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Lymphocyte Counts and Multiple Sclerosis Therapeutics: Between Mechanisms of Action and Treatment-Limiting Side Effects. Cells 2021; 10:cells10113177. [PMID: 34831400 PMCID: PMC8625745 DOI: 10.3390/cells10113177] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/04/2021] [Accepted: 11/09/2021] [Indexed: 01/18/2023] Open
Abstract
Although the detailed pathogenesis of multiple sclerosis (MS) is not completely understood, a broad range of disease-modifying therapies (DMTs) are available. A common side effect of nearly every MS therapeutic agent is lymphopenia, which can be both beneficial and, in some cases, treatment-limiting. A sound knowledge of the underlying mechanism of action of the selected agent is required in order to understand treatment-associated changes in white blood cell counts, as well as monitoring consequences. This review is a comprehensive summary of the currently available DMTs with regard to their effects on lymphocyte count. In the first part, we describe important general information about the role of lymphocytes in the course of MS and the essentials of lymphopenic states. In the second part, we introduce the different DMTs according to their underlying mechanism of action, summarizing recommendations for lymphocyte monitoring and definitions of lymphocyte thresholds for different therapeutic regimens.
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152
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Avolio C, Centonze D. Pivotal Trials in Multiple Sclerosis: Similarities Prove Not to Be Useful. Neurol Ther 2021; 11:1-8. [PMID: 34718965 PMCID: PMC8857371 DOI: 10.1007/s40120-021-00291-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 10/08/2021] [Indexed: 11/28/2022] Open
Abstract
We present a commentary on the inclusion criteria and outcome measures of the major randomized trials on multiple sclerosis. A qualitative comparison of the characteristics of the enrolled patients is done. The objective is to stimulate a discussion about the need to improve research strategies. The discovery of new drugs studied without personalized criteria does not allow for useful advances in knowledge.
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Affiliation(s)
- Carlo Avolio
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy. .,Multiple Sclerosis Intradipartimental Center, Department of Neurosciences, Policlinico Riuniti, Viale Luigi Pinto 1, 71100, Foggia, Italy.
| | - Diego Centonze
- Multiple Sclerosis Research Unit, Department of Systems Medicine, Tor Vergata University, Rome, Italy.,Unit of Neurology and Neurorehabilitation, IRCCS Istituto Neurologico Mediterraneo (INM) Neuromed, Pozzilli, Italy
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153
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Walo-Delgado PE, Monreal E, Medina S, Quintana E, Sainz de la Maza S, Fernández-Velasco JI, Lapuente P, Comabella M, Ramió-Torrentà L, Montalban X, Midaglia L, Villarrubia N, Carrasco-Sayalero A, Rodríguez-Martín E, Roldán E, Meca-Lallana J, Alvarez-Lafuente R, Masjuan J, Costa-Frossard L, Villar LM. Role of B Cell Profile for Predicting Secondary Autoimmunity in Patients Treated With Alemtuzumab. Front Immunol 2021; 12:760546. [PMID: 34691084 PMCID: PMC8531491 DOI: 10.3389/fimmu.2021.760546] [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: 08/18/2021] [Accepted: 09/21/2021] [Indexed: 11/27/2022] Open
Abstract
Objective To explore if baseline blood lymphocyte profile could identify relapsing remitting multiple sclerosis (RRMS) patients at higher risk of developing secondary autoimmune adverse events (AIAEs) after alemtuzumab treatment. Methods Multicenter prospective study including 57 RRMS patients treated with alemtuzumab followed for 3.25 [3.5-4.21] years, (median [interquartile range]). Blood samples were collected at baseline, and leukocyte subsets determined by flow cytometry. We had additional samples one year after the first cycle of alemtuzumab treatment in 39 cases. Results Twenty-two patients (38.6%) developed AIAEs during follow-up. They had higher B-cell percentages at baseline (p=0.0014), being differences mainly due to plasmablasts/plasma cells (PB/PC, p=0.0011). Those with no AIAEs had higher percentages of CD4+ T cells (p=0.013), mainly due to terminally differentiated (TD) (p=0.034) and effector memory (EM) (p=0.031) phenotypes. AIAEs- patients also showed higher values of TNF-alpha-producing CD8+ T cells (p=0.029). The percentage of PB/PC was the best variable to differentiate both groups of patients. Baseline values >0.10% closely associated with higher AIAE risk (Odds ratio [OR]: 5.91, 95% CI: 1.83-19.10, p=0.004). When excluding the 12 patients with natalizumab, which decreases blood PB/PC percentages, being the last treatment before alemtuzumab, baseline PB/PC >0.1% even predicted more accurately the risk of AIAEs (OR: 11.67, 95% CI: 2.62-51.89, p=0.0007). The AIAEs+ group continued having high percentages of PB/PC after a year of alemtuzumab treatment (p=0.0058). Conclusions A PB/PC percentage <0.1% at baseline identifies MS patients at low risk of secondary autoimmunity during alemtuzumab treatment.
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Affiliation(s)
- Paulette Esperanza Walo-Delgado
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Enric Monreal
- Department of Neurology, Ramón y Cajal University Hospital, IRYCIS, Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Silvia Medina
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Ester Quintana
- Neuroimmunology and Multiple Sclerosis Unit, Neurology Department, Neurodegeneration and Neuroinflammation Research Group, Biomedical Research Institute (IDIBGI), Red Española de Esclerosis Múltiple (REEM), Girona, Spain
| | - Susana Sainz de la Maza
- Department of Neurology, Ramón y Cajal University Hospital, IRYCIS, Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - José Ignacio Fernández-Velasco
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Paloma Lapuente
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Manuel Comabella
- Servei de Neurologia-Neuroimmunologia, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Institut de Recerca Vall d'Hebron (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Red Española de Esclerosis Múltiple (REEM), Barcelona, Spain
| | - Lluis Ramió-Torrentà
- Neuroimmunology and Multiple Sclerosis Unit, Neurology Department, Neurodegeneration and Neuroinflammation Research Group, Biomedical Research Institute (IDIBGI), Red Española de Esclerosis Múltiple (REEM), Girona, Spain
| | - Xavier Montalban
- Servei de Neurologia-Neuroimmunologia, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Institut de Recerca Vall d'Hebron (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Red Española de Esclerosis Múltiple (REEM), Barcelona, Spain
| | - Luciana Midaglia
- Servei de Neurologia-Neuroimmunologia, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Institut de Recerca Vall d'Hebron (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Red Española de Esclerosis Múltiple (REEM), Barcelona, Spain
| | - Noelia Villarrubia
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Angela Carrasco-Sayalero
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Eulalia Rodríguez-Martín
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Ernesto Roldán
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - José Meca-Lallana
- Department of Neurology, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | - Roberto Alvarez-Lafuente
- Grupo de Investigación de Factores Ambientales en Enfermedades Degenerativas, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, Hospital Clínico San Carlos, Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Jaime Masjuan
- Department of Neurology, Ramón y Cajal University Hospital, IRYCIS, Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Lucienne Costa-Frossard
- Department of Neurology, Ramón y Cajal University Hospital, IRYCIS, Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Luisa Maria Villar
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
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154
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Gabelić T, Barun B, Adamec I, Krbot Skorić M, Habek M. Product review on MAbs (alemtuzumab and ocrelizumab) for the treatment of multiple sclerosis. Hum Vaccin Immunother 2021; 17:4345-4362. [PMID: 34668842 DOI: 10.1080/21645515.2021.1969850] [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] [Indexed: 01/03/2023] Open
Abstract
Traditionally, the management of active relapsing remitting MS was based on the, so-called, maintenance therapy, which is characterized by continuous treatment with particular disease modifying therapy (DMT), and a return of disease activity when the drug is discontinued. Another approach is characterized by a short treatment course of a DMT, which is hypothesized to act as an immune reconstitution therapy (IRT), with the potential to protect against relapses for years after a short course of treatment. Introduction of monoclonal antibodies in the treatment of MS has revolutionized MS treatment in the last decade. However, given the increasingly complex landscape of DMTs approved for MS, people with MS and neurologists are constantly faced with the question which DMT is the most appropriate for the given patient, a question we still do not have an answer to. In this product review, we will discuss the first DMT that acts as IRT, an anti-CD52 monoclonal antibody alemtuzumab and an anti CD20 monoclonal antibody, ocrelizumab that has the potential to act as an IRT, but is administered continuously. Special emphasis will be given on safety in the context of COVID-19 pandemics and vaccination strategies.
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Affiliation(s)
- Tereza Gabelić
- Department of Neurology, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Barbara Barun
- Department of Neurology, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ivan Adamec
- Department of Neurology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Magdalena Krbot Skorić
- Department of Neurology, University Hospital Center Zagreb, Zagreb, Croatia.,Faculty of Electrical Engineering and Computing, University of Zagreb, Zagreb, Croatia
| | - Mario Habek
- Department of Neurology, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
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155
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Maltby VE, Lea RA, Monif M, Fabis-Pedrini MJ, Buzzard K, Kalincik T, Kermode AG, Taylor B, Hodgkinson S, McCombe P, Butzkueven H, Barnett M, Lechner-Scott J. Efficacy of Cladribine Tablets as a Treatment for People With Multiple Sclerosis: Protocol for the CLOBAS Study (Cladribine, a Multicenter, Long-term Efficacy and Biomarker Australian Study). JMIR Res Protoc 2021; 10:e24969. [PMID: 34665152 PMCID: PMC8564661 DOI: 10.2196/24969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 05/04/2021] [Accepted: 05/28/2021] [Indexed: 01/26/2023] Open
Abstract
Background Cladribine tablets (marketed as Mavenclad) are a new oral therapy, which has recently been listed on the pharmaceutical benefits scheme in Australia for the treatment of relapsing multiple sclerosis (MS). The current dosing schedule is for 2 courses given a year apart, which has been shown to be effective for treatment of MS for up to 4 years in 75% of patients (based on annualized relapse rate). However, the reinitiation of therapy after year 4 has not been studied. Objective This study aims to evaluate the safety and efficacy of cladribine tablets over a 6-year period, according to no evidence of disease activity 3. Methods This will be a multicenter, 6-year, phase IV, low interventional, observational study that incorporates clinical, hematological, biochemical, epigenetic, radiological and cognitive biomarkers of disease. Participants considered for treatment with cladribine as part of their routine clinical care will be consented to take part in the study. They will be monitored at regular intervals during the initial course of medication administration in years 1 and 2. After year 3, patients will have the option of redosing, if clinically indicated, or to switch to another disease-modifying therapy. Throughout the duration of the study, we will assess blood-based biomarkers including lymphocyte subsets, serum neurofilament light chain, DNA methylation, and RNA analysis as well as magnetic resonance imaging findings (brain volume and/or lesion load) and cognitive performance. Results This study has been approved by the Hunter New England Local Health District Human Research Ethics Committee. Recruitment began in March of 2019 and was completed by June 2021. Conclusions This will be the first long-term efficacy trial of cladribine, which offers reinitiation of therapy in the 3rd year, based on disease activity, after the initial 2 courses. We expect that this study will indicate whether any of the assessed biomarkers can be used to predict treatment efficacy or the need for future reinitiation of cladribine in people with MS. Trial Registration This study is registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12619000257167) with Universal Trial Number (U1111-1228-2165). International Registered Report Identifier (IRRID) DERR1-10.2196/24969
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Affiliation(s)
- Vicki E Maltby
- Department of Neurology, John Hunter Hospital, New Lambton Heights, Australia.,School for Medicine and Public Health, University of Newcastle, Callaghan, Australia.,Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Rodney A Lea
- School for Medicine and Public Health, University of Newcastle, Callaghan, Australia.,Hunter Medical Research Institute, New Lambton Heights, Australia.,Institute of Health and Biomedical Innovations, Genomics Research Centre, Queensland University of Technology, Kelvin Grove, Australia
| | - Mastura Monif
- Department of Neurosciences, Eastern Health Clinical School, Monash University, Box Hill Hospital, Melbourne, Australia.,Department of Neurology, Alfred Health, Melbourne, Australia.,Department of Neurology, Melbourne Multiple Sclerosis Centre, Melbourne Health, Melbourne, Australia
| | - Marzena J Fabis-Pedrini
- Centre for Neuromuscular and Neurological Disorders, Perron Institute for Neurological and Translational Science, University of Western Australia, Perth, Australia
| | - Katherine Buzzard
- Department of Neurosciences, Eastern Health Clinical School, Monash University, Box Hill Hospital, Melbourne, Australia.,Department of Neurology, Melbourne Multiple Sclerosis Centre, Melbourne Health, Melbourne, Australia
| | - Tomas Kalincik
- Department of Neurology, Melbourne Multiple Sclerosis Centre, Melbourne Health, Melbourne, Australia.,Clinical Outcomes Research (CORe) Unit, Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Allan G Kermode
- Centre for Neuromuscular and Neurological Disorders, Perron Institute for Neurological and Translational Science, University of Western Australia, Perth, Australia.,Institute for Immunology and Infectious Disease, Murdoch University, Perth, Australia
| | - Bruce Taylor
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Suzanne Hodgkinson
- Department of Medicine, University of New South Wales, Sydney, Australia.,Department of Neurology, Liverpool Hospital, Sydney, Australia.,Immune Tolerance Laboratory, Ingham Institute, Sydney, Australia
| | - Pamela McCombe
- Centre for Clinical Research, University of Queensland, Brisbane, Australia
| | - Helmut Butzkueven
- Department of Neurology, Alfred Health, Melbourne, Australia.,Clinical Outcomes Research (CORe) Unit, Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Michael Barnett
- Brain and Mind Centre, University of Sydney, Sydney, Australia.,Sydney Neuroimaging Analysis Centre, Sydney, Australia
| | - Jeannette Lechner-Scott
- Department of Neurology, John Hunter Hospital, New Lambton Heights, Australia.,School for Medicine and Public Health, University of Newcastle, Callaghan, Australia.,Hunter Medical Research Institute, New Lambton Heights, Australia
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156
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Bar-Or A, Wiendl H, Montalban X, Alvarez E, Davydovskaya M, Delgado SR, Evdoshenko EP, Giedraitiene N, Gross-Paju K, Haldre S, Herrman CE, Izquierdo G, Karelis G, Leutmezer F, Mares M, Meca-Lallana JE, Mickeviciene D, Nicholas J, Robertson DS, Sazonov DV, Sharlin K, Sundaram B, Totolyan N, Vachova M, Valis M, Bagger M, Häring DA, Ludwig I, Willi R, Zalesak M, Su W, Merschhemke M, Fox EJ. Rapid and sustained B-cell depletion with subcutaneous ofatumumab in relapsing multiple sclerosis: APLIOS, a randomized phase-2 study. Mult Scler 2021; 28:910-924. [PMID: 34605319 PMCID: PMC9024029 DOI: 10.1177/13524585211044479] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background: Ofatumumab, the first fully human anti-CD20 monoclonal antibody, is approved in several countries for relapsing multiple sclerosis (RMS). Objective: To demonstrate the bioequivalence of ofatumumab administered by an autoinjector versus a pre-filled syringe (PFS) and to explore the effect of ofatumumab on B-cell depletion. Methods: APLIOS (NCT03560739) is a 12-week, open-label, parallel-group, phase-2 study in patients with RMS receiving subcutaneous ofatumumab 20 mg every 4 weeks (q4w) (from Week 4, after initial doses on Days 1, 7, and 14). Patients were randomized 10:10:1:1 to autoinjector or PFS in the abdomen, or autoinjector or PFS in the thigh, respectively. Bioequivalence was determined by area under the curve (AUCτ) and maximum plasma concentration (Cmax) for Weeks 8–12. B-cell depletion and safety/tolerability were assessed. Results: A total of 256 patients contributed to the bioequivalence analyses (autoinjector-abdomen, n = 128; PFS-abdomen, n = 128). Abdominal ofatumumab pharmacokinetic exposure was bioequivalent for autoinjector and PFS (geometric mean AUCτ, 487.7 vs 474.1 h × µg/mL (ratio 1.03); Cmax, 1.409 vs 1.409 µg/mL (ratio 1.00)). B-cell counts (median cells/µL) depleted rapidly in all groups from 214.0 (baseline) to 2.0 (Day 14). Ofatumumab was well tolerated. Conclusion: Ofatumumab 20 mg q4w self-administered subcutaneously via autoinjector is bioequivalent to PFS administration and provides rapid B-cell depletion.
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Affiliation(s)
- Amit Bar-Or
- A Bar-Or Center for Neuroinflammation and Experimental Therapeutics and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street - 3 Gates Building, Philadelphia, PA 19104, USA.,Center for Neuroinflammation and Experimental Therapeutics and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Xavier Montalban
- Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Enrique Alvarez
- Department of Neurology, Rocky Mountain MS Center, University of Colorado, Aurora, CO, USA
| | - Maria Davydovskaya
- Pirogov Russian National Research Medical University, Moscow, Russian Federation
| | - Silvia R Delgado
- MS Center and Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Evgeniy P Evdoshenko
- St Petersburg Center for Multiple Sclerosis and Other Autoimmune Diseases, St Petersburg, Russian Federation
| | - Natasa Giedraitiene
- Clinic of Neurology and Neurosurgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Katrin Gross-Paju
- West-Tallinn Central Hospital, Tallinn, Estonia/Institute of Health Care Technology, TalTech, Tallinn, Estonia
| | - Sulev Haldre
- Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia/Neurology Clinic, Tartu University Hospital, Tartu, Estonia
| | | | | | - Guntis Karelis
- Neurology and Neurosurgery Department, Riga East University Hospital and Riga Stradins University, Riga, Latvia
| | - Fritz Leutmezer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Miroslav Mares
- Department of Neurology, Pardubice Regional Hospital, Pardubice, Czech Republic
| | - Jose E Meca-Lallana
- Multiple Sclerosis CSUR, Department of Neurology, Virgen de la Arrixaca Clinical University Hospital-IMIB-Arrixaca, Murcia, Spain/Clinical Neuroimmunology and Multiple Sclerosis Cathedra, Universidad Católica San Antonio (UCAM), Murcia, Spain
| | | | | | - Derrick S Robertson
- Multiple Sclerosis Division, Department of Neurology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Denis V Sazonov
- Department of Clinical Trials FSBIH SDMC of FMBA of Russia, Novosibirsk, Russian Federation
| | | | | | - Natalia Totolyan
- Department of Neurology, First Pavlov State Medical University of St Petersburg, St Petersburg, Russian Federation
| | - Marta Vachova
- Department of Neurology, Teplice Hospital, Teplice, Czech Republic
| | - Martin Valis
- Department of Neurology, Faculty of Medicine in Hradec Králové, Charles University in Prague and University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | | | | | | | | | | | - Wendy Su
- Novartis Pharmaceutical Corporation, East Hanover, NJ, USA
| | | | - Edward J Fox
- Central Texas Neurology Consultants PA, Round Rock, TX, USA
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157
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Meca-Lallana J, Álvarez-Cermeño J, Casanova Estruch B, Izquierdo Ayuso G, Ortiz Castillo R, Rodríguez-Antigüedad A, Calles Hernández C. Inicio temprano de alemtuzumab: cambio en el paradigma de tratamiento en esclerosis múltiple. Análisis intermedio del estudio LEMVIDA. Neurologia 2021. [DOI: 10.1016/j.nrl.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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158
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Thompson KK, Tsirka SE. Immunosuppression in Multiple Sclerosis and Other Neurologic Disorders. Handb Exp Pharmacol 2021; 272:245-265. [PMID: 34595582 DOI: 10.1007/164_2021_545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Multiple sclerosis (MS) is an autoimmune disease of the central nervous system (CNS) characterized by peripheral immune cell infiltration into the brain and spinal cord, demyelination, glial cell activation, and neuronal damage. Currently there is no cure for MS, however, available disease-modifying agents minimize inflammation in the CNS by various mechanisms. Approved drugs lessen severity of the disease and delay disease progression, however, they are still suboptimal as patients experience adverse effects and varying efficacies. Additionally, there is only one disease-modifying therapy available for the more debilitating, progressive form of MS. This chapter focuses on the presently-available therapeutics and, importantly, the future directions of MS therapy based on preclinical studies and early clinical trials. Immunosuppression in other neurological disorders including neuromyelitis optica spectrum disorders, myasthenia gravis, and Guillain-Barré syndrome is also discussed.
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Affiliation(s)
| | - Stella E Tsirka
- Department of Pharmacological Sciences, Stony Brook University, Stony Brook, NY, USA.
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159
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Russo CV, Saccà F, Frau J, Annovazzi P, Signoriello E, Bonavita S, Grasso R, Clerico M, Cordioli C, Laroni A, Capobianco M, Torri Clerici V, Sartori A, Cavalla P, Maniscalco GT, La Gioia S, Caleri F, Giugno A, Iodice R, Carotenuto A, Cocco E, Fenu G, Zaffaroni M, Baroncini D, Lus G, Gallo A, De Mercanti SF, Lapucci C, Di Francescantonio V, Brambilla L, Sormani MP, Signori A. A real-world study of alemtuzumab in a cohort of Italian patients. Eur J Neurol 2021; 29:257-266. [PMID: 34558755 PMCID: PMC9293282 DOI: 10.1111/ene.15121] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 09/16/2021] [Accepted: 09/19/2021] [Indexed: 01/02/2023]
Abstract
Background and purpose Real‐world data on alemtuzumab are limited and do not provide evidence of its effectiveness after various disease‐modifying therapies (DMTs). Our aim was to provide real‐world data on the impact of clinical variables and previous DMTs on clinical response to alemtuzumab. Methods Sixteen Italian multiple sclerosis centers retrospectively included patients who started alemtuzumab from January 2015 to December 2018, and recorded demographics, previous therapies, washout duration, relapses, Expanded Disability Status Scale (EDSS) score, and magnetic resonance imaging data. Negative binomial regression models were used to assess the effect of factors on annualized relapse (ARR) after alemtuzumab initiation. Results We studied 322 patients (mean age 36.8 years, median EDSS score 3, median follow‐up 1.94 years). Previous treatments were: fingolimod (106), natalizumab (80), first‐line oral agents (56), first‐line injectables (interferon/glatiramer acetate; 30), and other drugs (15). Thirty‐five patients were treatment‐naïve. The pre‐alemtuzumab ARR was 0.99 and decreased to 0.13 during alemtuzumab treatment (p < 0.001). The number of previous‐year relapses was associated with alemtuzumab ARR (adjusted risk ratio [RR] 1.38, p = 0.009). Progression‐free survival was 94.5% after 1 year, and 89.2% after 2 years of alemtuzumab treatment. EDSS score improvement occurred in 13.5% after 1 year, and 20.6% after 2 years. Re‐baselining patients after 6 months of alemtuzumab treatment, led to no evidence of disease activity status in 71.6% after 1 year and 58.9% after 2 years. Conclusions Alemtuzumab decreases ARR independent of previous therapy, including patients with disease activity during natalizumab treatment. Overall, 90% of patients showed no disease progression, and 20% an improvement after 2 years of alemtuzumab.
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Affiliation(s)
| | - Francesco Saccà
- NSRO Department, University of Naples Federico II, Napoli, Italy
| | - Jessica Frau
- Centro Sclerosi Multipla, ASSL Cagliari (ATS Sardegna); Dipartimento di Scienze Mediche e Sanità Pubblica, University of Cagliari, Cagliari, Italy
| | - Pietro Annovazzi
- Multiple Sclerosis Center, ASST della Valle Olona, Hospital of Gallarate, Gallarate, Italy
| | | | | | | | - Marinella Clerico
- Dipartimento di Scienze Cliniche e Biologiche, University of Torino, Torino, Italy
| | - Cinzia Cordioli
- Multiple Sclerosis Center, ASST Spedali Civili di Brescia, Montichiari Hospital, Montichiari, Italy
| | - Alice Laroni
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health and Center of Excellence for Biomedical Research (CEBR) and IRCCS San Martino-IST, University of Genova, Genova, Italy
| | - Marco Capobianco
- SC Neurologia e Centro di Riferimento Regionale SM - AOU S. Luigi, Orbassano, Torino, Italy
| | - Valentina Torri Clerici
- Neuro-Immunology and Neuromuscolar Diseases Unit, IRCCS Foundation Carlo Besta Neurological Institute, Milano, Italy
| | - Arianna Sartori
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, ASUGI, University of Trieste, Trieste, Italy
| | - Paola Cavalla
- MS Center, City of Health & Science University Hospital, Torino, Italy
| | | | - Sara La Gioia
- Centro Sclerosi Multipla, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Francesca Caleri
- Neurology Department, F. Tappeiner Hospital Meran (BZ) of Neurology, Franz Tappeiner Hospital, Merano, Italy
| | - Alessia Giugno
- Institute of Neurology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Rosa Iodice
- NSRO Department, University of Naples Federico II, Napoli, Italy
| | | | - Eleonora Cocco
- Centro Sclerosi Multipla, ASSL Cagliari (ATS Sardegna); Dipartimento di Scienze Mediche e Sanità Pubblica, University of Cagliari, Cagliari, Italy
| | - Giuseppe Fenu
- Centro Sclerosi Multipla, ASSL Cagliari (ATS Sardegna); Dipartimento di Scienze Mediche e Sanità Pubblica, University of Cagliari, Cagliari, Italy
| | - Mauro Zaffaroni
- Multiple Sclerosis Center, ASST della Valle Olona, Hospital of Gallarate, Gallarate, Italy
| | - Damiano Baroncini
- Multiple Sclerosis Center, ASST della Valle Olona, Hospital of Gallarate, Gallarate, Italy
| | - Giacomo Lus
- University of Campania Luigi Vanvitelli, Napoli, Italy
| | - Antonio Gallo
- University of Campania "Luigi Vanvitelli", Napoli, Italy
| | | | - Caterina Lapucci
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health and Center of Excellence for Biomedical Research (CEBR) and IRCCS San Martino-IST, University of Genova, Genova, Italy
| | | | - Laura Brambilla
- Neuro-Immunology and Neuromuscolar Diseases Unit, IRCCS Foundation Carlo Besta Neurological Institute, Milano, Italy
| | - Maria Pia Sormani
- Department of Health Sciences (DISSAL), Section of Biostatistics, University of Genova, Genova, Italy
| | - Alessio Signori
- Department of Health Sciences (DISSAL), Section of Biostatistics, University of Genova, Genova, Italy
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160
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Avxentyev NA, Davydovskaya MV, Makarova YV, Frolov MY, Klabukova DL. [Pharmacoeconomic aspects of using cladribine (in tablets) for treatment of adult patients with remitting multiple sclerosis]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:30-36. [PMID: 34481433 DOI: 10.17116/jnevro202112108130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To conduct a pharmacoeconomic analysis of using cladribine (in tablets) as a second-line treatment option for adult patients with highly active remitting multiple sclerosis in Russia. MATERIAL AND METHODS Current treatment practice of highly active multiple sclerosis (natalizumab, fingolimod, alemtuzumab, ocrelizumab) was considered as a comparator for cladribine (in tablets). Clinical and economic study was conducted using the «cost minimization» method. For budget impact analysis cost of using cladribine (in tablets) was compared to the cost of using current treatment practice. RESULTS Cladribine in tablets is a cost-saving alternative for treatment of patients with highly active multiple sclerosis compared to the current treatment practice. Within a 4-year period direct medical costs reduction is 2 million RUB (50.1%) per person. CONCLUSION In case of switching the patients, who are currently provided with other disease modifying drugs, to cladribine, in 4 years health budget will save up to 6284 million RUB (50.1%).
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Affiliation(s)
- N A Avxentyev
- Financial Research Institute, Moscow, Russia.,The Russian Presidential Academy of National Economy and Public Administration, Moscow, Russia
| | - M V Davydovskaya
- Clinical and Economic Analysis Scientific-Practical Center of the Moscow Region Healthcare Ministry, Moscow, Russia.,Pirogov Russian National Research Medical University, Moscow, Russia
| | - Y V Makarova
- The Russian Presidential Academy of National Economy and Public Administration, Moscow, Russia
| | - M Yu Frolov
- Volgograd State Medical University, Volgograd, Russia.,Volgograd Medical Scientific Center, Volgograd, Russia
| | - D L Klabukova
- Clinical and Economic Analysis Scientific-Practical Center of the Moscow Region Healthcare Ministry, Moscow, Russia
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161
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Pfeuffer S, Ruck T, Pul R, Rolfes L, Korsukewitz C, Pawlitzki M, Wildemann B, Klotz L, Kleinschnitz C, Scalfari A, Wiendl H, Meuth SG. Impact of previous disease-modifying treatment on effectiveness and safety outcomes, among patients with multiple sclerosis treated with alemtuzumab. J Neurol Neurosurg Psychiatry 2021; 92:1007-1013. [PMID: 33712515 PMCID: PMC8372391 DOI: 10.1136/jnnp-2020-325304] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 01/14/2021] [Accepted: 02/07/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Alemtuzumab is effective in patients with active multiple sclerosis but has a complex safety profile, including the development of secondary autoimmunity. Most of patients enrolled in randomised clinical trials with alemtuzumab were either treatment naïve or pretreated with injectable substances. Other previous disease-modifying treatments (DMTs) were not used in the study cohorts, and therefore, associated risks might yet remain unidentified. METHODS We retrospectively evaluated a prospective dual-centre alemtuzumab cohort of 170 patients. We examined the baseline characteristics as well as safety and effectiveness outcomes, including the time to first relapse, the time to 3 months confirmed disability worsening and the time to secondary autoimmunity. RESULTS The regression analysis showed that, among all previously used DMTs, the pretreatment with fingolimod (n=33 HRs for the time to first relapse (HR 5.420, 95% CI 2.520 to 11.660; p<0.001)) and for the time to worsening of disability (HR 7.676, 95% CI 2.870 to 20.534; p<0.001). Additionally, patients pretreated with fingolimod were more likely to experience spinal relapses (55% vs 10% among previously naïve patients; p<0.001) and had an increased risk of secondary autoimmunity (HR 5.875, 95% CI 2.126 to 16.27; p<0.001). CONCLUSION In the real-world setting, we demonstrated suboptimal disease control and increased risk of secondary autoimmunity following alemtuzumab, among patients previously treated with fingolimod. These data can provide guidance for improving MS therapeutic management.
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Affiliation(s)
- Steffen Pfeuffer
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Tobias Ruck
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany.,Department of Neurology, Heinrich-Heine-University, Düsseldorf, Germany
| | - Refik Pul
- Department of Neurology, Universitat Duisburg-Essen, Duisburg, Germany
| | - Leoni Rolfes
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Catharina Korsukewitz
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Marc Pawlitzki
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Brigitte Wildemann
- Division of Molecular Neuroimmunology, Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Luisa Klotz
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | | | - Antonio Scalfari
- Centre for Neuroscience, Division of Experimental Medicine, Hammersmith Hospital, Imperial College London, London, UK
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany.,Department of Neurology, Heinrich-Heine-University, Düsseldorf, Germany
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162
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Gaj S, Ontaneda D, Nakamura K. Automatic segmentation of gadolinium-enhancing lesions in multiple sclerosis using deep learning from clinical MRI. PLoS One 2021; 16:e0255939. [PMID: 34469432 PMCID: PMC8409666 DOI: 10.1371/journal.pone.0255939] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 07/27/2021] [Indexed: 01/18/2023] Open
Abstract
Gadolinium-enhancing lesions reflect active disease and are critical for in-patient monitoring in multiple sclerosis (MS). In this work, we have developed the first fully automated method to segment and count the gadolinium-enhancing lesions from routine clinical MRI of MS patients. The proposed method first segments the potential lesions using 2D-UNet from multi-channel scans (T1 post-contrast, T1 pre-contrast, FLAIR, T2, and proton-density) and classifies the lesions using a random forest classifier. The algorithm was trained and validated on 600 MRIs with manual segmentation. We compared the effect of loss functions (Dice, cross entropy, and bootstrapping cross entropy) and number of input contrasts. We compared the lesion counts with those by radiologists using 2,846 images. Dice, lesion-wise sensitivity, and false discovery rate with full 5 contrasts were 0.698, 0.844, and 0.307, which improved to 0.767, 0.969, and 0.00 in large lesions (>100 voxels). The model using bootstrapping loss function provided a statistically significant increase of 7.1% in sensitivity and of 2.3% in Dice compared with the model using cross entropy loss. T1 post/pre-contrast and FLAIR were the most important contrasts. For large lesions, the 2D-UNet model trained using T1 pre-contrast, FLAIR, T2, PD had a lesion-wise sensitivity of 0.688 and false discovery rate 0.083, even without T1 post-contrast. For counting lesions in 2846 routine MRI images, the model with 2D-UNet and random forest, which was trained with bootstrapping cross entropy, achieved accuracy of 87.7% using T1 pre-contrast, T1 post-contrast, and FLAIR when lesion counts were categorized as 0, 1, and 2 or more. The model performs well in routine non-standardized MRI datasets, allows large-scale analysis of clinical datasets, and may have clinical applications.
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Affiliation(s)
- Sibaji Gaj
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Daniel Ontaneda
- Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Kunio Nakamura
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio, United States of America
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163
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Ziemssen T, Hoffmann F, Richter S, Engelmann U, White R. Alemtuzumab in a Large Real-Life Cohort: Interim Baseline Data of the TREAT-MS Study. Front Neurol 2021; 12:620758. [PMID: 34421780 PMCID: PMC8375470 DOI: 10.3389/fneur.2021.620758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 04/30/2021] [Indexed: 11/13/2022] Open
Abstract
The non-interventional long-Term study foR obsErvAtion of Treatment with alemtuzumab in active relapsing-remitting MS (TREAT-MS) study collects the so far largest real-life cohort regarding utilization, long-term effectiveness, and safety of alemtuzumab, a humanized monoclonal antibody directed against the cell surface glycoprotein CD52, in adult patients with active relapsing-remitting multiple sclerosis (RRMS). An interim analysis of baseline parameters at inclusion of a non-interventional real-world study about alemtuzumab in Germany including previous multiple sclerosis (MS) medication utilization, MS activity, severity, and duration, as well as comorbidities was performed. Of the 883 patients, 71.6% were women. Mean age was 35.7 ± 9.2 years, time since first MS symptoms (=disease duration) is 8.0 ± 6.8 years, and Expanded Disability Status Scale (EDSS) is 2.7 ± 1.8 points (range, 0.0-7.5 points). The number of relapses in the 12 and 24 months prior to inclusion were 1.6 ± 1.2 and 2.2 ± 1.8, respectively. Of the patients, 14.4% were treatment naive, while for the majority, a wide spectrum of MS disease-modifying treatments (DMTs) and treatment sequences were documented. Overall, interferon beta (IFN-beta) was reported most frequently (52.4%), followed by fingolimod (35.2%), natalizumab (34.9%), and glatiramer acetate (28.9%). Patients with longer disease duration and higher EDSS had a higher number of previous DMTs. Compared to the pivotal phase 2/3 studies, RRMS patients starting alemtuzumab treatment had a longer disease duration in real-world conditions. There was variety of different treatment sequences before the final switch to alemtuzumab. In the future, linking these treatment sequences or other baseline characteristics with effectiveness and safety outcomes might be useful to support treatment decisions. Registered at Paul-Ehrlich-Institut under NIS 281.
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Affiliation(s)
- Tjalf Ziemssen
- Department of Neurology, Center of Clinical Neuroscience, Carl Gustav Carus University Hospital, Dresden, Germany
| | - Frank Hoffmann
- Klinik für Neurologie, Krankenhaus Martha-Maria Halle-Doelau, Halle (Saale), Germany
| | - Stephan Richter
- Zentrum für Neurologie und Psychiatrie, MIND, Stuttgart, Germany
| | - Ulrich Engelmann
- Medical Affairs, Sanofi-Aventis Deutschland GmbH, Neu-Isenburg, Germany
| | - Robin White
- Medical Affairs, Sanofi-Aventis Deutschland GmbH, Neu-Isenburg, Germany
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164
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Dikeoulia E, Neufeld M, Pawlitzki M, Böhm M. Alemtuzumab‐induzierte Alopecia areata – Fallbericht und systematische Literaturübersicht zu Alemtuzumab‐assoziierten kutanen Nebenwirkungen. J Dtsch Dermatol Ges 2021; 19:1159-1164. [PMID: 34390148 DOI: 10.1111/ddg.14448_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 01/28/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Elsa Dikeoulia
- Klinik für, Hautkrankheiten, Universitätsklinikum Münster
| | | | - Marc Pawlitzki
- Klinik für, Hautkrankheiten, Universitätsklinikum Münster
| | - Markus Böhm
- Klinik für, Hautkrankheiten, Universitätsklinikum Münster
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165
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Kuhle J, Daizadeh N, Benkert P, Maceski A, Barro C, Michalak Z, Sormani MP, Godin J, Shankara S, Samad TA, Jacobs A, Chung L, Rӧsch N, Kaiser C, Mitchell CP, Leppert D, Havari E, Kappos L. Sustained reduction of serum neurofilament light chain over 7 years by alemtuzumab in early relapsing-remitting MS. Mult Scler 2021; 28:573-582. [PMID: 34378446 PMCID: PMC8958562 DOI: 10.1177/13524585211032348] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Alemtuzumab efficacy and safety was demonstrated in CARE-MS I and extension studies (CAMMS03409; TOPAZ). Objective: Evaluate serum neurofilament light chain (sNfL) in CARE-MS I patients and highly active disease (HAD) subgroup, over 7 and 2 years for alemtuzumab and subcutaneous interferon beta-1a (SC IFNB-1a), respectively. Methods: Patients received SC IFNB-1a 44 µg 3×/week or alemtuzumab 12 mg/day at baseline and month 12, with further as-needed 3-day courses. sNfL was measured using single-molecule array (Simoa™). HAD definition was ⩾2 relapses in year before randomization and ⩾1 baseline gadolinium-enhancing lesion. Results: Baseline median sNfL levels were similar in alemtuzumab (n = 354) and SC IFNB-1a–treated (n = 159) patients (31.7 vs 31.4 pg/mL), but decreased with alemtuzumab versus SC IFNB-1a until year 2 (Y2; 13.2 vs 18.7 pg/mL; p < 0.0001); 12.7 pg/mL for alemtuzumab at Y7. Alemtuzumab-treated patients had sNfL at/below healthy control median at Y2 (72% vs 47%; p < 0.0001); 73% for alemtuzumab at Y7. HAD patients (n = 102) had higher baseline sNfL (49.4 pg/mL) versus overall population; alemtuzumab HAD patients attained similar levels (Y2, 12.8 pg/mL; Y7, 12.7 pg/mL; 75% were at/below control median at Y7). Conclusion: Alemtuzumab was superior to SC IFNB-1a in reducing sNfL, with levels in alemtuzumab patients remaining stable through Y7. ClinicalTrials.gov identifier: NCT00530348, NCT00930553, NCT02255656
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Affiliation(s)
- Jens Kuhle
- Neurologic Clinic and Policlinic, MS Center and Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), Departments of Medicine, Biomedicine, and Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | | | - Pascal Benkert
- Clinical Trial Unit Basel, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Aleksandra Maceski
- Neurologic Clinic and Policlinic, MS Center and Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), Departments of Medicine, Biomedicine, and Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian Barro
- Neurologic Clinic and Policlinic, MS Center and Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel, University of Basel, Basel, Switzerland Current affiliation: Ann Romney Center for Neurologic Diseases, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Zuzanna Michalak
- Neurologic Clinic and Policlinic, MS Center and Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel, University of Basel, Basel, Switzerland Current affiliation: F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | - Maria Pia Sormani
- Department of Health Sciences, University of Genoa and IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | | | - Tarek A Samad
- Sanofi, Framingham, MA, USA.,Current affiliation: Immunitas Therapeutics, Inc., Cambridge, MA, USA
| | - Alan Jacobs
- Sanofi, Cambridge, MA, USA.,Current affiliation: Immunovant, New York, NY, USA
| | - Luke Chung
- Sanofi, Cambridge, MA, USA.,Current affiliation: Immune-Onc Therapeutics, Palo Alto, CA, USA
| | | | | | | | - David Leppert
- Neurologic Clinic and Policlinic, MS Center and Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), Departments of Medicine, Biomedicine, and Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | | | - Ludwig Kappos
- Neurologic Clinic and Policlinic, MS Center and Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), Departments of Medicine, Biomedicine, and Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
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166
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Baker D, Asardag AN, Quinn OA, Efimov A, Kang AS. Anti-drug antibodies to antibody-based therapeutics in multiple sclerosis. Hum Antibodies 2021; 29:255-262. [PMID: 34397407 DOI: 10.3233/hab-210453] [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] [Indexed: 11/15/2022]
Abstract
Multiple sclerosis is the major demyelinating autoimmune disease of the central nervous system. Relapsing MS can be treated by a number of approved monoclonal antibodies that currently target: CD20, CD25 (withdrawn), CD49d and CD52. These all target potentially pathogenic memory B cell subsets and perhaps functionally inhibit pathogenic T cell function. These consist of chimeric, humanized and fully human antibodies. However, despite humanization it is evident that all of these monoclonal antibodies can induce binding and neutralizing antibodies ranging from < 1% to over 80% within a year of treatment. Importantly, it is evident that monitoring these allow prediction of future treatment-failure in some individuals and treatment cessation and switching therefore potentially limiting disease breakthrough and disability accumulation. In response to the COVID-19 pandemic and the need to avoid hospitals, shortened infusion times and extended dose intervals have been implemented, importantly, subcutaneous delivery of alternative treatments or formulations have been developed to allow for home treatment. Therefore, hospital-based and remote monitoring of ADA could therefore be advantageous to optimize patient responses in the future.
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Affiliation(s)
- David Baker
- Blizard Institute, Barts and London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - A Nazli Asardag
- Blizard Institute, Barts and London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Olivia A Quinn
- Blizard Institute, Barts and London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Alex Efimov
- Camstech Limited, Daresbury Laboratory Science and Technology Facilities Council Sci-Tech, Keckwick, Cheshire, UK
| | - Angray S Kang
- Blizard Institute, Barts and London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Centre for Oral Immunobiology and Regenerative Medicine, Dental Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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167
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Buonomo AR, Viceconte G, Zappulo E, Maraolo AE, Russo CV, Carotenuto A, Moccia M, Gentile I. Update on infective complications in patients treated with alemtuzumab for multiple sclerosis: review and meta-analysis of real-world and randomized studies. Expert Opin Drug Saf 2021; 20:1237-1246. [PMID: 34310251 DOI: 10.1080/14740338.2021.1942454] [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] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We aimed to systematically assess the pooled prevalence of infective complications in randomized controlled trials (RCTs) and real-world studies (RWSs) investigating alemtuzumab treatment in multiple sclerosis (MS), also looking at selected infections and their severity. METHODS We included in the analysis RCTs and RWSs investigating the use of alemtuzumab in MS in which infective complications were reported, as well as case reports of rare infections. We conducted a meta-analysis of proportions and a random effect model meta-regression to investigate heterogeneity. RESULTS The pooled prevalence of infective complications in alemtuzumab treated MS patients is 24%. The most common reported infections are respiratory tract infections (47%) and the most part of the infections are mild-to-moderate (85%). Severe infections account for 6% of the total estimate. We found first-time-reported cases of invasive aspergillosis, hepatitis E virus infection, EBV hepatitis, and cerebral toxoplasmosis. The prevalence of infections is higher in studies conducted before 2009, and in studies with higher proportion of male participants. CONCLUSIONS Clinicians should be aware that the prevalence of serious infections during alemtuzumab can be higher than expected from RCTs. Peculiar opportunistic infections should be considered when evaluating a patient treated with alemtuzumab who develops signs of infection.
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Affiliation(s)
- Antonio Riccardo Buonomo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples "Federico II", Napoli, Italy
| | - Giulio Viceconte
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples "Federico II", Napoli, Italy
| | - Emanuela Zappulo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples "Federico II", Napoli, Italy
| | - Alberto Enrico Maraolo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples "Federico II", Napoli, Italy
| | - Cinzia Valeria Russo
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Napoli, Italy
| | - Antonio Carotenuto
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Napoli, Italy
| | - Marcello Moccia
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Napoli, Italy
| | - Ivan Gentile
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples "Federico II", Napoli, Italy
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168
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Rauma I, Mustonen T, Seppä JM, Ukkonen M, Männikkö M, Verkkoniemi-Ahola A, Kartau M, Saarinen JT, Luostarinen L, Simula S, Ryytty M, Ahmasalo R, Sipilä JOT, Pieninkeroinen I, Tapiola T, Remes AM, Kuusisto H. Safety of alemtuzumab in a nationwide cohort of Finnish multiple sclerosis patients. J Neurol 2021; 269:824-835. [PMID: 34255182 PMCID: PMC8782800 DOI: 10.1007/s00415-021-10664-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 06/08/2021] [Accepted: 06/14/2021] [Indexed: 12/05/2022]
Abstract
Background Alemtuzumab is an effective disease-modifying therapy (DMT) for highly active multiple sclerosis (MS). However, safety concerns limit its use in clinical practice. Objectives To evaluate the safety of alemtuzumab in a nationwide cohort of Finnish MS patients. Methods In this retrospective case series study, we analyzed the data of all but two MS patients who had received alemtuzumab in Finland until 2019. Data were systematically collected from patient files. Results Altogether 121 patients were identified, most of whom had received previous DMTs (82.6%). Median follow-up time after treatment initiation was 30.3 months and exceeded 24 months in 78 patients. Infusion-associated reactions (IARs) were observed in 84.3%, 57.3%, and 57.1% of patients during alemtuzumab courses 1–3, respectively. Serious adverse events (SAEs) were observed in 32.2% of patients, serious IARs in 12.4% of patients, and SAEs other than IARs in 23.1% of patients. Autoimmune adverse events were observed in 30.6% of patients. One patient died of hemophagocytic lymphohistiocytosis, and one patient died of pneumonia. A previously unreported case of thrombotic thrombocytopenic purpura was documented. Conclusions SAEs were more frequent in the present cohort than in previous studies. Even though alemtuzumab is a highly effective therapy for MS, vigorous monitoring with a long enough follow-up time is advised.
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Affiliation(s)
- Ilkka Rauma
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland. .,Department of Neurology, Tampere University Hospital, Tampere, Finland. .,Department of Neurology, Seinäjoki Central Hospital, Seinäjoki, Finland.
| | - Tiina Mustonen
- Neuro Center, Kuopio University Hospital, Kuopio, Finland
| | | | - Maritta Ukkonen
- Department of Neurology, Tampere University Hospital, Tampere, Finland
| | - Marianne Männikkö
- Department of Neurology, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Auli Verkkoniemi-Ahola
- Clinical Neurosciences, Neurology, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Marge Kartau
- Clinical Neurosciences, Neurology, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | | | - Liisa Luostarinen
- Department of Neurology, Päijät-Häme Central Hospital, Lahti, Finland
| | - Sakari Simula
- Department of Neurology, Mikkeli Central Hospital, Mikkeli, Finland
| | - Mervi Ryytty
- Medical Research Center, Oulu University Hospital, Oulu, Finland.,Research Unit of Clinical Neuroscience, University of Oulu, Faculty of Medicine, Oulu, Finland
| | - Riitta Ahmasalo
- Department of Neurology, Lapland Central Hospital, Rovaniemi, Finland
| | - Jussi O T Sipilä
- Department of Neurology, North Karelia Central Hospital, Siun Sote, Joensuu, Finland.,Department of Clinical Neurosciences, University of Turku, Turku, Finland
| | | | - Tero Tapiola
- Department of Neurology, South Karelia Central Hospital, Lappeenranta, Finland
| | - Anne M Remes
- Medical Research Center, Oulu University Hospital, Oulu, Finland.,Research Unit of Clinical Neuroscience, University of Oulu, Faculty of Medicine, Oulu, Finland
| | - Hanna Kuusisto
- Department of Neurology, Tampere University Hospital, Tampere, Finland.,Department of Health and Social Management, University of Eastern Finland, Kuopio, Finland.,Department of Neurology, Kanta-Häme Central Hospital, Hämeenlinna, Finland
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169
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Kasarello K, Mirowska-Guzel D. Anti-CD52 Therapy for Multiple Sclerosis: An Update in the COVID Era. Immunotargets Ther 2021; 10:237-246. [PMID: 34268256 PMCID: PMC8273745 DOI: 10.2147/itt.s240890] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/22/2021] [Indexed: 01/01/2023] Open
Abstract
CD52 is a small surface glycoprotein composed of 12 amino acids. CD52 is found mostly on the surface of mature immune cells, such as lymphocytes, monocytes, eosinophils, and dendritic cells, as well as the male genital tract: within the epididymis and on the surface of mature sperm. Low CD52 expression is also found in neutrophils. CD52 function is not fully understood, although experiments with anti-CD52 antibodies have shown that CD52 is essential for lymphocyte transendothelial migration and may contribute to costimulation of CD4+ T cells and T-cell activation and proliferation. Although knowledge about exact CD52 function is still poor, CD52 presence on the surface of a broad spectrum of immune cells makes it a therapeutic target, especially in immunomediated diseases, such as multiple sclerosis. In multiple sclerosis, alemtuzumab is registered for adult patients with the relapsing–remitting form of the disease defined by clinical and imaging features. Despite the high efficacy of the drug, the main issue is its safety. The main adverse effects of alemtuzumab are associated with drug infusion due to cytokine release and cytotoxic effects of antibodies associated with lymphocyte depletion, which leads to immunosuppression, and secondary autoimmunity that may be the effect of excessive B-cell repopulation and cancer. This review presents current knowledge on the drug’s mechanism of action, efficacy and safety data from clinical trials, and real-world observations, including available though scarce data on using alemtuzumab in the COVID era.
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Affiliation(s)
- Kaja Kasarello
- Department of Experimental and Clinical Physiology, Centre for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - Dagmara Mirowska-Guzel
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research, Medical University of Warsaw, Warsaw, Poland.,Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
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170
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Cencioni MT, Mattoscio M, Magliozzi R, Bar-Or A, Muraro PA. B cells in multiple sclerosis - from targeted depletion to immune reconstitution therapies. Nat Rev Neurol 2021; 17:399-414. [PMID: 34075251 DOI: 10.1038/s41582-021-00498-5] [Citation(s) in RCA: 99] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2021] [Indexed: 02/04/2023]
Abstract
Increasing evidence indicates the involvement of B cells in the pathogenesis of multiple sclerosis (MS), but their precise roles are unclear. In this Review, we provide an overview of the development and physiological functions of B cells and the main mechanisms through which B cells are thought to contribute to CNS autoimmunity. In MS, abnormalities of B cell function include pro-inflammatory cytokine production, defective B cell regulatory function and the formation of tertiary lymphoid-like structures in the CNS, which are the likely source of abnormal immunoglobulin production detectable in the cerebrospinal fluid. We also consider the hypothesis that Epstein-Barr virus (EBV) is involved in the B cell overactivation that leads to inflammatory injury to the CNS in MS. We also review the immunological effects - with a focus on the effects on B cell subsets - of several successful therapeutic approaches in MS, including agents that selectively deplete B cells (rituximab, ocrelizumab and ofatumumab), agents that less specifically deplete lymphocytes (alemtuzumab and cladribine) and autologous haematopoietic stem cell transplantation, in which the immune system is unselectively ablated and reconstituted. We consider the insights that these effects on B cell populations provide and their potential to further our understanding and targeting of B cells in MS.
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Affiliation(s)
- Maria T Cencioni
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, London, UK
| | - Miriam Mattoscio
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, London, UK
| | - Roberta Magliozzi
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, London, UK.,Department of Neurology, University of Verona, Verona, Italy
| | - Amit Bar-Or
- Center for Neuroinflammation and Experimental Therapeutics and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Paolo A Muraro
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, London, UK.
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171
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Schweitzer F, Laurent S, Fink GR, Barnett MH, Hartung HP, Warnke C. Effects of disease-modifying therapy on peripheral leukocytes in patients with multiple sclerosis. J Neurol 2021; 268:2379-2389. [PMID: 32036423 PMCID: PMC8217029 DOI: 10.1007/s00415-019-09690-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 12/24/2019] [Indexed: 12/11/2022]
Abstract
Modern disease-modifying therapies (DMTs) in multiple sclerosis (MS) have variable modes of action and selectively suppress or modulate the immune system. In this review, we summarize the predicted and intended as well as unwanted adverse effects on leukocytes in peripheral blood as a result of treatment with DMTs for MS. We link changes in laboratory tests to the possible therapeutic risks that include secondary autoimmunity, infections, and impaired response to vaccinations. Profound knowledge of the intended effects on leukocyte counts, in particular lymphocytes, explained by the mode of action, and adverse effects which may require additional laboratory and clinical vigilance or even drug discontinuation, is needed when prescribing DMTs to treat patients with MS.
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Affiliation(s)
- F Schweitzer
- Department of Neurology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - S Laurent
- Department of Neurology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - G R Fink
- Department of Neurology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
- Cognitive Neuroscience, Institute of Neuroscience and Medicine (INM-3), Research Center Jülich, Jülich, Germany
| | - Michael H Barnett
- Department of Neurology, Royal Prince Alfred Hospital, and Brain and Mind Centre, University of Sydney, Sydney, Australia
| | - H P Hartung
- Department of Neurology, Medical Faculty, and Center for Neurology and Neuropsychiatry, LVR Klinikum, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - C Warnke
- Department of Neurology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany.
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172
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Elsbernd PM, Carter JL. Using Monoclonal Antibody Therapies for Multiple Sclerosis: A Review. Biologics 2021; 15:255-263. [PMID: 34234409 PMCID: PMC8255409 DOI: 10.2147/btt.s267273] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/31/2021] [Indexed: 11/25/2022]
Abstract
Monoclonal antibody therapies have secured an important role in the therapeutic landscape for the treatment of both relapsing and progressive forms of multiple sclerosis due to their potent efficacy, convenient dosing schedules, and well-defined side effect profiles. Each therapy has unique risks and benefits associated with its specific mechanism of action which ultimately guides clinical decision-making for individual patients. This review will summarize the mechanisms of action, evidence leading to their approval, and clinically relevant considerations for each of the current monoclonal antibody therapies approved for the treatment of multiple sclerosis.
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173
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Hunter SF, Aburashed RA, Alroughani R, Chan A, Dive D, Eichau S, Kantor D, Kim HJ, Lycke J, Macdonell RAL, Pozzilli C, Scott T, Sharrack B, Wiendl H, Chung L, Daizadeh N, Baker DP, Vermersch P. Confirmed 6-Month Disability Improvement and Worsening Correlate with Long-term Disability Outcomes in Alemtuzumab-Treated Patients with Multiple Sclerosis: Post Hoc Analysis of the CARE-MS Studies. Neurol Ther 2021; 10:803-818. [PMID: 34165694 PMCID: PMC8571457 DOI: 10.1007/s40120-021-00262-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 06/03/2021] [Indexed: 11/28/2022] Open
Abstract
Introduction In the 2-year CARE-MS trials (NCT00530348; NCT00548405) in patients with relapsing–remitting multiple sclerosis, alemtuzumab showed superior efficacy versus subcutaneous interferon beta-1a. Efficacy was maintained in two consecutive extensions (NCT00930553; NCT02255656). This post hoc analysis compared disability outcomes over 9 years among alemtuzumab-treated patients according to whether they experienced confirmed disability improvement (CDI) or worsening (CDW) or neither CDI nor CDW. Methods CARE-MS patients were randomized to receive two alemtuzumab courses (12 mg/day; 5 days at baseline; 3 days at 12 months), with additional as-needed 3-day courses in the extensions. CDI or CDW were defined as ≥ 1.0-point decrease or increase, respectively, in Expanded Disability Status Scale (EDSS) score from core study baseline confirmed over 6 months, assessed in patients with baseline EDSS score ≥ 2.0. Improved or stable EDSS scores were defined as ≥ 1-point decrease or ≤ 0.5-point change (either direction), respectively, from core study baseline. Functional systems (FS) scores were also assessed. Results Of 511 eligible patients, 43% experienced CDI and 34% experienced CDW at any time through year 9 (patients experiencing both CDI and CDW were counted in each individual group); 29% experienced neither CDI nor CDW. At year 9, patients with CDI had a −0.58-point mean EDSS score change from baseline; 88% had stable or improved EDSS scores. Improvements occurred across all FS, primarily in sensory, pyramidal, and cerebellar domains. Patients with CDW had a +1.71-point mean EDSS score change; 16% had stable or improved EDSS scores. Patients with neither CDI nor CDW had a −0.10-point mean EDSS score change; 98% had stable or improved EDSS scores. Conclusion CDI achievement at any point during the CARE-MS studies was associated with improved disability at year 9, highlighting the potential of alemtuzumab to change the multiple sclerosis course. Conversely, CDW at any point was associated with worsened disability at year 9. Supplementary Information The online version contains supplementary material available at 10.1007/s40120-021-00262-3.
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Affiliation(s)
- Samuel F Hunter
- Advanced Neurosciences Institute, 101 Forrest Crossing Blvd., Franklin, TN, 37064, USA.
| | - Rany A Aburashed
- Institute for Neurosciences and Multiple Sclerosis, Owosso, MI, USA
| | - Raed Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Sharq, Kuwait
| | - Andrew Chan
- Department of Neurology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Sara Eichau
- Hospital Universitario Virgen Macarena, Seville, Spain
| | - Daniel Kantor
- Florida Atlantic University, Boca Raton, FL, USA.,Nova Southeastern University, Fort Lauderdale, FL, USA.,Penn Center for Global Health, Philadelphia, PA, USA
| | - Ho Jin Kim
- Research Institute and Hospital of National Cancer Center, Goyang, Korea
| | - Jan Lycke
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Richard A L Macdonell
- Austin Health and Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia
| | - Carlo Pozzilli
- Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Thomas Scott
- Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, PA, USA
| | - Basil Sharrack
- Sheffield NIHR Neuroscience BRC and Sheffield Teaching Hospitals, Sheffield, UK
| | | | | | | | | | - Patrick Vermersch
- Univ. Lille, INSERM U1172 LilNCog, CHU Lille, FHU Precise, Lille, France
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174
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Jakimovski D, Zivadinov R, Vaughn CB, Ozel O, Weinstock-Guttman B. Clinical effects associated with five-year retinal nerve fiber layer thinning in multiple sclerosis. J Neurol Sci 2021; 427:117552. [PMID: 34175775 DOI: 10.1016/j.jns.2021.117552] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 06/18/2021] [Accepted: 06/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Neurodegenerative changes in multiple sclerosis (MS) are associated with long-term disability progression (DP). Optical coherence tomography (OCT) measures may be used to monitor DP. OBJECTIVE To determine significant effects driving the changes in OCT-based peripapillary retinal nerve fiber layer (pRNFL) in heterogeneous group of MS patients. METHODS Total of 144 MS patients (109 relapsing-remitting MS and 35 progressive MS (PMS) with mean age at baseline of 47.6 and 56.5 years old, respectively) underwent clinical and OCT examination over 5-year follow-up. All OCT exams were reviewed using the OSCAR-IB criteria. The 5-year DP was determined based on Expanded Disability Status Scale (EDSS) changes and MS clinical trial criteria. Data regarding previous history of MS optic neuritis (MSON) and use of disease modifying treatment (DMT) was derived by in-person interview and review of electronic medical records. Mixed model-type of repeated measure analysis determined effects driving pRNFL change for analysis which utilized all eyes separately. RESULTS Over an average of 5.3-years follow-up, the MS population demonstrated significant pRNFL thinning (F = 16.108, p < 0.001). The pRNFL thinning was greater due to progressive MS subtype (F = 5.102, p = 0.025), greater age at baseline (F = 4.554, p = 0.034), occurrence of DP (F = 6.583, p = 0.011), and previous history of MSON (F = 7.053, p = 0.008). Use of any or highly potent DMT (natalizumab versus first-line injectable treatments versus no DMT) significantly reduced the pRNFL thinning (F = 8.367, p = 0.004) over the follow-up. Lastly, occurrence of DP in PMS patients older than 50 years old was associated with greater pRNFL thinning (F = 6.667, p = 0.013). CONCLUSION Longitudinal pRNFL changes are modified by age, disease subtype, disabiltiy progression, history of MSON, DMT use and their interactions.
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Affiliation(s)
- Dejan Jakimovski
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA; Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA.
| | - Robert Zivadinov
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA; Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA; Center for Biomedical Imaging at Clinical Translational Science Institute, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Caila B Vaughn
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Osman Ozel
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Bianca Weinstock-Guttman
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
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175
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Piehl F. Current and emerging disease-modulatory therapies and treatment targets for multiple sclerosis. J Intern Med 2021; 289:771-791. [PMID: 33258193 PMCID: PMC8246813 DOI: 10.1111/joim.13215] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/08/2020] [Accepted: 10/22/2020] [Indexed: 12/11/2022]
Abstract
The treatment of multiple sclerosis (MS), the most common chronic inflammatory, demyelinating and neurodegenerative disease of the central nervous system (CNS), continues to transform. In recent years, a number of novel and increasingly effective disease-modulatory therapies (DMTs) have been approved, including oral fumarates and selective sphingosine 1-phosphate modulators, as well as cell-depleting therapies such as cladribine, anti-CD20 and anti-CD52 monoclonals. Amongst DMTs in clinical development, inhibitors of Bruton's tyrosine kinase represent an entirely new emerging drug class in MS, with three different drugs entering phase III trials. However, important remaining fields of improvement comprise tracking of long-term benefit-risk with existing DMTs and exploration of novel treatment targets relating to brain inherent disease processes underlying the progressive neurodegenerative aspect of MS, which accumulating evidence suggests start already early in the disease process. The aim here is to review current therapeutic options in relation to an improved understanding of the immunopathogenesis of MS, also highlighting examples where controlled trials have not generated the desired results. An additional aim is to review emerging therapies undergoing clinical development, including agents that interfere with disease processes believed to be important for neurodegeneration or aiming to enhance reparative responses. Notably, early trials now have shown initial evidence of enhanced remyelination both with small molecule compounds and biologicals. Finally, accumulating evidence from clinical trials and post-marketing real-world patient populations, which underscore the importance of early high effective therapy whilst maintaining acceptable tolerability, is discussed.
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Affiliation(s)
- F. Piehl
- From theDepartment of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
- The Karolinska University Hospital and Academic Specialist CentreStockholm Health ServicesStockholmSweden
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176
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Long-Term Stability of Neuroaxonal Structure in Alemtuzumab-Treated Relapsing-Remitting Multiple Sclerosis Patients. J Neuroophthalmol 2021; 40:37-43. [PMID: 32045393 DOI: 10.1097/wno.0000000000000802] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Patients with multiple sclerosis (MS) experience progressive thinning in optical coherence tomography (OCT) measures of neuroaxonal structure regardless of optic neuritis history. Few prospective studies have investigated the effects of disease-modifying therapies on neuroaxonal degeneration in the retina. Alemtuzumab is a monoclonal antibody shown to be superior to interferon β-1a in treating relapsing-remitting MS (RRMS). The purpose of this study was to assess the effects of alemtuzumab and first-line injectable treatments on OCT measures of neuroaxonal structure including peripapillary retinal nerve fiber layer (RNFL) thickness and combined ganglion cell-inner plexiform (GCIP) layer volume in RRMS patients followed up over 5 years. METHODS In this retrospective pilot study with prospectively collected double cohort data, spectral domain OCT measures of RNFL thickness and GCIP volume were compared between alemtuzumab-treated RRMS patients (N = 24) and RRMS patients treated with either interferon-β or glatiramer acetate (N = 21). RESULTS Over a median of 60 months (range 42-60 months), the alemtuzumab cohort demonstrated a change in the mean RNFL thickness (thinning from baseline) of -0.88 μm (95% confidence interval [CI] -2.63 to 0.86; P = 0.32) and mean GCIP volume of +0.013 mm (95% CI -0.006 to 0.032; P = 0.18). Over the same time period, the first-line therapy-treated cohort demonstrated greater degrees of RNFL thinning (mean change in RNFL thickness was -3.65 μm [95% CI -5.40 to -1.89; P = 0.0001]). There was also more prominent GCIP volume loss relative to baseline in the first-line therapy group (-0.052 mm [95% CI -0.070 to -0.034; P < 0.0001]). CONCLUSIONS Alemtuzumab-treated patients with RRMS demonstrated relative stability of OCT-measured neuroaxonal structure compared with RRMS patients treated with either interferon-β or glatiramer acetate over a 5-year period. These findings, along with previous demonstration of improved brain atrophy rates, suggest that alemtuzumab may offer long-term preservation of neuroaxonal structure in patients with RRMS.
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177
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Callegari I, Derfuss T, Galli E. Update on treatment in multiple sclerosis. Presse Med 2021; 50:104068. [PMID: 34033862 DOI: 10.1016/j.lpm.2021.104068] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/29/2021] [Accepted: 05/06/2021] [Indexed: 11/17/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system. In recent years, many disease-modifying therapies (DMT) have been approved for MS treatment. For this reason, a profound knowledge of the characteristics and indications of the available compounds is required to tailor the therapeutic strategy to the individual patient characteristics. This should include the mechanism of action and pharmacokinetic of the drug, the safety and efficacy profile provided by clinical trials, as well as the understanding of possible side effects. Moreover, the evolving knowledge of the disease is paving the way to new and innovative therapeutic approaches, as well as the development of new biomarkers to monitor the therapeutic response and to guide the clinician's therapeutic choices. In this review we provide a comprehensive overview on currently approved therapies in MS and the emerging evidence-based strategies to adopt for initiating, monitoring, and eventually adapting a therapeutic regimen with DMT.
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Affiliation(s)
- Ilaria Callegari
- Department of Biomedicine, University Hospital Basel, University of Basel, Hebelstrasse 20, 4031 Basel, Switzerland
| | - Tobias Derfuss
- Department of Biomedicine, University Hospital Basel, University of Basel, Hebelstrasse 20, 4031 Basel, Switzerland; Department of Neurology, University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland.
| | - Edoardo Galli
- Department of Biomedicine, University Hospital Basel, University of Basel, Hebelstrasse 20, 4031 Basel, Switzerland; Department of Neurology, University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland
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178
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Infection Mitigation Strategies for Multiple Sclerosis Patients on Oral and Monoclonal Disease-Modifying Therapies. Curr Neurol Neurosci Rep 2021; 21:36. [PMID: 34009478 PMCID: PMC8132488 DOI: 10.1007/s11910-021-01117-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW The newer, higher-efficacy disease-modifying therapies (DMTs) for multiple sclerosis (MS)-orals and monoclonals-have more profound immunomodulatory and immunosuppressive properties than the older, injectable therapies and require risk mitigation strategies to reduce the risk of serious infections. This review will provide a systematic framework for infectious risk mitigation strategies relevant to these therapies. RECENT FINDINGS We classify risk mitigation strategies according to the following framework: (1) screening and patient selection, (2) vaccinations, (3) antibiotic prophylaxis, (4) laboratory and MRI monitoring, (5) adjusting dose and frequency of DMT, and (6) behavioral modifications to limit the risk of infection. We systematically apply this framework to the infections for which risk mitigations are available: hepatitis B, herpetic infections, progressive multifocal leukoencephalopathy, and tuberculosis. We also discuss up-to-date recommendations regarding COVID-19 vaccinations for patients on DMTs. We offer a practical, comprehensive, DMT-specific framework of derisking strategies designed to minimize the risk of infections associated with the newer MS therapies.
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179
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Deeb O, Nabulsi M. Exploring Multiple Sclerosis (MS) and Amyotrophic Lateral Scler osis (ALS) as Neurodegenerative Diseases and their Treatments: A Review Study. Curr Top Med Chem 2021; 20:2391-2403. [PMID: 32972341 DOI: 10.2174/1568026620666200924114827] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/31/2020] [Accepted: 09/04/2020] [Indexed: 12/11/2022]
Abstract
Growing concern about neurodegenerative diseases is becoming a global issue. It is estimated that not only will their prevalence increase but also morbidity and health burden will be concerning. Scientists, researchers and clinicians share the responsibility of raising the awareness and knowledge about the restricting and handicapping health restrains related to these diseases. Multiple Sclerosis (MS), as one of the prevalent autoimmune diseases, is characterized by abnormal regulation of the immune system that periodically attacks parts of the nervous system; brain and spinal cord. Symptoms and impairments include weakness, numbness, visual problems, tingling pain that are quietly variable among patients. Amyotrophic Lateral Sclerosis (ALS) is another neurodegenerative disease that is characterized by the degeneration of motor neurons in the brain and spinal cord. Unlike MS, symptoms begin with muscle weakness and progress to affect speech, swallowing and finally breathing. Despite the major differences between MS and ALS, misdiagnosis is still influencing disease prognosis and patient's quality of life. Diagnosis depends on obtaining a careful history and neurological examination as well as the use of Magnetic Resonance Imaging (MRI), which are considered challenging and depend on the current disease status in individuals. Fortunately, a myriad of treatments is available now for MS. Most of the cases are steroid responsive. Disease modifying therapy is amongst the most important set of treatments. In ALS, few medications that slow down disease progression are present. The aim of this paper is to summarize what has been globally known and practiced about MS and ALS, as they are currently classified as important growing key players among autoimmune diseases. In terms of treatments, it is concluded that special efforts and input should be directed towards repurposing of older drugs and on stem cells trials. As for ALS, it is highlighted that supportive measurements and supplementary treatments remain essentially needed for ALS patients and their families. On the other hand, it is noteworthy to clarify that the patient-doctor communication is relatively a cornerstone in selecting the best treatment for each MS patient.
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Affiliation(s)
- Omar Deeb
- Faculty of Pharmacy, Al-Quds University, P.O. Box 20002 Jerusalem, Palestinian Territory, Occupied
| | - Maisa Nabulsi
- Faculty of Pharmacy, Al-Quds University, P.O. Box 20002 Jerusalem, Palestinian Territory, Occupied
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180
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Simpson A, Mowry EM, Newsome SD. Early Aggressive Treatment Approaches for Multiple Sclerosis. Curr Treat Options Neurol 2021; 23:19. [PMID: 34025110 PMCID: PMC8121641 DOI: 10.1007/s11940-021-00677-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2021] [Indexed: 12/19/2022]
Abstract
Purpose of review This review presents a comprehensive analysis of the current high-efficacy disease-modifying therapies (DMTs) available for treatment of multiple sclerosis (MS). We discuss the existing approved and emerging therapeutics in patients with relapsing and progressive forms of MS using data from clinical trials and observational studies. Treatment considerations in pediatric and pregnant populations are also reviewed. Finally, we discuss the treatment paradigms of the escalation and early aggressive approaches to treatment of MS, with review of ongoing clinical trials to compare these approaches. Recent findings Natalizumab has shown promising data on efficacy in not only randomized trials but also observational studies when compared with placebo, the injectable DMTs, and fingolimod. The anti-CD20 B cell depleting therapies (rituximab, ocrelizumab, and ofatumumab) have also demonstrated superiority in randomized clinical trials compared to their comparator group (placebo, interferon, and teriflunomide, respectively) and rituximab has shown in observational studies to be more effective than older injectable therapies and some of the oral therapies. Alemtuzumab has shown good efficacy in randomized controlled trials and observational studies yet has several potentially severe side effects limiting its use. Mitoxantrone has similarly demonstrated significant reduction in new disease activity compared to placebo but is rarely used due to its severe side effects. Cladribine is an oral DMT often grouped in discussion with other higher efficacy DMTs but may be slightly less effective than the other therapies described in this review. Many emerging targets for therapeutic intervention are currently under investigation that may prove to be beneficial in early aggressive MS, including autologous hematopoietic stem cell transplantation. Summary Traditionally, MS has been treated with an escalation approach, starting patients on a modestly effective DMT and subsequently escalating to a higher efficacy DMT when there is evidence of clinical and/or radiologic breakthrough activity. With the development of higher efficacy therapies and emerging data showing the potential positive long-term impact of these therapies when started earlier in the disease course, many clinicians have shifted to an early aggressive treatment approach in which patients are initially started on a higher efficacy DMT. Two clinical trials, the TRaditional versus Early Aggressive Therapy for MS (TREAT-MS) trial and the Determining the Effectiveness of earLy Intensive Versus Escalation approaches for the treatment of Relapsing-remitting MS (DELIVER-MS) trial, aim to directly compare these treatment strategies and their impact on clinical and radiologic outcomes.
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Affiliation(s)
- Alexandra Simpson
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Ellen M Mowry
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Scott D Newsome
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD USA.,Division of Neuroimmunology and Neurological Infections, Johns Hopkins Hospital, 600 North Wolfe St., Pathology 627, Baltimore, MD 21287 USA
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181
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Dikeoulia E, Neufeld M, Pawlitzki M, Böhm M. Alemtuzumab-induced Alopecia areata - a case report and systematic literature review of adverse events associated with Alemtuzumab. J Dtsch Dermatol Ges 2021; 19:1159-1163. [PMID: 33973347 DOI: 10.1111/ddg.14448] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 01/28/2021] [Indexed: 11/28/2022]
Abstract
Alemtuzumab is currently approved for the treatment of active relapsing-remitting multiple sclerosis (RRMS). Despite the efficacy of this therapy several side effects in the skin have been noted during or after infusion including vitiligo, alopecia areata, malignant skin tumors and infections. Awareness of these effects and their treatment is of essential interdisciplinary importance. This minireview provides an overview of the dermatological side effects described in the current literature. We also suggest pathomechanisms underlying these phenomena. To introduce this review, we present the case of a woman with RRMS who developed severe alopecia areata for the first time on alemtuzumab.
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Affiliation(s)
- Elsa Dikeoulia
- Klinik für Hautkrankheiten, Universitätsklinikum Münster [Dermatology clinic, University Hospital Münster, Germany
| | - Matthias Neufeld
- Klinik für Hautkrankheiten, Universitätsklinikum Münster [Dermatology clinic, University Hospital Münster, Germany
| | - Marc Pawlitzki
- Klinik für Hautkrankheiten, Universitätsklinikum Münster [Dermatology clinic, University Hospital Münster, Germany
| | - Markus Böhm
- Klinik für Hautkrankheiten, Universitätsklinikum Münster [Dermatology clinic, University Hospital Münster, Germany
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182
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Häußler V, Ufer F, Pöttgen J, Wolschke C, Friese MA, Kröger N, Heesen C, Stellmann JP. aHSCT is superior to alemtuzumab in maintaining NEDA and improving cognition in multiple sclerosis. Ann Clin Transl Neurol 2021; 8:1269-1278. [PMID: 33949790 PMCID: PMC8164852 DOI: 10.1002/acn3.51366] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 03/27/2021] [Indexed: 12/29/2022] Open
Abstract
Objective Autologous hematopoietic stem cell transplantation (aHSCT) is increasingly recognized as a potential therapy for patients with highly active multiple sclerosis (MS). This study aims to assess outcome differences in disease activity in MS patients treated either with aHSCT or alemtuzumab. Methods We conducted a monocentric registry‐based cohort study by recording the clinical course (EDSS and relapses), MRI parameters (new T2 lesions), and neuropsychological assessment in all 19 MS patients receiving aHSCT, and all 21 patients receiving alemtuzumab between 2007 and 2018. We used survival analyses of no evidence of disease activity (NEDA) as the primary objective which was defined by no EDSS progression, no relapse, and no new T2 lesion on MRI. Secondary objectives were EDSS improvement and neurocognitive performance. Results Both treatment groups were similar in respect of age, gender, disability, and neurocognitive performance except for significantly longer disease duration in the alemtuzumab group. Mean follow‐up was 58.8 [range 29–140] months in the aHSCT group compared to 27.6 [range 11–52] months in the alemtuzumab‐treated group. We observed significantly more patients maintaining NEDA in the aHSCT group (p = 0.048) compared to the alemtuzumab‐treated patients. Furthermore, 37% of the aHSCT patients showed an improvement of EDSS compared to none in the alemtuzumab‐treated group (p = 0.033). It is of note that cognitive function was significantly improved in the aHSCT‐treated patients. Interpretation aHSCT suppresses inflammatory activity more effectively than alemtuzumab and might enable improvement of overall disability and cognition in MS.
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Affiliation(s)
- Vivien Häußler
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Centre Hamburg-Eppendorf, Falkenried 94, Hamburg, 20251, Germany.,Department of Neurology, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, Hamburg, 20246, Germany
| | - Friederike Ufer
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Centre Hamburg-Eppendorf, Falkenried 94, Hamburg, 20251, Germany.,Department of Neurology, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, Hamburg, 20246, Germany
| | - Jana Pöttgen
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Centre Hamburg-Eppendorf, Falkenried 94, Hamburg, 20251, Germany.,Department of Neurology, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, Hamburg, 20246, Germany
| | - Christine Wolschke
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistraße 52, Hamburg, 20246, Germany
| | - Manuel A Friese
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Centre Hamburg-Eppendorf, Falkenried 94, Hamburg, 20251, Germany.,Department of Neurology, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, Hamburg, 20246, Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistraße 52, Hamburg, 20246, Germany
| | - Christoph Heesen
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Centre Hamburg-Eppendorf, Falkenried 94, Hamburg, 20251, Germany.,Department of Neurology, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, Hamburg, 20246, Germany
| | - Jan-Patrick Stellmann
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Centre Hamburg-Eppendorf, Falkenried 94, Hamburg, 20251, Germany.,Department of Neurology, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, Hamburg, 20246, Germany.,APHM, Hopital de la Timone, CEMEREM, Marseille, France.,Aix Marseille Univ, CNRS, CRMBM, UMR 7339, Marseille, France
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183
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Oksbjerg NR, Nielsen SD, Blinkenberg M, Magyari M, Sellebjerg F. Anti-CD20 antibody therapy and risk of infection in patients with demyelinating diseases. Mult Scler Relat Disord 2021; 52:102988. [PMID: 33979772 DOI: 10.1016/j.msard.2021.102988] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 04/22/2021] [Accepted: 04/25/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Anti-CD20 antibody therapy may be associated with an increased risk of infections. We therefore investigated risk factors for infection in patients with demyelinating diseases treated with anti-CD20 antibody therapy. METHODS In this retrospective uncontrolled study, patients ever treated with anti-CD20 antibodies at an academic clinic were identified through the Danish Multiple Sclerosis Registry (DMSR). Data were collected from medical charts and the DMSR. We assessed occurrence of severe infections (requiring hospitalization), varicella zoster virus (VZV), major comorbidities and routine laboratory values for lymphocytes, IgG and IgM. RESULTS A total of 447 patients ever treated with anti-CD20 antibody therapy were identified; of these 416 with 649 patient years of follow-up were still under therapy. In this group, seven patients had VZV infections, and 16 patients had been hospitalized with infections during up to three years of follow-up on anti-CD20 therapy. Comorbidity was recorded in 80 patients. The risk of severe infection was associated with comorbidities, higher age, longer duration of treatment, and higher Expanded Disability Status Scale (EDSS) scores. In multivariable analyses treatment duration, EDSS scores and presence of comorbidity were independently associated with risk of severe infections. Serum concentrations of IgG and IgM decreased with increasing duration of therapy but were not associated with risk of severe infections. Patients with VZV infection had lower lymphocyte counts and lower serum concentrations of IgM. In multivariable analyses only lymphocyte counts were independently associated with risk of VZV infection. CONCLUSIONS In this retrospective study of patients treated with anti-CD20 antibodies, the risk of infections requiring hospitalization was independently associated with comorbidities, duration of treatment, and higher EDSS scores. Risk of VZV infection was independently associated with lymphopenia. Future studies investigating strategies for mitigating risk of infection in patients treated with anti-CD20 antibodies are warranted, especially for older patients, patients with higher levels of disability and for patients with a longer duration of treatment.
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Affiliation(s)
- N R Oksbjerg
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
| | - S D Nielsen
- Department of Infectious Medicine, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - M Blinkenberg
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
| | - M Magyari
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; The Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
| | - F Sellebjerg
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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184
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Choi S, Spini M, Hua J, Harrison DM. Blood-brain barrier breakdown in non-enhancing multiple sclerosis lesions detected by 7-Tesla MP2RAGE ΔT1 mapping. PLoS One 2021; 16:e0249973. [PMID: 33901207 PMCID: PMC8075220 DOI: 10.1371/journal.pone.0249973] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 03/28/2021] [Indexed: 11/19/2022] Open
Abstract
Although the blood-brain barrier (BBB) is altered in most multiple sclerosis (MS) lesions, gadolinium enhancement is seen only in acute lesions. In this study, we aimed to investigate gadolinium-induced changes in T1 relaxation time in MS lesions on 7-tesla (7T) MRI as a means to quantify BBB breakdown in non-enhancing MS lesions. Forty-seven participants with MS underwent 7T MRI of the brain with a magnitude-prepared rapid acquisition of 2 gradient echoes (MP2RAGE) sequence before and after contrast. Subtraction of pre- and post-contrast T1 maps was used to measure T1 relaxation time change (ΔT1) from gadolinium. ΔT1 values were interrogated in enhancing white matter lesions (ELs), non-enhancing white matter lesions (NELs), and normal appearing white matter (NAWM) and metrics were compared to clinical data. ΔT1 was measurable in NELs (median: -0.139 (-0.304, 0.174) seconds; p < 0.001) and was negligible in NAWM (median: -0.001 (-0.036, 0.155) seconds; p = 0.516). Median ΔT1 in NELs correlated with disability as measured by Expanded Disability Status Scale (EDSS) (rho = -0.331, p = 0.026). Multiple measures of NEL ΔT1 variability also correlated with EDSS. NEL ΔT1 values were greater and more variable in patients with progressive forms of MS and greater in those not on MS treatment. Measurement of the changes in T1 relaxation time caused by contrast on 7T MP2RAGE reveals clinically relevant evidence of BBB breakdown in NELs in MS. This data suggests that NEL ΔT1 should be evaluated further as a potential biomarker of persistently disrupted BBB in MS.
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Affiliation(s)
- Seongjin Choi
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Margaret Spini
- University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Jun Hua
- Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, United Stated of America
- F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, Maryland, United States of America
| | - Daniel M. Harrison
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- * E-mail:
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185
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Coles AJ, Arnold DL, Bass AD, Boster AL, Compston DAS, Fernández Ó, Havrdová EK, Nakamura K, Traboulsee A, Ziemssen T, Jacobs A, Margolin DH, Huang X, Daizadeh N, Chirieac MC, Selmaj KW. Efficacy and safety of alemtuzumab over 6 years: final results of the 4-year CARE-MS extension trial. Ther Adv Neurol Disord 2021; 14:1756286420982134. [PMID: 34035833 PMCID: PMC8072102 DOI: 10.1177/1756286420982134] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 11/09/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In the 2-year CARE-MS I and II trials, alemtuzumab 12 mg administered on 5 consecutive days at core study baseline and on 3 consecutive days 12 months later significantly improved outcomes versus subcutaneous interferon beta-1a (SC IFNB-1a) in relapsing-remitting multiple sclerosis patients. Here, we present the final 6-year CARE-MS extension trial results (CAMMS03409), and compare outcomes over 6 years in patients randomized to both treatment groups at core study baseline. METHODS Over a 4-year extension, alemtuzumab patients (alemtuzumab-only) received as-needed additional alemtuzumab (⩾12 months apart) for disease activity after course 2. SC IFNB-1a patients who entered the extension discontinued SC IFNB-1a and received 2 alemtuzumab 12 mg courses (IFN-alemtuzumab), followed by additional, as-needed, alemtuzumab. RESULTS Through year 6, 63% of CARE-MS I and 50% of CARE-MS II alemtuzumab-only patients received neither additional alemtuzumab nor other disease-modifying therapy, with lasting suppression of disease activity, improved disability, and slowing of brain volume loss (BVL). In CARE-MS I patients (treatment-naive; less disability; shorter disease duration), disease activity and BVL were significantly reduced in IFN-alemtuzumab patients, similar to alemtuzumab-only patients at year 6. Among CARE-MS II patients (inadequate response to prior treatment; more disability; longer disease duration), alemtuzumab significantly improved clinical and magnetic resonance imaging outcomes, including BVL, in IFN-alemtuzumab patients; however, disability outcomes were less favorable versus alemtuzumab-only patients. Safety profiles, including infections and autoimmunities, following alemtuzumab were similar between treatment groups. CONCLUSION This study demonstrates the high efficacy of alemtuzumab over 6 years, with a similar safety profile between treatment groups. CLINICALTRIALSGOV IDENTIFIERS NCT00530348; NCT00548405; NCT00930553.
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Affiliation(s)
- Alasdair J. Coles
- Department of Clinical Neurosciences, University
of Cambridge, Box 165, Addenbrooke’s Hospital, Cambridge CB2 0QQ, UK
| | - Douglas L. Arnold
- NeuroRx Research, Montréal, Québec, Canada
- Department of Neurology and Neurosurgery,
Montréal Neurological Institute, McGill University, Montréal, Québec,
Canada
| | - Ann D. Bass
- Neurology Center of San Antonio, San Antonio,
TX, USA
| | | | | | - Óscar Fernández
- Instituto de Investigación Biomédica de Málaga
(IBIMA), Málaga, Spain
| | - Eva Kubala Havrdová
- Department of Neurology and Center for Clinical
Neuroscience, First Medical Faculty, Charles University, Prague, Czech
Republic
| | - Kunio Nakamura
- Department of Biomedical Engineering, Cleveland
Clinic, Cleveland, OH, USA
| | | | - Tjalf Ziemssen
- Center of Clinical Neuroscience, Carl Gustav
Carus University Hospital, Dresden, Germany
| | - Alan Jacobs
- Immunovant, Inc., New York, NY, USA
- Sanofi, Cambridge, MA, USA
| | | | - Xiaobi Huang
- Sanofi, Cambridge, MA, USA
- Biogen, Cambridge, MA, USA
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186
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Scotto R, Reia A, Buonomo AR, Moccia M, Viceconte G, Pisano E, Zappulo E, Brescia Morra V, Gentile I. Risk of invasive fungal infections among patients treated with disease modifying treatments for multiple sclerosis: a comprehensive review. Expert Opin Drug Saf 2021; 20:925-936. [PMID: 33880975 DOI: 10.1080/14740338.2021.1918673] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Disease modifying treatments are commonly used in the treatment of multiple sclerosis. As different opportunistic infections have been reported, concerns are also raised regarding the risk of invasive fungal infections.Areas covered: Both clinical trials and observational studies on safety and efficacy of diseases modifying treatment for multiple sclerosis were reviewed and data regarding the occurrence of invasive fungal infections were reported. Papers evaluating the following drugs were reviewed: rituximab, ocrelizumab, alemtuzumab, fingolimod, natalizumab, dimethyl fumarate, interferon, glatiramer acetate, cladribine, teriflunomide.Expert opinion: Overall, the occurrence of invasive fungal infections was low, with most infective events reported among patients treated with monoclonal antibodies and fingolimod. Aspergillosis and cryptococcal meningitidis were the most representative fungal infections. Although not common, these infections may be difficult to diagnose and their fatality rate is often high. For this reason, screening protocols for fungal infections must be implemented in the clinical practice when managing patients with MS.
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Affiliation(s)
- R Scotto
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - A Reia
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Centre, University of Naples Federico II, Italy
| | - A R Buonomo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - M Moccia
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Centre, University of Naples Federico II, Italy
| | - G Viceconte
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - E Pisano
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Centre, University of Naples Federico II, Italy
| | - E Zappulo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - V Brescia Morra
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Centre, University of Naples Federico II, Italy
| | - I Gentile
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
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187
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Liu Z, Liao Q, Wen H, Zhang Y. Disease modifying therapies in relapsing-remitting multiple sclerosis: A systematic review and network meta-analysis. Autoimmun Rev 2021; 20:102826. [PMID: 33878488 DOI: 10.1016/j.autrev.2021.102826] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 02/17/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To compare the efficacy and compliance of up-to-date disease modifying therapies (DMTs) in patients with remitting-relapsing MS (RRMS). METHODS We searched PubMed, EMBASE and Cochrane Library for eligible studies. Annualized relapse rate, discontinuation due to adverse events (AEs) were assessed as primary outcomes. Sensitivity analysis and inconsistency detection were performed to evaluated whether exclusion of high-risk studies affected the validity. Risk of bias was assessed using Cochrane's Risk-of-Bias Tool 2. Surface under the cumulative ranking curve (SUCRA) was used to estimate the rankings among different DMTs. RESULTS 21 studies were included for main report. Seven studies were evaluated as "high risk" and were therefore excluded. Exclusion of high-risk studies did not affect the validity of evidence. The risk of relapses for most DMTs except Betaseron 50 μg was significantly lower comparing to placebo. Incompliance in patients treated with DMTs was not significantly increased comparing to placebo. Dimethyl fumarate and ocrelizumab had superiority in improving MRI outcomes. Ocrelizumab and ofatumumab had the largest reduction of risk in disability progression at 3 months. Referring to SUCRA, ofatumumab, alemtuzumab and natalizumab showed the best efficacy and compliance. CONCLUSION The present study demonstrated the hierarchy of DMTs treating RRMS. Ofatumumab, alemtuzumab and natalizumab have superiority with respect to effectiveness and compliance. More studies are required to explore the long-term effect of DMTs. Our findings could provide helpful information and contribute to clinical treatment decision-making.
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Affiliation(s)
- Zhuoyi Liu
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Qiao Liao
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Haicheng Wen
- Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yihao Zhang
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China.
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188
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Valeria RC, Roberta L, Francesco S, Marcello M, Antonio C, Vincenzo BM. Pregnancy outcomes in alemtuzumab treated women with multiple sclerosis: a case series. Neurol Sci 2021; 42:3427-3430. [PMID: 33860394 DOI: 10.1007/s10072-020-04975-5] [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: 05/25/2020] [Accepted: 12/07/2020] [Indexed: 11/28/2022]
Abstract
Data on pregnancy outcome in alemtuzumab-treated women are scarce and derived from safety reports of clinical trials. We report on seven women with overall eight pregnancies during treatment with alemtuzumab in a real-world setting. All pregnancies occurred within 9 months after alemtuzumab treatment, and two of them within 4 months despite patients being informed on pregnancy prevention. We found one congenital cytomegalovirus infection, one spontaneous abortion, one elective abortion due to extrauterine pregnancy, and five live births without congenital abnormalities or birth defects.
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Affiliation(s)
- Russo Cinzia Valeria
- Department of Neurological Sciences, Reproductive and Odontostomatological Sciences, University Federico II, Naples, Italy.
| | - Lanzillo Roberta
- Department of Neurological Sciences, Reproductive and Odontostomatological Sciences, University Federico II, Naples, Italy
| | - Saccà Francesco
- Department of Neurological Sciences, Reproductive and Odontostomatological Sciences, University Federico II, Naples, Italy
| | - Moccia Marcello
- Department of Neurological Sciences, Reproductive and Odontostomatological Sciences, University Federico II, Naples, Italy
| | - Carotenuto Antonio
- Department of Neurological Sciences, Reproductive and Odontostomatological Sciences, University Federico II, Naples, Italy
| | - Brescia Morra Vincenzo
- Department of Neurological Sciences, Reproductive and Odontostomatological Sciences, University Federico II, Naples, Italy
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189
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Theodorsdottir A, Debrabant B, Magyari M, Kant M, Rasmussen PV, Malmberg CF, Norberg IA, Hansen V, Bech D, Schmidt MF, Schreiber K, Frederiksen JL, Sellebjerg F, Illes Z. Alemtuzumab treatment in Denmark: A national study based on the Danish Multiple Sclerosis Registry. Mult Scler 2021; 27:2254-2266. [PMID: 33779361 DOI: 10.1177/13524585211003291] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To investigate clinical outcomes in a real-world setting in the complete population-based cohort of alemtuzumab-treated MS patients in Denmark. METHODS Data were retrieved from The Danish Multiple Sclerosis Registry between 2009 and 2019. Demographic and disease-specific patient parameters related to treatment history, efficacy, and safety outcomes were assessed at baseline and during follow-up visits. RESULTS A total of 209 patients (78% female) started treatment with alemtuzumab during the study period with 3.1 ± 1.4 years follow-up. After 2 years, 75% of patients were relapse-free compared to 48% the year before alemtuzumab (p < 0.001). The annual number of relapses was reduced by 69% in year 4 compared with the year prior alemtuzumab. More active disease before alemtuzumab increased the annual hazard rate for relapse (HR: 2.88, p < 0.001). The Expanded Disability Status Scale (EDSS) score remained stable or improved in 81% of patients after 2 years. The need for an additional treatment course was associated with higher number of relapses in the year before alemtuzumab (odds ratio (OR) = 1.95, p = 0.001). CONCLUSION In a country with primarily escalation strategy, relapse rate reduction was maintained for 5 years, and EDSS stabilized/improved in majority of patients. Higher relapse rate 1 year before alemtuzumab increased the odds for additional courses. Novel serious AEs were not observed.
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Affiliation(s)
- Asta Theodorsdottir
- Department of Neurology, Odense University Hospital, Odense, Denmark/Department of Neurology, Hospital Lillebaelt, Kolding, Denmark/Institute of Clinical Research, University of Southern Denmark, Odense, Denmark/OPEN, Odense Patient Data Explorative Network, Odense University Hospital, Odense, Denmark
| | - Birgit Debrabant
- Department of Public Health, Epidemiology, Biostatistics & Biodemography, University of Southern Denmark, Odense, Denmark
| | - Melinda Magyari
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark/The Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark
| | - Matthias Kant
- Department of Neurology, Hospital of Southern Jutland, Sønderborg, Denmark
| | - Peter V Rasmussen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Iver A Norberg
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Victoria Hansen
- Department of Neurology, Aalborg University Hospital, Aalborg, Denmark
| | - Danny Bech
- Department of Neurology, Regional Hospital of Viborg, Viborg, Denmark
| | - Mathias F Schmidt
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark
| | - Karen Schreiber
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark
| | - Jette L Frederiksen
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark/The Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark
| | - Zsolt Illes
- Department of Neurology, Odense University Hospital, Odense, Denmark/Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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190
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Alonso-Moreno M, Ladrón-Guevara M, Ciudad-Gutiérrez P. Systematic review of gender bias in clinical trials of monoclonal antibodies for the treatment of multiple sclerosis. Neurologia 2021; 38:S0213-4853(21)00008-6. [PMID: 33775476 DOI: 10.1016/j.nrl.2021.01.003] [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: 10/21/2020] [Accepted: 01/01/2021] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION This article analyses the presence of gender bias in clinical trials of monoclonal antibodies used to treat multiple sclerosis. MATERIAL AND METHODS We performed a systematic review of controlled clinical trials of 4 monoclonal antibodies used to treat multiple sclerosis (natalizumab, rituximab, alemtuzumab, and ocrelizumab). We searched the PubMed/MEDLINE database for articles published in English before March 2020. The study was conducted in accordance with the relevant international recommendations. RESULTS The search identified 89 articles, 55 of which met the inclusion criteria. Of all patients included in these trials, 64.6% were women. The lead authors of 10 of the studies were women. Fifteen of the 55 studies included a sex-based analysis of the primary endpoint. Only 8 articles discussed the results separately for men and for women. CONCLUSIONS The clinical trials of these 4 monoclonal antibodies present a significant gender bias. In most cases, the primary and secondary endpoints are not analyzed according to patient sex, despite the fact that international recommendations include this as a minimum requirement for ensuring scientific validity and obtaining appropriate results for extrapolation to the wider population.
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Affiliation(s)
- M Alonso-Moreno
- Pharmacy Service, Hospital Universitario Virgen del Rocío, Avenue Manuel Siurot, 41013 Seville, Spain.
| | - M Ladrón-Guevara
- Pharmacy Service, Hospital Universitario Virgen del Rocío, Avenue Manuel Siurot, 41013 Seville, Spain
| | - P Ciudad-Gutiérrez
- Pharmacy Service, Hospital Universitario Virgen del Rocío, Avenue Manuel Siurot, 41013 Seville, Spain
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191
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Abstract
Herpesviruses such as herpes simplex virus (HSV) type 1 and 2, varicella-zoster virus (VZV), and cytomegalovirus (CMV) maintain lifelong latency in the host after primary infection and can reactivate periodically either as asymptomatic viral shedding or as clinical disease. Immunosuppression, including biologic therapy, may increase frequency and severity of herpesvirus reactivation and infection. Licensed biologics are reviewed regarding their risks of potentiating HSV, VZV, and CMV reactivation and infection. Approaches to prophylaxis against HSV, VZV, and CMV infection or reactivation are discussed.
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Affiliation(s)
- Dora Y Ho
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Lane Building L-135, Stanford, CA 94305-5107, USA.
| | - Kyle Enriquez
- Stanford University, 450 Serra Mall, Stanford, CA 94305, USA
| | - Ashrit Multani
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue CHS 37-121, Los Angeles, CA 90095-1688, USA
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192
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Brecl Jakob G, Barun B, Gomezelj S, Gabelić T, Šega Jazbec S, Adamec I, Horvat Ledinek A, Rot U, Krbot Skorić M, Habek M. Effectiveness and safety of alemtuzumab in the treatment of active relapsing-remitting multiple sclerosis: a multicenter, observational study. Neurol Sci 2021; 42:4591-4597. [PMID: 33660157 DOI: 10.1007/s10072-021-05145-x] [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: 11/09/2020] [Accepted: 02/22/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE So far, a limited number of real-world evidence studies about the effectiveness and safety of alemtuzumab (ALM) have been published, some of them with a relatively small number of included patients. We aimed to study the efficacy and safety of ALM in real-world clinical practice in two MS centers in Slovenia and Croatia. METHODS This was a retrospective chart review of 71 consecutive patients with relapsing-remitting MS who were treated with ALM from 2015 till 2018. The following data were collected: gender, age at disease onset, disease duration at ALM initiation, previous disease modifying therapy, number of relapses, active MRI lesions, and EDSS in the year prior to ALM initiation and every year of follow-up. RESULTS All patients completed the standard dosing schedule and were followed for a mean time of 3.2±1.1 years after the initiation of treatment. Complete data for the 2 years after treatment (relapses, EDSS, and MRI) were available for 48 patients, of which 14 (29.2%) achieved NEDA. Clinical NEDA was achieved in 38 out of 63 participants (60.3%). In year 1, 24 out of 57 (42.1%) patients achieved NEDA. In year 2, 26 out of 41 (63.4%) patients achieved NEDA. Lower EDSS prior to starting ALM was the only independent predictor of NEDA in a multivariable model. Adverse events occurred in 58 participants (84.1%), with no new safety signals identified. CONCLUSION According to the data from our cohort of early active RRMS patients we conclude ALM efficacy remains high in the real-world clinical practice.
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Affiliation(s)
- Gregor Brecl Jakob
- Department of Neurology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Barbara Barun
- Department of Neurology, University Hospital Center Zagreb, Kišpatićeva 12, HR-10000, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Sarah Gomezelj
- Department of Neurology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Tereza Gabelić
- Department of Neurology, University Hospital Center Zagreb, Kišpatićeva 12, HR-10000, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Saša Šega Jazbec
- Department of Neurology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Ivan Adamec
- Department of Neurology, University Hospital Center Zagreb, Kišpatićeva 12, HR-10000, Zagreb, Croatia
| | | | - Uroš Rot
- Department of Neurology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Magdalena Krbot Skorić
- Department of Neurology, University Hospital Center Zagreb, Kišpatićeva 12, HR-10000, Zagreb, Croatia.,Faculty of Electrical Engineering and Computing, University of Zagreb, Zagreb, Croatia
| | - Mario Habek
- Department of Neurology, University Hospital Center Zagreb, Kišpatićeva 12, HR-10000, Zagreb, Croatia. .,School of Medicine, University of Zagreb, Zagreb, Croatia.
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193
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Abstract
IMPORTANCE Multiple sclerosis (MS) is an autoimmune-mediated neurodegenerative disease of the central nervous system characterized by inflammatory demyelination with axonal transection. MS affects an estimated 900 000 people in the US. MS typically presents in young adults (mean age of onset, 20-30 years) and can lead to physical disability, cognitive impairment, and decreased quality of life. This review summarizes current evidence regarding diagnosis and treatment of MS. OBSERVATIONS MS typically presents in young adults aged 20 to 30 years with unilateral optic neuritis, partial myelitis, sensory disturbances, or brainstem syndromes such as internuclear ophthalmoplegia developing over several days. The prevalence of MS worldwide ranges from 5 to 300 per 100 000 people and increases at higher latitudes. Overall life expectancy is less than in the general population (75.9 vs 83.4 years), and MS more commonly affects women (female to male sex distribution of nearly 3:1). Diagnosis is made based on a combination of signs and symptoms, radiographic findings (eg, magnetic resonance imaging [MRI] T2 lesions), and laboratory findings (eg, cerebrospinal fluid-specific oligoclonal bands), which are components of the 2017 McDonald Criteria. Nine classes of disease-modifying therapies (DMTs), with varying mechanisms of action and routes of administration, are available for relapsing-remitting MS, defined as relapses at onset with stable neurologic disability between episodes, and secondary progressive MS with activity, defined as steadily increasing neurologic disability following a relapsing course with evidence of ongoing inflammatory activity. These drugs include interferons, glatiramer acetate, teriflunomide, sphingosine 1-phosphate receptor modulators, fumarates, cladribine, and 3 types of monoclonal antibodies. One additional DMT, ocrelizumab, is approved for primary progressive MS. These DMTs reduce clinical relapses and MRI lesions (new T2 lesions, gadolinium-enhancing lesions). Efficacy rates of current DMTs, defined by reduction in annualized relapse rates compared with placebo or active comparators, range from 29%-68%. Adverse effects include infections, bradycardia, heart blocks, macular edema, infusion reactions, injection-site reactions, and secondary autoimmune adverse effects, such as autoimmune thyroid disease. CONCLUSIONS AND RELEVANCE MS is characterized by physical disability, cognitive impairment, and other symptoms that affect quality of life. Treatment with DMT can reduce the annual relapse rate by 29% to 68% compared with placebo or active comparator.
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Affiliation(s)
| | | | - Alexander D Rae-Grant
- Cleveland Clinic Mellen Center, Cleveland, Ohio
- Now with Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
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194
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Samjoo IA, Worthington E, Drudge C, Zhao M, Cameron C, Häring DA, Stoneman D, Klotz L, Adlard N. Efficacy classification of modern therapies in multiple sclerosis. J Comp Eff Res 2021; 10:495-507. [PMID: 33620251 DOI: 10.2217/cer-2020-0267] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background: The Association of British Neurologists (ABN) 2015 guidelines suggested classifying multiple sclerosis therapies according to their average relapse reduction. We sought to classify newer therapies (cladribine, ocrelizumab, ofatumumab, ozanimod) based on these guidelines. Materials & methods: Therapies were classified by using direct comparative trial results as per ABN guidelines and generating classification probabilities for each therapy based on comparisons versus placebo in a network meta-analysis for annualized relapse rate. Results: For both approaches, cladribine and ofatumumab were classified as high efficacy. Ocrelizumab and ozanimod (1.0 mg) were classified as moderate or high efficacy depending on the approach used. Conclusion: Cladribine and ofatumumab have an efficacy comparable with therapies classified in the ABN guidelines as high efficacy.
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Affiliation(s)
| | | | | | | | | | | | | | - Luisa Klotz
- Department of Neurology, University Hospital Münster, Westfälische-Wilhelms-University Münster, Münster, Germany
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195
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Remez L, Ganelin-Cohen E, Safina D, Hellmann MA, Lotan I, Bosak N, Buxbaum C, Vaknin A, Shifrin A, Rozenberg A. Alemtuzumab mediates the CD39 + T-regulatory cell response via CD23 + macrophages. Immunol Cell Biol 2021; 99:521-531. [PMID: 33306219 DOI: 10.1111/imcb.12431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 09/22/2020] [Accepted: 12/08/2020] [Indexed: 11/24/2022]
Abstract
Alemtuzumab (ALM) effectively prevents relapses of multiple sclerosis (MS). It causes lymphocyte depletion with subsequent enhancement of the T-regulatory cell population. Direct administration of ALM to T cells causes cytolysis. However, the T cells may be indirectly affected by monocyte-derived cells, which are resistant to ALM cytotoxicity. We aimed to examine whether ALM modulates monocytes and whether the crosstalk between monocytes and lymphocytes previously exposed to ALM would result in anti-inflammatory effects. The CD14+ monocytes of 10 healthy controls and 10 MS (treatment naive) patients were isolated from peripheral blood mononuclear cells (PBMCs), exposed to ALM and reintroduced to PBMCs depleted of CD14+ cells. The macrophage profile was assessed and T-cell markers were measured. ALM promoted M2 anti-inflammatory phenotype as noted by an increased percentage in the populations of CD23+ , CD83+ and CD163+ cells. The CD23+ cells were the most upregulated (7-fold, P = 0.0002), and the observed effect was higher in patients with MS than in healthy subjects. ALM-exposed macrophages increased the proportion of T-regulatory cells, without affecting the proportion of T-effector cells. Neutralizing the CD23+ monocytes with antibodies reversed the effect specifically on the CD4+ CD39+ T-regulatory cell subpopulation but not on the CD4+ CD25hi CD127lo FOXP3+ subpopulation. ALM induces the conversion of monocytes into anti-inflammatory macrophages, which in turn promotes T-regulatory cell enhancement, in a CD23-dependent manner. These findings suggest that the mechanism of action of ALM is relevant to aspects of MS pathogenesis.
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Affiliation(s)
- Lital Remez
- Neuroimmunology Laboratory, Department of Neurology, Rambam Health Care Campus, Haifa, Israel
| | - Esther Ganelin-Cohen
- Neuroimmunological Clinic, Institute of Pediatric Neurology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dina Safina
- Neuroimmunology Laboratory, Department of Neurology, Rambam Health Care Campus, Haifa, Israel
| | - Mark A Hellmann
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Neurology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Itay Lotan
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Neurology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Noam Bosak
- Department of Neurology, Rambam Health Care Campus, Haifa, Israel
| | - Chen Buxbaum
- Department of Neurology, Rambam Health Care Campus, Haifa, Israel
| | - Adi Vaknin
- Unit for Neuro-Immunology, Multiple Sclerosis & Cell Therapy, Department of Neurology, Hadassah Medical Center, Jerusalem, Israel
| | - Alla Shifrin
- Department of Neurology, Rambam Health Care Campus, Haifa, Israel
| | - Ayal Rozenberg
- Neuroimmunology Laboratory, Department of Neurology, Rambam Health Care Campus, Haifa, Israel.,Department of Neurology, Rambam Health Care Campus, Haifa, Israel
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196
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Nosher S, Fuad S, Mishra N, Alrashid ZA, Rathod B, Mohan D, Basavanagowda DM, Kaur A, Heindl SE. Role of Monoclonal Antibody "Alemtuzumab" in the Treatment of Multiple Sclerosis. Cureus 2021; 13:e13246. [PMID: 33728194 PMCID: PMC7948316 DOI: 10.7759/cureus.13246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/08/2021] [Indexed: 11/30/2022] Open
Abstract
This article will review current treatment options for multiple sclerosis (MS) while keeping our primary focus on alemtuzumab, as it is now approved in more than 65 countries. From a pathophysiological point of view, MS is a disabling disease impacting a patient's life both physically and mentally, leading to devastating social and economic impact. This review will elaborate on alemtuzumab's role in treating relapsing-remitting MS (RRMS) by comparing its efficacy, side effects, and monitoring with other disease-modifying therapies (DMTs) available in the market. It is a point of great concern not only for physicians but also for neurologists, nephrologists, endocrinologists, dermatologists, and oncologists when encountering long-term effects of alemtuzumab in the life of treated MS patients. We hope that our review will not only benefit treating faculties but also those who are suffering from this devastating disease.
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Affiliation(s)
- Sadia Nosher
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sehrish Fuad
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Nupur Mishra
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Zaid A Alrashid
- Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- School of Medicine, Spartan Health Sciences University, Vieux Fort, LCA
| | - Bindu Rathod
- Psychiatry and Behavioral Sciences, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Devyani Mohan
- Surgery, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Deepak M Basavanagowda
- Psychiatry and Behavioral Sciences, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Arveen Kaur
- Psychiatry and Behavioral Sciences, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Stacey E Heindl
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Medicine, Avalon University School of Medicine, Willemstad, CUW
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197
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Hernandez L, O'Donnell M, Postma M. Predictors of Health Utility in Relapsing-Remitting and Secondary-Progressive Multiple Sclerosis: Implications for Future Economic Models of Disease-Modifying Therapies. PHARMACOECONOMICS 2021; 39:243-256. [PMID: 32989685 PMCID: PMC7867536 DOI: 10.1007/s40273-020-00964-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/16/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Decision-analytic models used in economic evaluations of disease-modifying therapies for relapsing-remitting multiple sclerosis (RRMS) have characterized disease progression and accrue quality-adjusted life-years from utility values based on the Expanded Disability Status Scale (EDSS), the occurrence of relapses, and progression to secondary-progressive multiple sclerosis (SPMS). The EDSS, used to characterize disability progression, has several limitations. If the EDSS is the only disability measure used in economic evaluations, the long-term clinical and economic implications of disease-modifying therapies may not be properly assessed. OBJECTIVE The objective of this study was to explore if supplementary disability measures including the Timed 25-Foot Walk (T25FW), 9-Hole Peg Test (9HPT), and Paced Auditory Serial Addition Test (PASAT) significantly contribute additional information on health utility in RRMS and SPMS otherwise not captured by the EDSS and relapses and, therefore, should be considered in future economic evaluations of disease-modifying therapies. METHODS Short-Form Six-Dimension utility scores were derived from the RAND 36-Item Health Survey 1.0 individual-level data available in the Multiple Sclerosis Outcome Assessment Consortium (MSOAC) Placebo Database. Repeated-measures mixed-effects models were conducted to estimate the effects of EDSS, T25FW, 9HPT (dominant and non-dominant hand), PASAT, and relapses on changes in utility over time, controlling for demographics. RESULTS A higher level of EDSS, longer time to complete the T25FW test, and a recent relapse were significant predictors of lower utility in people with RRMS and SPMS. 9HPT and PASAT were not significant predictors. CONCLUSIONS This study suggests that in addition to EDSS and recent relapses, T25FW significantly predicts utility in RRMS and SPMS. These findings support the use of T25FW to supplement the EDSS and the occurrence of relapses to characterize the course of disease progression and to more accurately accrue quality-adjusted life-years in future economic evaluations of disease-modifying therapies for the treatment of RRMS.
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Affiliation(s)
- Luis Hernandez
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | | | - Maarten Postma
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Unit of Pharmacotherapy, Epidemiology and Economics, University of Groningen, Groningen Research Institute of Pharmacy, Groningen, The Netherlands
- Department of Economics, Econometrics and Finance, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
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198
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Zhukovsky C, Sandgren S, Silfverberg T, Einarsdottir S, Tolf A, Landtblom AM, Novakova L, Axelsson M, Malmestrom C, Cherif H, Carlson K, Lycke J, Burman J. Autologous haematopoietic stem cell transplantation compared with alemtuzumab for relapsing-remitting multiple sclerosis: an observational study. J Neurol Neurosurg Psychiatry 2021; 92:189-194. [PMID: 33106366 PMCID: PMC7841472 DOI: 10.1136/jnnp-2020-323992] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 09/02/2020] [Accepted: 09/06/2020] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To compare outcomes after treatment with autologous haematopoietic stem cell transplantation (AHSCT) and alemtuzumab (ALZ) in patients with relapsing-remitting multiple sclerosis. METHODS Patients treated with AHSCT (n=69) received a conditioning regimen of cyclophosphamide (200 mg/kg) and rabbit anti-thymocyte globulinerG (6.0 mg/kg). Patients treated with ALZ (n=75) received a dose of 60 mg over 5 days, a repeated dose of 36 mg over 3 days after 1 year and then as needed. Follow-up visits with assessment of the expanded disability status scale score, adverse events and MR investigations were made at least yearly. RESULTS The Kaplan-Meier estimates of the primary outcome measure 'no evidence of disease activity' was 88% for AHSCT and 37% for ALZ at 3 years, p<0.0001. The secondary endpoint of annualised relapse rate was 0.04 for AHSCT and 0.1 for ALZ, p=0.03. At last follow-up, the proportions of patients who improved, were stable or worsened were 57%/41%/1% (AHSCT) and 45%/43%/12% (ALZ), p=0.06 Adverse events grade three or higher were present in 48/69 patients treated with AHSCT and 0/75 treated with ALZ in the first 100 days after treatment initiation. The most common long-term adverse event was thyroid disease with Kaplan-Meier estimates at 3 years of 21% for AHSCT and 46% for ALZ, p=0.005. CONCLUSIONS In this observational cohort study, treatment with AHSCT was associated with a higher likelihood of maintaining 'no evidence of disease activity'. Adverse events were more frequent with AHSCT in the first 100 days, but thereafter more common in patients treated with ALZ.
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Affiliation(s)
| | - Sofia Sandgren
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Thomas Silfverberg
- Department of of Medical Sciences, Uppsala University, Uppsala, Sweden.,Center for Clinical Research Dalarna, Uppsala University, Uppsala, Sweden
| | - Sigrun Einarsdottir
- Department of Hematology and Coagulation, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Andreas Tolf
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | | | - Lenka Novakova
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Markus Axelsson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Clas Malmestrom
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Honar Cherif
- Department of of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Kristina Carlson
- Department of of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Jan Lycke
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Joachim Burman
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
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199
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Alping P, Burman J, Lycke J, Frisell T, Piehl F. Safety of Alemtuzumab and Autologous Hematopoietic Stem Cell Transplantation Compared to Noninduction Therapies for Multiple Sclerosis. Neurology 2021; 96:e1574-e1584. [PMID: 33514645 PMCID: PMC8032381 DOI: 10.1212/wnl.0000000000011545] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 12/07/2020] [Indexed: 11/15/2022] Open
Abstract
Objective To assess safety outcomes for the induction therapies alemtuzumab and autologous hematopoietic stem cell transplantation (AHSCT) compared to noninduction disease-modifying therapies. Methods We performed a population-based cohort study linking the Swedish Multiple Sclerosis Register to national health care registers. Alemtuzumab, AHSCT, and a matched reference group of noninduction therapies (natalizumab, dimethyl fumarate, rituximab, fingolimod) were included if started between 2008 and 2017. Main outcomes were death, thyroid disease, nonthyroid autoimmune disease, and infection. Results We identified 132 alemtuzumab-treated and 139 AHSCT-treated (68% high-dose cyclophosphamide and anti-thymocyte globulin [ATG], 32% BCNU, etoposide, cytosine-arabinoside, and melphalan/ATG) patients, together with 2,486 matched patients treated with noninduction therapies. Four patients in the alemtuzumab group died (incidence rate [IR] per 1,000 person-years 8.6, 95% confidence interval [CI] 2.3–22.0) compared to 1 patient in the AHSCT group (IR 1.7, 95% CI 0.0–9.6), and the mortality rate in the reference group was 0.7 (95% CI 0.3–1.3). Thyroid disease was most frequent in the alemtuzumab group (IR 109, 95% CI 75–154) but also occurred more often for AHSCT (IR 34, 95% CI 18–56) compared to the reference (IR 5.3 95% CI 3.9–7.1). The incidence of nonthyroid autoimmune disease was similar in all groups. IR for infection diagnosed ≥6 months from therapy initiation was 53 (95% CI 30–87) for alemtuzumab, 108 (95% CI 75–150) for AHSCT, and 51 (95% CI 46–57) for the reference. Conclusion We confirmed a high incidence of thyroid disease in alemtuzumab- and, to a smaller extent, AHSCT-treated patients and found a higher incidence of infection for AHSCT compared to both alemtuzumab and noninduction therapies. The incidence of nonthyroid autoimmune disease was low for both therapies. Classification of Evidence This study provides Class III evidence of an increased risk of thyroid disease with alemtuzumab and an increased risk of infection with AHSCT treatment.
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Affiliation(s)
- Peter Alping
- From the Department of Clinical Neuroscience (P.A., F.P.) and Clinical Epidemiology Division (P.A., T.F.), Department of Medicine Solna, Karolinska Institutet, Stockholm; Department of Neuroscience (J.B.), Uppsala University; Department of Clinical Neuroscience (J.L.), Institute of Neuroscience and Physiology, University of Gothenburg; and Academic Specialist Centre (F.P.), Stockholm Health Services, Sweden.
| | - Joachim Burman
- From the Department of Clinical Neuroscience (P.A., F.P.) and Clinical Epidemiology Division (P.A., T.F.), Department of Medicine Solna, Karolinska Institutet, Stockholm; Department of Neuroscience (J.B.), Uppsala University; Department of Clinical Neuroscience (J.L.), Institute of Neuroscience and Physiology, University of Gothenburg; and Academic Specialist Centre (F.P.), Stockholm Health Services, Sweden
| | - Jan Lycke
- From the Department of Clinical Neuroscience (P.A., F.P.) and Clinical Epidemiology Division (P.A., T.F.), Department of Medicine Solna, Karolinska Institutet, Stockholm; Department of Neuroscience (J.B.), Uppsala University; Department of Clinical Neuroscience (J.L.), Institute of Neuroscience and Physiology, University of Gothenburg; and Academic Specialist Centre (F.P.), Stockholm Health Services, Sweden
| | - Thomas Frisell
- From the Department of Clinical Neuroscience (P.A., F.P.) and Clinical Epidemiology Division (P.A., T.F.), Department of Medicine Solna, Karolinska Institutet, Stockholm; Department of Neuroscience (J.B.), Uppsala University; Department of Clinical Neuroscience (J.L.), Institute of Neuroscience and Physiology, University of Gothenburg; and Academic Specialist Centre (F.P.), Stockholm Health Services, Sweden
| | - Fredrik Piehl
- From the Department of Clinical Neuroscience (P.A., F.P.) and Clinical Epidemiology Division (P.A., T.F.), Department of Medicine Solna, Karolinska Institutet, Stockholm; Department of Neuroscience (J.B.), Uppsala University; Department of Clinical Neuroscience (J.L.), Institute of Neuroscience and Physiology, University of Gothenburg; and Academic Specialist Centre (F.P.), Stockholm Health Services, Sweden
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200
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Prevention and management of adverse effects of disease modifying treatments in multiple sclerosis. Curr Opin Neurol 2021; 33:286-294. [PMID: 32374570 DOI: 10.1097/wco.0000000000000824] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW To summarize the currently known side effects of the approved therapies of multiple sclerosis and to suggest monitoring procedures. RECENT FINDINGS The progress in the treatment of multiple sclerosis with new very effective therapies is accompanied by a number of side effects. Some of these have already been described in the approval studies, but some only after approval in a real world situation. The reason for this is the short duration of the clinical studies, the very heterogeneous patient profile in the real world setting with a number of comorbidities, pretherapies, and wider age range. The side effects may occur during application of therapies or afterwards during the course of the treatment. The side effects may range from mild infections, mild laboratory abnormalities, secondary autoimmune diseases to life-threatening side effects such as progressive multifocal leukoencephalopathy. SUMMARY It has to be pointed out that these side effects are not to be considered as final and neurologists should be vigilant against new unknown side effects. The doctor should be aware of these undesirable effects, should weigh the benefits of the therapies against the risks, but at the same time she/he should keep in mind that multiple sclerosis can be a very disabling disease if not treated properly.
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