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Akgün K, Blankenburg J, Marggraf M, Haase R, Ziemssen T. Event-Driven Immunoprofiling Predicts Return of Disease Activity in Alemtuzumab-Treated Multiple Sclerosis. Front Immunol 2020; 11:56. [PMID: 32082320 PMCID: PMC7005935 DOI: 10.3389/fimmu.2020.00056] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 01/09/2020] [Indexed: 12/19/2022] Open
Abstract
Background: Alemtuzumab is a highly effective drug for the treatment of multiple sclerosis (MS), characterized by specific patterns of depletion and repopulation. As an induction-like treatment concept, two mandatory infusion courses can inhibit long-term disease activity in the majority of patients, and additional courses can successfully manage subsequent re-emergence of disease activity. Currently, there are no biomarkers to identify patients with re-emergent disease activity requiring retreatment. Methods: In this study, we systematically characterized 16 MS patients commencing alemtuzumab. Clinical parameters, MRI and detailed immunoprofiling were conducted every 3 months for up to 84 months. Results: Alemtuzumab led to significant decrease in clinical disease activity in all evaluated patients. Nine out of 16 patients presented with no evidence of disease activity (NEDA)-3 up to 84 months (“complete-responder”), while 7 patients demonstrated clinical or/and subclinical MRI disease activity and received alemutzumab retreatment (“partial-responder”). In both response categories, all T- and B-cell subsets were markedly depleted after alemtuzumab therapy. In particular, absolute numbers of Th1 and Th17 cells were markedly decreased and remained stable below baseline levels—this effect was particularly pronounced in complete-responders. While mean cell numbers did not differ significantly between groups, analysis of event-driven immunoprofiling demonstrated that absolute numbers of Th1 and Th17 cells showed a reproducible increase starting 6 months before relapse activity. This change appears to predict emergent disease activity when compared with stable disease. Conclusion: Studies with larger patient populations are needed to confirm that frequent immunoprofiling may assist in evaluating clinical decision-making of alemtuzumab retreatment.
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Affiliation(s)
- Katja Akgün
- Center of Clinical Neuroscience, University Hospital, Technical University Dresden, Dresden, Germany
| | - Judith Blankenburg
- Center of Clinical Neuroscience, University Hospital, Technical University Dresden, Dresden, Germany
| | - Michaela Marggraf
- Center of Clinical Neuroscience, University Hospital, Technical University Dresden, Dresden, Germany
| | - Rocco Haase
- Center of Clinical Neuroscience, University Hospital, Technical University Dresden, Dresden, Germany
| | - Tjalf Ziemssen
- Center of Clinical Neuroscience, University Hospital, Technical University Dresden, Dresden, Germany
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Förster M, Küry P, Aktas O, Warnke C, Havla J, Hohlfeld R, Mares J, Hartung HP, Kremer D. Managing Risks with Immune Therapies in Multiple Sclerosis. Drug Saf 2020; 42:633-647. [PMID: 30607830 DOI: 10.1007/s40264-018-0782-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Since the introduction of the interferons in the 1990s, a multitude of different immunomodulatory and immunosuppressant disease-modifying therapies for multiple sclerosis (MS) have been developed. They have all shown positive effects on clinical endpoints such as relapse rate and disease progression and are a heterogeneous group of therapeutics comprising recombinant pegylated and non-pegylated interferon-β variants, peptide combinations, monoclonal antibodies, and small molecules. However, they have relevant side effect profiles, which necessitate thorough monitoring and straightforward patient education. In individual cases, side effects can be severe and potentially life-threatening, which is why knowledge about (neurological and non-neurological) adverse drug reactions is essential for prescribing neurologists as well as general practitioners. This paper aims to provide an overview of currently available MS therapies, their modes of action and safety profiles, and the necessary therapy monitoring.
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Affiliation(s)
- Moritz Förster
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Patrick Küry
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Orhan Aktas
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Clemens Warnke
- Department of Neurology, University Hospital Cologne, Cologne, Germany
| | - Joachim Havla
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, Ludwig-Maximilian-Universität München, Munich, Germany
| | - Reinhard Hohlfeld
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, Ludwig-Maximilian-Universität München, Munich, Germany.,The Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Jan Mares
- Department of Neurology, University Hospital and Faculty of Medicine and Dentistry, Palacky University, Olomouc, Czech Republic
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
| | - David Kremer
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
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Zhang X, Hubal MJ, Kraus VB. Immune cell extracellular vesicles and their mitochondrial content decline with ageing. IMMUNITY & AGEING 2020; 17:1. [PMID: 31911808 PMCID: PMC6942666 DOI: 10.1186/s12979-019-0172-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/29/2019] [Indexed: 12/30/2022]
Abstract
Background Although the mechanisms of action are not fully understood, extracellular vesicles (EVs) have emerged as key indicators and effectors of immune function. Characterizing circulating EVs associated with stem and immune cells across the lifespan of healthy individuals could aid an understanding of immunosenescence, a process of age-related decline of cells in both adaptive and innate immune systems. Results Using high resolution multicolor flow cytometry, we identified three major subsets of EVs of varying sizes in healthy control (HC) plasma. Multiple plasma EVs associated with immune cells declined with ageing in HCs. In addition, we observed age-associated declines of respiring mitochondria cargo in EVs of several types of immune cells, suggesting that these parent cells may experience a decline in mitophagy or a mitochondrial dysfunction-induced immunosenescence. By contrast, the number of CD34+ hematopoietic stem cell-associated EVs were high and carried respiring mitochondria, which did not decline with age. Conclusion As demonstrated here, multicolor flow cytometry simultaneously measures plasma EV size, surface markers and cargo that reflect biological processes of specific cell types. The distinct surface markers and cytokine cargo of plasma EVs suggest that they may carry different bio-messages and originate by different biogenesis pathways.
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Affiliation(s)
- Xin Zhang
- 1Duke Molecular Physiology Institute, Duke University School of Medicine, Duke University, Durham, North Carolina 27701 USA.,2Department of Orthopaedic Surgery, Duke University School of Medicine, Duke University, Durham, North Carolina USA
| | - Monica Jeanne Hubal
- 3School of Health and Human Sciences, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana USA
| | - Virginia Byers Kraus
- 1Duke Molecular Physiology Institute, Duke University School of Medicine, Duke University, Durham, North Carolina 27701 USA.,4Department of Medicine, Duke University School of Medicine, Duke University, Durham, North Carolina USA
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Okai AF, Amezcua L, Berkovich RR, Chinea AR, Edwards KR, Steingo B, Walker A, Jacobs AK, Daizadeh N, Williams MJ. Efficacy and Safety of Alemtuzumab in Patients of African Descent with Relapsing-Remitting Multiple Sclerosis: 8-Year Follow-up of CARE-MS I and II (TOPAZ Study). Neurol Ther 2019; 8:367-381. [PMID: 31654272 PMCID: PMC6858901 DOI: 10.1007/s40120-019-00159-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Multiple sclerosis (MS) patients of African descent have increased risk for disease progression and may be less responsive to disease-modifying therapy. METHODS Patients in the CARE-MS studies received alemtuzumab 12 mg/day [initial alemtuzumab treatment (IAT); baseline: 5 days; 12 months later: 3 days] or subcutaneous interferon beta-1a (SC IFNB-1a) 3 ×/week. Core study outcomes were compared between treatment groups. In the extension study CAMMS03409, SC IFNB-1a-treated patients switched to alemtuzumab [delayed alemtuzumab treatment (DAT)]. Data from IAT and DAT arms were pooled to assess outcomes through 6 years post alemtuzumab initiation; IAT patients had an additional 2 years of follow-up in TOPAZ. RESULTS Of 1200 CARE-MS patients, 43 (4%) were of African descent (35 IAT; 8 DAT) and received alemtuzumab in the 2-year core and/or 6-year extension; 29 (67%) remained on study at the time of analysis (24 IAT patients completed year 8 post alemtuzumab; 5 DAT patients completed year 6 post alemtuzumab). In year 2, annualized relapse rate (ARR; 0.09 versus 0.42), percentage of patients with improved Expanded Disability Status Scale (EDSS; 18% versus 11%), 6-month confirmed disability improvement (CDI; 28% versus 13%), no evidence of disease activity (55% versus 13%), and cumulative brain volume loss (BVL; - 0.55% versus - 1.32%) favored alemtuzumab versus SC IFNB-1a. Alemtuzumab remained efficacious at year 6 (pooled IAT/DAT) and at year 8 (IAT only) post alemtuzumab (ARR: 0.15 and 0.30; improved EDSS: 17% and 25%; CDI: 47% and 55%; BVL: - 1.14% and - 0.70%, respectively). No safety signals were unique to this population. CONCLUSIONS Alemtuzumab was efficacious in a small cohort of relapsing-remitting MS patients of African descent over 8 years. Safety was consistent with the overall CARE-MS population, although the small sample size may have prevented the detection of known low-frequency adverse events. CLINICALTRIALS. GOV REGISTRATION NUMBERS CARE-MS I, II, extension, TOPAZ: NCT00530348, NCT00548405, NCT00930553, NCT02255656. FUNDING Sanofi (Cambridge, MA, USA) and Bayer HealthCare Pharmaceuticals (Leverkusen, Germany).
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Affiliation(s)
- Annette F Okai
- Multiple Sclerosis Treatment Center of Dallas, Dallas, TX, USA.
| | - Lilyana Amezcua
- Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Regina R Berkovich
- Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
- , West Hollywood, CA, USA
| | | | | | - Brian Steingo
- Fort Lauderdale Multiple Sclerosis Center, Fort Lauderdale, FL, USA
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IL-21 and IL-21-producing T cells are involved in multiple sclerosis severity and progression. Immunol Lett 2019; 216:12-20. [DOI: 10.1016/j.imlet.2019.09.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 08/27/2019] [Accepted: 09/16/2019] [Indexed: 12/14/2022]
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Comi G, Alroughani R, Boster AL, Bass AD, Berkovich R, Fernández Ó, Kim HJ, Limmroth V, Lycke J, Macdonell RA, Sharrack B, Singer BA, Vermersch P, Wiendl H, Ziemssen T, Jacobs A, Daizadeh N, Rodriguez CE, Traboulsee A. Efficacy of alemtuzumab in relapsing-remitting MS patients who received additional courses after the initial two courses: Pooled analysis of the CARE-MS, extension, and TOPAZ studies. Mult Scler 2019; 26:1866-1876. [PMID: 31762387 PMCID: PMC7720359 DOI: 10.1177/1352458519888610] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background: Alemtuzumab is given as two annual courses. Patients with continued disease activity may receive as-needed additional courses. Objective: To evaluate efficacy and safety of additional alemtuzumab courses in the CARE-MS (Comparison of Alemtuzumab and Rebif® Efficacy in Multiple Sclerosis) studies and their extensions. Methods: Subgroups were based on the number of additional alemtuzumab courses received. Exclusion criteria: other disease-modifying therapy (DMT); <12-month follow-up after last alemtuzumab course. Results: In the additional-courses groups, Courses 3 and 4 reduced annualized relapse rate (12 months before: 0.73 and 0.74, respectively; 12 months after: 0.07 and 0.08). For 36 months after Courses 3 and 4, 89% and 92% of patients were free of 6-month confirmed disability worsening, respectively, with 20% and 26% achieving 6-month confirmed disability improvement. Freedom from magnetic resonance imaging (MRI) disease activity increased after Courses 3 and 4 (12 months before: 43% and 53%, respectively; 12 months after: 73% and 74%). Safety was similar across groups; serious events occurred irrespective of the number of courses. Conclusion: Additional alemtuzumab courses significantly improved outcomes, without increased safety risks, in CARE-MS patients with continued disease activity after Course 2. How this compares to outcomes if treatment is switched to another DMT instead remains unknown.
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Affiliation(s)
- Giancarlo Comi
- Department of Neurology, University Vita-Salute San Raffaele, Milan, Italy
| | | | | | - Ann D Bass
- Neurology Center of San Antonio, San Antonio, TX, USA
| | - Regina Berkovich
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA/Regina Berkovich, MD, PhD, Inc., West Hollywood, CA, USA
| | - Óscar Fernández
- Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | - Ho Jin Kim
- Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Volker Limmroth
- Klinik für Neurologie und Palliativmedizin, Cologne, Germany
| | - Jan Lycke
- Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Richard Al Macdonell
- Department of Neurology, Austin Health and Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia
| | - Basil Sharrack
- NIHR Sheffield Biomedical Research Centre, Sheffield Teaching Hospitals, University of Sheffield, Sheffield, UK
| | - Barry A Singer
- MS Center for Innovations in Care, Missouri Baptist Medical Center, St Louis, MO, USA
| | - Patrick Vermersch
- Univ. Lille, INSERM U995, CHU Lille, FHU Imminent, F-59000 Lille, France
| | - Heinz Wiendl
- Department of Neurology, University of Münster, Münster, Germany
| | - Tjalf Ziemssen
- Center of Clinical Neuroscience, Carl Gustav Carus University Hospital, Dresden, Germany
| | | | | | | | - Anthony Traboulsee
- Division of Neurology, Department of Medicine, The University of British Columbia, Vancouver, BC, Canada
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Immune reconstitution therapies: concepts for durable remission in multiple sclerosis. Nat Rev Neurol 2019; 16:56-62. [PMID: 31649335 DOI: 10.1038/s41582-019-0268-z] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2019] [Indexed: 12/29/2022]
Abstract
New so-called immune reconstitution therapies (IRTs) have the potential to induce long-term or even permanent drug-free remission in people with multiple sclerosis (MS). These therapies deplete components of the immune system with the aim of allowing the immune system to renew itself. Haematopoietic stem cell transplantation, the oral formulation cladribine and the monoclonal antibodies alemtuzumab, rituximab and ocrelizumab are frequently categorized as IRTs. However, the evidence that IRTs indeed renew adaptive immune cell repertoires and rebuild a healthy immune system in people with MS is variable. Instead, IRTs might foster the expansion of those cells that survive immunosuppression, and this expansion could be associated with acquisition of new functional phenotypes. Understanding immunological changes induced by IRTs and how they correlate with clinical outcomes will be instrumental in guiding the optimal use of immune reconstitution as a durable therapeutic strategy. This Perspectives article critically discusses the efficacy and potential mechanisms of IRTs in the context of immune system renewal and durable disease remission in MS.
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An anti-CD103 antibody-drug conjugate prolongs the survival of pancreatic islet allografts in mice. Cell Death Dis 2019; 10:735. [PMID: 31570722 PMCID: PMC6769010 DOI: 10.1038/s41419-019-1980-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/12/2019] [Accepted: 09/16/2019] [Indexed: 02/05/2023]
Abstract
CD103 mediates T-cell infiltration and organ allograft rejection, and depletion of CD103-expressing cells is a promising therapeutic strategy for allograft intolerance. Recently, we verified that M290-MC-MMAF, an anti-CD103 antibody-drug conjugate, potently eliminates CD103-positive cells in vivo, with high specificity and minimal toxicity. However, the contribution of M290-MC-MMAF to blocking the CD103/E-cadherin pathway involved in transplant rejection remains unclear. Herein, we examined the impact of systemic administration of M290-MC-MMAF on allografts in an islet transplantation model. M290-MC-MMAF treatment maintained the long-term survival of islet allografts (>60 days) compared to mock injection or unconjugated M290 antibody treatment (<18 days). The change was associated with a decrease in CD103+CD8+ effector T cells and an increase in CD4+CD25+ regulatory T cells. CD103+CD8+ effector T-cell transfer or CD4+CD25+ regulatory T-cell depletion resulted in a rapid loss of allografts in long-surviving islet hosts. Moreover, M290-MC-MMAF treatment reduced IL-4, IL-6, and TNF-α expression levels and increased IL-10 expression in the grafts, which presented an immunosuppressive cytokine profile. In conclusion, targeting CD103 with M290-MC-MMAF induced immunosuppression and prolonged the survival of pancreatic islet allografts in mice, indicating the potential clinical value of M290-MC-MMAF in therapeutic interventions for allograft rejection.
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Holmøy T, Fevang B, Olsen DB, Spigset O, Bø L. Adverse events with fatal outcome associated with alemtuzumab treatment in multiple sclerosis. BMC Res Notes 2019; 12:497. [PMID: 31405369 PMCID: PMC6689881 DOI: 10.1186/s13104-019-4507-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 07/20/2019] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Sporadic fatal adverse events have been reported during treatment of multiple sclerosis with alemtuzumab. To provide a systematic overview, we searched the centralized European Medicines Agency database of suspected adverse reactions related to medicinal products (EudraVigilance) for fatal adverse events associated with treatment with alemtuzumab (Lemtrada®) for multiple sclerosis. Four independent reviewers with expertise on MS, clinical immunology, infectious diseases and clinical pharmacology reviewed the reports, and scored the likelihood for causality. RESULTS We identified nine cases with a probable and one case with a possible causal relationship between alemtuzumab treatment and a fatal adverse event. Six of these patients died within one month after treatment; one from intracerebral hemorrhage, two from acute multiple organ failure and septic shock, one from listeriosis, one from pneumonia and one from agranulocytosis. Four patients died several months after administration of alemtuzumab from either autoimmune hepatitis, immune-mediated thrombocytopenia, autoimmune hemolytic anemia or agranulocytosis. Four of the 10 cases had been published previously in case reports or congress abstracts. Fatal adverse events related to treatment with alemtuzumab occur more frequently than previously published in the literature. A significant proportion occurs in the first month after treatment.
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Affiliation(s)
- Trygve Holmøy
- Department of Neurology, Akershus University Hospital, Post Office Box 1000, 1478, Lørenskog, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Børre Fevang
- Centre for Rare Disorders, Oslo University Hospital, Sognsvannsveien 20, 0372, Oslo, Norway.,Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital, Sognsvannsveien 20, 0372, Oslo, Norway
| | - David Benee Olsen
- Department of Pharmacovigilance, Norwegian Medicines Agency, Post Office Box 240, Skøyen, 0213, Oslo, Norway
| | - Olav Spigset
- Department of Clinical Pharmacology, St. Olavs University Hospital, Post Office Box 3250, Torgarden, 7006, Trondheim, Norway.,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Lars Bø
- Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Post Office Box 1400, 5021, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Zhang X, Kiapour N, Kapoor S, Khan T, Thamilarasan M, Tao Y, Cohen S, Miller R, Sobel RA, Markovic-Plese S. IL-11 Induces Encephalitogenic Th17 Cells in Multiple Sclerosis and Experimental Autoimmune Encephalomyelitis. THE JOURNAL OF IMMUNOLOGY 2019; 203:1142-1150. [PMID: 31341075 DOI: 10.4049/jimmunol.1900311] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 07/01/2019] [Indexed: 01/04/2023]
Abstract
IL-11+CD4+ cells accumulate in the cerebrospinal fluid of patients with early relapsing-remitting multiple sclerosis (MS) and in active brain MS lesions. Mouse studies have confirmed a causal role of IL-11 in the exacerbation of relapsing-remitting experimental autoimmune encephalomyelitis (RREAE). Administration of IL-11 at the time of clinical onset of RREAE induced an acute exacerbation and increased clinical scores, which persisted during the entire course of the disease. IL-11 increased the numbers of spinal cord inflammatory foci, as well as the numbers of peripheral and CNS-infiltrating IL-17+CD4+ cells and IL-17A serum levels. Ag recall assays revealed that IL-11 induces IL-17A+, GM-CSF+, and IL-21+CD4+ myelin Ag-reactive cells. Passive transfer of these encephalitogenic CD4+ T cells induced severe RREAE with IL-17A+CCR6+ CD4+ and B cell accumulation within the CNS. Furthermore, passive transfer of nonmanipulated CNS-derived mononuclear cells from mice with RREAE after a single dose of IL-11 induced severe RREAE with increased accumulation of IL-17A+ and CCR6+ CD4+ cells within the CNS. These results suggest that IL-11 might serve as a biomarker of early autoimmune response and a selective therapeutic target for patients with early relapsing-remitting MS.
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Affiliation(s)
- Xin Zhang
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
| | - Nazanin Kiapour
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
| | - Sahil Kapoor
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
| | - Tabish Khan
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
| | - Madhan Thamilarasan
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
| | - Yazhong Tao
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
| | - Stephanie Cohen
- Lineberger Cancer Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
| | - Ryan Miller
- Department of Pathology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
| | - Raymond A Sobel
- Department of Pathology, Stanford University, Palo Alto, CA 94394
| | - Silva Markovic-Plese
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599; .,Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599; and.,Department of Neurology, Thomas Jefferson University, Philadelphia, PA 19107
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Osherov M, Milo R. B Cell-based Therapies for Multiple Sclerosis. EMERGING DRUGS AND TARGETS FOR MULTIPLE SCLEROSIS 2019. [DOI: 10.1039/9781788016070-00134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The traditional view of multiple sclerosis (MS) as a T cell mediated autoimmune disease of the central nervous system (CNS) has evolved into a concept of an immune-mediated disease where complex bi-directional interactions between T cells, B cells and myeloid cells underlie and shape CNS-directed autoimmunity. B cells are now recognized as major contributors to the pathogenesis of MS, largely due to increased understanding of their biology and the profound anti-inflammatory effects demonstrated by B cell depletion in MS. In this chapter we discuss the fundamental roles B cells play in the pathogenesis of MS and review current and future therapeutic strategies targeting B cells in MS, including B cell depletion with various monoclonal antibodies (mAbs) against the B cell surface markers CD20 and CD19, anti-B cell cytokine therapies, blocking Bruton's tyrosine kinase (BTK) in B cells, and various immunomodulatory and immunosuppressive effects exerted on B cells by virtually all other approved therapies for MS.
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Affiliation(s)
- Michael Osherov
- Department of Neurology, Barzilai University Medical Center 2 Hahistadrut St. Ashkelon 7830604 Israel
| | - Ron Milo
- Department of Neurology, Barzilai University Medical Center 2 Hahistadrut St. Ashkelon 7830604 Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev Beer-Sheva Israel
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Haas J, Würthwein C, Korporal-Kuhnke M, Viehoever A, Jarius S, Ruck T, Pfeuffer S, Meuth SG, Wildemann B. Alemtuzumab in Multiple Sclerosis: Short- and Long-Term Effects of Immunodepletion on the Peripheral Treg Compartment. Front Immunol 2019; 10:1204. [PMID: 31214176 PMCID: PMC6558003 DOI: 10.3389/fimmu.2019.01204] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 05/13/2019] [Indexed: 11/30/2022] Open
Abstract
Treatment with alemtuzumab is followed by an early increase in Treg frequencies. Whether naïve and memory subsets are differentially affected and how depletion influences dysfunctional MS-Treg is unclear. In this study, we analyzed the effect of alemtuzumab on regulatory T-cells (Treg) in patients with multiple sclerosis (MS). For this purpose 182 blood samples from 25 MS patients were taken shortly before treatment and serially for up to 24 months after two alemtuzumab cycles. We studied Treg by flow cytometry (quantitation, phenotypical characterization), real-time polymerase chain reaction (T-cell receptor (TCR) excision circles [TREC] content), CDR3-spectratyping (clonal distribution), and proliferation assays (suppressive function). CD52-mediated cytolysis of Treg and conventional T-cells was determined by a complement-dependent cytolysis assay. Our studies revealed that 1 week post-alemtuzumab, Treg were depicted at constant frequencies among CD4+ T-cells. In contrast, Treg frequencies were massively increased at month 1. Post-depletional Treg exhibited a CD45RO+ memory phenotype, a skewed TCR repertoire, and contained minimum TREC numbers. Naïve Treg, thymic markers, and TCR-variability commenced to rise after 6 months but did not attain baseline levels. In vitro, Treg exhibited higher susceptibility to lysis than Tcon. Treg suppressive function constantly increased within 1 year when co-cultured with syngeneic T-cells, but remained stable against allogeneic T-cells from normal donors. Our findings suggest that (1) Treg are not spared from alemtuzumab-mediated depletion and thymopoiesis does not considerably contribute to long-term recovery, (2) either homeostatic proliferation and/or conversion from residual Tcon contributes to Treg expansion during the early post-treatment phase (3) the enhanced inhibitory effect of Treg following alemtuzumab is due to altered composition and reactivity of post-depletional Tcon.
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Affiliation(s)
- Jürgen Haas
- Division of Molecular Neuroimmunology, Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Cornelia Würthwein
- Division of Molecular Neuroimmunology, Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Mirjam Korporal-Kuhnke
- Division of Molecular Neuroimmunology, Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Andrea Viehoever
- Division of Molecular Neuroimmunology, Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Sven Jarius
- Division of Molecular Neuroimmunology, Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Tobias Ruck
- Department of Neurology and With Institute for Translational Neurology, University of Muenster, Muenster, Germany
| | - Steffen Pfeuffer
- Department of Neurology and With Institute for Translational Neurology, University of Muenster, Muenster, Germany
| | - Sven G Meuth
- Department of Neurology and With Institute for Translational Neurology, University of Muenster, Muenster, Germany
| | - Brigitte Wildemann
- Division of Molecular Neuroimmunology, Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
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Black C, Stevens R, Clancy M, Morgan S, Hillstrand M. Alemtuzumab Associated Listeria Monocytogenes Meningitis. JOURNAL OF CONTEMPORARY PHARMACY PRACTICE 2019. [DOI: 10.37901/jcphp18-00023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Purpose
Describe a case of Listeria monocytogenes meningitis following initiation of alemtuzumab therapy in a patient diagnosed with relapsing–remitting multiple sclerosis (RRMS).
Summary
A 44-year-old female presented with headache and fever seven days after completion of an initial course of alemtuzumab for the treatment of RRMS. Blood cultures were positive for gram-positive bacilli. A lumbar puncture revealed cell counts, consistent with bacterial meningitis and magnetic resonance imaging (MRI) revealed abnormal signal enhancement of the left cingulate gyrus. Vancomycin, ceftriaxone, and ampicillin were initiated empirically. Both blood and cerebrospinal fluid cultures resulted positive for Listeria monocytogenes. Antibiotics were narrowed to ampicillin for a treatment duration of 21 days, after which symptoms resolved and she was transitioned home. Alemtuzumab is a CD52-directed cytolytic monoclonal antibody that has previously been implicated in association with cases of Listeria monocytogenes meningitis in other countries. Based on its mechanism of action, previous association, and positive temporal relationship, we hypothesize that alemtuzumab played a substantial role in the development of L. monocytogenes meningitis in this patient.
Conclusion
To our knowledge, this is the first reported case of alemtuzumab associated Listeria meningitis in the United States. This case highlights the severe lymphopenia associated with alemtuzumab therapy and risk of subsequent opportunistic infection. Heightened vigilance in counseling and monitoring of dietary restrictions is critical both prior to and during alemtuzumab therapy. A greater role of prophylactic antibiotics may also be warranted.
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De Giglio L, Grimaldi AE, Fubelli F, Marinelli F, Pozzilli C. Advances in preventing adverse events during monoclonal antibody management of multiple sclerosis. Expert Rev Neurother 2019; 19:417-429. [PMID: 31094239 DOI: 10.1080/14737175.2019.1610393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Decades of pharmacological research in Multiple Sclerosis (MS) led to the development of therapeutic Monoclonal Antibodies (MAbs) with many different mechanisms of action (MoA), potentially able to improve disability outcome but also determining a more complex management of patients. Areas covered: When clinicians select MS treatments, they should consider adverse events (AEs) on individual basis to minimize patients' risks. Some AEs are common and can be easily handled, but rare complications should also be taken into account. The aim of this review is to summarize existing evidence and provide practical recommendations for the management of therapeutic MAbs in MS. Expert opinion: The introduction of MAbs revolutionized MS treatment with an improvement in effectiveness. Unfortunately, this has been coupled with a more complex array of AEs needing a tighter surveillance strategy. A close interaction between general practitioners, neurologists, and other specialists is the key for a safer use of such effective drugs.
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Affiliation(s)
- Laura De Giglio
- a MS Center Sant'Andrea Hospital, Sapienza University of Rome , Rome , Italy.,b Department of Human Neuroscience , Sapienza University of Rome , Rome , Italy
| | | | - Federica Fubelli
- a MS Center Sant'Andrea Hospital, Sapienza University of Rome , Rome , Italy
| | | | - Carlo Pozzilli
- a MS Center Sant'Andrea Hospital, Sapienza University of Rome , Rome , Italy.,b Department of Human Neuroscience , Sapienza University of Rome , Rome , Italy
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DeLeonibus A, Mitro G, Brooks J, Rees M, Ortiz J. Alemtuzumab Induction Is Associated With Equalization of Graft Outcomes Between Elderly and Nonelderly Kidney Transplant Recipients: A Single-Center Report. EXP CLIN TRANSPLANT 2019; 18:284-291. [PMID: 31050614 DOI: 10.6002/ect.2018.0296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Alemtuzumab (monoclonal anti-CD52 antibody) provides profound lymphocyte depletion and offers numerous advantages as an induction agent. Elderly recipients (> 65 years old) traditionally have inferior posttransplant outcomes versus younger recipients. We investigated short-term and long-term patient and graft survival rates following alemtuzumab induction in elderly recipients. MATERIALS AND METHODS This retrospective analysis, which included 676 renal allograft transplant recipients with alemtuzumab induction, was conducted at the University of Toledo Medical Center between March 2006 and November 2015. We used 2-sided t test, Pearson chi-square test, Fisher exact test, and Cox proportional hazard regressions with 95% confidence interval for analyses. P < .05 was significant. RESULTS Elderly recipients were more likely to receive a kidney from an inferior donor (deceased donor: 82% vs 72.4%; P = .030) and have higher mean kidney donor profile index (46.2 vs 38.4; P = .024) than nonelderly recipients. Elderly recipients were more likely to experience delayed graft function (15.1% vs 8.5%; P = .038). Elderly recipients demonstrated death-censored graft survival (1 year: 95.4% vs 93.1%; 3 years: 88.5% vs 93.3%; 5 years: 83.1% vs 86.4%) and rejection rates (1 year: 19.8% vs 21.2%; 3 years: 22.1% vs 25.3%; 5 years: 23.8% vs 26.9%) similar to nonelderly recipients. Elderly recipients had significantly higher overall mortality rates than recipients under 65 years old (29.8% vs. 13.2%; P = .001). Although 1-year patient survival was similar to younger recipients (94.8% vs 96.3%; P = .431), 3-year (80.0% vs 91.5%; P = .006) and 5-year (72.9% vs 86.2%; P = .19) rates were significantly decreased in elderly recipients. CONCLUSIONS Elderly age is not a predictor of rejection or death-censored graft loss in individuals who receive alemtuzumab induction. Despite elevated overall mortality, elderly recipients induced with alemtuzumab demonstrated rejection, graft, and short-term patient survival rates similar to younger recipients.
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Affiliation(s)
- Anthony DeLeonibus
- From the College of Medicine and Life Sciences, University of Toledo, Toledo, Ohio, USA
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Sandal S, Bae S, McAdams-DeMarco M, Massie AB, Lentine KL, Cantarovich M, Segev DL. Induction immunosuppression agents as risk factors for incident cardiovascular events and mortality after kidney transplantation. Am J Transplant 2019; 19:1150-1159. [PMID: 30372596 PMCID: PMC6433494 DOI: 10.1111/ajt.15148] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 09/30/2018] [Accepted: 10/19/2018] [Indexed: 01/25/2023]
Abstract
Low T cell counts and acute rejection are associated with increased cardiovascular events (CVEs); T cell-depleting agents decrease both. Thus, we aimed to characterize the risk of CVEs by using an induction agent used in kidney transplant recipients. We conducted a secondary data analysis of patients who received a kidney transplant and used Medicare as their primary insurance from 1999 to 2010. Outcomes of interest were incident CVE, all-cause mortality, CVE-related mortality, and a composite outcome of mortality and CVE. Of 47 258 recipients, 29.3% received IL-2 receptor antagonist (IL-2RA), 33.3% received anti-thymocyte globulin (ATG), 7.3% received alemtuzumab, and 30.0% received no induction. Compared with IL-2RA, there was no difference in the risk of CVE in the ATG (adjusted hazard ratio [aHR] 0.98, 95% confidence interval [CI] 0.92-1.05) and alemtuzumab group (aHR 1.01, 95% CI 0.89-1.16), but slightly higher in the no induction group (aHR 1.06, 95% CI 1.00-1.14). Acute rejection did not modify this association in the latter group but did increase CVE by 46% in the alemtuzumab group. There was no difference in the hazard of all-cause or CVE-related mortality. Only in the ATG group, a 7% lower hazard of the composite outcome of mortality and CVE was noted. Induction agents are not associated with incident CVE, although prospective trials are needed to determine a personalized approach to prevention.
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Affiliation(s)
- Shaifali Sandal
- Department of Medicine, Divisions of Nephrology and Multi-Organ Transplant Program, McGill University Health Centre, Montreal, QC
| | - Sunjae Bae
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mara McAdams-DeMarco
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allan B. Massie
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Krista L. Lentine
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Marcelo Cantarovich
- Department of Medicine, Divisions of Nephrology and Multi-Organ Transplant Program, McGill University Health Centre, Montreal, QC
| | - Dorry L. Segev
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Dunn A, Lam A, Hidalgo L, Shapiro AMJ, Senior PA. Autoimmune Thyroid Disease in Islet Transplant Recipients Discontinuing Immunosuppression Late After Lymphodepletion. J Clin Endocrinol Metab 2019; 104:1141-1147. [PMID: 30398662 DOI: 10.1210/jc.2018-01652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/30/2018] [Indexed: 01/11/2023]
Abstract
CONTEXT Clinical islet transplantation (CIT) is an innovative strategy to treat highly selected individuals with type 1 diabetes mellitus (T1DM). Lymphodepletion with alemtuzumab or thymoglobulin is often used for induction therapy in CIT. Alemtuzumab was recently licensed as a treatment of relapsing remitting multiple sclerosis (RRMS). In RRMS, autoimmune thyroid disease (AITD) has developed in up to 40% of individuals treated with alemtuzumab. The appearance of AITD after CIT is not well described. We herein explore factors associated with AITD developing after CIT and any relationship with exposure to lymphodepleting antibodies (alemtuzumab or thymoglobulin). CASE DESCRIPTION Five cases of AITD developing after CIT for T1DM are described. All were female. Four cases had received alemtuzumab (20 to 40 mg) prior to at least one islet infusion, and one received thymoglobulin induction. The presentation with AITD was 18 to 135 months after first transplant and 11 to 18 months after withdrawal of all maintenance immunosuppression (IS). Four cases presented with clinical and biochemical evidence of hyperthyroidism from Graves disease. One case presented with biochemical evidence of hypothyroidism and positive TSH receptor antibodies. All were treated with conventional therapies for AITD. CONCLUSIONS Despite routine use of alemtuzumab, clinical presentations of AITD seem to be uncommon in patients with CIT receiving IS. However, AITD can develop after withdrawal of IS, highlighting the need for careful thyroid surveillance in this population.
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Affiliation(s)
- Alanna Dunn
- Division of Endocrinology, University of Alberta, Edmonton, Alberta, Canada
| | - Anna Lam
- Division of Endocrinology, University of Alberta, Edmonton, Alberta, Canada
- Clinical Islet Transplant Program, University of Alberta, Edmonton, Alberta, Canada
| | - Luis Hidalgo
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - A M James Shapiro
- Clinical Islet Transplant Program, University of Alberta, Edmonton, Alberta, Canada
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Peter A Senior
- Division of Endocrinology, University of Alberta, Edmonton, Alberta, Canada
- Clinical Islet Transplant Program, University of Alberta, Edmonton, Alberta, Canada
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Barclay K, Carruthers R, Traboulsee A, Bass AD, LaGanke C, Bertolotto A, Boster A, Celius EG, de Seze J, Cruz DD, Habek M, Lee JM, Limmroth V, Meuth SG, Oreja-Guevara C, Pagnotta P, Vos C, Ziemssen T, Baker DP, Wijmeersch BV. Best Practices for Long-Term Monitoring and Follow-Up of Alemtuzumab-Treated MS Patients in Real-World Clinical Settings. Front Neurol 2019; 10:253. [PMID: 30967831 PMCID: PMC6439479 DOI: 10.3389/fneur.2019.00253] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 02/25/2019] [Indexed: 12/02/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic autoimmune neurological disease that typically affects young adults, causing irreversible physical disability and cognitive impairment. Alemtuzumab, administered intravenously as 2 initial courses of 12 mg/day (5 consecutive days at baseline, and 3 consecutive days 12 months later), resulted in significantly greater improvements in clinical and MRI outcomes vs. subcutaneous interferon beta-1a over 2 years in patients with active relapsing-remitting MS (RRMS) who were either treatment-naive (CARE-MS I; NCT00530348) or had an inadequate response to prior therapy (CARE-MS II; NCT00548405). Efficacy with alemtuzumab was maintained over 7 years in subsequent extension studies (NCT00930553; NCT02255656), in the absence of continuous treatment and with a consistent safety profile. There is an increased incidence of autoimmune events in patients treated with alemtuzumab (mainly thyroid events, but also immune thrombocytopenia and nephropathy), which imparts a need for mandatory safety monitoring for 4 years following the last treatment. The risk management strategy for alemtuzumab-treated patients includes laboratory monitoring and a comprehensive patient education and support program that enables early detection and effective management of autoimmune events, yielding optimal outcomes for MS patients. Here we provide an overview of tools and techniques that have been implemented in real-world clinical settings to reduce the burden of monitoring for both patients and healthcare providers, including customized educational materials, the use of social media, and interactive online databases for managing healthcare data. Many practices are also enhancing patient outreach efforts through coordination with specialized nursing services and ancillary caregivers. The best practice recommendations for safety monitoring described in this article, based on experiences in real-world clinical settings, may enable early detection and management of autoimmune events, and help with implementation of monitoring requirements while maximizing the benefits of alemtuzumab treatment for MS patients.
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Affiliation(s)
| | | | | | - Ann D. Bass
- Neurology Center of San Antonio, San Antonio, TX, United States
| | | | | | - Aaron Boster
- OhioHealth Neurological Physicians, Columbus, OH, United States
| | - Elisabeth G. Celius
- Oslo University Hospital Ullevål and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jérôme de Seze
- Clinical Research Center (CIC), INSERM 1434, Strasbourg University, Strasbourg, France
| | | | - Mario Habek
- University of Zagreb, School of Medicine and University Medical Center, Zagreb, Croatia
| | - Jong-Mi Lee
- Stanford Healthcare, Palo Alto, CA, United States
| | - Volker Limmroth
- Klinik für Neurologie und Palliativmedizin, Cologne, Germany
| | - Sven G. Meuth
- Clinic of Neurology with Institute of Translational Neurology, University Hospital Müenster, Müenster, Germany
| | - Celia Oreja-Guevara
- El Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Cindy Vos
- Revalidatie & MS Centrum, Overpelt, Belgium
| | - Tjalf Ziemssen
- Center of Clinical Neuroscience, University Clinic Carl Gustav Carus, Dresden, Germany
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Shaker OG, Mahmoud RH, Abdelaleem OO, Ibrahem EG, Mohamed AA, Zaki OM, Abdelghaffar NK, Ahmed TI, Hemeda NF, Ahmed NA, Mansour DF. LncRNAs, MALAT1 and lnc-DC as potential biomarkers for multiple sclerosis diagnosis. Biosci Rep 2019; 39:BSR20181335. [PMID: 30514825 PMCID: PMC6331681 DOI: 10.1042/bsr20181335] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 11/21/2018] [Accepted: 11/23/2018] [Indexed: 12/27/2022] Open
Abstract
Long non-coding RNAs (lncRNAs) play an important role in gene regulation and show greater tissue specificity and complexity of biological functions. There is on-going research in their contribution in autoimmune diseases like multiple sclerosis (MS). Our study aimed at the evaluation of serum levels of lncRNAs, MALAT1 and lnc-DC in MS patients and the investigation of the association between these lncRNAs and the disease activity. Serum from 45 MS patients and 45 healthy controls was separated. MALAT1 and lnc-DC expression levels were assayed by qRT-PCR. MALAT1 and lnc-DC were significantly increased in MS patients (P=0.004 and P=0.006, respectively) in comparison with controls. There was a significant increase in expression of MALAT1 in secondary progressive MS (SPMS) subgroup compared with controls (P<0.0001); however, significant elevation of lnc-DC was demonstrated in relapsing remitting MS (RRMS) subtype (P=0.003) compared with normal controls. A positive association between the expression levels of MALAT1 and lnc-DC (r = 0.513, P < 0.0001) in MS patients was detected. Moreover, positive correlation was observed between MALAT1and lnc-DC in RRMS (r = 0.569, P = 0.001). Serum levels of MALAT1 and lnc-DC may serve as potential novel molecular biomarkers for MS diagnosis and may provide a new direction for its treatment.
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MESH Headings
- Adult
- Biomarkers/blood
- Case-Control Studies
- Female
- Humans
- Male
- Multiple Sclerosis, Chronic Progressive/blood
- Multiple Sclerosis, Chronic Progressive/diagnosis
- Multiple Sclerosis, Chronic Progressive/genetics
- Multiple Sclerosis, Chronic Progressive/pathology
- Multiple Sclerosis, Relapsing-Remitting/blood
- Multiple Sclerosis, Relapsing-Remitting/diagnosis
- Multiple Sclerosis, Relapsing-Remitting/genetics
- Multiple Sclerosis, Relapsing-Remitting/pathology
- RNA, Long Noncoding/blood
- RNA, Long Noncoding/genetics
- Severity of Illness Index
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Affiliation(s)
- Olfat G Shaker
- Department of Medical Biochemistry and Molecular Biology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Rania H Mahmoud
- Department of Medical Biochemistry and Molecular Biology, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Omayma O Abdelaleem
- Department of Medical Biochemistry and Molecular Biology, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Enas G Ibrahem
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Abdelrahmaan A Mohamed
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Othman M Zaki
- Department of Clinical pathology, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Noha K Abdelghaffar
- Department of Clinical pathology, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Tarek I Ahmed
- Department of Internal medicine, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Nada F Hemeda
- Department of Genetics, Faculty of Agriculture, Fayoum University, Fayoum, Egypt
| | - Naglaa A Ahmed
- Department of Physiology, Faculty of Medicine, Zagazig University, Zagazig, Sharkea, Egypt
| | - Dina F Mansour
- Department of Neurology, Faculty of Medicine, Minia University, Minia, Egypt
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Napier J, Rose L, Adeoye O, Hooker E, Walsh KB. Modulating acute neuroinflammation in intracerebral hemorrhage: the potential promise of currently approved medications for multiple sclerosis. Immunopharmacol Immunotoxicol 2019; 41:7-15. [PMID: 30702002 DOI: 10.1080/08923973.2019.1566361] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The secondary inflammatory injury following intracerebral hemorrhage (ICH) results in increased morbidity and mortality. White blood cells have been implicated as critical mediators of this inflammatory injury. Currently, no medications have been clinically proven to ameliorate or beneficially modulate inflammation, or to improve outcomes by any mechanism, following ICH. However, other neuroinflammatory conditions, such as multiple sclerosis, have approved pharmacologic therapies that modulate the inflammatory response and minimize the damage caused by inflammatory cells. Thus, there is substantial interest in existing therapies for neuroinflammation and their potential applicability to other acute neurological diseases such as ICH. In this review, we examined the mechanism of action of twelve currently approved medications for multiple sclerosis: alemtuzumab, daclizumab, dimethyl fumarate, fingolimod, glatiramer acetate, interferon beta-1a, interferon beta-1b, mitoxantrone, natalizumab, ocrelizumab, rituximab, teriflunomide. We analyzed the existing literature pertaining to the effects of these medications on various leukocytes and also with emphasis on mechanisms of action during the acute period following initiation of therapy. As a result, we provide a valuable summary of the current body of knowledge regarding these therapies and evidence that supports or refutes their likely promise for treating neuroinflammation following ICH.
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Affiliation(s)
- Jarred Napier
- a College of Medicine , University of Cincinnati , Cincinnati , OH , USA
| | - Lucas Rose
- a College of Medicine , University of Cincinnati , Cincinnati , OH , USA
| | - Opeolu Adeoye
- b Department of Emergency Medicine , University of Cincinnati , Cincinnati , OH , USA.,c Gardner Neuroscience Institute , University of Cincinnati , Cincinnati , OH , USA
| | - Edmond Hooker
- b Department of Emergency Medicine , University of Cincinnati , Cincinnati , OH , USA
| | - Kyle B Walsh
- b Department of Emergency Medicine , University of Cincinnati , Cincinnati , OH , USA.,c Gardner Neuroscience Institute , University of Cincinnati , Cincinnati , OH , USA
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Fox EJ, Buckle GJ, Singer B, Singh V, Boster A. Lymphopenia and DMTs for relapsing forms of MS: Considerations for the treating neurologist. Neurol Clin Pract 2019; 9:53-63. [PMID: 30859008 PMCID: PMC6382377 DOI: 10.1212/cpj.0000000000000567] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose of review To provide neurologists with an update on the proposed mechanisms of action (MOAs) of disease-modifying therapies (DMTs) for the treatment of relapsing MS, and their effect on peripheral blood leukocytes, in order to inform treatment decisions. Recent findings DMTs have vastly differing MOAs, including effects on peripheral blood leukocyte counts, particularly lymphocytes. The clinical implications of changes in lymphocyte counts need to be understood in the context of the underlying MOAs of each respective DMT, with treatment tailored to individual patient needs. Summary DMTs can alter lymphocyte counts, subsets, activation, and distribution, and thus can influence immune surveillance. Serial monitoring of total leukocytes and absolute lymphocyte counts (ALCs) is advisable in patients receiving DMTs. ALCs should be interpreted regarding expected immunologic changes and individual patient characteristics. Any decision to switch DMTs should consider these factors, along with drug efficacy, safety, and effect on quality of life.
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Affiliation(s)
- Edward J Fox
- Multiple Sclerosis Clinic of Central Texas (EJF), Central Texas Neurology Consultants, Round Rock, TX; MS Institute at Shepherd Center (GJB), Atlanta, GA; The MS Center for Innovations in Care (BS), Missouri Baptist Medical Center, St Louis, MO; Indicia Medical Ltd. (VS), Part of the Fishawack Group of Companies, Hyderabad, India; and OhioHealth Multiple Sclerosis Center (AB), Riverside Methodist Hospital, Columbus, OH
| | - Guy J Buckle
- Multiple Sclerosis Clinic of Central Texas (EJF), Central Texas Neurology Consultants, Round Rock, TX; MS Institute at Shepherd Center (GJB), Atlanta, GA; The MS Center for Innovations in Care (BS), Missouri Baptist Medical Center, St Louis, MO; Indicia Medical Ltd. (VS), Part of the Fishawack Group of Companies, Hyderabad, India; and OhioHealth Multiple Sclerosis Center (AB), Riverside Methodist Hospital, Columbus, OH
| | - Barry Singer
- Multiple Sclerosis Clinic of Central Texas (EJF), Central Texas Neurology Consultants, Round Rock, TX; MS Institute at Shepherd Center (GJB), Atlanta, GA; The MS Center for Innovations in Care (BS), Missouri Baptist Medical Center, St Louis, MO; Indicia Medical Ltd. (VS), Part of the Fishawack Group of Companies, Hyderabad, India; and OhioHealth Multiple Sclerosis Center (AB), Riverside Methodist Hospital, Columbus, OH
| | - Vibhuti Singh
- Multiple Sclerosis Clinic of Central Texas (EJF), Central Texas Neurology Consultants, Round Rock, TX; MS Institute at Shepherd Center (GJB), Atlanta, GA; The MS Center for Innovations in Care (BS), Missouri Baptist Medical Center, St Louis, MO; Indicia Medical Ltd. (VS), Part of the Fishawack Group of Companies, Hyderabad, India; and OhioHealth Multiple Sclerosis Center (AB), Riverside Methodist Hospital, Columbus, OH
| | - Aaron Boster
- Multiple Sclerosis Clinic of Central Texas (EJF), Central Texas Neurology Consultants, Round Rock, TX; MS Institute at Shepherd Center (GJB), Atlanta, GA; The MS Center for Innovations in Care (BS), Missouri Baptist Medical Center, St Louis, MO; Indicia Medical Ltd. (VS), Part of the Fishawack Group of Companies, Hyderabad, India; and OhioHealth Multiple Sclerosis Center (AB), Riverside Methodist Hospital, Columbus, OH
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General Principles of Immunotherapy in Neurological Diseases. CONTEMPORARY CLINICAL NEUROSCIENCE 2019. [DOI: 10.1007/978-3-030-19515-1_12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Regulatory B and T lymphocytes in multiple sclerosis: friends or foes? AUTOIMMUNITY HIGHLIGHTS 2018; 9:9. [PMID: 30415321 PMCID: PMC6230324 DOI: 10.1007/s13317-018-0109-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 10/17/2018] [Indexed: 12/12/2022]
Abstract
Current clinical experience with immunomodulatory agents and monoclonal antibodies in principle has established the benefit of depleting lymphocytic populations in relapsing–remitting multiple sclerosis (RRMS). B and T cells may exert multiple pro-inflammatory actions, but also possess regulatory functions making their role in RRMS pathogenesis much more complex. There is no clear correlation of Tregs and Bregs with clinical features of the disease. Herein, we discuss the emerging data on regulatory T and B cell subset distributions in MS and their roles in the pathophysiology of MS and its murine model, experimental autoimmune encephalomyelitis (EAE). In addition, we summarize the immunomodulatory properties of certain MS therapeutic agents through their effect on such regulatory cell subsets and their relevance to clinical outcomes.
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Restoration of regulatory B cell deficiency following alemtuzumab therapy in patients with relapsing multiple sclerosis. J Neuroinflammation 2018; 15:300. [PMID: 30373595 PMCID: PMC6206644 DOI: 10.1186/s12974-018-1334-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 10/15/2018] [Indexed: 01/04/2023] Open
Abstract
Background Regulatory B cells (Bregs), which protect from autoimmunity, are deficient in multiple sclerosis (MS). Novel regulatory B cell subsets CD19+CD24hiCD38hi cells and CD19+PD-L1hi cells, with disparate regulatory mechanisms have been defined. Alemtuzumab provides a long-lasting suppression of disease activity in MS. In contrast to its documented efficacy, alemtuzumab’s mechanism of action is not fully understood and information about the composition of repopulating B cell pool is scarce. Aim To characterize repopulated B cell subsets and elucidate alemtuzumab’s mechanism of action in B cell perspective. Methods The frequency and the absolute number of Bregs were studied in peripheral blood mononuclear cells (PBMC) of 37 MS patients and 11 healthy controls (HC). Longitudinal analysis of the frequency and the absolute number of Bregs in PBMC of 11 MS patients was evaluated, before and at 6, 9, and 12 months post alemtuzumab. Results We found deficiency of CD19+CD24hiCD38hi cells during relapse compared to remission and HC (relapse vs remission: p = 0.0006, relapse vs HC: p = 0.0004). CD19+PD-L1hi cells were deficient during relapse than remission and HC (relapse vs remission: p = 0.0113, relapse vs HC: p = 0.0007). Following alemtuzumab, the distribution of B cells shifts towards naïve phenotype and Breg deficiency is restored. The frequency of CD19+CD24hiCD38hi cells was significantly increased at 6 M and 9 M compared to 0 M (6 M vs 0 M: p = 0.0004, 9 M vs 0 M: p = 0.0079). At 9 M, the frequency of CD19+CD24hiCD38hi cells started to decrease and by 12 M the frequency was reduced compared to 6 M, although it was significantly higher than baseline level (12 M vs 0 M: p = 0.0257). The absolute number was significantly increased at 6 M and 9 M post-alemtuzumab (6 M vs 0 M: p = 0.0063, 9 M vs 0 M: p = 0.02). The frequency of CD19+PD-L1hi cells significantly increased until 12 M (6 M vs 0 M: p = 0.0004, 12 M vs 0 M: p = 0.0036). The frequency of CD19+PD-L1hi cells at 12 M was significantly higher than 9 M (p = 0.0311). We further pinpoint that CD19+CD24hiCD38hi cells were deficient at severe relapses following alemtuzumab infusion and restored during recovery. Conclusions Our results highlight the preferential reconstitution of Bregs as a possible mechanism of action of alemtuzumab and CD19+CD24hiCD38hi cells as a potential biomarker for disease activity.
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76
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Graf J, Ringelstein M, Lepka K, Schaller J, Quack H, Hartung HP, Aktas O, Albrecht P. Acute sarcoidosis in a multiple sclerosis patient after alemtuzumab treatment. Mult Scler 2018; 24:1776-1778. [DOI: 10.1177/1352458518771276] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Understanding the long-term effect of alemtuzumab on the immune system of multiple sclerosis (MS) patients is crucial. Objective: To report a case of acute sarcoidosis (Löfgren’s syndrome) in a relapsing-remitting MS patient, 1.5 years after the second course of alemtuzumab treatment. Case report: Sarcoidosis was confirmed dermatohistologically, radiologically, and serologically. Analysis of the lymphocyte subpopulations showed a persistent effect of alemtuzumab treatment (CD4/CD8 ratio increased, absolute lymphocyte count of CD19-positive cells increased while CD3/4/8-positive cells were decreased). Conclusion: Our case highlights the profound effect of alemtuzumab on the immune system and its possible risk for autoimmune complications.
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Affiliation(s)
- Jonas Graf
- Department of Neurology, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Marius Ringelstein
- Department of Neurology, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Klaudia Lepka
- Department of Neurology, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | | | - Helmut Quack
- Gemeinschaftspraxis für Radiologie und Nuklearmedizin am Bethesda Krankenhaus, Mönchengladbach, Germany
| | - Hans-Peter Hartung
- Department of Neurology, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Orhan Aktas
- Department of Neurology, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Philipp Albrecht
- Department of Neurology, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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77
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Wray S, Havrdova E, Snydman DR, Arnold DL, Cohen JA, Coles AJ, Hartung HP, Selmaj KW, Weiner HL, Daizadeh N, Margolin DH, Chirieac MC, Compston DAS. Infection risk with alemtuzumab decreases over time: pooled analysis of 6-year data from the CAMMS223, CARE-MS I, and CARE-MS II studies and the CAMMS03409 extension study. Mult Scler 2018; 25:1605-1617. [PMID: 30289355 PMCID: PMC6764150 DOI: 10.1177/1352458518796675] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background: Reduced MS disease activity with alemtuzumab versus subcutaneous interferon
beta-1a (SC IFNB-1a) in core phase 2/3 studies was accompanied by increased
incidence of infections that were mainly nonserious and responsive to
treatment. Alemtuzumab efficacy was durable over 6 years. Objective: To evaluate infections over 6 years in alemtuzumab-treated patients. Methods: Three randomized trials (CAMMS223, Comparison of Alemtuzumab and Rebif
Efficacy in Multiple Sclerosis (CARE-MS) I, and CARE-MS II) compared two
courses of alemtuzumab 12 mg with SC IFNB-1a 44 μg in patients with active
relapsing-remitting MS. An extension study (CAMMS03409) provided further
evaluation and as-needed alemtuzumab retreatment. Results: Infections occurred more frequently with alemtuzumab 12 mg than SC IFNB-1a
during Years 1 (58.7% vs 41.3%) and 2 (52.6% vs 37.7%), but declined for
alemtuzumab-treated patients in Years 3 (46.6%), 4 (42.8%), 5 (40.9%), and 6
(38.1%). Serious infections were uncommon (1.0%–1.9% per year). Infections
were predominantly (>95%) mild to moderate and included upper respiratory
tract infections, urinary tract infections, and mucocutaneous herpetic
infections. Prophylactic acyclovir reduced herpetic infections. Lymphocyte
counts after alemtuzumab therapy did not predict infection risk. Conclusion: Infections with alemtuzumab were mostly mild to moderate and decreased over
time, consistent with preservation of components of protective immunity.
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Affiliation(s)
- Sibyl Wray
- Hope Neurology MS Center, Knoxville, TN, USA
| | - Eva Havrdova
- MS Center, Department of Neurology, First Medical Faculty, Charles University, Prague, Czech Republic
| | - David R Snydman
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, MA, USA
| | - Douglas L Arnold
- Montréal Neurological Institute, McGill University, Montréal, QC, Canada
| | - Jeffrey A Cohen
- Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Alasdair J Coles
- University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | | | - Howard L Weiner
- The Ann Romney Center for Neurologic Diseases, Brigham and Women's Hospital, Boston, MA, USA
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78
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Li Z, Richards S, Surks HK, Jacobs A, Panzara MA. Clinical pharmacology of alemtuzumab, an anti-CD52 immunomodulator, in multiple sclerosis. Clin Exp Immunol 2018; 194:295-314. [PMID: 30144037 PMCID: PMC6231011 DOI: 10.1111/cei.13208] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2018] [Indexed: 01/05/2023] Open
Abstract
Alemtuzumab, a humanized anti‐CD52 monoclonal antibody, is approved for treatment of relapsing multiple sclerosis (MS). In the Phase II/III trials, patients received 12 or 24 mg/day of alemtuzumab in two treatment courses (5 days for course 1 and 3 days for course 2), 12 months apart. Serum concentrations of alemtuzumab peaked on the last day of dosing in each course and mostly fell below the limit of quantitation by day 30. Alemtuzumab rapidly depleted circulating T and B lymphocytes, with the lowest observed values occurring within days. Lymphocytes repopulated over time, with B cell recovery usually complete within 6 months. T lymphocytes recovered more slowly and generally did not return to baseline by 12 months post‐treatment. Approximately 40 and 80% of patients had total lymphocyte counts, reaching the lower limit of normal by 6 and 12 months after each course, respectively. The clearance of alemtuzumab is dependent on circulating lymphocyte count. A majority of treated patients tested positive for anti‐alemtuzumab antibodies, including inhibitory antibodies, during the 2‐year studies, and a higher proportion of patients tested positive in course 2 than in course 1. The presence of anti‐alemtuzumab antibody appeared to be associated with slower clearance of alemtuzumab from the circulation but had no impact on the pharmacodynamics. No effects of age, race or gender on the pharmacokinetics or pharmacodynamics were observed. Together, the pharmacokinetics, pharmacodynamics and immunogenicity results support the continued development and use of alemtuzumab for the treatment of MS, and probably explain its sustained effects beyond the dosing interval.
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Affiliation(s)
- Z Li
- Sanofi, Cambridge, MA, USA
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79
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IL-11 antagonist suppresses Th17 cell-mediated neuroinflammation and demyelination in a mouse model of relapsing-remitting multiple sclerosis. Clin Immunol 2018; 197:45-53. [PMID: 30149119 DOI: 10.1016/j.clim.2018.08.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 07/12/2018] [Accepted: 08/15/2018] [Indexed: 12/19/2022]
Abstract
IL-11 induced differentiation and expansion of Th17 cells in patients with early relapsing-remitting multiple sclerosis (RRMS). In mice with relapsing-remitting experimental autoimmune encephalomyelitis (RREAE), IL-11 exacerbated disease, induced demyelination in the central nervous system (CNS), increased the percentage of IL-17A+CD4+ Th17 cells in the CNS in the early acute phase, and up-regulated serum IL-17A levels and the percentage of IL-17A+CD4+ Th17 cells in lymph nodes, and IFN-γ+CD4+ T cells in spinal cord in the RR phase. IL-11 antagonist suppressed RREAE disease activities, inhibited IL-17A+CD4+ cell infiltration and demyelination in the CNS, and decreased the percentage of IL-17A+CD4+ T cells in peripheral blood mononuclear cells and ICAM1+CD4+ T cells in brain and SC. Diffusion Tensor Imaging indicated that IL-11 antagonist inhibited demyelination in several brain regions. We conclude that by suppressing Th17 cell-mediated neuroinflammation and demyelination, IL-11 antagonist can be further studied as a potential selective and early therapy for RRMS.
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80
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Simon M, Ipek R, Homola GA, Rovituso DM, Schampel A, Kleinschnitz C, Kuerten S. Anti-CD52 antibody treatment depletes B cell aggregates in the central nervous system in a mouse model of multiple sclerosis. J Neuroinflammation 2018; 15:225. [PMID: 30098594 PMCID: PMC6086993 DOI: 10.1186/s12974-018-1263-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 07/30/2018] [Indexed: 02/07/2023] Open
Abstract
Background Multiple sclerosis (MS) is a chronic autoimmune disease of the central nervous system (CNS) for which several new treatment options were recently introduced. Among them is the monoclonal anti-CD52 antibody alemtuzumab that depletes mainly B cells and T cells in the immune periphery. Considering the ongoing controversy about the involvement of B cells and in particular the formation of B cell aggregates in the brains of progressive MS patients, an in-depth understanding of the effects of anti-CD52 antibody treatment on the B cell compartment in the CNS itself is desirable. Methods We used myelin basic protein (MBP)-proteolipid protein (PLP)-induced experimental autoimmune encephalomyelitis (EAE) in C57BL/6 (B6) mice as B cell-dependent model of MS. Mice were treated intraperitoneally either at the peak of EAE or at 60 days after onset with 200 μg murine anti-CD52 vs. IgG2a isotype control antibody for five consecutive days. Disease was subsequently monitored for 10 days. The antigen-specific B cell/antibody response was measured by ELISPOT and ELISA. Effects on CNS infiltration and B cell aggregation were determined by immunohistochemistry. Neurodegeneration was evaluated by Luxol Fast Blue, SMI-32, and Olig2/APC staining as well as by electron microscopy and phosphorylated heavy neurofilament serum ELISA. Results Treatment with anti-CD52 antibody attenuated EAE only when administered at the peak of disease. While there was no effect on the production of MP4-specific IgG, the treatment almost completely depleted CNS infiltrates and B cell aggregates even when given as late as 60 days after onset. On the ultrastructural level, we observed significantly less axonal damage in the spinal cord and cerebellum in chronic EAE after anti-CD52 treatment. Conclusion Anti-CD52 treatment abrogated B cell infiltration and disrupted existing B cell aggregates in the CNS. Electronic supplementary material The online version of this article (10.1186/s12974-018-1263-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Micha Simon
- Department of Anatomy and Cell Biology, University of Würzburg, Würzburg, Germany
| | - Rojda Ipek
- Department of Anatomy and Cell Biology, University of Würzburg, Würzburg, Germany
| | - György A Homola
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Würzburg, Würzburg, Germany
| | - Damiano M Rovituso
- Department of Anatomy and Cell Biology, University of Würzburg, Würzburg, Germany
| | - Andrea Schampel
- Department of Anatomy and Cell Biology, University of Würzburg, Würzburg, Germany
| | - Christoph Kleinschnitz
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany.,Department of Neurology, University Hospital Essen, Essen, Germany
| | - Stefanie Kuerten
- Department of Anatomy and Cell Biology, University of Würzburg, Würzburg, Germany. .,Institute of Anatomy and Cell Biology, Friedrich Alexander University Erlangen-Nürnberg (FAU), Krankenhausstr. 9, 91054, Erlangen, Bavaria, Germany.
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81
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Lohmann L, Janoschka C, Schulte-Mecklenbeck A, Klinsing S, Kirstein L, Hanning U, Wirth T, Schneider-Hohendorf T, Schwab N, Gross CC, Eveslage M, Meuth SG, Wiendl H, Klotz L. Immune Cell Profiling During Switching from Natalizumab to Fingolimod Reveals Differential Effects on Systemic Immune-Regulatory Networks and on Trafficking of Non-T Cell Populations into the Cerebrospinal Fluid-Results from the ToFingo Successor Study. Front Immunol 2018; 9:1560. [PMID: 30050529 PMCID: PMC6052886 DOI: 10.3389/fimmu.2018.01560] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 06/25/2018] [Indexed: 11/13/2022] Open
Abstract
Leukocyte sequestration is an established therapeutic concept in multiple sclerosis (MS) as represented by the trafficking drugs natalizumab (NAT) and fingolimod (FTY). However, the precise consequences of targeting immune cell trafficking for immunoregulatory network functions are only incompletely understood. In the present study, we performed an in-depth longitudinal characterization of functional and phenotypic immune signatures in peripheral blood (PB) and cerebrospinal fluid (CSF) of 15 MS patients during switching from long-term NAT to FTY treatment after a defined 8-week washout period within a clinical trial (ToFingo successor study; ClinicalTrials.gov: NCT02325440). Unbiased visualization and analysis of high-dimensional single cell flow-cytometry data revealed that switching resulted in a profound alteration of more than 80% of investigated innate and adaptive immune cell subpopulations in the PB, revealing an unexpectedly broad effect of trafficking drugs on peripheral immune signatures. Longitudinal CSF analysis demonstrated that NAT and FTY both reduced T cell subset counts and proportions in the CSF of MS patients with equal potency; NAT however was superior with regard to sequestering non-T cell populations out of the CSF, including B cells, natural killer cells and inflammatory monocytes, suggesting that disease exacerbation in the context of switching might be driven by non-T cell populations. Finally, correlation of our immunological data with signs of disease exacerbation in this small cohort suggested that both (i) CD49d expression levels under NAT at the time of treatment cessation and (ii) swiftness of FTY-mediated effects on immune cell subsets in the PB together may predict stability during switching later on.
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Affiliation(s)
- Lisa Lohmann
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Muenster, Germany
| | - Claudia Janoschka
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Muenster, Germany
| | - Andreas Schulte-Mecklenbeck
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Muenster, Germany
| | - Svenja Klinsing
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Muenster, Germany
| | - Lucienne Kirstein
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Muenster, Germany
| | - Uta Hanning
- Department of Radiology, University Hospital Münster, Muenster, Germany
| | - Timo Wirth
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Muenster, Germany
| | - Tilman Schneider-Hohendorf
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Muenster, Germany
| | - Nicholas Schwab
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Muenster, Germany
| | - Catharina C Gross
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Muenster, Germany
| | - Maria Eveslage
- Institute of Biostatistics and Clinical Research, University of Münster, Muenster, Germany
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Muenster, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Muenster, Germany
| | - Luisa Klotz
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Muenster, Germany
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82
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Li R, Patterson KR, Bar-Or A. Reassessing B cell contributions in multiple sclerosis. Nat Immunol 2018; 19:696-707. [PMID: 29925992 DOI: 10.1038/s41590-018-0135-x] [Citation(s) in RCA: 253] [Impact Index Per Article: 42.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 05/09/2018] [Indexed: 02/06/2023]
Abstract
There is growing recognition that B cell contributions to normal immune responses extend well beyond their potential to become antibody-producing cells, including roles at the innate-adaptive interface and their potential to modulate the responses of other immune cells such as T cells and myeloid cells. These B cell functions can have both pathogenic and protective effects in the context of central nervous system (CNS) inflammation. Here, we review recent advances in the field of multiple sclerosis (MS), which has traditionally been viewed as primarily a T cell-mediated disease, and we consider antibody-dependent and, particularly, emerging antibody-independent functions of B cells that may be relevant in both the peripheral and CNS disease compartments.
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Affiliation(s)
- Rui Li
- Center for Neuroinflammation and Experimental Therapeutics (CNET) and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kristina R Patterson
- Center for Neuroinflammation and Experimental Therapeutics (CNET) and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Amit Bar-Or
- Center for Neuroinflammation and Experimental Therapeutics (CNET) and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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83
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Whiteside D, Barth S, Datta A, Trip SA. Pneumonitis secondary to alemtuzumab in a patient with multiple sclerosis - A non-infectious cause of breathlessness. Mult Scler Relat Disord 2018; 22:139-140. [PMID: 29684788 DOI: 10.1016/j.msard.2018.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/05/2018] [Accepted: 04/02/2018] [Indexed: 01/26/2023]
Abstract
The most common adverse events associated with the monoclonal antibody alemtuzumab are infusion associated reactions and secondary autoimmune disease. Respiratory complications are unusual following treatment with alemtuzumab, but can be precipitated by an infectious cause. We describe a case of a sub-acute steroid responsive non-infectious pneumonitis affecting a 51 year old woman, who presented one month after initiation of therapy for multiple sclerosis with alemtuzumab.
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Affiliation(s)
- D Whiteside
- Department of Neurology, Northwick Park Hospital, London, UK
| | - S Barth
- Department of Respiratory Medicine, Northwick Park Hospital, London, UK
| | - A Datta
- Department of Respiratory Medicine, Northwick Park Hospital, London, UK
| | - S A Trip
- Department of Neurology, Northwick Park Hospital, London, UK; Queen Square MS Centre, National Hospital for Neurology & Neurosurgery, London, UK.
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84
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Massey JC, Sutton IJ, Ma DDF, Moore JJ. Regenerating Immunotolerance in Multiple Sclerosis with Autologous Hematopoietic Stem Cell Transplant. Front Immunol 2018; 9:410. [PMID: 29593711 PMCID: PMC5857574 DOI: 10.3389/fimmu.2018.00410] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 02/14/2018] [Indexed: 12/20/2022] Open
Abstract
Multiple sclerosis (MS) is an inflammatory disorder of the central nervous system where evidence implicates an aberrant adaptive immune response in the accrual of neurological disability. The inflammatory phase of the disease responds to immunomodulation to varying degrees of efficacy; however, no therapy has been proven to arrest progression of disability. Recently, more intensive therapies, including immunoablation with autologous hematopoietic stem cell transplantation (AHSCT), have been offered as a treatment option to retard inflammatory disease, prior to patients becoming irreversibly disabled. Empirical clinical observations support the notion that the immune reconstitution (IR) that occurs following AHSCT is associated with a sustained therapeutic benefit; however, neither the pathogenesis of MS nor the mechanism by which AHSCT results in a therapeutic benefit has been clearly delineated. Although the antigenic target of the aberrant immune response in MS is not defined, accumulated data suggest that IR following AHSCT results in an immunotolerant state through deletion of pathogenic clones by a combination of direct ablation and induction of a lymphopenic state driving replicative senescence and clonal attrition. Restoration of immunoregulation is evidenced by changes in regulatory T cell populations following AHSCT and normalization of genetic signatures of immune homeostasis. Furthermore, some evidence exists that AHSCT may induce a rebooting of thymic function and regeneration of a diversified naïve T cell repertoire equipped to appropriately modulate the immune system in response to future antigenic challenge. In this review, we discuss the immunological mechanisms of IR therapies, focusing on AHSCT, as a means of recalibrating the dysfunctional immune response observed in MS.
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Affiliation(s)
- Jennifer C Massey
- Haematology and Bone Marrow Transplantation, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia.,Neurology, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia.,Centre for Applied Medical Research, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Ian J Sutton
- Neurology, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - David D F Ma
- Haematology and Bone Marrow Transplantation, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia.,Centre for Applied Medical Research, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - John J Moore
- Haematology and Bone Marrow Transplantation, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia.,Centre for Applied Medical Research, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
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85
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Devonshire V, Phillips R, Wass H, Da Roza G, Senior P. Monitoring and management of autoimmunity in multiple sclerosis patients treated with alemtuzumab: practical recommendations. J Neurol 2018. [PMID: 29525836 PMCID: PMC6182701 DOI: 10.1007/s00415-018-8822-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Alemtuzumab is a humanized anti-CD52 monoclonal antibody approved in more than 65 countries for the treatment of relapsing–remitting multiple sclerosis (RRMS). Compared with subcutaneous interferon-beta-1a, alemtuzumab significantly reduced clinical disease activity and the rate of brain volume loss, and improved disability outcomes in patients with active RRMS who were either treatment naive (CARE-MS I study) or who had an inadequate response (≥ 1 relapse after ≥ 6 months of treatment) to prior therapy (CARE-MS II study). Adverse events (AEs) associated with alemtuzumab include infusion-associated reactions, infections, and autoimmunity. The most commonly reported autoimmune AEs observed with alemtuzumab involve the thyroid gland, followed by immune thrombocytopenia and nephropathies. A monitoring program was designed and implemented to facilitate the early detection of autoimmune events to ensure timely and adequate management. The aim of this article is to provide physicians (including neurologists, general practitioners, endocrinologists, hematologists, and nephrologists who may be less familiar with the symptoms and treatment of autoimmune events), with practical real-world recommendations for the monitoring and management of autoimmunity associated with alemtuzumab treatment.
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Affiliation(s)
- Virginia Devonshire
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada. .,Djavad Mowafaghian Centre for Brain Health, Vancouver, BC, Canada.
| | - Richard Phillips
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Gerald Da Roza
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Peter Senior
- Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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86
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Barbour M, Wood R, Hridi SU, Wilson C, McKay G, Bushell TJ, Jiang HR. The therapeutic effect of anti-CD52 treatment in murine experimental autoimmune encephalomyelitis is associated with altered IL-33 and ST2 expression levels. J Neuroimmunol 2018. [PMID: 29526407 DOI: 10.1016/j.jneuroim.2018.02.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Experimental autoimmune encephalomyelitis (EAE) mice were administered with murine anti-CD52 antibody to investigate its therapeutic effect and whether the treatment modulates IL-33 and ST2 expression. EAE severity and central nervous system (CNS) inflammation were reduced following the treatment, which was accompanied by peripheral T and B lymphocyte depletion and reduced production of various cytokines including IL-33, while sST2 was increased. In spinal cords of EAE mice, while the number of IL-33+ cells remained unchanged, the extracellular level of IL-33 protein was significantly reduced in anti-CD52 antibody treated mice compared with controls. Furthermore the number of ST2+ cells in the spinal cord of treated EAE mice was downregulated due to decreased inflammation and immune cell infiltration in the CNS. These results suggest that treatment with anti-CD52 antibody differentially alters expression of IL-33 and ST2, both systemically and within the CNS, which may indicate IL-33/ST2 axis is involved in the action of the antibody in inhibiting EAE.
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Affiliation(s)
- Mark Barbour
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, 161 Cathedral Street, Glasgow G4 0RE, UK
| | - Rachel Wood
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, 161 Cathedral Street, Glasgow G4 0RE, UK
| | - Shehla U Hridi
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, 161 Cathedral Street, Glasgow G4 0RE, UK
| | - Chelsey Wilson
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, 161 Cathedral Street, Glasgow G4 0RE, UK
| | - Grant McKay
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, 161 Cathedral Street, Glasgow G4 0RE, UK
| | - Trevor J Bushell
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, 161 Cathedral Street, Glasgow G4 0RE, UK
| | - Hui-Rong Jiang
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, 161 Cathedral Street, Glasgow G4 0RE, UK.
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87
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van der Zwan M, Baan CC, van Gelder T, Hesselink DA. Review of the Clinical Pharmacokinetics and Pharmacodynamics of Alemtuzumab and Its Use in Kidney Transplantation. Clin Pharmacokinet 2018; 57:191-207. [PMID: 28669130 PMCID: PMC5784003 DOI: 10.1007/s40262-017-0573-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Alemtuzumab is a humanized monoclonal antibody against CD52 and causes depletion of T and B lymphocytes, monocytes, and NK cells. Alemtuzumab is registered for the treatment of multiple sclerosis (MS) and is also used in chronic lymphocytic leukemia (CLL). Alemtuzumab is used off-label in kidney transplantation as induction and anti-rejection therapy. The objective of this review is to present a review of the pharmacokinetics, pharmacodynamics, and use of alemtuzumab in kidney transplantation. A systematic literature search was conducted using Ovid Medline, Embase, and Cochrane Central Register of controlled trials. No pharmacokinetic or dose-finding studies of alemtuzumab have been performed in kidney transplantation. Although such studies were conducted in patients with CLL and MS, these findings cannot be directly extrapolated to transplant recipients, because CLL patients have a much higher load of CD52-positive cells and, therefore, target-mediated clearance will differ between these two indications. Alemtuzumab used as induction therapy in kidney transplantation results in a lower incidence of acute rejection compared to basiliximab therapy and comparable results as compared with rabbit anti-thymocyte globulin (rATG). Alemtuzumab used as anti-rejection therapy results in a comparable graft survival rate compared with rATG, although infusion-related side effects appear to be less. There is a need for pharmacokinetic and dose-finding studies of alemtuzumab in kidney transplant recipients to establish the optimal balance between efficacy and toxicity. Furthermore, randomized controlled trials with sufficient follow-up are necessary to provide further evidence for the treatment of severe kidney transplant rejection.
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Affiliation(s)
- Marieke van der Zwan
- Division of Nephrology and Kidney Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Room NA523, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Carla C Baan
- Division of Nephrology and Kidney Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Room NA523, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Teun van Gelder
- Division of Nephrology and Kidney Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Room NA523, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
- Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dennis A Hesselink
- Division of Nephrology and Kidney Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Room NA523, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
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88
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Havrdova E, Cohen JA, Horakova D, Kovarova I, Meluzinova E. Understanding the positive benefit:risk profile of alemtuzumab in relapsing multiple sclerosis: perspectives from the Alemtuzumab Clinical Development Program. Ther Clin Risk Manag 2017; 13:1423-1437. [PMID: 29081658 PMCID: PMC5652900 DOI: 10.2147/tcrm.s143509] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
The introduction of high-efficacy therapies for relapsing–remitting multiple sclerosis has driven re-evaluation of treatment goals and benefit:risk considerations in treatment choice. In the alemtuzumab Phase II and III clinical trials, patients treated with alemtuzumab 12 mg versus subcutaneous interferon beta-1a demonstrated significantly reduced annualized relapse rates and improved magnetic resonance imaging outcomes, and were significantly more likely to achieve no evidence of disease activity and reduction in brain volume loss. In two of the studies, alemtuzumab-treated patients had a significantly reduced risk of 6-month confirmed disease worsening, compared with subcutaneous interferon beta-1a. Benefits were maintained throughout 5 years, with a majority of patients receiving no alemtuzumab retreatment or other disease-modifying therapy. Trial results support alemtuzumab’s manageable, consistent safety profile in relapsing–remitting multiple sclerosis. Infusion-associated reactions, the most frequent adverse events (AEs), can be minimized by corticosteroid pretreatment, monitoring, and symptomatic management. Other AEs include infections and autoimmune events. Oral anti-herpes prophylaxis should be initiated on the first day of each alemtuzumab treatment course and continued according to local guidelines. Overall cancer risk was lower in the alemtuzumab clinical trials than in a reference population; however, continuing surveillance will determine if alemtuzumab may be associated with certain malignancies such as thyroid papillary carcinoma and melanoma, which are currently identified as potential risks. The post-approval risk management strategy includes a safety monitoring program. Autoimmune AEs (thyroid events, immune thrombocytopenia, nephropathies) can be detected in a timely manner with the monitoring program, which includes physician and patient education about the signs and symptoms, monthly renal and hematologic monitoring, and quarterly thyroid function monitoring for 48 months after the last alemtuzumab course. Education, vigilance by physicians and patients, and monthly laboratory monitoring are recommended to maintain alemtuzumab’s positive benefit:risk profile.
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Affiliation(s)
- Eva Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Jeffrey A Cohen
- Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Ivana Kovarova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Eva Meluzinova
- Department of Neurology, Second Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic
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89
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Roman C, Menning K. Treatment and disease management of multiple sclerosis patients: A review for nurse practitioners. J Am Assoc Nurse Pract 2017; 29:629-638. [PMID: 29029375 DOI: 10.1002/2327-6924.12514] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 07/31/2017] [Accepted: 08/01/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND PURPOSE This review discusses the role of the nurse practitioner (NP) in evaluating the clinical effects, potential side effects, and monitoring requirements for treatment options in multiple sclerosis (MS) and provides guidance on how to help patients understand these issues. METHODS A literature search was conducted on PubMed to identify publications on monitoring and disease management of MS patients. Additional resources included drug information web sites and package inserts. CONCLUSIONS NPs play an active role in the management of MS patients via effective monitoring and communication throughout the patient's treatment regimen and disease course. In the shared decision-making model of MS treatment, NPs ensure that patients understand the implications of their disease-modifying therapies (DMTs). As patients move through treatments during the course of their disease, the importance of this role increases, and it is critical that NPs follow the guidelines in each medication's product label and take into account any potential lingering effects of prior medications. IMPLICATIONS FOR PRACTICE It is critical for NPs to promote patient adherence, to ensure that patients understand treatment side effects and monitoring requirements, and to take sequencing and reversibility implications of DMTs into account when making clinical decisions.
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90
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Fernández Ó. Is there a change of paradigm towards more effective treatment early in the course of apparent high-risk MS? Mult Scler Relat Disord 2017; 17:75-83. [DOI: 10.1016/j.msard.2017.07.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 06/26/2017] [Accepted: 07/02/2017] [Indexed: 01/02/2023]
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91
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Baker D, Herrod SS, Alvarez-Gonzalez C, Giovannoni G, Schmierer K. Interpreting Lymphocyte Reconstitution Data From the Pivotal Phase 3 Trials of Alemtuzumab. JAMA Neurol 2017; 74:961-969. [PMID: 28604916 DOI: 10.1001/jamaneurol.2017.0676] [Citation(s) in RCA: 175] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance Alemtuzumab, a CD52-depleting monoclonal antibody, effectively inhibits relapsing multiple sclerosis (MS) but is associated with a high incidence of secondary B-cell autoimmunities that limit use. These effects may be avoided through control of B-cell hyperproliferation. Objective To investigate whether the data describing the effect of alemtuzumab on lymphocyte subsets collected during the phase 3 trial program reveal mechanisms explaining efficacy and the risk for secondary autoimmunity with treatment of MS. Design, Setting, and Participants Lymphocyte reconstitution data from regulatory submissions of the pivotal Comparison of Alemtuzumab and Rebif Efficacy in Multiple Sclerosis I and II (CARE-MS I and II) trials were obtained from the European Medicines Agency via Freedom of Information requests. Data used in this study were reported from June 22 to October 12, 2016. Main Outcomes and Measures Tabulated data from T- and B-lymphocyte subset analysis and antidrug antibody responses were extracted from the supplied documents. Results Alemtuzumab depleted CD4+ T cells by more than 95%, including regulatory cells (-80%) and CD8+ T cells (>80% depletion), which remained well below reference levels throughout the trials. However, although CD19+ B cells were initially also depleted (>85%), marked (180% increase) hyperrepopulation of immature B cells occurred with conversion to mature B cells over time. These lymphocyte kinetics were associated with rapid development of alemtuzumab-binding and -neutralizing antibodies and subsequent occurrence of secondary B-cell autoimmunity. Hyperrepopulation of B cells masked a marked, long-term depletion of CD19+ memory B cells that may underpin efficacy in MS. Conclusions and Relevance Although blockade of memory T and B cells may limit MS, rapid CD19+ B-cell subset repopulation in the absence of effective T-cell regulation has implications for the safety and efficacy of alemtuzumab. Controlling B-cell proliferation until T-cell regulation recovers may limit secondary autoimmunity, which does not occur with other B-cell-depleting agents.
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Affiliation(s)
- David Baker
- Centre for Neuroscience and Trauma, Blizard Institute, Queen Mary University of London, England
| | - Samuel S Herrod
- Centre for Neuroscience and Trauma, Blizard Institute, Queen Mary University of London, England
| | - Cesar Alvarez-Gonzalez
- Centre for Neuroscience and Trauma, Blizard Institute, Queen Mary University of London, England
| | - Gavin Giovannoni
- Centre for Neuroscience and Trauma, Blizard Institute, Queen Mary University of London, England.,Emergency Care and Acute Medicine, Clinical Academic Group Neuroscience, Barts Health NHS (National Health Service) Trust, The Royal London Hospital, London, England
| | - Klaus Schmierer
- Centre for Neuroscience and Trauma, Blizard Institute, Queen Mary University of London, England.,Emergency Care and Acute Medicine, Clinical Academic Group Neuroscience, Barts Health NHS (National Health Service) Trust, The Royal London Hospital, London, England
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92
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Abstract
Alemtuzumab is a humanised anti-CD52 monoclonal antibody approved for use in active, relapsing multiple sclerosis (MS). Administration results in a rapid depletion of circulating lymphocytes with a subsequent beneficial immune reconstitution. Early open-label experience and recent clinical trials have demonstrated a dramatic effect on relapse rates as well as a positive effect on radiological disease outcomes and disability measures. Despite a mechanism of action that results in profound lymphopaenia, opportunistic infections are rarely seen and no excess association with malignancy has been identified. However, acquired autoimmune disease (AID) is a common adverse event following treatment, necessitating rigorous monitoring in order to facilitate prompt detection and management. Despite this issue, a unique dosing schedule and durability of effect make alemtuzumab a welcome addition to currently available treatment options for MS.
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Affiliation(s)
- Mark D Willis
- Institute of Psychological Medicine and Clinical Neuroscience, University Hospital of Wales, Cardiff University, Heath Park, Cardiff, CF14 4XN, UK
| | - Neil P Robertson
- Institute of Psychological Medicine and Clinical Neuroscience, University Hospital of Wales, Cardiff University, Heath Park, Cardiff, CF14 4XN, UK.
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93
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Ziemssen T, Thomas K. Alemtuzumab in the long-term treatment of relapsing-remitting multiple sclerosis: an update on the clinical trial evidence and data from the real world. Ther Adv Neurol Disord 2017; 10:343-359. [PMID: 28966663 PMCID: PMC5607928 DOI: 10.1177/1756285617722706] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 06/23/2017] [Indexed: 12/12/2022] Open
Abstract
Alemtuzumab is a humanized monoclonal antibody approved for the treatment of relapsing-remitting multiple sclerosis (RRMS), given as two annual courses on five consecutive days at baseline and on three consecutive days 12 months later. Here we provide an update on the long-term efficacy and safety of alemtuzumab in RRMS, including real-world experience, and advances in our understanding of its mechanism of action. Recent data from the phase II/III extension study have demonstrated that alemtuzumab reduces relapse rates, disability worsening, and the rate of brain volume loss over the long term, with many patients achieving no evidence of disease activity. In high proportions of patients, preexisting disability remained stable or improved. Alemtuzumab is associated with a consistent safety profile over the long term, with no new safety signals emerging and the overall annual incidence of reported adverse events decreasing after the first year on treatment. Acyclovir prophylaxis reduces herpetic infections, and monitoring has been shown to mitigate the risk of autoimmune adverse events, allowing early detection and overall effective management. Data from clinical practice and ongoing observational studies are providing additional information on the real-world use of alemtuzumab. Recent evidence on the mechanism of action of alemtuzumab indicates that in addition to its previously known effects of inducing depletion and repopulation of T and B lymphocytes, it also results in a relative increase of cells with memory and regulatory phenotypes and a decrease in cells with a proinflammatory signature, and may further promote an immunoregulatory environment through an impact on other innate immune cells (e.g. dendritic cells) that play a role in MS. These effects may allow preservation of innate immunity and immunosurveillance. Together, these lines of evidence help explain the durable clinical efficacy of alemtuzumab, in the absence of continuous treatment, in patients with RRMS.
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Affiliation(s)
- Tjalf Ziemssen
- Center of Clinical Neuroscience, Carl Gustav Carus University Clinic, Dresden University of Technology, Dresden, Germany
| | - Katja Thomas
- Center of Clinical Neuroscience, Carl Gustav Carus University Clinic, Dresden University of Technology, Dresden, Germany
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94
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Cytomegalovirus Immunity After Alemtuzumab Induction in Desensitized Kidney Transplant Patients. Transplantation 2017; 101:1720-1726. [DOI: 10.1097/tp.0000000000001573] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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95
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Gallo P, Centonze D, Marrosu MG. Alemtuzumab for multiple sclerosis: the new concept of immunomodulation. ACTA ACUST UNITED AC 2017. [DOI: 10.1186/s40893-017-0024-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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96
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Zhao Y, Su H, Shen X, Du J, Zhang X, Zhao Y. The immunological function of CD52 and its targeting in organ transplantation. Inflamm Res 2017; 66:571-578. [PMID: 28283679 DOI: 10.1007/s00011-017-1032-8] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 02/18/2017] [Accepted: 02/22/2017] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION CD52 (Campath-1 antigen), a glycoprotein of 12 amino acids anchored to glycosylphosphatidylinositol, is widely expressed on the cell surface of immune cells, such as mature lymphocytes, natural killer cells (NK), eosinophils, neutrophils, monocytes/macrophages, and dendritic cells (DCs). The anti-CD52 mAb, alemtuzumab, was used widely in clinics for the treatment of patients such as organ transplantation. In the present manuscript, we will briefly summarize the immunological function of CD52 and discuss the application of anti-CD52 mAb in transplantation settings. FINDINGS We reviewed studies published until July 2016 to explore the role of CD52 in immune cell function and its implication in organ transplantation. We showed that ligation of cell surface CD52 molecules may offer costimulatory signals for T-cell activation and proliferation. However, soluble CD52 molecules will interact with the inhibitory sialic acid-binding immunoglobulin-like lectin 10 (Siglec10) to significantly inhibit T cell proliferation and activation. Although the physiological and pathological significances of CD52 molecules are still poorly understood, the anti-CD52 mAb, alemtuzumab, was used widely for the treatment of patients with chronic lymphocytic leukemia, autoimmune diseases as well as cell and organ transplantation in clinics. CONCLUSION Studies clearly showed that CD52 can modulate T-cell activation either by its intracellular signal pathways or by the interaction of soluble CD52 and Siglec-10 expressing on T cells. However, the regulatory functions of CD52 on other immune cell subpopulations in organ transplantation require to be studied in the near future.
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Affiliation(s)
- Yang Zhao
- Transplantation Biology Research Division, State Key Laboratory of Membrane Biology, Institute of Zoology, Chinese Academy of Sciences, Beichen West Road 1-5, Chaoyang District, Beijing, 100101, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Huiting Su
- Transplantation Biology Research Division, State Key Laboratory of Membrane Biology, Institute of Zoology, Chinese Academy of Sciences, Beichen West Road 1-5, Chaoyang District, Beijing, 100101, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Xiaofei Shen
- Transplantation Biology Research Division, State Key Laboratory of Membrane Biology, Institute of Zoology, Chinese Academy of Sciences, Beichen West Road 1-5, Chaoyang District, Beijing, 100101, China
- Department of General Surgery, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Junfeng Du
- Department of General Surgery, PLA Army General Hospital, Dongsishitiao Namencang 5, Dongcheng District, Beijing, 100007, China.
| | - Xiaodong Zhang
- Department of Urology, Beijing Chaoyang Hospital, Capital Medical University, 8 Gong Ti Nan Road, Chaoyang District, Beijing, 100020, China.
| | - Yong Zhao
- Transplantation Biology Research Division, State Key Laboratory of Membrane Biology, Institute of Zoology, Chinese Academy of Sciences, Beichen West Road 1-5, Chaoyang District, Beijing, 100101, China.
- University of Chinese Academy of Sciences, Beijing, China.
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97
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Klotz L, Berthele A, Brück W, Chan A, Flachenecker P, Gold R, Haghikia A, Hellwig K, Hemmer B, Hohlfeld R, Korn T, Kümpfel T, Lang M, Limmroth V, Linker RA, Meier U, Meuth SG, Paul F, Salmen A, Stangel M, Tackenberg B, Tumani H, Warnke C, Weber MS, Ziemssen T, Zipp F, Wiendl H. [Monitoring of blood parameters under course-modified MS therapy : Substance-specific relevance and current recommendations for action]. DER NERVENARZT 2017; 87:645-59. [PMID: 26927677 DOI: 10.1007/s00115-016-0077-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
With the approval of various substances for the immunotherapy of multiple sclerosis (MS), treatment possibilities have improved significantly over the last few years. Indeed, the choice of individually tailored preparations and treatment monitoring for the treating doctor is becoming increasingly more complex. This is particularly applicable for monitoring for a treatment-induced compromise of the immune system. The following article by members of the German Multiple Sclerosis Skills Network (KKNMS) and the task force "Provision Structures and Therapeutics" summarizes the practical recommendations for approved immunotherapy for mild to moderate and for (highly) active courses of MS. The focus is on elucidating the substance-specific relevance of particular laboratory parameters with regard to the mechanism of action and the side effects profile. To enable appropriate action to be taken in clinical practice, any blood work changes that can be expected, in addition to any undesirable laboratory findings and their causes and relevance, should be elucidated.
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Affiliation(s)
- L Klotz
- Department für Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
| | - A Berthele
- Neurologische Klinik und Poliklinik, Klinikum rechts der Isar der TU München, Ismaninger Straße 22, 81675, München, Deutschland
| | - W Brück
- Institut für Neuropathologie, Universitätsmedizin Göttingen der Georg-August-Universität, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - A Chan
- Neurologische Klinik, St. Josef-Hospital, Universitätsklinikum der Ruhr-Universität Bochum, Gudrunstr. 56, 44791, Bochum, Deutschland
| | - P Flachenecker
- Neurologisches Rehabilitationszentrum Quellenhof in Bad Wildbad GmbH, Kuranlagenallee 2, 75323, Bad Wildbad, Deutschland
| | - R Gold
- Neurologische Klinik, St. Josef-Hospital, Universitätsklinikum der Ruhr-Universität Bochum, Gudrunstr. 56, 44791, Bochum, Deutschland
| | - A Haghikia
- Neurologische Klinik, St. Josef-Hospital, Universitätsklinikum der Ruhr-Universität Bochum, Gudrunstr. 56, 44791, Bochum, Deutschland
| | - K Hellwig
- Neurologische Klinik, St. Josef-Hospital, Universitätsklinikum der Ruhr-Universität Bochum, Gudrunstr. 56, 44791, Bochum, Deutschland
| | - B Hemmer
- Neurologische Klinik und Poliklinik, Klinikum rechts der Isar der TU München, Ismaninger Straße 22, 81675, München, Deutschland
| | - R Hohlfeld
- Institut für Klinische Neuroimmunologie, Klinikum der Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - T Korn
- Neurologische Klinik und Poliklinik, Klinikum rechts der Isar der TU München, Ismaninger Straße 22, 81675, München, Deutschland
| | - T Kümpfel
- Institut für Klinische Neuroimmunologie, Klinikum der Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - M Lang
- NeuroTransConcept GmbH, Centers of Excellence, Pfauengasse 8, 89073, Ulm, Deutschland
| | - V Limmroth
- Klinik für Neurologie und Palliativmedizin, Kliniken der Stadt Köln, Ostmerheimer Str. 200, 51109, Köln - Merheim, Deutschland
| | - R A Linker
- Neurologische Klinik, Universitätsklinikum Erlangen, Schwabachanlage 6, 91054, Erlangen, Deutschland
| | - U Meier
- Berufsverband Deutscher Neurologen BDN, Am Ziegelkamp 1f, 41515, Grevenbroich, Deutschland
| | - S G Meuth
- Department für Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
| | - F Paul
- Institut für Neuroimmunologie, Universitätsklinikum Charité, Schumannstr. 20/21, 10117, Berlin, Deutschland
| | - A Salmen
- Neurologische Klinik, St. Josef-Hospital, Universitätsklinikum der Ruhr-Universität Bochum, Gudrunstr. 56, 44791, Bochum, Deutschland
| | - M Stangel
- Klinik für Neurologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - B Tackenberg
- Klinik für Neurologie, Philipps-Universität und Universitätsklinikum Marburg, Baldingerstr. 1, 35043, Marburg, Deutschland
| | - H Tumani
- Neurologische Universitätsklinik der Universität Ulm, Oberer Eselsberg 45, 89081, Ulm, Deutschland.,Fachklinik für Neurologie Dietenbronn, Dietenbronn 7, 88477, Schwendi, Deutschland
| | - C Warnke
- Klinik für Neurologie, Universitätsklinikum Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland
| | - M S Weber
- Institut für Neuropathologie, Universitätsmedizin Göttingen der Georg-August-Universität, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - T Ziemssen
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Carl Gustav Carus der TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - F Zipp
- Klinik für Neurologie, Universitätsmedizin der Johannes-Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - H Wiendl
- Department für Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland.
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98
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Kasarełło K, Cudnoch-Jędrzejewska A, Członkowski A, Mirowska-Guzel D. Mechanism of action of three newly registered drugs for multiple sclerosis treatment. Pharmacol Rep 2017; 69:702-708. [PMID: 28550802 DOI: 10.1016/j.pharep.2017.02.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 01/16/2017] [Accepted: 02/16/2017] [Indexed: 11/16/2022]
Abstract
Multiple sclerosis (MS) is a disease of suspected autoimmune origin leading to neurodegeneration. The disease pathomechanism is considered to be primarily based on neuroinflammation directed against myelin antigens caused by autoreactive T cells. MS etiology remains still unknown, which makes it difficult to create an efficient therapy, therefore, MS treatment targets mechanisms involved in disease pathology. In this review, we present the mechanism of action of three newly registered drugs for MS. Dimethyl fumarate (DMF) is an agent presenting a broad spectrum of action. Its main activity is based on activating the nuclear factor E2 dependent pathway leading to antioxidant enzyme synthesis. DMF in general suppresses the pro-inflammatory immune activity and exerts a neuroprotective action. Teriflunomide is a more focused drug, acting as an inhibitor of pyrimidines synthesis, important for rapidly dividing cells such as activated lymphocytes. Similarly, alemtuzumab, an anti-CD52 antibody, causes depletion of mainly lymphocytes. Since in MS pathology, T and B cells are involved, this mode of action is promising.
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Affiliation(s)
- Kaja Kasarełło
- Department of Experimental and Clinical Physiology, Medical University of Warsaw, Warszawa, Poland
| | | | - Andrzej Członkowski
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warszawa, Poland
| | - Dagmara Mirowska-Guzel
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warszawa, Poland; Second Department of Neurology, Institute of Psychiatry and Neurology, Warszawa, Poland.
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99
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Orthmann-Murphy JL, Calabresi PA. Therapeutic Application of Monoclonal Antibodies in Multiple Sclerosis. Clin Pharmacol Ther 2016; 101:52-64. [PMID: 27804128 DOI: 10.1002/cpt.547] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 10/24/2016] [Accepted: 10/26/2016] [Indexed: 01/11/2023]
Abstract
Multiple sclerosis (MS) is a heterogeneous inflammatory demyelinating disorder of the central nervous system (CNS). People with MS typically have a relapsing remitting disease course, with episodic neurological dysfunction corresponding to inflammation in the brain or spinal cord. Some relapsing patients develop a secondary progressive disease course, with accumulation of disability over time, yet other people with MS only experience a primary progressive course. Over the past 20 years, 14 immunomodulatory therapies have been approved in MS in order to reduce the frequency of inflammatory relapses and prevent CNS damage. Of the available types of therapies, the monoclonal antibodies are generally the most effective at dampening MS disease activity. In this review we will discuss the development of effective monoclonal antibody therapies coinciding with a better understanding of the complex immunopathogenesis of MS, both successes and failures, as well as targets for future development that address the mechanisms underlying progressive disease.
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Affiliation(s)
- J L Orthmann-Murphy
- Division of Neuroimmunology and Neuroinfectious Disease, Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - P A Calabresi
- Division of Neuroimmunology and Neuroinfectious Disease, Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Winqvist M, Mozaffari F, Palma M, Eketorp Sylvan S, Hansson L, Mellstedt H, Österborg A, Lundin J. Phase I-II study of lenalidomide and alemtuzumab in refractory chronic lymphocytic leukemia (CLL): effects on T cells and immune checkpoints. Cancer Immunol Immunother 2016; 66:91-102. [PMID: 27815572 PMCID: PMC5222940 DOI: 10.1007/s00262-016-1922-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 10/27/2016] [Indexed: 11/21/2022]
Abstract
This phase I–II study explored safety, immunomodulatory and clinical effects of lenalidomide (weeks 1–16) and alemtuzumab (weeks 5–16) in 23 patients with refractory chronic lymphocytic leukemia. Most patients had Rai stage III/IV disease and were heavily pretreated (median 4 prior therapies), and 61% had del(17p)/del(11q). Eleven of 19 evaluable patients (58%) responded, with a median response duration of 12 months (1–29+); time to progression was short in non-responders. Lenalidomide had a narrow therapeutic dose range, 2.5 mg/day was not efficient, and maximum tolerated dose was 5 mg/day. Grade 3–4 neutropenia and thrombocytopenia occurred in 84 and 55%, 30% had febrile neutropenia, and CMV-reactivation requiring valganciclovir occurred in 30% of patients. The frequency of proliferating (Ki67+) CD8+ T cells was increased at week 4, with further increase in both the CD4+ and CD8+ subsets (p < 0.01 and <0.05), which was accompanied by significant upregulation of HLA-DR after addition of alemtuzumab. Antigen-experienced cells increased at week 4 as the frequency of effector memory cells increased in the CD8+ subset (p < 0.003), while effector cells decreased in both the CD8+ and CD4+ subsets (p < 0.0001 and p < 0.01). The Th1/Th2 balance was unchanged at week 4 but shifted toward a Th2 profile after combination therapy. At end of treatment, the frequency of Th17 and regulatory T cells was reduced (p < 0.01), naïve T cells decreased, and effector memory T cells increased (p < 0.05 and p < 0.01). Granzyme B+ T cells increased at 30-week follow-up (p < 0.05). PD-1 expression was unaffected. In conclusion, low-dose lenalidomide and alemtuzumab induced major perturbations of T cells, including increased proliferative activity and cytotoxic potential.
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Affiliation(s)
- Maria Winqvist
- Department of Hematology, Karolinska University Hospital Solna, 171 76, Stockholm, Sweden. .,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.
| | - Fariba Mozaffari
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Marzia Palma
- Department of Hematology, Karolinska University Hospital Solna, 171 76, Stockholm, Sweden.,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | | | - Lotta Hansson
- Department of Hematology, Karolinska University Hospital Solna, 171 76, Stockholm, Sweden.,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Håkan Mellstedt
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Anders Österborg
- Department of Hematology, Karolinska University Hospital Solna, 171 76, Stockholm, Sweden.,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Jeanette Lundin
- Department of Hematology, Karolinska University Hospital Solna, 171 76, Stockholm, Sweden.,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
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