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Bose G, Healy BC, Barro C, Glanz BI, Lokhande HA, Polgar-Turcsanyi M, Guttmann CR, Bakshi R, Weiner HL, Chitnis T. Younger age at multiple sclerosis onset is associated with worse outcomes at age 50. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2022-329353. [PMID: 35953266 DOI: 10.1136/jnnp-2022-329353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/26/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Older age at multiple sclerosis (MS) onset has been associated with worse 10-year outcomes. However, disease duration often exceeds 10 years and age-related comorbidities may also contribute to disability. We investigated patients with>10 years disease duration to determine how age at MS onset is associated with clinical, MRI and occupational outcomes at age 50. METHODS We included patients enrolled in the Comprehensive Longitudinal Investigation of Multiple Sclerosis at the Brigham and Women's Hospital with disease duration>10 years. Outcomes at age 50 included the Expanded Disability Status Scale (EDSS), development of secondary-progressive multiple sclerosis (SPMS), brain T2-lesion volume (T2LV) and brain parenchymal fraction (BPF), and occupational status. We assessed how onset age was independently associated with each outcome when adjusting for the date of visit closest to age 50, sex, time to first treatment, number of treatments by age 50 and exposure to high-efficacy treatments by age 50. RESULTS We included 661 patients with median onset at 31.4 years. The outcomes at age 50 were worse the younger first symptoms developed: for every 5 years earlier, the EDSS was 0.22 points worse (95% CI: 0.04 to 0.40; p=0.015), odds of SPMS 1.33 times higher (95% CI: 1.08 to 1.64; p=0.008), T2LV 1.86 mL higher (95% CI: 1.02 to 2.70; p<0.001), BPF 0.97% worse (95% CI: 0.52 to 1.42; p<0.001) and odds of unemployment from MS 1.24 times higher (95% CI: 1.01 to 1.53; p=0.037). CONCLUSIONS All outcomes at age 50 were worse in patients with younger age at onset. Decisions to provide high-efficacy treatments should consider younger age at onset, equating to a longer expected disease duration, as a poor prognostic factor.
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Affiliation(s)
- Gauruv Bose
- Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
| | - Brian C Healy
- Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
| | - Christian Barro
- Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
| | - Bonnie I Glanz
- Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Mariann Polgar-Turcsanyi
- Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Rohit Bakshi
- Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
| | - Howard L Weiner
- Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
| | - Tanuja Chitnis
- Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
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102
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Brod SA. The genealogy, methodology, similarities and differences of immune reconstitution therapies for multiple sclerosis and neuromyelitis optica. Autoimmun Rev 2022; 21:103170. [PMID: 35963569 DOI: 10.1016/j.autrev.2022.103170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/07/2022] [Indexed: 11/09/2022]
Abstract
Immune reconstitution therapies (IRTs) are a type of short course procedure or pharmaceutical agent within the MS pharmacopeia. They emanate from oncology and induce transient incomplete lympho-ablation with or without myelo-ablation, resulting in potential prolonged immunomodulation. Thus, they provide significant prophylaxis from disease activity without retreatment. Modern IRT for autoimmunity encompasses a heterogeneous group of pulsed lympho- and non-myelo-ablative treatments designed to re-boot the adaptive immune system in a quasi-permanent manner - a re-induction of ontogeny. IRT is the extensive debulking of an auto-aggressive immune system to attempt to reach the Holy Grail of immune tolerance. This incomplete yet significant lympho-ablation induces lymphoproliferation, reduces pathogenic clonal cells, causes thymopoiesis and results in the induction of immune tolerance. Lympho-ablation with immune reconstitution can result in minimal residual autoimmunity. There is a resetting of the immune thermostat - i.e., the immunostat. IRTs have the potential to provide prolonged periods of disease inactivity without retreatment in part through the immunological results of their pulsatile lymphocyte depletion. It is vital to increase our understanding of how IRTs alter a patient's immune response to the antigenic target of the disease so that we can devise newer, more durable and safer forms of such agents. What common features do extant IRTs (i.e., stem cell transplant, alemtuzumab and oral cladribine) have to produce the durable therapeutic response without long term treatment in neuroimmunological diseases such as MS (multiple sclerosis) and NMOSD (neuromyelitis optica spectrum disorders)? Can we learn from these critical features to predict what other maneuvers or agents might effect similar clinical results with equal or greater efficacy and safety?
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Affiliation(s)
- Staley A Brod
- Division of MS/Neuro-immunology, Department of Neurology, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226, USA.
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103
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Kvistad SAS, Burman J, Lehmann AK, Tolf A, Zjukovskaja C, Melve GK, Bø L, Torkildsen Ø. Impact of previous disease-modifying treatment on safety and efficacy in patients with MS treated with AHSCT. J Neurol Neurosurg Psychiatry 2022; 93:844-848. [PMID: 35508373 PMCID: PMC9304086 DOI: 10.1136/jnnp-2022-328797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/18/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND Autologous haematopoietic stem cell transplantation (AHSCT) is a highly effective treatment for multiple sclerosis (MS). The impact of previous long-lasting disease-modifying treatments (DMT) for safety and efficacy of AHSCT is unknown. OBJECTIVE To explore whether previous DMTs with long-lasting effects on the immune system (anti-CD20 therapy, alemtuzumab and cladribine) affect treatment-related complications, long-term outcome and risk of new MS disease activity in patients treated with AHSCT. METHODS Retrospective observational study of 104 relapsing remitting patients with MS treated by AHSCT in Sweden and Norway from 2011 to 2021, grouped according to the last DMT used ≤6 months prior to AHSCT. The primary outcomes were early AHSCT-related complications (mortality, neutropenic fever and hospitalisation length), long-term complications (secondary autoimmunity) and proportion of patients with No Evidence of Disease Activity (NEDA-3 status): no new relapses, no MRI activity and no disease progression during the follow-up. RESULTS The mean follow-up time was 39.5 months (range 1-95). Neutropenic fever was a common AHSCT-related complication affecting 69 (66%) patients. There was no treatment-related mortality. During the follow-up period, 20 patients (19%) were diagnosed with autoimmunity. Occurrence of neutropenic fever, hospitalisation length or secondary autoimmunity did not vary dependent on the last DMT used prior to AHSCT. A total of 84 patients (81%) achieved NEDA-3 status, including all patients (100%) using rituximab, alemtuzumab or cladribine before AHSCT. CONCLUSION This study provides level 4 evidence that AHSCT in patients previously treated with alemtuzumab, cladribine or rituximab is safe and efficacious.
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Affiliation(s)
- Silje Agnethe Stokke Kvistad
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway .,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Joachim Burman
- Department of Neuroscience, Uppsala Universitet, Uppsala, Sweden
| | - Anne Kristine Lehmann
- Department of Medicine, Section of Hematology, Haukeland University Hospital, Bergen, Norway
| | - Andreas Tolf
- Department of Neuroscience, Uppsala Universitet, Uppsala, Sweden.,Department of Neurology, Akademiska sjukhuset, Uppsala, Sweden
| | | | - Guro Kristin Melve
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Lars Bø
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Norwegian Multiple Sclerosis Competence Centre, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Neurology, Norwegian Multiple Sclerosis Competence Centre, Bergen, Norway
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104
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Safety and efficacy of rituximab versus dimethyl fumarate in patients with relapsing-remitting multiple sclerosis or clinically isolated syndrome in Sweden: a rater-blinded, phase 3, randomised controlled trial. Lancet Neurol 2022; 21:693-703. [DOI: 10.1016/s1474-4422(22)00209-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/24/2022] [Accepted: 05/03/2022] [Indexed: 12/15/2022]
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105
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Abstract
PURPOSE OF REVIEW Given the expansion of options for the treatment of relapsing multiple sclerosis, this review outlines the framework for developing a treatment strategy, with consideration of when to switch or discontinue therapies, and a comprehensive elaboration of the mechanisms of action, efficacy, and safety considerations for each of the therapeutic classes. RECENT FINDINGS The armamentarium of immunotherapies has grown rapidly, to encompass 19 US Food and Drug Administration (FDA)-approved immunotherapies available in 2021, which are addressed in the review. The coronavirus pandemic that began in 2020 underscored existing concerns regarding vaccine efficacy in those treated with immune-suppressing immunotherapies, which are also addressed here. SUMMARY By choosing a treatment strategy before exploring the individual medications, patients and providers can focus their efforts on a subset of the therapeutic options. Although the mechanisms of action, routes of administration, efficacy, safety, and tolerability of the described agents and classes differ, all are effective in reducing relapse frequency in multiple sclerosis (MS), with most also showing a reduction in the accumulation of neurologic disability. These powerful effects are improving the lives of people with MS. Pharmacovigilance is critical for the safe use of these immune-modulating and -suppressing agents, and vaccine efficacy may be reduced by those with immune-suppressing effects.
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106
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Bierhansl L, Hartung HP, Aktas O, Ruck T, Roden M, Meuth SG. Thinking outside the box: non-canonical targets in multiple sclerosis. Nat Rev Drug Discov 2022; 21:578-600. [PMID: 35668103 PMCID: PMC9169033 DOI: 10.1038/s41573-022-00477-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 12/11/2022]
Abstract
Multiple sclerosis (MS) is an immune-mediated disease of the central nervous system that causes demyelination, axonal degeneration and astrogliosis, resulting in progressive neurological disability. Fuelled by an evolving understanding of MS immunopathogenesis, the range of available immunotherapies for clinical use has expanded over the past two decades. However, MS remains an incurable disease and even targeted immunotherapies often fail to control insidious disease progression, indicating the need for new and exceptional therapeutic options beyond the established immunological landscape. In this Review, we highlight such non-canonical targets in preclinical MS research with a focus on five highly promising areas: oligodendrocytes; the blood-brain barrier; metabolites and cellular metabolism; the coagulation system; and tolerance induction. Recent findings in these areas may guide the field towards novel targets for future therapeutic approaches in MS.
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Affiliation(s)
- Laura Bierhansl
- Department of Neurology, Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Brain and Mind Centre, University of Sydney, Sydney, NSW, Australia
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Orhan Aktas
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Tobias Ruck
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Michael Roden
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Endocrinology and Diabetology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
- German Center of Diabetes Research, Partner Düsseldorf, Neuherberg, Germany
| | - Sven G Meuth
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.
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107
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Cauchi M, Willis M, Andrews A, Backx M, Brownlee W, Ford HL, Gran B, Jolles S, Price S, Rashid W, Schmierer K, Tallantyre EC. Multiple sclerosis and the risk of infection: Association of British Neurologists consensus guideline. Pract Neurol 2022; 22:practneurol-2022-003370. [PMID: 35863879 DOI: 10.1136/practneurol-2022-003370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 11/03/2022]
Abstract
Infection in people with multiple sclerosis (MS) is of major concern, particularly for those receiving disease-modifying therapies. This article explores the risk of infection in people with MS and provides guidance-developed by Delphi consensus by specialists involved in their management-on how to screen for, prevent and manage infection in this population.
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Affiliation(s)
- Marija Cauchi
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, University Hospital of Wales, Cardiff, UK
| | - Mark Willis
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, University Hospital of Wales, Cardiff, UK
| | - Angela Andrews
- Pharmacy Neurosciences Directorate, University Hospital of Wales, Cardiff, UK
| | - Matthijs Backx
- Infectious Diseases, University Hospital of Wales and Department of Microbiology, Public Health Wales, Cardiff, UK
| | - Wallace Brownlee
- Queen Square MS Centre, University College London Institute of Neurology, Queen Square Multiple Sclerosis Centre, London, UK
| | - Helen L Ford
- Centre for Neurosciences, Leeds Teaching Hospitals NHS Trust, Leeds, UK, Leeds, UK
| | - Bruno Gran
- Department of Neurology, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Mental Health and Clinical Neuroscience Academic Unit, University of Nottingham School of Medicine, Nottingham, UK
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Sian Price
- Department of Neuroscience, University of Sheffield, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Waqar Rashid
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Klaus Schmierer
- The Blizard Institute (Neuroscience, Surgery & Trauma), Queen Mary University of London Faculty of Medicine and Dentistry, London, UK
- Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Emma C Tallantyre
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, University Hospital of Wales, Cardiff, UK
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108
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Sattarnezhad N, Healy BC, Baharnoori M, Diaz-Cruz C, Stankiewicz J, Weiner HL, Chitnis T. Comparison of dimethyl fumarate and interferon outcomes in an MS cohort. BMC Neurol 2022; 22:252. [PMID: 35820822 PMCID: PMC9277810 DOI: 10.1186/s12883-022-02761-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background To compare the effectiveness of dimethyl fumarate (DMF) with subcutaneous interferon beta-1a (IFNβ-1a) in controlling disease activity in patients with relapsing–remitting Multiple Sclerosis (MS). Methods Clinical and imaging data from patients treated with either IFNβ-1a or DMF for at least one year were reviewed. The proportion of patients with at least one clinical relapse within 3–15 months after treatment onset, the proportion of patients with new T2 or gadolinium-enhancing lesions, and the proportion of subjects who achieved no evidence of disease activity (NEDA) status were assessed. Results Three hundred sixteen (98 on IFNβ-1a, 218 on DMF) subjects were included. Baseline demographics were comparable between groups except for age, disease duration, and the number of previous treatments being higher and relapse rate in the prior year being lower in the DMF-treated group. The proportion of patients having a clinical relapse (24.5% vs. 9.6%; OR = 3.04; P < 0.001) or a new MRI lesion (28.6% vs. 8.7%; OR = 4.19, P < 0.001) at 15 months were higher on IFNβ-1a. 79.9% of the patients achieved NEDA status at 15 months on DMF (vs. 51.1% for IFNβ-1a; OR = 0.26, P < 0.001). Further adjustment for demographics, disease characteristics, treatment and relapse history, and subgroup analyses confirmed these findings. Conclusion DMF was associated with less clinical and radiological disease activity compared to IFNβ-1a. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02761-8.
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Affiliation(s)
- Neda Sattarnezhad
- Harvard Medical School, Boston, Massachusetts, 02115, USA.,Brigham Multiple Sclerosis Center, Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA
| | - Brian C Healy
- Harvard Medical School, Boston, Massachusetts, 02115, USA.,Brigham Multiple Sclerosis Center, Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA.,Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Moogeh Baharnoori
- Harvard Medical School, Boston, Massachusetts, 02115, USA.,Brigham Multiple Sclerosis Center, Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA
| | - Camilo Diaz-Cruz
- Harvard Medical School, Boston, Massachusetts, 02115, USA.,Brigham Multiple Sclerosis Center, Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA
| | - James Stankiewicz
- Harvard Medical School, Boston, Massachusetts, 02115, USA.,Brigham Multiple Sclerosis Center, Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA
| | - Howard L Weiner
- Harvard Medical School, Boston, Massachusetts, 02115, USA.,Brigham Multiple Sclerosis Center, Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA
| | - Tanuja Chitnis
- Harvard Medical School, Boston, Massachusetts, 02115, USA. .,Brigham Multiple Sclerosis Center, Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA.
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109
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Stem Cell Therapy in Neuroimmunological Diseases and Its Potential Neuroimmunological Complications. Cells 2022; 11:cells11142165. [PMID: 35883607 PMCID: PMC9318423 DOI: 10.3390/cells11142165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/03/2022] [Accepted: 07/06/2022] [Indexed: 12/29/2022] Open
Abstract
Background: Since the 1990s, transplantations of hematopoietic and mesenchymal stem cells (HSCT and MSCT) and dendritic cell (DCT) have been investigated for the treatment of neurological autoimmune disorders (NADs). With the growing number of transplanted patients, awareness of neuroimmunolgical complications has increased. Therefore, an overview of SCT for the most common NADs and reports of secondary immunity after SCT is provided. Methods: For this narrative review, a literature search of the PubMed database was performed. A total of 86 articles reporting on different SCTs in NADs and 61 articles dealing with immune-mediated neurological complications after SCT were included. For multiple sclerosis (MS), only registered trials and phase I/II or II studies were considered, whereas all available articles on other disorders were included. The different transplantation procedures and efficacy and safety data are presented. Results: In MS patients, beneficial effects of HSCT, MSCT, and DCT with a decrease in disability and stabilization of disease activity have been reported. These effects were also shown in other NADs mainly in case reports. In seven of 132 reported patients with immune-mediated neurological complications, the outcome was fatal. Conclusions: Phase III trials are ongoing for MS, but the role of SCT in other NADs is currently limited to refractory patients due to occasional serious complications.
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110
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Leckey R, Borsellino L, Rawlings AM, Ashkenas J, Suri A. Acute infusion effects in relapsing multiple sclerosis patients receiving alemtuzumab under a modified prophylaxis regimen. Mult Scler Relat Disord 2022; 66:104030. [PMID: 35870368 DOI: 10.1016/j.msard.2022.104030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/13/2022] [Accepted: 07/03/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Use of alemtuzumab in relapsing multiple sclerosis (RMS) is limited by safety concerns, notably risk of rare, serious vascular events. Along with other vital sign (VS) changes, acute increase in systolic blood pressure (SBP) is monitored as a marker of vascular risk. Peri-infusion prophylaxis is used to manage clinical risk by moderating cytokine release; protocols are not fully specified and vary across sites. Here, we report a modified prophylaxis regimen developed at Maritime Neurology. This single-center observational cohort study (NCT04633967) aimed to examine acute responses (VS events and infusion-associated reactions) in RMS patients receiving alemtuzumab infusion under this regimen. In a post hoc analysis, we examined incidence of acute SBP increase at this clinic versus the Bayshore network of Canadian infusion centers, where a standard prophylaxis regimen is used. METHODS Alemtuzumab was infused on 5 consecutive days (Course 1; n = 29) and 3 consecutive days one year later (Course 2; n = 28). In addition to intravenous methylprednisolone 500mg on each infusion day, patients received daily prophylactic treatment with oral prednisone 50mg from 5 days before to 5 days after treatment (infusion days excepted) and oral H1 and H2 antihistaminics from 7 days before to 7 days after treatment. Excursions in SBP and other VS were relative to prespecified ranges; persistent excursions were those for which two sequential measurements were outside these ranges. In comparing VS events at Maritime Neurology and the Bayshore centers, acute SBP increase was defined as ≥20 mmHg increase in mean SBP, or any SBP reading ≥20% over patient's pre-course baseline. RESULTS Mean (SD) VS were within range at pre-course and all other daily baselines. VS changes, including persistent excursions, were generally subclinical; all infusion-associated reactions were mild. One patient discontinued treatment after Course 1 due to immune thrombocytopenia purpura. Acute SBP increase occurred in 11/28 (39%) Maritime Neurology versus 367/610 (60%) Bayshore (p = 0.028). CONCLUSION The modified peri-infusion prophylaxis regimen was well tolerated and may reduce incidence of acute SBP increase. FUNDING This project was funded by Sanofi, Canada.
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Affiliation(s)
- Richard Leckey
- Maritime Neurology, 349 Herring Cove Road, Herring Cove, Halifax, NS B3R 1V9, Canada; Division of Neurology, Dalhousie University, Halifax, NS, Canada.
| | | | | | | | - Amit Suri
- Sanofi Canada, Mississauga, ON, Canada
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111
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Kiapour N, Wu B, Wang Y, Seyedsadr M, Kapoor S, Zhang X, Elzoheiry M, Kasimoglu E, Wan Y, Markovic-Plese S. Therapeutic Effect of Anti-CD52 Monoclonal Antibody in Multiple Sclerosis and Its Animal Models Is Mediated via T Regulatory Cells. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2022; 209:49-56. [PMID: 35750335 PMCID: PMC9458467 DOI: 10.4049/jimmunol.2100176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/27/2022] [Indexed: 06/15/2023]
Abstract
The objective of this study is to determine the mechanism of action of anti-CD52 mAb treatment in patients with relapsing-remitting multiple sclerosis (RRMS). Experimental autoimmune encephalomyelitis (EAE), an animal model of the disease, was used to address the role of T regulatory cells (Tregs) in the anti-CD52 mAb-induced suppression of the disease. In vitro studies on PBMCs from RRMS patients and matched healthy controls determined the effect of IL-7 on the expansion of CD4+CD25+CD127- Tregs and induction of their suppressive phenotype. This study using EAE animal models of MS has shown that mouse anti-CD52 mAb suppression of clinical disease was augmented by coadministration of IL-7 and partially reversed by anti-IL-7 mAb. In vitro human studies showed that IL-7 induced expansion of CD4+CD25+CD127- Tregs and increased their FOXP3, GITIR, CD46, CTLA-4, granzyme B, and perforin expression. Anti-CD52 mAb treatment of mice with relapsing-remitting EAE induced expansion of Foxp3+CD4+ Tregs and the suppression of IL-17A+CD4+ and IFN-γ+CD4+ cells in peripheral immune organs and CNS infiltrates. The effect was detected immediately after the treatment and maintained over long-term follow-up. Foxp3+CD4+ Treg-mediated suppression of IL-17A+CD4+ and IFN-γ+CD4+ cells in the spinal cord infiltrates was reversed after inducible Foxp3 depletion. Our results demonstrated that the therapeutic effect of U.S. Food and Drug Administration-approved anti-CD52 mAb is dependent on the presence of Tregs.
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Affiliation(s)
- Nazanin Kiapour
- Department of Neurology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Cell Biology and Physiology, UNC Neuroscience Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Bing Wu
- Department of Microbiology and Immunology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
- Frontier Science Center for Immunology and Metabolism of Medical Research Institute, Wuhan University, Wuhan, China
| | - Yan Wang
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA; and
| | | | - Sahil Kapoor
- Department of Neurology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Cell Biology and Physiology, UNC Neuroscience Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Xin Zhang
- Department of Neurology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
- Duke Molecular Physiology Institute, Department of Orthopedic Surgery, Duke University, Durham, NC
| | - Manal Elzoheiry
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA; and
| | - Ezgi Kasimoglu
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA; and
| | - Yisong Wan
- Department of Microbiology and Immunology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Silva Markovic-Plese
- Department of Neurology, The University of North Carolina at Chapel Hill, Chapel Hill, NC;
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA; and
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112
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Di Pauli F, Riedl K, Hegen H, Auer M, Berek K, Krajnc N, Leutmezer F, Zinganell A, Berger T, Deisenhammer F, Bsteh G. Alemtuzumab induced hemodynamic change in relapsing multiple sclerosis occurs independent of corticosteroid premedication – a retrospective multicentre study. Mult Scler Relat Disord 2022; 63:103810. [DOI: 10.1016/j.msard.2022.103810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 04/03/2022] [Accepted: 04/15/2022] [Indexed: 11/28/2022]
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113
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Kearns PKA, Martin SJ, Chang J, Meijboom R, York EN, Chen Y, Weaver C, Stenson A, Hafezi K, Thomson S, Freyer E, Murphy L, Harroud A, Foley P, Hunt D, McLeod M, O'Riordan J, Carod-Artal FJ, MacDougall NJJ, Baranzini SE, Waldman AD, Connick P, Chandran S. FutureMS cohort profile: a Scottish multicentre inception cohort study of relapsing-remitting multiple sclerosis. BMJ Open 2022; 12:e058506. [PMID: 35768080 PMCID: PMC9244691 DOI: 10.1136/bmjopen-2021-058506] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE Multiple sclerosis (MS) is an immune-mediated, neuroinflammatory disease of the central nervous system and in industrialised countries is the most common cause of progressive neurological disability in working age persons. While treatable, there is substantial interindividual heterogeneity in disease activity and response to treatment. Currently, the ability to predict at diagnosis who will have a benign, intermediate or aggressive disease course is very limited. There is, therefore, a need for integrated predictive tools to inform individualised treatment decision making. PARTICIPANTS Established with the aim of addressing this need for individualised predictive tools, FutureMS is a nationally representative, prospective observational cohort study of 440 adults with a new diagnosis of relapsing-remitting MS living in Scotland at the time of diagnosis between May 2016 and March 2019. FINDINGS TO DATE The study aims to explore the pathobiology and determinants of disease heterogeneity in MS and combines detailed clinical phenotyping with imaging, genetic and biomarker metrics of disease activity and progression. Recruitment, baseline assessment and follow-up at year 1 is complete. Here, we describe the cohort design and present a profile of the participants at baseline and 1 year of follow-up. FUTURE PLANS A third follow-up wave for the cohort has recently begun at 5 years after first visit and a further wave of follow-up is funded for year 10. Longer-term follow-up is anticipated thereafter.
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Affiliation(s)
- Patrick K A Kearns
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh Centre for Clinical Brain Sciences, Edinburgh, UK
- Chromatin Lab, Genome Regulation Section, The University of Edinburgh MRC Human Genetics Unit, Edinburgh, UK
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
- Department of Neurology, Institute of Clinical Neurosciences, NHS Greater Glasgow and Clyde, Glasgow, UK
- Institute of Genetics and Cancer, The University of Edinburgh, Edinburgh, UK
| | - Sarah J Martin
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
- Department of Neurology, Institute of Clinical Neurosciences, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Jessie Chang
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh Centre for Clinical Brain Sciences, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Rozanna Meijboom
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Elizabeth N York
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Yingdi Chen
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh Centre for Clinical Brain Sciences, Edinburgh, UK
| | - Christine Weaver
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh Centre for Clinical Brain Sciences, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Amy Stenson
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh Centre for Clinical Brain Sciences, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | | | - Stacey Thomson
- Institute of Genetics and Cancer, The University of Edinburgh, Edinburgh, UK
| | - Elizabeth Freyer
- Institute of Genetics and Cancer, The University of Edinburgh, Edinburgh, UK
| | - Lee Murphy
- Wellcome Trust Clinical Research Facility, Edinburgh, UK
| | - Adil Harroud
- Department of Neurology, Weill Institute of Clinical Neuroscience, San Francisco, California, USA
| | - Peter Foley
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh Centre for Clinical Brain Sciences, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - David Hunt
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh Centre for Clinical Brain Sciences, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Margaret McLeod
- Department of Neurology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Jonathon O'Riordan
- Tayside Centre for Clinical Neurosciences, University of Dundee Division of Neuroscience, Dundee, UK
| | | | - Niall J J MacDougall
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh Centre for Clinical Brain Sciences, Edinburgh, UK
- Department of Neurology, Wishaw General Hospital, Wishaw, UK
| | - Sergio E Baranzini
- Department of Neurology, Weill Institute of Clinical Neuroscience, San Francisco, California, USA
| | - Adam D Waldman
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Peter Connick
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Siddharthan Chandran
- Anne Rowling Regenerative Neurology Clinic, The University of Edinburgh Centre for Clinical Brain Sciences, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
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114
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Chan C, Beauchemin P, Sayao AL, Carruthers M. Autoimmune storm following alemtuzumab. BMJ Case Rep 2022; 15:e248037. [PMID: 35760506 PMCID: PMC9237871 DOI: 10.1136/bcr-2021-248037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2022] [Indexed: 11/03/2022] Open
Abstract
Alemtuzumab has been associated with the emergence of secondary autoimmune diseases. We report a case of a patient with relapsing-remitting multiple sclerosis who developed a refractory immune thrombocytopaenia associated with vasculitis, myelofibrosis and later Guillain-Barré syndrome following alemtuzumab. The medical community should be aware of unusual and unexpected adverse events that may be associated with alemtuzumab, especially when occurring simultaneously in the same patient.
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Affiliation(s)
- Chelsea Chan
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Philippe Beauchemin
- Department of Neurology, University of British Columbia, Vancouver, British Columbia, Canada
- Neurologie, Faculte de medecine - Universite Laval, Quebec City, Quebec, Canada
| | - Ana-Luiza Sayao
- Division of Neurology, Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Mollie Carruthers
- Rheumatology, Arthritis Research Canada, Vancouver, British Columbia, Canada
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115
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Yang JH, Rempe T, Whitmire N, Dunn-Pirio A, Graves JS. Therapeutic Advances in Multiple Sclerosis. Front Neurol 2022; 13:824926. [PMID: 35720070 PMCID: PMC9205455 DOI: 10.3389/fneur.2022.824926] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
Multiple sclerosis (MS) is an autoimmune disease affecting the central nervous system that causes significant disability and healthcare burden. The treatment of MS has evolved over the past three decades with development of new, high efficacy disease modifying therapies targeting various mechanisms including immune modulation, immune cell suppression or depletion and enhanced immune cell sequestration. Emerging therapies include CNS-penetrant Bruton's tyrosine kinase inhibitors and autologous hematopoietic stem cell transplantation as well as therapies aimed at remyelination or neuroprotection. Therapy development for progressive MS has been more challenging with limited efficacy of current approved agents for inactive disease and older patients with MS. The aim of this review is to provide a broad overview of the current therapeutic landscape for MS.
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Affiliation(s)
- Jennifer H. Yang
- Department of Neurosciences, University of California San Diego, San Diego, CA, United States
- *Correspondence: Jennifer H. Yang
| | - Torge Rempe
- Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Natalie Whitmire
- Department of Neurosciences, University of California San Diego, San Diego, CA, United States
| | - Anastasie Dunn-Pirio
- Department of Neurosciences, University of California San Diego, San Diego, CA, United States
| | - Jennifer S. Graves
- Department of Neurosciences, University of California San Diego, San Diego, CA, United States
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116
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Coles A. Campath, clones and the cause of autoimmunity. Brain 2022; 145:1579-1580. [PMID: 35661862 DOI: 10.1093/brain/awac162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 04/28/2022] [Indexed: 11/13/2022] Open
Abstract
This scientific commentary refers to ‘Alemtuzumab-induced immune phenotype and repertoire changes: implications for secondary autoimmunity’ by Ruck et al. (https://doi.org/10.1093/brain/awac064).
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Affiliation(s)
- Alasdair Coles
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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117
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Erfani Z, Jelodari Mamaghani H, Rawling JA, Eajazi A, Deever D, Mirmoeeni S, Azari Jafari A, Seifi A. Pneumonia in Nervous System Injuries: An Analytic Review of Literature and Recommendations. Cureus 2022; 14:e25616. [PMID: 35784955 PMCID: PMC9249029 DOI: 10.7759/cureus.25616] [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] [Accepted: 06/02/2022] [Indexed: 11/09/2022] Open
Abstract
Pneumonia is one of the most common complications in intensive care units and is the most common nosocomial infection in this setting. Patients with neurocritical conditions who are admitted to ICUs are no exception, and in fact, are more prone to infections such as pneumonia because of factors such as swallow dysfunction, need for mechanical ventilation, longer length of stay in hospitals, etc. Common central nervous system pathologies such as ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage, neuromuscular disorders, status epilepticus, and demyelinating diseases can cause long in-hospital admissions and increase the risk of pneumonia each with a mechanism of its own. Brain injury-induced immunosuppression syndrome is usually considered the common mechanism through which patients with critical central nervous system conditions become susceptible to different kinds of infection including pneumonia. Evaluating the patients and assessment of the risk factors can lead our attention toward better infection control in this population and therefore decrease the risk of infections in central nervous system injuries.
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Abstract
PURPOSE OF REVIEW To discuss recent changes in the multiple sclerosis (MS) treatment algorithm and to present therapies currently in MS clinical trials. RECENT FINDINGS High efficacy disease modifying therapies are optimally beneficial when used in the early, inflammatory phase of MS. Bruton's tyrosine kinase has emerged as an important therapeutic target for both relapsing and progressive forms of MS. Multiple therapies targeting remyelination failed to provide conclusive evidence of broad therapeutic benefit; however, more targeted approaches offer hope that myelin repair might be achieved resulting in specific clinical improvements. Strategies targeting chronic Epstein-Barr virus infection and dysbiosis of the gut microbiome are the first to link microbial risk factors for MS and therapeutic interventions. SUMMARY A striking number of diverse treatments under investigation bodes well for development of better and more effective therapies in MS.
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119
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Abstract
The development of antidrug antibodies (ADAs) is a major problem in several recombinant protein therapies used in the treatment of multiple sclerosis (MS). The etiology of ADAs is multifaceted. The predisposition for a breakdown of immune tolerance is probably genetically determined, and many factors may contribute to the immunogenicity, including structural properties, formation of aggregates, and presence of contaminants and impurities from the industrial manufacturing process. ADAs may have a neutralizing capacity and can reduce or abrogate the bioactivity and therapeutic efficacy of the drug and cause safety issues. Interferon (IFN)-β was the first drug approved for the treatment of MS, and-although it is generally recognized that neutralizing antibodies (NAbs) appear and potentially have a negative effect on therapeutic efficacy-the use of routine measurements of NAbs and the interpretation of the presence of NAbs has been debated at length. NAbs appear after 9-18 months of therapy in up to 40% of patients treated with IFNβ, and the frequency and titers of NAbs depend on the IFNβ preparation. Although all pivotal clinical trials of approved IFNβ products in MS exhibited a detrimental effect of NAbs after prolonged therapy, some subsequent studies did not observe clinical effects from NAbs, which led to the claim that NAbs did not matter. However, it is now largely agreed that persistently high titers of NAbs indicate an abrogation of the biological response and, hence, an absence of therapeutic efficacy, and this observation should lead to a change of therapy. Low and medium titers are ambiguous, and treatment decisions should be guided by determination of in vivo messenger RNA myxovirus resistance protein A induction after IFNβ administration and clinical disease activity. During treatment with glatiramer acetate, ADAs occur frequently but do not appear to adversely affect treatment efficacy or result in adverse events. ADAs occur in approximately 5% of patients treated with natalizumab within 6 months of therapy, and persistent NAbs are associated with a lack of efficacy and acute infusion-related reactions and should instigate a change of therapy. When using the anti-CD20 monoclonal antibodies ocrelizumab and ofatumumab in the treatment of MS, it is not necessary to test for NAbs as these occur very infrequently. Alemtuzumab is immunogenic, but routine measurements of ADAs are not recommended as the antibodies in the pivotal 2-year trials at the population level did not influence lymphocyte depletion or repopulation, efficacy, or safety. However, in some individuals, NAbs led to poor lymphocyte depletion.
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120
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Blood-brain barrier permeability changes in the first year after alemtuzumab treatment predict 2-year outcomes in relapsing-remitting multiple sclerosis. Mult Scler Relat Disord 2022; 63:103891. [DOI: 10.1016/j.msard.2022.103891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/01/2022] [Accepted: 05/13/2022] [Indexed: 11/22/2022]
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121
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Okuda DT, Burgess KW, Cook K, McCreary M, Winkler MD, Moog TM. Hiding in Plain Sight: The Magnitude of Unused Disease Modifying Therapies in Multiple Sclerosis and Strategies for Reducing the Economic Burden of Care. Mult Scler Relat Disord 2022; 63:103920. [DOI: 10.1016/j.msard.2022.103920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 05/06/2022] [Accepted: 05/26/2022] [Indexed: 11/30/2022]
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122
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Apóstolos SLP, Boaventura M, Mendes NT, Teixeira LS, Campana IG. How to choose initial treatment in multiple sclerosis patients: a case-based approach. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:159-172. [PMID: 35976318 PMCID: PMC9491420 DOI: 10.1590/0004-282x-anp-2022-s128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Immunotherapy dramatically changed the natural history of multiple sclerosis (MS), which was classically associated with severe disability. Treatment strategies advocate that early control of disease activity is crucial to avoid progressive disability, and the use of high efficacy drugs may be beneficial, but safety is a concern. Choosing the disease-modifying therapy is challenging in clinical practice and should be further discussed. OBJECTIVE To discuss the state of art of selecting the initial therapy for relapsing MS patients. METHODS We used a case-based approach followed by clinical discussion, exploring therapeutic options in different MS settings. RESULTS We presented clinical cases profile compatible with the use of MS therapies, classified into moderate and high efficacy. In the moderate efficacy group, we discussed interferons, glatiramer acetate, teriflunomide and dimethyl fumarate, while in the high efficacy group we discussed fingolimod, cladribine, natalizumab, ocrelizumab, alemtuzumab and ofatumumab. CONCLUSION Advances in MS treatment are remarkable. Strong evidence supports the use of early high efficacy therapy. However, biomarkers, clinical and radiologic prognostic factors, as well as patients' individual issues, should be valued and considered for a personalized treatment decision.
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Affiliation(s)
- Samira Luisa Pereira Apóstolos
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil
| | - Mateus Boaventura
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil
| | - Natalia Trombini Mendes
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil
| | - Larissa Silva Teixeira
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil
| | - Igor Gusmão Campana
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil
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123
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Ramírez-Sánchez AD, Chu X, Modderman R, Kooy-Winkelaar Y, Koletzko S, Korponay-Szabó IR, Troncone R, Wijmenga C, Mearin L, Withoff S, Jonkers IH, Li Y. Single-Cell RNA Sequencing of Peripheral Blood Mononuclear Cells From Pediatric Coeliac Disease Patients Suggests Potential Pre-Seroconversion Markers. Front Immunol 2022; 13:843086. [PMID: 35371081 PMCID: PMC8964997 DOI: 10.3389/fimmu.2022.843086] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 02/22/2022] [Indexed: 11/30/2022] Open
Abstract
Celiac Disease (CeD) is a complex immune disorder involving villous atrophy in the small intestine that is triggered by gluten intake. Current CeD diagnosis is based on late-stage pathophysiological parameters such as detection of specific antibodies in blood and histochemical detection of villus atrophy and lymphocyte infiltration in intestinal biopsies. To date, no early onset biomarkers are available that would help prevent widespread villous atrophy and severe symptoms and co-morbidities. To search for novel CeD biomarkers, we used single-cell RNA sequencing (scRNAseq) to investigate PBMC samples from 11 children before and after seroconversion for CeD and 10 control individuals matched for age, sex and HLA-genotype. We generated scRNAseq profiles of 9559 cells and identified the expected major cellular lineages. Cell proportions remained stable across the different timepoints and health conditions, but we observed differences in gene expression profiles in specific cell types when comparing patient samples before and after disease development and comparing patients with controls. Based on the time when transcripts were differentially expressed, we could classify the deregulated genes as biomarkers for active CeD or as potential pre-diagnostic markers. Pathway analysis showed that active CeD biomarkers display a transcriptional profile associated with antigen activation in CD4+ T cells, whereas NK cells express a subset of biomarker genes even before CeD diagnosis. Intersection of biomarker genes with CeD-associated genetic risk loci pinpointed genetic factors that might play a role in CeD onset. Investigation of potential cellular interaction pathways of PBMC cell subpopulations highlighted the importance of TNF pathways in CeD. Altogether, our results pinpoint genes and pathways that are altered prior to and during CeD onset, thereby identifying novel potential biomarkers for CeD diagnosis in blood.
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Affiliation(s)
- Aarón D Ramírez-Sánchez
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Xiaojing Chu
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.,Department of Computational Biology for Individualised Medicine, Centre for Individualised Infection Medicine (CiiM) & TWINCORE, Joint Ventures Between the Helmholtz-Centre for Infection Research (HZI) and the Hannover Medical School (MHH), Hannover, Germany
| | - Rutger Modderman
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Yvonne Kooy-Winkelaar
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, Netherlands
| | - Sibylle Koletzko
- Department of Pediatrics, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-Universität München (LMU) Klinikum Munich, Munich, Germany.,Department of Pediatric Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
| | - Ilma R Korponay-Szabó
- Coeliac Disease Center, Heim Pál National Paediatric Institute, Budapest, Hungary.,Department of Paediatrics, Faculty of Medicine and Clinical Center, University of Debrecen, Debrecen, Hungary
| | - Riccardo Troncone
- Department of Medical Translational Sciences and European Laboratory for the Investigation of Food Induced Diseases, University Federico II, Naples, Italy
| | - Cisca Wijmenga
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Luisa Mearin
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, Netherlands
| | - Sebo Withoff
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Iris H Jonkers
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Yang Li
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.,Department of Computational Biology for Individualised Medicine, Centre for Individualised Infection Medicine (CiiM) & TWINCORE, Joint Ventures Between the Helmholtz-Centre for Infection Research (HZI) and the Hannover Medical School (MHH), Hannover, Germany.,Department of Internal Medicine and Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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Krajnc N, Bsteh G, Berger T, Mares J, Hartung HP. Monoclonal Antibodies in the Treatment of Relapsing Multiple Sclerosis: an Overview with Emphasis on Pregnancy, Vaccination, and Risk Management. Neurotherapeutics 2022; 19:753-773. [PMID: 35378683 PMCID: PMC8978776 DOI: 10.1007/s13311-022-01224-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 01/10/2023] Open
Abstract
Monoclonal antibodies have become a mainstay in the treatment of patients with relapsing multiple sclerosis (RMS) and provide some benefit to patients with primary progressive MS. They are highly precise by specifically targeting molecules displayed on cells involved in distinct immune mechanisms of MS pathophysiology. They not only differ in the target antigen they recognize but also by the mode of action that generates their therapeutic effect. Natalizumab, an [Formula: see text]4[Formula: see text]1 integrin antagonist, works via binding to cell surface receptors, blocking the interaction with their ligands and, in that way, preventing the migration of leukocytes across the blood-brain barrier. On the other hand, the anti-CD52 monoclonal antibody alemtuzumab and the anti-CD20 monoclonal antibodies rituximab, ocrelizumab, ofatumumab, and ublituximab work via eliminating selected pathogenic cell populations. However, potential adverse effects may be serious and can necessitate treatment discontinuation. Most importantly, those are the risk for (opportunistic) infections, but also secondary autoimmune diseases or malignancies. Monoclonal antibodies also carry the risk of infusion/injection-related reactions, primarily in early phases of treatment. By careful patient selection and monitoring during therapy, the occurrence of these potentially serious adverse effects can be minimized. Monoclonal antibodies are characterized by a relatively long pharmacologic half-life and pharmacodynamic effects, which provides advantages such as permitting infrequent dosing, but also creates disadvantages regarding vaccination and family planning. This review presents an overview of currently available monoclonal antibodies for the treatment of RMS, including their mechanism of action, efficacy and safety profile. Furthermore, we provide practical recommendations for risk management, vaccination, and family planning.
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Affiliation(s)
- Nik Krajnc
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Jan Mares
- Department of Neurology, Palacky University Olomouc, Olomouc, Czech Republic
| | - Hans-Peter Hartung
- Department of Neurology, Medical University of Vienna, Vienna, Austria.
- Department of Neurology, Palacky University Olomouc, Olomouc, Czech Republic.
- Department of Neurology, Medical Faculty, Heinrich-Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
- Brain and Mind Center, University of Sydney, Sydney, Australia.
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Gopaluni S, Smith R, Goymer D, Cahill H, Broadhurst E, Wallin E, McClure M, Chaudhry A, Jayne D. Alemtuzumab for refractory primary systemic vasculitis-a randomised controlled dose ranging clinical trial of efficacy and safety (ALEVIATE). Arthritis Res Ther 2022; 24:81. [PMID: 35365179 PMCID: PMC8972754 DOI: 10.1186/s13075-022-02761-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/06/2022] [Indexed: 12/21/2022] Open
Abstract
Background Primary systemic vasculitis (PSV) is a heterogeneous group of autoimmune conditions. There is an unmet need for alternative therapies that lead to sustained remission in patients with refractory disease. Alemtuzumab, an anti-CD52 antibody, depletes lymphocytes for prolonged periods and, in retrospective studies, has induced sustained, treatment-free remissions in patients with refractory/relapsing vasculitis but has raised safety concerns of infection and secondary autoimmunity. This phase IIb clinical trial aimed to assess the efficacy and safety of alemtuzumab, at two different doses, in inducing remission in refractory vasculitis patients. Methods The ALEVIATE trial was a randomised, prospective, open-label, dose ranging clinical trial. Patients with refractory ANCA-associated vasculitis (AAV) or Behçet’s disease (BD) were randomised to receive either 60 mg or 30 mg alemtuzumab. Treatments were administered at baseline and 6 months or earlier where clinically appropriate. A maximum of three treatments were allowed within the 12-month study period. Results Twenty-three patients received at least one dose of alemtuzumab. Twelve had AAV, and 11 a diagnosis of BD. The median age was 40 years (range 28–44), with a prior disease duration of 61 months (42–103). Sixteen (70%) achieved either complete (6/23, 26%) or partial (10/23, 44%) response at 6 months. Eight (35%) maintained remission to the end of the trial without relapse. Ten severe adverse events were observed in 7 (30%) patients; 4 were related to alemtuzumab. There were no differences in clinical endpoints between the 60 and 30 mg alemtuzumab treatment groups. Conclusion In a selected group of refractory vasculitis patients, alemtuzumab led to remission in two thirds of patients at 6 months. Remission was maintained to 12 months in a third of the patients, and the safety profile was acceptable. Trial registration ClinicalTrials.gov identifier: NCT01405807, EudraCT Number: 2009-017087-17. Registered on April 07, 2011. Supplementary Information The online version contains supplementary material available at 10.1186/s13075-022-02761-6.
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Affiliation(s)
- Seerapani Gopaluni
- University of Cambridge, Box 118, Addenbrooke's Hospital, Hills Road, Cambridge, CB20QQ, UK.
| | - Rona Smith
- University of Cambridge, Box 118, Addenbrooke's Hospital, Hills Road, Cambridge, CB20QQ, UK.,Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Donna Goymer
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Hugh Cahill
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Elizabeth Wallin
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Mark McClure
- University of Cambridge, Box 118, Addenbrooke's Hospital, Hills Road, Cambridge, CB20QQ, UK.,Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Afzal Chaudhry
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - David Jayne
- University of Cambridge, Box 118, Addenbrooke's Hospital, Hills Road, Cambridge, CB20QQ, UK.,Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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126
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Low vitamin D levels do not predict risk of autoimmune disease following alemtuzumab treatment for multiple sclerosis. Mult Scler Relat Disord 2022; 59:103511. [DOI: 10.1016/j.msard.2022.103511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 12/08/2021] [Accepted: 01/08/2022] [Indexed: 11/23/2022]
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Bónitto JRG, Ayala OD, Botero LC. REAL-LIFE EVIDENCE OF TREATMENT WITH ALEMTUZUMAB IN PATIENTS DIAGNOSED WITH RELAPSING-REMITTING MULTIPLE SCLEROSIS IN COLOMBIA. Mult Scler Relat Disord 2022; 61:103780. [DOI: 10.1016/j.msard.2022.103780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/26/2022] [Accepted: 03/26/2022] [Indexed: 10/18/2022]
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Rolla S, De Mercanti SF, Bardina V, Maglione A, Taverna D, Novelli F, Cocco E, Vladic A, Habek M, Adamec I, Annovazzi POL, Horakova D, Clerico M. Long-Term Effects of Alemtuzumab on CD4+ Lymphocytes in Multiple Sclerosis Patients: A 72-Month Follow-Up. Front Immunol 2022; 13:818325. [PMID: 35296069 PMCID: PMC8919044 DOI: 10.3389/fimmu.2022.818325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 02/07/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction Alemtuzumab is highly effective in the treatment of patients with relapsing multiple sclerosis (PwRMS) and selectively targets the CD52 antigen, with a consequent profound lymphopenia, particularly of CD4+ T lymphocytes. However, the immunological basis of its long-term efficacy has not been clearly elucidated. Methods We followed up 29 alemtuzumab-treated RMS patients over a period of 72 months and studied the immunological reconstitution of their CD4+ T cell subsets by means of phenotypic and functional analysis and through mRNA-related molecule expression, comparing them to healthy subject (HS) values (rate 2:1). Results In patients receiving only two-course alemtuzumab, the percentage of CD4+ lymphocytes decreased and returned to basal levels only at month 48. Immune reconstitution of the CD4+ subsets was characterized by a significant increase (p < 0.001) in Treg cell percentage at month 24, when compared to baseline, and was accompanied by restoration of the Treg suppressor function that increased within a range from 2- to 6.5-fold compared to baseline and that persisted through to the end of the follow-up. Furthermore, a significant decrease in self-reactive myelin basic protein-specific Th17 (p < 0.0001) and Th1 (p < 0.05) cells reaching HS values was observed starting from month 12. There was a change in mRNA of cytokines, chemokines, and transcriptional factors related to Th17, Th1, and Treg cell subset changes, consequently suggesting a shift toward immunoregulation and a reduction of T cell recruitment to the central nervous system. Conclusions These data provide further insight into the mechanism that could contribute to the long-term 6-year persistence of the clinical effect of alemtuzumab on RMS disease activity.
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Affiliation(s)
- Simona Rolla
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- *Correspondence: Simona Rolla,
| | | | - Valentina Bardina
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- Laboratory of Microbiology and Virology, Amedeo di Savoia Hospital, Torino, Italy
| | - Alessandro Maglione
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Daniela Taverna
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Francesco Novelli
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Eleonora Cocco
- Department of Medical Science and Public Health, University of Cagliari and Multiple Sclerosis Center, Cagliari, Italy
| | - Anton Vladic
- Department of Neurology, Clinical Hospital Sveti Duh Zagreb and Medical Faculty, University J.J Strossmayer Osijek, Prague, Croatia
| | - Mario Habek
- Referral Center for Autonomic Nervous System, University Hospital Center Zagreb, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ivan Adamec
- Referral Center for Autonomic Nervous System, University Hospital Center Zagreb, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | | | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
| | - Marinella Clerico
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
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Tur C, Dubessy AL, Otero-Romero S, Amato MP, Derfuss T, Di Pauli F, Iacobaeus E, Mycko M, Abboud H, Achiron A, Bellinvia A, Boyko A, Casanova JL, Clifford D, Dobson R, Farez MF, Filippi M, Fitzgerald KC, Fonderico M, Gouider R, Hacohen Y, Hellwig K, Hemmer B, Kappos L, Ladeira F, Lebrun-Frénay C, Louapre C, Magyari M, Mehling M, Oreja-Guevara C, Pandit L, Papeix C, Piehl F, Portaccio E, Ruiz-Camps I, Selmaj K, Simpson-Yap S, Siva A, Sorensen PS, Sormani MP, Trojano M, Vaknin-Dembinsky A, Vukusic S, Weinshenker B, Wiendl H, Winkelmann A, Zuluaga Rodas MI, Tintoré M, Stankoff B. The risk of infections for multiple sclerosis and neuromyelitis optica spectrum disorder disease-modifying treatments: Eighth European Committee for Treatment and Research in Multiple Sclerosis Focused Workshop Review. April 2021. Mult Scler 2022; 28:1424-1456. [PMID: 35196927 DOI: 10.1177/13524585211069068] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Over the recent years, the treatment of multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) has evolved very rapidly and a large number of disease-modifying treatments (DMTs) are now available. However, most DMTs are associated with adverse events, the most frequent of which being infections. Consideration of all DMT-associated risks facilitates development of risk mitigation strategies. An international focused workshop with expert-led discussions was sponsored by the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS) and was held in April 2021 to review our current knowledge about the risk of infections associated with the use of DMTs for people with MS and NMOSD and corresponding risk mitigation strategies. The workshop addressed DMT-associated infections in specific populations, such as children and pregnant women with MS, or people with MS who have other comorbidities or live in regions with an exceptionally high infection burden. Finally, we reviewed the topic of DMT-associated infectious risks in the context of the current SARS-CoV-2 pandemic. Herein, we summarize available evidence and identify gaps in knowledge which justify further research.
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Affiliation(s)
- Carmen Tur
- Multiple Sclerosis Centre of Catalonia (Cemcat), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Anne-Laure Dubessy
- Sorbonne Université, Inserm, CNRS, UMR7225, Institut du Cerveau et de la Moelle épinière (ICM), Paris, France/ Department of Neurology, Saint Antoine Hospital, AP-HP, Paris, France
| | - Susana Otero-Romero
- Multiple Sclerosis Centre of Catalonia (Cemcat), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Maria Pia Amato
- Department of NEUROFARBA, University of Florence, Florence, Italy/IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Tobias Derfuss
- Neurology Clinic and Policlinic, Departments of Medicine, Clinical Research and Biomedicine and Research Center for Clinical Neuroimmunology and Neuroscience Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Franziska Di Pauli
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Ellen Iacobaeus
- Division of Neurology, Department of Clinical Neuroscience, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Marcin Mycko
- Department of Neurology, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
| | - Hesham Abboud
- Multiple Sclerosis and Neuroimmunology Program, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland Medical Center, Cleveland, OH, USA
| | - Anat Achiron
- Sheba Medical Center at Tel Hashomer and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Angelo Bellinvia
- Department of NEUROFARBA, University of Florence, Florence, Italy
| | - Alexey Boyko
- Department of Neurology, Neurosurgery and Medical Genetics, Pirogov Russian National Research Medical University, Moscow, Russia/Institute of Clinical Neurology and Department of Neuroimmunology, Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
| | - Jean-Laurent Casanova
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY, USA
| | - David Clifford
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK/Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Mauricio F Farez
- Center for Research on Neuroimmunological Diseases, FLENI, Buenos Aires, Argentina
| | - Massimo Filippi
- Neurology Unit, Neurorehabilitation Unit and Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy/Vita-Salute San Raffaele University, Milan, Italy
| | - Kathryn C Fitzgerald
- Department of Neurology and Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Mattia Fonderico
- Department of NEUROFARBA, University of Florence, Florence, Italy
| | - Riadh Gouider
- Department of Neurology, Razi Hospital, Tunis, Tunisia
| | - Yael Hacohen
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Institute of Neurology, London, UK
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Bernhard Hemmer
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany; Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Ludwig Kappos
- Neurologic Clinic and Policlinic, Departments of Medicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital, University of Basel, Basel, Switzerland
| | - Filipa Ladeira
- Neurology Department, Hospital Santo António dos Capuchos, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Christine Lebrun-Frénay
- CRCSEP Côte d'Azur, CHU de Nice Pasteur 2, UR2CA-URRIS, Université Nice Côte d'Azur, Nice, France
| | - Céline Louapre
- Sorbonne Université, Inserm, CNRS, UMR7225, Institut du Cerveau et de la Moelle épinière (ICM), Paris, France/Sorbonne University, Paris Brain Institute-ICM, Assistance Publique Hôpitaux de Paris, Inserm, CNRS, Hôpital de la Pitié Salpêtrière, CIC Neurosciences, Paris, France
| | - Melinda Magyari
- Department of Neurology, Danish Multiple Sclerosis Center, Copenhagen University Hospital, Copenhagen, Denmark
| | - Matthias Mehling
- Neurology Clinic and Policlinic, Departments of Medicine, Clinical Research and Biomedicine and Research Center for Clinical Neuroimmunology and Neuroscience Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Celia Oreja-Guevara
- Department of Neurology, Hospital Clínico San Carlos, Idissc, Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Lekha Pandit
- Center for Advanced Neurological Research, KS Hegde Medical Academy, Nitte (Deemed to be University), Mangalore, India
| | - Caroline Papeix
- Sorbonne Université, Inserm, CNRS, UMR7225, Institut du Cerveau et de la Moelle épinière (ICM), Paris, France/Sorbonne University, Paris Brain Institute-ICM, Assistance Publique Hôpitaux de Paris, Inserm, CNRS, Hôpital de la Pitié Salpêtrière, CIC Neurosciences, Paris, France
| | - Fredrik Piehl
- Division of Neurology, Department of Clinical Neuroscience, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Emilio Portaccio
- Department of NEUROFARBA, University of Florence, Florence, Italy
| | - Isabel Ruiz-Camps
- Servicio de Enfermedades Infecciosas, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Krzysztof Selmaj
- Collegium Medicum, Department of Neurology, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland/Center of Neurology, Lodz, Poland
| | - Steve Simpson-Yap
- Clinical Outcomes Research Unit, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Aksel Siva
- Department of Neurology, Istanbul University Cerrahpasa School of Medicine, Istanbul, Turkey
| | - Per Soelberg Sorensen
- Department of Neurology, Danish Multiple Sclerosis Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Maria Pia Sormani
- Department of Health Sciences, University of Genoa and IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Maria Trojano
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro," Bari, Italy
| | - Adi Vaknin-Dembinsky
- Hadassah-Hebrew University Medical Center, Department of Neurology, The Agnes-Ginges Center for Neurogenetics Jerusalem, Jerusalem, Israel
| | - Sandra Vukusic
- Service de neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France/Centre des Neurosciences de Lyon, Observatoire Français de la Sclérose en Plaques, INSERM 1028 et CNRS UMR5292, Lyon, France/Université Claude Bernard Lyon 1, Faculté de médecine Lyon Est, Lyon, France
| | | | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Münster, Germany
| | | | | | - Mar Tintoré
- Multiple Sclerosis Centre of Catalonia (Cemcat), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Bruno Stankoff
- Sorbonne Université, Inserm, CNRS, UMR7225, Institut du Cerveau et de la Moelle épinière (ICM), Paris, France/ Department of Neurology, Saint Antoine Hospital, AP-HP, Paris, France
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Cencioni MT, Genchi A, Brittain G, de Silva TI, Sharrack B, Snowden JA, Alexander T, Greco R, Muraro PA. Immune Reconstitution Following Autologous Hematopoietic Stem Cell Transplantation for Multiple Sclerosis: A Review on Behalf of the EBMT Autoimmune Diseases Working Party. Front Immunol 2022; 12:813957. [PMID: 35178046 PMCID: PMC8846289 DOI: 10.3389/fimmu.2021.813957] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 12/29/2021] [Indexed: 12/18/2022] Open
Abstract
Multiple sclerosis (MS) is a central nervous system (CNS) disorder, which is mediated by an abnormal immune response coordinated by T and B cells resulting in areas of inflammation, demyelination, and axonal loss. Disease-modifying treatments (DMTs) are available to dampen the inflammatory aggression but are ineffective in many patients. Autologous hematopoietic stem cell transplantation (HSCT) has been used as treatment in patients with a highly active disease, achieving a long-term clinical remission in most. The rationale of the intervention is to eradicate inflammatory autoreactive cells with lympho-ablative regimens and restore immune tolerance. Immunological studies have demonstrated that autologous HSCT induces a renewal of TCR repertoires, resurgence of immune regulatory cells, and depletion of proinflammatory T cell subsets, suggesting a "resetting" of immunological memory. Although our understanding of the clinical and immunological effects of autologous HSCT has progressed, further work is required to characterize the mechanisms that underlie treatment efficacy. Considering that memory B cells are disease-promoting and stem-like T cells are multipotent progenitors involved in self-regeneration of central and effector memory cells, investigating the reconstitution of B cell compartment and stem and effector subsets of immunological memory following autologous HSCT could elucidate those mechanisms. Since all subjects need to be optimally protected from vaccine-preventable diseases (including COVID-19), there is a need to ensure that vaccination in subjects undergoing HSCT is effective and safe. Additionally, the study of vaccination in HSCT-treated subjects as a means of evaluating immune responses could further distinguish broad immunosuppression from immune resetting.
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Affiliation(s)
- Maria Teresa Cencioni
- Division of Neurology, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Angela Genchi
- Department of Neurology, Neurology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Gavin Brittain
- South Yorkshire Regional Department of Infection and Tropical Medicine, Sheffield Teaching Hospitals National Health Service (NHS) Foundation Trust, Sheffield, United Kingdom.,Institute for Translational Neuroscience and Sheffield Neuroscience Biomedical Research Centre (BRC), Sheffield, United Kingdom
| | - Thushan I de Silva
- South Yorkshire Regional Department of Infection and Tropical Medicine, Sheffield Teaching Hospitals National Health Service (NHS) Foundation Trust, Sheffield, United Kingdom.,Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, United Kingdom
| | - Basil Sharrack
- South Yorkshire Regional Department of Infection and Tropical Medicine, Sheffield Teaching Hospitals National Health Service (NHS) Foundation Trust, Sheffield, United Kingdom.,Institute for Translational Neuroscience and Sheffield Neuroscience Biomedical Research Centre (BRC), Sheffield, United Kingdom
| | - John Andrew Snowden
- Department of Haematology, Sheffield Teaching Hospitals National Health Service (NHS) Foundation Trust, Sheffield, United Kingdom.,Department of Oncology and Metabolism, The University of Sheffield, Sheffield, United Kingdom
| | - Tobias Alexander
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Rheumatology and Clinical Immunology, Berlin, Germany.,Deutsches Rheuma-Forschungszentrum, ein Leibniz Institut, Berlin, Germany
| | - Raffaella Greco
- Unit of Haematology and Bone Marrow Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Paolo A Muraro
- Division of Neurology, Department of Brain Sciences, Imperial College London, London, United Kingdom
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131
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Talwar A, Earla JR, Hutton GJ, Aparasu RR. Prescribing of disease modifying agents in older adults with multiple sclerosis. Mult Scler Relat Disord 2022; 57:103308. [PMID: 35158421 DOI: 10.1016/j.msard.2021.103308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/22/2021] [Accepted: 10/02/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND The use of disease-modifying agents (DMAs) to treat Multiple Sclerosis (MS) in older adults is debated as the disease activity decreases with aging. However, limited data exist regarding prescribing patterns of DMAs among older adults with MS. OBJECTIVE To examine prescribing patterns of DMAs and the factors associated with DMA prescribing practices among older adults with MS using electronic medical records (EMR) data. METHODS A retrospective longitudinal cohort study was conducted using the TriNetX, a federated EMR network from the US, data from 2016 to 2019. The study included older adults (≥60 years) with MS diagnosis and at least one prescription record during the study period. Patients with DMA prescriptions were identified and further classified into injectable, oral, or infusion users based on their last DMA prescription. A multivariable logistic regression model was used to evaluate the factors associated with prescribing of DMAs. A multinomial logistic regression model was also used to determine the factors associated with prescribing a particular dosage form of DMA. RESULTS The study cohort consisted of 12,922 older adults with MS, with 2,455 (18.99%) receiving DMA prescriptions. The commonly prescribed DMAs were injectables (10.46%), followed by orals (6.06%) and infusions (2.40%). Multivariable logistic regression revealed that older adults between 60- to 64 years (Adjusted Odds Ratio [aOR]= 2.38) and 65-69 years (aOR=1.60) had higher odds of receiving DMA compared to older adults of 70 years and above. African Americans (aOR=1.71) had higher odds of receiving DMA prescriptions compared to Caucasians. The presence of symptoms (pain, fatigue, speech, walking difficulty) and use of symptomatic medication (anti-fatigue medication, bladder dysfunction medication, antispasmodics, antidepressants, and relapse medication) increased the odds of being prescribed DMAs. Multinomial logistic regression found that patients 60-64 years of age had higher odds of being prescribed infusion (aOR, 95% Confidence Interval [CI] =2.06, 1.35-3.15) and oral (65-69 years: aOR=1.60, 1.24-2.07) over injectable DMAs compared to the older adults aged 70 years and above.Older males (aOR=1.68, 95% CI: 1.23-2.30) were associated with increased odds of being prescribed infusion DMA over injectable DMA compared to females. The presence of comorbidities such as coagulopathy and peripheral vascular disorders decreased the odds of being prescribed oral DMA over injectable DMA. Patients with cerebellar symptoms had an increased likelihood of being prescribed with an infusion DMA over injectable DMA. Patients using drugs for treating relapses had higher odds of being prescribed an infusion DMA over an injectable DMA. In terms of healthcare utilization, older adults with outpatient visits had higher odds of being prescribed an infusion DMA over an injectable DMA, while older adults with inpatient visits had lower odds of being prescribed an infusion DMA over an injectable DMA. CONCLUSION Nearly one in five older adults with MS are prescribed DMAs, with a majority receiving injectable DMAs. Several demographic and clinical factors were associated with DMA prescribing . This study fills the data gap regarding the utilization of DMAs in older adults with MS.
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Affiliation(s)
- Ashna Talwar
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, TX, United States
| | | | | | - Rajender R Aparasu
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, TX, United States.
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132
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Kołtuniuk A, Chojdak-Łukasiewicz J. Adherence to Therapy in Patients with Multiple Sclerosis-Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19042203. [PMID: 35206387 PMCID: PMC8872308 DOI: 10.3390/ijerph19042203] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/27/2022] [Accepted: 02/12/2022] [Indexed: 12/04/2022]
Abstract
Multiple sclerosis (MS) is a chronic, autoimmune, demyelinating disease of the central nervous system (CNS). MS is an incurable disease. The goal of disease-modifying therapies (DMT) is to slow the progression of the disease, prevent relapses and increase the patient’s overall quality of life. According to the World Health Organisation definition, adherence means the extent to which a person’s medication-taking behaviour corresponds with the agreed upon treatment recommendations from a healthcare provider. Accurate adherence is necessary for efficient treatment. Non-adherence is related to unsuccessful treatments, the risk of relapses and increased healthcare costs. The aim of this study is to present the main factors relating to non-adherence in MS patients.
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Affiliation(s)
- Aleksandra Kołtuniuk
- Division of Internal Medicine Nursing, Faculty of Health Sciences, Wroclaw Medical University, Bartla 5, 51-618 Wroclaw, Poland;
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Patti F, Chisari CG, Toscano S, Arena S, Finocchiaro C, Cimino V, Milone G. Autologous Hematopoietic Stem Cell Transplantation in Multiple Sclerosis Patients: Monocentric Case Series and Systematic Review of the Literature. J Clin Med 2022; 11:jcm11040942. [PMID: 35207216 PMCID: PMC8875789 DOI: 10.3390/jcm11040942] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 02/05/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic, inflammatory and immune-mediated disease of the central nervous system (CNS), commonly affecting young adults and potentially associated with life-long disability. About 14 disease-modifying treatments (DMTs) are currently approved for the treatment of MS. However, despite the use of highly effective therapies, some patients exhibit a highly active disease with an aggressive course from onset and a higher risk of long-term disability accrual. In the last few years, several retrospective studies, clinical trials, meta-analyses and systematic reviews have investigated autologous hematopoietic stem cell transplantation (AHSCT) as a possible therapeutic option in order to address this unmet clinical need. These studies demonstrated that AHSCT is a highly efficacious and relatively safe therapeutic option for the treatment of highly active MS. Particularly, over recent years, the amount of evidence has grown, with significant improvements in the development of patient selection criteria, choice of the most suitable transplant technique and clinical experience. In this paper, we present six patients who received AHSCT in our MS center and we systematically reviewed recent evidence about the long-term efficacy and safety of AHSCT and the placement of AHSCT in the rapidly evolving therapeutic armamentarium for MS.
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Affiliation(s)
- Francesco Patti
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
- Correspondence: (F.P.); (C.G.C.); Tel.: +39-09-5378-2620 (F.P.)
| | - Clara Grazia Chisari
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
- Correspondence: (F.P.); (C.G.C.); Tel.: +39-09-5378-2620 (F.P.)
| | - Simona Toscano
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
| | - Sebastiano Arena
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
| | - Chiara Finocchiaro
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
| | - Vincenzo Cimino
- IRCCS Centro Neurolesi “Bonino Pulejo”, 98124 Messina, Italy;
| | - Giuseppe Milone
- Hematology and Bone Marrow Transplant Unit, Azienda Policlinico-Vittorio Emanuele, 95124 Catania, Italy;
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Räuber S, Pawlitzki M, Korsen M, Kullmann JS, Thoene D, Pfeuffer S, Rolfes L, Nelke C, Melzer N, Ruck T, Meuth SG, On behalf of the INFUSE-MS study group. A national, multi-center study in Germany to assess implementation of infusion management, treatment satisfaction and quality of life in MS patients receiving alemtuzumab. Mult Scler Relat Disord 2022; 59:103670. [DOI: 10.1016/j.msard.2022.103670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/27/2021] [Accepted: 02/03/2022] [Indexed: 10/19/2022]
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135
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From Diagnosis to Satisfaction in Multiple Sclerosis: A Swiss Patient Survey Highlighting the Importance of the First Diagnostic Consultation. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2022. [DOI: 10.3390/ctn6010004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: An early treatment start with disease modifying therapies (DMT) and long-term adherence is crucial in the treatment of people with multiple sclerosis (PwMS) to prevent future disability. Objectives: To gain information on the diagnostic process, decision making, treatment start and adherence with regard to DMT as well as satisfaction in PwMS in Switzerland to optimize management of PwMS. Methods: A survey was conducted between June 2017 and March 2018 in six hospital-based MS centres and eight private practices in Switzerland. PwMS according to the 2010 McDonald criteria, aged 18–60 years, having a clinical isolated syndrome, relapsing remitting MS, or secondary progressive MS were eligible. The survey contained 40 questions, covering participants’ background and circumstances, treatment decisions, therapy start, treatment adherence, and satisfaction (EKNZ Req-2016-00701). Results: 212 questionnaires were returned for analysis. Of these, 125 (59.0%) were answered by patients treated by practice-based neurologists and 85 (40.1%) by patients treated in hospitals. That PwMS were satisfied overall with current medical care, that they were free of relapses and disease progression, and that they were able to live independently were the main goals of patients. Satisfaction was reflected by an early therapy start and a high adherence to DMT in our cohort. The treating neurologist played a major role in this regard. Furthermore, a satisfactory first diagnostic consultation (FDC) was crucial for successful long-term patient care positively influencing an early treatment start, longer duration of the initial therapy, as well as adherence to treatments and general satisfaction. Conclusion: The treating neurologist and especially a satisfactory FDC play a major role for the successful long-term treatment of PwMS. Detailed information on various aspects of the disease and time with the treating neurologist seems to be of major importance.
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Casanova B, Quintanilla-Bordás C, Gascón F. Escalation vs. Early Intense Therapy in Multiple Sclerosis. J Pers Med 2022; 12:119. [PMID: 35055434 PMCID: PMC8778390 DOI: 10.3390/jpm12010119] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/28/2021] [Accepted: 01/01/2022] [Indexed: 02/01/2023] Open
Abstract
The treatment strategy of multiple sclerosis (MS) is a highly controversial debate. Currently, there are up to 19 drugs approved. However, there is no clear evidence to guide fundamental decisions such as what treatment should be chosen in first place, when treatment failure or suboptimal response should be considered, or what treatment should be considered in these cases. The "escalation strategy" consists of starting treatment with drugs of low side-effect profile and low efficacy, and "escalating" to drugs of higher efficacy-with more potential side-effects-if necessary. This strategy has prevailed over the years. However, the evidence supporting this strategy is based on short-term studies, in hope that the benefits will stand in the long term. These studies usually do not consider the heterogeneity of the disease and the limited effect that relapses have on the long-term. On the other hand, "early intense therapy" strategy refers to starting treatment with drugs of higher efficacy from the beginning, despite having a less favorable side-effect profile. This approach takes advantage of the so-called "window of opportunity" in hope to maximize the clinical benefits in the long-term. At present, the debate remains open. In this review, we will critically review both strategies. We provide a summary of the current evidence for each strategy without aiming to reach a definite conclusion.
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Affiliation(s)
- Bonaventura Casanova
- Unitat de Neuroimmunologia, Hospital Universitari i Politècnic La Fe. València, la Universitat de València, 46026 Valencia, Spain;
| | - Carlos Quintanilla-Bordás
- Unitat de Neuroimmunologia, Hospital Universitari i Politècnic La Fe. València, la Universitat de València, 46026 Valencia, Spain;
| | - Francisco Gascón
- Unitat de Neuroimmunologia, Hospital Clínic Universitari de València, 46010 Valencia, Spain;
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Hussain RZ, Sguigna PV, Okai A, Wright C, Madinawala M, Bass AD, Cutter GR, Manouchehri N, Stuve O. The sequential natalizumab – alemtuzumab therapy in patients with relapsing forms of multiple sclerosis (SUPPRESS) trial – Part I: Rationale and objectives. J Cent Nerv Syst Dis 2022; 14:11795735221123911. [PMID: 36062026 PMCID: PMC9434668 DOI: 10.1177/11795735221123911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background Natalizumab is a recombinant humanized monoclonal antibody (mAb) against α4-integrin
that is approved for relapsing forms of multiple sclerosis (MS). Natalizumab is
associated with an increased risk of developing progressive multifocal
leukoencephalopathy (PML), and with disease reactivation after cessation of treatment
that is likely mediated by an accumulation of pro-inflammatory lymphocytes in the blood
during therapy. Alemtuzumab is a mAb against CD52 that reduces the number of peripheral
lymphocytes. Rationale To determine if treatment with alemtuzumab after natalizumab reduces disease activity
in patients with relapsing forms of MS. This review article will outline the rationale
and objectives of the sequential natalizumab – alemtuzumab therapy in patients with
relapsing forms of multiple sclerosis (SUPPRESS; ClinicalTrials.gov ID: NCT03135249)
trial in greater detail than would be feasible in a manuscript that summarizes the study
results. Methods The SUPPRESS trial is single arm, open-label, multicenter, efficacy pilot study that
aims to establish a disease-free state over a 24-months period in patients who received
the natalizumab- alemtuzumab sequential therapy. Participants will be recruited from
four different sites. The primary endpoint is the annualized relapse rate (ARR) from the
time of cessation of natalizumab treatment. Key secondary endpoint is freedom of relapse
at 12-months, the number of new/enlarging T2 lesions on magnetic resonance imaging
(MRI), and the number of gadolinium (Gd)-enhancing lesions on MRI. An exploratory
endpoint is the Expanded Disability Status Scale (EDSS), retinal nerve fiber layer
(RNFL) thickness assessment by optic coherence tomography (OCT) and assessment of
quality of life (QoL) measures by a pre-defined, self-administered testing battery. To
evaluate immunological effects, blood leukocytes will be collected and immunophenotyped
by multi-parameter flow cytometry. Conclusion The SUPPRESS trial will provide clinical, imaging, and biological data to determine
whether sequential natalizumab to alemtuzumab combination therapy establish a
disease-free state in patients with relapsing forms of MS.
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Affiliation(s)
- Rehana Z Hussain
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Peter V Sguigna
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Annette Okai
- North Texas Institute of Neurology & Headache, Plano, TX, USA
| | - Crystal Wright
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mariam Madinawala
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ann D Bass
- Neurology Center of San Antonio, Dallas, TX, USA
| | - Gary R Cutter
- Department of Biostatistics, Section on Research Methods and Clinical Trials, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Navid Manouchehri
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Olaf Stuve
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Neurology Section, VA North Texas Health Care System, Dallas, TX, USA
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138
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Freeman L, Longbrake EE, Coyle PK, Hendin B, Vollmer T. High-Efficacy Therapies for Treatment-Naïve Individuals with Relapsing-Remitting Multiple Sclerosis. CNS Drugs 2022; 36:1285-1299. [PMID: 36350491 PMCID: PMC9645316 DOI: 10.1007/s40263-022-00965-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2022] [Indexed: 11/11/2022]
Abstract
There are > 18 distinct disease-modifying therapy (DMT) options covering 10 mechanisms of action currently approved by the US Food and Drug Administration for the treatment of relapsing-remitting multiple sclerosis (RRMS). Given the multitude of available treatment options, and recent international consensus guidelines offering differing recommendations, there is broad heterogeneity in how the DMTs are used in clinical practice. Choosing a DMT for newly diagnosed patients with MS is currently a topic of significant debate in MS care. Historically, an escalation approach to DMT was used for newly diagnosed patients with RRMS. However, the evidence for clinical benefits of early treatment with high-efficacy therapies (HETs) in this population is emerging. In this review, we provide an overview of the DMT options and MS treatment strategies, and discuss the clinical benefits of HETs (including ofatumumab, ocrelizumab, natalizumab, alemtuzumab, and cladribine) in the early stages of MS, along with safety concerns associated with these DMTs. By minimizing the accumulation of neurological damage early in the disease course, early treatment with HETs may enhance long-term clinical outcomes over the lifetime of the patient.
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Affiliation(s)
- Léorah Freeman
- Department of Neurology, Dell Medical School, The University of Texas at Austin, 1601 Trinity St, Austin, TX, 78701, USA.
| | | | - Patricia K. Coyle
- Department of Neurology, Stony Brook University Medical Center, Stony Brook, NY USA
| | - Barry Hendin
- Banner, University Medicine Neurosciences Clinic, Phoenix, AZ USA
| | - Timothy Vollmer
- Department of Neurology, University of Colorado, Anschutz Medical Campus, Aurora, CO USA
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Palmeri S, Ponzano M, Ivaldi F, Signori A, Lapucci C, Casella V, Ferrò MT, Vigo T, Inglese M, Mancardi GL, Uccelli A, Laroni A. Impact of Natural Killer (NK) Cells on Immune Reconstitution, and Their Potential as a Biomarker of Disease Activity, in Alemtuzumab-Treated Patients with Relapsing Remitting Multiple Sclerosis: An Observational Study. CNS Drugs 2022; 36:83-96. [PMID: 34894339 DOI: 10.1007/s40263-021-00875-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Defining immune mechanisms leading to multiple sclerosis (MS) is difficult, due to the great inter-individual difference in immune system responses. The anti-CD52 antibody alemtuzumab transiently abolishes differences in immune parameters among individuals, allowing analysis of subsequent immune cell repopulation patterns, and their possible role in MS. OBJECTIVE To evaluate the correlation between innate and adaptive immune cell subsets and disease activity in MS in the context of treatment with alemtuzumab. METHODS A two-center observational cohort of patients treated with alemtuzumab underwent immune profiling of T, B, and natural killer (NK) cells, biomarker, clinical and radiological follow-up. RESULTS After treatment, the percentage of NK and B cells increased; NK, T- and B-cell populations underwent a profound rearrangement. Within the effector T-cell compartment, treatment led to a transient decrease, followed by an increase, of T-helper 1 cells, and to a transient decrease of T-helper 17 cells. Within the T-regulatory compartment, naïve T-regulatory cells increased. Within the B-cell compartment, memory B cells and mature B cells decreased, whereas transitional B cells increased. Within the NK cell compartment, CD56bright NK cells increased. Subjects without disease activity had a greater decrease in serum NfL and greater NK cell/CD3+ T cell ratio. NK cell numbers at baseline and after treatment influenced reconstitution of T and B cells, being inversely correlated with the reconstitution of proinflammatory CD3+ T cells and mature B cells, and directly correlated to the increase in transitional B cells. CONCLUSIONS The results of this study provide novel evidence that NK cells influence reconstitution of adaptive immune cells upon alemtuzumab and that patients with a successful response to alemtuzumab have an early immune reconstitution dominated by NK cells.
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Affiliation(s)
- Serena Palmeri
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Largo Daneo 3, 16132, Genoa, Italy.,University of Genova and IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Marta Ponzano
- Department of Health Sciences, Section of Biostatistics, University of Genova, Genoa, Italy
| | - Federico Ivaldi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Largo Daneo 3, 16132, Genoa, Italy
| | - Alessio Signori
- Department of Health Sciences, Section of Biostatistics, University of Genova, Genoa, Italy
| | - Caterina Lapucci
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Largo Daneo 3, 16132, Genoa, Italy.,IRRCS Ospedale Policlinico San Martino, Largo Rosanna Benzi, Genoa, Italy
| | - Valentina Casella
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Largo Daneo 3, 16132, Genoa, Italy
| | - Maria Teresa Ferrò
- Neuroimmunology, Center for Multiple Sclerosis, Cerebrovascular Department, ASST Crema, Crema, Italy
| | - Tiziana Vigo
- IRRCS Ospedale Policlinico San Martino, Largo Rosanna Benzi, Genoa, Italy
| | - Matilde Inglese
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Largo Daneo 3, 16132, Genoa, Italy.,IRRCS Ospedale Policlinico San Martino, Largo Rosanna Benzi, Genoa, Italy
| | - Giovanni Luigi Mancardi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Largo Daneo 3, 16132, Genoa, Italy
| | - Antonio Uccelli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Largo Daneo 3, 16132, Genoa, Italy.,IRRCS Ospedale Policlinico San Martino, Largo Rosanna Benzi, Genoa, Italy
| | - Alice Laroni
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Largo Daneo 3, 16132, Genoa, Italy. .,IRRCS Ospedale Policlinico San Martino, Largo Rosanna Benzi, Genoa, Italy.
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Chukwu CA, Spiers HV, Middleton R, Kalra PA, Asderakis A, Rao A, Augustine T. Alemtuzumab in renal transplantation. Reviews of literature and usage in the United Kingdom. Transplant Rev (Orlando) 2022; 36:100686. [DOI: 10.1016/j.trre.2022.100686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/20/2022] [Accepted: 01/24/2022] [Indexed: 11/24/2022]
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141
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Ruck T, Barman S, Schulte-Mecklenbeck A, Pfeuffer S, Steffen F, Nelke C, Schroeter CB, Willison A, Heming M, Müntefering T, Melzer N, Krämer J, Lindner M, Riepenhausen M, Gross CC, Klotz L, Bittner S, Muraro PA, Schneider-Hohendorf T, Schwab N, Meyer zu Hörste G, Goebels N, Meuth SG, Wiendl H. OUP accepted manuscript. Brain 2022; 145:1711-1725. [PMID: 35661859 PMCID: PMC9166548 DOI: 10.1093/brain/awac064] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/04/2022] [Accepted: 01/27/2022] [Indexed: 11/12/2022] Open
Abstract
Alemtuzumab is a monoclonal antibody that causes rapid depletion of CD52-expressing immune cells. It has proven to be highly efficacious in active relapsing–remitting multiple sclerosis; however, the high risk of secondary autoimmune disorders has greatly complicated its use. Thus, deeper insight into the pathophysiology of secondary autoimmunity and potential biomarkers is urgently needed. The most critical time points in the decision-making process for alemtuzumab therapy are before or at Month 12, where the ability to identify secondary autoimmunity risk would be instrumental. Therefore, we investigated components of blood and CSF of up to 106 multiple sclerosis patients before and after alemtuzumab treatment focusing on those critical time points. Consistent with previous reports, deep flow cytometric immune-cell profiling (n = 30) demonstrated major effects on adaptive rather than innate immunity, which favoured regulatory immune cell subsets within the repopulation. The longitudinally studied CSF compartment (n = 18) mainly mirrored the immunological effects observed in the periphery. Alemtuzumab-induced changes including increased numbers of naïve CD4+ T cells and B cells as well as a clonal renewal of CD4+ T- and B-cell repertoires were partly reminiscent of haematopoietic stem cell transplantation; in contrast, thymopoiesis was reduced and clonal renewal of T-cell repertoires after alemtuzumab was incomplete. Stratification for secondary autoimmunity did not show clear immununological cellular or proteomic traits or signatures associated with secondary autoimmunity. However, a restricted T-cell repertoire with hyperexpanded T-cell clones at baseline, which persisted and demonstrated further expansion at Month 12 by homeostatic proliferation, identified patients developing secondary autoimmune disorders (n = 7 without secondary autoimmunity versus n = 5 with secondary autoimmunity). Those processes were followed by an expansion of memory B-cell clones irrespective of persistence, which we detected shortly after the diagnosis of secondary autoimmune disease. In conclusion, our data demonstrate that (i) peripheral immunological alterations following alemtuzumab are mirrored by longitudinal changes in the CSF; (ii) incomplete T-cell repertoire renewal and reduced thymopoiesis contribute to a proautoimmune state after alemtuzumab; (iii) proteomics and surface immunological phenotyping do not identify patients at risk for secondary autoimmune disorders; (iv) homeostatic proliferation with disparate dynamics of clonal T- and B-cell expansions are associated with secondary autoimmunity; and (v) hyperexpanded T-cell clones at baseline and Month 12 may be used as a biomarker for the risk of alemtuzumab-induced autoimmunity.
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Affiliation(s)
- Tobias Ruck
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, 40225 Düsseldorf, Germany
- Correspondence to: PD Dr. med. Tobias Ruck Department of Neurology with Institute of Translational Neurology University Hospital Muenster Albert-Schweitzer-Campus 1 D-48149 Muenster, Germany E-mail:
| | - Sumanta Barman
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Andreas Schulte-Mecklenbeck
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Steffen Pfeuffer
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Falk Steffen
- Department of Neurology, Focus Program Translational Neuroscience (FTN) and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany
| | - Christopher Nelke
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Christina B. Schroeter
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Alice Willison
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Michael Heming
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Thomas Müntefering
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Nico Melzer
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Julia Krämer
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Maren Lindner
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Marianne Riepenhausen
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Catharina C. Gross
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Luisa Klotz
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Stefan Bittner
- Department of Neurology, Focus Program Translational Neuroscience (FTN) and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany
| | - Paolo A. Muraro
- Department of Brain Sciences, Imperial College London, London, UK
| | - Tilman Schneider-Hohendorf
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Nicholas Schwab
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Gerd Meyer zu Hörste
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
| | - Norbert Goebels
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Sven G. Meuth
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, 48149 Muenster, Germany
- Correspondence may also be addressed to: Univ.-Prof. Prof. h.c. Dr. med. Heinz Wiendl E-mail:
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Adegoke AO, Lin J, Anderson CC. Loss of thymic function promotes EAE relapse in anti-CD52-treated mice. CURRENT RESEARCH IN IMMUNOLOGY 2022; 3:37-41. [PMID: 35496821 PMCID: PMC9040091 DOI: 10.1016/j.crimmu.2022.03.001] [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: 12/30/2021] [Revised: 02/07/2022] [Accepted: 03/01/2022] [Indexed: 11/19/2022] Open
Abstract
Anti-CD52 treatment creates a long-lasting CD4 T cell lymphopenia and reduces multiple sclerosis (MS) relapses in humans. In contrast, anti-CD52 therapy at disease onset more fully suppresses experimental autoimmune encephalomyelitis (EAE) in mice, and T cell repopulation is rapid. To test whether prolonged T cell lymphopenia promotes relapses, we thymectomized mice prior to EAE induction and anti-CD52 treatment. Thymectomy greatly reduced the number of recent thymic emigrant T cells and was associated with a prolonged reduction in CD4 T cells in peripheral blood. Two-thirds of thymectomized C57BL/6 mice had an EAE relapse post anti-CD52 treatment, while no surgery and sham surgery euthymic controls remained relapse-free. These data demonstrate that thymus function can alter the effectiveness of anti-CD52 treatment. Thymectomy significantly reduces the proportion of newly generated T cells. Thymectomy predisposes anti-CD52-treated mice to EAE relapse. Thymectomy-promoted EAE relapse in anti-CD52 treated mice is associated with weight decline and prolonged T cell lymphopenia.
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Affiliation(s)
- Adeolu O. Adegoke
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
- Alberta Diabetes and Transplant Institutes, University of Alberta, Edmonton, Alberta, Canada
| | - Jiaxin Lin
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
- Alberta Diabetes and Transplant Institutes, University of Alberta, Edmonton, Alberta, Canada
| | - Colin C. Anderson
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
- Alberta Diabetes and Transplant Institutes, University of Alberta, Edmonton, Alberta, Canada
- Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, Alberta, Canada
- Corresponding author. Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
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143
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Garbo R, Cutuli D, Lorenzut S, Gigli GL, Bagatto D, Valente M. Opportunities and Obstacles Associated With Sequential Immune Reconstitution Therapy for Multiple Sclerosis: A Case Report. Front Neurol 2021; 12:664596. [PMID: 34956035 PMCID: PMC8692884 DOI: 10.3389/fneur.2021.664596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 11/08/2021] [Indexed: 11/24/2022] Open
Abstract
Cladribine is an effective disease-modifying treatment for relapsing-remitting multiple sclerosis that acts as an immune reconstitution therapy and is administered in a pulsed manner. Despite its efficacy, severe disease reactivation early after treatment represents a serious clinical problem, and clear evidence to guide the management of such a situation is lacking. Here, we describe the case of a patient experiencing considerable disease activity during the 1st year after the initiation of cladribine treatment. The patient was switched to alemtuzumab and, therefore, received double immune reconstitution therapy. Data regarding this approach are lacking, and real-world observations may be of interest. Despite achieving good control of disease activity, we observed several serious infectious complications. Our results suggest that sequential immune reconstitution therapies may be effective; however, at the price of higher susceptibility to infections.
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Affiliation(s)
- Riccardo Garbo
- Clinical Neurology Unit, Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Daniela Cutuli
- Neurology Unit, Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Simone Lorenzut
- Neurology Unit, Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Gian Luigi Gigli
- Clinical Neurology Unit, Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy.,Department of Medical Area (DAME), University of Udine, Udine, Italy
| | - Daniele Bagatto
- Neuroradiology Unit, Department of Diagnostic Imaging, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Mariarosaria Valente
- Clinical Neurology Unit, Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy.,Department of Medical Area (DAME), University of Udine, Udine, Italy
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144
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Ruck T, Nimmerjahn F, Wiendl H, Lünemann JD. Next generation antibody-based therapies in neurology. Brain 2021; 145:1229-1241. [PMID: 34928330 DOI: 10.1093/brain/awab465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/04/2021] [Accepted: 11/25/2021] [Indexed: 11/13/2022] Open
Abstract
Antibody (Ab)-based therapeutics are now standard in the treatment of neuroinflammatory diseases, and the spectrum of neurological diseases targeted by those approaches continues to grow. The efficacy of Ab-based drug-platforms is largely determined by the specificity-conferring antigen-binding fragment (Fab) and the crystallizable fragment (Fc) driving antibody function. The latter provides specific instructions to the immune system by interacting with cellular Fc receptors and complement components. Extensive engineering efforts enabled tuning of Fc functions to modulate effector functions and to prolong or reduce Ab serum half-lives. Technologies that improve bioavailability of Ab-based treatment platforms within the central nervous system parenchyma are being developed and could invigorate drug discovery for a number of brain diseases for which current therapeutic options are limited. These powerful approaches are currently being tested in clinical trials or have been successfully translated into the clinic. Here, we review recent developments in the design and implementation of Ab-based treatment modalities in neurological diseases.
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Affiliation(s)
- Tobias Ruck
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, 48149 Münster, Germany.,Department of Neurology, Heinrich-Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Falk Nimmerjahn
- Department of Biology, Division of Genetics, University of Erlangen-Nuremberg, 91058 Erlangen, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, 48149 Münster, Germany
| | - Jan D Lünemann
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, 48149 Münster, Germany
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Hao W, Luo Q, Menger MD, Fassbender K, Liu Y. Treatment With CD52 Antibody Protects Neurons in Experimental Autoimmune Encephalomyelitis Mice During the Recovering Phase. Front Immunol 2021; 12:792465. [PMID: 34975892 PMCID: PMC8716455 DOI: 10.3389/fimmu.2021.792465] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 12/01/2021] [Indexed: 12/11/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic autoimmune disease driven by T and B lymphocytes. The remyelination failure and neurodegeneration results in permanent clinical disability in MS patients. A desirable therapy should not only modulate the immune system, but also promote neuroprotection and remyelination. To investigate the neuroprotective effect of CD52 antibody in MS, both C57BL/6J and SJL mice with experimental autoimmune encephalomyelitis (EAE) were treated with CD52 antibody at the peak of disease. Treatment with CD52 antibody depleted T but not B lymphocytes in the blood, reduced the infiltration of T lymphocytes and microglia/macrophages in the spinal cord. Anti-CD52 therapy attenuated EAE scores during the recovery phase. It protected neurons immediately after treatment (within 4 days) as shown by reducing the accumulation of amyloid precursor proteins. It potentially promoted remyelination as it increased the number of olig2/CC-1-positive mature oligodendrocytes and prevented myelin loss in the following days (e.g., 14 days post treatment). In further experiments, EAE mice with a conditional knockout of BDNF in neurons were administered with CD52 antibodies. Neuronal deficiency of BDNF attenuated the effect of anti-CD52 treatment on reducing EAE scores and inflammatory infiltration but did not affect anti-CD52 treatment-induced improvement of myelin coverage in the spinal cord. In summary, anti-CD52 therapy depletes CD4-positive T lymphocytes, prevents myelin loss and protects neurons in EAE mice. Neuronal BDNF regulates neuroprotective and anti-inflammatory effect of CD52 antibody in EAE mice.
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MESH Headings
- Animals
- Anti-Inflammatory Agents/pharmacology
- Antibodies/pharmacology
- Brain-Derived Neurotrophic Factor/genetics
- Brain-Derived Neurotrophic Factor/metabolism
- CD4-Positive T-Lymphocytes/drug effects
- CD4-Positive T-Lymphocytes/immunology
- CD4-Positive T-Lymphocytes/metabolism
- CD52 Antigen/antagonists & inhibitors
- CD52 Antigen/immunology
- CD52 Antigen/metabolism
- Encephalomyelitis, Autoimmune, Experimental/drug therapy
- Encephalomyelitis, Autoimmune, Experimental/immunology
- Encephalomyelitis, Autoimmune, Experimental/metabolism
- Encephalomyelitis, Autoimmune, Experimental/pathology
- Inflammation Mediators/metabolism
- Mice, Inbred C57BL
- Mice, Knockout
- Neurons/drug effects
- Neurons/immunology
- Neurons/metabolism
- Neurons/pathology
- Neuroprotective Agents/pharmacology
- Remyelination/drug effects
- Spinal Cord/drug effects
- Spinal Cord/immunology
- Spinal Cord/metabolism
- Spinal Cord/pathology
- Mice
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Affiliation(s)
- Wenlin Hao
- Department of Neurology, Saarland University, Homburg, Germany
- Department of Neurology, Diakonie Klinikum Neunkirchen, Neunkirchen, Germany
| | - Qinghua Luo
- Department of Neurology, Saarland University, Homburg, Germany
| | - Michael D. Menger
- Department of Experimental Surgery, Saarland University, Homburg, Germany
| | | | - Yang Liu
- Department of Neurology, Saarland University, Homburg, Germany
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146
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Vakrakou AG, Tzanetakos D, Evangelopoulos ME, Fragoulis GE, Kazakou P, Lekka E, Kafasi N, Tzartos JS, Andreadou E, Koutsis G, Gialafos E, Dimitrakopoulos A, Zampeli E, Rontogianni D, Theocharis S, Zapanti E, Stathopoulos PA, Anagnostouli M, Stefanis L, Kilidireas C. IgG4-related autoimmune manifestations in Alemtuzumab-treated multiple sclerosis patients. J Neuroimmunol 2021; 361:577759. [PMID: 34742035 DOI: 10.1016/j.jneuroim.2021.577759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/09/2021] [Accepted: 10/25/2021] [Indexed: 12/12/2022]
Abstract
We aimed to determine whether Alemtuzumab-induced immune reconstitution affects immunoglobulin and complement levels in the serum of Relapsing-Remitting Multiple Sclerosis (RRMS) patients. IgG4-levels were increased 24-months after treatment initiation compared to baseline levels in twenty-nine patients. Alemtuzumab-treated patients with the highest IgG4-levels were more prone to thyroid-related autoimmune manifestations and specific autoimmune adverse events such as Crohn's disease, Graves' disease, and hemolytic anemia. Compared to baseline, total IgG-levels showed a trend towards reduced levels following two-courses of Alemtuzumab, but no significant change of C3 and/or C4-levels was observed. In conclusion, monitoring of IgG4-levels can serve as a marker for secondary autoimmunity risk in multiple sclerosis patients treated with Alemtuzumab.
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Affiliation(s)
- Aigli G Vakrakou
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Greece.
| | - Dimitrios Tzanetakos
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Greece
| | - Maria-Eleptheria Evangelopoulos
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Greece
| | - George E Fragoulis
- Department of Propaedeutic Internal Medicine, Medical School, Rheumatology Unit, "Laiko" General Hospital, National and Kapodistrian University of Athens, Greece
| | - Paraskevi Kazakou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | - Eleni Lekka
- Department of Immunology, Laiko General Hospital, 17 Agiou Thoma str, Athens 11527, Greece
| | - Nikolitsa Kafasi
- Department of Immunology, Laiko General Hospital, 17 Agiou Thoma str, Athens 11527, Greece
| | - John S Tzartos
- Second Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, "Attikon" University Hospital, Rimini 1, Chaidari, 12462, Athens, Greece; Tzartos NeuroDiagnostics, Neuroimmunology, Eslin street 3, 115 23 Athens, Greece
| | - Elissavet Andreadou
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Greece
| | - Georgios Koutsis
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Greece
| | - Elias Gialafos
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Greece
| | - Antonios Dimitrakopoulos
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Greece
| | - Evanthia Zampeli
- Gastroenterology Department, "Alexandra" Hospital, Athens, Greece
| | | | - Stamatios Theocharis
- First Department of Pathology, Medical School, National and Kapodistrian University of Athens, Greece
| | | | - Panos-Alexis Stathopoulos
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Greece
| | - Maria Anagnostouli
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Greece
| | - Leonidas Stefanis
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Greece
| | - Constantinos Kilidireas
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Greece
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147
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Coles AJ, Jones JL, Vermersch P, Traboulsee A, Bass AD, Boster A, Chan A, Comi G, Fernández Ó, Giovannoni G, Kubala Havrdova E, LaGanke C, Montalban X, Oreja-Guevara C, Piehl F, Wiendl H, Ziemssen T. Autoimmunity and long-term safety and efficacy of alemtuzumab for multiple sclerosis: Benefit/risk following review of trial and post-marketing data. Mult Scler 2021; 28:842-846. [PMID: 34882037 PMCID: PMC8978465 DOI: 10.1177/13524585211061335] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Does preexisting or treatment-emergent autoimmunity increase the risk of
subsequent autoimmune disease in individuals with relapsing-remitting multiple
sclerosis (MS) after alemtuzumab? In the extended phase 2/3 trials, 34/96
(35.4%) patients with and 395/1120 (35.3%) without preexisting autoimmunity
developed non-MS autoimmunity. Thyroid autoimmunity after alemtuzumab courses 1
or 2 did not increase subsequent non-thyroid autoimmune adverse events.
Therefore, autoimmune disease before or after alemtuzumab treatment does not
predict autoimmunity after further courses, so should not preclude adequate
alemtuzumab dosing to control MS. Finally, post-marketing safety data contribute
toward a full record of the alemtuzumab benefit/risk profile for the MS
field.
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Affiliation(s)
- Alasdair J Coles
- Department of Clinical Neuroscience, School of Medicine, University of Cambridge, Cambridge, UK
| | - Joanne L Jones
- Department of Clinical Neuroscience, School of Medicine, University of Cambridge, Cambridge, UK
| | - Patrick Vermersch
- Univ. Lille, INSERM UMR-S1172-Lille Neuroscience et Cognition, CHU Lille, FHU Precise, Lille, France
| | | | - Ann D Bass
- Neurology Center of San Antonio, San Antonio, TX, USA
| | | | - Andrew Chan
- Bern University Hospital and University of Bern, Bern, Switzerland
| | | | - Óscar Fernández
- Fundacion IMABIS, Hospital Universitario Carlos Haya, Málaga, Spain
| | - Gavin Giovannoni
- Barts and The London School of Medicine, Queen Mary University of London, London, UK
| | - Eva Kubala Havrdova
- Department of Neurology, First Medical Faculty, Charles University, Prague, Czech Republic
| | | | - Xavier Montalban
- Department of Neurology-Neuroimmunology, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Celia Oreja-Guevara
- Department of Neurology, Hospital Clínico San Carlos, IdISSC, Madrid, Spain/Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid (UCM), Madrid, Spain
| | - Fredrik Piehl
- Neuroimmunology Unit, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | | | - Tjalf Ziemssen
- Center of Clinical Neuroscience, Department of Neurology Carl Gustav Carus University Hospital, Dresden University of Technology, Dresden, Germany
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148
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Espinoza MA, Rojas R, Zaupa A, Balmaceda C. A Model-Based Economic Evaluation of Cladribine Versus Alemtuzumab, Ocrelizumab and Natalizumab for the Treatment of Relapsing-Remitting Multiple Sclerosis with High Disease Activity in Chile. PHARMACOECONOMICS - OPEN 2021; 5:635-647. [PMID: 34224114 PMCID: PMC8611154 DOI: 10.1007/s41669-021-00282-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 06/13/2023]
Abstract
PURPOSE The aim of this study was to evaluate the cost effectiveness of cladribine compared with alemtuzumab, natalizumab, and ocrelizumab for the treatment of highly active multiple sclerosis (HAD-MS) from the perspective of the Chilean health care public sector. MATERIALS AND METHODS A Markov model was used to compare costs and quality-adjusted life-years (QALYs) over a 45-year time horizon using a 3% discount rate for costs and outcomes. Natural history of the disease was modeled in terms of progression of disability according to the Expanded Disability Status Scale (EDSS). A network meta-analysis was used as a source of comparative effectiveness for disability progression and annual relapse rates. Differences in costs and outcomes were modeled for only 10 years due to high temporal uncertainty. Ocrelizumab was assumed to have the same efficacy as cladribine due to lack of data. Direct costs were taken from national tariffs and expressed in 2019 US dollars. Utilities for EDSS health states were obtained from the literature. Second-order uncertainty was characterized through deterministic and probabilistic sensitivity analysis. FINDINGS Compared with natalizumab (the current strategy covered in Chile), cladribine is associated with incremental costs and QALYs of US$70,989 and 1.875, respectively (incremental cost-effectiveness ratio [ICER] $37,861). Ocrelizumab was extendedly dominated by cladribine and natalizumab, and alemtuzumab was dominated by cladribine. A scenario analysis of a 10% discount did not modify the results substantially, but showed a decrease in the ICER of cladribine versus natalizumab (ICER $29,833/QALY). IMPLICATIONS Cladribine is a new oral alternative to treat patients with HAD-MS that is expected to produce higher QALYs than all evaluated alternatives. In the context of a conservative analysis, cladribine cannot be considered cost effective for the Chilean health care public sector using a 1 GDP per capita threshold. However, under reasonable discount scenarios, cladribine becomes an attractive alternative for the health system.
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Affiliation(s)
- Manuel Antonio Espinoza
- Unidad de Evaluación de Tecnologías en Salud, Centro de Investigación Clínica, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Piso 2, Santiago, Chile
- Departamento de Salud Pública, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Piso 2, Santiago, Chile
| | | | - Alessandro Zaupa
- Departamento de Salud Pública, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Piso 2, Santiago, Chile
| | - Carlos Balmaceda
- Unidad de Evaluación de Tecnologías en Salud, Centro de Investigación Clínica, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Piso 2, Santiago, Chile.
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149
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Zmira O, Halpern AI, Abraham L, Achiron A. Efficacy and safety of alemtuzumab treatment in a real-world cohort of patients with multiple sclerosis. Acta Neurol Belg 2021; 121:1513-1518. [PMID: 32447722 DOI: 10.1007/s13760-020-01375-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/12/2020] [Indexed: 12/15/2022]
Abstract
Alemtuzumab is a monoclonal anti-CD52 antibody prescribed to treat relapsing-remitting multiple sclerosis (RRMS). Alemtuzumab affects the balance of the immune system by depleting circulating lymphocytes, leading to the formation of a new immune repertoire less likely to induce autoimmune attack against CNS myelin. We collected real-world data of RRMS patients treated with alemtuzumab. We assessed relapse rate, disability progression, and MRI-related disease activity over a 24 month period. Our study included 35 RRMS patients (19 female and 16 male) with a mean age of 37.3 years (SD = 10.5). The patient cohort had a mean disease duration of 10.4 years, median previous disease modifying treatments (DMTs) of 3.0, and a median expanded disability status scale (EDSS) score of 4.0 (IQR 2.5-6.0). Neurological disability remained stable during treatment and there was no statistically significant change in EDSS score. Prior to treatment, the median relapse rate was 2.0 (IQR 1.0-3.0); after treatment the median relapse rate was 0.0. This 2.0 decrease in relapse rate is statistically significant (p < 0.0001). Moreover, the treated patients exhibited a statistically significant decrease in gadolinium (GD) enhancing lesions on MRI [both in number (p < 0.005) and volume (p < 0.005)]. Thirty-three percent of patients reached NEDA-3 (no evidence of disease activity) status by the end of treatment. In a real-world setting, alemtuzumab treatment significantly decreased relapse rate and GD-enhancing lesions while preventing disability progression. Tolerability of treatment was high, with patients experiencing only minor adverse events.
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150
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Dobson R, Craner M, Waddingham E, Miller A, Cavey A, Webb S, Hemingway C, Hobart J, Evangelou N, Scolding N, Rog D, Nicholas R, Marta M, Blain C, Young CA, Ford HL, Matthews PM. OPTIMISE: MS study protocol: a pragmatic, prospective observational study to address the need for, and challenges with, real world pharmacovigilance in multiple sclerosis. BMJ Open 2021; 11:e050176. [PMID: 34824113 PMCID: PMC8627413 DOI: 10.1136/bmjopen-2021-050176] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 10/25/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The power of 'real world' data to improve our understanding of the clinical aspects of multiple sclerosis (MS) is starting to be realised. Disease modifying therapy (DMT) use across the UK is driven by national prescribing guidelines. As such, the UK provides an ideal country in which to gather MS outcomes data. A rigorously conducted observational study with a focus on pharmacovigilance has the potential to provide important data to inform clinicians and patients while testing the reliability of estimates from pivotal trials when applied to patients in the UK. METHODS AND ANALYSIS The primary aim of this study is to characterise the incidence and compare the risk of serious adverse events in people with MS treated with DMTs. The OPTIMISE:MS database enables electronic data capture and secure data transfer. Selected clinical data, clinical histories and patient-reported outcomes are collected in a harmonised fashion across sites at the time of routine clinical visits. The first patient was recruited to the study on 24 May 2019. As of January 2021, 1615 individuals have baseline data recorded; follow-up data are being captured and will be reported in due course. ETHICS AND DISSEMINATION This study has ethical permission (London City and East; Ref 19/LO/0064). Potential concerns around data storage and sharing are mitigated by the separation of identifiable data from all other clinical data, and limiting access to any identifiable data. The results of this study will be disseminated via publication. Participants provide consent for anonymised data to be shared for further research use, further enhancing the value of the study.
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Affiliation(s)
- Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Matthew Craner
- Department of Neurology, John Radcliffe Hospital NHS Trust, Oxford, UK
- Department of Neurology, Frimley Park Health Foundation NHS Trust, Frimley, UK
| | - Ed Waddingham
- Department of Brain Sciences, Imperial College London and UK Dementia Research Institute, Imperial College London, London, UK
| | - Aleisha Miller
- Department of Brain Sciences, Imperial College London and UK Dementia Research Institute, Imperial College London, London, UK
| | - Ana Cavey
- Department of Neurology, John Radcliffe Hospital NHS Trust, Oxford, UK
| | - Stewart Webb
- Queen Elizabeth University Hospital, Glasgow, UK
| | | | - Jeremy Hobart
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
- Department of Neurology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - Neil Scolding
- Department of Neurology, Southmead Hospital NHS Trust, Bristol, UK
- Department of Neurosciences, University of Bristol, Bristol, UK
| | - David Rog
- Department of Neurology, Greater Manchester Neurosciences Centre, Salford Royal NHS Foundation Trust, Salford, UK
| | - Richard Nicholas
- Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Monica Marta
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
- Department of Neurology, Southend Hospital, Westcliff-on-Sea, UK
| | - Camilla Blain
- Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Helen L Ford
- Centre for Neurosciences, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul M Matthews
- Department of Brain Sciences, Imperial College London and UK Dementia Research Institute, Imperial College London, London, UK
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