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<label for="email-citation-format" class="action-panel-label">
Format:
</label>
<select id="email-citation-format" name="citation-format" class="action-panel-selector email-citation-format">
<option selected="selected" value="summary">Summary</option>
<option value="summary-text">Summary (text)</option>
<option value="abstract">Abstract</option>
<option value="abstract-text">Abstract (text)</option>
</select>
</div>
<div class="include-supplemental-container">
<input type="checkbox" aria-label="Include MeSH and other data" name="include-supplemental" id="email-include-supplemental" class="email-include-supplemental">
<label for="email-include-supplemental" class="email-include-supplemental-label">MeSH and other data</label>
</div>
<div class="form-field recaptcha ">
<div class="g-recaptcha" id="id-recaptcha" data-sitekey="6LfsWHMdAAAAAClKbtOpjQ2pMjgsGxvv7NdZW9uI"></div>
</div>
<div id="captcha-error-message" class="usa-input-error-message captcha-validation-message" role="alert"></div>
<div class="action-panel-actions">
<button class="action-panel-submit"
type="submit"
data-loading-label="Sending..."
data-ga-category="save_share"
data-ga-action="email"
data-ga-label="send">
Send email
</button>
<button class="action-panel-cancel"
aria-label="Close 'Email citations' panel"
ref="linksrc=close_email_panel"
aria-controls="email-action-panel"
aria-expanded="false"
data-ga-category="save_share"
data-ga-action="email"
data-ga-label="cancel">
Cancel
</button>
</div>
<input type="hidden" name="email-search-details" value="" />
<input type="hidden" name="email-search-details-hash" value="0e42663a6c3bd85498fcb88798998fed7bfdc45d457db35281e41afe13cc0524" />
</form>
</div>
</div>
<div id="collections-action-panel"
class="collections-action-panel action-panel in-progress-dots-panel"
aria-hidden="true"
data-collections-open-panel-enabled="false"
data-collections-open-panel-url-hash="#open-collections-panel">
<div class="inner-wrap">
<h3 class="action-panel-heading">
Add to Collections
</h3>
<form id="collections-action-panel-form"
class="collections-action-panel-form action-panel-content action-form action-panel-smaller-selectors"
data-existing-collections-url="/list-existing-collections/"
data-add-to-existing-collection-url="/add-to-existing-collection/"
data-create-and-add-to-new-collection-url="/create-and-add-to-new-collection/"
data-get-article-ids-by-search-url="/get-article-ids-by-search/"
data-myncbi-max-collection-name-length="100"
data-add-to-collection-max-amount="1000"
data-collections-root-url="https://www.ncbi.nlm.nih.gov/myncbi/collections/">
<input type="hidden" name="csrfmiddlewaretoken" value="6z7Ej415NcnGUtnPP5N58tjJNfk4SOtKnmRJWUurnNaaOUtFsoq7CBPnlj2gLp14">
<div class="choice-group" role="radiogroup">
<ul class="radio-group-items">
<li>
<input type="radio"
id="collections-action-panel-new"
class="collections-new"
name="collections"
value="new"
data-ga-category="save_share"
data-ga-action="collections"
data-ga-label="collections_radio_new">
<label for="collections-action-panel-new">Create a new collection</label>
</li>
<li>
<input type="radio"
id="collections-action-panel-existing"
class="collections-existing"
name="collections"
value="existing"
checked="true"
data-ga-category="save_share"
data-ga-action="collections"
data-ga-label="collections_radio_existing">
<label for="collections-action-panel-existing">Add to an existing collection</label>
</li>
</ul>
</div>
<div class="controls-wrapper">
<div class="action-panel-control-wrap new-collections-controls">
<label for="collections-action-panel-add-to-new" class="action-panel-label required-field-asterisk">
Name your collection:
</label>
<input
type="text"
name="add-to-new-collection"
id="collections-action-panel-add-to-new"
class="collections-action-add-to-new"
pattern="[^&quot;&amp;=&lt;&gt;\/]*" title="The following characters are not allowed in the Name field: &quot;&amp;=&lt;&gt;/"
maxlength="100"
data-ga-category="save_share"
data-ga-action="create_collection"
data-ga-label="non_favorties_collection">
<div class="collections-new-name-too-long usa-input-error-message selection-validation-message">
Name must be less than 100 characters
</div>
</div>
<div class="action-panel-control-wrap existing-collections-controls">
<label for="collections-action-panel-add-to-existing" class="action-panel-label">
Choose a collection:
</label>
<select id="collections-action-panel-add-to-existing"
class="action-panel-selector collections-action-add-to-existing"
data-ga-category="save_share"
data-ga-action="select_collection"
data-ga-label="($('#collections-action-add-to-existing').val() === 'Favorites') ? 'Favorites' : 'non_favorites_collection'">
</select>
<div class="collections-retry-load-on-error usa-input-error-message selection-validation-message">
Unable to load your collection due to an error<br>
<a href="#">Please try again</a>
</div>
</div>
</div>
<div class="action-panel-actions">
<button class="action-panel-submit"
type="submit"
data-loading-label="Adding..."
data-pinger-ignore
data-ga-category="save_share"
data-ga-action="collections"
data-ga-label="add">
Add
</button>
<button class="action-panel-cancel"
aria-label="Close 'Add to Collections' panel"
ref="linksrc=close_collections_panel"
aria-controls="collections-action-panel"
aria-expanded="false"
data-ga-category="save_share"
data-ga-action="collections"
data-ga-label="cancel">
Cancel
</button>
</div>
</form>
</div>
</div>
<div id="bibliography-action-panel"
class="bibliography-action-panel action-panel in-progress-dots-panel"
aria-hidden="true"
data-bibliography-open-panel-enabled="false"
data-bibliography-open-panel-url-hash="#open-bibliography-panel">
<div class="inner-wrap">
<h3 class="action-panel-heading">
Add to My Bibliography
</h3>
<form id="bibliography-action-panel-form"
class="bibliography-action-panel-form action-panel-content action-form action-panel-smaller-selectors"
data-add-to-bibliography-max-amount="100"
data-add-to-bibliography-batch-size="10"
data-bibliography-delegates-url="/list-bibliography-delegates/"
data-add-to-bibliography-url="/add-to-bibliography/"
data-get-article-ids-by-search-url="/get-article-ids-by-search/"
data-mybib-root-url="https://www.ncbi.nlm.nih.gov/myncbi/collections/mybibliography/">
<input type="hidden" name="csrfmiddlewaretoken" value="6z7Ej415NcnGUtnPP5N58tjJNfk4SOtKnmRJWUurnNaaOUtFsoq7CBPnlj2gLp14">
<div class="action-panel-control-wrap bibliographies-controls">
<div class="choice-group">
<ul class="bibliographies-action-add radio-group-items">
<li>
<input name="bibliography" id="my-bibliography" class="my-bibliography" type="radio" checked/>
<label for="my-bibliography">My Bibliography</label>
</li>
</ul>
</div>
</div>
<div class="bibliographies-retry-load-on-error usa-input-error-message selection-validation-message">
Unable to load your delegates due to an error<br>
<a href="#">Please try again</a>
</div>
<div class="action-panel-actions">
<button class="action-panel-submit"
type="submit"
data-loading-label="Adding..."
data-pinger-ignore>
Add
</button>
<button class="action-panel-cancel"
aria-label="Close 'Add to bibliography' panel"
ref="linksrc=close_bibliography_panel"
aria-controls="bibliography-action-panel"
aria-expanded="false"
data-ga-category="save_share"
data-ga-action="mybib"
data-ga-label="cancel">
Cancel
</button>
</div>
</form>
</div>
</div>
<div id="saved-search-action-panel" class="saved-search-action-panel action-panel " aria-hidden="true"
data-saved-search-open-panel-enabled="false"
data-saved-search-open-panel-url-hash="#open-saved-search-panel">
<div class="inner-wrap">
<h2 class="action-panel-heading">
Your saved search
</h2>
<form id="saved-search-action-panel-form"
class="saved-search-action-panel-form action-panel-content action-form"
data-create-saved-search-url="/create-saved-search/"
data-try-search-terms-url="/try-search-term/"
data-saved-search-root-url="https://www.ncbi.nlm.nih.gov/myncbi/searches/">
<input type="hidden" name="csrfmiddlewaretoken" value="6z7Ej415NcnGUtnPP5N58tjJNfk4SOtKnmRJWUurnNaaOUtFsoq7CBPnlj2gLp14">
<div class="action-panel-control-wrap">
<label for="saved-search-name" class="action-panel-label saved-search-name-label required-field-asterisk">
Name of saved search:
</label>
<input maxlength="200"
type="text"
name="saved-search-name"
id="saved-search-name"
class="saved-search-name"
value=""
required
pattern="[^&quot;&amp;=&lt;&gt;\/]*" title="The following characters are not allowed in the Name field: &quot;&amp;=&lt;&gt;/">
</div>
<div class="action-panel-control-wrap">
<label for="saved-search-term" class="action-panel-label required-field-asterisk">
Search terms:
</label>
<textarea name="saved-search-term" id="saved-search-term" class="saved-search-term" required></textarea>
</div>
<div class="test-search-term-wrap">
<a href="#" class="try-search-term">Test search terms</a>
</div>
<div class="choice-group action-panel-extra-margin-top">
<span class="action-panel-label" id="fieldset-label">
Would you like email updates of new search results?
</span>
<fieldset id="saved-search-alert" aria-describedby="fieldset-label">
<legend class="usa-sr-only">Saved Search Alert Radio Buttons</legend>
<ul class="radio-group-items">
<li>
<input type="radio" id="saved-search-alert-yes" class="saved-search-alert-yes" name="saved-search-alert" value="yes" checked>
<label for="saved-search-alert-yes" class="action-panel-label">Yes</label>
</li>
<li>
<input aria-label="No radio input" type="radio" id="saved-search-alert-no" class="saved-search-alert-no" name="saved-search-alert" value="no">
<label for="saved-search-alert-no" class="action-panel-label">No</label>
</li>
</ul>
</fieldset>
</div>
<div class="alert-schedule-wrap">
<div class="action-panel-control-wrap">
<label class="action-panel-label">
Email:
</label>
<span aria-label="Email address" id="saved-search-email" class="action-panel-label"><span class="action-panel-label-bold"></span> (<a class="myncbi-account-settings" href="https://www.ncbi.nlm.nih.gov/account/settings/">change</a>)</span>
</div>
<div class="action-panel-control-wrap action-panel-extra-margin-top">
<label for="saved-search-frequency" class="action-panel-label">
Frequency:
</label>
<select id="saved-search-frequency" class="no-border-panel-selector saved-search-frequency">
<option value="monthly">Monthly</option>
<option value="weekly">Weekly</option>
<option value="daily">Daily</option>
</select>
</div>
<div class="action-panel-control-wrap saved-search-monthly-additional">
<label for="saved-search-monthly-on-day" class="action-panel-label">
Which day?
</label>
<select id="saved-search-monthly-on-day" class="no-border-panel-selector">
<option value="Sunday">The first Sunday</option>
<option value="Monday">The first Monday</option>
<option value="Tuesday">The first Tuesday</option>
<option value="Wednesday">The first Wednesday</option>
<option value="Thursday">The first Thursday</option>
<option value="Friday">The first Friday</option>
<option value="Saturday">The first Saturday</option>
<option value="day">The first day</option>
<option value="weekday">The first weekday</option>
</select>
</div>
<div class="action-panel-control-wrap saved-search-weekly-additional">
<label for="saved-search-weekly-on-day" class="action-panel-label">
Which day?
</label>
<select id="saved-search-weekly-on-day" class="no-border-panel-selector saved-search-weekly-on-day">
<option value="Sunday">Sunday</option>
<option value="Monday">Monday</option>
<option value="Tuesday">Tuesday</option>
<option value="Wednesday">Wednesday</option>
<option value="Thursday">Thursday</option>
<option value="Friday">Friday</option>
<option value="Saturday">Saturday</option>
</select>
</div>
<div class="action-panel-control-wrap">
<label for="saved-search-report" class="action-panel-label">
Report format:
</label>
<select id="saved-search-report" class="no-border-panel-selector saved-search-report">
<option value="DocSum">Summary</option>
<option value="DocSumText">Summary (text)</option>
<option value="Abstract">Abstract</option>
<option value="AbstractText">Abstract (text)</option>
<option value="MEDLINE">PubMed</option>
</select>
</div>
<div class="action-panel-control-wrap">
<label for="saved-search-amount" class="action-panel-label">
Send at most:
</label>
<select id="saved-search-amount" class="no-border-panel-selector saved-search-amount">
<option value="1">1 item</option>
<option value="5" selected>5 items</option>
<option value="10">10 items</option>
<option value="20">20 items</option>
<option value="50">50 items</option>
<option value="100">100 items</option>
<option value="200">200 items</option>
</select>
</div>
<div>
<input type="checkbox" id="saved-search-send-if-no-result" class="saved-search-send-if-no-result" name="saved-search-send-if-no-result">
<label for="saved-search-send-if-no-result" class="action-panel-label smaller-checkbox">
Send even when there aren't any new results
</label>
</div>
<div class="action-panel-control-wrap option-text-in-email-wrap">
<label for="saved-search-email-text" class="action-panel-label">
Optional text in email:
</label>
<textarea name="saved-search-email-text"
id="saved-search-email-text"
class="saved-search-email-text"></textarea>
</div>
</div>
<div class="action-panel-actions">
<button class="action-panel-submit"
type="submit"
data-loading-label="Saving..."
data-ga-category="save_share"
data-ga-action="alert"
data-ga-label="save">
Save
</button>
<button class="action-panel-cancel"
aria-label="Close 'Your saved search' panel"
ref="linksrc=close_saved_search_panel"
aria-controls="saved-search-action-panel"
aria-expanded="false"
data-ga-category="save_share"
data-ga-action="alert"
data-ga-label="cancel">
Cancel
</button>
</div>
</form>
</div>
</div>
<div id="citation-manager-action-panel" class="citation-manager-action-panel action-panel" aria-hidden="true">
<div class="inner-wrap">
<h2 class="action-panel-heading">
Create a file for external citation management software
</h2>
<form id="citation-manager-action-panel-form"
class="action-panel-content action-form"
action="/results-export-ids/"
data-by-search-action="/results-export-search-data/"
data-by-ids-action="/results-export-ids/"
method="post"
data-by-search-method="post"
data-by-ids-method="post">
<input type="hidden" name="csrfmiddlewaretoken" value="6z7Ej415NcnGUtnPP5N58tjJNfk4SOtKnmRJWUurnNaaOUtFsoq7CBPnlj2gLp14">
<input name="results-format" type="hidden" value="pubmed"/>
<div class="action-panel-actions">
<button class="action-panel-submit"
type="submit"
data-loading-label="Sending..."
data-ga-category="save_share"
data-ga-action="citation_manager"
data-ga-label="save">
Create file
</button>
<button class="action-panel-cancel"
aria-label="Close 'Send citations to citation manager' panel"
ref="linksrc=close_citation_manager_panel"
aria-controls="citation-manager-action-panel"
aria-expanded="false"
data-ga-category="save_share"
data-ga-action="citation_manager"
data-ga-label="cancel">
Cancel
</button>
</div>
</form>
</div>
</div>
<div id="rss-action-panel" class="rss-action-panel action-panel " aria-hidden="true">
<div class="inner-wrap">
<h2 class="action-panel-heading">
Your RSS Feed
</h2>
<form id="rss-action-panel-form"
class="rss-action-panel-form action-panel-content action-form"
data-create-rss-feed-url="/create-rss-feed-url/"
data-search-form-term-value="">
<input type="hidden" name="csrfmiddlewaretoken" value="6z7Ej415NcnGUtnPP5N58tjJNfk4SOtKnmRJWUurnNaaOUtFsoq7CBPnlj2gLp14">
<div class="action-panel-control-wrap">
<label for="rss-name" class="action-panel-label required-field-asterisk">
Name of RSS Feed:
</label>
<input maxlength="200"
placeholder="Name"
type="text"
name="rss-name"
id="rss-name"
class="rss-name"
value=''
required
pattern="[^&quot;&amp;=&lt;&gt;\/]*" title="The following characters are not allowed in the Name field: &quot;&amp;=&lt;&gt;/">
</div>
<div class="rss-limit-wrap">
<div class="action-panel-control-wrap action-panel-extra-margin-top">
<label for="rss-limit" class="action-panel-label">
Number of items displayed:
</label>
<select id="rss-limit" class="no-border-panel-selector rss-limit">
<option value="5">5</option>
<option value="10">10</option>
<option value="15" selected="selected">15</option>
<option value="20">20</option>
<option value="50">50</option>
<option value="100">100</option>
</select>
</div>
</div>
<div class="action-panel-actions">
<button class="action-panel-submit"
type="submit"
data-loading-label="Creating..."
data-ga-category="save_share"
data-ga-action="alert"
data-ga-label="save">
Create RSS
</button>
<button class="action-panel-cancel"
aria-label="Close 'Your RSS' panel"
ref="linksrc=close_rss_panel"
aria-controls="rss-action-panel"
aria-expanded="false"
data-ga-category="save_share"
data-ga-action="alert"
data-ga-label="cancel">
Cancel
</button>
</div>
<div class="action-panel-control-wrap rss-link-copy-wrap">
<label for="rss-link" class="usa-sr-only">RSS Link</label>
<input placeholder="Your RSS Feed Link" type="text" name="rss-link" id="rss-link" class="rss-link" title="RSS Link">
<button
type="button"
disabled
class="rss-link-copy-button disabled"
data-ga-category="save_share"
data-ga-action="rss"
data-ga-label="copy">
Copy
</button>
</div>
</form>
</div>
</div>
</div>
</div>
<div class="article-page" id="article-page" data-article-pmid="38318236">
<aside class="page-sidebar">
<div class="inner-wrap">
<div class="full-text-links">
<div class="full-view">
<h3 class="title">
Full text links
</h3>
<div class="full-text-links-list">
<a class="link-item
dialog-focus"
href="https://doi.org/10.3389/fneur.2023.1284444"
target="_blank"
rel="noopener"
ref="linksrc=fulltextorjournal_fulltext&amp;is_pmc=False&amp;PrId=6956&amp;itool=Abstract-def&amp;log$=linkouticon&amp;uid=38318236&amp;db=pubmed&amp;nlmid=101546899"
title="See full text options at Frontiers Media SA"
data-ga-category="full_text"
data-ga-action="Frontiers Media SA"
data-ga-label="38318236"
><img src="https://cdn.ncbi.nlm.nih.gov/corehtml/query/egifs/https:--www.frontiersin.org-alerts-logo-PubMed.png" alt="Frontiers Media SA full text link"><span class="text">
Frontiers Media SA
</span></a><a class="link-item
pmc
"
href="https://pmc.ncbi.nlm.nih.gov/articles/pmid/38318236/"
target="_blank"
rel="noopener"
ref="linksrc=fulltextorjournal_fulltext&amp;is_pmc=True&amp;PrId=3494&amp;itool=Abstract-def&amp;log$=linkouticon&amp;uid=38318236&amp;db=pubmed&amp;nlmid=101546899"
title="Free full text at PubMed Central"
data-ga-category="full_text"
data-ga-action="PMC"
data-ga-label="38318236"
><span class="text">
Free PMC article
</span></a>
</div>
</div>
<div class="short-view">
<a href="#" class="full-text-links-button full-text-links-dialog-trigger">
Full text links
</a>
</div>
</div>
<div class="actions-buttons sidebar"><h3 class="title">Actions</h3><div class="inner-wrap"><button class="citation-button citation-dialog-trigger"
aria-label="Open dialog with citation text in different styles"
data-ga-category="save_share"
data-ga-action="cite"
data-ga-label="open"
data-all-citations-url="/38318236/citations/"
data-citation-style="nlm"
data-pubmed-format-link="/38318236/export/"><span class="button-label">Cite</span></button><link type="text/css" href="ncbi-overlay-block/src/overlay-block.css"><div class="collections-button-container" data-article-id="38318236" data-article-db="pubmed"><button class="collections-button collections-dialog-trigger"
aria-label="Save article in MyNCBI collections."
data-ga-category="collections_button"
data-ga-action="click"
data-ga-label="collections_button"
data-collections-open-dialog-enabled="false"
data-collections-open-dialog-url="https://account.ncbi.nlm.nih.gov/?back_url=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F38318236%2F%23open-collections-dialog"
data-in-collections="false"><span class="button-label">Collections</span></button><div class="overlay" role="dialog"><div id="collections-action-dialog"
class="dialog collections-dialog"
aria-hidden="true"><div class="title">Add to Collections</div><div class="collections-action-panel action-panel"><form id="collections-action-dialog-form"
class="collections-action-panel-form action-panel-content action-form action-panel-smaller-selectors"
data-existing-collections-url="/list-existing-collections/"
data-add-to-existing-collection-url="/add-to-existing-collection/"
data-create-and-add-to-new-collection-url="/create-and-add-to-new-collection/"
data-myncbi-max-collection-name-length="100"
data-collections-root-url="https://www.ncbi.nlm.nih.gov/myncbi/collections/"><input type="hidden" name="csrfmiddlewaretoken" value="6z7Ej415NcnGUtnPP5N58tjJNfk4SOtKnmRJWUurnNaaOUtFsoq7CBPnlj2gLp14"><div class="choice-group" role="radiogroup"><ul class="radio-group-items"><li><input type="radio"
id="collections-action-dialog-new"
class="collections-new"
name="collections"
value="new"
data-ga-category="collections_button"
data-ga-action="click"
data-ga-label="collections_radio_new"><label for="collections-action-dialog-new">Create a new collection</label></li><li><input type="radio"
id="collections-action-dialog-existing"
class="collections-existing"
name="collections"
value="existing"
checked="true"
data-ga-category="collections_button"
data-ga-action="click"
data-ga-label="collections_radio_existing"><label for="collections-action-dialog-existing">Add to an existing collection</label></li></ul></div><div class="controls-wrapper"><div class="action-panel-control-wrap new-collections-controls"><label for="collections-action-dialog-add-to-new" class="action-panel-label required-field-asterisk">
Name your collection:
</label><input
type="text"
name="add-to-new-collection"
id="collections-action-dialog-add-to-new"
class="collections-action-add-to-new"
pattern="[^&quot;&amp;=&lt;&gt;\/]*" title="The following characters are not allowed in the Name field: &quot;&amp;=&lt;&gt;/"
maxlength="100"
data-ga-category="collections_button"
data-ga-action="create_collection"
data-ga-label="non_favorties_collection"><div class="collections-new-name-too-long usa-input-error-message selection-validation-message">
Name must be less than 100 characters
</div></div><div class="action-panel-control-wrap existing-collections-controls"><label for="collections-action-dialog-add-to-existing" class="action-panel-label">
Choose a collection:
</label><select id="collections-action-dialog-add-to-existing"
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Long-term safety, tolerability, and efficacy of efgartigimod (ADAPT+): interim results from a phase 3 open-label extension study in participants with generalized myasthenia gravis
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Long-term safety, tolerability, and efficacy of efgartigimod (ADAPT+): interim results from a phase 3 open-label extension study in participants with generalized myasthenia gravis
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</a></sup><span class="comma">,&nbsp;</span></span><span class="authors-list-item "><a class="full-name"
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</a></sup><span class="comma">,&nbsp;</span></span><span class="authors-list-item "><a class="full-name"
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</a></sup><span class="semicolon">;&nbsp;</span></span><span class="authors-list-item "><a class="full-name"
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<li data-affiliation-id="short-view-affiliation-1"
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><sup class="key">1</sup> Department of Neurology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.</li>
<li data-affiliation-id="short-view-affiliation-2"
id="short-view-affiliation-2"
><sup class="key">2</sup> Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, ON, Canada.</li>
<li data-affiliation-id="short-view-affiliation-3"
id="short-view-affiliation-3"
><sup class="key">3</sup> Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, FL, United States.</li>
<li data-affiliation-id="short-view-affiliation-4"
id="short-view-affiliation-4"
><sup class="key">4</sup> Penn Neuroscience Center-Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States.</li>
<li data-affiliation-id="short-view-affiliation-5"
id="short-view-affiliation-5"
><sup class="key">5</sup> Neurology Clinic, University Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia.</li>
<li data-affiliation-id="short-view-affiliation-6"
id="short-view-affiliation-6"
><sup class="key">6</sup> Department of Neurology and Neuromuscular Reference Center, Ghent University Hospital, Ghent, Belgium.</li>
<li data-affiliation-id="short-view-affiliation-7"
id="short-view-affiliation-7"
><sup class="key">7</sup> Department of Neurology, School of Medicine, International University of Health and Welfare, Narita, Japan.</li>
<li data-affiliation-id="short-view-affiliation-8"
id="short-view-affiliation-8"
><sup class="key">8</sup> Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.</li>
<li data-affiliation-id="short-view-affiliation-9"
id="short-view-affiliation-9"
><sup class="key">9</sup> Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States.</li>
<li data-affiliation-id="short-view-affiliation-10"
id="short-view-affiliation-10"
><sup class="key">10</sup> Department of Neurology, University of Kansas Medical Center, Kansas City, KS, United States.</li>
<li data-affiliation-id="short-view-affiliation-11"
id="short-view-affiliation-11"
><sup class="key">11</sup> argenx, Ghent, Belgium.</li>
<li data-affiliation-id="short-view-affiliation-12"
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><sup class="key">12</sup> Department of Neurology, Hanamaki General Hospital, Hanamaki, Japan.</li>
<li data-affiliation-id="short-view-affiliation-13"
id="short-view-affiliation-13"
><sup class="key">13</sup> Department of Neurology, Leiden University Medical Center, Leiden, Netherlands.</li>
<li data-affiliation-id="short-view-affiliation-14"
id="short-view-affiliation-14"
><sup class="key">14</sup> Department of Neuroimmunology and Neuromuscular Diseases, Fondazione Istituto Carlo Besta, Milan, Italy.</li>
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Abstract
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<p>
<strong class="sub-title">
Objective:
</strong>
ADAPT+ assessed the long-term safety, tolerability, and efficacy of efgartigimod in adult participants with generalized myasthenia gravis (gMG).
</p>
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<strong class="sub-title">
Methods:
</strong>
ADAPT+ was an open-label, single-arm, multicenter, up to 3-year extension of the pivotal phase 3 ADAPT study. Efgartigimod was administered in treatment cycles of 4 intravenous infusions (one 10 mg/kg infusion per week). Initiation of subsequent treatment cycles was individualized based on clinical evaluation. Safety endpoints included incidence and severity of adverse events. Efficacy endpoints assessed disease severity using Myasthenia Gravis-Activities of Daily Living (MG-ADL) and Quantitative Myasthenia Gravis (QMG) scores.
</p>
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<strong class="sub-title">
Results:
</strong>
As of January 2022, 151 participants had rolled over to ADAPT+ and 145 had received ≥1 dose of efgartigimod, of whom, 111 (76.6%) were AChR-Ab+ and 34 (23.4%) were AChR-Ab-. Mean study duration (treatment plus follow-up) was 548 days, and participants received up to 17 treatment cycles, corresponding to 217.6 participant-years of exposure. In the overall population, 123 (84.8%) participants reported ≥1 treatment-emergent adverse event; most frequent were headache (36 [24.8%]), COVID-19 (22 [15.2%]), and nasopharyngitis (20 [13.8%]). Clinically meaningful improvement (CMI) in mean MG-ADL and QMG scores was seen as early as 1 week following the first infusion across multiple cycles in AChR-Ab+ and AChR-Ab- participants. Maximal MG-ADL and QMG improvements aligned with onset and magnitude of total IgG and AChR-Ab reductions. For AChR-Ab+ participants at any time point in each of the first 10 treatment cycles, more than 90% had a maximum reduction of ≥2 points (CMI) in MG-ADL total score; across the 7 cycles in which QMG was measured, 69.4% to 91.3% of participants demonstrated a maximum reduction of ≥3 points (CMI) in QMG total score. Many participants demonstrated improvements well beyond CMI thresholds. In AChR-Ab+ participants with ≥1 year of combined follow-up between ADAPT and ADAPT+, mean number of annualized cycles was 4.7 per year (median [range] 5.0 [0.5-7.6]).
</p>
<p>
<strong class="sub-title">
Conclusion:
</strong>
Results of ADAPT+ corroborate the substantial clinical improvements seen with efgartigimod in ADAPT and support its long-term safety, tolerability, and efficacy, as well as an individualized dosing regimen for treatment of gMG.
</p>
<p>
<strong class="sub-title">
Clinical trial registration:
</strong>
https://classic.clinicaltrials.gov/ct2/show/NCT03770403, <a href="http://clinicaltrials.gov/show/NCT03770403" title="See in ClinicalTrials.gov">NCT03770403</a>.
</p>
</div>
<p>
<strong class="sub-title">
Keywords:
</strong>
FcRn; IgG recycling; antibody fragment; autoantibody reduction; efgartigimod; myasthenia gravis; neonatal Fc receptor; neonatal Fc receptor antagonist.
</p>
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<p class="copyright" id="copyright">
Copyright © 2024 Howard, Bril, Vu, Karam, Peric, De Bleecker, Murai, Meisel, Beydoun, Pasnoor, Guglietta, Van Hoorick, Steeland, Tjoen, Utsugisawa, Verschuuren, Mantegazza, the ADAPT+ Study Group.
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</h2>
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<p xmlns:xlink="http://www.w3.org/1999/xlink" xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:p1="http://pubmed.gov/pub-one">SS, CTj, and BH are employees of argenx, Ghent, Belgium. AG was an employee of argenx during study execution and at the initiation of this manuscript; he is currently an independent consultant for the biotechnology and pharmaceutical industry. JH has received research support (paid to his institution) from Alexion Pharmaceuticals, argenx, Cartesian Therapeutics, the Centers for Disease Control and Prevention (Atlanta, GA, USA), the Myasthenia Gravis Foundation of America, the Muscular Dystrophy Association, the National Institutes of Health (including the National Institute of Neurological Disorders and Stroke and the National Institute of Arthritis and Musculoskeletal and Skin Diseases), PCORI, Ra Pharmaceuticals (now UCB Biosciences), and Millennium Pharmaceuticals/Takeda Pharmaceuticals; honoraria from AcademicCME, Alexion Pharmaceuticals, argenx, Biologix Pharma, F. Hoffman-LaRoche Ltd., Horizon Therapeutics, Immunovant Inc., Medscape CME, Merck EMB Serono, Novartis Pharmaceuticals, PeerView CME, Ra Pharmaceuticals (now UCB Biosciences), Regeneron Pharmaceuticals, Sanofi US, and Zai Laboratories; and non-financial support from Alexion Pharmaceuticals, argenx BVBA, Ra Pharmaceuticals (now UCB Biosciences), and Toleranzia AB. VB has participated in scientific advisory boards for CSL Behring, Baxalta, Grifols, argenx, Octapharma, Alpha Technologies, Powell Mansfield Inc., Shire, Akcea, UCB, and Alnylam. She has received funding for travel or speaker honoraria from CSL Behring and has consultancies with CSL Behring, Grifols, BioNevia, Octapharma, Powell Mansfield Inc., argenx, Alpha Technologies, Baxalta, Akcea, UCB, Alnylam, and Pfizer. TV served as site principal investigator for MG clinical trials sponsored by Alexion, argenx, Ra/UCB, Horizon/Viela Bio, Janssen/Momenta, Regeneron, and Cartesian Therapeutics and is a consultant for UCB, Alexion, Dianthus, and argenx. CK has participated in scientific advisory boards for CSL Behring, Takeda, argenx, AstraZeneca, Alexion, Alpine, Corino, Ionis, Sanofi, UCB, and Alnylam. He has received research funding from Ionis. JV has been involved in MG research sponsored by the Prinses Beatrix Spierfonds, Health Holland, and consultancies for argenx, Alexion, and NMD Pharma. Reimbursements were received by the LUMC. He is coinventor on patent applications based on MuSK-related research. He is a member of the European Reference Network for Rare Neuromuscular Diseases (ERN EURO-NMD). SP has served as site principal investigator for MG clinical trials sponsored by argenx, Ra/UCB, Takeda/Millennium, and Alexion and is a consultant for argenx and Dianthus. JB has served as a paid consultant for or received speaker honoraria from argenx, UCB Pharma, Alexion Pharmaceuticals, Sanofi, and Biogen. HM has served as a paid consultant for Alexion, AstraZeneca Rare Disease, argenx, UCB Pharma, and Roche and has received speaker honoraria from the Japan Blood Products Organization and Chugai Pharmaceutical and research support from the Ministry of Health, Labour and Welfare, Japan. AM has served as advisor, consultant, principal investigator, or speaker and has received research grants (paid to his employer) and honoraria from Alexion, argenx, Axunio, Grifols, Hormosan, Janssen, Merck, Octapharma, and UCB. He serves as chair of the medical advisory board of the German Myasthenia Gravis Society. SB has participated in research studies sponsored by argenx, Sanofi, UCB, Regeneron, Genentech, Janssen, Amylyx, and Healey ALS. He is a paid consultant and speaker for Takeda, Alnylam, Alexion, Grifols, Amylyx, argenx, and CSL. MP has served as a consultant or medical advisor to Terumo BCT, Alexion, CSL Behring, Momenta, Catalyst, UCB, Immunovant, and Janssen. KU has served as a paid consultant for argenx, UCB Pharma, Janssen Pharma, Viela Bio, Chugai Pharma, Merck, and Mitsubishi Tanabe Pharma and has received speaker honoraria from argenx, Alexion Pharmaceuticals, UCB Pharma, and the Japan Blood Products Organization. RM has received funding for travel, meeting attendance, and advisory board participation from Alexion, argenx, Biomarin, Catalyst, Sanofi, Regeneron, and UCB.</p>
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Figures
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<div class="figure-caption-contents"><p> Study design. AChEI, acetylcholinesterase inhibitor;… </p></div>
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<div class="figure-caption-contents"><p> Study design. AChEI, acetylcholinesterase inhibitor; AChR, acetylcholine receptor; gMG, generalized myasthenia gravis; HCP,… </p></div>
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Figure 1
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<div class="figure-caption-contents">Study design. AChEI, acetylcholinesterase inhibitor; AChR, acetylcholine receptor; gMG, generalized myasthenia gravis; HCP, healthcare provider; IgG, immunoglobulin G; IV, intravenous; MG-ADL, Myasthenia Gravis-Activities of Daily Living; MGFA, Myasthenia Gravis Foundation of America; NSIST, nonsteroidal immunosuppressive therapy. In ADAPT+ efgartigimod was administered in treatment cycles comprising 4 once-weekly IV infusions (10mg/kg over 1h) per cycle on days 1, 8, 15, and 22 of each cycle, with follow-up of at least 4weeks. <sup>a</sup> Participants who required retreatment but were unable to complete a treatment cycle within the time frame of ADAPT were eligible to be rolled over to ADAPT+. <sup>b</sup> Subsequent cycles initiated if ≥5weeks from last infusion, MG-ADL score improvement &lt;2 points from baseline, and MG-ADL total score ≥5 (&gt;50% due to nonocular items). <sup>c</sup> Participants requiring rescue therapy in ADAPT and in year 1 of ADAPT+ were discontinued from the study. Participants requiring rescue in years 2 and 3 of ADAPT+ were not discontinued. <sup>d</sup> Subsequent cycles initiated in the first year of ADAPT+ if ≥4weeks from last infusion of previous cycle, MG-ADL score improvement &lt;2 points from cycle baseline, and MG-ADL total score≥5 (&gt;50% due to nonocular items). <sup>e</sup> Subsequent cycles were initiated in years 2 and 3 of ADAPT+ if ≥4weeks from last infusion of previous cycle, at the discretion of the investigator. <sup>f</sup> AChEI, corticosteroid, and/or NSIST. HCPs could not change concomitant therapies in ADAPT; HCPs could change concomitant therapies in ADAPT+.</div>
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<p> Figure 2 </p>
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<div class="figure-caption-contents"><p> Study participant disposition. AChR-Ab, acetylcholine… </p></div>
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<p> Figure 2 </p>
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<div class="figure-caption-contents"><p> Study participant disposition. AChR-Ab, acetylcholine receptor antibody. <sup> a </sup> 6 participants who rolled over… </p></div>
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Figure 2
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<div class="figure-caption-contents">Study participant disposition. AChR-Ab, acetylcholine receptor antibody. <sup>a</sup> 6 participants who rolled over to ADAPT+ did not require subsequent treatment cycles based on the defined clinical evaluation criteria. <sup>b</sup> 1 of the 2 participants who had been discontinued due to using prohibited medications later died; therefore, this participant was not considered as having discontinued treatment due to death. <sup>c</sup> Eligibility for ADAPT-SC+ study was based on completion of at least 1cycle of treatment and at least 1year of ADAPT+ study and had started year 2.</div>
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<div class="figure-caption-contents"><p> Treatment-emergent adverse events, by cycle… </p></div>
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<div class="figure-caption-contents"><p> Treatment-emergent adverse events, by cycle (safety analysis set). TEAE, treatment-emergent adverse event. Numbers… </p></div>
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Figure 3
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<div class="figure-caption-contents">Treatment-emergent adverse events, by cycle (safety analysis set). TEAE, treatment-emergent adverse event. Numbers above bars indicate exact percentage value.</div>
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<div class="figure-caption-contents"><p> Mean percentage change from cycle… </p></div>
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<div class="figure-caption-contents"><p> Mean percentage change from cycle baseline in total IgG (overall and AChR-Ab+ populations)… </p></div>
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<div class="figure-caption-contents">Mean percentage change from cycle baseline in total IgG (overall and AChR-Ab+populations) and AChR-Ab level. Data for week 11 were not graphed for cycles 6 and 7 because they were unavailable. AChR-Ab, acetylcholine receptor antibody; IgG, immunoglobulin G. <b>(A)</b> Mean percentage change from cycle baseline in total IgG (overall). <b>(B)</b> Mean percentage change from cycle baseline in total IgG (AChR-Ab+). <b>(C)</b> Mean percentage change from cycle baseline in AChR-Ab (AChR-Ab+).</div>
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<p> Figure 5 </p>
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<div class="figure-caption-contents"><p> Mean change from cycle baseline… </p></div>
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<p> Figure 5 </p>
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<div class="figure-caption-contents"><p> Mean change from cycle baseline in MG-ADL total score, by cycle (AChR-Ab+, AChR-Ab,… </p></div>
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Figure 5
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<div class="figure-caption-contents">Mean change from cycle baseline in MG-ADL total score, by cycle (AChR-Ab+, AChR-Ab, and overall populations; safety analysis set). Only time points with ≥3 participants are included. AChR-Ab+, acetylcholine receptor antibodypositive; AChR-Ab, acetylcholine receptor antibodynegative; CMI, clinically meaningful improvement; MG-ADL, Myasthenia Gravis-Activities of Daily Living. <b>(A)</b> Mean (SE) change from cycle baseline in MG-ADL total score (AChR-Ab+). <b>(B)</b> Mean (SE) change from cycle baseline in MG-ADL total score (AChR-Ab). <b>(C)</b> Mean (SE) change from cycle baseline in MG-ADL total score (overall population). Dashed line indicates CMI.</div>
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<p> Figure 6 </p>
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<div class="figure-caption-contents"><p> Mean change from cycle baseline… </p></div>
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<p> Figure 6 </p>
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<div class="figure-caption-contents"><p> Mean change from cycle baseline in QMG total score, by cycle (AChR-Ab+, AChR-Ab,… </p></div>
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Figure 6
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<div class="figure-caption-contents">Mean change from cycle baseline in QMG total score, by cycle (AChR-Ab+, AChR-Ab, and overall populations; safety analysis set). Only time points with ≥3 participants are included. Data for week 11 were not graphed for cycles 6 and 7 because they were unavailable. AChR-Ab+, acetylcholine receptor antibodypositive; AChR-Ab, acetylcholine receptor antibodynegative; CMI, clinically meaningful improvement; QMG, Quantitative Myasthenia Gravis. <b>(A)</b> Mean (SE) change from cycle baseline in QMG total score (AChR-Ab+). <b>(B)</b> Mean (SE) change from cycle baseline in QMG total score (AChR-Ab). <b>(C)</b> Mean (SE) change from cycle baseline in QMG total score (overall population). Dashed line indicates CMI.</div>
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<div class="figure-caption-contents"><p> Median cycle proportion of participants… </p></div>
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<div class="figure-caption-contents"><p> Median cycle proportion of participants with increasing threshold of MG-ADL or QMG improvement,… </p></div>
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<div class="figure-caption-contents">Median cycle proportion of participants with increasing threshold of MG-ADL or QMG improvement, over multiple cycles in ADAPT+ (AChR-Ab+ participants). AChR-Ab+, acetylcholine receptor antibodypositive; CMI, clinically meaningful improvement; MG-ADL, Myasthenia Gravis-Activities of Daily Living; QMG, Quantitative Myasthenia Gravis. Median proportion of AChR-Ab+ participants with increasing thresholds of improvement in MG-ADL (cycle 1 through cycle 10), QMG (cycle 1 through cycle 7), and QMG total score at week 3. Placebo data depicted are from the phase 3 ADAPT study which included 1 cycle (30). Dashed line indicates CMI.</div>
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<p> Figure 8 </p>
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<div class="figure-caption-contents"><p> Mean time between cycles in… </p></div>
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<p> Figure 8 </p>
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<div class="figure-caption-contents"><p> Mean time between cycles in AChR-Ab+ population with ≥1 year of follow-up in… </p></div>
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Figure 8
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<div class="figure-caption-contents">Mean time between cycles in AChR-Ab+population with≥1year of follow-up in ADAPT/ADAPT+ (<i>n</i>=95). AChR-Ab+, acetylcholine receptor antibodypositive. <i>Post hoc</i> analysis of mean time between cycles in AChR-Ab+ participants with ≥1year of follow-up in ADAPT/ADAPT+. For each individual participant, time between the last infusion of preceding cycle and the first infusion of the following cycle was calculated, and average duration was calculated for each participant for all completed cycles.</div>
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