thus preventing the consequent loss of ERT effectiveness. As demonstrated inside a prior study by Banugaria et al.,23 a three-drug ITI regimen (methotrexate, rituximab, and intravenous immunoglobulin) initiated concurrently with ERT in 7 CRIM-negative classic IOPD individuals C four individuals by no means seroconverted (developed antibodies), 1 patient died of respiratory failure, and 2 individuals required additional ITI programs, which remaining their antibody titers lower than in ERT-treated CRIM-negative babies without ITI. A follow-up study with the same three-drug ITI routine in 19 CRIM-negative individuals, including the 7 individuals in Banugaria et al.,23 showed that 15 of 19 individuals either did not seroconvert or managed low antibody titers, in contrast to the natural course of CRIM-negative individuals on ERT monotherapy. Only one of these 19 individuals broke tolerance and developed HSAT. This individual was consequently rescued using a bortezomib-based ITI protocol.24 The same prophylactic ITI regimen successfully induced tolerance in the CRIM-positive younger sibling of a CRIM-positive Pompe patient who had developed HSAT on ERT monotherapy.25 Prophylactic ITI protocols concurrent with ERT initiation are used increasingly by treating physicians worldwide and are considered a standard of care for CRIM-negative patients. A subset of CRIM-positive individuals also develop a sustained immune response,13.

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