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Pipek LZ, Mahler JV, Nascimento RFV, Apóstolos-Pereira SL, Silva GD, Callegaro D. Cost, efficacy, and safety comparison between early intensive and escalating strategies for multiple sclerosis: A systematic review and meta-analysis. Mult Scler Relat Disord 2023; 71:104581. [PMID: 36848839 DOI: 10.1016/j.msard.2023.104581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/07/2023] [Accepted: 02/14/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND The optimal treatment strategy of multiple sclerosis (MS) is a matter of debate. The classical approach is the escalating (ESC) strategy, which consists of starting with low- to moderate-efficacy disease-modifying drugs (DMDs) and upscale to high-efficacy DMDs when noting some evidence of active disease. Another approach, the early intensive (EIT) strategy, is starting with high-efficiency DMDs as first-line therapy. Our goal was to compare effectiveness, safety, and cost of ESC and EIT strategies. METHODS We searched MEDLINE, EMBASE and SCOPUS until September 2022, for studies comparing EIT and ESC strategies in adult participants with relapsing-remitting MS and a minimum follow-up of 5 years. We examined the Expanded Disability Severity Scale (EDSS), the proportion of severe adverse events, and cost in a 5-year period. Random-effects meta-analysis summarized the efficacy and safety and an EDSS-based Markov model estimated the cost. RESULTS Seven studies with 3,467 participants showed a 30% reduction in EDSS worsening in 5 years (RR 0.7; [0.59-0.83]; p < 0.001) in the EIT group vs in the ESC group. Two studies with 1,118 participants suggested a similar safety profile for these strategies (RR 1.92; [0.38-9.72]; p = 0.4324). EIT with natalizumab in extended interval dosing, rituximab, alemtuzumab, and cladribine demonstrated cost-effectiveness in our model. DISCUSSION EIT presents higher efficacy in preventing disability progression, a similar safety profile, and can be cost-effective within a 5-year timeline.
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Affiliation(s)
- Leonardo Zumerkorn Pipek
- Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, SP, BR, Av. Dr. Arnaldo, 455 - Cerqueira César, São Paulo, SP 01246-903, Brazil.
| | - João Vitor Mahler
- Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, SP, BR, Av. Dr. Arnaldo, 455 - Cerqueira César, São Paulo, SP 01246-903, Brazil
| | | | | | - Guilherme Diogo Silva
- Department of Neurology Hospital of Clinics, University of São Paulo, São Paulo, Brazil
| | - Dagoberto Callegaro
- Department of Neurology Hospital of Clinics, University of São Paulo, São Paulo, Brazil
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Abstract
The multiple sclerosis (MS) neurotherapeutic landscape is rapidly evolving. New disease-modifying therapies (DMTs) with improved efficacy and safety, in addition to an expanding pipeline of agents with novel mechanisms, provide more options for patients with MS. While treatment of MS neuroinflammation is well tailored in the existing DMT armamentarium, concerted efforts are currently underway for identifying neuropathological targets and drug discovery for progressive MS. There is also ongoing research to develop agents for remyelination and neuroprotection. Further insights are needed to guide DMT initiation and sequencing as well as to determine the role of autologous stem cell transplantation in relapsing and progressive MS. This review provides a summary of these updates.
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Affiliation(s)
- Moein Amin
- Cleveland Clinic, Department of Neurology, Cleveland, OH 44195, USA
| | - Carrie M Hersh
- Cleveland Clinic, Lou Ruvo Center for Brain Health, Las Vegas, NV 89106, USA
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Peptide Mimotope-Enabled Quantification of Natalizumab Arm Exchange During Multiple Sclerosis Treatment. Ther Drug Monit 2023; 45:55-60. [PMID: 36201847 DOI: 10.1097/ftd.0000000000001038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Natalizumab, a therapeutic antibody used to treat multiple sclerosis, undergoes in vivo Fab arm exchange to form a monovalent bispecific antibody. Although highly efficacious, the immunosuppressive activity of natalizumab has been associated with JC polyomavirus-driven progressive multifocal leukoencephalopathy (PML). Development of assays that can distinguish between and quantify bivalent (unexchanged) and monovalent (exchanged) forms of natalizumab in clinical samples may be useful for optimizing extended interval dosing and reducing the risk of PML. METHODS In vitro natalizumab arm exchange was conducted, along with peptide mimotope and anti-idiotype surface capture chemistry, to enable the development of enzyme-linked immunosorbent assays. RESULTS An assay using a unique peptide Veritope TM was developed, which can exclusively bind to bivalent natalizumab. In combination with enzyme-linked immunosorbent assays that quantifies total natalizumab, the assay system allows quantification of both natalizumab forms. CONCLUSIONS In this article, a novel assay for the quantification of unexchanged and exchanged natalizumab variants in clinical samples was developed. This assay will enable investigations into the clinical significance of the relationship of PK/PD with the monovalent-to-bivalent ratio, as it relates to the efficacy of the drug and risk of PML.
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Multiple Sclerosis in Mongolia; the First Study Exploring Predictors of Disability and Depression in Mongolian MS Patients. PATHOPHYSIOLOGY 2023; 30:15-26. [PMID: 36810422 PMCID: PMC9944952 DOI: 10.3390/pathophysiology30010003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 01/09/2023] [Accepted: 01/17/2023] [Indexed: 01/24/2023] Open
Abstract
Mongolia is located at 45° north latitude in the center of the Asian continent, and about 80% of the territory is at 1000 m above sea level. Epidemiologically, multiple sclerosis (MS) has not been investigated in Mongolia, although there have been a few MS case reports. We investigated the characteristics of MS in Mongolia for the first time, focusing on the association between MS-related parameters and depression levels. We initiated cross-sectional analyses, using data from 27 MS patients aged 20 to 60 years in Ulaanbaatar, Mongolia. The patients completed a questionnaire on their lifestyles and clinical information. We classified the MS patients on the basis of disability levels using the expanded disability status scale (EDSS) scores: 11.1% mild disability and 88.9% moderate to severe disability (median EDSS score, 5.5). We also classified the patients on the basis of depression levels using the 9-item patient health questionnaire (PHQ-9) scores: 44.4% mild depression, 40.7% moderate depression, and 14.8% severe depression (mean PHQ-9's score, 9.96 ± 5.05). We used multivariate logistical regression analyses to identify predictors of EDSS or PHQ-9 scores. Disability levels were associated with vision and balance problems. Depression levels were associated with corticosteroid treatment; no patients were treated with disease-modifying drugs (DMDs). The odds ratios for disease onset age and treatment duration were associated with EDSS scores. In conclusion, MS onset age and treatment duration were independent predicting factors influencing the level of disability. Appropriate DMD treatment would lower the disability and depression levels.
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Hapfelmeier A, On BI, Mühlau M, Kirschke JS, Berthele A, Gasperi C, Mansmann U, Wuschek A, Bussas M, Boeker M, Bayas A, Senel M, Havla J, Kowarik MC, Kuhn K, Gatz I, Spengler H, Wiestler B, Grundl L, Sepp D, Hemmer B. Retrospective cohort study to devise a treatment decision score predicting adverse 24-month radiological activity in early multiple sclerosis. Ther Adv Neurol Disord 2023; 16:17562864231161892. [PMID: 36993939 PMCID: PMC10041597 DOI: 10.1177/17562864231161892] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 02/19/2023] [Indexed: 03/31/2023] Open
Abstract
Background Multiple sclerosis (MS) is a chronic neuroinflammatory disease affecting about 2.8 million people worldwide. Disease course after the most common diagnoses of relapsing-remitting multiple sclerosis (RRMS) and clinically isolated syndrome (CIS) is highly variable and cannot be reliably predicted. This impairs early personalized treatment decisions. Objectives The main objective of this study was to algorithmically support clinical decision-making regarding the options of early platform medication or no immediate treatment of patients with early RRMS and CIS. Design Retrospective monocentric cohort study within the Data Integration for Future Medicine (DIFUTURE) Consortium. Methods Multiple data sources of routine clinical, imaging and laboratory data derived from a large and deeply characterized cohort of patients with MS were integrated to conduct a retrospective study to create and internally validate a treatment decision score [Multiple Sclerosis Treatment Decision Score (MS-TDS)] through model-based random forests (RFs). The MS-TDS predicts the probability of no new or enlarging lesions in cerebral magnetic resonance images (cMRIs) between 6 and 24 months after the first cMRI. Results Data from 65 predictors collected for 475 patients between 2008 and 2017 were included. No medication and platform medication were administered to 277 (58.3%) and 198 (41.7%) patients. The MS-TDS predicted individual outcomes with a cross-validated area under the receiver operating characteristics curve (AUROC) of 0.624. The respective RF prediction model provides patient-specific MS-TDS and probabilities of treatment success. The latter may increase by 5-20% for half of the patients if the treatment considered superior by the MS-TDS is used. Conclusion Routine clinical data from multiple sources can be successfully integrated to build prediction models to support treatment decision-making. In this study, the resulting MS-TDS estimates individualized treatment success probabilities that can identify patients who benefit from early platform medication. External validation of the MS-TDS is required, and a prospective study is currently being conducted. In addition, the clinical relevance of the MS-TDS needs to be established.
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Affiliation(s)
| | - Begum Irmak On
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig-Maximilians-Universität in Munich, Munich, Germany
- Data Integration for Future Medicine (DIFUTURE) Consortium, Munich, Germany
| | - Mark Mühlau
- Department of Neurology, Klinikum rechts der Isar School of Medicine, Technical University of Munich, Munich, Germany
| | - Jan S. Kirschke
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Achim Berthele
- Department of Neurology, Klinikum rechts der Isar School of Medicine, Technical University of Munich, Munich, Germany
| | - Christiane Gasperi
- Department of Neurology, Klinikum rechts der Isar School of Medicine, Technical University of Munich, Munich, Germany
| | - Ulrich Mansmann
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig-Maximilians-Universität in Munich, Munich, Germany
- Data Integration for Future Medicine (DIFUTURE) Consortium, Munich, Germany
| | - Alexander Wuschek
- Department of Neurology, Klinikum rechts der Isar School of Medicine, Technical University of Munich, Munich, Germany
| | - Matthias Bussas
- Department of Neurology, Klinikum rechts der Isar School of Medicine, Technical University of Munich, Munich, Germany
| | - Martin Boeker
- Institute of AI and Informatics in Medicine, School of Medicine, Technical University of Munich, Munich, Germany
- Data Integration for Future Medicine (DIFUTURE) Consortium, Munich, Germany
| | - Antonios Bayas
- Department of Neurology, Medical Faculty, University of Augsburg, Augsburg, Germany
- Data Integration for Future Medicine (DIFUTURE) Consortium, Munich, Germany
| | - Makbule Senel
- Department of Neurology, Ulm University Hospital, Ulm, Germany
- Data Integration for Future Medicine (DIFUTURE) Consortium, Munich, Germany
| | - Joachim Havla
- Institute of Clinical Neuroimmunology, LMU Hospital, Ludwig-Maximilians-Universität in Munich, Munich, Germany
- Data Integration for Future Medicine (DIFUTURE) Consortium, Munich, Germany
| | - Markus C. Kowarik
- Department of Neurology & Stroke and Hertie-Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
- Data Integration for Future Medicine (DIFUTURE) Consortium, Munich, Germany
| | - Klaus Kuhn
- Institute of AI and Informatics in Medicine, School of Medicine, Technical University of Munich, Munich, Germany
- Data Integration for Future Medicine (DIFUTURE) Consortium, Munich, Germany
| | - Ingrid Gatz
- Institute of AI and Informatics in Medicine, School of Medicine, Technical University of Munich, Munich, Germany
- Data Integration for Future Medicine (DIFUTURE) Consortium, Munich, Germany
| | - Helmut Spengler
- Institute of AI and Informatics in Medicine, School of Medicine, Technical University of Munich, Munich, Germany
- Data Integration for Future Medicine (DIFUTURE) Consortium, Munich, Germany
| | - Benedikt Wiestler
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Lioba Grundl
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Dominik Sepp
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Bernhard Hemmer
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
- Data Integration for Future Medicine (DIFUTURE) Consortium, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
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Alifirova VM, Titova MA, Kamenskikh EM, Shaglaeva IS, Pashkovskaya DV, Musina NF, Nikolaeva TN. [Clinical factors and response to therapy with disease-modifying drugs for multiple sclerosis: the experience of the Tomsk region]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:53-59. [PMID: 37560834 DOI: 10.17116/jnevro202312307253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
OBJECTIVE To investigate a disease-modifying drugs (DMD) response in multiple sclerosis (MS) in the Tomsk region population and detect clinical factors associated with the treatment response. MATERIAL AND METHODS A 5-year prospective clinical study included 363 MS patients of the Tomsk region taking DMDs of the «first-line» and «second-line treatments». The response to DMDs therapy and the impact of MS clinical characteristics on response to treatment were assessed. RESULTS Clinical factors associated with resistance to DMD are male gender, partial reduce of the MS onset symptoms, short period of the first remission, severe neurological impairment, high relapse rate and disease progression rate. CONCLUSION Clinical features of MS are crucial factors associated with DMD response and should be used to prescribe DMD. This factor assessment can improve efficacy of the personalized MS treatment.
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Affiliation(s)
| | - M A Titova
- Siberian State Medical University, Tomsk, Russia
| | | | | | | | - N F Musina
- Siberian State Medical University, Tomsk, Russia
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Stamatellos VP, Papazisis G. Safety and Monitoring of the Treatment with Disease-Modifying Therapies (DMTs) for Multiple Sclerosis (MS). Curr Rev Clin Exp Pharmacol 2023; 18:39-50. [PMID: 35418296 DOI: 10.2174/2772432817666220412110720] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 01/08/2022] [Accepted: 01/27/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Disease-Modifying Therapies (DMTs) for Multiple Sclerosis (MS) are widely used given their proven efficacy in the relapsing form of the disease, while recently, Siponimod and Ocrelizumab have been approved for the progressive forms of the disease. Currently, 22 diseasemodifying drugs are approved by the FDA, while in 2012, only nine were present in the market. From March 2019 until August 2020, six new drugs were approved. This rapid development of new DMTs highlighted the need to update our knowledge about their short and long-term safety. OBJECTIVE This review summarizes the available safety data for all the Disease-Modifying Therapies for Multiple Sclerosis and presents the monitoring plan before and during the treatment. METHODS A literature search was conducted using PUBMED and COCHRANE databases. Key journals and abstracts from major annual meetings of Neurology, references of relevant reviews, and relative articles were also manually searched. We prioritized systematic reviews, large randomized controlled trials (RCTs), prospective cohort studies, and other observational studies. Special attention was paid to guidelines and papers focusing on the safety and monitoring of DMTs. CONCLUSION Data for oral (Sphingosine 1-phosphate (S1P) receptor modulators, Fumarates, Teriflunomide, Cladribine), injectables (Interferons, Glatiramer acetate, Ofatumumab), and infusion therapies (Natalizumab, Ocrelizumab, Alemtuzumab) are presented.
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Affiliation(s)
| | - Georgios Papazisis
- Clinical Trials Unit, Special Unit for Biomedical Research and Education & Department of Clinical Pharmacology School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Muacevic A, Adler JR, Albeladi F, Tahiri AA, Kinani EM, Almohsen RA, Alamoudi NH, Alanazi AA, Alkhamshi SJ, Althomali NA, Alrubaiei SN, Altowairqi FK. An Overview of the History, Pathophysiology, and Pharmacological Interventions of Multiple Sclerosis. Cureus 2023; 15:e33242. [PMID: 36733554 PMCID: PMC9888604 DOI: 10.7759/cureus.33242] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2023] [Indexed: 01/03/2023] Open
Abstract
Multiple sclerosis (MS) is an immune-inflammatory disease that attacks and damages myelinated axons in the central nervous system (CNS) and causes nontraumatic neurological impairment in young people. Historically, Lidwina of Schiedam documented the first MS case. After that, Augustus d'Este wrote for years about how his MS symptoms worsened. Age, sex, genetics, environment, smoking, injuries, and infections, including herpes simplex and rabies, are risk factors for MS. According to epidemiology, the average age of onset is between 20 and 40 years. MS is more prevalent in women and is common in Europe and America. As diagnostic methods and criteria change, people with MS may be discovered at earlier and earlier stages of the disease. MS therapy has advanced dramatically due to breakthroughs in our knowledge of the disease's etiology and progression. Therefore, the efficacy and risk of treatment medications increased exponentially. Management goals include reducing lesion activity and avoiding secondary progression. Current treatment approaches focus on managing acute episodes, relieving symptoms, and reducing biological activity. Disease-modifying drugs such as fingolimod, interferon-beta, natalizumab, and dimethyl fumarate are the most widely used treatments for MS. For proof of the efficacy and safety of these medications, investigations in the real world are necessary.
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Pape K, Rolfes L, Steffen F, Muthuraman M, Korsen M, Meuth SG, Zipp F, Bittner S. Comparative effectiveness of natalizumab versus ocrelizumab in multiple sclerosis: a real-world propensity score-matched study. Ther Adv Neurol Disord 2022; 15:17562864221142924. [PMID: 36568489 PMCID: PMC9772974 DOI: 10.1177/17562864221142924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 11/16/2022] [Indexed: 12/23/2022] Open
Abstract
Background For treatment of relapsing-remitting multiple sclerosis (RRMS), a broad range of disease-modifying therapies (DMT) is available. However, few comparative effectiveness studies between different drugs have been performed. Objectives This study aimed to compare the efficacy and treatment continuation of natalizumab and ocrelizumab in a real-world cohort of patients with relapsing-remitting multiple sclerosis (RRMS) from two German university hospitals. Methods We performed a retrospective analysis of RRMS patients who initiated treatment with natalizumab or ocrelizumab between January 2016 and April 2019 at the German university hospitals of Mainz and Düsseldorf. Bayesian propensity score matching was conducted to correct for differences in baseline characteristics. Our primary outcome was no evidence of disease activity [NEDA-3: no relapses, no confirmed disability progression, and no magnetic resonance imaging (MRI) activity] and its subcomponents. Secondary outcomes included measurement of neurofilament light chain (NfL) in serum, analysis of premature discontinuation, and evidence of rebound activity in patients switching from natalizumab to ocrelizumab. Results We identified 63 patients starting treatment with natalizumab and 76 patients starting with ocrelizumab. Binary logistic regression showed that treatment with natalizumab or a higher number of relapses in the previous year were independently associated with a higher risk for relapses. Patients receiving natalizumab had a higher probability of premature discontinuation of therapy (p = 0.002). After propensity score matching of the two treatment arms, 55 patients remained per group. NEDA-3 after 30 months of follow-up was reached by 53.1% in the ocrelizumab group and 36.1% in the natalizumab group (p = 0.177). Ocrelizumab was superior to natalizumab concerning the occurrence of relapses in log-rank test (p = 0.019). NfL levels in serum were low under both treatments. Patients who switched from natalizumab to ocrelizumab showed no increased rebound activity. Discussion This study provides class IV evidence that treatment of RRMS patients with ocrelizumab and natalizumab show comparable effectiveness in combined endpoints, while ocrelizumab might be more effective in preventing the occurrence of relapses.
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Affiliation(s)
- Katrin Pape
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Leoni Rolfes
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Falk Steffen
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Muthuraman Muthuraman
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Melanie Korsen
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Sven G. Meuth
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Frauke Zipp
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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Zhu C, Zhou Z, Roos I, Merlo D, Kalincik T, Ozakbas S, Skibina O, Kuhle J, Hodgkinson S, Boz C, Alroughani R, Lechner-Scott J, Barnett M, Izquierdo G, Prat A, Horakova D, Kubala Havrdova E, Macdonell R, Patti F, Khoury SJ, Slee M, Karabudak R, Onofrj M, Van Pesch V, Prevost J, Monif M, Jokubaitis V, van der Walt A, Butzkueven H. Comparing switch to ocrelizumab, cladribine or natalizumab after fingolimod treatment cessation in multiple sclerosis. J Neurol Neurosurg Psychiatry 2022; 93:1330-1337. [PMID: 36261289 DOI: 10.1136/jnnp-2022-330104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/26/2022] [Indexed: 03/16/2023]
Abstract
BACKGROUND To compare the effectiveness and treatment persistence of ocrelizumab, cladribine and natalizumab in patients with relapsing-remitting multiple sclerosis switching from fingolimod. METHODS Using data from MSBase registry, this multicentre cohort study included subjects who had used fingolimod for ≥6 months and then switched to ocrelizumab, cladribine or natalizumab within 3 months after fingolimod discontinuation. We analysed relapse and disability outcomes after balancing covariates using an inverse-probability-treatment-weighting method. Propensity scores for the three treatments were obtained using multinomial-logistic regression. Due to the smaller number of cladribine users, comparisons of disability outcomes were limited to natalizumab and ocrelizumab. RESULTS Overall, 1045 patients switched to ocrelizumab (n=445), cladribine (n=76) or natalizumab (n=524) after fingolimod. The annualised relapse rate (ARR) for ocrelizumab was 0.07, natalizumab 0.11 and cladribine 0.25. Compared with natalizumab, the ARR ratio (95% confidence interval [CI]) was 0.67 (0.47 to 0.96) for ocrelizumab and 2.31 (1.30 to 4.10) for cladribine; the hazard ratio (95% CI) for time to first relapse was 0.57 (0.40 to 0.83) for ocrelizumab and 1.18 (0.47 to 2.93) for cladribine. Ocrelizumab users had an 89% lower discontinuation rate (95% CI, 0.07 to 0.20) than natalizumab, but also a 51% lower probability of confirmed disability improvement (95% CI, 0.32 to 0.73). There was no difference in disability accumulation. CONCLUSION After fingolimod cessation, ocrelizumab and natalizumab were more effective in reducing relapses than cladribine. Due to the low ARRs in all three treatment groups, additional observation time is required to determine if statistical difference in ARRs results in long-term disability differences.
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Affiliation(s)
- Chao Zhu
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Zhen Zhou
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Izanne Roos
- Clinical Outcomes Research Unit, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Daniel Merlo
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Tomas Kalincik
- Clinical Outcomes Research Unit, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | | | - Olga Skibina
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Jens Kuhle
- Neurologic Clinic and Policlinic, Departments of Medicine and Clinical Research, University Hospital and University of Basel, Basel, Switzerland
| | - Suzanne Hodgkinson
- Departments of Nephrology and Neurology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Cavit Boz
- KTU Medical Faculty Farabi Hospital, Trabzon, Turkey
| | | | - Jeannette Lechner-Scott
- Department of Neurology, John Hunter Hospital, Newcastle, New South Wales, Australia.,School of Medicine and Public Health, University Newcastle, Newcastle, New South Wales, Australia
| | - Michael Barnett
- Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
| | | | - Alexandre Prat
- Hôpital Notre Dame, CHUM and Universite de Montreal, Montreal, Québec, Canada
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Eva Kubala Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | | | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies, GF Ingrassia, Catania, Italy.,Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Samia Joseph Khoury
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mark Slee
- Flinders University, Adelaide, South Australia, Australia
| | - Rana Karabudak
- Department of Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Marco Onofrj
- Department of Neuroscience, Imaging, and Clinical Sciences, University G. d'Annunzio, Chieti, Italy
| | | | - Julie Prevost
- Centre integre de sante et de services sociaux des Laurentides point de service de Saint-Jerome, Saint-Jerome, Quebec, Canada
| | - Mastura Monif
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Vilija Jokubaitis
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Anneke van der Walt
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
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Controversies in neuroimmunology: multiple sclerosis, vaccination, SARS-CoV-2 and other dilemas. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2022; 42:78-99. [PMID: 36322548 PMCID: PMC9714524 DOI: 10.7705/biomedica.6366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Indexed: 12/04/2022]
Abstract
Neuroimmunology is a discipline that increasingly broadens its horizons in the understanding of neurological diseases. At the same time, and in front of the pathophysiological links of neurological diseases and immunology, specific diagnostic and therapeutic approaches have been proposed. Despite the important advances in this discipline, there are multiple dilemmas that concern and filter into clinical practice. This article presents 15 controversies and a discussion about them, which are built with the most up-to-date evidence available. The topics included in this review are: steroid decline in relapses of multiple sclerosis; therapeutic recommendations in MS in light of the SARS-CoV-2 pandemic; evidence of vaccination in multiple sclerosis and other demyelinating diseases; overview current situation of isolated clinical and radiological syndrome; therapeutic failure in multiple sclerosis, as well as criteria for suspension of disease-modifying therapies; evidence of the management of mild relapses in multiple sclerosis; recommendations for prophylaxis against Strongyloides stercolaris; usefulness of a second course of immunoglobulin in the Guillain-Barré syndrome; criteria to differentiate an acute-onset inflammatory demyelinating chronic polyneuropathy versus Guillain-Barré syndrome; and, the utility of angiotensin-converting enzyme in neurosarcoidosis. In each of the controversies, the general problem is presented, and specific recommendations are offered that can be adopted in daily clinical practice.
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Perncezky J, Sellner J. Natalizumab extended-interval dosing in multiple sclerosis to mitigate progressive multifocal leukoencephalopathy risk: initial study evidence and real-world experience. J Cent Nerv Syst Dis 2022; 14:11795735221135485. [PMID: 36277271 PMCID: PMC9580073 DOI: 10.1177/11795735221135485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The high efficacy of natalizumab in the treatment of relapsing-remitting multiple sclerosis (MS) is without controversy. Indeed, effective disease control was not only demonstrated in the pivotal trials but has been corroborated impressively in real-world observations. This monoclonal IgG4 antibody blocks the α4β1 integrin-mediated leukocyte-endothelial interaction and thereby inhibits the migration of immune cells to the brain parenchyma. However, treatment with natalizumab carries the risk of progressive multifocal leukoencephalopathy (PML). This potentially lethal side effect is a significant limitation for treatment initiation and long-term therapy. Natalizumab is given intravenously or subcutaneously in the standard dose of 300 mg every 4 weeks, allowing drug concentrations at levels that ensure continuous α4β1 integrin receptor saturation on the surface of immune cells. Extended-interval dosing (EID) is an emerging treatment approach that aims to mitigate the natalizumab-related PML risk by prolonging the standard infusion intervals to 6 weeks or even more. This treatment approach may abrogate the PML risk due to improved immune surveillance within the central nervous system while maintaining clinical efficacy. Moreover, even an individual interval dosing can be envisioned based on the availability of a biomarker that is capable of monitoring both safety and efficacy aspects. This review summarizes the early and encouraging evidence for EID from observational and randomized-controlled trials and discusses current limitations and upcoming challenges for introducing a tailored treatment approach.
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Affiliation(s)
- Julian Perncezky
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria
| | - Johann Sellner
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria,Johann Sellner, Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Liechtensteinstr 67, Mistelbach 2130, Austria.
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Auer M, Bauer A, Oftring A, Rudzki D, Hegen H, Bsteh G, Di Pauli F, Berek K, Zinganell A, Berger T, Reindl M, Deisenhammer F. Soluble Vascular Cell Adhesion Molecule-1 (sVCAM-1) and Natalizumab Serum Concentration as Potential Biomarkers for Pharmacodynamics and Treatment Response of Patients with Multiple Sclerosis Receiving Natalizumab. CNS Drugs 2022; 36:1121-1131. [PMID: 36173556 DOI: 10.1007/s40263-022-00953-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Natalizumab (NTZ) is an established treatment for highly active, relapsing-remitting multiple sclerosis. In the context of rare progressive multifocal leukoencephalopathy and extended interval dosing as a treatment option, biomarkers for treatment monitoring are required. Natalizumab serum concentration (NTZ SC) and soluble vascular cell adhesion molecule 1 (sVCAM-1) concentration were shown to change on treatment with NTZ. We aimed to investigate whether NTZ SC and sVCAM-1 could be suitable pharmacodynamic markers and whether they could predict disease activity on NTZ, improving the concept of personalized multiple sclerosis treatment. METHODS In a retrospective study at the Medical University of Innsbruck, Austria, we identified patients treated with NTZ and chose samples longitudinally collected during routine follow-ups for the measurement of NTZ SC and sVCAM-1 by an enzyme-linked immunosorbent assay. We correlated these with clinical and demographic variables and clinical outcomes. Furthermore, we analyzed the stability of NTZ SC and sVCAM-1 during treatment. RESULTS One hundred and thirty-seven patients were included. We found a strong negative correlation between NTZ SC and sVCAM-1. Both showed significant associations with body mass index, infusion interval, sample age, and anti-drug-antibodies. Natalizumab serum concentration was reduced in extended interval dosing, but not sVCAM-1. Only sVCAM-1 showed a weak association with relapses during treatment, while there was no association with disease progression. Both NTZ SC and sVCAM-1 showed a wide inter-individual distribution while levels in single patients were stable on treatment. CONCLUSIONS Soluble vascular cell adhesion molecule 1 is a suitable pharmacodynamic marker during treatment with NTZ, which is significantly reduced already after the first dose, remains stable in individual patients even on extended interval dosing, and strongly correlates with NTZ SC. Because of the high inter-individual range, absolute levels of sVCAM-1 and NTZ SC are difficult to introduce as treatment monitoring biomarkers in order to predict disease activity in single patients.
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Affiliation(s)
- Michael Auer
- Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
| | - Angelika Bauer
- Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Antonia Oftring
- Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Dagmar Rudzki
- Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Wien, Austria
| | - Franziska Di Pauli
- Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Klaus Berek
- Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Anne Zinganell
- Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Wien, Austria
| | - Markus Reindl
- Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Florian Deisenhammer
- Department of Neurology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
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Persson Berg L, Eriksson M, Longhi S, Kockum I, Warnke C, Thomsson E, Bäckström M, Olsson T, Fogdell-Hahn A, Bergström T. Serum IgG levels to Epstein-Barr and measles viruses in patients with multiple sclerosis during natalizumab and interferon beta treatment. BMJ Neurol Open 2022; 4:e000271. [PMID: 35978722 PMCID: PMC9335035 DOI: 10.1136/bmjno-2022-000271] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 07/13/2022] [Indexed: 12/16/2022] Open
Abstract
Background Patients with multiple sclerosis (MS) demonstrate higher seroprevalence of Epstein-Barr virus (EBV) and increased anti-EBV IgG levels in serum compared with healthy controls. Intrathecal antibody production to measles virus (MeV) is a common finding in patients with MS. Objective To measure serum IgG reactivity to EBV glycoprotein 350 (gp350) and MeV nucleocapsid protein (NCORE) in patients with MS and healthy controls and to determine if reactivity changed in patients during interferon beta (IFNβ) and/or natalizumab (NAT) treatment. A secondary aim was to determine the seroprevalence of EBV in patients and controls. Methods Patients with MS (n=728) were included from the Swedish pharmacovigilance study for NAT. Paired serum samples from 714 patients drawn before and during NAT treatment and paired samples from 170 patients during prior IFNβ treatment were analysed. In total, 156 patients were included in both groups. Samples from 144 matched blood donors served as controls. Indirect ELISA was applied using recombinant EBVgp350 and MeV NCORE as antigens. EBVgp350 IgG seronegative samples were also analysed using EBV nuclear antigen 1 and viral capsid antigen (VCA). Results Patients with MS showed higher serum levels of anti-EBVgp350 and anti-MeV NCORE IgG compared with controls. During NAT treatment, the levels of anti-EBVgp350 and anti-MeV NCORE IgG declined, compared with the relatively stable levels noted during prior IFNβ treatment. Ten patients failed to demonstrate anti-EBVgp350 IgG but did show detectable anti-VCA IgG, indicating EBV seropositivity. In contrast, 10/144 controls were EBV seronegative. Conclusions Treatment with NAT, which is considered a selective immunosuppressive agent with a compartmentalised effect on the central nervous system, appeared to be associated with a moderate decrease in circulating IgG levels to EBVgp350 and MeV NCORE. All patients with MS were EBV IgG seropositive, supporting the potential role of EBV in the pathogenesis of MS.
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Affiliation(s)
- Linn Persson Berg
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Microbiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Marcus Eriksson
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Sonia Longhi
- Lab. Architecture et Fonction des Macromolécules Biologiques (AFMB), UMR 7257, Aix Marseille University and Centre National de la Recherche Scientifique (CNRS), Marseille, France
| | - Ingrid Kockum
- Department of Clinical Neuroscience, Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Clemens Warnke
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Elisabeth Thomsson
- Mammalian Protein Expression Core Facility, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Malin Bäckström
- Mammalian Protein Expression Core Facility, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Tomas Olsson
- Department of Clinical Neuroscience, Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Anna Fogdell-Hahn
- Department of Clinical Neuroscience, Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Tomas Bergström
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Microbiology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Gentile MT, Muto G, Lus G, Lövblad KO, Svenningsen ÅF, Colucci-D’Amato L. Angiogenesis and Multiple Sclerosis Pathogenesis: A Glance at New Pharmaceutical Approaches. J Clin Med 2022; 11:jcm11164643. [PMID: 36012883 PMCID: PMC9410525 DOI: 10.3390/jcm11164643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/27/2022] [Accepted: 08/04/2022] [Indexed: 12/19/2022] Open
Abstract
Multiple sclerosis is a chronic disease of the central nervous system characterized by demyelination and destruction of axons. The most common form of the disease is the relapsing-remitting multiple sclerosis in which episodic attacks with typical neurological symptoms are followed by episodes of partial or complete recovery. One of the underestimated factors that contribute to the pathogenesis of multiple sclerosis is excessive angiogenesis. Here, we review the role of angiogenesis in the onset and in the development of the disease, the molecular mechanisms underlying angiogenesis, the current therapeutic approaches, and the potential therapeutic strategies with a look at natural compounds as multi-target drugs with both neuroprotective and anti-angiogenic properties.
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Affiliation(s)
- Maria Teresa Gentile
- Laboratory of Cellular and Molecular Neuropathology, Department of Environmental, Biological and Pharmaceutical Science and Technology, University of Campania “L. Vanvitelli”, 81100 Caserta, Italy
| | - Gianluca Muto
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Giacomo Lus
- Multiple Sclerosis Center, II Division of Neurology, Department of Advanced Medical and Surgical Sciences, University of Campania “L. Vanvitelli”, 81100 Caserta, Italy
| | - Karl-Olof Lövblad
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Åsa Fex Svenningsen
- Department of Neurobiology, Institute of Molecular Medicine, University of Southern Denmark, 5000 Odense, Denmark
| | - Luca Colucci-D’Amato
- Laboratory of Cellular and Molecular Neuropathology, Department of Environmental, Biological and Pharmaceutical Science and Technology, University of Campania “L. Vanvitelli”, 81100 Caserta, Italy
- InterUniversity Center for Research in Neurosciences (CIRN), University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
- Correspondence: ; Tel.: +39-366-9763554
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Abstract
PURPOSE OF REVIEW Given the expansion of options for the treatment of relapsing multiple sclerosis, this review outlines the framework for developing a treatment strategy, with consideration of when to switch or discontinue therapies, and a comprehensive elaboration of the mechanisms of action, efficacy, and safety considerations for each of the therapeutic classes. RECENT FINDINGS The armamentarium of immunotherapies has grown rapidly, to encompass 19 US Food and Drug Administration (FDA)-approved immunotherapies available in 2021, which are addressed in the review. The coronavirus pandemic that began in 2020 underscored existing concerns regarding vaccine efficacy in those treated with immune-suppressing immunotherapies, which are also addressed here. SUMMARY By choosing a treatment strategy before exploring the individual medications, patients and providers can focus their efforts on a subset of the therapeutic options. Although the mechanisms of action, routes of administration, efficacy, safety, and tolerability of the described agents and classes differ, all are effective in reducing relapse frequency in multiple sclerosis (MS), with most also showing a reduction in the accumulation of neurologic disability. These powerful effects are improving the lives of people with MS. Pharmacovigilance is critical for the safe use of these immune-modulating and -suppressing agents, and vaccine efficacy may be reduced by those with immune-suppressing effects.
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Chen J, Diouf I, Taylor BV, Kalincik T, van der Mei I. Superior effects of natalizumab versus other DMTs on patient-reported outcomes in people with multiple sclerosis. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2022-329223. [PMID: 35902227 DOI: 10.1136/jnnp-2022-329223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 07/05/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Little is known about the comparative effectiveness of multiple sclerosis (MS) disease-modifying therapies (DMTs) on patient-reported outcomes in MS. We compared the effects of natalizumab to other DMTs in relation to MS symptom severity, quality of life, disability, disease progression and employment outcomes using real-world data. METHODS We included 2817 observations in 2015, 2016 and 2017 from 1382 participants in the Australian MS Longitudinal Study. Information on treatment, health and employment outcomes was prospectively collected by questionnaires. Marginal structural models with interaction terms for DMT×time were used to compare natalizumab and other comparator treatment groups. RESULTS Natalizumab was associated with improvements over time, or general trends of improvement, in the severity of many symptoms and work productivity loss. Compared with any other DMTs, natalizumab was associated with superior effects over time for 8 of 23 patient-reported outcomes, with similar directions of effect observed for another 6, demonstrating consistency. There were no differences in effect for spasticity, fatigue, pain, feelings of depression, disability, European quality of life five dimension index, presenteeism and work status. Natalizumab did not perform significantly worse over time compared with any other DMTs for any of the outcomes. CONCLUSIONS Natalizumab was associated with superior outcomes over time for many patient-reported health and employment outcomes when compared with other DMTs in this large prospective cohort study. These findings may influence treatment selection in clinical practice and future treatment cost-effectiveness analyses.
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Affiliation(s)
- Jing Chen
- Department of Geriatrics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Diagnosis and Treatment of Aging and Physic-chemical Injury Diseases of Zhejiang Province, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ibrahima Diouf
- Clinical Outcomes Research Unit (CORe), Faculty of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Bruce V Taylor
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Tomas Kalincik
- Clinical Outcomes Research Unit (CORe), Faculty of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Neurology, The Royal Melbourne Hospital City Campus, Parkville, Victoria, Australia
| | - Ingrid van der Mei
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
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Valero-López G, Millán-Pascual J, Iniesta-Martínez F, Delgado-Marín JL, Jimenez-Veiga J, Tejero-Martín AB, León-Hernández A, Zamarro-Parra J, Morales-Ortiz A, Meca-Lallana JE. Treatment with natalizumab during pregnancy in multiple sclerosis: The experience of implementing a clinical practice protocol (NAP-30). Mult Scler Relat Disord 2022; 66:104038. [PMID: 35870370 DOI: 10.1016/j.msard.2022.104038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/24/2022] [Accepted: 07/05/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pregnancy planning in women with highly active multiple sclerosis (HAMS) who need a high-efficacy disease-modifying therapy (heDMT) currently requires a careful risk-benefit evaluation. This includes minimizing fetal drug toxicity and preventing MS reactivation. We describe our experience with natalizumab in women with HAMS and unplanned pregnancy by implementing a clinical practice protocol (NAP-30) designed to maintain the effectiveness of natalizumab during pregnancy, reduce fetal exposure and prevent complications. METHODS This was an observational retrospective study including women with HAMS on active treatment with natalizumab who became unexpectedly pregnant in the period 2018-2021 and continued this treatment during pregnancy according to the NAP-30 protocol. MS clinical and radiological variables were analyzed before and during pregnancy and in the postpartum period, along with maternal and fetal toxicity during pregnancy and safety findings in newborns. We also describe the NAP-30 protocol, which includes the use of a bridging dose to adjust and maintain natalizumab infusions every 6 weeks during pregnancy up to week 30 and scheduled delivery at week 40. RESULTS Six women (one in her first gestation) with a median age of 31.5 years at the onset of pregnancy (min-max: 24-37 years) were included. All were negative for anti-John Cunningham virus (JCV) antibodies and were on treatment with intravenous natalizumab 300 mg every 4 weeks. At the time of conception, three patients had received 12, 17 and 53 infusions of natalizumab, respectively, while for the remaining three patients natalizumab was their first DMT (two patients had received 6 infusions and one patient had received 3 infusions of natalizumab). All six patients received 6 doses of natalizumab during pregnancy according to the NAP-30 protocol. After delivery, all six patients restarted natalizumab every 4 weeks (median: 3 days; range: 2-4 days). No patients had relapses during pregnancy or at 6 months postpartum, nor did they develop any general health or laboratory abnormalities. The MRI scan performed at 4-6 months postpartum showed no new T2 lesions or gadolinium-enhancing lesions. No miscarriages or threatened miscarriages were reported. One of the patients underwent elective preterm delivery at week 35 after mild-to-moderate anemia was detected by fetal Doppler scan. The newborn had low birth weight (2080 g) and mild anemia, which resolved within two months with oral iron supplementation. The other infants were born with normal birth weight and showed no blood count abnormalities. After a median follow-up of 10 months, all six babies showed normal development with no complications detected. CONCLUSIONS Based on our experience, the implementation of the NAP-30 protocol in women with HAMS and unplanned pregnancy undergoing treatment with natalizumab allows the continuation of natalizumab during pregnancy, with a very favorable clinical and radiological effectiveness and maternal-fetal safety profile during pregnancy and postpartum. Both in pregnancy with HAMS and in general, and particularly for successful implementation of the NAP-30 protocol, obstetric support and monitoring is essential for adequate pregnancy management.
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Affiliation(s)
- Gabriel Valero-López
- CSUR Multiple Sclerosis and Clinical Neuroimmunology Unit, Neurology Department. "Virgen de la Arrixaca" Clinical University Hospital, IMIB-Arrixaca. Murcia, Spain; Clinical Neuroimmunology and Multiple Sclerosis Cathedra. UCAM. Universidad Católica San Antonio, Murcia, Spain
| | - Jorge Millán-Pascual
- CSUR Multiple Sclerosis and Clinical Neuroimmunology Unit, Neurology Department. "Virgen de la Arrixaca" Clinical University Hospital, IMIB-Arrixaca. Murcia, Spain; Clinical Neuroimmunology and Multiple Sclerosis Cathedra. UCAM. Universidad Católica San Antonio, Murcia, Spain
| | - Francisca Iniesta-Martínez
- CSUR Multiple Sclerosis and Clinical Neuroimmunology Unit, Neurology Department. "Virgen de la Arrixaca" Clinical University Hospital, IMIB-Arrixaca. Murcia, Spain; Clinical Neuroimmunology and Multiple Sclerosis Cathedra. UCAM. Universidad Católica San Antonio, Murcia, Spain.
| | - Juan L Delgado-Marín
- Fetal Medicine Unit, Obstetrics Department, "Virgen de la Arrixaca" Clinical University Hospital, IMIB-Arrixaca, Murcia, Spain.
| | - Judith Jimenez-Veiga
- CSUR Multiple Sclerosis and Clinical Neuroimmunology Unit, Neurology Department. "Virgen de la Arrixaca" Clinical University Hospital, IMIB-Arrixaca. Murcia, Spain; Clinical Neuroimmunology and Multiple Sclerosis Cathedra. UCAM. Universidad Católica San Antonio, Murcia, Spain
| | - Ana B Tejero-Martín
- CSUR Multiple Sclerosis and Clinical Neuroimmunology Unit, Neurology Department. "Virgen de la Arrixaca" Clinical University Hospital, IMIB-Arrixaca. Murcia, Spain.
| | - Adelaida León-Hernández
- Neurorradiology Unit, Radiodiagnostic Department, "Virgen de la Arrixaca" Clinical University Hospital. IMIB-Arrixaca, Murcia, Spain
| | - Joaquín Zamarro-Parra
- Neurorradiology Unit, Radiodiagnostic Department, "Virgen de la Arrixaca" Clinical University Hospital. IMIB-Arrixaca, Murcia, Spain
| | - Ana Morales-Ortiz
- CSUR Multiple Sclerosis and Clinical Neuroimmunology Unit, Neurology Department. "Virgen de la Arrixaca" Clinical University Hospital, IMIB-Arrixaca. Murcia, Spain
| | - José E Meca-Lallana
- CSUR Multiple Sclerosis and Clinical Neuroimmunology Unit, Neurology Department. "Virgen de la Arrixaca" Clinical University Hospital, IMIB-Arrixaca. Murcia, Spain; Clinical Neuroimmunology and Multiple Sclerosis Cathedra. UCAM. Universidad Católica San Antonio, Murcia, Spain.
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Sirbu CA, Ivan R, Vasile TM, Eftimie LG, Costache DO. Cutaneous Adverse Reactions Associated with Monoclonal Antibodies Treatment in Multiple Sclerosis: Case Reports and Short Literature Review. J Clin Med 2022; 11:jcm11133702. [PMID: 35806991 PMCID: PMC9267819 DOI: 10.3390/jcm11133702] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/17/2022] [Accepted: 06/25/2022] [Indexed: 02/05/2023] Open
Abstract
Background and aims. Multiple sclerosis is a disease of the central nervous system, whose treatment often involves the use of monoclonal antibodies. This can lead to a series of complications that the clinician should pay attention to and accordingly adjust the therapy. We aim to emphasize real-life experiences with adverse cutaneous reactions to monoclonal antibodies by presenting a series of two cases from our clinic. Methods. In the first case, a female patient was treated with natalizumab for eight years and developed relapsing-remitting cutaneous lesions following the monthly administration of the treatment. The second case is of a male patient treated with ocrelizumab, who developed plaque-like lesions following the fifth administration. We analyzed the biological parameters and performed investigations, dermatological evaluation and skin biopsies. Results. The result of the skin biopsy for the natalizumab patient showed a chronic spongiotic dermatitis, with the anti-natalizumab antibodies being negative. The patient who received ocrelizumab developed nummular eczema, disseminated on his trunk and limbs. Conclusions. Given the fact that these therapies are frequently used in multiple sclerosis patients, and their skin adverse reactions are known, we described some particularities and a brief review of the literature with practical implications. Further studies need to be conducted to establish a firm association between monoclonal antibodies therapy and adverse cutaneous reactions, but the clinician should be aware of their existence.
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Affiliation(s)
- Carmen Adella Sirbu
- Department of Neurology, ‘Dr. Carol Davila’ Central Military Emergency University Hospital, 010242 Bucharest, Romania; (C.A.S.); (R.I.)
| | - Raluca Ivan
- Department of Neurology, ‘Dr. Carol Davila’ Central Military Emergency University Hospital, 010242 Bucharest, Romania; (C.A.S.); (R.I.)
| | - Titus Mihai Vasile
- Clinical Neurosciences Department, University of Medicine and Pharmacy “Carol Davila” Bucharest, 050474 Bucharest, Romania
- Correspondence: (T.M.V.); (L.G.E.)
| | - Lucian George Eftimie
- Department of Pathology, ‘Dr. Carol Davila’ Central Military Emergency University Hospital, 010242 Bucharest, Romania
- Correspondence: (T.M.V.); (L.G.E.)
| | - Daniel Octavian Costache
- Department of Dermatology, ‘Dr. Carol Davila’ Central Military Emergency University Hospital, 010242 Bucharest, Romania;
- 2nd Dermatology Discipline, Faculty of Medicine, University of Medicine and Pharmacy “Carol Davila” Bucharest, 050474 Bucharest, Romania
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Hernández-Preciado MR, Marquez-Pedroza J, Sánchez-Rosales NA, García-Rivera JDJ, Kobayashi-Gutiérrez A, Torres-Mendoza BM, Chavarría-Avila E, Montaño-Serrano RA, Cortes-Enriquez F, Mireles-Ramírez MA. Effect of Rituximab Compared with Natalizumab and Fingolimod in Patients with Relapsing-Remitting Multiple Sclerosis: A Cohort Study. J Clin Med 2022; 11:jcm11133584. [PMID: 35806869 PMCID: PMC9267823 DOI: 10.3390/jcm11133584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/16/2022] [Accepted: 06/20/2022] [Indexed: 02/01/2023] Open
Abstract
The objective of this study was to evaluate the clinical files of patients with RRMS who started rituximab (RTX) compared with a second-line treatment (natalizumab (NTZ) or fingolimod (FTY)). This was a historical cohort study. We compared the effect according to the Expanded Disability Status Scale (EDSS) and the number of relapses in RRMS patients receiving these treatments after a mean period of 12 months. We found a statistically significant difference (p < 0.001) when comparing the EDSS scores and the annual relapse rates of patients receiving RTX with those receiving NTZ or FTY. This study is essential for our clinical practice, since patients with limited treatment options represent a challenge with regard to the management of their medical care. However, clinical trials and prospective studies with long follow-up periods are necessary to provide sufficient evidence on the efficacy of RTX and thus include this treatment in the therapeutic profile of patients with MS.
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Affiliation(s)
- Martha Rocio Hernández-Preciado
- High Specialty Medical Unit, Western National Medical Center of the Mexican Institute of Social Security, Guadalajara 44340, Mexico
- Neurosciences Division, Western Biomedical Research Center (IMSS), Guadalajara 44340, Mexico
| | - Jazmin Marquez-Pedroza
- High Specialty Medical Unit, Western National Medical Center of the Mexican Institute of Social Security, Guadalajara 44340, Mexico
| | - Nayeli Alejandra Sánchez-Rosales
- High Specialty Medical Unit, Western National Medical Center of the Mexican Institute of Social Security, Guadalajara 44340, Mexico
| | - José de Jesús García-Rivera
- High Specialty Medical Unit, Western National Medical Center of the Mexican Institute of Social Security, Guadalajara 44340, Mexico
| | - Antonio Kobayashi-Gutiérrez
- High Specialty Medical Unit, Western National Medical Center of the Mexican Institute of Social Security, Guadalajara 44340, Mexico
| | - Blanca Miriam Torres-Mendoza
- Neurosciences Division, Western Biomedical Research Center (IMSS), Guadalajara 44340, Mexico
- Department of Philosophical and Methodological Disciplines, University Health Sciences Center, University of Guadalajara, Guadalajara 44340, Mexico
| | - Efraín Chavarría-Avila
- Department of Philosophical and Methodological Disciplines, University Health Sciences Center, University of Guadalajara, Guadalajara 44340, Mexico
| | | | - Fernando Cortes-Enriquez
- Department of Neurology, Hospital General Regional No 45 of the Mexican Institute of Social Security, Guadalajara 44910, Mexico
| | - Mario Alberto Mireles-Ramírez
- High Specialty Medical Unit, Western National Medical Center of the Mexican Institute of Social Security, Guadalajara 44340, Mexico
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Yang JH, Rempe T, Whitmire N, Dunn-Pirio A, Graves JS. Therapeutic Advances in Multiple Sclerosis. Front Neurol 2022; 13:824926. [PMID: 35720070 PMCID: PMC9205455 DOI: 10.3389/fneur.2022.824926] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
Multiple sclerosis (MS) is an autoimmune disease affecting the central nervous system that causes significant disability and healthcare burden. The treatment of MS has evolved over the past three decades with development of new, high efficacy disease modifying therapies targeting various mechanisms including immune modulation, immune cell suppression or depletion and enhanced immune cell sequestration. Emerging therapies include CNS-penetrant Bruton's tyrosine kinase inhibitors and autologous hematopoietic stem cell transplantation as well as therapies aimed at remyelination or neuroprotection. Therapy development for progressive MS has been more challenging with limited efficacy of current approved agents for inactive disease and older patients with MS. The aim of this review is to provide a broad overview of the current therapeutic landscape for MS.
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Affiliation(s)
- Jennifer H. Yang
- Department of Neurosciences, University of California San Diego, San Diego, CA, United States
- *Correspondence: Jennifer H. Yang
| | - Torge Rempe
- Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Natalie Whitmire
- Department of Neurosciences, University of California San Diego, San Diego, CA, United States
| | - Anastasie Dunn-Pirio
- Department of Neurosciences, University of California San Diego, San Diego, CA, United States
| | - Jennifer S. Graves
- Department of Neurosciences, University of California San Diego, San Diego, CA, United States
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Interrogating large multiple sclerosis registries and databases: what information can be gained? Curr Opin Neurol 2022; 35:271-277. [PMID: 35674068 DOI: 10.1097/wco.0000000000001057] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Although substantial progress has been made in understanding the natural history of multiple sclerosis (MS) and the development of new therapies, many questions concerning disease behavior and therapeutics remain to be answered. Data generated from real-world observational studies, based on large MS registries and databases and analyzed with advanced statistical methods, are offering the scientific community answers to some of these questions that are otherwise difficult or impossible to address. This review focuses on observational studies published in the last 2 years designed to compare the effectiveness of escalation vs. induction treatment strategies, to assess the effectiveness of treatment in pediatric-onset and late-onset MS, and to identify the clinical phenotype of secondary progressive (SP)MS. RECENT FINDINGS The main findings originating from real-world studies suggest that MS patients who will qualify for high-efficacy disease-modifying therapies (DMTs) should be offered these as early as possible to prevent irreversible accumulation of neurological disability. Especially pediatric patients derive substantial benefits from early treatment. In patients with late-onset MS, sustained exposure to DMTs may result in more favorable outcomes. Data-driven definitions are more accurate in defining transition to SPMS than diagnosis based solely on neurologists' judgment. SUMMARY Patients, physicians, industry, and policy-makers have all benefited from real-world evidence based on registry data, in answering questions of diagnostics, choice of treatment, and timing of treatment decisions.
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Morrow SA, Clift F, Devonshire V, Lapointe E, Schneider R, Stefanelli M, Vosoughi R. Use of natalizumab in persons with multiple sclerosis: 2022 update. Mult Scler Relat Disord 2022; 65:103995. [DOI: 10.1016/j.msard.2022.103995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/04/2022] [Accepted: 06/23/2022] [Indexed: 11/25/2022]
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Abstract
The development of antidrug antibodies (ADAs) is a major problem in several recombinant protein therapies used in the treatment of multiple sclerosis (MS). The etiology of ADAs is multifaceted. The predisposition for a breakdown of immune tolerance is probably genetically determined, and many factors may contribute to the immunogenicity, including structural properties, formation of aggregates, and presence of contaminants and impurities from the industrial manufacturing process. ADAs may have a neutralizing capacity and can reduce or abrogate the bioactivity and therapeutic efficacy of the drug and cause safety issues. Interferon (IFN)-β was the first drug approved for the treatment of MS, and-although it is generally recognized that neutralizing antibodies (NAbs) appear and potentially have a negative effect on therapeutic efficacy-the use of routine measurements of NAbs and the interpretation of the presence of NAbs has been debated at length. NAbs appear after 9-18 months of therapy in up to 40% of patients treated with IFNβ, and the frequency and titers of NAbs depend on the IFNβ preparation. Although all pivotal clinical trials of approved IFNβ products in MS exhibited a detrimental effect of NAbs after prolonged therapy, some subsequent studies did not observe clinical effects from NAbs, which led to the claim that NAbs did not matter. However, it is now largely agreed that persistently high titers of NAbs indicate an abrogation of the biological response and, hence, an absence of therapeutic efficacy, and this observation should lead to a change of therapy. Low and medium titers are ambiguous, and treatment decisions should be guided by determination of in vivo messenger RNA myxovirus resistance protein A induction after IFNβ administration and clinical disease activity. During treatment with glatiramer acetate, ADAs occur frequently but do not appear to adversely affect treatment efficacy or result in adverse events. ADAs occur in approximately 5% of patients treated with natalizumab within 6 months of therapy, and persistent NAbs are associated with a lack of efficacy and acute infusion-related reactions and should instigate a change of therapy. When using the anti-CD20 monoclonal antibodies ocrelizumab and ofatumumab in the treatment of MS, it is not necessary to test for NAbs as these occur very infrequently. Alemtuzumab is immunogenic, but routine measurements of ADAs are not recommended as the antibodies in the pivotal 2-year trials at the population level did not influence lymphocyte depletion or repopulation, efficacy, or safety. However, in some individuals, NAbs led to poor lymphocyte depletion.
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Lefort M, Sharmin S, Andersen JB, Vukusic S, Casey R, Debouverie M, Edan G, Ciron J, Ruet A, De Sèze J, Maillart E, Zephir H, Labauge P, Defer G, Lebrun-Frenay C, Moreau T, Berger E, Clavelou P, Pelletier J, Stankoff B, Gout O, Thouvenot E, Heinzlef O, Al-Khedr A, Bourre B, Casez O, Cabre P, Montcuquet A, Wahab A, Camdessanché JP, Maurousset A, Ben Nasr H, Hankiewicz K, Pottier C, Maubeuge N, Dimitri-Boulos D, Nifle C, Laplaud DA, Horakova D, Havrdova EK, Alroughani R, Izquierdo G, Eichau S, Ozakbas S, Patti F, Onofrj M, Lugaresi A, Terzi M, Grammond P, Grand'Maison F, Yamout B, Prat A, Girard M, Duquette P, Boz C, Trojano M, McCombe P, Slee M, Lechner-Scott J, Turkoglu R, Sola P, Ferraro D, Granella F, Shaygannejad V, Prevost J, Maimone D, Skibina O, Buzzard K, Van der Walt A, Karabudak R, Van Wijmeersch B, Csepany T, Spitaleri D, Vucic S, Koch-Henriksen N, Sellebjerg F, Soerensen PS, Hilt Christensen CC, Rasmussen PV, Jensen MB, Frederiksen JL, Bramow S, Mathiesen HK, Schreiber KI, Butzkueven H, Magyari M, Kalincik T, Leray E. Impact of methodological choices in comparative effectiveness studies: application in natalizumab versus fingolimod comparison among patients with multiple sclerosis. BMC Med Res Methodol 2022; 22:155. [PMID: 35637426 PMCID: PMC9150358 DOI: 10.1186/s12874-022-01623-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 04/25/2022] [Indexed: 11/18/2022] Open
Abstract
Background Natalizumab and fingolimod are used as high-efficacy treatments in relapsing–remitting multiple sclerosis. Several observational studies comparing these two drugs have shown variable results, using different methods to control treatment indication bias and manage censoring. The objective of this empirical study was to elucidate the impact of methods of causal inference on the results of comparative effectiveness studies. Methods Data from three observational multiple sclerosis registries (MSBase, the Danish MS Registry and French OFSEP registry) were combined. Four clinical outcomes were studied. Propensity scores were used to match or weigh the compared groups, allowing for estimating average treatment effect for treated or average treatment effect for the entire population. Analyses were conducted both in intention-to-treat and per-protocol frameworks. The impact of the positivity assumption was also assessed. Results Overall, 5,148 relapsing–remitting multiple sclerosis patients were included. In this well-powered sample, the 95% confidence intervals of the estimates overlapped widely. Propensity scores weighting and propensity scores matching procedures led to consistent results. Some differences were observed between average treatment effect for the entire population and average treatment effect for treated estimates. Intention-to-treat analyses were more conservative than per-protocol analyses. The most pronounced irregularities in outcomes and propensity scores were introduced by violation of the positivity assumption. Conclusions This applied study elucidates the influence of methodological decisions on the results of comparative effectiveness studies of treatments for multiple sclerosis. According to our results, there are no material differences between conclusions obtained with propensity scores matching or propensity scores weighting given that a study is sufficiently powered, models are correctly specified and positivity assumption is fulfilled. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-022-01623-8.
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Affiliation(s)
- M Lefort
- Arènes - UMR 6051, RSMS (Recherche sur les Services et Management en Santé) - U 1309, Univ Rennes, EHESP, CNRS, Inserm, Rennes, France.,Univ Rennes, CHU Rennes, Investigation Clinique de Rennes)], CIC 1414 [(Centre d, 35000, InsermRennes, France
| | - S Sharmin
- Department of Medicine, University of Melbourne, Melbourne, Australia.,Melbourne MS Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia
| | - J B Andersen
- Department of Neurology, The Danish Multiple Sclerosis Registry, Copenhagen University Hospital, Rigshospitalet Glostrup, Denmark
| | - S Vukusic
- Service de Neurologie, Sclérose en Plaques, Pathologies de La Myéline Et Neuro-Inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, 69677, Lyon/Bron, France.,Centre Des Neurosciences de Lyon, UMR5292, Observatoire Français de La Sclérose en Plaques, INSERM, 1028 et CNRS, 69003, Lyon, France.,Université, Claude Bernard Lyon 1, Faculté de médecine Lyon Est, 69000, Lyon, France
| | - R Casey
- Service de Neurologie, Sclérose en Plaques, Pathologies de La Myéline Et Neuro-Inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, 69677, Lyon/Bron, France.,Centre Des Neurosciences de Lyon, UMR5292, Observatoire Français de La Sclérose en Plaques, INSERM, 1028 et CNRS, 69003, Lyon, France.,Université, Claude Bernard Lyon 1, Faculté de médecine Lyon Est, 69000, Lyon, France.,Eugene Devic EDMUS Foundation, 69677, Lyon/Bron, France
| | - M Debouverie
- Centre Hospitalier Régional Universitaire de Nancy, Hôpital Central, Service de neurologie, Nancy, France
| | - G Edan
- Centre Hospitalier Universitaire de Rennes, Hôpital Pontchaillou, Service de neurologie, Rennes, France
| | - J Ciron
- Centre Hospitalier Universitaire de Toulouse, Hôpital Purpan, CRC-SEP, Département de neurologie, Toulouse, France
| | - A Ruet
- Centre Hospitalier Universitaire de Bordeaux, Hôpital Pellegrin, Service de neurologie, Bordeaux, France
| | - J De Sèze
- Service des maladies inflammatoires du système nerveux - neurologie, centre d'investigation clinique de Strasbourg, Hôpitaux Universitaire de Strasbourg, Hôpital de Hautepierre, INSERM 1434, Strasbourg, France
| | - E Maillart
- Assistance Publique Des Hôpitaux de Paris, Hôpital de La Pitié-Salpêtrière, Service de neurologie, Paris, France
| | - H Zephir
- Centre Hospitalier Universitaire de Lille, Hôpital Salengro, Service de neurologie D, Lille, France
| | - P Labauge
- Centre Hospitalier Universitaire de Montpellier, Hôpital Gui de Chauliac, Service de neurologie, Montpellier, France
| | - G Defer
- Centre Hospitalier Universitaire de Caen Normandie, Hôpital Côte de Nacre, Service de neurologie, Caen, France
| | - C Lebrun-Frenay
- Centre Hospitalier Universitaire de Nice, UR2CA-URRIS,, Université Nice Côte d'Azur, Hôpital, Pasteur 2, Service de neurologie, Nice, France
| | - T Moreau
- Centre Hospitalier Universitaire Dijon Bourgogne, Hôpital François Mitterrand, Maladies Inflammatoires du Système Nerveux Et Neurologie Générale, Service de neurologie, Dijon, France
| | - E Berger
- Centre Hospitalier Régional Universitaire de Besançon, Hôpital Jean Minjoz, Service de neurologie, Besançon, France
| | - P Clavelou
- Centre Hospitalier Universitaire de Clermont-Ferrand, Hôpital Gabriel-Montpied, Service de neurologie, Clermont-Ferrand, France
| | - J Pelletier
- Service de Neurologie, Aix Marseille Univ, APHM, Hôpital de La Timone, Pôle de Neurosciences Cliniques, 13005, Marseille, France
| | - B Stankoff
- Assistance Publique Des Hôpitaux de Paris, Hôpital Saint-Antoine, Service de neurologie, Paris, France
| | - O Gout
- Fondation Adolphe de Rothschild de L'œil Et du Cerveau, Service de neurologie, Paris, France
| | - E Thouvenot
- Centre Hospitalier Universitaire de Nîmes, Hôpital Carémeau, Service de neurologie, Nîmes, France
| | - O Heinzlef
- Centre Hospitalier Intercommunal de Poissy Saint-Germain-en-Laye, Service de neurologie, Poissy, France
| | - A Al-Khedr
- Centre Hospitalier Universitaire d'Amiens Picardie, Site sud, Service de neurologie, Amiens, France
| | - B Bourre
- Rouen University Hospital, 76000, Rouen, France
| | - O Casez
- Centre Hospitalier Universitaire Grenoble-Alpes, Site nord, Service de neurologie, Grenoble/La Tronche, France
| | - P Cabre
- Centre Hospitalier Universitaire de Martinique, Hôpital Pierre Zobda-Quitman, Service de neurologie, Fort-de-France, France
| | - A Montcuquet
- Centre Hospitalier Universitaire Limoges, Hôpital Dupuytren, Service de neurologie, Limoges, France
| | - A Wahab
- Assistance Publique Des Hôpitaux de Paris, Hôpital Henri Mondor, Service de neurologie, Créteil, France
| | - J P Camdessanché
- Centre Hospitalier Universitaire de Saint-Étienne, Hôpital Nord, Service de neurologie, Saint-Étienne, France
| | - A Maurousset
- Centre Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, Service de neurologie, Tours, France
| | - H Ben Nasr
- Centre Hospitalier Sud Francilien, Service de neurologie, Corbeil-Essonnes, France
| | - K Hankiewicz
- Centre Hospitalier de Saint-Denis, Hôpital Casanova, Service de neurologie, Saint-Denis, France
| | - C Pottier
- Centre Hospitalier de Pontoise, Service de neurologie, Pontoise, France
| | - N Maubeuge
- Centre Hospitalier Universitaire de Poitiers, Site de La Milétrie, Service de neurologie, Poitiers, France
| | - D Dimitri-Boulos
- Assistance Publique Des Hôpitaux de Paris, Hôpital Bicêtre, Service de neurologie, Le Kremlin-Bicêtre, France
| | - C Nifle
- Centre Hospitalier de Versailles, Hôpital André-Mignot, Service de neurologie, Le Chesnay, France
| | - D A Laplaud
- CHU de Nantes, Service de Neurologie & CIC015 INSERM, 44093, Nantes, France.,INSERM CR1064, 44000, Nantes, France
| | - D Horakova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - E K Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - R Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Sharq, Kuwait
| | - G Izquierdo
- Hospital Universitario Virgen Macarena, Seville, Spain
| | - S Eichau
- Hospital Universitario Virgen Macarena, Seville, Spain
| | - S Ozakbas
- Dokuz Eylul University, Konak/Izmir, Turkey
| | - F Patti
- GF Ingrassia Department, University of Catania, Catania, Italy.,Policlinico G Rodolico, Catania, Italy
| | - M Onofrj
- Department of Neuroscience, Imaging, and Clinical Sciences, University G. d'Annunzio, Chieti, Italy
| | - A Lugaresi
- Dipartimento Di Scienze Biomediche E Neuromotorie, Università Di Bologna, Bologna, Italy.,IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | - M Terzi
- Medical Faculty, 19 Mayis University, Samsun, Turkey
| | - P Grammond
- CISSS Chaudiere-Appalache, Levis, Canada
| | | | - B Yamout
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - A Prat
- Hopital Notre Dame, Montreal, Canada.,CHUM and Universite de Montreal, Montreal, Canada
| | - M Girard
- Hopital Notre Dame, Montreal, Canada.,CHUM and Universite de Montreal, Montreal, Canada
| | - P Duquette
- Hopital Notre Dame, Montreal, Canada.,CHUM and Universite de Montreal, Montreal, Canada
| | - C Boz
- KTU Medical Faculty Farabi Hospital, Trabzon, Turkey
| | - M Trojano
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari, Bari, Italy
| | - P McCombe
- University of Queensland, Brisbane, Australia.,Royal Brisbane and Women's Hospital, Herston, Australia
| | - M Slee
- Flinders University, Adelaide, Australia
| | - J Lechner-Scott
- School of Medicine and Public Health, University Newcastle, Newcastle, Australia.,Department of Neurology, John Hunter Hospital, Hunter New England Health, Newcastle, Australia
| | - R Turkoglu
- Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - P Sola
- Department of Neuroscience, Azienda Ospedaliera Universitaria, Modena, Italy
| | - D Ferraro
- Department of Neuroscience, Azienda Ospedaliera Universitaria, Modena, Italy
| | - F Granella
- Department of Medicine and Surgery, University of Parma, Parma, Italy.,Department of Emergency and General Medicine, Parma University Hospital, Parma, Italy
| | | | - J Prevost
- CSSS Saint-Jérôme, Saint-Jerome, Canada
| | | | - O Skibina
- Monash University, Melbourne, Australia
| | - K Buzzard
- Monash University, Melbourne, Australia
| | | | | | - B Van Wijmeersch
- Rehabilitation and MS-Centre Overpelt and Hasselt University, Hasselt, Belgium
| | - T Csepany
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - D Spitaleri
- Azienda Ospedaliera Di Rilievo Nazionale San Giuseppe Moscati Avellino, Avellino, Italy
| | - S Vucic
- Westmead Hospital, Sydney, Australia
| | - N Koch-Henriksen
- Department of Clinical Epidemiology, Aarhus University Hospital Aarhus, Aarhus, Denmark
| | - F Sellebjerg
- Danish Multiple Sclerosis Centre, Department of Neurology, Copenhagen University Hospital, Rigshospitalet Glostrup, 2600, Glostrup, Denmark
| | - P S Soerensen
- Danish Multiple Sclerosis Centre, Department of Neurology, Copenhagen University Hospital, Rigshospitalet Glostrup, 2600, Glostrup, Denmark
| | - C C Hilt Christensen
- Department of Neurology, Aalborg University Hospital, Multiple Sclerosis Unit, Aalborg, Denmark
| | - P V Rasmussen
- Aarhus University Hospital, Neurology, PJJ Boulevard, DK-8200, Aarhus N, Denmark
| | - M B Jensen
- Department of Neurology, University Hospital of Northern Sealand, Copenhagen, Denmark
| | - J L Frederiksen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - S Bramow
- Danish Multiple Sclerosis Centre, Department of Neurology, Copenhagen University Hospital, Rigshospitalet Glostrup, 2600, Glostrup, Denmark
| | - H K Mathiesen
- Department of Neurology, Copenhagen University Hospital Herlev, Copenhagen, Denmark
| | - K I Schreiber
- Danish Multiple Sclerosis Centre, Department of Neurology, Copenhagen University Hospital, Rigshospitalet Glostrup, 2600, Glostrup, Denmark
| | - H Butzkueven
- Central Clinical School, Monash University, Melbourne, Australia.,Department of Neurology, The Alfred Hospital, Melbourne, Australia.,Department of Neurology, Box Hill Hospital, Monash University, Melbourne, Australia
| | - M Magyari
- Melbourne MS Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia.,Danish Multiple Sclerosis Centre, Department of Neurology, Copenhagen University Hospital, Rigshospitalet Glostrup, 2600, Glostrup, Denmark
| | - T Kalincik
- Department of Medicine, University of Melbourne, Melbourne, Australia.
| | - E Leray
- Arènes - UMR 6051, RSMS (Recherche sur les Services et Management en Santé) - U 1309, Univ Rennes, EHESP, CNRS, Inserm, Rennes, France. .,Univ Rennes, CHU Rennes, Investigation Clinique de Rennes)], CIC 1414 [(Centre d, 35000, InsermRennes, France.
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Ruck T, Nimmerjahn F, Wiendl H, Lünemann JD. Next-generation antibody-based therapies in neurology. Brain 2022; 145:1229-1241. [PMID: 34928330 PMCID: PMC9630709 DOI: 10.1093/brain/awab465] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/04/2021] [Accepted: 11/25/2021] [Indexed: 11/13/2022] Open
Abstract
Antibody-based therapeutics are now standard in the treatment of neuroinflammatory diseases, and the spectrum of neurological diseases targeted by those approaches continues to grow. The efficacy of antibody-based drug platforms is largely determined by the specificity-conferring antigen-binding fragment (Fab) and the crystallizable fragment (Fc) driving antibody function. The latter provides specific instructions to the immune system by interacting with cellular Fc receptors and complement components. Extensive engineering efforts have enabled tuning of Fc functions to modulate effector functions and to prolong or reduce antibody serum half-lives. Technologies that improve bioavailability of antibody-based treatment platforms within the CNS parenchyma are being developed and could invigorate drug discovery for a number of brain diseases for which current therapeutic options are limited. These powerful approaches are currently being tested in clinical trials or have been successfully translated into the clinic. Here, we review recent developments in the design and implementation of antibody-based treatment modalities in neurological diseases.
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Affiliation(s)
- Tobias Ruck
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, 48149 Münster, Germany
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Falk Nimmerjahn
- Department of Biology, Division of Genetics, University of Erlangen-Nuremberg, 91058 Erlangen, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, 48149 Münster, Germany
| | - Jan D Lünemann
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, 48149 Münster, Germany
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Sharmin S, Bovis F, Malpas C, Horakova D, Havrdova EK, Izquierdo G, Eichau S, Trojano M, Prat A, Girard M, Duquette P, Onofrj M, Lugaresi A, Grand'Maison F, Grammond P, Sola P, Ferraro D, Terzi M, Gerlach O, Alroughani R, Boz C, Shaygannejad V, van Pesch V, Cartechini E, Kappos L, Lechner-Scott J, Bergamaschi R, Turkoglu R, Solaro C, Iuliano G, Granella F, Van Wijmeersch B, Spitaleri D, Slee M, McCombe P, Prevost J, Ampapa R, Ozakbas S, Sanchez-Menoyo JL, Soysal A, Vucic S, Petersen T, de Gans K, Butler E, Hodgkinson S, Sidhom Y, Gouider R, Cristiano E, Castillo-Triviño T, Saladino ML, Barnett M, Moore F, Rozsa C, Yamout B, Skibina O, van der Walt A, Buzzard K, Gray O, Hughes S, Perez Sempere A, Singhal B, Fragoso Y, Shaw C, Kermode A, Taylor B, Simo M, Shuey N, Al-Harbi T, Macdonell R, Dominguez JA, Csepany T, Sirbu CA, Sormani MP, Butzkueven H, Kalincik T. Confirmed disability progression as a marker of permanent disability in multiple sclerosis. Eur J Neurol 2022; 29:2321-2334. [PMID: 35582938 PMCID: PMC9539581 DOI: 10.1111/ene.15406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 05/05/2022] [Indexed: 11/30/2022]
Abstract
Background and purpose The prevention of disability over the long term is the main treatment goal in multiple sclerosis (MS); however, randomized clinical trials evaluate only short‐term treatment effects on disability. This study aimed to define criteria for 6‐month confirmed disability progression events of MS with a high probability of resulting in sustained long‐term disability worsening. Methods In total, 14,802 6‐month confirmed disability progression events were identified in 8741 patients from the global MSBase registry. For each 6‐month confirmed progression event (13,321 in the development and 1481 in the validation cohort), a sustained progression score was calculated based on the demographic and clinical characteristics at the time of progression that were predictive of long‐term disability worsening. The score was externally validated in the Cladribine Tablets Treating Multiple Sclerosis Orally (CLARITY) trial. Results The score was based on age, sex, MS phenotype, relapse activity, disability score and its change from baseline, number of affected functional system domains and worsening in six of the domains. In the internal validation cohort, a 61% lower chance of improvement was estimated with each unit increase in the score (hazard ratio 0.39, 95% confidence interval 0.29–0.52; discriminatory index 0.89). The proportions of progression events sustained at 5 years stratified by the score were 1: 72%; 2: 88%; 3: 94%; 4: 100%. The results of the CLARITY trial were confirmed for reduction of disability progression that was >88% likely to be sustained (events with score ˃1.5). Conclusions Clinicodemographic characteristics of 6‐month confirmed disability progression events identify those at high risk of sustained long‐term disability. This knowledge will allow future trials to better assess the effect of therapy on long‐term disability accrual.
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Affiliation(s)
- Sifat Sharmin
- CORe, Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Francesca Bovis
- Department of Health Sciences (DISSAL), University of Genoa, Italy
| | - Charles Malpas
- CORe, Department of Medicine, University of Melbourne, Melbourne, Australia.,Melbourne MS Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Eva Kubala Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | | | - Sara Eichau
- Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Maria Trojano
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari, Bari, Italy
| | - Alexandre Prat
- Hopital Notre Dame, Montreal, Canada; CHUM and Universite de Montreal, Montreal, Canada
| | - Marc Girard
- Hopital Notre Dame, Montreal, Canada; CHUM and Universite de Montreal, Montreal, Canada
| | - Pierre Duquette
- Hopital Notre Dame, Montreal, Canada; CHUM and Universite de Montreal, Montreal, Canada
| | - Marco Onofrj
- Department of Neuroscience, Imaging, and Clinical Sciences, University G. d'Annunzio, Chieti, Italy
| | - Alessandra Lugaresi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italia; Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italia
| | | | | | - Patrizia Sola
- Department of Neuroscience, Azienda Ospedaliera Universitaria, Modena, Italy
| | - Diana Ferraro
- Department of Neuroscience, Azienda Ospedaliera Universitaria, Modena, Italy
| | - Murat Terzi
- Medical Faculty, 19 Mayis University, Samsun, Turkey
| | - Oliver Gerlach
- Department of Neurology, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - Raed Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Sharq, Kuwait
| | - Cavit Boz
- KTU Medical Faculty Farabi Hospital, Trabzon, Turkey
| | | | - Vincent van Pesch
- Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | | | - Ludwig Kappos
- Neurologic Clinic and Policlinic, Departments of Medicine and Clinical Research, University Hospital and University of Basel, Basel, Switzerland
| | - Jeannette Lechner-Scott
- School of Medicine and Public Health, University Newcastle, Newcastle, Australia; Department of Neurology, John Hunter Hospital, Hunter New England Health, Newcastle, Australia
| | | | - Recai Turkoglu
- Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - Claudio Solaro
- Department of Rehabilitaiton, ML Novarese Hospital Moncrivello, Italy
| | | | - Franco Granella
- Department of Medicine and Surgery, University of Parma, Parma, Italy; Department of General Medicine, Parma University Hospital, Parma, Italy
| | - Bart Van Wijmeersch
- Rehabilitation and MS-Centre Overpelt and Hasselt University, Hasselt, Belgium
| | - Daniele Spitaleri
- Azienda Ospedaliera di Rilievo Nazionale San Giuseppe Moscati Avellino, Avellino, Italy
| | - Mark Slee
- Flinders University, Adelaide, Australia
| | - Pamela McCombe
- University of Queensland, Brisbane, Australia; Royal Brisbane and Women's Hospital, Brisbane, Australia
| | | | | | | | | | - Aysun Soysal
- Bakirkoy Education and Research Hospital for Psychiatric and Neurological Diseases, Istanbul, Turkey
| | | | | | | | | | | | - Youssef Sidhom
- Department of Neurology, Razi Hospital, Manouba, Tunisia
| | - Riadh Gouider
- Department of Neurology, Razi Hospital, Manouba, Tunisia
| | | | - Tamara Castillo-Triviño
- Instituto de Investigación Sanitaria Biodonostia, Department of Neurology, Hospital Universitario Donostia, San Sebastián, Spain
| | | | | | | | - Csilla Rozsa
- Jahn Ferenc Teaching Hospital, Budapest, Hungary
| | - Bassem Yamout
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - Olga Skibina
- Central Clinical School, Monash University, Melbourne, Australia; Department of Neurology, The Alfred Hospital, Melbourne, Australia
| | - Anneke van der Walt
- Central Clinical School, Monash University, Melbourne, Australia; Department of Neurology, The Alfred Hospital, Melbourne, Australia
| | - Katherine Buzzard
- Central Clinical School, Monash University, Melbourne, Australia; Department of Neurology, The Alfred Hospital, Melbourne, Australia
| | - Orla Gray
- South East Trust, Belfast, United Kingdom
| | | | | | - Bhim Singhal
- Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | - Yara Fragoso
- Universidade Metropolitana de Santos, Santos, Brazil
| | | | - Allan Kermode
- Perron Institute, University of Western Australia, Nedlands, Australia; Institute of Immunology and Infectious Diseases, Murdoch University, Sir Charles Gairdner Hospital, Perth, Australia
| | | | | | - Neil Shuey
- St Vincents Hospital, Fitzroy, Melbourne, Australia
| | - Talal Al-Harbi
- Neurology Department, King Fahad Specialist Hospital-, Dammam, Saudi Arabia
| | | | | | - Tunde Csepany
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Carmen Adella Sirbu
- Titu Maiorescu University, Central Military Emergency University Hospital, Bucharest, Romania
| | | | - Helmut Butzkueven
- Central Clinical School, Monash University, Melbourne, Australia; Department of Neurology, The Alfred Hospital, Melbourne, Australia
| | - Tomas Kalincik
- CORe, Department of Medicine, University of Melbourne, Melbourne, Australia.,Melbourne MS Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia
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Zhang Y, Cofield S, Cutter G, Krieger S, Wolinsky JS, Lublin F. Predictors of Disease Activity and Worsening in Relapsing-Remitting Multiple Sclerosis. Neurol Clin Pract 2022; 12:e58-e65. [DOI: 10.1212/cpj.0000000000001177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/11/2022] [Indexed: 11/15/2022]
Abstract
Background and Objectives:Disease activity in multiple sclerosis (MS) is highly variable, and there are limited prospective studies on predictors of disease outcomes. The goal of the study is to identify and assess patient characteristics in MS that predict disease activity and worsening.Methods:The study population consisted of a prospective cohort of 1,008 participants with relapsing-remitting (RR) onset MS enrolled in the CombiRx trial. Cox regression analysis was used to determine hazard ratio (HR) associations between baseline (BL) demographics, clinical history, MRI metrics, and treatment; with outcomes of time to first new disease activity over up to 7-years of follow-up including relapse, MRI activity, and disease worsening.Results:1,008 participants were randomized, with 959 eligible for assessment of disease activity and worsening on follow-up. In the multivariable models, risk of relapse was higher in participants younger than 38 at BL vs. older (HR range 1.36-1.43), with presence of Gd+ lesions at baseline (HR 1.38, [95%CI: 1.14, 1.67]), and with BL EDSS ≥3.5 vs. <3.5 (HR range 1.63-1.67). Risk of new MRI activity was higher in younger participants (HR range 1.58-1.84), with higher preexisting lesion counts greater than the median lesion count with ≥71 T2 hyperintense lesions vs. <71 (HR 1.50, [95%CI 1.27, 1.77]), with presence of BL Gd+ lesions (HR 1.75, [95%CI: 1.49, 2.06]), and higher baseline T2 lesion volume (HR 1.02 for every unit increase in baseline volume, [95% CI 1.01, 1.03]). Risk of new MRI activity was lower in those receiving combination therapy compared to either GA (HR range 0.67-0.68) or IFN (HR range 0.68-0.70). Risk of disease worsening was higher for those with higher T2 volume (HR for 1 unit increase in volume 1.01, 95% CI 1.004, 1.03) and BL EDSS <2 (HR range 2.79-2.96). There were no associations between sex, race, and disease duration on relapse, MRI activity, or disease worsening in multivariable analysis.Conclusion:Prospective data from a large clinical trial cohort shows that younger MS patients with high baseline relapses and MRI lesion burden have the highest risk of subsequent disease activity.CombiRx was registered at ClinicalTrials.gov (NCT00211887) on September 21, 2005. Study enrollment began in January 2005.
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79
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Heng AHS, Han CW, Abbott C, McColl SR, Comerford I. Chemokine-Driven Migration of Pro-Inflammatory CD4 + T Cells in CNS Autoimmune Disease. Front Immunol 2022; 13:817473. [PMID: 35250997 PMCID: PMC8889115 DOI: 10.3389/fimmu.2022.817473] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/25/2022] [Indexed: 12/13/2022] Open
Abstract
Pro-inflammatory CD4+ T helper (Th) cells drive the pathogenesis of many autoimmune conditions. Recent advances have modified views of the phenotype of pro-inflammatory Th cells in autoimmunity, extending the breadth of known Th cell subsets that operate as drivers of these responses. Heterogeneity and plasticity within Th1 and Th17 cells, and the discovery of subsets of Th cells dedicated to production of other pro-inflammatory cytokines such as GM-CSF have led to these advances. Here, we review recent progress in this area and focus specifically upon evidence for chemokine receptors that drive recruitment of these various pro-inflammatory Th cell subsets to sites of autoimmune inflammation in the CNS. We discuss expression of specific chemokine receptors by subsets of pro-inflammatory Th cells and highlight which receptors may be tractable targets of therapeutic interventions to limit pathogenic Th cell recruitment in autoimmunity.
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Affiliation(s)
- Aaron H S Heng
- The Chemokine Biology Laboratory, Department of Molecular and Biomedical Science, School of Biological Sciences, Faculty of Science, The University of Adelaide, Adelaide, SA, Australia
| | - Caleb W Han
- The Chemokine Biology Laboratory, Department of Molecular and Biomedical Science, School of Biological Sciences, Faculty of Science, The University of Adelaide, Adelaide, SA, Australia
| | - Caitlin Abbott
- The Chemokine Biology Laboratory, Department of Molecular and Biomedical Science, School of Biological Sciences, Faculty of Science, The University of Adelaide, Adelaide, SA, Australia
| | - Shaun R McColl
- The Chemokine Biology Laboratory, Department of Molecular and Biomedical Science, School of Biological Sciences, Faculty of Science, The University of Adelaide, Adelaide, SA, Australia
| | - Iain Comerford
- The Chemokine Biology Laboratory, Department of Molecular and Biomedical Science, School of Biological Sciences, Faculty of Science, The University of Adelaide, Adelaide, SA, Australia
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80
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Korsen M, Pfeuffer S, Rolfes L, Meuth SG, Hartung HP. Neurological update: treatment escalation in multiple sclerosis patients refractory to fingolimod-potentials and risks of subsequent highly active agents. J Neurol 2022; 269:2806-2818. [PMID: 34999925 PMCID: PMC9021111 DOI: 10.1007/s00415-021-10956-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 12/30/2021] [Indexed: 12/01/2022]
Abstract
A critical issue in the management of relapsing MS (RMS) is the discontinuation of disease-modifying treatments (DMT) due to lack of efficacy, intolerability or impending risks. With new therapeutic agents introduced into the treatment of RMS, immediate- and long-term consequences of sequential drug use, as well as the effect of the sequence in which the drugs are given, are unclear but may affect efficacy, adverse events, and long-term immunocompetence. In the absence of clinical studies specifically addressing these concerns, observations from clinical practice are of particular value in guiding current management algorithms. Prompted by a study published by Ferraro et al. in this journal, we set out to provide an overview of the published real-world evidence on the effectiveness and safety of switching from fingolimod to another DMT in patients with active RMS. Seventeen publications reporting relevant information were identified. The literature suggests that immune cell depletion induced by alemtuzumab or ocrelizumab is associated with an increased risk of relapse and worsening disability in patients switching from fingolimod compared to patients switching from other therapeutic agents. However, the evidence reported for natalizumab and cladribine is inconclusive. While shortening of the washout period may limit early disease reactivation after fingolimod discontinuation, there is no strong evidence that the duration of the washout period or the absolute lymphocyte count at baseline are predictors of attenuated long-term efficacy. Further real-world studies are required to better understand outcomes among patients who are under-represented in controlled trials.
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Affiliation(s)
- Melanie Korsen
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | | | - Leoni Rolfes
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Sven G. Meuth
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
- Brain and Mind Centre, University of Sydney, Sydney, Australia
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Department of Neurology, Palacky University Olomouc, Olomouc, Czech Republic
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81
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Apóstolos SLP, Boaventura M, Mendes NT, Teixeira LS, Campana IG. How to choose initial treatment in multiple sclerosis patients: a case-based approach. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:159-172. [PMID: 35976318 PMCID: PMC9491420 DOI: 10.1590/0004-282x-anp-2022-s128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Immunotherapy dramatically changed the natural history of multiple sclerosis (MS), which was classically associated with severe disability. Treatment strategies advocate that early control of disease activity is crucial to avoid progressive disability, and the use of high efficacy drugs may be beneficial, but safety is a concern. Choosing the disease-modifying therapy is challenging in clinical practice and should be further discussed. OBJECTIVE To discuss the state of art of selecting the initial therapy for relapsing MS patients. METHODS We used a case-based approach followed by clinical discussion, exploring therapeutic options in different MS settings. RESULTS We presented clinical cases profile compatible with the use of MS therapies, classified into moderate and high efficacy. In the moderate efficacy group, we discussed interferons, glatiramer acetate, teriflunomide and dimethyl fumarate, while in the high efficacy group we discussed fingolimod, cladribine, natalizumab, ocrelizumab, alemtuzumab and ofatumumab. CONCLUSION Advances in MS treatment are remarkable. Strong evidence supports the use of early high efficacy therapy. However, biomarkers, clinical and radiologic prognostic factors, as well as patients' individual issues, should be valued and considered for a personalized treatment decision.
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Affiliation(s)
- Samira Luisa Pereira Apóstolos
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil
| | - Mateus Boaventura
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil
| | - Natalia Trombini Mendes
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil
| | - Larissa Silva Teixeira
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil
| | - Igor Gusmão Campana
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil
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Natalizumab therapy in patients with pediatric-onset multiple sclerosis in Greece: clinical and immunological insights of time-long administration and future directions-a single-center retrospective observational study. Naunyn Schmiedebergs Arch Pharmacol 2022; 395:933-943. [PMID: 35471586 DOI: 10.1007/s00210-022-02238-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 04/01/2022] [Indexed: 10/18/2022]
Abstract
Pediatric-onset multiple sclerosis (MS, POMS) accounts for 3-5% of all MS cases and is characterized by a highly inflammatory profile, often warranting treatment with high-efficacy agents. Our aim is to present real-world data of a series of 18 Hellenic POMS patients treated with natalizumab (NTZ) either as adolescents or as adults, after high disease activity has efficiently subsided. Clinical and imaging/laboratory data from 18 POMS patients who have received at least one NTZ infusion were selected in this single-center retrospective observational study. Human leukocyte antigen (HLA) genotyping was performed with standard low-resolution sequence-specific oligonucleotide techniques. Eighteen patients with a mean age of disease onset of 15.3 ± 2.4 years were treated with NTZ with a mean of 51.7 ± 46.4 infusions, 6 as adolescents and 12 as adults. 22.2% were treatment naïve. At the end of the observational period, patients of both groups remained relapse-free, with no radiological activity and significantly reduced disability accumulation. No evidence of disease activity (NEDA)-3 status was achieved in 66.7% of all patients, 58.3% in the adult-treated, and 83.3% in the adolescent-treated POMS patients. NTZ was generally well tolerated. Only 5 adverse events were observed, in 3 patients who were carriers of the HLA-DRB1*15 (HLA-DRB1*15/HLA-DRB1*11 and HLA-DRB1*15/HLA-DRB1*13 genotypes), 1 homozygous for the HLA-DRB1*03 allele and 1 heterozygous for HLA-DRB1*04 and HLA-DRB1*16 alleles. NTZ is highly efficacious and mostly safe for POMS patients with high disease activity in all age groups. The role of immunogenetics in personalized patient evaluation and treatment needs to be further investigated.
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83
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Krämer J, Wiendl H. What Have Failed, Interrupted, and Withdrawn Antibody Therapies in Multiple Sclerosis Taught Us? Neurotherapeutics 2022; 19:785-807. [PMID: 35794296 PMCID: PMC9294122 DOI: 10.1007/s13311-022-01246-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2022] [Indexed: 12/13/2022] Open
Abstract
In the past two decades, monoclonal antibodies (mAbs) have revolutionized the treatment of multiple sclerosis (MS). However, a remarkable number of mAbs failed due to negative study results were withdrawn because of unexpected serious adverse events (SAEs) or due to studies being halted for other reasons. While trials with positive outcomes are usually published in prestigious journals, negative trials are merely published as abstracts or not at all. This review summarizes MS mAbs that have either failed in phase II-III trials, have been interrupted for various reasons, or withdrawn from the market since 2015. The main conclusions that can be drawn from these 'negative' experiences are as follows. mAbs that have been proven to be safe in other autoimmune conditions, will not have the same safety profile in MS due to immunopathogenetic differences in these diseases (e.g., daclizumab). Identification of SAEs in clinical trials is difficult highlighting the importance of phase IV studies. Memory B cells are central players in MS immunopathogenesis (e.g., tabalumab). The pathophysiological mechanisms of disease progression are independent of leukocyte 'outside-in' traffic which drives relapses in MS. Therefore, therapies for progressive MS must be able to sufficiently cross the blood-brain barrier. Sufficiently long trial duration and multicomponent outcome measures are important for clinical studies in progressive MS. The success of trials on remyelination-promoting therapies mainly depends on the sufficient high dose of mAb, the optimal readout for 'proof of concept', time of treatment initiation, and appropriate selection of patients. Failed strategies are highly important to better understand assumed immunopathophysiological mechanisms and optimizing future trial designs.
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Affiliation(s)
- Julia Krämer
- Department of Neurology With Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany
| | - Heinz Wiendl
- Department of Neurology With Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany
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84
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Hellwig K. Natalizumab for multiple sclerosis: the dilemma of NOVA. Lancet Neurol 2022; 21:579-581. [DOI: 10.1016/s1474-4422(22)00170-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/14/2022] [Accepted: 04/20/2022] [Indexed: 11/24/2022]
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Krajnc N, Bsteh G, Berger T, Mares J, Hartung HP. Monoclonal Antibodies in the Treatment of Relapsing Multiple Sclerosis: an Overview with Emphasis on Pregnancy, Vaccination, and Risk Management. Neurotherapeutics 2022; 19:753-773. [PMID: 35378683 PMCID: PMC8978776 DOI: 10.1007/s13311-022-01224-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 01/10/2023] Open
Abstract
Monoclonal antibodies have become a mainstay in the treatment of patients with relapsing multiple sclerosis (RMS) and provide some benefit to patients with primary progressive MS. They are highly precise by specifically targeting molecules displayed on cells involved in distinct immune mechanisms of MS pathophysiology. They not only differ in the target antigen they recognize but also by the mode of action that generates their therapeutic effect. Natalizumab, an [Formula: see text]4[Formula: see text]1 integrin antagonist, works via binding to cell surface receptors, blocking the interaction with their ligands and, in that way, preventing the migration of leukocytes across the blood-brain barrier. On the other hand, the anti-CD52 monoclonal antibody alemtuzumab and the anti-CD20 monoclonal antibodies rituximab, ocrelizumab, ofatumumab, and ublituximab work via eliminating selected pathogenic cell populations. However, potential adverse effects may be serious and can necessitate treatment discontinuation. Most importantly, those are the risk for (opportunistic) infections, but also secondary autoimmune diseases or malignancies. Monoclonal antibodies also carry the risk of infusion/injection-related reactions, primarily in early phases of treatment. By careful patient selection and monitoring during therapy, the occurrence of these potentially serious adverse effects can be minimized. Monoclonal antibodies are characterized by a relatively long pharmacologic half-life and pharmacodynamic effects, which provides advantages such as permitting infrequent dosing, but also creates disadvantages regarding vaccination and family planning. This review presents an overview of currently available monoclonal antibodies for the treatment of RMS, including their mechanism of action, efficacy and safety profile. Furthermore, we provide practical recommendations for risk management, vaccination, and family planning.
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Affiliation(s)
- Nik Krajnc
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Jan Mares
- Department of Neurology, Palacky University Olomouc, Olomouc, Czech Republic
| | - Hans-Peter Hartung
- Department of Neurology, Medical University of Vienna, Vienna, Austria.
- Department of Neurology, Palacky University Olomouc, Olomouc, Czech Republic.
- Department of Neurology, Medical Faculty, Heinrich-Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
- Brain and Mind Center, University of Sydney, Sydney, Australia.
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86
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Ingelfinger F, Gerdes LA, Kavaka V, Krishnarajah S, Friebel E, Galli E, Zwicky P, Furrer R, Peukert C, Dutertre CA, Eglseer KM, Ginhoux F, Flierl-Hecht A, Kümpfel T, De Feo D, Schreiner B, Mundt S, Kerschensteiner M, Hohlfeld R, Beltrán E, Becher B. Twin study reveals non-heritable immune perturbations in multiple sclerosis. Nature 2022; 603:152-158. [PMID: 35173329 PMCID: PMC8891021 DOI: 10.1038/s41586-022-04419-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 01/04/2022] [Indexed: 02/07/2023]
Abstract
Multiple sclerosis (MS) is a chronic inflammatory disorder of the central nervous system underpinned by partially understood genetic risk factors and environmental triggers and their undefined interactions1,2. Here we investigated the peripheral immune signatures of 61 monozygotic twin pairs discordant for MS to dissect the influence of genetic predisposition and environmental factors. Using complementary multimodal high-throughput and high-dimensional single-cell technologies in conjunction with data-driven computational tools, we identified an inflammatory shift in a monocyte cluster of twins with MS, coupled with the emergence of a population of IL-2 hyper-responsive transitional naive helper T cells as MS-related immune alterations. By integrating data on the immune profiles of healthy monozygotic and dizygotic twin pairs, we estimated the variance in CD25 expression by helper T cells displaying a naive phenotype to be largely driven by genetic and shared early environmental influences. Nonetheless, the expanding helper T cells of twins with MS, which were also elevated in non-twin patients with MS, emerged independent of the individual genetic makeup. These cells expressed central nervous system-homing receptors, exhibited a dysregulated CD25-IL-2 axis, and their proliferative capacity positively correlated with MS severity. Together, our matched-pair analysis of the extended twin approach allowed us to discern genetically and environmentally determined features of an MS-associated immune signature.
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Affiliation(s)
- Florian Ingelfinger
- Institute of Experimental Immunology, University of Zurich, Zurich, Switzerland
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Lisa Ann Gerdes
- Institute of Clinical Neuroimmunology, University Hospital, LMU Munich, Munich, Germany
- Biomedical Center (BMC), Faculty of Medicine, LMU Munich, Martinsried, Germany
- Munich Cluster of Systems Neurology (SyNergy), Munich, Germany
| | - Vladyslav Kavaka
- Institute of Clinical Neuroimmunology, University Hospital, LMU Munich, Munich, Germany
- Biomedical Center (BMC), Faculty of Medicine, LMU Munich, Martinsried, Germany
| | | | - Ekaterina Friebel
- Institute of Experimental Immunology, University of Zurich, Zurich, Switzerland
| | - Edoardo Galli
- Institute of Experimental Immunology, University of Zurich, Zurich, Switzerland
- Neurologic Clinic and Policlinic, University Hospital Basel, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Pascale Zwicky
- Institute of Experimental Immunology, University of Zurich, Zurich, Switzerland
| | - Reinhard Furrer
- Department of Mathematics, University of Zurich, Zurich, Switzerland
- Department of Computational Science, University of Zurich, Zurich, Switzerland
| | - Christian Peukert
- Department of Strategy, Globalization and Society, University of Lausanne, Lausanne, Switzerland
| | - Charles-Antoine Dutertre
- Gustave Roussy Cancer Campus, Villejuif, France
- Institut National de la Santé Et de la Recherche Médicale (INSERM) U1015, Equipe Labellisée-Ligue Nationale contre le Cancer, Villejuif, France
| | - Klara Magdalena Eglseer
- Institute of Clinical Neuroimmunology, University Hospital, LMU Munich, Munich, Germany
- Biomedical Center (BMC), Faculty of Medicine, LMU Munich, Martinsried, Germany
| | | | - Andrea Flierl-Hecht
- Institute of Clinical Neuroimmunology, University Hospital, LMU Munich, Munich, Germany
- Biomedical Center (BMC), Faculty of Medicine, LMU Munich, Martinsried, Germany
- Munich Cluster of Systems Neurology (SyNergy), Munich, Germany
| | - Tania Kümpfel
- Institute of Clinical Neuroimmunology, University Hospital, LMU Munich, Munich, Germany
- Biomedical Center (BMC), Faculty of Medicine, LMU Munich, Martinsried, Germany
- Munich Cluster of Systems Neurology (SyNergy), Munich, Germany
| | - Donatella De Feo
- Institute of Experimental Immunology, University of Zurich, Zurich, Switzerland
| | - Bettina Schreiner
- Institute of Experimental Immunology, University of Zurich, Zurich, Switzerland
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Sarah Mundt
- Institute of Experimental Immunology, University of Zurich, Zurich, Switzerland
| | - Martin Kerschensteiner
- Institute of Clinical Neuroimmunology, University Hospital, LMU Munich, Munich, Germany
- Biomedical Center (BMC), Faculty of Medicine, LMU Munich, Martinsried, Germany
- Munich Cluster of Systems Neurology (SyNergy), Munich, Germany
| | - Reinhard Hohlfeld
- Institute of Clinical Neuroimmunology, University Hospital, LMU Munich, Munich, Germany
- Biomedical Center (BMC), Faculty of Medicine, LMU Munich, Martinsried, Germany
- Munich Cluster of Systems Neurology (SyNergy), Munich, Germany
| | - Eduardo Beltrán
- Institute of Clinical Neuroimmunology, University Hospital, LMU Munich, Munich, Germany
- Biomedical Center (BMC), Faculty of Medicine, LMU Munich, Martinsried, Germany
- Munich Cluster of Systems Neurology (SyNergy), Munich, Germany
| | - Burkhard Becher
- Institute of Experimental Immunology, University of Zurich, Zurich, Switzerland.
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Tur C, Dubessy AL, Otero-Romero S, Amato MP, Derfuss T, Di Pauli F, Iacobaeus E, Mycko M, Abboud H, Achiron A, Bellinvia A, Boyko A, Casanova JL, Clifford D, Dobson R, Farez MF, Filippi M, Fitzgerald KC, Fonderico M, Gouider R, Hacohen Y, Hellwig K, Hemmer B, Kappos L, Ladeira F, Lebrun-Frénay C, Louapre C, Magyari M, Mehling M, Oreja-Guevara C, Pandit L, Papeix C, Piehl F, Portaccio E, Ruiz-Camps I, Selmaj K, Simpson-Yap S, Siva A, Sorensen PS, Sormani MP, Trojano M, Vaknin-Dembinsky A, Vukusic S, Weinshenker B, Wiendl H, Winkelmann A, Zuluaga Rodas MI, Tintoré M, Stankoff B. The risk of infections for multiple sclerosis and neuromyelitis optica spectrum disorder disease-modifying treatments: Eighth European Committee for Treatment and Research in Multiple Sclerosis Focused Workshop Review. April 2021. Mult Scler 2022; 28:1424-1456. [PMID: 35196927 DOI: 10.1177/13524585211069068] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Over the recent years, the treatment of multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) has evolved very rapidly and a large number of disease-modifying treatments (DMTs) are now available. However, most DMTs are associated with adverse events, the most frequent of which being infections. Consideration of all DMT-associated risks facilitates development of risk mitigation strategies. An international focused workshop with expert-led discussions was sponsored by the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS) and was held in April 2021 to review our current knowledge about the risk of infections associated with the use of DMTs for people with MS and NMOSD and corresponding risk mitigation strategies. The workshop addressed DMT-associated infections in specific populations, such as children and pregnant women with MS, or people with MS who have other comorbidities or live in regions with an exceptionally high infection burden. Finally, we reviewed the topic of DMT-associated infectious risks in the context of the current SARS-CoV-2 pandemic. Herein, we summarize available evidence and identify gaps in knowledge which justify further research.
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Affiliation(s)
- Carmen Tur
- Multiple Sclerosis Centre of Catalonia (Cemcat), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Anne-Laure Dubessy
- Sorbonne Université, Inserm, CNRS, UMR7225, Institut du Cerveau et de la Moelle épinière (ICM), Paris, France/ Department of Neurology, Saint Antoine Hospital, AP-HP, Paris, France
| | - Susana Otero-Romero
- Multiple Sclerosis Centre of Catalonia (Cemcat), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Maria Pia Amato
- Department of NEUROFARBA, University of Florence, Florence, Italy/IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Tobias Derfuss
- Neurology Clinic and Policlinic, Departments of Medicine, Clinical Research and Biomedicine and Research Center for Clinical Neuroimmunology and Neuroscience Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Franziska Di Pauli
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Ellen Iacobaeus
- Division of Neurology, Department of Clinical Neuroscience, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Marcin Mycko
- Department of Neurology, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
| | - Hesham Abboud
- Multiple Sclerosis and Neuroimmunology Program, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland Medical Center, Cleveland, OH, USA
| | - Anat Achiron
- Sheba Medical Center at Tel Hashomer and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Angelo Bellinvia
- Department of NEUROFARBA, University of Florence, Florence, Italy
| | - Alexey Boyko
- Department of Neurology, Neurosurgery and Medical Genetics, Pirogov Russian National Research Medical University, Moscow, Russia/Institute of Clinical Neurology and Department of Neuroimmunology, Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
| | - Jean-Laurent Casanova
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY, USA
| | - David Clifford
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK/Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Mauricio F Farez
- Center for Research on Neuroimmunological Diseases, FLENI, Buenos Aires, Argentina
| | - Massimo Filippi
- Neurology Unit, Neurorehabilitation Unit and Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy/Vita-Salute San Raffaele University, Milan, Italy
| | - Kathryn C Fitzgerald
- Department of Neurology and Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Mattia Fonderico
- Department of NEUROFARBA, University of Florence, Florence, Italy
| | - Riadh Gouider
- Department of Neurology, Razi Hospital, Tunis, Tunisia
| | - Yael Hacohen
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Institute of Neurology, London, UK
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Bernhard Hemmer
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany; Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Ludwig Kappos
- Neurologic Clinic and Policlinic, Departments of Medicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital, University of Basel, Basel, Switzerland
| | - Filipa Ladeira
- Neurology Department, Hospital Santo António dos Capuchos, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Christine Lebrun-Frénay
- CRCSEP Côte d'Azur, CHU de Nice Pasteur 2, UR2CA-URRIS, Université Nice Côte d'Azur, Nice, France
| | - Céline Louapre
- Sorbonne Université, Inserm, CNRS, UMR7225, Institut du Cerveau et de la Moelle épinière (ICM), Paris, France/Sorbonne University, Paris Brain Institute-ICM, Assistance Publique Hôpitaux de Paris, Inserm, CNRS, Hôpital de la Pitié Salpêtrière, CIC Neurosciences, Paris, France
| | - Melinda Magyari
- Department of Neurology, Danish Multiple Sclerosis Center, Copenhagen University Hospital, Copenhagen, Denmark
| | - Matthias Mehling
- Neurology Clinic and Policlinic, Departments of Medicine, Clinical Research and Biomedicine and Research Center for Clinical Neuroimmunology and Neuroscience Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Celia Oreja-Guevara
- Department of Neurology, Hospital Clínico San Carlos, Idissc, Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Lekha Pandit
- Center for Advanced Neurological Research, KS Hegde Medical Academy, Nitte (Deemed to be University), Mangalore, India
| | - Caroline Papeix
- Sorbonne Université, Inserm, CNRS, UMR7225, Institut du Cerveau et de la Moelle épinière (ICM), Paris, France/Sorbonne University, Paris Brain Institute-ICM, Assistance Publique Hôpitaux de Paris, Inserm, CNRS, Hôpital de la Pitié Salpêtrière, CIC Neurosciences, Paris, France
| | - Fredrik Piehl
- Division of Neurology, Department of Clinical Neuroscience, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Emilio Portaccio
- Department of NEUROFARBA, University of Florence, Florence, Italy
| | - Isabel Ruiz-Camps
- Servicio de Enfermedades Infecciosas, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Krzysztof Selmaj
- Collegium Medicum, Department of Neurology, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland/Center of Neurology, Lodz, Poland
| | - Steve Simpson-Yap
- Clinical Outcomes Research Unit, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Aksel Siva
- Department of Neurology, Istanbul University Cerrahpasa School of Medicine, Istanbul, Turkey
| | - Per Soelberg Sorensen
- Department of Neurology, Danish Multiple Sclerosis Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Maria Pia Sormani
- Department of Health Sciences, University of Genoa and IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Maria Trojano
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro," Bari, Italy
| | - Adi Vaknin-Dembinsky
- Hadassah-Hebrew University Medical Center, Department of Neurology, The Agnes-Ginges Center for Neurogenetics Jerusalem, Jerusalem, Israel
| | - Sandra Vukusic
- Service de neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France/Centre des Neurosciences de Lyon, Observatoire Français de la Sclérose en Plaques, INSERM 1028 et CNRS UMR5292, Lyon, France/Université Claude Bernard Lyon 1, Faculté de médecine Lyon Est, Lyon, France
| | | | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Münster, Germany
| | | | | | - Mar Tintoré
- Multiple Sclerosis Centre of Catalonia (Cemcat), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Bruno Stankoff
- Sorbonne Université, Inserm, CNRS, UMR7225, Institut du Cerveau et de la Moelle épinière (ICM), Paris, France/ Department of Neurology, Saint Antoine Hospital, AP-HP, Paris, France
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88
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Talwar A, Earla JR, Hutton GJ, Aparasu RR. Prescribing of disease modifying agents in older adults with multiple sclerosis. Mult Scler Relat Disord 2022; 57:103308. [PMID: 35158421 DOI: 10.1016/j.msard.2021.103308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/22/2021] [Accepted: 10/02/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND The use of disease-modifying agents (DMAs) to treat Multiple Sclerosis (MS) in older adults is debated as the disease activity decreases with aging. However, limited data exist regarding prescribing patterns of DMAs among older adults with MS. OBJECTIVE To examine prescribing patterns of DMAs and the factors associated with DMA prescribing practices among older adults with MS using electronic medical records (EMR) data. METHODS A retrospective longitudinal cohort study was conducted using the TriNetX, a federated EMR network from the US, data from 2016 to 2019. The study included older adults (≥60 years) with MS diagnosis and at least one prescription record during the study period. Patients with DMA prescriptions were identified and further classified into injectable, oral, or infusion users based on their last DMA prescription. A multivariable logistic regression model was used to evaluate the factors associated with prescribing of DMAs. A multinomial logistic regression model was also used to determine the factors associated with prescribing a particular dosage form of DMA. RESULTS The study cohort consisted of 12,922 older adults with MS, with 2,455 (18.99%) receiving DMA prescriptions. The commonly prescribed DMAs were injectables (10.46%), followed by orals (6.06%) and infusions (2.40%). Multivariable logistic regression revealed that older adults between 60- to 64 years (Adjusted Odds Ratio [aOR]= 2.38) and 65-69 years (aOR=1.60) had higher odds of receiving DMA compared to older adults of 70 years and above. African Americans (aOR=1.71) had higher odds of receiving DMA prescriptions compared to Caucasians. The presence of symptoms (pain, fatigue, speech, walking difficulty) and use of symptomatic medication (anti-fatigue medication, bladder dysfunction medication, antispasmodics, antidepressants, and relapse medication) increased the odds of being prescribed DMAs. Multinomial logistic regression found that patients 60-64 years of age had higher odds of being prescribed infusion (aOR, 95% Confidence Interval [CI] =2.06, 1.35-3.15) and oral (65-69 years: aOR=1.60, 1.24-2.07) over injectable DMAs compared to the older adults aged 70 years and above.Older males (aOR=1.68, 95% CI: 1.23-2.30) were associated with increased odds of being prescribed infusion DMA over injectable DMA compared to females. The presence of comorbidities such as coagulopathy and peripheral vascular disorders decreased the odds of being prescribed oral DMA over injectable DMA. Patients with cerebellar symptoms had an increased likelihood of being prescribed with an infusion DMA over injectable DMA. Patients using drugs for treating relapses had higher odds of being prescribed an infusion DMA over an injectable DMA. In terms of healthcare utilization, older adults with outpatient visits had higher odds of being prescribed an infusion DMA over an injectable DMA, while older adults with inpatient visits had lower odds of being prescribed an infusion DMA over an injectable DMA. CONCLUSION Nearly one in five older adults with MS are prescribed DMAs, with a majority receiving injectable DMAs. Several demographic and clinical factors were associated with DMA prescribing . This study fills the data gap regarding the utilization of DMAs in older adults with MS.
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Affiliation(s)
- Ashna Talwar
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, TX, United States
| | | | | | - Rajender R Aparasu
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, TX, United States.
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89
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Patti F, Chisari CG, Toscano S, Arena S, Finocchiaro C, Cimino V, Milone G. Autologous Hematopoietic Stem Cell Transplantation in Multiple Sclerosis Patients: Monocentric Case Series and Systematic Review of the Literature. J Clin Med 2022; 11:jcm11040942. [PMID: 35207216 PMCID: PMC8875789 DOI: 10.3390/jcm11040942] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 02/05/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic, inflammatory and immune-mediated disease of the central nervous system (CNS), commonly affecting young adults and potentially associated with life-long disability. About 14 disease-modifying treatments (DMTs) are currently approved for the treatment of MS. However, despite the use of highly effective therapies, some patients exhibit a highly active disease with an aggressive course from onset and a higher risk of long-term disability accrual. In the last few years, several retrospective studies, clinical trials, meta-analyses and systematic reviews have investigated autologous hematopoietic stem cell transplantation (AHSCT) as a possible therapeutic option in order to address this unmet clinical need. These studies demonstrated that AHSCT is a highly efficacious and relatively safe therapeutic option for the treatment of highly active MS. Particularly, over recent years, the amount of evidence has grown, with significant improvements in the development of patient selection criteria, choice of the most suitable transplant technique and clinical experience. In this paper, we present six patients who received AHSCT in our MS center and we systematically reviewed recent evidence about the long-term efficacy and safety of AHSCT and the placement of AHSCT in the rapidly evolving therapeutic armamentarium for MS.
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Affiliation(s)
- Francesco Patti
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
- Correspondence: (F.P.); (C.G.C.); Tel.: +39-09-5378-2620 (F.P.)
| | - Clara Grazia Chisari
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
- Correspondence: (F.P.); (C.G.C.); Tel.: +39-09-5378-2620 (F.P.)
| | - Simona Toscano
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
| | - Sebastiano Arena
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
| | - Chiara Finocchiaro
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
| | - Vincenzo Cimino
- IRCCS Centro Neurolesi “Bonino Pulejo”, 98124 Messina, Italy;
| | - Giuseppe Milone
- Hematology and Bone Marrow Transplant Unit, Azienda Policlinico-Vittorio Emanuele, 95124 Catania, Italy;
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90
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Butzkueven H, Giacomini PS, Cohan S, Ziemssen T, Sienkiewicz D, Zhang Y, Geissbühler Y, Silva D, Tomic D, Kropshofer H, Trojano M. Safety of Fingolimod in Patients with Multiple Sclerosis Switched from Natalizumab: Results from TRANSITION―A 2-Year, Multicenter, Observational, Cohort Study. Brain Sci 2022; 12:brainsci12020215. [PMID: 35203978 PMCID: PMC8870332 DOI: 10.3390/brainsci12020215] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/27/2022] [Accepted: 01/29/2022] [Indexed: 12/10/2022] Open
Abstract
Multiple sclerosis (MS) patients receiving natalizumab and who are at risk of developing progressive multifocal leukoencephalopathy (PML) often switch to other high-efficacy disease-modifying therapies including fingolimod as a risk mitigation strategy, which could impact treatment safety and effectiveness. The TRANSITION study aimed to evaluate the safety of fingolimod over two years in patients with MS after switching from natalizumab in a real-world setting. The safety and effectiveness were assessed by monitoring serious and other adverse events (SAEs, AEs). We assessed effectiveness by recording relapses, Expanded Disability Status Scale (EDSS) scores, and MRI activity. Of 637 patients enrolled, 505 completed the study (mean age, 42 years). Overall, 72.8% and 12.7% experienced AEs and SAEs respectively. The most common AEs were fatigue, headache, and urinary tract infection; no cases of PML were observed. Fingolimod treatment resulted in low disease activity. Patients with ≤8 weeks washout period had a markedly lower risk of relapses (4.5%) than those with >8 weeks (51.4%). In patients switching from natalizumab to fingolimod, no new safety signals with overall low relapse activity were observed in patients with washout latencies of ≤8 weeks before fingolimod initiation. Fingolimod was found to be safe and effective in patients transitioning from natalizumab.
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Affiliation(s)
- Helmut Butzkueven
- Department of Neuroscience, Monash University, Melbourne, VIC 3004, Australia
- Department of Neurology, Alfred Hospital, Melbourne, VIC 3004, Australia
- Correspondence:
| | - Paul S. Giacomini
- Department of Neurology and Neurosurgery, McGill University, Montreal, QC H3A 0G4, Canada;
- Multiple Sclerosis Clinic, Montreal Neurological Institute and Hospital, Montreal, QC H3A 2B4, Canada
| | - Stanley Cohan
- Providence Multiple Sclerosis Center, Portland, OR 97225, USA;
| | - Tjalf Ziemssen
- Center of Clinical Neurosciences, University Hospital Carl Gustav Carus, 01307 Dresden, Germany;
| | - Daniel Sienkiewicz
- Novartis Pharmaceuticals Corporation, East Hanover, NJ 07936, USA; (D.S.); (Y.Z.)
| | - Ying Zhang
- Novartis Pharmaceuticals Corporation, East Hanover, NJ 07936, USA; (D.S.); (Y.Z.)
| | - Yvonne Geissbühler
- Novartis Pharma AG, 4056 Basel, Switzerland; (Y.G.); (D.S.); (D.T.); (H.K.)
| | - Diego Silva
- Novartis Pharma AG, 4056 Basel, Switzerland; (Y.G.); (D.S.); (D.T.); (H.K.)
| | - Davorka Tomic
- Novartis Pharma AG, 4056 Basel, Switzerland; (Y.G.); (D.S.); (D.T.); (H.K.)
| | - Harald Kropshofer
- Novartis Pharma AG, 4056 Basel, Switzerland; (Y.G.); (D.S.); (D.T.); (H.K.)
| | - Maria Trojano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, 70121 Bari, Italy;
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91
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Charabati M, Grasmuck C, Ghannam S, Bourbonnière L, Fournier AP, Lécuyer MA, Tastet O, Kebir H, Rébillard RM, Hoornaert C, Gowing E, Larouche S, Fortin O, Pittet C, Filali-Mouhim A, Lahav B, Moumdjian R, Bouthillier A, Girard M, Duquette P, Cayrol R, Peelen E, Quintana FJ, Antel JP, Flügel A, Larochelle C, Arbour N, Zandee S, Prat A. DICAM promotes T H17 lymphocyte trafficking across the blood-brain barrier during autoimmune neuroinflammation. Sci Transl Med 2022; 14:eabj0473. [PMID: 34985970 DOI: 10.1126/scitranslmed.abj0473] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Marc Charabati
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada.,Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montreal, Quebec H3T 1J4, Canada
| | - Camille Grasmuck
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada.,Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montreal, Quebec H3T 1J4, Canada
| | - Soufiane Ghannam
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada.,Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montreal, Quebec H3T 1J4, Canada
| | - Lyne Bourbonnière
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada
| | - Antoine P Fournier
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada.,Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montreal, Quebec H3T 1J4, Canada
| | - Marc-André Lécuyer
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada.,Department of Microbiology, Infectious Diseases and Immunology, Faculty of Medicine, Université de Montréal, Montreal, Quebec H3T 1J4, Canada.,Institute for Neuroimmunology and Multiple Sclerosis Research, University Medical Center Göttingen, Göttingen D-37073, Germany
| | - Olivier Tastet
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada
| | - Hania Kebir
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada.,Department of Microbiology, Infectious Diseases and Immunology, Faculty of Medicine, Université de Montréal, Montreal, Quebec H3T 1J4, Canada
| | - Rose-Marie Rébillard
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada.,Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montreal, Quebec H3T 1J4, Canada
| | - Chloé Hoornaert
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada.,Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montreal, Quebec H3T 1J4, Canada
| | - Elizabeth Gowing
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada.,Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montreal, Quebec H3T 1J4, Canada
| | - Sandra Larouche
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada
| | - Olivier Fortin
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada
| | - Camille Pittet
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada
| | - Ali Filali-Mouhim
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada
| | - Boaz Lahav
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada.,Multiple Sclerosis Clinic, Division of Neurology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec H2L 4M1, Canada
| | - Robert Moumdjian
- Division of Neurosurgery, Université de Montréal and CHUM, Montreal, Quebec H2L 4M1, Canada
| | - Alain Bouthillier
- Division of Neurosurgery, Université de Montréal and CHUM, Montreal, Quebec H2L 4M1, Canada
| | - Marc Girard
- Multiple Sclerosis Clinic, Division of Neurology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec H2L 4M1, Canada
| | - Pierre Duquette
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada.,Multiple Sclerosis Clinic, Division of Neurology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec H2L 4M1, Canada
| | - Romain Cayrol
- Department of Pathology, Université de Montréal and CHUM, Montreal, Quebec H2L 4M1, Canada
| | - Evelyn Peelen
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada.,Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montreal, Quebec H3T 1J4, Canada
| | - Francisco J Quintana
- Ann Romney Carter for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.,Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Jack P Antel
- Neuroimmunology Unit, Montreal Neurological Institute and Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec H3A 2B4, Canada
| | - Alexander Flügel
- Institute for Neuroimmunology and Multiple Sclerosis Research, University Medical Center Göttingen, Göttingen D-37073, Germany
| | - Catherine Larochelle
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada.,Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montreal, Quebec H3T 1J4, Canada.,Multiple Sclerosis Clinic, Division of Neurology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec H2L 4M1, Canada
| | - Nathalie Arbour
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada.,Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montreal, Quebec H3T 1J4, Canada
| | - Stephanie Zandee
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada.,Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montreal, Quebec H3T 1J4, Canada
| | - Alexandre Prat
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec H2X 0A9, Canada.,Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montreal, Quebec H3T 1J4, Canada.,Multiple Sclerosis Clinic, Division of Neurology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec H2L 4M1, Canada
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Hussain RZ, Sguigna PV, Okai A, Wright C, Madinawala M, Bass AD, Cutter GR, Manouchehri N, Stuve O. The sequential natalizumab – alemtuzumab therapy in patients with relapsing forms of multiple sclerosis (SUPPRESS) trial – Part I: Rationale and objectives. J Cent Nerv Syst Dis 2022; 14:11795735221123911. [PMID: 36062026 PMCID: PMC9434668 DOI: 10.1177/11795735221123911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background Natalizumab is a recombinant humanized monoclonal antibody (mAb) against α4-integrin
that is approved for relapsing forms of multiple sclerosis (MS). Natalizumab is
associated with an increased risk of developing progressive multifocal
leukoencephalopathy (PML), and with disease reactivation after cessation of treatment
that is likely mediated by an accumulation of pro-inflammatory lymphocytes in the blood
during therapy. Alemtuzumab is a mAb against CD52 that reduces the number of peripheral
lymphocytes. Rationale To determine if treatment with alemtuzumab after natalizumab reduces disease activity
in patients with relapsing forms of MS. This review article will outline the rationale
and objectives of the sequential natalizumab – alemtuzumab therapy in patients with
relapsing forms of multiple sclerosis (SUPPRESS; ClinicalTrials.gov ID: NCT03135249)
trial in greater detail than would be feasible in a manuscript that summarizes the study
results. Methods The SUPPRESS trial is single arm, open-label, multicenter, efficacy pilot study that
aims to establish a disease-free state over a 24-months period in patients who received
the natalizumab- alemtuzumab sequential therapy. Participants will be recruited from
four different sites. The primary endpoint is the annualized relapse rate (ARR) from the
time of cessation of natalizumab treatment. Key secondary endpoint is freedom of relapse
at 12-months, the number of new/enlarging T2 lesions on magnetic resonance imaging
(MRI), and the number of gadolinium (Gd)-enhancing lesions on MRI. An exploratory
endpoint is the Expanded Disability Status Scale (EDSS), retinal nerve fiber layer
(RNFL) thickness assessment by optic coherence tomography (OCT) and assessment of
quality of life (QoL) measures by a pre-defined, self-administered testing battery. To
evaluate immunological effects, blood leukocytes will be collected and immunophenotyped
by multi-parameter flow cytometry. Conclusion The SUPPRESS trial will provide clinical, imaging, and biological data to determine
whether sequential natalizumab to alemtuzumab combination therapy establish a
disease-free state in patients with relapsing forms of MS.
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Affiliation(s)
- Rehana Z Hussain
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Peter V Sguigna
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Annette Okai
- North Texas Institute of Neurology & Headache, Plano, TX, USA
| | - Crystal Wright
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mariam Madinawala
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ann D Bass
- Neurology Center of San Antonio, Dallas, TX, USA
| | - Gary R Cutter
- Department of Biostatistics, Section on Research Methods and Clinical Trials, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Navid Manouchehri
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Olaf Stuve
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Neurology Section, VA North Texas Health Care System, Dallas, TX, USA
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93
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van Kempen ZLE, Toorop AA, Sellebjerg F, Giovannoni G, Killestein J. Extended dosing of monoclonal antibodies in multiple sclerosis. Mult Scler 2021; 28:2001-2009. [PMID: 34949134 DOI: 10.1177/13524585211065711] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Over the past two decades, treatment options for patients with multiple sclerosis (MS) have increased exponentially. In the current therapeutic landscape, "no evidence of MS disease activity" is within reach in many of our patients. Minimizing risks of complications, improving treatment convenience, and decreasing health care costs are goals that are yet to be reached. One way to optimize MS therapy is to implement personalized or extended interval dosing. Monoclonal antibodies are suitable candidates for personalized dosing (by therapeutic drug monitoring) or extended interval dosing. An increasing number of studies are performed and underway reporting on altered dosing intervals of anti-α4β1-integrin treatment (natalizumab) and anti-CD20 treatment (ocrelizumab, rituximab, and ofatumumab) in MS. In this review, current available evidence regarding personalized and extended interval dosing of monoclonal antibodies in MS is discussed with recommendations for future research and clinical practice.
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Affiliation(s)
- Zoé LE van Kempen
- MS Center Amsterdam, Amsterdam University Medical Center, location VUMC, Amsterdam, The Netherlands
| | - Alyssa A Toorop
- MS Center Amsterdam Amsterdam University Medical Center, location VUMC, Amsterdam, The Netherlands
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, Copenhagen University Hospital, Copenhagen, Denmark
| | - Gavin Giovannoni
- Barts and The London School of Medicine and Dentistry, London, UK
| | - Joep Killestein
- MS Center Amsterdam Amsterdam University Medical Center, location VUMC, Amsterdam, The Netherlands
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Assessing Blood-Based Biomarkers to Define a Therapeutic Window for Natalizumab. J Pers Med 2021; 11:jpm11121347. [PMID: 34945819 PMCID: PMC8706232 DOI: 10.3390/jpm11121347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/29/2021] [Accepted: 12/03/2021] [Indexed: 12/21/2022] Open
Abstract
Natalizumab is a monoclonal antibody that binds CD49d. Although it is one of the most effective treatments for Relapsing-Remitting Multiple Sclerosis (RRMS), a dosing regimen has not been optimized for safety and efficacy in individual patients. We aimed to identify biomarkers to monitor Natalizumab treatment and to establish a personalized dose utilizing an ongoing longitudinal study in 29 RRMS patients under Natalizumab with standard interval dose (SD) of 300 mg/4wks or extended interval dose (EID) of 300 mg/6wks. Blood samples were analyzed by flow cytometry to determine CD49d saturation and expression in several T and B lymphocytes subpopulations. Each patient was analyzed at two different timepoints separated by 3 Natalizumab administrations. Natalizumab and sVCAM-1 levels in serum were also analyzed using ELISA. To determine the reproducibility of various markers, two different timepoints were compared and no significant differences were observed for CD49d expression nor for saturation; SD patients had higher saturation levels (~80%) than EID patients (~60%). A positive correlation exists between CD49d saturation and Natalizumab serum levels. CD49d expression and saturation are stable parameters that could be used as biomarkers in the immunomonitoring of Natalizumab treatment. Moreover, Natalizumab and sVCAM-1 serum levels could be used to optimize an individual's dosing schedule.
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95
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Experiences in treatment of multiple sclerosis with natalizumab from a real-life cohort over 15 years. Sci Rep 2021; 11:23317. [PMID: 34857795 PMCID: PMC8639988 DOI: 10.1038/s41598-021-02665-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/16/2021] [Indexed: 11/29/2022] Open
Abstract
Natalizumab (NTZ) has been used for treatment of highly active relapsing–remitting multiple sclerosis (MS). When stopping NTZ the risk of severe rebound phenomenon has to be considered. We aimed to investigate the use of NTZ in clinical routine and focused on identification of potential risk factors for disease reactivation after treatment discontinuation. At the Medical University of Innsbruck, Austria, we identified all MS patients who were treated with NTZ and performed a retrospective analysis on therapeutic decision making, disease course before, during and after treatment with NTZ and on risk factors for disease reactivation after NTZ discontinuation. 235 NTZ treated MS patients were included, of whom 105 had discontinued treatment. At NTZ start disease duration was 5.09 (IQR 2.09–10.57) years, average number of total relapses was 4 (IQR 3–6) and median EDSS 2.0 (range 0–6.5), whereby these values significantly decreased over time. Reduction of annualized relapse rate (ARR) on treatment was 93% and EDSS remained stable in 64%. In multivariate regression models only conversion to secondary progressive MS (SPMS) on treatment was significantly associated with lower risk of disease reactivation after NTZ, while ARR before treatment was associated with earlier disease reactivation. We could confirm the high therapeutic efficacy of NTZ which trends to be used earlier in the disease course nowadays. Discontinuation of NTZ seems safe only in patients who convert to SPMS during treatment, while higher ARR before NTZ increases the risk of disease reactivation after treatment discontinuation.
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96
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Natalizumab Induces Changes of Cerebrospinal Fluid Measures in Multiple Sclerosis. Diagnostics (Basel) 2021; 11:diagnostics11122230. [PMID: 34943468 PMCID: PMC8699923 DOI: 10.3390/diagnostics11122230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/19/2021] [Accepted: 11/25/2021] [Indexed: 11/17/2022] Open
Abstract
Background: There is a lack of knowledge about the evolution of cerebrospinal fluid (CSF) markers in multiple sclerosis (MS) patients undergoing natalizumab treatment. Aim: We aimed to evaluate the effect of natalizumab on basic inflammatory CSF and MRI measures. Methods: Together, 411 patients were screened for eligibility and 93 subjects with ≥2 CSF examinations ≤6 months before and ≥12 months after natalizumab initiation were recruited. The effect of natalizumab on CSF as well as clinical and paraclinical measures was analyzed using adjusted mixed models. Results: Natalizumab induced a decrease in CSF leukocytes (p < 1 × 10−15), CSF protein (p = 0.00007), the albumin quotient (p = 0.007), the IgG quotient (p = 6 × 10−15), the IgM quotient (p = 0.0002), the IgG index (p = 0.0004), the IgM index (p = 0.003) and the number of CSF-restricted oligoclonal bands (OCBs) (p = 0.0005). CSF-restricted OCBs positivity dropped from 94.6% to 86% but 26 patients (28%) had an increased number of OCBs at the follow-up. The baseline to follow-up EDSS and T2-LV were stable; a decrease in the relapse rate was consistent with a decrease in the CSF inflammatory markers and previous knowledge about the effectiveness of natalizumab. The average annualized brain volume loss during the follow-up was −0.50% (IQR = −0.96, −0.16) and was predicted by the baseline IgM index (B = −0.37; p = 0.003). Conclusions: Natalizumab is associated with a reduction of basic CSF inflammatory measures supporting its strong anti-inflammatory properties. The IgM index at the baseline predicted future brain volume loss during the course of natalizumab treatment.
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97
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Dobson R, Craner M, Waddingham E, Miller A, Cavey A, Webb S, Hemingway C, Hobart J, Evangelou N, Scolding N, Rog D, Nicholas R, Marta M, Blain C, Young CA, Ford HL, Matthews PM. OPTIMISE: MS study protocol: a pragmatic, prospective observational study to address the need for, and challenges with, real world pharmacovigilance in multiple sclerosis. BMJ Open 2021; 11:e050176. [PMID: 34824113 PMCID: PMC8627413 DOI: 10.1136/bmjopen-2021-050176] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 10/25/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The power of 'real world' data to improve our understanding of the clinical aspects of multiple sclerosis (MS) is starting to be realised. Disease modifying therapy (DMT) use across the UK is driven by national prescribing guidelines. As such, the UK provides an ideal country in which to gather MS outcomes data. A rigorously conducted observational study with a focus on pharmacovigilance has the potential to provide important data to inform clinicians and patients while testing the reliability of estimates from pivotal trials when applied to patients in the UK. METHODS AND ANALYSIS The primary aim of this study is to characterise the incidence and compare the risk of serious adverse events in people with MS treated with DMTs. The OPTIMISE:MS database enables electronic data capture and secure data transfer. Selected clinical data, clinical histories and patient-reported outcomes are collected in a harmonised fashion across sites at the time of routine clinical visits. The first patient was recruited to the study on 24 May 2019. As of January 2021, 1615 individuals have baseline data recorded; follow-up data are being captured and will be reported in due course. ETHICS AND DISSEMINATION This study has ethical permission (London City and East; Ref 19/LO/0064). Potential concerns around data storage and sharing are mitigated by the separation of identifiable data from all other clinical data, and limiting access to any identifiable data. The results of this study will be disseminated via publication. Participants provide consent for anonymised data to be shared for further research use, further enhancing the value of the study.
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Affiliation(s)
- Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Matthew Craner
- Department of Neurology, John Radcliffe Hospital NHS Trust, Oxford, UK
- Department of Neurology, Frimley Park Health Foundation NHS Trust, Frimley, UK
| | - Ed Waddingham
- Department of Brain Sciences, Imperial College London and UK Dementia Research Institute, Imperial College London, London, UK
| | - Aleisha Miller
- Department of Brain Sciences, Imperial College London and UK Dementia Research Institute, Imperial College London, London, UK
| | - Ana Cavey
- Department of Neurology, John Radcliffe Hospital NHS Trust, Oxford, UK
| | - Stewart Webb
- Queen Elizabeth University Hospital, Glasgow, UK
| | | | - Jeremy Hobart
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
- Department of Neurology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - Neil Scolding
- Department of Neurology, Southmead Hospital NHS Trust, Bristol, UK
- Department of Neurosciences, University of Bristol, Bristol, UK
| | - David Rog
- Department of Neurology, Greater Manchester Neurosciences Centre, Salford Royal NHS Foundation Trust, Salford, UK
| | - Richard Nicholas
- Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Monica Marta
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
- Department of Neurology, Southend Hospital, Westcliff-on-Sea, UK
| | - Camilla Blain
- Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Helen L Ford
- Centre for Neurosciences, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul M Matthews
- Department of Brain Sciences, Imperial College London and UK Dementia Research Institute, Imperial College London, London, UK
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98
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Quirant-Sánchez B, Mansilla MJ, Navarro-Barriuso J, Presas-Rodríguez S, Teniente-Serra A, Fondelli F, Ramo-Tello C, Martínez-Cáceres E. Combined Therapy of Vitamin D3-Tolerogenic Dendritic Cells and Interferon-β in a Preclinical Model of Multiple Sclerosis. Biomedicines 2021; 9:biomedicines9121758. [PMID: 34944573 PMCID: PMC8698295 DOI: 10.3390/biomedicines9121758] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/18/2021] [Accepted: 11/20/2021] [Indexed: 12/17/2022] Open
Abstract
Autologous antigen-specific therapies based on tolerogenic dendritic cells (tolDC) offer the possibility to treat autoimmune diseases by restoring homeostasis and targeting specifically autoreactive responses. Here, we explore the hypothesis that systemic inflammation occurring in autoimmune diseases, such as multiple sclerosis (MS), can generate a disease-specific environment able to alter the functionality of tolDC. In this context in fact, a combined therapy of tolDC with an immunomodulatory treatment could potentiate the beneficial effect of this antigen-specific cell therapy. For this purpose, we analyzed the efficacy of a combined therapy based on the use of vitamin D3 (VitD3)-tolDC plus interferon beta (IFN-beta) in MS. VitD3-tolDC were generated from healthy donors and MS patients and co-cultured with allogeneic peripheral blood mononuclear cells, in the presence or absence of IFN-beta. In vitro, VitD3-tolDC treatment reduced the percentage of activated T cells and allogeneic proliferation, whereas VitD3-tolDC+IFN-beta treatment enhanced the suppressive ability of VitD3-tolDC and, additionally, induced a shift towards a Th2 profile. To determine the clinical benefit of the combined therapy, C57BL/6-experimental autoimmune encephalomyelitis (EAE)-induced mice were treated with antigen-specific VitD3-tolDC and/or IFN-beta. Treatment of EAE mice with combined therapy ameliorated the disease course compared to each monotherapy. These results suggest that a combined therapy based on antigen-specific VitD3-tolDC and IFN-beta may represent a promising strategy for MS patients.
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Affiliation(s)
- Bibiana Quirant-Sánchez
- Immunology Division, LCMN, Germans Trias i Pujol University Hospital and Research Institute, Campus Can Ruti, 08916 Badalona, Spain; (B.Q.-S.); (M.J.M.); (J.N.-B.); (A.T.-S.); (F.F.)
- Department of Cellular Biology, Physiology and Immunology, Campus Bellaterra, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain
| | - María José Mansilla
- Immunology Division, LCMN, Germans Trias i Pujol University Hospital and Research Institute, Campus Can Ruti, 08916 Badalona, Spain; (B.Q.-S.); (M.J.M.); (J.N.-B.); (A.T.-S.); (F.F.)
- Department of Cellular Biology, Physiology and Immunology, Campus Bellaterra, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain
| | - Juan Navarro-Barriuso
- Immunology Division, LCMN, Germans Trias i Pujol University Hospital and Research Institute, Campus Can Ruti, 08916 Badalona, Spain; (B.Q.-S.); (M.J.M.); (J.N.-B.); (A.T.-S.); (F.F.)
- Department of Cellular Biology, Physiology and Immunology, Campus Bellaterra, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain
| | - Silvia Presas-Rodríguez
- Multiple Sclerosis Unit, Department of Neurosciences, Germans Trias i Pujol University Hospital, 08916 Badalona, Spain;
- Department of Medicine, Campus Bellaterra, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain
| | - Aina Teniente-Serra
- Immunology Division, LCMN, Germans Trias i Pujol University Hospital and Research Institute, Campus Can Ruti, 08916 Badalona, Spain; (B.Q.-S.); (M.J.M.); (J.N.-B.); (A.T.-S.); (F.F.)
- Department of Cellular Biology, Physiology and Immunology, Campus Bellaterra, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain
| | - Federico Fondelli
- Immunology Division, LCMN, Germans Trias i Pujol University Hospital and Research Institute, Campus Can Ruti, 08916 Badalona, Spain; (B.Q.-S.); (M.J.M.); (J.N.-B.); (A.T.-S.); (F.F.)
- Department of Cellular Biology, Physiology and Immunology, Campus Bellaterra, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain
| | - Cristina Ramo-Tello
- Multiple Sclerosis Unit, Department of Neurosciences, Germans Trias i Pujol University Hospital, 08916 Badalona, Spain;
- Department of Medicine, Campus Bellaterra, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain
- Correspondence: or (C.R.-T.); (E.M.-C.); Tel.: +34-93-497-8433 (C.R.-T.); +34-93-497-8666 (E.M.-C.)
| | - Eva Martínez-Cáceres
- Immunology Division, LCMN, Germans Trias i Pujol University Hospital and Research Institute, Campus Can Ruti, 08916 Badalona, Spain; (B.Q.-S.); (M.J.M.); (J.N.-B.); (A.T.-S.); (F.F.)
- Department of Cellular Biology, Physiology and Immunology, Campus Bellaterra, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain
- Correspondence: or (C.R.-T.); (E.M.-C.); Tel.: +34-93-497-8433 (C.R.-T.); +34-93-497-8666 (E.M.-C.)
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99
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Jakimovski D, Kavak KS, Vaughn CB, Goodman AD, Coyle PK, Krupp L, Gottesman M, Edwards KR, Lenihan M, Perel A, Zivadinov R, Weinstock-Guttman B. Discontinuation of disease modifying therapies is associated with disability progression regardless of prior stable disease and age. Mult Scler Relat Disord 2021; 57:103406. [PMID: 34915316 DOI: 10.1016/j.msard.2021.103406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 10/02/2021] [Accepted: 11/13/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Multiple sclerosis (MS) patients with stable disease course might view continued treatment as unnecessary. However, guidelines regarding treatment discontinuation are currently lacking. OBJECTIVE To assess the clinical course after treatment discontinuation in MS patients with long disease duration. METHODS Patients who discontinued disease-modifying treatments (DMTs) and not resume treatment (n = 216) were extracted from New York State MS Consortium (NYSMSC) and followed across three time points (average 4.6 years). Stable course was defined as no change in Expanded Disability Status Scale (EDSS) scores (<1.0 increase if EDSS<6.0 or <0.5-point increase if EDSS≥6.0) from baseline (time 1) to DMT discontinuation (time 2). Both stable and worsening MS patients were later assessed again after the DMT discontinuation (time 3). Additional analyses were performed based on disease subtype, type of medication, age cut-off of 55 and EDSS of 6.0. RESULTS From the cohort of 216 MS patients who discontinued DMT, 161 (72.5%) were classified as stable before DMT discontinuation. After DMT discontinuation, 53 previously stable MS patients (32.9%) experienced disability worsening/progression (DWP). 29.2 and 40% of previously stable RRMS and SPMS respectively had DWP after DMT discontinuation. Over two years after DMT discontinuation, the rate of DWP was similar between patients younger or older than 55 years (31.1% vs 25.9%, respectively). MS patients with EDSS≥6.0 had greater DWP when compared to less disabled patients while remaining on therapy as well as after discontinuation (40.7% vs 15.4%, p < 0.001 and 39.6% vs 15.2%, p < 0.001, respectively). CONCLUSION MS patients with stable disease course experience DWP after treatment discontinuation, with no clear relation to age and disease subtype. Patients with EDSS≥6.0 are at higher risk for DWP.
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Affiliation(s)
- Dejan Jakimovski
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA; Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo, 1010 Main Street, Buffalo, NY 14202, USA
| | - Katelyn S Kavak
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo, 1010 Main Street, Buffalo, NY 14202, USA
| | - Caila B Vaughn
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo, 1010 Main Street, Buffalo, NY 14202, USA
| | - Andrew D Goodman
- Department of Neurology, University of Rochester, Rochester, NY USA
| | | | | | - Malcolm Gottesman
- Division of Neurology, Winthrop University Hospital, Mineola, NY, USA
| | - Keith R Edwards
- MS Center of Northeastern NY - Empire Neurology, P.C. Latham, NY, USA
| | | | | | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA; Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo, 1010 Main Street, Buffalo, NY 14202, USA; Center for Biomedical Imaging at Clinical Translational Science Institute, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Bianca Weinstock-Guttman
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo, 1010 Main Street, Buffalo, NY 14202, USA.
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100
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Lymphocyte Counts and Multiple Sclerosis Therapeutics: Between Mechanisms of Action and Treatment-Limiting Side Effects. Cells 2021; 10:cells10113177. [PMID: 34831400 PMCID: PMC8625745 DOI: 10.3390/cells10113177] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/04/2021] [Accepted: 11/09/2021] [Indexed: 01/18/2023] Open
Abstract
Although the detailed pathogenesis of multiple sclerosis (MS) is not completely understood, a broad range of disease-modifying therapies (DMTs) are available. A common side effect of nearly every MS therapeutic agent is lymphopenia, which can be both beneficial and, in some cases, treatment-limiting. A sound knowledge of the underlying mechanism of action of the selected agent is required in order to understand treatment-associated changes in white blood cell counts, as well as monitoring consequences. This review is a comprehensive summary of the currently available DMTs with regard to their effects on lymphocyte count. In the first part, we describe important general information about the role of lymphocytes in the course of MS and the essentials of lymphopenic states. In the second part, we introduce the different DMTs according to their underlying mechanism of action, summarizing recommendations for lymphocyte monitoring and definitions of lymphocyte thresholds for different therapeutic regimens.
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