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Meta-Analysis
. 2017 May 8;5(5):CD003280.
doi: 10.1002/14651858.CD003280.pub5.

Immunomodulatory treatment other than corticosteroids, immunoglobulin and plasma exchange for chronic inflammatory demyelinating polyradiculoneuropathy

Mohamed Mahdi-Rogers  1 , Ruth Brassington  2 , Angela A Gunn  2 , Pieter A van Doorn  3 , Richard Ac Hughes  2
Affiliations
Meta-Analysis

Immunomodulatory treatment other than corticosteroids, immunoglobulin and plasma exchange for chronic inflammatory demyelinating polyradiculoneuropathy

Mohamed Mahdi-Rogers et al. Cochrane Database Syst Rev. .

Abstract

Background: Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a disease that causes progressive or relapsing and remitting weakness and numbness. It is probably caused by an autoimmune process. Immunosuppressive or immunomodulatory drugs would be expected to be beneficial. This review was first published in 2003 and has been updated most recently in 2016.

Objectives: To assess the effects of immunomodulatory and immunosuppressive agents other than corticosteroids, immunoglobulin, and plasma exchange in CIDP.

Search methods: On 24 May 2016, we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 4) in the Cochrane Library, MEDLINE, Embase, CINAHL, and LILACS for completed trials, and clinical trial registers for ongoing trials. We contacted the authors of the trials identified and other disease experts seeking other published and unpublished trials.

Selection criteria: We sought randomised and quasi-randomised trials of all immunosuppressive agents, such as azathioprine, cyclophosphamide, methotrexate, ciclosporin, mycophenolate mofetil, and rituximab, and all immunomodulatory agents, such as interferon (IFN) alfa and IFN beta, in participants fulfilling standard diagnostic criteria for CIDP. We included all comparisons of these agents with placebo, another treatment, or no treatment.

Data collection and analysis: We used standard methodological procedures expected by Cochrane. We wanted to measure the change in disability after one year as our primary outcome. Our secondary outcomes were change in disability after four or more weeks (from randomisation); change in impairment after at least one year; change in maximum motor nerve conduction velocity and compound muscle action potential amplitude after one year; and for participants who were receiving corticosteroids or intravenous immunoglobulin (IVIg), the amount of this medication given during at least one year after randomisation. Participants with one or more serious adverse events during the first year was also a secondary outcome.

Main results: Four trials fulfilled the selection criteria: one of azathioprine (27 participants), two of IFN beta-1a (77 participants in total) and one of methotrexate (60 participants). The risk of bias was considered low in the trials of IFN beta-1a and methotrexate but high in the trial of azathioprine. None of the trials showed significant benefit in any of the outcomes selected by their authors. The results of the outcomes which approximated most closely to the primary outcome for this review were as follows.In the azathioprine trial there was a median improvement in the Neuropathy Impairment Scale (scale range 0 to 280) after nine months of 29 points (range 49 points worse to 84 points better) in the azathioprine and prednisone treated participants compared with 30 points worse (range 20 points worse to 104 points better) in the prednisone alone group. There were no reports of adverse events.In a cross-over trial of IFN beta-1a with 20 participants, the treatment periods were 12 weeks. The median improvement in the Guy's Neurological Disability Scale (range 1 to 10) was 0.5 grades (interquartile range (IQR) 1.8 grades better to zero grade change) in the IFN beta-1a treatment period and 0.5 grades (IQR 1.8 grades better to 1.0 grade worse) in the placebo treatment period. There were no serious adverse events in either treatment period.In a parallel group trial of IFN beta-1a with 67 participants, none of the outcomes for this review was available. The trial design involved withdrawal from ongoing IVIg treatment. The primary outcome used by the trial authors was total IVIg dose administered from week 16 to week 32 in the placebo group compared with the IFN beta-1a groups. This was slightly but not significantly lower in the combined IFN beta-1a groups (1.20 g/kg) compared with the placebo group (1.34 g/kg, P = 0.75). There were four participants in the IFN beta-1a group and none in the placebo group with one or more serious adverse events, risk ratio (RR) 4.50 (95% confidence interval (CI) 0.25 to 80.05).The methotrexate trial had a similar design involving withdrawal from ongoing corticosteroid or IVIg treatment. At the end of the trial (approximately 40 weeks) there was no significant difference in the change in the Overall Neuropathy Limitations Scale, a disability scale (scale range 0 to 12), the median change being 0 (IQR -1 to 0) in the methotrexate group and 0 (IQR -0.75 to 0) in the placebo group. These changes in disability might have been confounded by the reduction in corticosteroid or IVIg dose required by the protocol. There were three participants in the methotrexate group and one in the placebo with one or more serious adverse events, RR 3.56 (95% CI 0.39 to 32.23).

Authors' conclusions: Low-quality evidence from randomised trials does not show significant benefit from azathioprine or interferon beta-1a and moderate-quality evidence from one randomised trial does not show significant benefit from a relatively low dose of methotrexate for the treatment of CIDP. None of the trials was large enough to rule out small or moderate benefit. The evidence from observational studies is insufficient to avoid the need for randomised controlled trials to discover whether these drugs are beneficial. Future trials should have improved designs, more sensitive outcome measures relevant to people with CIDP, and longer treatment durations.

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Conflict of interest statement

MM‐R was an investigator and trial coordinator for RMC 2009 and has received a travel grant from Grifols.

AAG is the Information Specialist of the Cochrane Neuromuscular. She has no commercial conflicts of interest.

RB is the Managing Editor of Cochrane Neuromuscular. She has no commercial conflicts of interest. She played no role in the later stages of the editorial process in accordance with Cochrane policy (Cochrane 2016).

PAvD participated in RMC 2009. He and his institution are in receipt of funding from Talecris and CSL Behring in relation to serving on the scientific board of the ICE trial in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and scientific board on IVIg in chronic polyneuropathy. His institution is in receipt of a grant from Baxter to conduct a randomised controlled trial (RCT) comparing intravenous immunoglobulin (IVIg) with IVIg and steroids in Guillain‐Barré Syndrome (GBS), a grant from Sanquin to conduct a RCT investigating the effect of a second course of IVIg (SID‐trial) in people with GBS with a poor prognosis and a grant from Talecris to conduct a prospective international study on the effect of a second course of IVIg in people with GBS with a poor prognosis (I‐SID study).

RACH was the principal investigator of an investigator‐led trial of IFNb‐1a in CIDP (Hadden 1999) which was funded by Serono, a Biogen sponsored trial of IFNb‐1a for CIDP (Hughes 2010), and an investigator‐led trial of methotrexate for CIDP (RMC 2009), all of which are included in this review. He is chair of the steering committee for the ongoing fingolimod trial (FORCIDP trial). RACH has consulted or is consulting for Baxter, CSL Behring, Grifols, LFB and Octapharma which all manufacture human immunoglobulin, an alternative treatment for CIDP not considered in this review. RACH has consulted for Biogen and Serono which manufacture BIFN‐1a, which is considered in this review with the conclusion that it is not effective. RACH is also consulting for Novartis, which is conducting a trial of fingolimod in CIDP (FORCIDP trial). He will demit authorship of this review when fingolimod is considered. RACH is an honorary member of the Board of GBS CIDP Foundation International and Medical Patron of GAIN, the British charity which cares for CIDP. RACH is a member of the Cochrane Neuromuscular Editorial Board. He did not participate in the editorial process for this review.

The review is not compliant with the Cochrane Commerical Sponsorship policy. The update willl have a majority of authors and lead author free of conflicts.

Figures

1
1
Study flow diagram.
2
2
'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study. Red (‐) = high risk of bias; yellow (?) = unclear risk of bias; green (+) = low risk of bias.
1.1
1.1. Analysis
Comparison 1 Methotrexate versus placebo, Outcome 1 Serious adverse events.
2.1
2.1. Analysis
Comparison 2 IFNb‐1a versus placebo, Outcome 1 Serious adverse events.
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References

References to studies included in this review

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