Immunoadsorption to remove ß2 adrenergic receptor antibodies in CFS/ME.

sb4

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Can you explain more what you mean re: that you can't shake the feeling that this is significant? Also, how do you determine that "M3" is the autoantibody that correlates with your particular symptoms? Is there a list or description somewhere of which specific symptoms correlate with each autoantibody? (I sincerely apologize if you have told me this before and I did not retain it)! Science is not my background at all.
Yes I remember talking to you also but can't remember what was said.

I am interested in M3 (and M4) in particular as it correlates with my symptoms, is shown to be more elevated than the others in other people with POTS/CFS, and is significantly more elevated in me than the rest.

I got the info on its functions from wiki https://en.wikipedia.org/wiki/Muscarinic_acetylcholine_receptor_M3#Effects
I looked at each ones effects.
Basically M3 is responsible for gland secretion (dry mouth), relaxation and constriction of smooth muscles (gut motility = gastroparesis, blood vessels = heart pounding/POTS), secretions from stomach (gastroparesis), and also in diabetes. All of these correlate with my worst symptoms.

Heart pounding and general blood flow issues resulting in fatigue/etc is #1. Gastroparesis is #2. Dry mouth #3. Intolerance to carbs #4 (heart pounding is far worse on higher carb).

I know it's a bit of a shot in the dark as my test results are far less bad than yours or those peoples in the study. I'm just wandering if it's not neccesarily the numbers that matter but the ratios or how active the antibodies are?

I remember talking with someone here who said that if there are antibodies against a certain receptor then the cell can just produce more receptors. This makes sense but how does in know how to do this? Also since M1/etc are activated by the same substance as M3, could the ratio be problematic? Ie M1 works fine, M3 is dulled due to antibodies, body cannot get around this by upping the acetylcholine release as then M1 would get too much activation so it just sits in the middle and hence my symptoms of underactive M3.
 
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Those graphs look a bit disappointing. It seems only a small minority of patients have substantial improvements with this or Rituximab, but no one seems to be able to predict who.

I do not particularly subscribe to the placebo effect, especially in severe patients, but if just one had a large one it alters the trial measurably here.
Everyone is susceptible to reporting biases, including severe patients. Questionnaire answering behaviour is affected by many things. This is not the same as a placebo effect, though many people (eg. doctors) get this confused.
 

Gingergrrl

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They could have used a non-elution comparator as a placebo or saline vehicle with crossover at six months. The reason this was not done is because the authors have a monetary conflict of interest in the auto-antibody portion of their study.
I have read this paragraph like ten times but cannot figure out what it means! What is a "non-elution comparator" and what is a "saline vehicle with crossover"? I didn't understand how the authors of the study have a monetary conflict of interest but maybe this is b/c I do not know what all of these terms mean?

If someone can find the FACT-F study that included a... urological cancer?
What does urological cancer have to do with this study? Sorry for my confusion.

I got the info on its functions from wiki https://en.wikipedia.org/wiki/Muscarinic_acetylcholine_receptor_M3#Effects I looked at each ones effects.
Thank you @sb4 and I bookmarked this to read later.

I remember talking with someone here who said that if there are antibodies against a certain receptor then the cell can just produce more receptors.
I had not heard that before and have no idea if it is accurate but maybe someone else knows?!

Those graphs look a bit disappointing. It seems only a small minority of patients have substantial improvements with this or Rituximab, but no one seems to be able to predict who.
I didn't know how to read the graphs but I agree there seems to be no way to predict who might be a responder. I have never had plasmapheresis or immunoadsorption but with my treatments (IVIG and Rituximab) I literally went into it with zero expectations. I planned for every scenario from death, to it making me a little bit worse, to neutral, to making me a little better, to a lot better, to full remission/recovery.
 
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I have read this paragraph like ten times but cannot figure out what it means! What is a "non-elution comparator" and what is a "saline vehicle with crossover"? I didn't understand how the authors of the study have a monetary conflict of interest but maybe this is b/c I do not know what all of these terms mean?
I am inquiring why plasmapheresis was not done alone since it is less expensive and more widely available, and no trials to date have this modality for CFS (that I know of). It would have also made for an excellent control group. Crossover just means a placebo group and the active group switch during the trial; it is good when a trial has a small amount of participants or it is unethical to withhold treatment.

The researchers pulled out a single antibody. This only matters because a researcher has a financial interest in that antibody.

The scale they use for an outcome is for cancer fatigue, but it is not frequently used even within oncology. It is definitely not used in CFS. It is a good and thorough questionnaire, however there is a lack of data to compare the results. If there was any placebo effect, at all, the results are invalid.

The urology study I was referencing shows improvements in fatigue with a placebo using the FACT-F scale. Others show fatigue worsens with placebo, but these are terminal cancer patients.

I probably made it more confusing not less, but I did the best I could.
 

junkcrap50

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The researchers pulled out a single antibody. This only matters because a researcher has a financial interest in that antibody.
Are you sure? Why do you think this. I do not believe they pulled only a single antibody. They just tracked and measured the levels of 1 antibody. I'm pretty sure the immunoabsorber is nonspecific in regards to antibodies.

EDIT: Thinking about this more and reading @alex3619's post below, I now believe I am (and my statement above is) wrong and you are correct. I had never heard of immunoabsorption and was marvled by it because I thought it was absorbed all antibodies, which would be incredible. But it would also be redundant as regular plasmapharesis would achieve the same thing.
 
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alex3619

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Removing antibodies would be by binding to a target binding molecule. It could be general, but more likely is targeted to a small group of antibody types. One way to do this is to coat the beads in the columns with the target molecule for the antibody in question. It wont work on antibodies for other targets. So this technique would work like Rituximab, but less successfully in general. However by selecting only patients with that specific antibody they increase the response rate. As a general technique its not great. For some specific autoimmune issues it might be a major technique. The problem is we do not know how much these antibodies contribute to ME symptoms ... and its only that part of the issue that can be fixed, and even then its temporary.
 

Gingergrrl

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I am going to reply to you guys but have to put the disclaimer first that my questions might appear idiotic. I really want to understand this topic (removing autoantibodies) since it most directly relates to my own situation. I will never be one of the great scientific minds of PR... and thank you all for bearing with my questions :D

I am inquiring why plasmapheresis was not done alone since it is less expensive and more widely available, and no trials to date have this modality for CFS (that I know of). It would have also made for an excellent control group.
Isn't the main difference between PP and IA that in PP the plasma is removed and replaced with blood transfusion or albumin vs. in IA only the autoantibodies are removed and then the plasma is filtered and put back into the body? If this is the main difference, why would it matter which one was done in the study or that PP was less expensive or widely available? (which also varies depending where you are: Europe/Asia vs. the US, etc).

Also, why would one technique (PP vs. IA) change the outcome of the study and what do you mean that "it would have made an excellent control group"? Isn't the control group the one that does not receive the treatment (in this case, the PP or IA) and only receives saline or dextrose (something without the actual med or treatment in it)?

Crossover just means a placebo group and the active group switch during the trial; it is good when a trial has a small amount of participants or it is unethical to withhold treatment.
How would they switch in the middle? Do you mean switch PP to IA, or vice versa, or do you mean switch to plain saline? If the autoantibodies were already removed, how would giving saline change anything? I don't get it!

The researchers pulled out a single antibody. This only matters because a researcher has a financial interest in that antibody.
How would PP or IA only pull out a single autoantibody? Doesn't it (temporarily) remove all autoantibodies from the blood? I have eleven known autoantibodies (and my doctors suspect I probably have more) but wouldn't a treatment like PP or IA pull out even the ones that I did not know that I had?

I also still do not understand what this has to do with financial interest? If you are studying a specific autoantibody(ies), wouldn't you WANT a treatment that targets those autoantibodies?

The scale they use for an outcome is for cancer fatigue, but it is not frequently used even within oncology. It is definitely not used in CFS. It is a good and thorough questionnaire, however there is a lack of data to compare the results. If there was any placebo effect, at all, the results are invalid.
I thought every study has some number of participants in which their improvement is attributed to the placebo effect? Or are you saying that b/c this scale was designed for cancer (not for ME/CFS) it makes it invalid as a measurement and all results become placebo effect?

Also, wouldn't it be possible that some of the participants had symptoms from the autoantibodies that were disabling but were NOT actually ME/CFS? In this case, couldn't it be useful to study these autoantibodies in and of themselves and how they effect people who have them?

I probably made it more confusing not less, but I did the best I could.
No, it is definitely not you and it is me who does not understand! I test positive for 7 of the 9 Cell Trend autoantibodies (plus four other autoantibodies) and really want to understand this but it's possible I never will!

EDIT: Thinking about this more and reading @alex3619's post below, I now believe I am (and my statement above is) wrong and you are correct. I had never heard of immunoabsorption and was marvled by it because I thought it was absorbed all antibodies, which would be incredible. But it would also be redundant as regular plasmapharesis would achieve the same thing.
So immunoadsorption (IA) only targets a single autoantibody at a time? I thought the difference between PP and IA was what I described above (replacing the plasma vs. returning it to the body after it is filtered). Don't both treatments remove all pathogenic autoantibodies? I know it means that there are two redundant techniques but for whatever reason, IA is common in Europe/Asia and PP in the US. Some people might be allergic to the blood transfusion or react the albumin so it seemed that IA might be safer (unless you were allergic to the product that filtered the blood).

Removing antibodies would be by binding to a target binding molecule. It could be general, but more likely is targeted to a small group of antibody types. One way to do this is to coat the beads in the columns with the target molecule for the antibody in question. It wont work on antibodies for other targets. So this technique would work like Rituximab, but less successfully in general.
I know anything scientific from Alex is correct, so forgive my question, but how does this technique work similarly to Rituximab? Wouldn't the mechanism of Rituximab (killing the B-cells) stop the future production of ALL autoantibodies at the source? How could you make Rituximab only target certain autoantibodies? I am NOT saying you are wrong, I just had never heard of this before and would love to understand it all better.

However by selecting only patients with that specific antibody they increase the response rate.
I don't quite get this part either. If you know that you are studying a specific autoantibody (ies) then wouldn't you WANT to select patients who have those autoantibodies? Otherwise what would be the purpose of the study? Since you can actually measure autoantibodies in the blood, it seems like this kind of study could truly select patients who met the criteria by having the autoantibody (vs. studies with patients with ME/CFS are often critiqued that the patients did not really meet the CCC or ICC criteria etc)? It seems like having the autoantibody is the criteria for the study but would not necessarily change the response rate.

The problem is we do not know how much these antibodies contribute to ME symptoms ... and its only that part of the issue that can be fixed, and even then its temporary.
I totally agree with this but it is a way to study the autoantibodies itself and if treatments like PP or IA are effective. Couldn't this be useful in and of itself?
 

alex3619

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I know anything scientific from Alex is correct, so forgive my question, but how does this technique work similarly to Rituximab? Wouldn't the mechanism of Rituximab (killing the B-cells) stop the future production of ALL autoantibodies at the source?
I mean the effect would be similar, not the mechanism. My bad. Rituximab responders might benefit from this. Rituximab non-responders might not benefit. If someone does not respond to Rituximab then this technique probably wont work.

Also, never presume I am correct. Any good scientist will tell you that the essence of science is questioning, evidence, and reasoning, which means good experimental design in studies as well. So you asking questions is really a scientific thing to do. :) If more people asked questions, and I don't mean about trivial things, the world might be a better place.
 

alex3619

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I don't quite get this part either. If you know that you are studying a specific autoantibody (ies) then wouldn't you WANT to select patients who have those autoantibodies?
Plasmapheresis for example is broad spectrum, and if you do not know if a patient has a specific antibody it will be hit and miss. Such as with Rituximab. By using a specific target molecule on patients with a specific autoantibody you guarantee that you are depleting that specific antibody.

Now in the case of Rituximab and an antibody problem, you don't know if the known autoantibody being decreased by B cell depletion is causing changes or if its a different undiscovered autoantibody or something else entirely. In other words, it better targets a treating hypothesis to work on one single autoantibody.

Now if it fails to make improvements, or makes poor improvements, that wont prove its not an autoantibody problem since only one type of autoantibody was targeted. You might have picked the wrong autoantibody or not know if others exist. What you have shown is that particular autoantibody is not causing symptoms, or not many symptoms.

I sometimes make shortcuts in my explanations especially if fogged. Its OK to ask me to explain further.
 

M Paine

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Removing antibodies would be by binding to a target binding molecule. It could be general, but more likely is targeted to a small group of antibody types.
From the paper

The plasma is passed through an absorber which selectively binds IgG and can be regenerated and reloaded during processing of the plasma allowing a highly effective removal of IgG with little side-effects
 

alex3619

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From the paper

The plasma is passed through an absorber which selectively binds IgG and can be regenerated and reloaded during processing of the plasma allowing a highly effective removal of IgG with little side-effects
This means they have gone the general route, and are binding an entire class of molecule. It is likely then they coat their beads with their own lab grown antibody. Antibodies can be made to bind other antibodies.
 

M Paine

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Yes, it is 'general', but I don't really see how they could make it specific, do you? Does the technology exist to specifically target a class of IgG based on binding afinity to a protein? And to do so quickly enough to process the blood volume of a person in one sitting?
 

Gingergrrl

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I mean the effect would be similar, not the mechanism. My bad. Rituximab responders might benefit from this. Rituximab non-responders might not benefit. If someone does not respond to Rituximab then this technique probably wont work.
I agree with this and it is part of why I was so curious to try PP (for diagnostic reasons) to see if I was a responder which could tell us that autoimmunity was the problem (even if it did not tell us which specific autoantibodies were the problem). I agree that responders to PP or IA would more likely be responders to high dose IVIG and Rituximab than non-responders.

Also, never presume I am correct. Any good scientist will tell you that the essence of science is questioning, evidence, and reasoning, which means good experimental design in studies as well. So you asking questions is really a scientific thing to do. :) If more people asked questions, and I don't mean about trivial things, the world might be a better place.
I will probably still assume you are correct on anything related to science (vs. me!) but thank you for saying that my asking questions is a scientific thing to do and this is a high compliment coming from you.

Plasmapheresis for example is broad spectrum, and if you do not know if a patient has a specific antibody it will be hit and miss. Such as with Rituximab. By using a specific target molecule on patients with a specific autoantibody you guarantee that you are depleting that specific antibody.
I want to make sure that I understand correctly b/c in general someone doing PP or Rituximab would not be part of a study where specific autoantibodies are being targeted. I would assume that even if you did not know which autoantibody (ies) you had, if these treatments were beneficial, you could still safely assume that autoimmunity was the source of the problem? (or is this incorrect)?

Now in the case of Rituximab and an antibody problem, you don't know if the known autoantibody being decreased by B cell depletion is causing changes or if its a different undiscovered autoantibody or something else entirely. In other words, it better targets a treating hypothesis to work on one single autoantibody.
I agree that if someone improved from Rituximab, you would never know if it was due to specific autoantibodies that had been identified, or different ones that had not been identified or even discovered yet. But you would still know the mechanism of depleting B-cells and autoantibodies worked for the person.

Now if it fails to make improvements, or makes poor improvements, that wont prove its not an autoantibody problem since only one type of autoantibody was targeted. You might have picked the wrong autoantibody or not know if others exist. What you have shown is that particular autoantibody is not causing symptoms, or not many symptoms.
So wouldn't it be more useful not to target only one autoantibody and leave it more general like I am saying above? Unless you had endless time, money, and ability to keep repeating the experiments or treatments which is unrealistic.

This means they have gone the general route, and are binding an entire class of molecule. It is likely then they coat their beads with their own lab grown antibody. Antibodies can be made to bind other antibodies.
What do you mean when you say "coat the beads"? I've never had PP or IA and can't envision the process like I can with IVIG and Rituximab. What are the beads referring to?

Yes, it is 'general', but I don't really see how they could make it specific, do you? Does the technology exist to specifically target a class of IgG based on binding afinity to a protein? And to do so quickly enough to process the blood volume of a person in one sitting?
This confused me as well (but I am NOT saying that I am correct vs. that I just don't understand it)! Isn't PP or IA a general process in which all autoantibodies are removed from the plasma? How would only one specific autoantibody be removed (or is this what "coating the beads" refers to)? Thanks in advance to Alex and everyone else for explaining this!
 

alex3619

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What do you mean when you say "coat the beads"?
Usually with columns they are hollow, and filled with glass beads or similar. Those beads are treated with whatever chemical is needed. The blood then flows past the beads. I am unsure of the technology specifics in this case, this is a general answer.

By using beads you massively increase internal surface area. Its how much surface the blood flows over that determines how successful it is going to be. You could also use other internal shapes, beads are not the only option just one of the easiest to manufacture, and so one of the cheapest. How hard is it to make a big container of small round beads? You may or may not see beads though, just the columns, it depends on how its manufactured.

In a study using a general method, like plasmapheresis or Rituximab, you can never be sure why its working. As a clinical method this does not matter. If you are better, then you are better! In advancing our understanding of causation its very important. Each time you restrict the possible targets you increase the research value of the finding if its successful, and you can sometimes get better results from negative findings as well, as you know exactly what was targeted and so what failed.

Montoya at Stanford said last month that they think the reason why Rituximab was not more successful is it targets too narrow a region of the immune system, that the problems are much broader than just B cells in ME. I do not know if this is correct, but they are going to test their current theories, and indeed have a candidate drug in mind that targets exactly the cytokines they wish to investigate. I do not think this drug was named. It may be that they are wrong too, or only partly right. That is why we do further research.
 

M Paine

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Isn't PP or IA a general process in which all autoantibodies are removed from the plasma? How would only one specific autoantibody be removed
So really it's not just auto-antibodies being removed, it's any antibody which is of the IgG type. IgG is the most abundant type (around 75% of all IG), so really this type of treatment is pretty broad.

It's worth mentioning that IgA, IgE, IgM can all also be auto-reactive, it's just that IgG has a more prominent role in activating the immune system. I don't know if the other types of Ig are implicated in other auto-immune diseases. Presumably not so much.
 

alex3619

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The issue with removal of specific autoantibodies is that they are selected by the immune process to bind to specific target molecules. They do it themselves. The important points are to lock the target molecule, and maximize contact between antibody and target. This is often pH specific, so the antibodies can be unbound using either an acid or base solution, which is where the cleaning comes in. I am unsure how safe this would be. Reuse of the absorbing material might in theory lead to infections.

How effective this is is uncertain. I have yet to see a study showing its effective on single autoantibody types. However its essentially the same process used to bind IgG in the first place. If its ineffective for single autoantibody types then the whole process can be expected to be ineffective even for IgG. This means that some antibodies will be missed. I am guessing the hope would be to decrease the autoantibody quantity, rather than eliminate it.

Targeting specific autoantibodies for removal is long understood biomedical technology. This is used in research. How cheap it is, and how effective in a clinical setting, are the questions here. How it works is usually like this. You bind the target molecule for the antibody on a surface, and pass the blood over it. Keeping pH in a stable range and maximizing contact over time is important. Once the blood is gone you have a surface coated in antibodies that are bound to the target molecule. So you then wash the surface in a modified pH solution, and it unbinds the antibodies from the surface. Now you have an antibody solution. This is then able to be analyzed, probably after returning it to a desired pH range.

There was a study in ME a few years ago where candidate target molecules were used and patient blood passed over it. I lost the link and its been hard for me to re-find it. You can then identify what molecules commonly have antibodies that target them. I think they found weak evidence for a broad autoantibody issue, but I cannot check the results because I cannot find the study. This was from some years back, but post 2009.

On binding to IgG specifically, you need something that targets IgG. My guess is that would be a manufactured antibody designed to target main structural components that are unique to IgG. They may have figured out another way to do it though.
 

Gingergrrl

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In a study using a general method, like plasmapheresis or Rituximab, you can never be sure why its working. As a clinical method this does not matter. If you are better, then you are better! In advancing our understanding of causation its very important. Each time you restrict the possible targets you increase the research value of the finding if its successful, and you can sometimes get better results from negative findings as well, as you know exactly what was targeted and so what failed.
This makes sense, and if I am understanding correctly, in a study you can have a target molecule or target auto-antibody when you are doing plasmapheresis (or IA) but not with Rituximab which would kill all B-cells and therefore production of all B-cell driven auto-antibodies.

So really it's not just auto-antibodies being removed, it's any antibody which is of the IgG type. IgG is the most abundant type (around 75% of all IG), so really this type of treatment is pretty broad.
So PP or IA doesn't just target auto-antibodies, it removed regular antibodies and IgG? Is this why they gave the one dose of IgG in the study (so the participants were not as immuno-compromised at the end)? I thought they gave it for some other reason but this now makes more sense to me.

It's worth mentioning that IgA, IgE, IgM can all also be auto-reactive, it's just that IgG has a more prominent role in activating the immune system. I don't know if the other types of Ig are implicated in other auto-immune diseases. Presumably not so much.
I was tested for auto-antibodies for IgA (prior to starting IVIG) b/c if you have them (which I didn't) then it made you at a much higher risk of having an allergic reaction to IVIG than someone without them. It also meant you would choose a brand of IVIG with very low IgA content.
 

FMMM1

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Can someone please clarify, by immunoadsorption, are we just talking about plasmapheresis? Or are we talking about a selective form of plasmapheresis?
There's an article on simmaron research site which explains it; I only looked briefly at it [http://simmaronresearch.com/2018/04...rman-researcher-steps-forward/#comment-28799].

I emailed these folks once asking can you get a test done for these auto-antibodies but don't recall getting a reply. All looks good; how do we deliver it to patients?

Testing for some of the auto-antibodies is apparently difficult; comment from Jonathan Edwards. I think Jonathan was commenting on the Rituximab auto-antibody test results. It might be easier if they could move to the approach suggested by Ron Davis (https://med.stanford.edu/news/all-news/2018/02/tweak-to-assay-could-bolster-disease-detection.html).

I find it frustrating that we in the United Kingdom can't get access to this diagnostic testing [suggestion to NICE].

The European Union could fund research to deliver an improved test for these autoantibodies. Try getting your MEP to raise it. Also try the NIH i.e. in the USA.
 

Gingergrrl

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I find it frustrating that we in the United Kingdom can't get access to this diagnostic testing [suggestion to NICE].
I apologize that I did not go back and re-read this thread but if you are talking about the beta adrenergic and anti-muscarinic/cholinergic autoantibodies then you cannot get them in the US either. I had the tests done by Cell Trend, a lab in Germany, and sent the blood sample from Los Angeles to Germany which was challenging (and private pay) but was do-able and was worth it in my case.