101
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Goldschmidt CH, Hua LH. Re-Evaluating the Use of IFN-β and Relapsing Multiple Sclerosis: Safety, Efficacy and Place in Therapy. Degener Neurol Neuromuscul Dis 2020; 10:29-38. [PMID: 32617031 PMCID: PMC7326221 DOI: 10.2147/dnnd.s224912] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/10/2020] [Indexed: 01/06/2023] Open
Abstract
The advent of interferon therapy for the treatment of multiple sclerosis (MS) was a massive advancement in the field and changed the course of the disease. While the exact mechanism of interferon therapy in MS is unknown, disease control is likely mediated by reducing Th1 and Th17 cells while increasing regulatory T cells and altering the cytokine profile. Interferon therapy not only gave physicians and patients an evidence-based treatment option to treat MS by decreasing relapses and the accrual of disability but it also provided valuable insight into disease pathophysiology that allowed for the development of further treatments. Currently, there are 18 disease-modifying therapies available for the treatment of MS with varying efficacies, routes of administration, and mechanisms. As treatment options in the field have evolved, interferon therapy is less commonly prescribed as first-line therapy, because the newer therapies are more effective and better tolerated. That being said, interferons still have a place in the field in both clinical practice and clinical trial research. In this review, we will summarize the safety and efficacy of interferon therapy and discuss its current place in MS care.
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Affiliation(s)
- Carolyn H Goldschmidt
- Cleveland Clinic Mellen Center for the Treatment of Multiple Sclerosis, Cleveland, OH, USA
| | - Le H Hua
- Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV, USA
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102
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Ghezzi A, Banwell B, Bar-Or A, Chitnis T, Dale RC, Gorman M, Kornek B, Krupp L, Krysko KM, Nosadini M, Rostasy K, Salzer J, Schreiner T, Tenembaum S, Waubant E. Rituximab in patients with pediatric multiple sclerosis and other demyelinating disorders of the CNS: Practical considerations. Mult Scler 2020; 27:1814-1822. [PMID: 32552353 DOI: 10.1177/1352458520932798] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Anti-CD20 therapies have established efficacy in the treatment of immune-mediated neurological and non-neurological diseases. Rituximab, one of the first B-cell-directed therapies, is relatively inexpensive compared to newer anti-CD20 molecules, is available in many countries, and has been used off-label in pediatric patients with neuroimmune conditions. The objective of this paper is to describe the experience with rituximab in pediatric multiple sclerosis and other inflammatory immune-mediated disorders of the central nervous system (CNS), and to define a protocol for its use in clinical practice, in particular addressing doses, interval of administration, duration of treatment, and tests to perform at baseline and during follow-up.
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Affiliation(s)
- Angelo Ghezzi
- Centro Studi Sclerosi Multipla, Ospedale di Gallarate, ASST Valleolona, Gallarate, Italy
| | - Brenda Banwell
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Amit Bar-Or
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA/Center for Neuroinflammation and Experimental Therapeutics and the Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Tanuja Chitnis
- Partners Pediatric MS Center, Massachusetts General Hospital, Boston, MA, USA
| | - Russell C Dale
- Kids Neuroscience Centre and Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Mark Gorman
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Barbara Kornek
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Lauren Krupp
- Multiple Sclerosis Comprehensive Care Center, Department of Neurology, NYU Langone Health, New York, NY, USA
| | - Kristen M Krysko
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Margherita Nosadini
- Pediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Kevin Rostasy
- Department of Pediatric Neurology, Children's Hospital Datteln, University Witten/Herdecke, Witten, Germany
| | - Jonatan Salzer
- Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
| | - Teri Schreiner
- Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Silvia Tenembaum
- Pediatric Neuroimmunology Program, Department of Neurology, National Pediatric Hospital Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Emmanuelle Waubant
- UCSF Pediatric MS Clinic and UCSF Adult MS Clinic, Department of Neurology, University of California at San Francisco, San Francisco CA, USA
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103
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Abstract
Ocrelizumab ist ein monoklonaler Antikörper, der sich gegen das Differenzierungsantigen CD20 richtet und zu einer effektiven längerfristigen Depletion von Lymphozyten, insbesondere von B‑Zellen, führt. Unlängst publizierte Phase-3-Studien belegen, dass Ocrelizumab sowohl bei der Behandlung der schubförmigen als auch der primär progressiven Multiplen Sklerose (MS) wirksam ist. Darauf basierend wurde Ocrelizumab als erstes Medikament zur Behandlung der primär chronisch-progredienten MS zugelassen. Um diesen Durchbruch besser in den Kontext des heutigen MS-Therapiekanons einordnen zu können, lohnt sowohl ein Blick zurück auf die Entwicklung der antikörpervermittelten CD20-Depletion als auch auf die der Zulassung zugrunde liegenden Studien sowie deren Extensionsphasen. Diese Übersichtsarbeit diskutiert die verfügbaren Daten zur Wirksamkeit und Sicherheit der langfristigen B‑Zell-Depletion bei MS-Patienten und erörtert den aktuellen Kenntnisstand zur Rolle von B‑Lymphozyten in der Immunpathogenese der MS.
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104
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Hellgren J, Risedal A, Källén K. Rituximab in multiple sclerosis at general hospital level. Acta Neurol Scand 2020; 141:491-499. [PMID: 31990978 DOI: 10.1111/ane.13225] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 01/09/2020] [Accepted: 01/20/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The use of rituximab (RTX) in multiple sclerosis (MS) is a rapidly increasing choice of disease-modifying therapy. Efficacy outside specialized university hospital-based care is not yet systematically investigated. Our aim was to evaluate off-label RTX treatment for MS at a general hospital in Sweden. MATERIALS AND METHODS Subjects with definite MS with at least one rituximab infusion were eligible for inclusion in this retrospective, observational study. Effect was evaluated by monitoring clinical disability, annual relapse rate, new lesions on MRI, and safety by the incidence and severity of adverse events. RESULTS Among the 83 included subjects, 15 had clinical worsening of disease during the median 23.5 (1-76) months of follow-up after RTX initiation: 7/66 with relapsing-remitting multiple sclerosis (RRMS) and 8/17 with progressive subtypes (PMS). Cumulative survival without worsening was 86% in RRMS and 30% in PMS. The annual relapse rate before RTX vs follow-up dropped from 0.38 to 0.05 (P < .00001). Subjects with new enhancing lesions on MRI during the first year before RTX initiation vs the year after dropped from 0.94 to 0.024 (P < .00001) and was only seen in RRMS (1.05-0.31, P = .00003). Adverse events were mainly mild. Thirty-six out of 53 non-infusion-related adverse events were infections, of which four were serious, including a case of pneumonia with concomitant late-onset neutropenia. CONCLUSIONS Rituximab was as effective and safe when given at a general hospital outpatient clinic compared with results from previous university hospital-based studies. Vigilance is required concerning severe adverse events.
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Affiliation(s)
- Johan Hellgren
- Medical Faculty Department of Clinical Sciences Lund Lund University Lund Sweden
| | - Anette Risedal
- Medical Faculty Department of Clinical Sciences Lund Lund University Lund Sweden
- Department of Specialized Medicine Helsingborg General Hospital Helsingborg Sweden
| | - Kristina Källén
- Medical Faculty Department of Clinical Sciences Lund Lund University Lund Sweden
- Department of Specialized Medicine Helsingborg General Hospital Helsingborg Sweden
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105
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Mathew T, John SK, Kamath V, Murgod U, Thomas K, Baptist AA, Therambil M, Shaji A, Nadig R, Badachi S, Souza DD, Shivde S, Avati A, Sarma GRK, Sharath Kumar GG, Deepalam S, Parry GJ. Efficacy and safety of rituximab in multiple sclerosis: Experience from a developing country. Mult Scler Relat Disord 2020; 43:102210. [PMID: 32485634 DOI: 10.1016/j.msard.2020.102210] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/09/2020] [Accepted: 05/17/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Rituximab is increasingly being used in treatment of multiple Sclerosis (MS) in our centers due to its easy availability, efficacy and favorable side effect profile. Here we describe experience with rituximab over a period of 4 years from three MS centers from south India. METHODS The data of MS patients who were treated with rituximab in three MS centers at Bangalore, India, from December 2015 to December 2019 were collected and evaluated with respect to relapse rate, EDSS score and adverse events. RESULTS Over the four-year study period 118 MS patients were evaluated, 80 of whom were on rituximab. 58 (72%) had RRMS, 15 (19%) SPMS and 7 (9%) PPMS. Most patients (89%) received rituximab at a dose of 500 mg every 6-12 months. Nine patients (11%), all with progressive MS were on 1 gm to 2 gm every 6 months. Follow up ranged from 1 year to 3 years, with a median of 2 years. 56 (97%) RRMS patients had no relapses during follow up. EDSS score improved by a score of 0.5-2.0 in 68 (85%) patients, remained same in 10 (12.5%) and worsened in 2 patients (2.5%). Most patients (91%) tolerated rituximab infusions well. There were no opportunistic infections or neoplasms. CONCLUSION Anti B cell therapy with rituximab appears effective, safe and affordable in the treatment of MS in developing countries like India with resource limited settings.
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Affiliation(s)
- Thomas Mathew
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India.
| | - Saji K John
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India
| | - Vikram Kamath
- Department of Neurology, Apollo Hospital, Bengaluru, Karnataka, India
| | - Uday Murgod
- Department of Neurology, Manipal Hospital, Old Airport Road, Bangalore, India
| | - Kurian Thomas
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India
| | - Anita Angela Baptist
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India
| | - Manjusha Therambil
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India
| | - Asha Shaji
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India
| | - Raghunandan Nadig
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India
| | - Sagar Badachi
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India
| | - Delon D Souza
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India
| | - Sonia Shivde
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India; Department of Neurology, Apollo Hospital, Bengaluru, Karnataka, India; Department of Neurology, Manipal Hospital, Old Airport Road, Bangalore, India
| | - Amrutha Avati
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India; Department of Neurology, Apollo Hospital, Bengaluru, Karnataka, India; Department of Neurology, Manipal Hospital, Old Airport Road, Bangalore, India
| | - G R K Sarma
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India
| | - G G Sharath Kumar
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India
| | - Saikanth Deepalam
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India
| | - Gareth J Parry
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India
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106
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Siddiqui MK, Singh B, Attri S, Veraart C, Harty G, Wong SL. Use of rituximab in adults with relapsing-remitting multiple sclerosis: a systematic literature review. Curr Med Res Opin 2020; 36:809-826. [PMID: 32129684 DOI: 10.1080/03007995.2020.1739009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: Rituximab is used as an off-label treatment for relapsing-remitting multiple sclerosis (RRMS); however, the comparative efficacy and safety of rituximab versus currently licensed disease-modifying drugs (DMDs) for RRMS is unknown. A systematic literature review was conducted to evaluate the available data pertaining to efficacy and safety of rituximab in adult patients with RRMS and highly active relapsing multiple sclerosis (HA-RMS); data quality was critically assessed via risk of bias (RoB) assessment.Methods: Biomedical literature databases were searched until mid-2018 and key proceedings were searched from 2016 to 2018. Critical appraisal of non-randomized studies was conducted using the Cochrane RoB assessment tool; randomized controlled trials (RCTs) were appraised using comprehensive assessment criteria based on the NICE guidelines.Results: Thirty-eight unique studies based on 49 publications were identified: 25 RRMS studies (one RCT) and 13 HA-RMS studies (no RCTs). The evidence among patients with RRMS generally favored rituximab in comparison to placebo (relapse rate) and interferons/glatiramer acetate (relapse rate and disability progression), although much of the non-randomized data were descriptive and/or not statistically significant. In comparison to placebo, rituximab was associated with a greater risk of adverse events. Two-thirds of the non-randomized RRMS studies were associated with critical/serious RoB; the single RCT was associated with low RoB. Furthermore, all of the non-randomized HA-RMS studies were associated with critical/serious RoB.Conclusions: Available evidence of off-label rituximab use for the treatment of patients with RRMS suggests generally favorable efficacy versus placebo and interferons/glatiramer acetate; however, the poor quality of the included studies limits any robust conclusions.
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107
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Bellinvia A, Prestipino E, Portaccio E, Razzolini L, Fonderico M, Fratangelo R, Tudisco L, Pastò L, Amato MP. Experience with rituximab therapy in a real-life sample of multiple sclerosis patients. Neurol Sci 2020; 41:2939-2945. [PMID: 32350672 DOI: 10.1007/s10072-020-04434-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 04/16/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Multiple sclerosis (MS) is an autoimmune, neuroinflammatory, and neurodegenerative disease of the central nervous system. B cells have recently emerged as a promising target to significantly reduce inflammatory disease activity in MS, with successful trial studies using antiCD20 therapies. However, real-life data about safety and efficacy are limited. OBJECTIVES To analyze the clinical and radiological inflammatory activity, adherence to therapy, and safety of rituximab (RTX) in an MS patients' sample, treated from 2015 to 2018 in our center PATIENTS AND METHODS: Retrospective study on prospectively collected data about relapses, disability progression, and radiological activity (new T2 lesions and Gd-enhancing lesions) were recorded and used to assess no evidence of disease activity (NEDA) at 12 months. RTX-related adverse events were recorded. RTX was administered intravenously at a dosage of 1000 mg twice 2 weeks apart, then every 6 months. RESULTS Sixty-nine patients were included. Fifty-three (76.8%) had a relapsing-remitting, two a primary progressive course, and 14 a secondary progressive course. The mean follow-up period was 16 ± 9.7 months. Thirty-five (50.7%) patients had relapses in the year prior to RTX therapy, with a mean annualized relapse rate of 0.75, significantly reduced to 0.36 at 12 months (p < 0.001). Among the 36 patients included in the study who had an MRI available at 12 months, MRI activity was reduced from 88% (n = 32) to 8.3% (n = 3) at follow-up (p < 0.001). Twelve (17.4%) patients suspended RTX during the study. CONCLUSIONS Our real-life experience confirms that off-label therapy with RTX may represent a valid, cost-effective therapeutic option in MS.
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Affiliation(s)
- Angelo Bellinvia
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy
| | - Elio Prestipino
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy
| | - Emilio Portaccio
- SOC Neurologia, AUSL Toscana Centro, San Giovanni di Dio Hospital, Florence, Italy
| | - Lorenzo Razzolini
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy
| | - Mattia Fonderico
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy
| | - Roberto Fratangelo
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy
| | - Laura Tudisco
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy
| | - Luisa Pastò
- SOD Neurological Rehabilitation, Careggi University Hospital, Florence, Italy
| | - Maria P Amato
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy.
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy.
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108
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Delcoigne B, Manouchehrinia A, Barro C, Benkert P, Michalak Z, Kappos L, Leppert D, Tsai JA, Plavina T, Kieseier BC, Lycke J, Alfredsson L, Kockum I, Kuhle J, Olsson T, Piehl F. Blood neurofilament light levels segregate treatment effects in multiple sclerosis. Neurology 2020; 94:e1201-e1212. [PMID: 32047070 PMCID: PMC7387108 DOI: 10.1212/wnl.0000000000009097] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 10/21/2019] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To determine factors (including the role of specific disease modulatory treatments [DMTs]) associated with (1) baseline, (2) on-treatment, and (3) change (from treatment start to on-treatment assessment) in plasma neurofilament light chain (pNfL) concentrations in relapsing-remitting multiple sclerosis (RRMS). METHODS Data including blood samples analyses and long-term clinical follow-up information for 1,261 Swedish patients with RRMS starting novel DMTs were analyzed using linear regressions to model pNfL and changes in pNfL concentrations as a function of clinical variables and DMTs (alemtuzumab, dimethyl fumarate, fingolimod, natalizumab, rituximab, and teriflunomide). RESULTS The baseline pNfL concentration was positively associated with relapse rate, Expanded Disability Status Scale score, Age-Related MS Severity Score, and MS Impact Score (MSIS-29), and negatively associated with Symbol Digit Modalities Test performance and the number of previously used DMTs. All analyses, which used inverse propensity score weighting to correct for differences in baseline factors at DMT start, highlighted that both the reduction in pNfL concentration from baseline to on-treatment measurement and the on-treatment pNfL level differed across DMTs. Patients starting alemtuzumab displayed the highest reduction in pNfL concentration and lowest on-treatment pNfL concentrations, while those starting teriflunomide had the smallest decrease and highest on-treatment levels, but also starting from lower values. Both on-treatment pNfL and decrease in pNfL concentrations were highly dependent on baseline concentrations. CONCLUSION Choice of DMT in RRMS is significantly associated with degree of reduction in pNfL, which supports a role for pNfL as a drug response marker.
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Affiliation(s)
- Bénédicte Delcoigne
- From the Department of Medicine Solna, Clinical Epidemiology Division (B.D.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Department of Clinical Neuroscience (A.M., I.K., T.O., F.P.), and Institute of Environmental Medicine (L.A.), Karolinska Institutet; Centre for Molecular Medicine (A.M., I.K., T.O., F.P.), Karolinska University Hospital, Stockholm, Sweden; Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine, and Clinical Research (C.B., Z.M., L.K., D.L., J.K.), and Clinical Trial Unit, Department of Clinical Research (P.B.), University Hospital Basel, University of Basel, Switzerland; Sanofi Genzyme (J.A.T.), Stockholm, Sweden; Biogen (T.P., B.C.K.), Cambridge, MA; Department of Neurology, Medical Faculty (B.C.K.), Heinrich-Heine University, Duesseldorf, Germany; and Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Sweden.
| | - Ali Manouchehrinia
- From the Department of Medicine Solna, Clinical Epidemiology Division (B.D.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Department of Clinical Neuroscience (A.M., I.K., T.O., F.P.), and Institute of Environmental Medicine (L.A.), Karolinska Institutet; Centre for Molecular Medicine (A.M., I.K., T.O., F.P.), Karolinska University Hospital, Stockholm, Sweden; Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine, and Clinical Research (C.B., Z.M., L.K., D.L., J.K.), and Clinical Trial Unit, Department of Clinical Research (P.B.), University Hospital Basel, University of Basel, Switzerland; Sanofi Genzyme (J.A.T.), Stockholm, Sweden; Biogen (T.P., B.C.K.), Cambridge, MA; Department of Neurology, Medical Faculty (B.C.K.), Heinrich-Heine University, Duesseldorf, Germany; and Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Christian Barro
- From the Department of Medicine Solna, Clinical Epidemiology Division (B.D.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Department of Clinical Neuroscience (A.M., I.K., T.O., F.P.), and Institute of Environmental Medicine (L.A.), Karolinska Institutet; Centre for Molecular Medicine (A.M., I.K., T.O., F.P.), Karolinska University Hospital, Stockholm, Sweden; Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine, and Clinical Research (C.B., Z.M., L.K., D.L., J.K.), and Clinical Trial Unit, Department of Clinical Research (P.B.), University Hospital Basel, University of Basel, Switzerland; Sanofi Genzyme (J.A.T.), Stockholm, Sweden; Biogen (T.P., B.C.K.), Cambridge, MA; Department of Neurology, Medical Faculty (B.C.K.), Heinrich-Heine University, Duesseldorf, Germany; and Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Pascal Benkert
- From the Department of Medicine Solna, Clinical Epidemiology Division (B.D.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Department of Clinical Neuroscience (A.M., I.K., T.O., F.P.), and Institute of Environmental Medicine (L.A.), Karolinska Institutet; Centre for Molecular Medicine (A.M., I.K., T.O., F.P.), Karolinska University Hospital, Stockholm, Sweden; Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine, and Clinical Research (C.B., Z.M., L.K., D.L., J.K.), and Clinical Trial Unit, Department of Clinical Research (P.B.), University Hospital Basel, University of Basel, Switzerland; Sanofi Genzyme (J.A.T.), Stockholm, Sweden; Biogen (T.P., B.C.K.), Cambridge, MA; Department of Neurology, Medical Faculty (B.C.K.), Heinrich-Heine University, Duesseldorf, Germany; and Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Zuzanna Michalak
- From the Department of Medicine Solna, Clinical Epidemiology Division (B.D.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Department of Clinical Neuroscience (A.M., I.K., T.O., F.P.), and Institute of Environmental Medicine (L.A.), Karolinska Institutet; Centre for Molecular Medicine (A.M., I.K., T.O., F.P.), Karolinska University Hospital, Stockholm, Sweden; Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine, and Clinical Research (C.B., Z.M., L.K., D.L., J.K.), and Clinical Trial Unit, Department of Clinical Research (P.B.), University Hospital Basel, University of Basel, Switzerland; Sanofi Genzyme (J.A.T.), Stockholm, Sweden; Biogen (T.P., B.C.K.), Cambridge, MA; Department of Neurology, Medical Faculty (B.C.K.), Heinrich-Heine University, Duesseldorf, Germany; and Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Ludwig Kappos
- From the Department of Medicine Solna, Clinical Epidemiology Division (B.D.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Department of Clinical Neuroscience (A.M., I.K., T.O., F.P.), and Institute of Environmental Medicine (L.A.), Karolinska Institutet; Centre for Molecular Medicine (A.M., I.K., T.O., F.P.), Karolinska University Hospital, Stockholm, Sweden; Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine, and Clinical Research (C.B., Z.M., L.K., D.L., J.K.), and Clinical Trial Unit, Department of Clinical Research (P.B.), University Hospital Basel, University of Basel, Switzerland; Sanofi Genzyme (J.A.T.), Stockholm, Sweden; Biogen (T.P., B.C.K.), Cambridge, MA; Department of Neurology, Medical Faculty (B.C.K.), Heinrich-Heine University, Duesseldorf, Germany; and Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Sweden
| | - David Leppert
- From the Department of Medicine Solna, Clinical Epidemiology Division (B.D.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Department of Clinical Neuroscience (A.M., I.K., T.O., F.P.), and Institute of Environmental Medicine (L.A.), Karolinska Institutet; Centre for Molecular Medicine (A.M., I.K., T.O., F.P.), Karolinska University Hospital, Stockholm, Sweden; Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine, and Clinical Research (C.B., Z.M., L.K., D.L., J.K.), and Clinical Trial Unit, Department of Clinical Research (P.B.), University Hospital Basel, University of Basel, Switzerland; Sanofi Genzyme (J.A.T.), Stockholm, Sweden; Biogen (T.P., B.C.K.), Cambridge, MA; Department of Neurology, Medical Faculty (B.C.K.), Heinrich-Heine University, Duesseldorf, Germany; and Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Jon A Tsai
- From the Department of Medicine Solna, Clinical Epidemiology Division (B.D.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Department of Clinical Neuroscience (A.M., I.K., T.O., F.P.), and Institute of Environmental Medicine (L.A.), Karolinska Institutet; Centre for Molecular Medicine (A.M., I.K., T.O., F.P.), Karolinska University Hospital, Stockholm, Sweden; Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine, and Clinical Research (C.B., Z.M., L.K., D.L., J.K.), and Clinical Trial Unit, Department of Clinical Research (P.B.), University Hospital Basel, University of Basel, Switzerland; Sanofi Genzyme (J.A.T.), Stockholm, Sweden; Biogen (T.P., B.C.K.), Cambridge, MA; Department of Neurology, Medical Faculty (B.C.K.), Heinrich-Heine University, Duesseldorf, Germany; and Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Tatiana Plavina
- From the Department of Medicine Solna, Clinical Epidemiology Division (B.D.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Department of Clinical Neuroscience (A.M., I.K., T.O., F.P.), and Institute of Environmental Medicine (L.A.), Karolinska Institutet; Centre for Molecular Medicine (A.M., I.K., T.O., F.P.), Karolinska University Hospital, Stockholm, Sweden; Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine, and Clinical Research (C.B., Z.M., L.K., D.L., J.K.), and Clinical Trial Unit, Department of Clinical Research (P.B.), University Hospital Basel, University of Basel, Switzerland; Sanofi Genzyme (J.A.T.), Stockholm, Sweden; Biogen (T.P., B.C.K.), Cambridge, MA; Department of Neurology, Medical Faculty (B.C.K.), Heinrich-Heine University, Duesseldorf, Germany; and Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Bernd C Kieseier
- From the Department of Medicine Solna, Clinical Epidemiology Division (B.D.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Department of Clinical Neuroscience (A.M., I.K., T.O., F.P.), and Institute of Environmental Medicine (L.A.), Karolinska Institutet; Centre for Molecular Medicine (A.M., I.K., T.O., F.P.), Karolinska University Hospital, Stockholm, Sweden; Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine, and Clinical Research (C.B., Z.M., L.K., D.L., J.K.), and Clinical Trial Unit, Department of Clinical Research (P.B.), University Hospital Basel, University of Basel, Switzerland; Sanofi Genzyme (J.A.T.), Stockholm, Sweden; Biogen (T.P., B.C.K.), Cambridge, MA; Department of Neurology, Medical Faculty (B.C.K.), Heinrich-Heine University, Duesseldorf, Germany; and Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Jan Lycke
- From the Department of Medicine Solna, Clinical Epidemiology Division (B.D.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Department of Clinical Neuroscience (A.M., I.K., T.O., F.P.), and Institute of Environmental Medicine (L.A.), Karolinska Institutet; Centre for Molecular Medicine (A.M., I.K., T.O., F.P.), Karolinska University Hospital, Stockholm, Sweden; Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine, and Clinical Research (C.B., Z.M., L.K., D.L., J.K.), and Clinical Trial Unit, Department of Clinical Research (P.B.), University Hospital Basel, University of Basel, Switzerland; Sanofi Genzyme (J.A.T.), Stockholm, Sweden; Biogen (T.P., B.C.K.), Cambridge, MA; Department of Neurology, Medical Faculty (B.C.K.), Heinrich-Heine University, Duesseldorf, Germany; and Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Lars Alfredsson
- From the Department of Medicine Solna, Clinical Epidemiology Division (B.D.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Department of Clinical Neuroscience (A.M., I.K., T.O., F.P.), and Institute of Environmental Medicine (L.A.), Karolinska Institutet; Centre for Molecular Medicine (A.M., I.K., T.O., F.P.), Karolinska University Hospital, Stockholm, Sweden; Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine, and Clinical Research (C.B., Z.M., L.K., D.L., J.K.), and Clinical Trial Unit, Department of Clinical Research (P.B.), University Hospital Basel, University of Basel, Switzerland; Sanofi Genzyme (J.A.T.), Stockholm, Sweden; Biogen (T.P., B.C.K.), Cambridge, MA; Department of Neurology, Medical Faculty (B.C.K.), Heinrich-Heine University, Duesseldorf, Germany; and Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Ingrid Kockum
- From the Department of Medicine Solna, Clinical Epidemiology Division (B.D.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Department of Clinical Neuroscience (A.M., I.K., T.O., F.P.), and Institute of Environmental Medicine (L.A.), Karolinska Institutet; Centre for Molecular Medicine (A.M., I.K., T.O., F.P.), Karolinska University Hospital, Stockholm, Sweden; Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine, and Clinical Research (C.B., Z.M., L.K., D.L., J.K.), and Clinical Trial Unit, Department of Clinical Research (P.B.), University Hospital Basel, University of Basel, Switzerland; Sanofi Genzyme (J.A.T.), Stockholm, Sweden; Biogen (T.P., B.C.K.), Cambridge, MA; Department of Neurology, Medical Faculty (B.C.K.), Heinrich-Heine University, Duesseldorf, Germany; and Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Jens Kuhle
- From the Department of Medicine Solna, Clinical Epidemiology Division (B.D.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Department of Clinical Neuroscience (A.M., I.K., T.O., F.P.), and Institute of Environmental Medicine (L.A.), Karolinska Institutet; Centre for Molecular Medicine (A.M., I.K., T.O., F.P.), Karolinska University Hospital, Stockholm, Sweden; Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine, and Clinical Research (C.B., Z.M., L.K., D.L., J.K.), and Clinical Trial Unit, Department of Clinical Research (P.B.), University Hospital Basel, University of Basel, Switzerland; Sanofi Genzyme (J.A.T.), Stockholm, Sweden; Biogen (T.P., B.C.K.), Cambridge, MA; Department of Neurology, Medical Faculty (B.C.K.), Heinrich-Heine University, Duesseldorf, Germany; and Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Tomas Olsson
- From the Department of Medicine Solna, Clinical Epidemiology Division (B.D.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Department of Clinical Neuroscience (A.M., I.K., T.O., F.P.), and Institute of Environmental Medicine (L.A.), Karolinska Institutet; Centre for Molecular Medicine (A.M., I.K., T.O., F.P.), Karolinska University Hospital, Stockholm, Sweden; Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine, and Clinical Research (C.B., Z.M., L.K., D.L., J.K.), and Clinical Trial Unit, Department of Clinical Research (P.B.), University Hospital Basel, University of Basel, Switzerland; Sanofi Genzyme (J.A.T.), Stockholm, Sweden; Biogen (T.P., B.C.K.), Cambridge, MA; Department of Neurology, Medical Faculty (B.C.K.), Heinrich-Heine University, Duesseldorf, Germany; and Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Fredrik Piehl
- From the Department of Medicine Solna, Clinical Epidemiology Division (B.D.), The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Department of Clinical Neuroscience (A.M., I.K., T.O., F.P.), and Institute of Environmental Medicine (L.A.), Karolinska Institutet; Centre for Molecular Medicine (A.M., I.K., T.O., F.P.), Karolinska University Hospital, Stockholm, Sweden; Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine, and Clinical Research (C.B., Z.M., L.K., D.L., J.K.), and Clinical Trial Unit, Department of Clinical Research (P.B.), University Hospital Basel, University of Basel, Switzerland; Sanofi Genzyme (J.A.T.), Stockholm, Sweden; Biogen (T.P., B.C.K.), Cambridge, MA; Department of Neurology, Medical Faculty (B.C.K.), Heinrich-Heine University, Duesseldorf, Germany; and Institution of Neuroscience and Physiology (J.L.), Sahlgrenska Academy, University of Gothenburg, Sweden
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Al-Ani MR, Raju TK, Hachim MY, Hachim IY, Elemam NM, Guimei M, Bendardaf R, Maghazachi AA. Rituximab Prevents the Development of Experimental Autoimmune Encephalomyelitis (EAE): Comparison with Prophylactic, Therapeutic or Combinational Regimens. J Inflamm Res 2020; 13:151-164. [PMID: 32214838 PMCID: PMC7082624 DOI: 10.2147/jir.s243514] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 02/20/2020] [Indexed: 12/20/2022] Open
Abstract
Objective To investigate, in detail, the effects of rituximab (RTX), an off-label drug for treating multiple sclerosis (MS) disease on preventing and/or ameliorating experimental autoimmune encephalomyelitis (EAE). Methods Using bioinformatics analysis of publicly available transcriptomics data, we determined the accumulation of B cells, plasma cells and T cells in different compartments of multiple sclerosis patients (MS) and healthy individual brains. Based on these observations and on the literature search, we dosed RTX in EAE mice either orally, or injected intraperitoneally (IP). The latter route was used either prophylactically (asymptomatic stage; upon the induction of the disease), or therapeutically (acute stage; upon the appearance of the first sign of the disease). Further, we used RTX as a preventive drug either as a single agent or in combination with other routes of administration. Results Because no complete recovery was observed when RTX was used prophylactically or therapeutically, we devised another protocol of injecting this drug before the onset of the disease and designated this regiment as prevention. We demonstrated that the 20 μg/mouse prevention completely reduced the EAE clinical score, impaired infiltration of T and B cells into the perivascular space of mice brains, along with inhibiting the inflammation and demyelination. However, the 5 and 10 μg/mouse doses although reduced all aspects of inflammation in these mice, their effects were not as potent as the 20 μg/mouse RTX dose. Finally, we combined the 5 μg/mouse prevention treatment with either the prophylactic or therapeutic regimen and observed a robust effect. Conclusion We observed that combinatorial regimens resulted in further reduction of inflammation, T and B cell extravasation into the brains of EAE mice and improved the re-myelination.
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Affiliation(s)
- Mena R Al-Ani
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, 27272, United Arabs Emirates
| | - Tom K Raju
- Sharjah Institute for Medical Research (SIMR), University of Sharjah, Sharjah 27272, United Arabs Emirates
| | - Mahmood Y Hachim
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, 27272, United Arabs Emirates.,Sharjah Institute for Medical Research (SIMR), University of Sharjah, Sharjah 27272, United Arabs Emirates
| | - Ibrahim Y Hachim
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, 27272, United Arabs Emirates
| | - Noha M Elemam
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, 27272, United Arabs Emirates.,Sharjah Institute for Medical Research (SIMR), University of Sharjah, Sharjah 27272, United Arabs Emirates
| | - Maha Guimei
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, 27272, United Arabs Emirates.,Alexandria University, Alexandria, Egypt
| | | | - Azzam A Maghazachi
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, 27272, United Arabs Emirates.,Sharjah Institute for Medical Research (SIMR), University of Sharjah, Sharjah 27272, United Arabs Emirates
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110
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Soleimani B, Murray K, Hunt D. Established and Emerging Immunological Complications of Biological Therapeutics in Multiple Sclerosis. Drug Saf 2020; 42:941-956. [PMID: 30830572 DOI: 10.1007/s40264-019-00799-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Biologic immunotherapies have transformed the treatment landscape of multiple sclerosis. Such therapies include recombinant proteins (interferon beta), as well as monoclonal antibodies (natalizumab, alemtuzumab, daclizumab, rituximab and ocrelizumab). Monoclonal antibodies show particular efficacy in the treatment of the inflammatory phase of multiple sclerosis. However, the immunological perturbations caused by biologic therapies are associated with significant immunological adverse reactions. These include development of neutralising immunogenicity, secondary immunodeficiency and secondary autoimmunity. These complications can affect the balance of risks and benefits of biologic agents, and 2018 saw the withdrawal from the market of daclizumab, an anti-CD25 monoclonal antibody, due to concerns about the development of severe, unpredictable autoimmunity. Here we review established and emerging risks associated with multiple sclerosis biologic agents, with an emphasis on their immunological adverse effects. We also discuss the specific challenges that multiple sclerosis biologics pose to drug safety systems, and the potential for improvements in safety frameworks.
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Affiliation(s)
| | - Katy Murray
- Anne Rowling Clinic, University of Edinburgh, Edinburgh, UK
| | - David Hunt
- Anne Rowling Clinic, University of Edinburgh, Edinburgh, UK. .,MRC Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK.
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111
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Sellebjerg F, Blinkenberg M, Sorensen PS. Anti-CD20 Monoclonal Antibodies for Relapsing and Progressive Multiple Sclerosis. CNS Drugs 2020; 34:269-280. [PMID: 31994023 DOI: 10.1007/s40263-020-00704-w] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Multiple sclerosis (MS) was previously thought to be a T-cell-mediated, demyelinating disease of the central nervous system. Disease-modifying therapies targeting T cells have, indeed, shown remarkable efficacy in patients with relapsing-remitting MS. However, these therapies do also target B cells, and a B-cell-depleting monoclonal antibody (ocrelizumab) has recently been approved for MS therapy and is efficacious not only in relapsing forms of MS but also in some patients with primary progressive MS. This suggests that B cells may play a more important role in the pathogenesis of MS than previously appreciated. We review the potential roles of B cells, which are the precursors of antibody-secreting plasma cells in the pathogenesis of MS. Furthermore, we provide an overview of the characteristics and clinical data for the four monoclonal antibodies (ocrelizumab, ofatumumab, rituximab, and ublituximab) that have been approved, are currently been used off-label or are being investigated as treatments for MS. These antibodies all target the cluster of differentiation (CD)-20 molecule and bind to distinct or overlapping epitopes on B cells and a subset of T cells that express CD20. This leads to B-cell depletion and, possibly, to depletion of CD20-positive T cells. The net result is strong suppression of clinical and radiological disease activity as well as slowing of the development of persisting neurological impairment.
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Affiliation(s)
- Finn Sellebjerg
- Danish Multiple Sclerosis Clinic, Department of Neurology 2082, University of Copenhagen, Rigshospitalet, 9 Blegdamsvej, 2100, Copenhagen, Denmark
| | - Morten Blinkenberg
- Danish Multiple Sclerosis Clinic, Department of Neurology 2082, University of Copenhagen, Rigshospitalet, 9 Blegdamsvej, 2100, Copenhagen, Denmark
| | - Per Soelberg Sorensen
- Danish Multiple Sclerosis Clinic, Department of Neurology 2082, University of Copenhagen, Rigshospitalet, 9 Blegdamsvej, 2100, Copenhagen, Denmark.
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Abstract
PURPOSE OF REVIEW To critically assess the current landscape of disease-modifying agents for multiple sclerosis (MS). Treatment algorithms will be discussed and studies for new agents in late development or recently approved are analyzed in terms of their impact on current treatment strategies. RECENT FINDINGS A real-world study from Wales suggests that early initiation of highly effective therapy may provide more benefit that an escalation approach in relapsing MS. A study from the MSBase dataset found evidence that early treatment with highly effective therapies decreased the risk of developing secondary progressive MS. Ocrelizumab is highly efficacious in relapsing MS and in a group of patients with primary progressive MS. Another CD20 directed mAb, ofatumumab, is in phase 3. A large study examining extended interval dosing of natalizumab in an attempt to decrease the risk of developing progressive multifocal leukoencephalopathy is underway. Cladribine and alemtuzumab may work by immune reconstitution. Siponimod was recently approved by United States Federal Drug Administration for relapsing MS and active secondary progressive MS. Other S1P receptor modulators are being studied in phase 3 trials for relapsing MS. Cladribine received FDA approval as treatment for relapsing and active secondary progressive MS. Autologous hematopoetic stem-cell transplantation may be an option for treatment-refractory MS. SUMMARY Development of disease-modifying agents in MS continues to be successful. Treatment algorithms need to take new developments into account.
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113
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Tintore M, Vidal-Jordana A, Sastre-Garriga J. Treatment of multiple sclerosis - success from bench to bedside. Nat Rev Neurol 2020; 15:53-58. [PMID: 30315270 DOI: 10.1038/s41582-018-0082-z] [Citation(s) in RCA: 201] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The modern era of multiple sclerosis (MS) treatment began 25 years ago, with the approval of IFNβ and glatiramer acetate for the treatment of relapsing-remitting MS. Ten years later, the first monoclonal antibody, natalizumab, was approved, followed by a third important landmark with the introduction of oral medications, initially fingolimod and then teriflunomide, dimethyl fumarate and cladribine. Concomitantly, new monoclonal antibodies (alemtuzumab and ocrelizumab) have been developed and approved. The modern era of MS therapy reached primary progressive MS in 2018, with the approval of ocrelizumab. We have also learned the importance of starting treatment early and the importance of clinical and MRI monitoring to assess treatment response and safety. Treatment decisions should account for disease phenotype, prognostic factors, comorbidities, the desire for pregnancy and the patient's preferences in terms of acceptable risk. The development of treatment for MS during the past 25 years is a fantastic success of translational medicine.
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Affiliation(s)
- Mar Tintore
- Centre d'Esclerosi Múltiple de Catalunya, Department of Neurology/Neuroimmunology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Angela Vidal-Jordana
- Centre d'Esclerosi Múltiple de Catalunya, Department of Neurology/Neuroimmunology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jaume Sastre-Garriga
- Centre d'Esclerosi Múltiple de Catalunya, Department of Neurology/Neuroimmunology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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114
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Rojas JI, Pappolla A, Patrucco L, Cristiano E, Sánchez F. Do clinical trials for new disease modifying treatments include real world patients with multiple sclerosis? Mult Scler Relat Disord 2020; 39:101931. [PMID: 31924592 DOI: 10.1016/j.msard.2020.101931] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/31/2019] [Accepted: 01/02/2020] [Indexed: 01/31/2023]
Abstract
We often see that clinical and demographic characteristics of real-world studies (RWS) do not differ from patients included in randomized controlled trials (RCT). OBJECTIVE to compare clinical and demographic aspects of patients included in RCT and RWS that evaluated new disease modifying treatment in multiple sclerosis (MS). METHODS a systematic non-language-restricted literature search of RCT and RWS that evaluated new disease modifying treatments (natalizumab, alemtuzumab, ocrelizumab, fingolimod, teriflunomide, dimethyl fumarate and cladribine) from January 2005 to January 2019. Demographic and clinical data were extracted, described and compared. RESULTS 18 RCT and 73 RWS were included. We found no differences in clinical and demographic aspects between RCT and RWS except in the frequency of naïve patients included in RCT vs. RWS 65.6% (95%CI 52-74) vs. 36.4% (95%CI 21-46), respectively, (p = 0.013) at study entry, as well as for the inclusion of patients that used previous treatment 34.4% (95%CI 22-41) vs. 63.6% (95%CI 53-74) in RCT and RWS, respectively,(p = 0.007) at study entry. CONCLUSION We did not observe significant differences in most clinical and demographic aspects of included patients in RCT and RWS. Studies that include the full spectrum of MS patients followed in clinical practice are needed.
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Affiliation(s)
- Juan Ignacio Rojas
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Centro de Esclerosis Múltiple de Buenos Aires, Buenos Aires, Argentina.
| | - Agustín Pappolla
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Centro de Esclerosis Múltiple de Buenos Aires, Buenos Aires, Argentina
| | - Liliana Patrucco
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Centro de Esclerosis Múltiple de Buenos Aires, Buenos Aires, Argentina
| | - Edgardo Cristiano
- Centro de Esclerosis Múltiple de Buenos Aires, Buenos Aires, Argentina
| | - Francisco Sánchez
- Centro de Esclerosis Múltiple de Buenos Aires, Buenos Aires, Argentina
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Juto A, Fink K, Al Nimer F, Piehl F. Interrupting rituximab treatment in relapsing-remitting multiple sclerosis; no evidence of rebound disease activity. Mult Scler Relat Disord 2020; 37:101468. [DOI: 10.1016/j.msard.2019.101468] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 10/10/2019] [Accepted: 10/22/2019] [Indexed: 10/25/2022]
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Zeineddine MM. Treatment of multiple sclerosis in special populations: The case of refugees. Mult Scler J Exp Transl Clin 2020; 6:2055217319848466. [PMID: 31976080 PMCID: PMC6956602 DOI: 10.1177/2055217319848466] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 04/01/2019] [Accepted: 04/07/2019] [Indexed: 12/04/2022] Open
Abstract
Multiple sclerosis was long considered a relatively rare entity in the Middle East, but research over the past 10 years and the publication of the Middle East North Africa Committee for Treatment and Research in Multiple Sclerosis guidelines for multiple sclerosis have allowed diagnosis and treatment to occur more efficiently. Most of the first and second-line disease-modifying therapies approved by the Food and Drug Administration and the European Medicine Agency are available in the Middle East. However, the availability of disease-modifying therapies is quite variable, with some countries having access to all multiple sclerosis disease-modifying therapies, while in others there is only one therapeutic option. Economic limitations remain a challenge for the management of multiple sclerosis, especially in countries of war. Moreover, the burden of multiple sclerosis treatment in Syrian and Palestinian refugees is likely high due to the non-availability of funds to cover the high cost of disease-modifying therapies.
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Affiliation(s)
- Maya M Zeineddine
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Lebanon
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117
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Gross RH, Corboy JR. Monitoring, Switching, and Stopping Multiple Sclerosis Disease-Modifying Therapies. Continuum (Minneap Minn) 2019; 25:715-735. [PMID: 31162313 DOI: 10.1212/con.0000000000000738] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW This article reviews appropriate monitoring of the various multiple sclerosis (MS) disease-modifying therapies, summarizes the reasons patients switch or stop treatment, and provides a framework for making these management decisions. RECENT FINDINGS With the increasing number of highly effective immunotherapies available for MS, the possibility of better control of the disease has increased, but with it, the potential for side effects has rendered treatment decisions more complicated. Starting treatment early with more effective and better-tolerated disease-modifying therapies reduces the likelihood of switching because of breakthrough disease or lack of compliance. Clinical and radiographic surveillance, and often blood and other paraclinical tests, should be performed periodically, depending on the disease-modifying therapy. Helping patients navigate the uncertainty around switching or stopping treatment, either temporarily or permanently, is one of the most important things we do as providers of MS care. SUMMARY Ongoing monitoring of drug therapy is a crucial component of long-term MS care. Switching treatments may be necessary for a variety of reasons. Permanent discontinuation of treatment may be appropriate for some patients with MS, although more study is needed in this area.
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Krysko KM, LaHue SC, Anderson A, Rutatangwa A, Rowles W, Schubert RD, Marcus J, Riley CS, Bevan C, Hale TW, Bove R. Minimal breast milk transfer of rituximab, a monoclonal antibody used in neurological conditions. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 7:7/1/e637. [PMID: 31719115 PMCID: PMC6857908 DOI: 10.1212/nxi.0000000000000637] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 10/01/2019] [Indexed: 12/31/2022]
Abstract
Objective To determine the transfer of rituximab, an anti-CD20 monoclonal antibody widely used for neurologic conditions, into mature breast milk. Methods Breast milk samples were collected from 9 women with MS who received rituximab 500 or 1,000 mg intravenous once or twice while breastfeeding from November 2017 to April 2019. Serial breast milk samples were collected before infusion and at 8 hours, 24 hours, 7 days, and 18–21 days after rituximab infusion in 4 patients. Five additional patients provided 1–2 samples at various times after rituximab infusion. Results The median average rituximab concentration in mature breast milk was low at 0.063 μg/mL (range 0.046–0.097) in the 4 patients with serial breast milk collection, with an estimated median absolute infant dose of 0.0094 mg/kg/d and a relative infant dose (RID) of 0.08% (range 0.06%–0.10%). Most patients had a maximum concentration at 1–7 days after infusion. The maximum concentration occurred in a woman with a single breast milk sample and was 0.29 μg/mL at 11 days postinfusion, which corresponds with an estimated RID of 0.33%. Rituximab concentration in milk was virtually undetectable by 90 days postinfusion. Conclusions We determined minimal transfer of rituximab into mature breast milk. The RID for rituximab was less than 0.4% and well below theoretically acceptable levels of less than 10%. Low oral bioavailability would probably also limit the absorption of rituximab by the newborn. In women with serious autoimmune neurologic conditions, monoclonal antibody therapy may afford an acceptable benefit to risk ratio, supporting both maternal treatment and breastfeeding.
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Affiliation(s)
- Kristen M Krysko
- From the Department of Neurology (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), University of California, San Francisco; Weill Institute for Neurosciences (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), Department of Neurology, University of California, San Francisco; Department of Neurology (J.M.), Kaiser Permanente, San Francisco; Department of Neurology (C.S.R.), Columbia University, New York, New York; Department of Neurology (C.B.), Northwestern University, Chicago, Illinois; and Department of Pediatrics (T.W.H.), Texas Tech University School of Medicine, Amarillo
| | - Sara C LaHue
- From the Department of Neurology (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), University of California, San Francisco; Weill Institute for Neurosciences (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), Department of Neurology, University of California, San Francisco; Department of Neurology (J.M.), Kaiser Permanente, San Francisco; Department of Neurology (C.S.R.), Columbia University, New York, New York; Department of Neurology (C.B.), Northwestern University, Chicago, Illinois; and Department of Pediatrics (T.W.H.), Texas Tech University School of Medicine, Amarillo
| | - Annika Anderson
- From the Department of Neurology (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), University of California, San Francisco; Weill Institute for Neurosciences (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), Department of Neurology, University of California, San Francisco; Department of Neurology (J.M.), Kaiser Permanente, San Francisco; Department of Neurology (C.S.R.), Columbia University, New York, New York; Department of Neurology (C.B.), Northwestern University, Chicago, Illinois; and Department of Pediatrics (T.W.H.), Texas Tech University School of Medicine, Amarillo
| | - Alice Rutatangwa
- From the Department of Neurology (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), University of California, San Francisco; Weill Institute for Neurosciences (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), Department of Neurology, University of California, San Francisco; Department of Neurology (J.M.), Kaiser Permanente, San Francisco; Department of Neurology (C.S.R.), Columbia University, New York, New York; Department of Neurology (C.B.), Northwestern University, Chicago, Illinois; and Department of Pediatrics (T.W.H.), Texas Tech University School of Medicine, Amarillo
| | - William Rowles
- From the Department of Neurology (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), University of California, San Francisco; Weill Institute for Neurosciences (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), Department of Neurology, University of California, San Francisco; Department of Neurology (J.M.), Kaiser Permanente, San Francisco; Department of Neurology (C.S.R.), Columbia University, New York, New York; Department of Neurology (C.B.), Northwestern University, Chicago, Illinois; and Department of Pediatrics (T.W.H.), Texas Tech University School of Medicine, Amarillo
| | - Ryan D Schubert
- From the Department of Neurology (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), University of California, San Francisco; Weill Institute for Neurosciences (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), Department of Neurology, University of California, San Francisco; Department of Neurology (J.M.), Kaiser Permanente, San Francisco; Department of Neurology (C.S.R.), Columbia University, New York, New York; Department of Neurology (C.B.), Northwestern University, Chicago, Illinois; and Department of Pediatrics (T.W.H.), Texas Tech University School of Medicine, Amarillo
| | - Jacqueline Marcus
- From the Department of Neurology (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), University of California, San Francisco; Weill Institute for Neurosciences (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), Department of Neurology, University of California, San Francisco; Department of Neurology (J.M.), Kaiser Permanente, San Francisco; Department of Neurology (C.S.R.), Columbia University, New York, New York; Department of Neurology (C.B.), Northwestern University, Chicago, Illinois; and Department of Pediatrics (T.W.H.), Texas Tech University School of Medicine, Amarillo
| | - Claire S Riley
- From the Department of Neurology (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), University of California, San Francisco; Weill Institute for Neurosciences (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), Department of Neurology, University of California, San Francisco; Department of Neurology (J.M.), Kaiser Permanente, San Francisco; Department of Neurology (C.S.R.), Columbia University, New York, New York; Department of Neurology (C.B.), Northwestern University, Chicago, Illinois; and Department of Pediatrics (T.W.H.), Texas Tech University School of Medicine, Amarillo.
| | - Carolyn Bevan
- From the Department of Neurology (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), University of California, San Francisco; Weill Institute for Neurosciences (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), Department of Neurology, University of California, San Francisco; Department of Neurology (J.M.), Kaiser Permanente, San Francisco; Department of Neurology (C.S.R.), Columbia University, New York, New York; Department of Neurology (C.B.), Northwestern University, Chicago, Illinois; and Department of Pediatrics (T.W.H.), Texas Tech University School of Medicine, Amarillo
| | - Thomas W Hale
- From the Department of Neurology (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), University of California, San Francisco; Weill Institute for Neurosciences (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), Department of Neurology, University of California, San Francisco; Department of Neurology (J.M.), Kaiser Permanente, San Francisco; Department of Neurology (C.S.R.), Columbia University, New York, New York; Department of Neurology (C.B.), Northwestern University, Chicago, Illinois; and Department of Pediatrics (T.W.H.), Texas Tech University School of Medicine, Amarillo
| | - Riley Bove
- From the Department of Neurology (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), University of California, San Francisco; Weill Institute for Neurosciences (K.M.K., S.C.L., A.A., A.R., W.R., R.D.S., R.B.), Department of Neurology, University of California, San Francisco; Department of Neurology (J.M.), Kaiser Permanente, San Francisco; Department of Neurology (C.S.R.), Columbia University, New York, New York; Department of Neurology (C.B.), Northwestern University, Chicago, Illinois; and Department of Pediatrics (T.W.H.), Texas Tech University School of Medicine, Amarillo.
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Naser Moghadasi A, Darki A, Masoumi P, Hashemi SN, Ghadiri F. Evaluating the efficacy and safety of ZytuxTM (Rituximab, AryoGen pharmed) in Iranian multiple sclerosis patients: An observational study. Mult Scler Relat Disord 2019; 36:101419. [DOI: 10.1016/j.msard.2019.101419] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 08/12/2019] [Accepted: 09/25/2019] [Indexed: 01/06/2023]
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Vollmer B, Ontaneda D, Harris H, Nair K, Bermel RA, Corboy JR, Fox RJ, Vollmer T, Cohen JA, Alvarez E, Hersh CM. Comparative discontinuation, effectiveness, and switching practices of dimethyl fumarate and fingolimod at 36-month follow-up. J Neurol Sci 2019; 407:116498. [PMID: 31644992 DOI: 10.1016/j.jns.2019.116498] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 08/18/2019] [Accepted: 09/17/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Dimethyl fumarate (DMF) and fingolimod (FTY) are approved oral disease modifying therapies (DMTs) for relapsing multiple sclerosis (MS). There are currently no known head-to-head studies comparing DMF and FTY over 36 months, which leaves their relative effectiveness unknown. OBJECTIVE To assess real-world discontinuation, effectiveness, and switching practices of DMF and FTY over 36 months along with disease activity after switching DMT. METHODS Patients prescribed DMF (n = 737) and FTY (n = 535) from two academic MS centers were retrospectively reviewed. Discontinuation and effectiveness outcomes were assessed using propensity score (PS) weighting. PS model covariates included sociodemographics and clinical and MRI characteristics. RESULTS Discontinuation was more common in DMF (58.3%) versus FTY (45.2%) over 36 months [OR = 1.81, 95% CI (1.41-2.31), p < .001], largely driven by intolerance [OR = 1.63, 95% CI (1.18-1.73), p < .001]. There were no differences in clinical relapses [OR = 1.27, 95% CI (0.90-1.79), p = .17], gadolinium-enhancing (GdE) lesions [OR = 1.25, 95% CI (0.85-1.84), p = .26], or new T2-hyperintense lesions [OR = 0.99, 95% CI (0.74-1.32), p = .93]. Within 12 months of DMF/FTY discontinuation, switchers to highly effective therapy (HET) versus other DMTs (injectables/orals) had fewer relapses (DMF/HET, 5.9% versus DMF/Other, 14.2%, p = .03; FTY/HET, 11.6% versus FTY/Other, 18.0%, p = .04) and fewer GdE lesions post-FTY (DMF/HET, 10.3% versus DMF/Other, 14.3%, p = .36; FTY/HET, 11.9% versus FTY/Other, 21.5%, p = .04). CONCLUSION This combined analysis showed similar effectiveness for DMF and FTY over 36 months with higher DMF discontinuations. Disease activity was lower in switchers to HET versus injectable/oral therapies after DMF/FTY cessation.
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Affiliation(s)
- Brandi Vollmer
- Rocky Mountain Multiple Sclerosis Center at Anschutz Medical Campus, University of Colorado, Denver, CO, United States
| | - Daniel Ontaneda
- Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH, United States
| | - Haleigh Harris
- Lou Ruvo Center for Brain Health, Cleveland Clinic, Las Vegas, NV, United States
| | - Kavita Nair
- Rocky Mountain Multiple Sclerosis Center at Anschutz Medical Campus, University of Colorado, Denver, CO, United States
| | - Robert A Bermel
- Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH, United States
| | - John R Corboy
- Rocky Mountain Multiple Sclerosis Center at Anschutz Medical Campus, University of Colorado, Denver, CO, United States
| | - Robert J Fox
- Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH, United States
| | - Timothy Vollmer
- Rocky Mountain Multiple Sclerosis Center at Anschutz Medical Campus, University of Colorado, Denver, CO, United States
| | - Jeffrey A Cohen
- Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH, United States
| | - Enrique Alvarez
- Rocky Mountain Multiple Sclerosis Center at Anschutz Medical Campus, University of Colorado, Denver, CO, United States
| | - Carrie M Hersh
- Lou Ruvo Center for Brain Health, Cleveland Clinic, Las Vegas, NV, United States.
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B-cell related biomarkers associated with severity of the first demyelinating event of acute optic neuritis. Eye (Lond) 2019; 34:954-959. [PMID: 31601977 DOI: 10.1038/s41433-019-0614-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/27/2019] [Accepted: 07/28/2019] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Optic neuritis (ON) is the most common cause of acute unilateral visual loss in young adults and frequently occurs as the presenting symptom of multiple sclerosis (MS). Recently, we reported activation of peripheral blood CD19 + B-cells in the early stage of ON. In the current study we aimed to identify peripheral blood B-cell molecular markers associated with ON severity and visual outcome. METHODS Expression of B-cell related biomarkers were analysed in patients with the first clinical presentation of acute unilateral ON. Logarithm of the Minimum Angle of Resolution (LogMAR). visual acuity, Optical Coherence Tomography (OCT) imaging, Expanded Disability Status Scale (EDSS) visual score and visual evoked responses were evaluated at onset and visual acuity and EDSS visual score were repeated at 6 months post-ON. RESULTS Thirty patients with acute unilateral ON, 77% female, mean age 33 ± 2.0 years, were enroled in the study. Expression of CD19, CD79A and CD20 B-cell markers significantly correlated with LogMAR visual acuity of the affected eye (r = 0.44, p = 0.01, r = 0.37, p = 0.01 and r = 0.36, p = 0.04, respectively). The marker levels were elevated between 1.5 and 2.2-folds in the group with worse visual acuity (LogMAR>1.0) at onset (CD79A:×1.5, p = 0.013; CD19:×2.25, p = 0.007; CD20:×1.5, p = 0.015) and not correlated with 6 month visual outcome. CONCLUSIONS Among patient with a first event of acute ON, expression of B-cell biomarkers correlated with the severity of the disease. These results could add information on the role of B-cell dysfunction in the early stages of ON.
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Zecca C, Bovis F, Novi G, Capobianco M, Lanzillo R, Frau J, Repice AM, Hakiki B, Realmuto S, Bonavita S, Curti E, Brambilla L, Mataluni G, Cavalla P, Di Sapio A, Signoriello E, Barone S, Maniscalco GT, Maietta I, Maraffi I, Boffa G, Malucchi S, Nozzolillo A, Coghe G, Mechi C, Salemi G, Gallo A, Sacco R, Cellerino M, Malentacchi M, De Angelis M, Lorefice L, Magnani E, Prestipino E, Sperli F, Brescia Morra V, Fenu G, Barilaro A, Abbadessa G, Signori A, Granella F, Amato MP, Uccelli A, Gobbi C, Sormani MP. Treatment of multiple sclerosis with rituximab: A multicentric Italian-Swiss experience. Mult Scler 2019; 26:1519-1531. [PMID: 31573386 DOI: 10.1177/1352458519872889] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Rituximab, an anti-CD20 monoclonal antibody leading to B lymphocyte depletion, is increasingly used as an off-label treatment option for multiple sclerosis (MS). OBJECTIVE To investigate the effectiveness and safety of rituximab in relapsing-remitting (RR) and progressive MS. METHODS This is a multicenter, retrospective study on consecutive MS patients treated off-label with rituximab in 22 Italian and 1 Swiss MS centers. Relapse rate, time to first relapse, Expanded Disability Status Scale (EDSS) progression, incidence of adverse events, and radiological outcomes from 2009 to 2019 were analyzed. RESULTS A total of 355/451 enrolled subjects had at least one follow-up visit and were included in the outcome analysis. Annualized relapse rate significantly decreases after rituximab initiation versus the pre-rituximab start year in RRMS (from 0.86 to 0.09, p < .0001) and in secondary-progressive (SP) MS (from 0.34 to 0.06, p < .0001) and had a slight decrease in primary-progressive (PP) MS patients (from 0.12 to 0.07, p = 0.45). After 3 years from rituximab start, the proportion of patients with a confirmed EDSS progression was 14.6% in the RRMS group, 24.7% in the SPMS group, and 41.5% in the PPMS group. No major safety concerns arose. CONCLUSION Consistently with other observational studies, our data show effectiveness of rituximab in reducing disease activity in patients with MS.
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Affiliation(s)
- Chiara Zecca
- Neurocentre of Southern Switzerland, Department of Neurology, Ospedale Civico, Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Francesca Bovis
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Giovanni Novi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Sciences (DINOGMI), University of Genoa, Genoa, Italy/IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Marco Capobianco
- SCDO Neurologia e Centro di Riferimento Regionale Sclerosi Multipla, AOU San Luigi, Orbassano, Italy
| | - Roberta Lanzillo
- Multiple Sclerosis Clinical Care and Research Centre, Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Jessica Frau
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | | | - Bahia Hakiki
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Sabrina Realmuto
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Palermo, Italy/AOOR Villa Sofia-Cervello, Centro di Neuroimmunologia, UOC di Neurologia e Stroke Unit, Palermo, Italy
| | - Simona Bonavita
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Erica Curti
- Neurosciences Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Laura Brambilla
- Department of Neuroimmunology and Neuromuscular Diseases, Foundation IRCCS Neurological Institute Carlo Besta, Milan, Italy
| | - Giorgia Mataluni
- Multiple Sclerosis Unit, Department of System Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Paola Cavalla
- Multiple Sclerosis Center, Department of Neurosciences and Mental Health, City of Health and Science University Hospital of Turin, Turin, Italy
| | - Alessia Di Sapio
- Department of Neurology, Ospedale Regina Montis Regalis-ASLCN1, Mondovì, Italy
| | - Elisabetta Signoriello
- Multiple Sclerosis Center, II Division of Neurology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Stefania Barone
- Institute of Neurology, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Giorgia T Maniscalco
- Neurological Clinic and Multiple Sclerosis Center, "AORN A.Cardarelli," Naples, Italy
| | - Ilaria Maietta
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Isabella Maraffi
- Neurocentre of Southern Switzerland, Department of Neurology, Ospedale Civico, Lugano, Switzerland
| | - Giacomo Boffa
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Sciences (DINOGMI), University of Genoa, Genoa, Italy/IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Simona Malucchi
- SCDO Neurologia e Centro di Riferimento Regionale Sclerosi Multipla, AOU San Luigi, Orbassano, Italy
| | - Agostino Nozzolillo
- Multiple Sclerosis Clinical Care and Research Centre, Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Giancarlo Coghe
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Claudia Mechi
- Regional MS Center, Careggi University Hospital, Florence, Italy
| | - Giuseppe Salemi
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Antonio Gallo
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Rosaria Sacco
- Neurocentre of Southern Switzerland, Department of Neurology, Ospedale Civico, Lugano, Switzerland
| | - Maria Cellerino
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Sciences (DINOGMI), University of Genoa, Genoa, Italy/IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Maria Malentacchi
- SCDO Neurologia e Centro di Riferimento Regionale Sclerosi Multipla, AOU San Luigi, Orbassano, Italy
| | - Marcello De Angelis
- Multiple Sclerosis Clinical Care and Research Centre, Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Lorena Lorefice
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Eliana Magnani
- Regional MS Center, Careggi University Hospital, Florence, Italy
| | - Elio Prestipino
- NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy
| | - Francesca Sperli
- SCDO Neurologia e Centro di Riferimento Regionale Sclerosi Multipla, AOU San Luigi, Orbassano, Italy
| | - Vincenzo Brescia Morra
- Multiple Sclerosis Clinical Care and Research Centre, Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Giuseppe Fenu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | | | - Gianmarco Abbadessa
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Alessio Signori
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Franco Granella
- Neurosciences Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Maria Pia Amato
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy/NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy
| | - Antonio Uccelli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Sciences (DINOGMI), University of Genoa, Genoa, Italy/IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Claudio Gobbi
- Neurocentre of Southern Switzerland, Department of Neurology, Ospedale Civico, Lugano, Switzerland
| | - Maria Pia Sormani
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy/IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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Granqvist M, Burman J, Gunnarsson M, Lycke J, Nilsson P, Olsson T, Sundström P, Svenningsson A, Vrethem M, Frisell T, Piehl F. Comparative effectiveness of dimethyl fumarate as the initial and secondary treatment for MS. Mult Scler 2019; 26:1532-1539. [DOI: 10.1177/1352458519866600] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Population-based real-world evidence studies of the effectiveness and tolerability of dimethyl fumarate in relation to common treatment alternatives are still limited. Objective: To evaluate the clinical effectiveness and tolerability of dimethyl fumarate (DMF) as the initial and secondary treatment for relapsing-remitting multiple sclerosis (RRMS) patients compared with common treatment alternatives in Sweden. Methods: We conducted a nationwide retrospective observational cohort study of all RRMS patients identified through the Swedish MS registry initiating DMF ( n = 641) or interferons/glatiramer acetate (IFN/GA; n = 555) as the initial therapy, or DMF ( n = 703) or fingolimod (FGL; n = 194) after switch from IFN/GA between 1 January 2014 and 31 December 2016. Results: The discontinuation rate was lower with DMF as the initial treatment than IFN/GA (adjusted hazard rate (HR): 0.46, 95% confidence interval (CI): 0.37–0.58, p < 0.001), but higher than FGL as the secondary treatment (HR: 1.51, CI: 1.08–2.09, p < 0.05). Annualized relapse rate (ARR) was lower with DMF compared to IFN/GA (0.04, CI: 0.03–0.06 vs 0.10, CI: 0.07–0.13; p < 0.05), but not FGL (0.03, CI: 0.02–0.05 vs 0.02, CI: 0.01–0.04; p = 0.41). Finally, time to first relapse (TTFR) was longer with DMF as the initial, but not secondary, therapy ( p < 0.05 and p = 0.20, respectively). Conclusion: Our findings indicate that DMF performs better than IFN/GA as the initial treatment for RRMS. Compared to FGL, DMF displayed a lower tolerability, but largely similar effectiveness outcomes.
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Affiliation(s)
- Mathias Granqvist
- Department of Clinical Neuroscience, Center for Molecular Medicine (CMM), Karolinska Institutet, Stockholm, Sweden
| | - Joachim Burman
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | | | - Jan Lycke
- Department of Neuroscience and Physiology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Petra Nilsson
- Neurology Clinic, Skåne University Hospital, Lund, Sweden
| | - Tomas Olsson
- Department of Clinical Neuroscience, Center for Molecular Medicine (CMM), Karolinska Institutet, Stockholm, Sweden
| | - Peter Sundström
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Anders Svenningsson
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Vrethem
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Thomas Frisell
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Center for Molecular Medicine (CMM), Karolinska Institutet, Stockholm, Sweden
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Leonidou E, Pantzaris M, Kleopa KA, Loizidou MA, Kyriakides T, Christou YP. A retrospective observational study of rituximab treatment in multiple sclerosis patients in Cyprus. Postgrad Med 2019; 131:486-489. [DOI: 10.1080/00325481.2019.1649975] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Eleni Leonidou
- Neurology Clinic C, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Marios Pantzaris
- Neurology Clinic C, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
- The Cyprus School of Molecular Medicine, Nicosia, Cyprus
| | - Kleopas A. Kleopa
- The Cyprus School of Molecular Medicine, Nicosia, Cyprus
- Neurology Clinic E, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Maria A. Loizidou
- Department of EM/Molecular Pathology, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Theodoros Kyriakides
- The Cyprus School of Molecular Medicine, Nicosia, Cyprus
- Neurology Clinic A, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Yiolanda P. Christou
- Neurology Clinic D, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
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Observational designs in clinical multiple sclerosis research: Particulars, practices and potentialities. Mult Scler Relat Disord 2019; 35:142-149. [PMID: 31394404 DOI: 10.1016/j.msard.2019.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 07/03/2019] [Accepted: 07/19/2019] [Indexed: 11/24/2022]
Abstract
Observational studies investigate a wide range of topics in multiple sclerosis research. This paper presents an overview of the various observational designs and their applications in clinical studies. Observational studies are well suited for making discoveries and assessing new explanations of phenomena, but less so for establishing causal relationships, due to confounding by indication (selection bias), co-morbidity, socio-economic or other factors. Whether observational findings are demonstrative, indicative or only suggestive, depends on the research question, whether and how the design fits this question, analytical techniques, and the quality of data. Observational studies may be cross-sectional vs. longitudinal, and prospective vs. retrospective. The term 'retrograde' is proposed to explicate that cross-sectional studies may obtain data that cover (long) preceding periods. Case reports and case series are usually based on accidental observations or routinely collected data. Cross-sectional studies, by simultaneously assessing clinical phenomena and external factors, enable the discovery and quantification of associations. In ecological studies the unit of analysis is population or group, and relationships on patient level cannot be established. A cohort study is a longitudinal study that investigates patients with a defining characteristic, e.g. diagnosis or specific treatment, by analyzing data acquired at various intervals. Prospective cohort studies use (some) data that are not yet available at the time the research is conceived, whereas in retrospective studies the data already exist. In a case-control study a representative group of patients with a specific clinical feature is compared with controls, and the frequencies at which an external factor, e.g. infection, has occurred in each group is compared; in a nested case-control study controls are drawn from a fully known cohort. Randomized controlled trial (RCT)-extension studies are informative because, due to RCT randomization, they are free from confounding by indication. Patient or disease registries are organised systems for the long-term collection of uniform data on a population that is defined by a particular disease, condition or exposure, with the purpose to study changes over time. In pharmacotherapeutic research, accidental observations of unexpected beneficial effects may lead to further research into a drug's efficacy in other conditions. Uncontrolled phase 1 studies investigate safety and dosing aspects. Observational studies are alternatives to RCTs when these are not feasible for ethical or practical reasons. Phase 4 observational studies play a crucial role in the evaluation of the effectiveness of treatments in daily practice, the validation of RCT-based side effect profiles, and the discovery of late occurring or rare, potentially life-threatening side effects. Combinations of multidisciplinary longitudinal data bases into large data sets enable the development of algorithms for personalized treatments. To improve the reporting of observational findings on treatment effectiveness, it is proposed that abstracts define the research question(s) the study was meant to answer, study design and analytical methods, and identify and quantify the patient population, treatment of interest, relevant outcomes and the study's strengths and limitations. The development of guidelines for Strengthening the Reporting of Observational Studies in Effectiveness Research (STROBER), as an extension of the guidelines used in epidemiology, is wanted.
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Skoog B, Link J, Tedeholm H, Longfils M, Nerman O, Fagius J, Andersen O. Short-term prediction of secondary progression in a sliding window: A test of a predicting algorithm in a validation cohort. Mult Scler J Exp Transl Clin 2019; 5:2055217319875466. [PMID: 35145727 PMCID: PMC8822449 DOI: 10.1177/2055217319875466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 08/14/2019] [Accepted: 08/19/2019] [Indexed: 12/03/2022] Open
Abstract
Introduction The Multiple Sclerosis Prediction Score (MSPS, www.msprediction.com) estimates, for any month during the course of relapsing–remitting multiple sclerosis (MS), the individual risk of transition to secondary progression (SP) during the following year. Objective Internal verification of the MSPS algorithm in a derivation cohort, the Gothenburg Incidence Cohort (GIC, n = 144) and external verification in the Uppsala MS cohort (UMS, n = 145). Methods Starting from their second relapse, patients were included and followed for 25 years. A matrix of MSPS values was created. From this matrix, a goodness-of-fit test and suitable diagnostic plots were derived to compare MSPS-calculated and observed outcomes (i.e. transition to SP). Results The median time to SP was slightly longer in the UMS than in the GIC, 15 vs. 11.5 years (p = 0.19). The MSPS was calibrated with multiplicative factors: 0.599 for the UMS and 0.829 for the GIC; the calibrated MSPS provided a good fit between expected and observed outcomes (chi-square p = 0.61 for the UMS), which indicated the model was not rejected. Conclusion The results suggest that the MSPS has clinically relevant generalizability in new cohorts, provided that the MSPS was calibrated to the actual overall SP incidence in the cohort.
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Affiliation(s)
- B Skoog
- University of Gothenburg, the Sahlgrenska Academy, Institute of Neuroscience and Physiology, Section of Clinical Neuroscience and Rehabilitation, Sweden
| | - J Link
- Department of Clinical Neuroscience, Karolinska Institutet, Sweden
| | - H Tedeholm
- University of Gothenburg, the Sahlgrenska Academy, Institute of Neuroscience and Physiology, Section of Clinical Neuroscience and Rehabilitation, Sweden
| | - M Longfils
- Department of Mathematical Sciences, Chalmers University of Technology, Sweden
| | - O Nerman
- Department of Mathematical Sciences, Chalmers University of Technology, Sweden
| | - J Fagius
- Neurology, Department of Neuroscience, Uppsala University, Sweden
| | - O Andersen
- University of Gothenburg, the Sahlgrenska Academy, Institute of Neuroscience and Physiology, Section of Clinical Neuroscience and Rehabilitation, Sweden
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Abstract
Rituximab, a chimeric anti-CD20-antibody, attracts increasing attention as a treatment option for multiple sclerosis (MS). Apart from smaller controlled trials, an increasing number of studies in real-world populations indicate high efficacy based on clinical and neuroradiological outcomes for rituximab in relapsing-remitting MS patients. Additional evidence also demonstrates efficacy of rituximab with treatment of progressive MS phenotypes. In this topical review, we summarize and discuss current evidence on mechanisms of action, efficacy, safety, tolerance and other clinical aspects of rituximab in the treatment of MS. Finally, we will highlight current knowledge gaps and the need for comparative studies with other disease-modifying therapies in MS.
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Affiliation(s)
- Benjamin V Ineichen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden Division of Neuroradiology, Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Moridi
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden Center for Neurology, Academic Specialist Center, Stockholm Health Services, Stockholm, Sweden
| | - Tobias Granberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden Division of Neuroradiology, Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden Center for Neurology, Academic Specialist Center, Stockholm Health Services, Stockholm, Sweden
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Abstract
Pediatric-onset multiple sclerosis (MS) comprises 2-5% of MS cases, and is known to be associated with high disease activity and the accumulation of disability at an earlier age than their adult-onset counterparts. Appropriate therapy leading to disease control has the potential to alter the known trajectory of adverse long-term physical, cognitive, and psychosocial outcomes in this population. Thus, optimizing treatment for children and adolescents with MS is of paramount importance. The last decade has seen a growing number of disease-modifying therapies approved for relapsing MS in adults, and available agents now include oral, injectable, and infusion therapies. Recently, the development of randomized controlled MS trials in youth has led to the first agent approved by the US FDA for the treatment of pediatric MS-fingolimod. With this, we have entered a new era of knowledge and treatment in this population and ongoing pediatric trials are expected to further inform clinical management. With the emergence of highly effective therapies targeting the inflammatory component of the disease, there has been increased interest in identifying treatment strategies that instead target mechanisms such as remyelination/repair, neuroprotection, or rehabilitation. The potential role for such emerging therapies in the treatment of pediatric MS remains an important area of study. In this review, we discuss current evidence for MS therapies in children including the treatment of acute relapses, disease-modifying therapies, and symptomatic management. We will also discuss evidence for emerging therapies, including remyelinating and neuroprotective agents.
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Affiliation(s)
- Colin Wilbur
- Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - E Ann Yeh
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada.
- Division of Neurosciences and Mental Health, SickKids Research Institute, Toronto, ON, Canada.
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
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Moss BP, Cohen JA. The emergence of follow-on disease-modifying therapies for multiple sclerosis. Mult Scler 2019; 25:1560-1565. [DOI: 10.1177/1352458519845106] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Medication prices are a major contributor to the high cost of care for multiple sclerosis. Three generic glatiramer acetate products have regulatory approval in North America, Europe, or Latin America. The pending expiration of patents for other disease-modifying therapies for relapsing multiple sclerosis creates the opportunity for development and regulatory approval of additional follow-on alternatives (generics or biosimilars), potentially providing lower prices and cost savings to payors and patients. However, the complexities of development, regulatory approval, and marketing of follow-on products have some important differences compared to those of new drugs. This topical review provides background and a status update on the development of follow-on disease-modifying medications to treat multiple sclerosis.
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Affiliation(s)
- Brandon P Moss
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jeffrey A Cohen
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
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D'Amico E, Zanghì A, Gastaldi M, Patti F, Zappia M, Franciotta D. Placing CD20-targeted B cell depletion in multiple sclerosis therapeutic scenario: Present and future perspectives. Autoimmun Rev 2019; 18:665-672. [PMID: 31059839 DOI: 10.1016/j.autrev.2019.05.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 01/18/2019] [Indexed: 12/26/2022]
Abstract
Multiple sclerosis (MS) is an acquired demyelinating disease of the central nervous system (CNS) that traditionally has been considered to be mediated primarily by T cells. Increasing evidence, however, suggests the fundamental role of B cells in the pathogenesis and development of the disease. Recently, anti-CD20 B cell-based therapies have demonstrated impressive and somewhat surprising results in MS, showing profound anti-inflammatory effects with a favorable risk-benefit ratio. Moreover, for the first time in the MS therapeutic scenario, the anti-CD20 monoclonal antibody ocrelizumab has been granted for the treatment of the primary progressive form of the disease. In this review, we provide a brief overview about anti-CD20 B cell-based therapies in MS, in the perspective of their influence on the future management of the disease, and of their possible positioning in a new wider therapeutic scenario.
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Affiliation(s)
| | - Aurora Zanghì
- Department G.F.Ingrassia, University of Catania, Italy
| | - Matteo Gastaldi
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
| | | | - Mario Zappia
- Department G.F.Ingrassia, University of Catania, Italy
| | - Diego Franciotta
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
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Boremalm M, Juto A, Axelsson M, Novakova L, Frisell T, Svenningsson A, Lycke J, Piehl F, Salzer J. Natalizumab, rituximab and fingolimod as escalation therapy in multiple sclerosis. Eur J Neurol 2019; 26:1060-1067. [PMID: 30762259 DOI: 10.1111/ene.13936] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 02/12/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND PURPOSE Breakthrough disease on first-line injectables in relapsing-remitting multiple sclerosis (RRMS) is a common clinical situation where comparative studies between different escalation therapies are lacking. The aim of this study was to compare the efficacy, safety and medication persistence of natalizumab (NTZ), rituximab (RTX) and fingolimod (FGL) as escalation therapy in RRMS. METHODS Patients switching from interferon or glatiramer acetate to NTZ, RTX or FGL due to breakthrough disease were identified through the Swedish multiple sclerosis (MS) registry at four large MS centers in this retrospective observational study. Data were collected from the MS registry and medical charts. Hazard ratios (HRs) for relapses, adverse events and drug discontinuation with 95% confidence interval (CI) were calculated using multivariable confounder-adjusted Cox proportional hazard models. RESULTS A total of 241 patients were included. The annualized relapse rates were 0.02 for NTZ, 0.03 for RTX and 0.07 for FGL. Compared with NTZ, the adjusted HR for relapse was 1.0 (95% CI, 0.2-5.6) for RTX and 3.4 (95% CI, 1.3-9.2) for FGL. The annualized drug discontinuation rates were 0.15, 0.01 and 0.15 for NTZ, RTX and FGL, respectively. The adjusted HR for drug discontinuation was 0.05 (95% CI, 0.01-0.38) for RTX and 1.0 (95% CI, 0.6-1.7) for FGL vs. NTZ. CONCLUSIONS In patients with RRMS on interferon/glatiramer acetate with breakthrough disease, switching to NTZ or RTX was associated with less disease activity compared with FGL. RTX displayed superior medication persistence compared with both NTZ and FGL.
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Affiliation(s)
- M Boremalm
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå
| | - A Juto
- Department of Clinical Neuroscience, Center for Molecular Medicine, Karolinska Institutet, University Hospital Solna, Stockholm
| | - M Axelsson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg
| | - L Novakova
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg
| | - T Frisell
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm
| | - A Svenningsson
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm
| | - J Lycke
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg
| | - F Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - J Salzer
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå
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Efficacy and safety of rituximab for relapsing-remitting multiple sclerosis: A systematic review and meta-analysis. Autoimmun Rev 2019; 18:542-548. [PMID: 30844555 DOI: 10.1016/j.autrev.2019.03.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 12/29/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of rituximab for relapsing-remitting multiple sclerosis. RESULTS Fifteen studies that collectively included 946 patients were selected for the meta-analysis. Rituximab therapy was associated with the mean annualized relapse rates decreasing by 0.80 (95% confidence interval, 0.45-1.15) and the mean Expanded Disability Status Scale score decreasing by 0.46 (95% confidence interval, 0.05-0.87). The likelihood of patients experiencing a relapse after starting rituximab therapy was only 15% (95% confidence interval, 7%-26%). Although mild-to-moderate adverse events occurred in 29.6% of the patients, there were no severe adverse events. CONCLUSIONS AND RELEVANCE This systematic review and meta-analysis shows that rituximab is associated with reduced annualized relapse rates and disability levels in patients with relapsing-remitting multiple sclerosis. It is also well tolerated and is not associated with serious adverse events.
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Gregson A, Thompson K, Tsirka SE, Selwood DL. Emerging small-molecule treatments for multiple sclerosis: focus on B cells. F1000Res 2019; 8:F1000 Faculty Rev-245. [PMID: 30863536 PMCID: PMC6402079 DOI: 10.12688/f1000research.16495.1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2019] [Indexed: 12/27/2022] Open
Abstract
Multiple sclerosis (MS) is a major cause of disability in young adults. Following an unknown trigger (or triggers), the immune system attacks the myelin sheath surrounding axons, leading to progressive nerve cell death. Antibodies and small-molecule drugs directed against B cells have demonstrated good efficacy in slowing progression of the disease. This review focusses on small-molecule drugs that can affect B-cell biology and may have utility in disease management. The risk genes for MS are examined from the drug target perspective. Existing small-molecule therapies for MS with B-cell actions together with new drugs in development are described. The potential for experimental molecules with B-cell effects is also considered. Small molecules can have diverse actions on B cells and be cytotoxic, anti-inflammatory and anti-viral. The current B cell-directed therapies often kill B-cell subsets, which can be effective but lead to side effects and toxicity. A deeper understanding of B-cell biology and the effect on MS disease should lead to new drugs with better selectivity, efficacy, and an improved safety profile. Small-molecule drugs, once the patent term has expired, provide a uniquely sustainable form of healthcare.
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Affiliation(s)
- Aaron Gregson
- The Wolfson Institute for Biomedical Research, University College London, Gower Street, London, WC1E 6BT, UK
| | - Kaitlyn Thompson
- Department of Pharmacological Sciences, Stony Brook University, Stony Brook, New York, 11794, USA
| | - Stella E Tsirka
- Department of Pharmacological Sciences, Stony Brook University, Stony Brook, New York, 11794, USA
| | - David L Selwood
- The Wolfson Institute for Biomedical Research, University College London, Gower Street, London, WC1E 6BT, UK
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Honce JM, Nair KV, Sillau S, Valdez B, Miravalle A, Alvarez E, Schreiner T, Corboy JR, Vollmer TL. Rituximab vs placebo induction prior to glatiramer acetate monotherapy in multiple sclerosis. Neurology 2019; 92:e723-e732. [PMID: 30635477 PMCID: PMC6382366 DOI: 10.1212/wnl.0000000000006916] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 10/05/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine whether rituximab induction followed by glatiramer acetate (GA) monotherapy is more effective than GA alone for the treatment of relapsing multiple sclerosis with active disease. METHODS This was a single-center, double-blind, placebo-controlled study. Fifty-five participants were randomly assigned (1:1 ratio) to either rituximab (R-GA) or placebo (P-GA) induction, followed by GA therapy initiated in all participants. Participants were followed up to 3 years. The primary endpoint was the number of participants with no evidence of disease activity (NEDA): those without relapse, new MRI lesions, and sustained change in disability. RESULTS Twenty-eight and 27 participants received rituximab and placebo induction, respectively, with one participant in each arm withdrawing before 6-month MRI. There were no significant differences in baseline characteristics. At end of study, 44.44% of R-GA participants demonstrated NEDA vs 19.23% of P-GA participants (p = 0.049). Treatment failed for a smaller proportion of R-GA participants (37.04% R-GA vs 69.23% P-GA, p = 0.019), and time to treatment failure was longer (23.32 months R-GA vs 11.29 months P-GA, p = 0.027). Fewer participants in the R-GA arm had new lesions (25.93% R-GA vs 61.54% P-GA, p = 0.009), and there were fewer new T2 lesions (0.48 R-GA vs 1.96 P-GA, p = 0.027). Probability of demonstrating NEDA in the R-GA arm returned to baseline within the study period. There were no differences in adverse events. CONCLUSIONS Induction therapy with rituximab followed by GA may provide superior efficacy in the short term than GA alone in relapsing multiple sclerosis, but this benefit appears to wane within the study period. Larger studies are needed to assess sustainability of results. CLINICALTRIALSGOV IDENTIFIER NCT01569451.
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Affiliation(s)
- Justin M Honce
- From the Departments of Radiology (J.M.H.) and Clinical Pharmacy (K.V.N.), University of Colorado Hospital, Aurora; Department of Neurology (K.V.N., S.S., B.V., E.A., T.S., J.R.C., T.L.V.), University of Colorado, and Rocky Mountain Multiple Sclerosis Center at the University of Colorado, Aurora; and Department of Neurology (A.M.), University of Florida, Gainesville. Dr. Miravalle is currently at Advanced Neurology of Colorado, Fort Collins, Colorado
| | - Kavita V Nair
- From the Departments of Radiology (J.M.H.) and Clinical Pharmacy (K.V.N.), University of Colorado Hospital, Aurora; Department of Neurology (K.V.N., S.S., B.V., E.A., T.S., J.R.C., T.L.V.), University of Colorado, and Rocky Mountain Multiple Sclerosis Center at the University of Colorado, Aurora; and Department of Neurology (A.M.), University of Florida, Gainesville. Dr. Miravalle is currently at Advanced Neurology of Colorado, Fort Collins, Colorado
| | - Stefan Sillau
- From the Departments of Radiology (J.M.H.) and Clinical Pharmacy (K.V.N.), University of Colorado Hospital, Aurora; Department of Neurology (K.V.N., S.S., B.V., E.A., T.S., J.R.C., T.L.V.), University of Colorado, and Rocky Mountain Multiple Sclerosis Center at the University of Colorado, Aurora; and Department of Neurology (A.M.), University of Florida, Gainesville. Dr. Miravalle is currently at Advanced Neurology of Colorado, Fort Collins, Colorado
| | - Brooke Valdez
- From the Departments of Radiology (J.M.H.) and Clinical Pharmacy (K.V.N.), University of Colorado Hospital, Aurora; Department of Neurology (K.V.N., S.S., B.V., E.A., T.S., J.R.C., T.L.V.), University of Colorado, and Rocky Mountain Multiple Sclerosis Center at the University of Colorado, Aurora; and Department of Neurology (A.M.), University of Florida, Gainesville. Dr. Miravalle is currently at Advanced Neurology of Colorado, Fort Collins, Colorado
| | - Augusto Miravalle
- From the Departments of Radiology (J.M.H.) and Clinical Pharmacy (K.V.N.), University of Colorado Hospital, Aurora; Department of Neurology (K.V.N., S.S., B.V., E.A., T.S., J.R.C., T.L.V.), University of Colorado, and Rocky Mountain Multiple Sclerosis Center at the University of Colorado, Aurora; and Department of Neurology (A.M.), University of Florida, Gainesville. Dr. Miravalle is currently at Advanced Neurology of Colorado, Fort Collins, Colorado
| | - Enrique Alvarez
- From the Departments of Radiology (J.M.H.) and Clinical Pharmacy (K.V.N.), University of Colorado Hospital, Aurora; Department of Neurology (K.V.N., S.S., B.V., E.A., T.S., J.R.C., T.L.V.), University of Colorado, and Rocky Mountain Multiple Sclerosis Center at the University of Colorado, Aurora; and Department of Neurology (A.M.), University of Florida, Gainesville. Dr. Miravalle is currently at Advanced Neurology of Colorado, Fort Collins, Colorado
| | - Teri Schreiner
- From the Departments of Radiology (J.M.H.) and Clinical Pharmacy (K.V.N.), University of Colorado Hospital, Aurora; Department of Neurology (K.V.N., S.S., B.V., E.A., T.S., J.R.C., T.L.V.), University of Colorado, and Rocky Mountain Multiple Sclerosis Center at the University of Colorado, Aurora; and Department of Neurology (A.M.), University of Florida, Gainesville. Dr. Miravalle is currently at Advanced Neurology of Colorado, Fort Collins, Colorado
| | - John R Corboy
- From the Departments of Radiology (J.M.H.) and Clinical Pharmacy (K.V.N.), University of Colorado Hospital, Aurora; Department of Neurology (K.V.N., S.S., B.V., E.A., T.S., J.R.C., T.L.V.), University of Colorado, and Rocky Mountain Multiple Sclerosis Center at the University of Colorado, Aurora; and Department of Neurology (A.M.), University of Florida, Gainesville. Dr. Miravalle is currently at Advanced Neurology of Colorado, Fort Collins, Colorado
| | - Timothy L Vollmer
- From the Departments of Radiology (J.M.H.) and Clinical Pharmacy (K.V.N.), University of Colorado Hospital, Aurora; Department of Neurology (K.V.N., S.S., B.V., E.A., T.S., J.R.C., T.L.V.), University of Colorado, and Rocky Mountain Multiple Sclerosis Center at the University of Colorado, Aurora; and Department of Neurology (A.M.), University of Florida, Gainesville. Dr. Miravalle is currently at Advanced Neurology of Colorado, Fort Collins, Colorado.
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Whittam DH, Tallantyre EC, Jolles S, Huda S, Moots RJ, Kim HJ, Robertson NP, Cree BAC, Jacob A. Rituximab in neurological disease: principles, evidence and practice. Pract Neurol 2019; 19:5-20. [PMID: 30498056 DOI: 10.1136/practneurol-2018-001899] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Rituximab is a widely used B-cell-depleting monoclonal antibody. It is unlicensed for use in neurological disorders and there are no treatment guidelines. However, as a rapidly acting, targeted therapy with growing evidence of efficacy and tolerability in several neuroinflammatory disorders, it is an attractive alternative to conventional immunomodulatory medications. This practical review aims to explain the basic principles of B-cell depletion with therapeutic monoclonal antibodies. We present the evidence for using rituximab in neurological diseases, and describe the practical aspects of prescribing, including dosing, monitoring, safety, treatment failure and its use in special circumstances such as coexisting viral hepatitis, pregnancy and lactation. We provide an administration guide, checklist and patient information leaflet, which can be adapted for local use. Finally, we review the safety data of rituximab and ocrelizumab (a newer and recently licensed B-cell-depleting therapy for multiple sclerosis) and suggest monitoring and risk reduction strategies.
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Affiliation(s)
- Daniel H Whittam
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Emma C Tallantyre
- Helen Durham Centre for Neuroinflammation, University Hospital or Wales, Cardiff, UK
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
- School of Medicine, Cardiff University, Cardiff, UK
| | - Saif Huda
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Robert J Moots
- Department of Musculoskeletal Diseases, Institute of Ageing and Chronic Diseases, University of Liverpool, Liverpool, UK
| | - Ho Jin Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, South Korea
| | - Neil P Robertson
- Helen Durham Centre for Neuroinflammation, University Hospital or Wales, Cardiff, UK
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Bruce A C Cree
- Weill Institute for Neurosciences, University of California, San Francisco, California, USA
| | - Anu Jacob
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
- School of Medicine, University of Liverpool, Liverpool, UK
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Myhr KM, Torkildsen Ø, Lossius A, Bø L, Holmøy T. B cell depletion in the treatment of multiple sclerosis. Expert Opin Biol Ther 2019; 19:261-271. [PMID: 30632834 DOI: 10.1080/14712598.2019.1568407] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system. The latest development of B-cell depletion by anti-CD20 monoclonal antibodies has been a large step forward in the treatment of this devastating disease. AREAS COVERED In this manuscript, we review mechanisms of action, efficacy, safety, and tolerance of anti-CD20 therapies for MS, including rituximab, ocrelizumab, and ofatumumab. EXPERT OPINION B-cell depletion efficiently suppresses acute inflammatory disease activity in relapsing-remitting MS (RRMS), and may slowdown progression in primary progressive MS (PPMS). The treatment is generally well tolerated, with manageable adverse events related to infusion reactions and infections. Ocrelizumab, a humanized anti-CD20 monoclonal antibody, is the first therapy to be approved for the treatment of both RRMS and PPMS.
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Affiliation(s)
- Kjell-Morten Myhr
- a Department of Clinical Medicine , University of Bergen , Bergen , Norway.,b Department of Neurology , Haukeland University Hospital , Bergen , Norway
| | - Øivind Torkildsen
- a Department of Clinical Medicine , University of Bergen , Bergen , Norway.,b Department of Neurology , Haukeland University Hospital , Bergen , Norway
| | - Andreas Lossius
- c Department of Neurology , Akershus University Hospital , Lørenskog , Norway.,d Department of Immunology and Transfusion Medicine, Faculty of Medicine , University of Oslo and Oslo University Hospital Rikshospitalet , Oslo , Norway
| | - Lars Bø
- a Department of Clinical Medicine , University of Bergen , Bergen , Norway.,b Department of Neurology , Haukeland University Hospital , Bergen , Norway
| | - Trygve Holmøy
- c Department of Neurology , Akershus University Hospital , Lørenskog , Norway.,e Department of Clinical Medicine , University of Oslo , Oslo , Norway
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Vollmer BL, Nair KV, Sillau S, Corboy JR, Vollmer T, Alvarez E. Natalizumab versus fingolimod and dimethyl fumarate in multiple sclerosis treatment. Ann Clin Transl Neurol 2018; 6:252-262. [PMID: 30847358 PMCID: PMC6389745 DOI: 10.1002/acn3.700] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 10/04/2018] [Accepted: 10/21/2018] [Indexed: 12/16/2022] Open
Abstract
Objective To compare 2‐year effectiveness and discontinuation of natalizumab (NTZ) versus fingolimod (FTY) and dimethyl fumarate (DMF) in the treatment of multiple sclerosis (MS). Methods Patients prescribed NTZ, FTY, or DMF at the Rocky Mountain MS Center at University of Colorado were identified. Clinician‐reported data were retrospectively collected. Outcomes include a composite effectiveness measure consisting of new T2 lesion, gadolinium‐enhancing lesion, and/or clinical relapse, individual effectiveness outcomes and discontinuation over 2 years. Logistic regression was used for data analysis on patients matched by propensity scores and using ATT doubly robust weighting estimator. Results A total of 451, 271, and 342 patients were evaluated on NTZ, FTY, and DMF over 2 years, respectively. Patients had a mean age of 39.8 (NTZ), 42.5(FTY), and 45.8 (DMF) years; were predominantly female (76.7% NTZ; 72.0% FTY; 69.6% DMF); and had a mean MS disease duration of 11–12 years for all groups. At ≤24 months, 22.2%, 34.7%, and 33.6% experienced a new T2 lesion, gadolinium‐enhancing lesion, and/or clinical relapse on NTZ, FTY, and DMF, respectively. Using ATT doubly robust weighting estimator, FTY versus NTZ and DMF versus NTZ had an odds ratio of 2.00 (95%CI:[1.41–2.85], P < 0.001) and 2.38 [95% CI: 1.68–3.37], P < 0.001) respectively, for experiencing a new T2 lesion, gadolinium enhancing lesion, and/or clinical relapse. At ≤24 months, 32.6%, 34.3%, and 47.1% discontinued NTZ, FTY, and DMF, respectively. The majority of discontinuations were due to becoming JCV positive(12.6%) for NTZ and due to adverse events for both FTY(17%) and DMF(24.0%). Interpretation NTZ appears to be more effective and tolerable than FTY and DMF.
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Affiliation(s)
- Brandi L Vollmer
- Division of Neuroimmunology Department of Neurology Rocky Mountain Multiple Sclerosis Center at the University of Colorado Aurora Colorado
| | - Kavita V Nair
- Division of Neuroimmunology Department of Neurology Rocky Mountain Multiple Sclerosis Center at the University of Colorado Aurora Colorado.,Skaggs School of Pharmacy and Pharmaceutical Sciences University of Colorado Aurora Colorado
| | - Stefan Sillau
- Division of Neuroimmunology Department of Neurology Rocky Mountain Multiple Sclerosis Center at the University of Colorado Aurora Colorado
| | - John R Corboy
- Division of Neuroimmunology Department of Neurology Rocky Mountain Multiple Sclerosis Center at the University of Colorado Aurora Colorado
| | - Timothy Vollmer
- Division of Neuroimmunology Department of Neurology Rocky Mountain Multiple Sclerosis Center at the University of Colorado Aurora Colorado
| | - Enrique Alvarez
- Division of Neuroimmunology Department of Neurology Rocky Mountain Multiple Sclerosis Center at the University of Colorado Aurora Colorado
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139
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Safety and Efficacy of Rituximab in Multiple Sclerosis: A Retrospective Observational Study. J Immunol Res 2018; 2018:9084759. [PMID: 30539030 PMCID: PMC6260423 DOI: 10.1155/2018/9084759] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 08/31/2018] [Accepted: 09/16/2018] [Indexed: 12/18/2022] Open
Abstract
Objective To evaluate the efficacy and safety of rituximab in multiple sclerosis in a clinical practice setting. Methods Clinical data for all adult patients with multiple sclerosis (MS) treated with off-label rituximab at a single MS center in Lebanon between March 2008 and April 2017 were retrospectively collected from medical charts. The main efficacy outcomes assessed were annualized relapse rate (ARR) and proportion of patients free from relapses, disability progression, or magnetic resonance imaging (MRI) activity. Results A total of 89 rituximab-treated patients were included: 59 relapsing-remitting MS (RRMS) and 30 progressive MS (PMS). Patients were treated with 1000 or 2000 mg rituximab IV every 6-12 months for a mean duration of 22.2 ± 24.8 months. The subjects were 65.2% females with a mean age of 40.5 ± 12.3 years and a mean disease duration of 7.9 ± 6.2 years. During treatment, the ARR decreased from 1.07 at baseline to 0.11 in RRMS (p < 0.0001) and from 0.25 to 0.16 in PMS patients (p = 0.593). The mean Expanded Disability Status Scale (EDSS) remained unchanged in both RRMS and PMS patients. Between baseline and the last follow-up, the percent of patients free from any new MRI lesions increased from 18.6% to 92.6% in the RRMS group and from 43.3% to 82% in the PMS group. No evidence of disease activity (NEDA) was achieved in 74% of patients at 1 year of treatment. A total of 64 adverse events (AEs) (71.9%) were recorded with the most common being infusion-related reactions in 25.8% of patients, all mild in nature. Two of our rituximab-treated patients experienced serious AEs requiring surgical interventions: pyoderma gangrenosum vaginalis with perianal abscess and fistula and an increase in the size of a meningioma. No case of progressive multifocal leukoencephalopathy (PML) was detected. Conclusion In our real-world cohort, rituximab was well-tolerated and effective in reducing relapse rate and disability progression in relapsing-remitting and progressive MS patients.
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Abstract
Multiple sclerosis (MS) is the most common chronic inflammatory, demyelinating and neurodegenerative disease of the central nervous system in young adults. This disorder is a heterogeneous, multifactorial, immune-mediated disease that is influenced by both genetic and environmental factors. In most patients, reversible episodes of neurological dysfunction lasting several days or weeks characterize the initial stages of the disease (that is, clinically isolated syndrome and relapsing-remitting MS). Over time, irreversible clinical and cognitive deficits develop. A minority of patients have a progressive disease course from the onset. The pathological hallmark of MS is the formation of demyelinating lesions in the brain and spinal cord, which can be associated with neuro-axonal damage. Focal lesions are thought to be caused by the infiltration of immune cells, including T cells, B cells and myeloid cells, into the central nervous system parenchyma, with associated injury. MS is associated with a substantial burden on society owing to the high cost of the available treatments and poorer employment prospects and job retention for patients and their caregivers.
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Affiliation(s)
- Massimo Filippi
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy. .,Department of Neurology, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy.
| | - Amit Bar-Or
- Department of Neurology and Center for Neuroinflammation and Experimental Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Neuroimmunology Unit, Center for Molecular Medicine, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Paolo Preziosa
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy.,Department of Neurology, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandra Solari
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Sandra Vukusic
- Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Fondation Eugène Devic EDMUS Contre la Sclérose en Plaques, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
| | - Maria A Rocca
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy.,Department of Neurology, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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Rasche L, Paul F. Ozanimod for the treatment of relapsing remitting multiple sclerosis. Expert Opin Pharmacother 2018; 19:2073-2086. [PMID: 30407868 DOI: 10.1080/14656566.2018.1540592] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Ozanimod is a selective sphingosine 1-phosphate receptor 1 and 5 modulator under development by Celgene, for the treatment of relapsing remitting multiple sclerosis. Extensive clinical experience has become available for the related compound fingolimod, favoring the sphingosine 1-phosphate therapeutic concept. Off-target effects have been attributed to its low receptor specificity and have prompted the development of next generation sphingosine 1-phosphate receptor modulators. Areas covered: The authors evaluate the literature of ozanimod, using the PubMed database as well as repositories of the European Committee for Treatment and Research in Multiple Sclerosis and the American and European Academy of Neurology. Specifically, the authors cover and discuss the preclinical data on ozanimod, pharmacokinetics and dynamics, and data on efficacy and safety from the pivotal trials. Expert opinion: Superiority of ozanimod over intramuscular interferon β-1a with regard to reduction in annualized relapse rate and magnetic resonance imaging outcomes has been shown in two phase III trials. The beneficial effect on brain volume and gray matter loss are encouraging and in line with data on other newer immunomodulators. Ozanimod is a valuable contribution to the therapeutic armamentarium in MS, although the effect on disability progression is unclear and requires further investigations.
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Affiliation(s)
- Ludwig Rasche
- a NeuroCure Clinical Research Center , Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität, and Berlin Institute of Health , Berlin , Germany
| | - Friedemann Paul
- a NeuroCure Clinical Research Center , Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität, and Berlin Institute of Health , Berlin , Germany.,b Experimental and Clinical Research Center , Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität, and Berlin Institute of Health , Berlin , Germany.,c Department of Neurology , Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health , Berlin , Germany
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Han J, Zhu K, Zhang X, Harris RA. Enforced microglial depletion and repopulation as a promising strategy for the treatment of neurological disorders. Glia 2018; 67:217-231. [PMID: 30378163 PMCID: PMC6635749 DOI: 10.1002/glia.23529] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/17/2018] [Accepted: 08/22/2018] [Indexed: 01/18/2023]
Abstract
Microglia are prominent immune cells in the central nervous system (CNS) and are critical players in both neurological development and homeostasis, and in neurological diseases when dysfunctional. Our previous understanding of the phenotypes and functions of microglia has been greatly extended by a dearth of recent investigations. Distinct genetically defined subsets of microglia are now recognized to perform their own independent functions in specific conditions. The molecular profiling of single microglial cells indicates extensively heterogeneous reactions in different neurological disorders, resulting in multiple potentials for crosstalk with other kinds of CNS cells such as astrocytes and neurons. In settings of neurological diseases it could thus be prudent to establish effective cell‐based therapies by targeting entire microglial networks. Notably, activated microglial depletion through genetic targeting or pharmacological therapies within a suitable time window can stimulate replenishment of the CNS niche with new microglia. Additionally, enforced repopulation through provision of replacement cells also represents a potential means of exchanging dysfunctional with functional microglia. In each setting the newly repopulated microglia might have the potential to resolve ongoing neuroinflammation. In this review, we aim to summarize the most recent knowledge of microglia and to highlight microglial depletion and subsequent repopulation as a promising cell replacement therapy. Although glial cell replacement therapy is still in its infancy and future translational studies are still required, the approach is scientifically sound and provides new optimism for managing the neurotoxicity and neuroinflammation induced by activated microglia.
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Affiliation(s)
- Jinming Han
- Applied Immunology and Immunotherapy, Department of Clinical NeuroscienceKarolinska Institutet, Center for Molecular Medicine, Karolinska University Hospital at SolnaStockholmSweden
| | - Keying Zhu
- Applied Immunology and Immunotherapy, Department of Clinical NeuroscienceKarolinska Institutet, Center for Molecular Medicine, Karolinska University Hospital at SolnaStockholmSweden
| | - Xing‐Mei Zhang
- Applied Immunology and Immunotherapy, Department of Clinical NeuroscienceKarolinska Institutet, Center for Molecular Medicine, Karolinska University Hospital at SolnaStockholmSweden
| | - Robert A. Harris
- Applied Immunology and Immunotherapy, Department of Clinical NeuroscienceKarolinska Institutet, Center for Molecular Medicine, Karolinska University Hospital at SolnaStockholmSweden
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Mills EA, Begay JA, Fisher C, Mao-Draayer Y. Impact of trial design and patient heterogeneity on the identification of clinically effective therapies for progressive MS. Mult Scler 2018; 24:1795-1807. [PMID: 30303445 DOI: 10.1177/1352458518800800] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Clinically effective immunomodulatory therapies have been developed for relapsing-remitting multiple sclerosis (RRMS), but they have generally not translated to a corresponding slowing of disability accumulation in progressive forms of multiple sclerosis (MS). Since disability is multifaceted, progressive patients are heterogeneous, and the drivers of disease progression are still unclear, it has been difficult to identify the most informative outcome measures for progressive trials. Historically, secondary outcome measures have focused on inflammatory measures, which contributed to the recent identification of immunomodulatory therapies benefiting younger patients with more inflammatory progressive MS. Meanwhile, agents capable of treating late-stage disease have remained elusive. Consequently, measures of neurodegeneration are becoming common. Here, we review completed clinical trials testing immunomodulatory therapies in primary progressive multiple sclerosis (PPMS) or secondary progressive multiple sclerosis (SPMS) and discuss the features contributing to trial design variability in relation to trial outcomes, and how efforts toward better patient stratification and inclusion of reliable progression markers could improve outcomes.
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Affiliation(s)
- Elizabeth A Mills
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Joel A Begay
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Caitlyn Fisher
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Yang Mao-Draayer
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, USA/Graduate Program in Immunology, Program in Biomedical Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
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Hacohen Y, Brownlee WJ. Clinical commentary on ‘Late-onset neutropenia and neurological relapse during long-term rituximab therapy in MOG antibody spectrum disorder’. Mult Scler 2018; 24:1648. [DOI: 10.1177/1352458518775245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Yael Hacohen
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Institute of Neurology, University College London, London, UK/Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Wallace J Brownlee
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Institute of Neurology, University College London, London, UK
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Abu-Rub M, Miller RH. Emerging Cellular and Molecular Strategies for Enhancing Central Nervous System (CNS) Remyelination. Brain Sci 2018; 8:brainsci8060111. [PMID: 29914096 PMCID: PMC6024921 DOI: 10.3390/brainsci8060111] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 06/12/2018] [Accepted: 06/13/2018] [Indexed: 02/06/2023] Open
Abstract
Myelination is critical for the normal functioning of the central nervous system (CNS) in vertebrates. Conditions in which the development of myelin is perturbed result in severely compromised individuals often with shorter lifespans, while loss of myelin in the adult results in a variety of functional deficits. Although some form of spontaneous remyelination often takes place, the repair process as a whole often fails. Several lines of evidence suggest it is feasible to develop strategies that enhance the capacity of the CNS to undergo remyelination and potentially reverse functional deficits. Such strategies include cellular therapies using either neural or mesenchymal stem cells as well as molecular regulators of oligodendrocyte development and differentiation. Given the prevalence of demyelinating diseases and their effects on the quality of life for affected individuals it is imperative that effective therapies are developed. Here we discuss some of the new approaches to CNS myelin repair that hold promise for reducing the burden of diseases characterized by myelin loss.
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Affiliation(s)
- Mohammad Abu-Rub
- Department of Neurology, George Washington University School of Medicine and Health Sciences, Washington, DC 20037, USA.
| | - Robert H Miller
- Department of Anatomy and Regenerative Biology, George Washington University School of Medicine and Health Sciences, Washington, DC 20037, USA.
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Scotti B, Disanto G, Sacco R, Guigli M, Zecca C, Gobbi C. Effectiveness and safety of Rituximab in multiple sclerosis: an observational study from Southern Switzerland. PLoS One 2018; 13:e0197415. [PMID: 29758075 PMCID: PMC5951582 DOI: 10.1371/journal.pone.0197415] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 05/01/2018] [Indexed: 01/17/2023] Open
Abstract
Background Despite positive results from phase II and observational studies, Rituximab (RTX) is not currently approved for multiple sclerosis (MS) treatment and can only be used off-label. Objective To characterize MS patients treated with RTX and investigate its effectiveness and safety in a clinical practice setting. Methods Observational analysis of data collected from MS patients at the Neurocenter of Southern Switzerland. Relapses, EDSS worsening, MRI lesion accrual and "evidence of disease activity” (EDA) status were described by Cox regression. RTX and natalizumab treated patients were matched by propensity scores. Results Out of 453 MS patients, 82 were treated with RTX, 43 (52.4%) relapsing-remitting (RRMS) and 39 (47.6%) progressive MS (median age = 48 [40–54] years, females n = 60 [73.2%], EDSS = 4.0 [2.5–6.0], median follow-up = 1.5 [1.0–2.5] years). Three relapses occurred and 59 (75.6%) patients had not EDA at follow-up end. Time to EDA was similar in RTX and natalizumab treated RRMS patients (HR = 1.64, 95%CI = 0.46–5.85, p = 0.44). Twenty-four patients presented non infusion related adverse events (infections), requiring RTX discontinuation in 6 individuals. Conclusion These results provide further evidence for RTX being effective in MS treatment, to a similar extent to natalizumab in RRMS. Clinicians must be vigilant for the potential occurrence of infections.
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Affiliation(s)
- Barbara Scotti
- University Hospital Basel, University of Basel, Basel, Switzerland
| | - Giulio Disanto
- Neurocentre of Southern Switzerland, Ospedale Civico, Lugano, Switzerland
| | - Rosaria Sacco
- Neurocentre of Southern Switzerland, Ospedale Civico, Lugano, Switzerland
| | - Marilu’ Guigli
- Università della Svizzera Italiana (USI), Facoltà di scienze biomediche, Lugano, Switzerland
| | - Chiara Zecca
- Neurocentre of Southern Switzerland, Ospedale Civico, Lugano, Switzerland
| | - Claudio Gobbi
- University Hospital Basel, University of Basel, Basel, Switzerland
- Neurocentre of Southern Switzerland, Ospedale Civico, Lugano, Switzerland
- * E-mail:
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Jácome Sánchez EC, García Castillo MA, González VP, Guillén López F, Correa Díaz EP. Coexistence of systemic lupus erythematosus and multiple sclerosis. A case report and literature review. Mult Scler J Exp Transl Clin 2018; 4:2055217318768330. [PMID: 29662683 PMCID: PMC5894926 DOI: 10.1177/2055217318768330] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 03/01/2018] [Accepted: 03/08/2018] [Indexed: 02/06/2023] Open
Abstract
Multiple sclerosis (MS) and systemic lupus erythematous (SLE) are autoimmune diseases, the coexistence of which is uncommon in patients. Owing to the rarity of this condition, the distinction between MS and SLE is a diagnostic challenge for neurologists. We present a case report in which MS and SLE were present in the same patient. There are few case reports in the world on the association between MS and SLE. The following case report is the first of its kind in which both MS and SLE are present in a patient from a country with low prevalence of MS such as Ecuador.
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Affiliation(s)
| | | | | | - Fernando Guillén López
- Department of Neurology, Hospital José Carrasco de Cuenca, Popayán y Pacto Andino, Ecuador
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Wallin MT. Rituximab is an acceptable alternative to ocrelizumab for treating multiple sclerosis – No. Mult Scler 2018; 24:1159-1161. [DOI: 10.1177/1352458518757931] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Mitchell T Wallin
- VA Multiple Sclerosis Center of Excellence-East, Washington, DC, USA
- School of Medicine, Georgetown University, Washington, DC, USA
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Piehl F, Hillert J. Rituximab is an acceptable alternative to ocrelizumab for treating multiple sclerosis - Yes. Mult Scler 2018; 24:1157-1159. [PMID: 29468952 DOI: 10.1177/1352458518757930] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden/Department of Neurology, Karolinska University Hospital, Stockholm, Sweden/Neuroimmunology Unit, Center for Molecular Medicine, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Jan Hillert
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden/Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
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The changing multiple sclerosis treatment landscape: impact of new drugs and treatment recommendations. Eur J Clin Pharmacol 2018; 74:663-670. [PMID: 29429031 PMCID: PMC5893684 DOI: 10.1007/s00228-018-2429-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 02/01/2018] [Indexed: 11/03/2022]
Abstract
PURPOSE The purpose of this study is to describe the utilization of disease-modifying treatments (DMTs) in relapsing-remitting multiple sclerosis (MS) and assess the impact of both the introduction of new drugs and treatment recommendations (local recommendation on rituximab use issued at the largest MS clinic in Stockholm and regional Drug and Therapeutics Committee (DTC) recommendation on how dimethyl fumarate should be used). METHODS Interrupted time series analyses using monthly data on all MS patients treated with DMTs in the Stockholm County, Sweden, from January 2011 to December 2017. RESULTS There were 4765 individuals diagnosed with MS residing in the Stockholm County from 2011 to 2017. Of these, 2934 (62%) were treated with an MS DMT. Since 2011, fingolimod, alemtuzumab, teriflunomide, dimethyl fumarate, peginterferon beta-1a, and daclizumab were introduced. Only fingolimod and dimethyl fumarate significantly impacted MS DMT utilization. In parallel, the use of rituximab off-label increased steadily, reaching 58% of all DMT-treated MS patients by the end of the study period. The local recommendation on rituximab was associated with an increase in rituximab use. The regional DTC recommendation on dimethyl fumarate was associated with a decrease in dimethyl fumarate use. CONCLUSIONS Three MS DMTs-fingolimod, dimethyl fumarate, and rituximab off-label-impacted MS DMT utilization in the Stockholm County. The associations between the treatment recommendations and the subsequent changes in MS DMT utilization indicate that such interventions can influence the uptake and utilization of new drugs used in the specialized care setting.
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