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Pol S, Liang S, Schweser F, Dhanraj R, Schubart A, Preda M, Sveinsson M, Ramasamy DP, Dwyer MG, Weckbecker G, Zivadinov R. Subcutaneous anti-CD20 antibody treatment delays gray matter atrophy in human myelin oligodendrocyte glycoprotein-induced EAE mice. Exp Neurol 2020; 335:113488. [PMID: 32991933 DOI: 10.1016/j.expneurol.2020.113488] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/18/2020] [Accepted: 09/25/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND The human myelin oligodendrocyte glycoprotein-induced experimental autoimmune encephalomyelitis (huMOG-EAE) model, generates B-cell driven demyelination in mice, making it a suitable multiple sclerosis model to study B cell depletion. OBJECTIVES We investigated the effect of subcutaneous anti-CD20 antibody treatment on huMOG-EAE gray matter (GM) pathology. METHODS C57Bl/6, 8-week old mice were immunized with 200 huMOG1-125 and treated with 50 μg/mouse of anti-CD20 antibody (n = 16) or isotype control (n = 16). Serial brain volumetric 9.4 T MRI scans was performed at baseline, 1 and 5 wkPI. Disease severity was measured by clinical disability score (CDS) and performance on rotarod test. RESULTS Anti-CD20 antibody significantly reduced brain volume loss compared with the isotype control across all timepoints longitudinally in the basal ganglia (p = 0.01), isocortex (p = 0.025) and thalamus (p = 0.023). The CDS was reduced significantly with anti-CD20 antibody vs. the isotype control at 3 (p = 0.003) and 4 (p = 0.03) wkPI, while a trend was observed at 5 (p = 0.057) and 6 (p = 0.086) wkPI. Performance on rotarod was also improved significantly at 3 (p = 0.007) and 5 (p = 0.01) wkPI compared with the isotype control. At cellular level, anti-CD20 therapy suppressed the percentage of proliferative nuclear antigen positive microglia in huMOG-EAE isocortex (p = 0.016). Flow cytometry confirmed that anti-CD20 antibody strongly depleted the CD19-expressing B cell fraction in peripheral blood mononuclear cells, reducing it from 39.7% measured in isotype control to 1.59% in anti-CD20 treated mice (p < 0.001). CONCLUSIONS Anti-CD20 antibody treatment delayed brain tissue neurodegeneration in GM, and showed clinical benefit on measures of disease severity in huMOG-EAE mice.
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Affiliation(s)
- Suyog Pol
- 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
| | - Serena Liang
- 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
| | - Ferdinand Schweser
- 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, NY, USA
| | - Ravendra Dhanraj
- 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
| | - Anna Schubart
- Novartis Institutes of BioMedical Research, Department of Transplantation and Immunology, Novartis, Basel, Switzerland
| | - Marilena Preda
- 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
| | - Michele Sveinsson
- 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
| | - Deepa P Ramasamy
- 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
| | - Michael G Dwyer
- 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, NY, USA
| | - Gisbert Weckbecker
- Novartis Institutes of BioMedical Research, Department of Transplantation and Immunology, Novartis, Basel, Switzerland
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA; Center for Biomedical Imaging at Clinical Translational Science Institute, University at Buffalo, State University of New York, NY, USA.
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202
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Moiola L, Barcella V, Benatti S, Capobianco M, Capra R, Cinque P, Comi G, Fasolo MM, Franzetti F, Galli M, Gerevini S, Meroni L, Origoni M, Prosperini L, Puoti M, Scarpazza C, Tortorella C, Zaffaroni M, Riva A. The risk of infection in patients with multiple sclerosis treated with disease-modifying therapies: A Delphi consensus statement. Mult Scler 2020; 27:331-346. [PMID: 32940121 DOI: 10.1177/1352458520952311] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The risk of infection associated with immunomodulatory or immunosuppressive disease-modifying drugs (DMDs) in patients with multiple sclerosis (MS) has been increasingly addressed in recent scientific literature. A modified Delphi consensus process was conducted to develop clinically relevant, evidence-based recommendations to assist physicians with decision-making in relation to the risks of a wide range of infections associated with different DMDs in patients with MS. The current consensus statements, developed by a panel of experts (neurologists, infectious disease specialists, a gynaecologist and a neuroradiologist), address the risk of iatrogenic infections (opportunistic infections, including herpes and cryptococcal infections, candidiasis and listeria; progressive multifocal leukoencephalopathy; human papillomavirus and urinary tract infections; respiratory tract infections and tuberculosis; hepatitis and gastrointestinal infections) in patients with MS treated with different DMDs, as well as prevention strategies and surveillance strategies for the early identification of infections. In the discussion, more recent data emerged in the literature were taken into consideration. Recommended risk reduction and management strategies for infections include screening at diagnosis and before starting a new DMD, prophylaxis where appropriate, monitoring and early diagnosis.
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Affiliation(s)
- Lucia Moiola
- Multiple Sclerosis Center and Neurology Department, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Valeria Barcella
- Department of Neurology and Multiple Sclerosis Center, ASST 'Papa Giovanni XXIII', Bergamo, Italy
| | - Simone Benatti
- Department of Infectious Diseases, ASST 'Papa Giovanni XXIII', Bergamo, Italy
| | - Marco Capobianco
- SCDO Neurology and Regional Reference Multiple Sclerosis Center, A.O.U. San Luigi, Orbassano, Italy
| | - Ruggero Capra
- Multiple Sclerosis Center, Spedali Civili of Brescia, Montichiari, Italy
| | - Paola Cinque
- Division of Infectious Diseases, San Raffaele Scientific Institute, Milan, Italy
| | - Giancarlo Comi
- The Institute of Experimental Neurology and Multiple Sclerosis Center IRCCS, San Raffaele Hospital, Milan
| | - Maria Michela Fasolo
- Division of Infectious Diseases, Department of Infectious Diseases, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Fabio Franzetti
- Infectious Diseases Unit, Busto Arsizio Hospital, Busto Arsizio, Italy/Luigi Sacco University Hospital, III Division of Infectious Diseases, Milan and Infectious Diseases Unit, Busto Arsizio, Italy
| | - Massimo Galli
- III Division of Infectious Diseases, ASST Fatebenefratelli Sacco, Department of Biomedical and Clinical Sciences 'L.Sacco', University of Milan, Italy
| | - Simonetta Gerevini
- Division of Neuroradiology, IRCCS San Raffaele Scientific Institute, Milan, Italy/Neuroradiology Department, 'Papa Giovanni XXIII' Hospital, Bergamo, Italy
| | - Luca Meroni
- III Division of Infectious Diseases, ASST Fatebenefratelli Sacco, University of Milan, Italy
| | - Massimo Origoni
- Department of Gynecology and Obstetrics, Vita Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Luca Prosperini
- Department of Neuroscience, San Camillo-Forlanini Hospital, Rome, Italy
| | - Massimo Puoti
- SC Infectious Diseases ASST Niguarda Ca Grande Hospital, Milan, Italy
| | - Cristina Scarpazza
- Multiple Sclerosis Center, Spedali Civili of Brescia, Montichiari, Italy/Department of General Psychology, University of Padova, Padova, Italy
| | - Carla Tortorella
- Department of Neuroscience, San Camillo-Forlanini Hospital, Rome, Italy
| | - Mauro Zaffaroni
- Multiple Sclerosis Center, Hospital of Gallarate, ASST della Valle Olona, Gallarate, Italy
| | - Agostino Riva
- III Division of Infectious Diseases, ASST Fatebenefratelli Sacco, University of Milan, Milan, Italy
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203
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Bergman J, Burman J, Bergenheim T, Svenningsson A. Intrathecal treatment trial of rituximab in progressive MS: results after a 2-year extension. J Neurol 2020; 268:651-657. [PMID: 32901316 PMCID: PMC7880973 DOI: 10.1007/s00415-020-10210-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/31/2020] [Accepted: 09/02/2020] [Indexed: 10/29/2022]
Abstract
OBJECTIVES To evaluate the effect of intrathecally (IT) delivered rituximab as a therapeutic intervention for progressive multiple sclerosis (PMS) during a 3-year follow-up period. METHODS Participants of a 1-year open-label phase 1b study of IT delivered rituximab to patients with PMS were offered extended treatment with follow-up for an additional 2 years. During the extension phase, treatment with 25 mg rituximab was administered every 6 months via a subcutaneous Ommaya reservoir connected to the right frontal horn with a ventricular catheter. RESULTS Mild to moderate vertigo and nausea occurred in 4 out of 14 participants as temporary adverse events associated with IT rituximab infusion. During the entire 3-year period, two cases of low-virulent bacterial meningitis occurred, which were successfully treated. Walking speed deteriorated significantly during the study. CONCLUSIONS IT administration of rituximab via a ventricular catheter was well tolerated. Considering the meningitis cases, the risk of infection was not negligible. The continued loss of walking speed indicates that IT rituximab was not able to stop disease progression. CLASSIFICATION OF EVIDENCE This study provides class IV evidence that intraventricularly administered rituximab in progressive MS is associated with a risk for bacterial meningitis and does not halt disease progression. EU CLINICAL TRIAL REGISTER EudraCT; 2008-002626-11 and 2012-000721-53.
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Affiliation(s)
- Joakim Bergman
- Department of Clinical Science, Umeå University, Umeå, Sweden
| | - Joachim Burman
- Department of Neurosciences, Uppsala University, Uppsala, Sweden
| | | | - Anders Svenningsson
- Department of Clinical Science, Umeå University, Umeå, Sweden. .,Department of Clinical Sciences, Karolinska Institutet Danderyd Hospital, Danderyd Hospital, 182 88, Stockholm, Sweden.
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204
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Michel L, Grasmuck C, Charabati M, Lécuyer MA, Zandee S, Dhaeze T, Alvarez JI, Li R, Larouche S, Bourbonnière L, Moumdjian R, Bouthillier A, Lahav B, Duquette P, Bar-Or A, Gommerman JL, Peelen E, Prat A. Activated leukocyte cell adhesion molecule regulates B lymphocyte migration across central nervous system barriers. Sci Transl Med 2020; 11:11/518/eaaw0475. [PMID: 31723036 DOI: 10.1126/scitranslmed.aaw0475] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 07/10/2019] [Accepted: 10/21/2019] [Indexed: 12/19/2022]
Abstract
The presence of B lymphocyte-associated oligoclonal immunoglobulins in the cerebrospinal fluid is a classic hallmark of multiple sclerosis (MS). The clinical efficacy of anti-CD20 therapies supports a major role for B lymphocytes in MS development. Although activated oligoclonal populations of pathogenic B lymphocytes are able to traffic between the peripheral circulation and the central nervous system (CNS) in patients with MS, molecular players involved in this migration have not yet been elucidated. In this study, we demonstrated that activated leukocyte cell adhesion molecule (ALCAM/CD166) identifies subsets of proinflammatory B lymphocytes and drives their transmigration across different CNS barriers in mouse and human. We also showcased that blocking ALCAM alleviated disease severity in animals affected by a B cell-dependent form of experimental autoimmune encephalomyelitis. Last, we determined that the proportion of ALCAM+ B lymphocytes was increased in the peripheral blood and within brain lesions of patients with MS. Our findings indicate that restricting access to the CNS by targeting ALCAM on pathogenic B lymphocytes might represent a promising strategy for the development of next-generation B lymphocyte-targeting therapies for the treatment of MS.
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Affiliation(s)
- Laure Michel
- Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, QC Canada.,Neuroimmunology Unit, Centre de recherche du CHUM (CRCHUM), Montréal, QC H2X 0A9, Canada
| | - Camille Grasmuck
- Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, QC Canada.,Neuroimmunology Unit, Centre de recherche du CHUM (CRCHUM), Montréal, QC H2X 0A9, Canada
| | - Marc Charabati
- Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, QC Canada.,Neuroimmunology Unit, Centre de recherche du CHUM (CRCHUM), Montréal, QC H2X 0A9, Canada
| | - Marc-André Lécuyer
- Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, QC Canada.,Neuroimmunology Unit, Centre de recherche du CHUM (CRCHUM), Montréal, QC H2X 0A9, Canada
| | - Stephanie Zandee
- Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, QC Canada.,Neuroimmunology Unit, Centre de recherche du CHUM (CRCHUM), Montréal, QC H2X 0A9, Canada
| | - Tessa Dhaeze
- Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, QC Canada.,Neuroimmunology Unit, Centre de recherche du CHUM (CRCHUM), Montréal, QC H2X 0A9, Canada
| | - Jorge I Alvarez
- Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, QC Canada.,Neuroimmunology Unit, Centre de recherche du CHUM (CRCHUM), Montréal, QC H2X 0A9, Canada
| | - Rui Li
- Center for Neuroinflammation and Experimental Therapeutics and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Sandra Larouche
- Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, QC Canada.,Neuroimmunology Unit, Centre de recherche du CHUM (CRCHUM), Montréal, QC H2X 0A9, Canada
| | - Lyne Bourbonnière
- Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, QC Canada.,Neuroimmunology Unit, Centre de recherche du CHUM (CRCHUM), Montréal, QC H2X 0A9, Canada
| | | | | | - Boaz Lahav
- Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, QC Canada.,Neuroimmunology Unit, Centre de recherche du CHUM (CRCHUM), Montréal, QC H2X 0A9, Canada
| | - Pierre Duquette
- Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, QC Canada.,Neuroimmunology Unit, Centre de recherche du CHUM (CRCHUM), Montréal, QC H2X 0A9, Canada
| | - Amit Bar-Or
- Center for Neuroinflammation and Experimental Therapeutics and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | | | - Evelyn Peelen
- Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, QC Canada.,Neuroimmunology Unit, Centre de recherche du CHUM (CRCHUM), Montréal, QC H2X 0A9, Canada
| | - Alexandre Prat
- Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, QC Canada. .,Neuroimmunology Unit, Centre de recherche du CHUM (CRCHUM), Montréal, QC H2X 0A9, Canada
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205
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Disanto G, Ripellino P, Riccitelli GC, Sacco R, Scotti B, Fucili A, Pravatà E, Kuhle J, Gobbi C, Zecca C. De-escalating rituximab dose results in stability of clinical, radiological, and serum neurofilament levels in multiple sclerosis. Mult Scler 2020; 27:1230-1239. [PMID: 32840408 DOI: 10.1177/1352458520952036] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Phase II and observational studies support the use of rituximab in multiple sclerosis. Standard protocols are lacking, but studies suggest comparable efficacy between low- and high-dose regimens. OBJECTIVE To evaluate effectiveness and safety of de-escalating rituximab dose from 1000 to 500 mg/6 months in multiple sclerosis. METHODS Patients were switched from rituximab 1000 to 500 mg/6 months and prospectively followed for 12 months. Relapses, disability, occurrence of brain/spinal magnetic resonance imaging (MRI) lesions, serum neurofilament light chain (NfL), CD19+ B cell, and IgG concentrations were analyzed. RESULTS Fifty-nine patients were included (37 relapsing-remitting, 22 secondary progressive). No relapses occurred, with no difference in expanded disability status scale (EDSS) between baseline (4 (2.5-4.5) and 12 months (3.5 (2.5-5.5) p = 0.284). Overall, three new T2 lesions appeared during follow-up. NfL concentration was stable between baseline (7.9 (5.9-45.2) pg/mL) and 12 months (9.1 (5.9-21.3) pg/mL, p = 0.120). IgG concentrations decreased with greater rituximab load (coefficient = -0.439, p = 0.041). IgG deficient patients had greater risk of infections (OR = 6.27, 95% CI = 1.71-22.9, p = 0.005). CONCLUSION De-escalating rituximab dose from 1000 to 500 mg/6 months is safe, results in clinical and radiological stability, and does not affect serum NfL over 12 months. Rituximab load negatively influences IgG concentrations, and IgG deficient patients are at higher risk of infections.
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Affiliation(s)
- Giulio Disanto
- Multiple Sclerosis Center, Department of Neurology, Neurocenter of Southern Switzerland (NSI), Ospedale Civico, Lugano, Switzerland
| | - Paolo Ripellino
- Multiple Sclerosis Center, Department of Neurology, Neurocenter of Southern Switzerland (NSI), Ospedale Civico, Lugano, Switzerland
| | - Gianna C Riccitelli
- Multiple Sclerosis Center, Department of Neurology, Neurocenter of Southern Switzerland (NSI), Ospedale Civico, Lugano, Switzerland
| | - Rosaria Sacco
- Multiple Sclerosis Center, Department of Neurology, Neurocenter of Southern Switzerland (NSI), Ospedale Civico, Lugano, Switzerland
| | - Barbara Scotti
- Multiple Sclerosis Center, Department of Neurology, Neurocenter of Southern Switzerland (NSI), Ospedale Civico, Lugano, Switzerland
| | - Anita Fucili
- Multiple Sclerosis Center, Department of Neurology, Neurocenter of Southern Switzerland (NSI), Ospedale Civico, Lugano, Switzerland
| | - Emanuele Pravatà
- Department of Neuroradiology, Neurocenter of Southern Switzerland, Ospedale Civico, Lugano, Switzerland
| | - Jens Kuhle
- Neurology, Departments of Medicine, Clinical Research and Biomedicine, University Hospital and University of Basel, Basel, Switzerland
| | - Claudio Gobbi
- Multiple sclerosis Center, Department of Neurology, Neurocenter of Southern Switzerland (NSI), Ospedale Civico, Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Chiara Zecca
- Multiple sclerosis Center, Department of Neurology, Neurocenter of Southern Switzerland (NSI), Ospedale Civico, Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
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206
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Caldito NG, Shirani A, Salter A, Stuve O. Adverse event profile differences between rituximab and ocrelizumab: Findings from the FDA Adverse Event Reporting Database. Mult Scler 2020; 27:1066-1076. [PMID: 32820687 DOI: 10.1177/1352458520949986] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Rituximab and ocrelizumab are anti-CD20 monoclonal antibodies that have shown a marked reduction in multiple sclerosis (MS) inflammatory activity. However, their real-world safety profile has not been adequately compared. OBJECTIVE To investigate the adverse event (AE) profile of rituximab and ocrelizumab reported to the Food and Drug Administration Adverse Event Reporting System (FAERS) database. METHODS The FAERS database was filtered by indication (MS) and drug (rituximab or ocrelizumab). Disproportionality analyses including but not limited to reporting odds ratio (ROR) were conducted to identify drug-AE associations. A signal was detected if the lower limit of the 95% confidence interval of ROR (ROR025) exceeded 1. RESULTS There were 623 and 7948 reports for rituximab and ocrelizumab, respectively. The most frequent AEs with rituximab and ocrelizumab were infusion-related reaction (4.82%) and urinary tract infection (10.52%), respectively. The strongest drug-AE association for rituximab and ocrelizumab were ear pruritus (ROR025: 47.53) and oral herpes (ROR025: 38.99), respectively. Ocrelizumab was associated with an almost two times higher frequency of infections than rituximab (21.93% vs 11.05%, respectively). CONCLUSION This study revealed differences in reporting AEs between rituximab and ocrelizumab. Infections were reported more frequently with ocrelizumab. Although speculative, a potentially different or more extensive B-cell depletion by ocrelizumab might explain these findings. Additional pharmacovigilance studies need to be performed to better characterize differences in the AE profile in B-cell-depleting therapies.
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Affiliation(s)
- Natalia Gonzalez Caldito
- Department of Neurology & Neurotherapeutics, Immunology Graduate Program, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Afsaneh Shirani
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Amber Salter
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - Olaf Stuve
- Department of Neurology & Neurotherapeutics, Immunology Graduate Program, University of Texas Southwestern Medical Center, Dallas, TX, USA/Neurology Section, VA North Texas Health Care System, Dallas, TX, USA
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207
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Nayak S, Sechi E, Flanagan EP, Messina S, Kassa R, Kantarci O, Weinshenker BG, Keegan BM. Inflammatory activity following motor progression due to critical CNS demyelinating lesions. Mult Scler 2020; 27:1037-1045. [PMID: 32812487 DOI: 10.1177/1352458520948745] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND New inflammatory activity is of unclear frequency and clinical significance in progressive multiple sclerosis (MS); it is uncertain in patient cohorts with motor progression due to critical demyelinating lesions. OBJECTIVES The aim of this study is to determine the likelihood of central nervous system (CNS) inflammatory activity, assessed by new clinical relapses or active magnetic resonance imaging (MRI) lesions, following onset of motor progression due to critical demyelinating lesions. METHODS Patients with progressive upper motor neuron impairment for ⩾1 year attributable to critical demyelinating lesions with single CNS lesion (progressive solitary sclerosis (PSS)), 2 to 5 total CNS demyelinating lesions (progressive "pauci-sclerosis" (PPS)), or >5 CNS demyelinating lesions and progressive exclusively unilateral monoparesis or hemiparesis (PUHMS) were identified. Clinical data were reviewed for acute MS relapses, and subsequent MRI was reviewed for active T1-gadolinium-enhancing or T2-demyelinating lesions. RESULTS None of the 91 patients (22 PSS, 40 PPS, 29 PUHMS) identified experienced clinical relapses over a median clinical follow-up of 93 months (range: 12-518 months). Nine patients (10%) developed active lesions over median 84 months radiologic follow-up (range: 12-518 months). Active lesions occurred in 24% PUHMS, 5% PSS, and 3% PPS cohorts. CONCLUSION New inflammatory activity, defined by active lesions and clinical relapses following motor progression in patients with critical demyelinating lesions, is low. Disease-modifying therapies that reduce demyelinating relapses and active MRI lesions are of uncertain benefit in these cohorts.
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Affiliation(s)
- Shreya Nayak
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Elia Sechi
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Steven Messina
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Roman Kassa
- Department of Neurology, Mayo Clinic, Rochester, MN, USA/Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Orhun Kantarci
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - B Mark Keegan
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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208
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Rauer S, Hoshi MM, Pul R, Wahl M, Schwab M, Haas J, Ellrichmann G, Krumbholz M, Tackenberg B, Saum KU, Buck F, Leemhuis J, Kretschmann A, Aktas O. Ocrelizumab Treatment in Patients with Primary Progressive Multiple Sclerosis: Short-term Safety Results from a Compassionate Use Programme in Germany. Clin Neurol Neurosurg 2020; 197:106142. [PMID: 32920498 DOI: 10.1016/j.clineuro.2020.106142] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 06/26/2020] [Accepted: 08/05/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVES In January 2018, the European Union (EU) approved ocrelizumab in relapsing multiple sclerosis (RMS) and as the first disease-modifying therapy (DMT) for patients with primary progressive multiple sclerosis (PPMS) with efficacy proven in a phase 3 randomised controlled trial. Eleven months prior to the European regulatory approval, a compassionate use programme (CUP) made ocrelizumab available to 489 patients with PPMS in Germany, thereby for the first time providing a therapeutic option to patients with PPMS who could not participate in ocrelizumab studies. Here, we report real-world patient characteristics and short-term safety data of patients with PPMS treated with ocrelizumab in this CUP. PATIENTS AND METHODS This CUP was initiated in February 2017 - shortly before US Food and Drug administration approval in March 2017 - and ended in January 2018, following ocrelizumab approval in the EU. Adult patients (age ≥18 years) with PPMS who had a positive benefit/risk ratio according to the treating physician were eligible for inclusion at German treatment centres. The main exclusion criteria were current/recent treatment with other immune therapies and unresolved/chronic/active infections. Patients received methylprednisolone and an antihistamine before treatment with intravenous ocrelizumab in 6-month cycles. The first ocrelizumab dose was a 300 mg infusion followed by a second 300 mg infusion 2 weeks later; subsequent doses were delivered as a single 600 mg infusion. Adverse events were reported immediately. RESULTS Of 580 requests received from 104 centres, 525 patients met the eligibility criteria. Thirty-five patients did not participate due to withdrawal by the treating physician, and one due to death prior to treatment. A total of 489 patients received at least one 600 mg dose of ocrelizumab (administered as two 300 mg infusions) and 51 received a second dose. Due to termination of the CUP upon marketing authorisation, the maximum follow-up period was 12 months. Median patient age was 52 years (range: 24-73), and 49% were female. Previous immunomodulatory or immunosuppressive therapies had been received by 41% of patients, with the most commonly used being glucocorticoids, mitoxantrone, interferon-β and glatiramer acetate. Patients with a previous malignancy, serious disease or infection (42 patients, 9%) had recovered from this prior to the CUP. Nine serious adverse events and 70 non-serious adverse events were reported in 40 patients. Adverse event categories were generally consistent with the known safety profile of ocrelizumab; one patient had carry-over progressive multifocal leukoencephalopathy (PML) due to previous natalizumab treatment. CONCLUSION This CUP provides first real-world observations of ocrelizumab for the treatment of PPMS in a large patient cohort in Germany, supporting that ocrelizumab is generally well-tolerated in clinical practice. Physicians should be vigilant for early symptoms of PML, as to date, 9 PML cases that were all confounded have been reported in patients treated with ocrelizumab worldwide, with 8 carry-over cases from a prior DMT.
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Affiliation(s)
- Sebastian Rauer
- Klinik für Neurologie und Neurophysiologie, Universitätsklinikum Freiburg, Freiburg, Germany.
| | - Muna-Miriam Hoshi
- Neurologische Klinik, Technische Universität München, Munich, Germany.
| | - Refik Pul
- Klinik für Neurologie, Universitätsklinikum Essen, Essen, Germany.
| | - Mathias Wahl
- Zentrum der Neurologie und Neurochirugie, Universitätsklinikum Frankfurt, Frankfurt, Germany.
| | - Matthias Schwab
- Klinik für Neurologie, Universitätsklinikum Jena, Jena, Germany.
| | - Judith Haas
- Jüdisches Krankenhaus Berlin, Berlin, Germany.
| | | | - Markus Krumbholz
- Department of Neurology & Stroke and Hertie-Institute for Clinical Brain Research, Eberhard Karl University of Tübingen, Tübingen, Germany.
| | - Björn Tackenberg
- Zentrum für Neuroimmunologie, Universitätsklinikum Marburg, Marburg, Germany; F. Hoffmann-La Roche AG, Basel, Switzerland.
| | | | | | | | | | - Orhan Aktas
- Klinik für Neurologie, Medizinische Fakultät, Universitätsklinikum Düsseldorf, Düsseldorf, Germany.
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Vollmer BL, Wallach AI, Corboy JR, Dubovskaya K, Alvarez E, Kister I. Serious safety events in rituximab-treated multiple sclerosis and related disorders. Ann Clin Transl Neurol 2020; 7:1477-1487. [PMID: 32767531 PMCID: PMC7480911 DOI: 10.1002/acn3.51136] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 06/22/2020] [Accepted: 06/27/2020] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Studies investigating rates and risk factors for serious safety events (SSEs) during rituximab treatment of multiple sclerosis (MS), neuromyelitis optica spectrum disorders (NMOSD), and related disorders are limited. METHODS Rituximab-treated patients with MS, NMOSD, or related disorders at the Rocky Mountain and New York University MS Care Centers were included. The follow-up period was defined as the time from the initial dose of rituximab up to 12 months of last dose of rituximab or ocrelizumab (in patients who switched). Clinician-reported and laboratory data were retrospectively collected from electronic medical records. RESULTS One-thousand patients were included comprising 907 MS, 77 NMOSD, and 16 related disorders. Patients had a mean follow-up of 31.1 months and a mean cumulative rituximab dose of 4012 mg. Of the 169 patients who switched to ocrelizumab, the mean ocrelizumab dose was 1141 mg. Crude incidence rate per 1000 person-years (PY) for lymphopenia was 19.2, neutropenia 5.6, and hypogammaglobulinemia 17.8. Infections resulting in either hospitalization, IV antibiotics, or using antibiotics ≥14 days occurred at a rate of 38.6/1000 PY. Risk factors for infection were duration of therapy, male gender, increased disability, prior exposure to immunosuppression/chemotherapy, lymphopenia, and hypogammaglobulinemia. Particularly, wheelchair-bound patients had 8.56-fold increased odds of infections. Crude incidence rates of malignant cancer were 3.5, new autoimmune disease 2.3, thromboembolic event 3.1, and mortality of 5.4 per 1000 PY. INTERPRETATION Rates of SSEs in patients with MS, NMOSD, and related disorders were low. Through properly assessing risk:benefit of B-cell depleting therapy in neuroinflammatory disorders and continual monitoring, clinicians may decrease the risk of serious infections.
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Affiliation(s)
- Brandi L Vollmer
- Rocky Mountain Multiple Sclerosis Center, Department of Neurology, University of Colorado, Aurora, Colorado
| | - Asya I Wallach
- NYU Grossman School of Medicine, Department of Neurology, New York University School of Medicine, New York City, New York
| | - John R Corboy
- Rocky Mountain Multiple Sclerosis Center, Department of Neurology, University of Colorado, Aurora, Colorado
| | - Karolina Dubovskaya
- NYU Grossman School of Medicine, Department of Neurology, New York University School of Medicine, New York City, New York
| | - Enrique Alvarez
- Rocky Mountain Multiple Sclerosis Center, Department of Neurology, University of Colorado, Aurora, Colorado
| | - Ilya Kister
- NYU Grossman School of Medicine, Department of Neurology, New York University School of Medicine, New York City, New York
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Vollmer BL, Nair K, Sillau S, Corboy JR, Vollmer T, Alvarez E. Rituximab versus natalizumab, fingolimod, and dimethyl fumarate in multiple sclerosis treatment. Ann Clin Transl Neurol 2020; 7:1466-1476. [PMID: 32767538 PMCID: PMC7480919 DOI: 10.1002/acn3.51111] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/28/2020] [Accepted: 05/26/2020] [Indexed: 12/18/2022] Open
Abstract
Introduction Limited comparative effectiveness data for rituximab (RTX) versus natalizumab (NTZ), fingolimod (FTY), and dimethyl fumarate (DMF) for the treatment of multiple sclerosis (MS) exist. Methods Clinician‐reported data on patients prescribed RTX, NTZ, FTY, or DMF for the treatment of MS at the Rocky Mountain MS Center at the University of Colorado were retrospectively collected. Outcomes included a composite effectiveness measure consisting of clinical relapse, contrast‐enhancing lesions, and/or new T2 lesions, individual effectiveness outcomes, and discontinuation. Logistic regression was used on patients matched by propensity scores and using average treatment effect on treated doubly robust weighting estimator. Results A total of 182, 451, 271, and 342 patients initiated RTX, NTZ, FTY, and DMF and were followed for 2 years. Before and after adjustment, the odds of experiencing disease activity was significantly higher for FTY [adjusted OR (aOR) = 3.17 (95% CI: 1.81–5.55), P < 0.001].and DMF [aOR = 2.68 (95% CI:1.67–4.29), P < 0.001], and similar for NTZ [aOR = 1.36 (95% CI:0.83–2.23), P = 0.216] versus RTX. When examining months 6–24, NTZ demonstrated higher odds of disease activity compared to RTX [aOR = 2.21 (95% CI: 1.20–4.06), P = 0.007]. Similar odds of discontinuation were seen between NTZ and RTX [aOR = 1.39 (95% CI: 0.88–2.20), P = 0.157]; however, FTY [aOR = 2.02 (95% CI: 1.24–3.30), P = 0.005] and DMF [aOR = 3.27 (95% CI: 2.15–4.97), P < 0.001] had greater odds of discontinuation than RTX. Interpretation RTX demonstrated superior effectiveness and discontinuation outcomes compared to FTY and DMF. Although RTX demonstrated similar effectiveness and discontinuation compared to NTZ, RTX had superior effectiveness during months 6–24 and fewer discontinuations when excluding discontinuations due to insurance issues. Results suggest superiority of RTX in reducing disease activity and maintaining long‐term treatment in a real‐world MS cohort.
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Affiliation(s)
- Brandi L Vollmer
- Rocky Mountain Multiple Sclerosis Center at Anschutz Medical Campus, University of Colorado, Denver, Colorado
| | - Kavita Nair
- Rocky Mountain Multiple Sclerosis Center at Anschutz Medical Campus, University of Colorado, Denver, Colorado.,Skagg's School of Pharmacy and Pharmaceutical Sciences at Anschutz Medical Campus, University of Colorado, Denver, Colorado
| | - Stefan Sillau
- Rocky Mountain Multiple Sclerosis Center at Anschutz Medical Campus, University of Colorado, Denver, Colorado
| | - John R Corboy
- Rocky Mountain Multiple Sclerosis Center at Anschutz Medical Campus, University of Colorado, Denver, Colorado
| | - Timothy Vollmer
- Rocky Mountain Multiple Sclerosis Center at Anschutz Medical Campus, University of Colorado, Denver, Colorado
| | - Enrique Alvarez
- Rocky Mountain Multiple Sclerosis Center at Anschutz Medical Campus, University of Colorado, Denver, Colorado
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Prockl V, Nickel FT, Utz KS, Fröhlich K, Engelhorn T, Hilz MJ, Lee DH, Linker RA, Huhn K. Real world application of ocrelizumab in multiple sclerosis: Single-center experience of 128 patients. J Neurol Sci 2020; 415:116973. [DOI: 10.1016/j.jns.2020.116973] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/11/2020] [Accepted: 06/01/2020] [Indexed: 02/07/2023]
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Sorensen PS, Sellebjerg F, Hartung HP, Montalban X, Comi G, Tintoré M. The apparently milder course of multiple sclerosis: changes in the diagnostic criteria, therapy and natural history. Brain 2020; 143:2637-2652. [DOI: 10.1093/brain/awaa145] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/28/2020] [Accepted: 03/14/2020] [Indexed: 02/06/2023] Open
Abstract
Abstract
In the past decade, changes have occurred in the spectrum of multiple sclerosis courses. The natural history of multiple sclerosis appears milder from the first sign of demyelinating disease to the progressive course, probably as a result of an interplay between several factors including changes in the diagnostic criteria, changes in the epidemiology of multiple sclerosis, impact of early and appropriate disease-modifying treatment and improvement of the general state of health in the population. It has been suggested to regard incidental findings of demyelinating lesions in MRI in individuals without any history of clinical symptoms consistent with neurological dysfunction, so-called radiological isolated syndrome, as the initial course of multiple sclerosis. New diagnostic criteria have enabled the multiple sclerosis diagnosis in many patients at the first clinical demyelinating event, clinically isolated syndrome. The remaining patients with clinically isolated syndrome have a more benign prognosis, and for relapsing-remitting multiple sclerosis, the prognosis has become more favourable. Reduced disease activity in patients with relapsing-remitting multiple sclerosis can partly be ascribed to more efficacious new disease-modifying therapies but decrease in disease activity has also be seen in placebo-treated patients in clinical trials. This may be explained by several factors: change in the diagnostic criteria, more explicit inclusion criteria, exclusion of high-risk patients e.g. patients with co-morbidities, and more rigorous definitions of relapses and disease worsening. However, these factors also make the disease course in patients treated with disease-modifying therapies seem more favourable. In addition, change in the therapeutic target to stable disease (no evidence of disease activity = no relapses, no disease worsening and no MRI activity) could by itself change the course in relapsing-remitting multiple sclerosis. The effectiveness of disease-modifying drugs has reduced the transition from relapsing-remitting to secondary progressive multiple sclerosis. The concept of progressive multiple sclerosis has also evolved from two very distinct categories (primary progressive and secondary progressive multiple sclerosis) to a unified category of progressive multiple sclerosis, which can then be split into the categories of active or inactive. Also, an increasing tendency to treat progressive multiple sclerosis with disease-modifying therapies may have contributed to change the course in progressive multiple sclerosis. In conclusion, during the past decade the entire course of multiple sclerosis from the first sign of a demyelinating disorder through the progressive course appears to be milder due to a complex interplay of several factors.
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Affiliation(s)
- Per Soelberg Sorensen
- Danish Multiple Sclerosis Center, Department of Neurology, University of Copenhagen and Rigshospitalet, Copenhagen, Denmark
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, Department of Neurology, University of Copenhagen and Rigshospitalet, Copenhagen, Denmark
| | - Hans-Peter Hartung
- Department of Neurology, University Hospital, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Xavier Montalban
- Department of Neurology, Hospital General Universitari Vall D’Hebron, Cemcat, Barcelona, Spain
- Division of Neurology, University of Toronto, St. Michael’s Hospital, Toronto, Canada
| | - Giancarlo Comi
- Department of Neurology and Institute of Experimental Neurology, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Mar Tintoré
- Department of Neurology, Hospital General Universitari Vall D’Hebron, Cemcat, Barcelona, Spain
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Giovannoni G, Knappertz V, Steinerman JR, Tansy AP, Li T, Krieger S, Uccelli A, Uitdehaag BMJ, Montalban X, Hartung HP, Pia Sormani M, Cree BAC, Lublin F, Barkhof F. A randomized, placebo-controlled, phase 2 trial of laquinimod in primary progressive multiple sclerosis. Neurology 2020; 95:e1027-e1040. [PMID: 32651286 DOI: 10.1212/wnl.0000000000010284] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 02/20/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To evaluate efficacy, safety, and tolerability of laquinimod in patients with primary progressive multiple sclerosis (PPMS). METHODS In the randomized, double-blind, placebo-controlled, phase 2 study, ARPEGGIO (A Randomized Placebo-controlled Trial Evaluating Laquinimod in PPMS, Gauging Gradations in MRI and Clinical Outcomes), eligible patients with PPMS were randomized 1:1:1 to receive once-daily oral laquinimod 0.6 mg or 1.5 mg or matching placebo. Percentage brain volume change (PBVC; primary endpoint) from baseline to week 48 was assessed by MRI. Secondary and exploratory endpoints included clinical and MRI measures. Efficacy endpoints were evaluated using a predefined, hierarchical statistical testing procedure. Safety was monitored throughout the study. The laquinimod 1.5 mg dose arm was discontinued on January 1, 2016, due to findings of cardiovascular events. RESULTS A total of 374 patients were randomized to laquinimod 0.6 mg (n = 139) or 1.5 mg (n = 95) or placebo (n = 140). ARPEGGIO did not meet the primary endpoint of significant treatment effect with laquinimod 0.6 mg vs placebo on PBVC from baseline to week 48 (adjusted mean difference = 0.016%, p = 0.903). Laquinimod 0.6 mg reduced the number of new T2 brain lesions at week 48 (risk ratio 0.4; 95% confidence interval, 0.26-0.69; p = 0.001). Incidence of adverse events was higher among patients treated with laquinimod 0.6 mg (83%) vs laquinimod 1.5 mg (66%) and placebo (78%). CONCLUSIONS Laquinimod 0.6 mg did not demonstrate a statistically significant effect on brain volume loss in PPMS at week 48. CLINICALTRIALSGOV IDENTIFIER NCT02284568. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that, although well tolerated, laquinimod 0.6 mg did not demonstrate a significant treatment effect on PBVC in patients with PPMS.
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Affiliation(s)
- Gavin Giovannoni
- From Barts and The London School of Medicine and Dentistry (G.G.), Blizard Institute, Queen Mary University of London, UK; Teva Pharmaceuticals R&D (V.K.), Teva Pharmaceutical Industries (T.L.), Great Valley, PA; Department of Neurology, Medical Faculty (V.K., H.-P.H.), Heinrich-Heine Universität Düsseldorf, Germany; Teva Pharmaceutical Industries (J.R.S., A.P.T.), Malvern, PA; Corinne Goldsmith Dickinson Center for Multiple Sclerosis (S.K.) and Neurology (F.L.), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Neuroscience, Rehabilitation, Ophthalmology, Genetics, and Maternal and Child Health and Center of Excellence for Biomedical Research (A.U.) and Department of Health Sciences (M.P.S.), University of Genoa; Ospedale Policlinico San Martino-IRCCS (A.U.), Genoa, Italy; Department of Neurology (B.M.J.U.), MS Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands; Division of Neurology (X.M.), University of Toronto/MS Centre St Michael's Hospital, Canada; Neurology-Neuroimmunology Department and Neurorehabilitation Unit (X.M.), Multiple Sclerosis Centre of Catalonia; Department of Neurology (X.M.), Hospital Universitari de la Vall d'Hebron, Barcelona, Spain; Weill Institute for Neurosciences (B.A.C.C.), Department of Neurology, University of California San Francisco; Radiology & Nuclear Medicine (F.L.), VU University Medical Center, Amsterdam, the Netherlands; and UCL Institutes of Neurology and Healthcare Engineering (F.B.), London, UK.
| | - Volker Knappertz
- From Barts and The London School of Medicine and Dentistry (G.G.), Blizard Institute, Queen Mary University of London, UK; Teva Pharmaceuticals R&D (V.K.), Teva Pharmaceutical Industries (T.L.), Great Valley, PA; Department of Neurology, Medical Faculty (V.K., H.-P.H.), Heinrich-Heine Universität Düsseldorf, Germany; Teva Pharmaceutical Industries (J.R.S., A.P.T.), Malvern, PA; Corinne Goldsmith Dickinson Center for Multiple Sclerosis (S.K.) and Neurology (F.L.), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Neuroscience, Rehabilitation, Ophthalmology, Genetics, and Maternal and Child Health and Center of Excellence for Biomedical Research (A.U.) and Department of Health Sciences (M.P.S.), University of Genoa; Ospedale Policlinico San Martino-IRCCS (A.U.), Genoa, Italy; Department of Neurology (B.M.J.U.), MS Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands; Division of Neurology (X.M.), University of Toronto/MS Centre St Michael's Hospital, Canada; Neurology-Neuroimmunology Department and Neurorehabilitation Unit (X.M.), Multiple Sclerosis Centre of Catalonia; Department of Neurology (X.M.), Hospital Universitari de la Vall d'Hebron, Barcelona, Spain; Weill Institute for Neurosciences (B.A.C.C.), Department of Neurology, University of California San Francisco; Radiology & Nuclear Medicine (F.L.), VU University Medical Center, Amsterdam, the Netherlands; and UCL Institutes of Neurology and Healthcare Engineering (F.B.), London, UK
| | - Joshua R Steinerman
- From Barts and The London School of Medicine and Dentistry (G.G.), Blizard Institute, Queen Mary University of London, UK; Teva Pharmaceuticals R&D (V.K.), Teva Pharmaceutical Industries (T.L.), Great Valley, PA; Department of Neurology, Medical Faculty (V.K., H.-P.H.), Heinrich-Heine Universität Düsseldorf, Germany; Teva Pharmaceutical Industries (J.R.S., A.P.T.), Malvern, PA; Corinne Goldsmith Dickinson Center for Multiple Sclerosis (S.K.) and Neurology (F.L.), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Neuroscience, Rehabilitation, Ophthalmology, Genetics, and Maternal and Child Health and Center of Excellence for Biomedical Research (A.U.) and Department of Health Sciences (M.P.S.), University of Genoa; Ospedale Policlinico San Martino-IRCCS (A.U.), Genoa, Italy; Department of Neurology (B.M.J.U.), MS Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands; Division of Neurology (X.M.), University of Toronto/MS Centre St Michael's Hospital, Canada; Neurology-Neuroimmunology Department and Neurorehabilitation Unit (X.M.), Multiple Sclerosis Centre of Catalonia; Department of Neurology (X.M.), Hospital Universitari de la Vall d'Hebron, Barcelona, Spain; Weill Institute for Neurosciences (B.A.C.C.), Department of Neurology, University of California San Francisco; Radiology & Nuclear Medicine (F.L.), VU University Medical Center, Amsterdam, the Netherlands; and UCL Institutes of Neurology and Healthcare Engineering (F.B.), London, UK
| | - Aaron P Tansy
- From Barts and The London School of Medicine and Dentistry (G.G.), Blizard Institute, Queen Mary University of London, UK; Teva Pharmaceuticals R&D (V.K.), Teva Pharmaceutical Industries (T.L.), Great Valley, PA; Department of Neurology, Medical Faculty (V.K., H.-P.H.), Heinrich-Heine Universität Düsseldorf, Germany; Teva Pharmaceutical Industries (J.R.S., A.P.T.), Malvern, PA; Corinne Goldsmith Dickinson Center for Multiple Sclerosis (S.K.) and Neurology (F.L.), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Neuroscience, Rehabilitation, Ophthalmology, Genetics, and Maternal and Child Health and Center of Excellence for Biomedical Research (A.U.) and Department of Health Sciences (M.P.S.), University of Genoa; Ospedale Policlinico San Martino-IRCCS (A.U.), Genoa, Italy; Department of Neurology (B.M.J.U.), MS Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands; Division of Neurology (X.M.), University of Toronto/MS Centre St Michael's Hospital, Canada; Neurology-Neuroimmunology Department and Neurorehabilitation Unit (X.M.), Multiple Sclerosis Centre of Catalonia; Department of Neurology (X.M.), Hospital Universitari de la Vall d'Hebron, Barcelona, Spain; Weill Institute for Neurosciences (B.A.C.C.), Department of Neurology, University of California San Francisco; Radiology & Nuclear Medicine (F.L.), VU University Medical Center, Amsterdam, the Netherlands; and UCL Institutes of Neurology and Healthcare Engineering (F.B.), London, UK
| | - Thomas Li
- From Barts and The London School of Medicine and Dentistry (G.G.), Blizard Institute, Queen Mary University of London, UK; Teva Pharmaceuticals R&D (V.K.), Teva Pharmaceutical Industries (T.L.), Great Valley, PA; Department of Neurology, Medical Faculty (V.K., H.-P.H.), Heinrich-Heine Universität Düsseldorf, Germany; Teva Pharmaceutical Industries (J.R.S., A.P.T.), Malvern, PA; Corinne Goldsmith Dickinson Center for Multiple Sclerosis (S.K.) and Neurology (F.L.), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Neuroscience, Rehabilitation, Ophthalmology, Genetics, and Maternal and Child Health and Center of Excellence for Biomedical Research (A.U.) and Department of Health Sciences (M.P.S.), University of Genoa; Ospedale Policlinico San Martino-IRCCS (A.U.), Genoa, Italy; Department of Neurology (B.M.J.U.), MS Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands; Division of Neurology (X.M.), University of Toronto/MS Centre St Michael's Hospital, Canada; Neurology-Neuroimmunology Department and Neurorehabilitation Unit (X.M.), Multiple Sclerosis Centre of Catalonia; Department of Neurology (X.M.), Hospital Universitari de la Vall d'Hebron, Barcelona, Spain; Weill Institute for Neurosciences (B.A.C.C.), Department of Neurology, University of California San Francisco; Radiology & Nuclear Medicine (F.L.), VU University Medical Center, Amsterdam, the Netherlands; and UCL Institutes of Neurology and Healthcare Engineering (F.B.), London, UK
| | - Stephen Krieger
- From Barts and The London School of Medicine and Dentistry (G.G.), Blizard Institute, Queen Mary University of London, UK; Teva Pharmaceuticals R&D (V.K.), Teva Pharmaceutical Industries (T.L.), Great Valley, PA; Department of Neurology, Medical Faculty (V.K., H.-P.H.), Heinrich-Heine Universität Düsseldorf, Germany; Teva Pharmaceutical Industries (J.R.S., A.P.T.), Malvern, PA; Corinne Goldsmith Dickinson Center for Multiple Sclerosis (S.K.) and Neurology (F.L.), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Neuroscience, Rehabilitation, Ophthalmology, Genetics, and Maternal and Child Health and Center of Excellence for Biomedical Research (A.U.) and Department of Health Sciences (M.P.S.), University of Genoa; Ospedale Policlinico San Martino-IRCCS (A.U.), Genoa, Italy; Department of Neurology (B.M.J.U.), MS Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands; Division of Neurology (X.M.), University of Toronto/MS Centre St Michael's Hospital, Canada; Neurology-Neuroimmunology Department and Neurorehabilitation Unit (X.M.), Multiple Sclerosis Centre of Catalonia; Department of Neurology (X.M.), Hospital Universitari de la Vall d'Hebron, Barcelona, Spain; Weill Institute for Neurosciences (B.A.C.C.), Department of Neurology, University of California San Francisco; Radiology & Nuclear Medicine (F.L.), VU University Medical Center, Amsterdam, the Netherlands; and UCL Institutes of Neurology and Healthcare Engineering (F.B.), London, UK
| | - Antonio Uccelli
- From Barts and The London School of Medicine and Dentistry (G.G.), Blizard Institute, Queen Mary University of London, UK; Teva Pharmaceuticals R&D (V.K.), Teva Pharmaceutical Industries (T.L.), Great Valley, PA; Department of Neurology, Medical Faculty (V.K., H.-P.H.), Heinrich-Heine Universität Düsseldorf, Germany; Teva Pharmaceutical Industries (J.R.S., A.P.T.), Malvern, PA; Corinne Goldsmith Dickinson Center for Multiple Sclerosis (S.K.) and Neurology (F.L.), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Neuroscience, Rehabilitation, Ophthalmology, Genetics, and Maternal and Child Health and Center of Excellence for Biomedical Research (A.U.) and Department of Health Sciences (M.P.S.), University of Genoa; Ospedale Policlinico San Martino-IRCCS (A.U.), Genoa, Italy; Department of Neurology (B.M.J.U.), MS Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands; Division of Neurology (X.M.), University of Toronto/MS Centre St Michael's Hospital, Canada; Neurology-Neuroimmunology Department and Neurorehabilitation Unit (X.M.), Multiple Sclerosis Centre of Catalonia; Department of Neurology (X.M.), Hospital Universitari de la Vall d'Hebron, Barcelona, Spain; Weill Institute for Neurosciences (B.A.C.C.), Department of Neurology, University of California San Francisco; Radiology & Nuclear Medicine (F.L.), VU University Medical Center, Amsterdam, the Netherlands; and UCL Institutes of Neurology and Healthcare Engineering (F.B.), London, UK
| | - Bernard M J Uitdehaag
- From Barts and The London School of Medicine and Dentistry (G.G.), Blizard Institute, Queen Mary University of London, UK; Teva Pharmaceuticals R&D (V.K.), Teva Pharmaceutical Industries (T.L.), Great Valley, PA; Department of Neurology, Medical Faculty (V.K., H.-P.H.), Heinrich-Heine Universität Düsseldorf, Germany; Teva Pharmaceutical Industries (J.R.S., A.P.T.), Malvern, PA; Corinne Goldsmith Dickinson Center for Multiple Sclerosis (S.K.) and Neurology (F.L.), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Neuroscience, Rehabilitation, Ophthalmology, Genetics, and Maternal and Child Health and Center of Excellence for Biomedical Research (A.U.) and Department of Health Sciences (M.P.S.), University of Genoa; Ospedale Policlinico San Martino-IRCCS (A.U.), Genoa, Italy; Department of Neurology (B.M.J.U.), MS Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands; Division of Neurology (X.M.), University of Toronto/MS Centre St Michael's Hospital, Canada; Neurology-Neuroimmunology Department and Neurorehabilitation Unit (X.M.), Multiple Sclerosis Centre of Catalonia; Department of Neurology (X.M.), Hospital Universitari de la Vall d'Hebron, Barcelona, Spain; Weill Institute for Neurosciences (B.A.C.C.), Department of Neurology, University of California San Francisco; Radiology & Nuclear Medicine (F.L.), VU University Medical Center, Amsterdam, the Netherlands; and UCL Institutes of Neurology and Healthcare Engineering (F.B.), London, UK
| | - Xavier Montalban
- From Barts and The London School of Medicine and Dentistry (G.G.), Blizard Institute, Queen Mary University of London, UK; Teva Pharmaceuticals R&D (V.K.), Teva Pharmaceutical Industries (T.L.), Great Valley, PA; Department of Neurology, Medical Faculty (V.K., H.-P.H.), Heinrich-Heine Universität Düsseldorf, Germany; Teva Pharmaceutical Industries (J.R.S., A.P.T.), Malvern, PA; Corinne Goldsmith Dickinson Center for Multiple Sclerosis (S.K.) and Neurology (F.L.), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Neuroscience, Rehabilitation, Ophthalmology, Genetics, and Maternal and Child Health and Center of Excellence for Biomedical Research (A.U.) and Department of Health Sciences (M.P.S.), University of Genoa; Ospedale Policlinico San Martino-IRCCS (A.U.), Genoa, Italy; Department of Neurology (B.M.J.U.), MS Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands; Division of Neurology (X.M.), University of Toronto/MS Centre St Michael's Hospital, Canada; Neurology-Neuroimmunology Department and Neurorehabilitation Unit (X.M.), Multiple Sclerosis Centre of Catalonia; Department of Neurology (X.M.), Hospital Universitari de la Vall d'Hebron, Barcelona, Spain; Weill Institute for Neurosciences (B.A.C.C.), Department of Neurology, University of California San Francisco; Radiology & Nuclear Medicine (F.L.), VU University Medical Center, Amsterdam, the Netherlands; and UCL Institutes of Neurology and Healthcare Engineering (F.B.), London, UK
| | - Hans-Peter Hartung
- From Barts and The London School of Medicine and Dentistry (G.G.), Blizard Institute, Queen Mary University of London, UK; Teva Pharmaceuticals R&D (V.K.), Teva Pharmaceutical Industries (T.L.), Great Valley, PA; Department of Neurology, Medical Faculty (V.K., H.-P.H.), Heinrich-Heine Universität Düsseldorf, Germany; Teva Pharmaceutical Industries (J.R.S., A.P.T.), Malvern, PA; Corinne Goldsmith Dickinson Center for Multiple Sclerosis (S.K.) and Neurology (F.L.), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Neuroscience, Rehabilitation, Ophthalmology, Genetics, and Maternal and Child Health and Center of Excellence for Biomedical Research (A.U.) and Department of Health Sciences (M.P.S.), University of Genoa; Ospedale Policlinico San Martino-IRCCS (A.U.), Genoa, Italy; Department of Neurology (B.M.J.U.), MS Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands; Division of Neurology (X.M.), University of Toronto/MS Centre St Michael's Hospital, Canada; Neurology-Neuroimmunology Department and Neurorehabilitation Unit (X.M.), Multiple Sclerosis Centre of Catalonia; Department of Neurology (X.M.), Hospital Universitari de la Vall d'Hebron, Barcelona, Spain; Weill Institute for Neurosciences (B.A.C.C.), Department of Neurology, University of California San Francisco; Radiology & Nuclear Medicine (F.L.), VU University Medical Center, Amsterdam, the Netherlands; and UCL Institutes of Neurology and Healthcare Engineering (F.B.), London, UK
| | - Maria Pia Sormani
- From Barts and The London School of Medicine and Dentistry (G.G.), Blizard Institute, Queen Mary University of London, UK; Teva Pharmaceuticals R&D (V.K.), Teva Pharmaceutical Industries (T.L.), Great Valley, PA; Department of Neurology, Medical Faculty (V.K., H.-P.H.), Heinrich-Heine Universität Düsseldorf, Germany; Teva Pharmaceutical Industries (J.R.S., A.P.T.), Malvern, PA; Corinne Goldsmith Dickinson Center for Multiple Sclerosis (S.K.) and Neurology (F.L.), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Neuroscience, Rehabilitation, Ophthalmology, Genetics, and Maternal and Child Health and Center of Excellence for Biomedical Research (A.U.) and Department of Health Sciences (M.P.S.), University of Genoa; Ospedale Policlinico San Martino-IRCCS (A.U.), Genoa, Italy; Department of Neurology (B.M.J.U.), MS Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands; Division of Neurology (X.M.), University of Toronto/MS Centre St Michael's Hospital, Canada; Neurology-Neuroimmunology Department and Neurorehabilitation Unit (X.M.), Multiple Sclerosis Centre of Catalonia; Department of Neurology (X.M.), Hospital Universitari de la Vall d'Hebron, Barcelona, Spain; Weill Institute for Neurosciences (B.A.C.C.), Department of Neurology, University of California San Francisco; Radiology & Nuclear Medicine (F.L.), VU University Medical Center, Amsterdam, the Netherlands; and UCL Institutes of Neurology and Healthcare Engineering (F.B.), London, UK
| | - Bruce A C Cree
- From Barts and The London School of Medicine and Dentistry (G.G.), Blizard Institute, Queen Mary University of London, UK; Teva Pharmaceuticals R&D (V.K.), Teva Pharmaceutical Industries (T.L.), Great Valley, PA; Department of Neurology, Medical Faculty (V.K., H.-P.H.), Heinrich-Heine Universität Düsseldorf, Germany; Teva Pharmaceutical Industries (J.R.S., A.P.T.), Malvern, PA; Corinne Goldsmith Dickinson Center for Multiple Sclerosis (S.K.) and Neurology (F.L.), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Neuroscience, Rehabilitation, Ophthalmology, Genetics, and Maternal and Child Health and Center of Excellence for Biomedical Research (A.U.) and Department of Health Sciences (M.P.S.), University of Genoa; Ospedale Policlinico San Martino-IRCCS (A.U.), Genoa, Italy; Department of Neurology (B.M.J.U.), MS Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands; Division of Neurology (X.M.), University of Toronto/MS Centre St Michael's Hospital, Canada; Neurology-Neuroimmunology Department and Neurorehabilitation Unit (X.M.), Multiple Sclerosis Centre of Catalonia; Department of Neurology (X.M.), Hospital Universitari de la Vall d'Hebron, Barcelona, Spain; Weill Institute for Neurosciences (B.A.C.C.), Department of Neurology, University of California San Francisco; Radiology & Nuclear Medicine (F.L.), VU University Medical Center, Amsterdam, the Netherlands; and UCL Institutes of Neurology and Healthcare Engineering (F.B.), London, UK
| | - Fred Lublin
- From Barts and The London School of Medicine and Dentistry (G.G.), Blizard Institute, Queen Mary University of London, UK; Teva Pharmaceuticals R&D (V.K.), Teva Pharmaceutical Industries (T.L.), Great Valley, PA; Department of Neurology, Medical Faculty (V.K., H.-P.H.), Heinrich-Heine Universität Düsseldorf, Germany; Teva Pharmaceutical Industries (J.R.S., A.P.T.), Malvern, PA; Corinne Goldsmith Dickinson Center for Multiple Sclerosis (S.K.) and Neurology (F.L.), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Neuroscience, Rehabilitation, Ophthalmology, Genetics, and Maternal and Child Health and Center of Excellence for Biomedical Research (A.U.) and Department of Health Sciences (M.P.S.), University of Genoa; Ospedale Policlinico San Martino-IRCCS (A.U.), Genoa, Italy; Department of Neurology (B.M.J.U.), MS Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands; Division of Neurology (X.M.), University of Toronto/MS Centre St Michael's Hospital, Canada; Neurology-Neuroimmunology Department and Neurorehabilitation Unit (X.M.), Multiple Sclerosis Centre of Catalonia; Department of Neurology (X.M.), Hospital Universitari de la Vall d'Hebron, Barcelona, Spain; Weill Institute for Neurosciences (B.A.C.C.), Department of Neurology, University of California San Francisco; Radiology & Nuclear Medicine (F.L.), VU University Medical Center, Amsterdam, the Netherlands; and UCL Institutes of Neurology and Healthcare Engineering (F.B.), London, UK
| | - Frederik Barkhof
- From Barts and The London School of Medicine and Dentistry (G.G.), Blizard Institute, Queen Mary University of London, UK; Teva Pharmaceuticals R&D (V.K.), Teva Pharmaceutical Industries (T.L.), Great Valley, PA; Department of Neurology, Medical Faculty (V.K., H.-P.H.), Heinrich-Heine Universität Düsseldorf, Germany; Teva Pharmaceutical Industries (J.R.S., A.P.T.), Malvern, PA; Corinne Goldsmith Dickinson Center for Multiple Sclerosis (S.K.) and Neurology (F.L.), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Neuroscience, Rehabilitation, Ophthalmology, Genetics, and Maternal and Child Health and Center of Excellence for Biomedical Research (A.U.) and Department of Health Sciences (M.P.S.), University of Genoa; Ospedale Policlinico San Martino-IRCCS (A.U.), Genoa, Italy; Department of Neurology (B.M.J.U.), MS Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands; Division of Neurology (X.M.), University of Toronto/MS Centre St Michael's Hospital, Canada; Neurology-Neuroimmunology Department and Neurorehabilitation Unit (X.M.), Multiple Sclerosis Centre of Catalonia; Department of Neurology (X.M.), Hospital Universitari de la Vall d'Hebron, Barcelona, Spain; Weill Institute for Neurosciences (B.A.C.C.), Department of Neurology, University of California San Francisco; Radiology & Nuclear Medicine (F.L.), VU University Medical Center, Amsterdam, the Netherlands; and UCL Institutes of Neurology and Healthcare Engineering (F.B.), London, UK
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214
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Autologous Haematopoietic Stem Cell Transplantation in Multiple Sclerosis: a Review of Current Literature and Future Directions for Transplant Haematologists and Oncologists. Curr Hematol Malig Rep 2020; 14:127-135. [PMID: 30828772 PMCID: PMC6510794 DOI: 10.1007/s11899-019-00505-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Purpose of Review We summarise the current development of autologous haematopoietic stem cell transplantation (AHSCT) in treating multiple sclerosis (MS) and discuss future directions for the general neurologist, transplant haematologist and oncologist. Recent Findings AHSCT was initially performed to treat MS over 20 years ago. Over recent years, the evidence base has grown, especially in relapsing-remitting MS (RRMS), with significant improvements in safety and efficacy through better patient selection, choice of transplant technique and increase in centre experience. Summary AHSCT is now a treatment option in very carefully selected patients with severe, treatment-resistant RRMS. However, it is important for transplant haematologists and oncologists to work closely with specialist MS neurologists in patient selection, during transplant and in long-term follow-up of patients. Data should be registered into international transplant registries and, ideally, patients should be enrolled on prospective clinical trials in order to build the evidence base and refine transplant techniques.
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215
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Delate T, Hansen ML, Gutierrez AC, Le KN. Indications for Rituximab Use in an Integrated Health Care Delivery System. J Manag Care Spec Pharm 2020; 26:832-838. [PMID: 32584674 PMCID: PMC10391100 DOI: 10.18553/jmcp.2020.26.7.832] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Rituximab is a top-selling biologic that was first approved by the FDA in 1997 for a non-Hodgkin lymphoma orphan indication. It has since been approved for additional orphan indications, with rheumatoid arthritis as the only FDA-approved, nonorphan indication. Evidence suggests that rituximab is frequently used off-label, but information on its use over time and indications for use in the United States is limited. OBJECTIVE To assess incident rituximab use over time in an integrated health care delivery system. METHODS This was a cross-sectional, retrospective study. Data were collected from administrative databases and manual chart reviews. Patients who received their first rituximab infusion between October 1, 2009, and December 31, 2017, and who were not a part of a clinical trial were included. Indication for use (FDA-approved orphan/nonorphan, off-label) was determined. Proportions of use were assessed over time. Multivariable logistic regression modeling was performed to assess factors associated with receiving rituximab for an FDA-approved indication. RESULTS A total of 1,674 patients were included. The majority (66.4%) of patients had an FDA-approved indication, with lymphoma being the most common approved indication (66.4%). The most common indication for off-label use was neurologic conditions (72.7%), predominantly demyelinating diseases. Off-label indication use increased from 1.2% in 2009 to 55.6% in 2017. Factors associated with rituximab use for an FDA-approved indication included increased age (adjusted odds ratio [AOR] = 1.05, 95% CI = 1.04-1.07) and increased burden of chronic disease (chronic disease score: AOR = 1.07, 95% CI = 1.02-1.12; Charlson Comorbidity Index score: AOR = 3.52, 95% CI = 3.03-4.10). CONCLUSIONS Off-label use of rituximab grew dramatically over the course of the study. With the recent FDA approval of the rituximab biosimilar and its expected lower price, off-label use will likely continue to rise. Opportunities for cost savings and to ensure appropriate use of these medications should be evaluated. DISCLOSURES This study was funded by Kaiser Permanente. All authors except Hansen are employed by Kaiser Permanente. Hansen has nothing to disclose. Preliminary results were presented at the Mountain States Conference for Residents and Preceptors in May 2019 in Salt Lake City, UT, and at an encore presentation October 2019 at the American College of Clinical Pharmacy Annual Meeting in New York, NY.
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Affiliation(s)
- Thomas Delate
- Drug Use Management, Kaiser Permanente National Pharmacy, Aurora, Colorado, and Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora
| | - Margaret L. Hansen
- Neurology Department, Wexner Medical Center, The Ohio State University, Columbus
| | | | - Kim N. Le
- Drug Use Management, Kaiser Permanente National Pharmacy, Downey, California
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216
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Ghezzi A, Banwell B, Bar-Or A, Chitnis T, Dale RC, Gorman M, Kornek B, Krupp L, Krysko KM, Nosadini M, Rostasy K, Salzer J, Schreiner T, Tenembaum S, Waubant E. Rituximab in patients with pediatric multiple sclerosis and other demyelinating disorders of the CNS: Practical considerations. Mult Scler 2020; 27:1814-1822. [PMID: 32552353 DOI: 10.1177/1352458520932798] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Anti-CD20 therapies have established efficacy in the treatment of immune-mediated neurological and non-neurological diseases. Rituximab, one of the first B-cell-directed therapies, is relatively inexpensive compared to newer anti-CD20 molecules, is available in many countries, and has been used off-label in pediatric patients with neuroimmune conditions. The objective of this paper is to describe the experience with rituximab in pediatric multiple sclerosis and other inflammatory immune-mediated disorders of the central nervous system (CNS), and to define a protocol for its use in clinical practice, in particular addressing doses, interval of administration, duration of treatment, and tests to perform at baseline and during follow-up.
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Affiliation(s)
- Angelo Ghezzi
- Centro Studi Sclerosi Multipla, Ospedale di Gallarate, ASST Valleolona, Gallarate, Italy
| | - Brenda Banwell
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Amit Bar-Or
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA/Center for Neuroinflammation and Experimental Therapeutics and the Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Tanuja Chitnis
- Partners Pediatric MS Center, Massachusetts General Hospital, Boston, MA, USA
| | - Russell C Dale
- Kids Neuroscience Centre and Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Mark Gorman
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Barbara Kornek
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Lauren Krupp
- Multiple Sclerosis Comprehensive Care Center, Department of Neurology, NYU Langone Health, New York, NY, USA
| | - Kristen M Krysko
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Margherita Nosadini
- Pediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Kevin Rostasy
- Department of Pediatric Neurology, Children's Hospital Datteln, University Witten/Herdecke, Witten, Germany
| | - Jonatan Salzer
- Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
| | - Teri Schreiner
- Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Silvia Tenembaum
- Pediatric Neuroimmunology Program, Department of Neurology, National Pediatric Hospital Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Emmanuelle Waubant
- UCSF Pediatric MS Clinic and UCSF Adult MS Clinic, Department of Neurology, University of California at San Francisco, San Francisco CA, USA
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217
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Abstract
Ocrelizumab ist ein monoklonaler Antikörper, der sich gegen das Differenzierungsantigen CD20 richtet und zu einer effektiven längerfristigen Depletion von Lymphozyten, insbesondere von B‑Zellen, führt. Unlängst publizierte Phase-3-Studien belegen, dass Ocrelizumab sowohl bei der Behandlung der schubförmigen als auch der primär progressiven Multiplen Sklerose (MS) wirksam ist. Darauf basierend wurde Ocrelizumab als erstes Medikament zur Behandlung der primär chronisch-progredienten MS zugelassen. Um diesen Durchbruch besser in den Kontext des heutigen MS-Therapiekanons einordnen zu können, lohnt sowohl ein Blick zurück auf die Entwicklung der antikörpervermittelten CD20-Depletion als auch auf die der Zulassung zugrunde liegenden Studien sowie deren Extensionsphasen. Diese Übersichtsarbeit diskutiert die verfügbaren Daten zur Wirksamkeit und Sicherheit der langfristigen B‑Zell-Depletion bei MS-Patienten und erörtert den aktuellen Kenntnisstand zur Rolle von B‑Lymphozyten in der Immunpathogenese der MS.
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218
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Auguste P, Colquitt J, Connock M, Loveman E, Court R, Ciccarelli O, Counsell C, Armoiry X. Ocrelizumab for Treating Patients with Primary Progressive Multiple Sclerosis: An Evidence Review Group Perspective of a NICE Single Technology Appraisal. PHARMACOECONOMICS 2020; 38:527-536. [PMID: 32048205 DOI: 10.1007/s40273-020-00889-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Ocrelizumab is indicated for relapsing remitting and primary progressive multiple sclerosis (RRMS and PPMS, respectively). In an appraisal undertaken by the National Institute for Health and Care Excellence (NICE), the company Roche presented the evidence for ocrelizumab used in patients with PPMS, which came from one single randomised controlled trial (RCT) comparing ocrelizumab versus placebo. Based on results from this trial, the licensed indication was restricted to patients with early PPMS in terms of disease duration and level of disability, and with imaging features characteristic of inflammatory activity. Overall, the Evidence Review Group (ERG) found that the RCT had a low risk of bias. In the post-hoc defined magnetic resonance imaging (MRI) active subgroup, matching the label indication, the risk of confirmed disability progression sustained for 12 weeks (CDP-12) was significantly delayed in the ocrelizumab group compared to placebo. However, considering the same risk with progression sustained for 24 weeks (CDP-24), which was deemed the most clinically relevant, the benefit from ocrelizumab did not reach statistical significance. In the same MRI active subgroup, benefits from ocrelizumab on functional outcomes and on health-related quality of life were not clearly demonstrated. A de novo Markov model was used to estimate the cost-effectiveness of ocrelizumab versus best supportive care (BSC) for treating patients with PPMS. Health states were defined by the Expanded Disability Status Scale (EDSS), ranging from 0 to 9. Disability progression was based on the MSBase natural history cohort that exhibited disease progression in the absence of disease-modifying therapy. Treatment with ocrelizumab delayed disability progression, with evidence of its clinical effectiveness obtained from the RCT. The economic analysis was undertaken from the National Health Service and Personal Social Services perspective, and the outcomes were reported in terms of life years gained and quality-adjusted life years (QALYs), with the overall results reported in terms of an incremental cost-effectiveness ratio (ICER), expressed as cost per QALY gained over a 50-year time horizon. Both costs and effects were discounted at 3.5% per annum. The company undertook deterministic one-way sensitivity analyses and scenario analyses, including probabilistic sensitivity analysis (PSA). The ERG raised several concerns, which were discussed at the appraisal committee meetings, resulting in the committee's preferences being applied and a revised economic analysis from the company. Under an approved patient access scheme with appraisal committee preferences applied, analyses yielded an ICER of approximately £78,300 per QALY. Sensitivity analysis results indicated that the treatment effect on CDP-12 had the greatest impact. Results for the PSA showed that at a willingness-to-pay threshold of £30,000 per QALY gained, ocrelizumab versus BSC had a zero probability of being cost-effective. Following new analyses submitted by the company, with a revised confidential patient access scheme, NICE recommended ocrelizumab in the treatment of early PPMS in adults with imaging features characteristic of inflammatory activity.
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Affiliation(s)
- Peter Auguste
- Warwick Evidence, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK.
| | | | - Martin Connock
- Warwick Evidence, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | | | - Rachel Court
- Warwick Evidence, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | - Olga Ciccarelli
- University College London (UCL) Queen Square Institute of Neurology, London, UK
| | - Carl Counsell
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Xavier Armoiry
- Warwick Evidence, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
- Pharmacy Department, Lyon University, Claude Bernard University Lyon (UMR CNRS MATEIS), School of Pharmacy (ISPB)/Edouard Herriot Hospital, 69008, Lyon, France
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219
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Hellgren J, Risedal A, Källén K. Rituximab in multiple sclerosis at general hospital level. Acta Neurol Scand 2020; 141:491-499. [PMID: 31990978 DOI: 10.1111/ane.13225] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 01/09/2020] [Accepted: 01/20/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The use of rituximab (RTX) in multiple sclerosis (MS) is a rapidly increasing choice of disease-modifying therapy. Efficacy outside specialized university hospital-based care is not yet systematically investigated. Our aim was to evaluate off-label RTX treatment for MS at a general hospital in Sweden. MATERIALS AND METHODS Subjects with definite MS with at least one rituximab infusion were eligible for inclusion in this retrospective, observational study. Effect was evaluated by monitoring clinical disability, annual relapse rate, new lesions on MRI, and safety by the incidence and severity of adverse events. RESULTS Among the 83 included subjects, 15 had clinical worsening of disease during the median 23.5 (1-76) months of follow-up after RTX initiation: 7/66 with relapsing-remitting multiple sclerosis (RRMS) and 8/17 with progressive subtypes (PMS). Cumulative survival without worsening was 86% in RRMS and 30% in PMS. The annual relapse rate before RTX vs follow-up dropped from 0.38 to 0.05 (P < .00001). Subjects with new enhancing lesions on MRI during the first year before RTX initiation vs the year after dropped from 0.94 to 0.024 (P < .00001) and was only seen in RRMS (1.05-0.31, P = .00003). Adverse events were mainly mild. Thirty-six out of 53 non-infusion-related adverse events were infections, of which four were serious, including a case of pneumonia with concomitant late-onset neutropenia. CONCLUSIONS Rituximab was as effective and safe when given at a general hospital outpatient clinic compared with results from previous university hospital-based studies. Vigilance is required concerning severe adverse events.
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Affiliation(s)
- Johan Hellgren
- Medical Faculty Department of Clinical Sciences Lund Lund University Lund Sweden
| | - Anette Risedal
- Medical Faculty Department of Clinical Sciences Lund Lund University Lund Sweden
- Department of Specialized Medicine Helsingborg General Hospital Helsingborg Sweden
| | - Kristina Källén
- Medical Faculty Department of Clinical Sciences Lund Lund University Lund Sweden
- Department of Specialized Medicine Helsingborg General Hospital Helsingborg Sweden
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220
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Miao Q, Zhang XX, Han QX, Ren SS, Sui RX, Yu JW, Wang J, Wang Q, Yu JZ, Cao L, Xiao W, Xiao BG, Ma CG. The therapeutic potential of bilobalide on experimental autoimmune encephalomyelitis (EAE) mice. Metab Brain Dis 2020; 35:793-807. [PMID: 32215835 DOI: 10.1007/s11011-020-00555-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 02/24/2020] [Indexed: 12/15/2022]
Abstract
Inflammatory demyelination in the central nervous system (CNS) is a hallmark of multiple sclerosis (MS) and its animal model, experimental autoimmune encephalomyelitis (EAE). Besides MS disease-modifying therapy, targeting myelin sheath protection/regeneration is currently a hot spot in the treatment of MS. Here, we attempt to explore the therapeutic potential of Bilobalide (BB) for the myelin protection/regeneration in EAE model. The results showed that BB treatment effectively prevented worsening and demyelination of EAE, accompanied by the inhibition of neuroinflammation that should be closely related to T cell tolerance and M2 macrophages/microglia polarization. BB treatment substantially inhibited the infiltration of T cells and macrophages, thereby alleviating the enlargement of neuroinflammation and the apoptosis of oligodendrocytes in CNS. The accurate mechanism of BB action and the feasibility of clinical application in the prevention and treatment of demyelination remain to be further explored.
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Affiliation(s)
- Qiang Miao
- The Key Research Laboratory of Benefiting Qi for Acting Blood Circulation Method to Treat Multiple Sclerosis of State Administration of Traditional Chinese Medicine, Shanxi University of Chinese Medicine, Taiyuan, 030024, China
| | - Xiao-Xue Zhang
- The Key Research Laboratory of Benefiting Qi for Acting Blood Circulation Method to Treat Multiple Sclerosis of State Administration of Traditional Chinese Medicine, Shanxi University of Chinese Medicine, Taiyuan, 030024, China
| | - Qing-Xian Han
- The Key Research Laboratory of Benefiting Qi for Acting Blood Circulation Method to Treat Multiple Sclerosis of State Administration of Traditional Chinese Medicine, Shanxi University of Chinese Medicine, Taiyuan, 030024, China
| | - Si-Si Ren
- The Key Research Laboratory of Benefiting Qi for Acting Blood Circulation Method to Treat Multiple Sclerosis of State Administration of Traditional Chinese Medicine, Shanxi University of Chinese Medicine, Taiyuan, 030024, China
| | - Ruo-Xuan Sui
- The Key Research Laboratory of Benefiting Qi for Acting Blood Circulation Method to Treat Multiple Sclerosis of State Administration of Traditional Chinese Medicine, Shanxi University of Chinese Medicine, Taiyuan, 030024, China
| | - Jing-Wen Yu
- Institute of Brain Science, Shanxi Key Laboratory of Inflammatory Neurodegenerative Disease, Shanxi Datong University, Datong, 037009, China
| | - Jing Wang
- The First Clinical College, Shanxi Medical University, Taiyuan, 030001, China
| | - Qing Wang
- The Key Research Laboratory of Benefiting Qi for Acting Blood Circulation Method to Treat Multiple Sclerosis of State Administration of Traditional Chinese Medicine, Shanxi University of Chinese Medicine, Taiyuan, 030024, China
| | - Jie-Zhong Yu
- Institute of Brain Science, Shanxi Key Laboratory of Inflammatory Neurodegenerative Disease, Shanxi Datong University, Datong, 037009, China
| | - Liang Cao
- Key Laboratory of New-tech for Chinese Medicine Pharmaceutical Process, Lianyungang, 222002, China
| | - Wei Xiao
- Key Laboratory of New-tech for Chinese Medicine Pharmaceutical Process, Lianyungang, 222002, China
| | - Bao-Guo Xiao
- Institute of Neurology, Huashan Hospital, Institutes of Brain Science and State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, 200025, China.
| | - Cun-Gen Ma
- The Key Research Laboratory of Benefiting Qi for Acting Blood Circulation Method to Treat Multiple Sclerosis of State Administration of Traditional Chinese Medicine, Shanxi University of Chinese Medicine, Taiyuan, 030024, China.
- Institute of Brain Science, Shanxi Key Laboratory of Inflammatory Neurodegenerative Disease, Shanxi Datong University, Datong, 037009, China.
- The First Clinical College, Shanxi Medical University, Taiyuan, 030001, China.
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221
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Dhenni R, Phan TG. The geography of memory B cell reactivation in vaccine-induced immunity and in autoimmune disease relapses. Immunol Rev 2020; 296:62-86. [PMID: 32472583 DOI: 10.1111/imr.12862] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/05/2020] [Accepted: 04/27/2020] [Indexed: 12/14/2022]
Abstract
Memory B cells (Bmem) provide an active second layer of defense against re-infection by pathogens that have bypassed the passive first layer provided by neutralizing antibodies. Here, we review recent progress in our understanding of Bmem heterogeneity in terms of their origin (germinal center-dependent vs center-independent), phenotype (canonical vs atypical vs age-associated B cells), trafficking (recirculating vs tissue-resident), and fate (plasma cell vs germinal center differentiation). The development of transgenic models and intravital imaging technologies has made it possible to track the cellular dynamics of Bmem reactivation by antigen, their interactions with follicular memory T cells, and differentiation into plasma cells in subcapsular proliferative foci in the lymph nodes of immune animals. Such in situ studies have reinforced the importance of geography in shaping the outcome of the secondary antibody response. We also review the evidence for Bmem reactivation and differentiation into short-lived plasma cells in the pathogenesis of disease flares in relapsing-remitting autoimmune diseases. Elucidating the mechanisms that control the Bmem fate decision to differentiate into plasma cells or germinal center B cells will aid future efforts to more precisely engineer fit-for-purpose vaccines as well as to treat antibody-mediated autoimmune diseases.
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Affiliation(s)
- Rama Dhenni
- Immunology Division, Garvan Institute of Medical Research, Sydney, NSW, Australia.,St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
| | - Tri Giang Phan
- Immunology Division, Garvan Institute of Medical Research, Sydney, NSW, Australia.,St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
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222
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Mathew T, John SK, Kamath V, Murgod U, Thomas K, Baptist AA, Therambil M, Shaji A, Nadig R, Badachi S, Souza DD, Shivde S, Avati A, Sarma GRK, Sharath Kumar GG, Deepalam S, Parry GJ. Efficacy and safety of rituximab in multiple sclerosis: Experience from a developing country. Mult Scler Relat Disord 2020; 43:102210. [PMID: 32485634 DOI: 10.1016/j.msard.2020.102210] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/09/2020] [Accepted: 05/17/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Rituximab is increasingly being used in treatment of multiple Sclerosis (MS) in our centers due to its easy availability, efficacy and favorable side effect profile. Here we describe experience with rituximab over a period of 4 years from three MS centers from south India. METHODS The data of MS patients who were treated with rituximab in three MS centers at Bangalore, India, from December 2015 to December 2019 were collected and evaluated with respect to relapse rate, EDSS score and adverse events. RESULTS Over the four-year study period 118 MS patients were evaluated, 80 of whom were on rituximab. 58 (72%) had RRMS, 15 (19%) SPMS and 7 (9%) PPMS. Most patients (89%) received rituximab at a dose of 500 mg every 6-12 months. Nine patients (11%), all with progressive MS were on 1 gm to 2 gm every 6 months. Follow up ranged from 1 year to 3 years, with a median of 2 years. 56 (97%) RRMS patients had no relapses during follow up. EDSS score improved by a score of 0.5-2.0 in 68 (85%) patients, remained same in 10 (12.5%) and worsened in 2 patients (2.5%). Most patients (91%) tolerated rituximab infusions well. There were no opportunistic infections or neoplasms. CONCLUSION Anti B cell therapy with rituximab appears effective, safe and affordable in the treatment of MS in developing countries like India with resource limited settings.
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Affiliation(s)
- Thomas Mathew
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India.
| | - Saji K John
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India
| | - Vikram Kamath
- Department of Neurology, Apollo Hospital, Bengaluru, Karnataka, India
| | - Uday Murgod
- Department of Neurology, Manipal Hospital, Old Airport Road, Bangalore, India
| | - Kurian Thomas
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India
| | - Anita Angela Baptist
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India
| | - Manjusha Therambil
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India
| | - Asha Shaji
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India
| | - Raghunandan Nadig
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India
| | - Sagar Badachi
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India
| | - Delon D Souza
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India
| | - Sonia Shivde
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India; Department of Neurology, Apollo Hospital, Bengaluru, Karnataka, India; Department of Neurology, Manipal Hospital, Old Airport Road, Bangalore, India
| | - Amrutha Avati
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India; Department of Neurology, Apollo Hospital, Bengaluru, Karnataka, India; Department of Neurology, Manipal Hospital, Old Airport Road, Bangalore, India
| | - G R K Sarma
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India
| | - G G Sharath Kumar
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India
| | - Saikanth Deepalam
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India
| | - Gareth J Parry
- Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bengaluru, Karnataka,560034, India
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Abdelhak A, Huss A, Stahmann A, Senel M, Krumbholz M, Kowarik MC, Havla J, Kümpfel T, Kleiter I, Wüstinger I, Zettl UK, Schwartz M, Roesler R, Friede T, Ludolph AC, Ziemann U, Tumani H. Explorative study of emerging blood biomarkers in progressive multiple sclerosis (EmBioProMS): Design of a prospective observational multicentre pilot study. Contemp Clin Trials Commun 2020; 18:100574. [PMID: 32478196 PMCID: PMC7251538 DOI: 10.1016/j.conctc.2020.100574] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/04/2020] [Accepted: 05/17/2020] [Indexed: 11/18/2022] Open
Abstract
Background Defining clinical and subclinical progression in multiple sclerosis (MS) is challenging. Patient history, expanded disability status scale (EDSS), and magnetic resonance imaging (MRI) all have shortcomings and may underestimate disease dynamics. Emerging serum biomarkers such as glial fibrillary acidic protein (GFAP) and neurofilament light chain (NfL) proved useful in many cross-sectional studies. However, longitudinal data on patients with progressive MS is scarce. Objectives To assess whether the serum biomarkers GFAP and NfL might differentiate between patients with progressive vs. non-progressive disease stages and predict the disease course according to the Lublin criteria. Methods EmBioProMS is a pilot, observational, prospective, multicentric study funded by the German Multiple Sclerosis Society (DMSG). 200 patients with MS according to the 2017 McDonald criteria and history of relapse-independent progression at any time (progressive MS, PMS), younger than 65 years, and with EDSS ≤ 6.5 will be recruited in 6 centres in Germany. At baseline, month 6, and 18, medical history, EDSS, Nine-Hole-Peg-Test (9-HPT), Timed-25-Foot-Walk-Test (T-25FW), Symbol-Digit-Modalities-Test (SDMT), serum GFAP, and NfL, MRI (at least baseline and month 18) and optional optical coherence tomography (OCT) will be performed. Disease progression before and during the study is defined by confirmed EDSS progression, increase by ≥ 20% in 9-HPT or T-25FW time. Conclusions This longitudinal multicentre study will reveal to what extent the prediction of disease progression in patients with PMS will be improved by the analysis of serum biomarkers in conjunction with routine clinical data and neuroimaging measures.
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Affiliation(s)
- Ahmed Abdelhak
- Department of Neurology & Stroke, University Hospital of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
- Department of Neurology, University Hospital of Ulm, Ulm, Germany
| | - Andre Huss
- Department of Neurology, University Hospital of Ulm, Ulm, Germany
| | - Alexander Stahmann
- MS Forschungs- und Projektentwicklungs-gGmbH, MS-Registry by the German MS-Society, Hanover, Germany
| | - Makbule Senel
- Department of Neurology, University Hospital of Ulm, Ulm, Germany
| | - Markus Krumbholz
- Department of Neurology & Stroke, University Hospital of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Markus C. Kowarik
- Department of Neurology & Stroke, University Hospital of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Joachim Havla
- Institute of Clinical Neuroimmunology, Ludwig-Maximilians University, Munich, Germany
| | - Tania Kümpfel
- Institute of Clinical Neuroimmunology, Ludwig-Maximilians University, Munich, Germany
| | - Ingo Kleiter
- Marianne-Strauß-Klinik, Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke gGmbH, Berg, Germany
- St. Josef-Hospital, Department of Neurology, Ruhr-University, Bochum, Germany
| | - Isabella Wüstinger
- Marianne-Strauß-Klinik, Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke gGmbH, Berg, Germany
| | - Uwe K. Zettl
- Department of Neurology, Neuroimmunological Section, University of Rostock, Rostock, Germany
| | - Margit Schwartz
- Department of Neurology, Neuroimmunological Section, University of Rostock, Rostock, Germany
| | - Romy Roesler
- Fachklinik für Neurologie Dietenbronn, Schwendi, Germany
| | - Tim Friede
- Department of Medical Statistics, University Medical Centre Göttingen, Göttingen, Germany
| | | | - Ulf Ziemann
- Department of Neurology & Stroke, University Hospital of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Hayrettin Tumani
- Department of Neurology, University Hospital of Ulm, Ulm, Germany
- Fachklinik für Neurologie Dietenbronn, Schwendi, Germany
- Corresponding author. Universitäts- und Rehabilitationskliniken Ulm (RKU), Oberer Eselsberg 45, 89081, Ulm, Germany.
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Metaxakis A, Petratou D, Tavernarakis N. Molecular Interventions towards Multiple Sclerosis Treatment. Brain Sci 2020; 10:brainsci10050299. [PMID: 32429225 PMCID: PMC7287961 DOI: 10.3390/brainsci10050299] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 12/24/2022] Open
Abstract
Multiple sclerosis (MS) is an autoimmune life-threatening disease, afflicting millions of people worldwide. Although the disease is non-curable, considerable therapeutic advances have been achieved through molecular immunotherapeutic approaches, such as peptides vaccination, administration of monoclonal antibodies, and immunogenic copolymers. The main aims of these therapeutic strategies are to shift the MS-related autoimmune response towards a non-inflammatory T helper 2 (Th2) cells response, inactivate or ameliorate cytotoxic autoreactive T cells, induce secretion of anti-inflammatory cytokines, and inhibit recruitment of autoreactive lymphocytes to the central nervous system (CNS). These approaches can efficiently treat autoimmune encephalomyelitis (EAE), an essential system to study MS in animals, but they can only partially inhibit disease progress in humans. Nevertheless, modern immunotherapeutic techniques remain the most promising tools for the development of safe MS treatments, specifically targeting the cellular factors that trigger the initiation of the disease.
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Affiliation(s)
- Athanasios Metaxakis
- Institute of Molecular Biology and Biotechnology, Foundation for Research and Technology Hellas, Nikolaou Plastira 100, 70013 Heraklion, Greece; (A.M.); (D.P.)
| | - Dionysia Petratou
- Institute of Molecular Biology and Biotechnology, Foundation for Research and Technology Hellas, Nikolaou Plastira 100, 70013 Heraklion, Greece; (A.M.); (D.P.)
| | - Nektarios Tavernarakis
- Institute of Molecular Biology and Biotechnology, Foundation for Research and Technology Hellas, Nikolaou Plastira 100, 70013 Heraklion, Greece; (A.M.); (D.P.)
- Department of Basic Sciences, Faculty of Medicine, University of Crete, 71110 Heraklion, Greece
- Correspondence: ; Tel.: +30-2810-391066
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What are the infectious risks with disease-modifying drugs for multiple sclerosis and how to reduce them? A review of literature. Rev Neurol (Paris) 2020; 176:235-243. [DOI: 10.1016/j.neurol.2019.08.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 08/05/2019] [Accepted: 08/28/2019] [Indexed: 11/21/2022]
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Häusler D, Hajiyeva Z, Traub JW, Zamvil SS, Lalive PH, Brück W, Weber MS. Glatiramer acetate immune modulates B-cell antigen presentation in treatment of MS. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 7:e698. [PMID: 32184341 PMCID: PMC7136047 DOI: 10.1212/nxi.0000000000000698] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 01/31/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE We examined the effect of glatiramer acetate (GA) on B-cell maturation, differentiation, and antigen presentation in MS and experimental autoimmune encephalomyelitis (EAE). METHODS A cross-sectional study of blood samples from 20 GA-treated and 18 untreated patients with MS was performed by flow cytometry; 6 GA-treated patients with MS were analyzed longitudinally. GA-mediated effects on B-cell antigen-presenting function were investigated in EAE, or, alternatively, B cells were treated with GA in vitro using vehicle as a control. RESULTS In MS, GA diminished transitional B-cell and plasmablast frequency, downregulated CD69, CD25, and CD95 expression, and decreased TNF-α production, whereas IL-10 secretion and MHC Class II expression were increased. In EAE, we observed an equivalent dampening of proinflammatory B-cell properties and an enhanced expression of MHC Class II. When used as antigen-presenting cells for activation of naive T cells, GA-treated B cells promoted development of regulatory T cells, whereas proinflammatory T-cell differentiation was diminished. CONCLUSIONS GA immune modulates B-cell function in EAE and MS and efficiently interferes with pathogenic B cell-T cell interaction.
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Affiliation(s)
- Darius Häusler
- From the Institute of Neuropathology (D.H., J.W.T., W.B., M.S.W.), University Medical Center; Department of Neurology (Z.H., J.W.T., M.S.W.), University Medical Center, Göttingen, Germany; Department of Neurology (S.S.Z.), University of California, San Francisco; Division of Neurology (P.H.L.), Department of Neurosciences, Hospital and University of Geneva; and Department of Pathology and Immunology (P.H.L.), Faculty of Medicine, Geneva, Switzerland
| | - Zivar Hajiyeva
- From the Institute of Neuropathology (D.H., J.W.T., W.B., M.S.W.), University Medical Center; Department of Neurology (Z.H., J.W.T., M.S.W.), University Medical Center, Göttingen, Germany; Department of Neurology (S.S.Z.), University of California, San Francisco; Division of Neurology (P.H.L.), Department of Neurosciences, Hospital and University of Geneva; and Department of Pathology and Immunology (P.H.L.), Faculty of Medicine, Geneva, Switzerland
| | - Jan W Traub
- From the Institute of Neuropathology (D.H., J.W.T., W.B., M.S.W.), University Medical Center; Department of Neurology (Z.H., J.W.T., M.S.W.), University Medical Center, Göttingen, Germany; Department of Neurology (S.S.Z.), University of California, San Francisco; Division of Neurology (P.H.L.), Department of Neurosciences, Hospital and University of Geneva; and Department of Pathology and Immunology (P.H.L.), Faculty of Medicine, Geneva, Switzerland
| | - Scott S Zamvil
- From the Institute of Neuropathology (D.H., J.W.T., W.B., M.S.W.), University Medical Center; Department of Neurology (Z.H., J.W.T., M.S.W.), University Medical Center, Göttingen, Germany; Department of Neurology (S.S.Z.), University of California, San Francisco; Division of Neurology (P.H.L.), Department of Neurosciences, Hospital and University of Geneva; and Department of Pathology and Immunology (P.H.L.), Faculty of Medicine, Geneva, Switzerland
| | - Patrice H Lalive
- From the Institute of Neuropathology (D.H., J.W.T., W.B., M.S.W.), University Medical Center; Department of Neurology (Z.H., J.W.T., M.S.W.), University Medical Center, Göttingen, Germany; Department of Neurology (S.S.Z.), University of California, San Francisco; Division of Neurology (P.H.L.), Department of Neurosciences, Hospital and University of Geneva; and Department of Pathology and Immunology (P.H.L.), Faculty of Medicine, Geneva, Switzerland
| | - Wolfgang Brück
- From the Institute of Neuropathology (D.H., J.W.T., W.B., M.S.W.), University Medical Center; Department of Neurology (Z.H., J.W.T., M.S.W.), University Medical Center, Göttingen, Germany; Department of Neurology (S.S.Z.), University of California, San Francisco; Division of Neurology (P.H.L.), Department of Neurosciences, Hospital and University of Geneva; and Department of Pathology and Immunology (P.H.L.), Faculty of Medicine, Geneva, Switzerland
| | - Martin S Weber
- From the Institute of Neuropathology (D.H., J.W.T., W.B., M.S.W.), University Medical Center; Department of Neurology (Z.H., J.W.T., M.S.W.), University Medical Center, Göttingen, Germany; Department of Neurology (S.S.Z.), University of California, San Francisco; Division of Neurology (P.H.L.), Department of Neurosciences, Hospital and University of Geneva; and Department of Pathology and Immunology (P.H.L.), Faculty of Medicine, Geneva, Switzerland.
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Bellinvia A, Prestipino E, Portaccio E, Razzolini L, Fonderico M, Fratangelo R, Tudisco L, Pastò L, Amato MP. Experience with rituximab therapy in a real-life sample of multiple sclerosis patients. Neurol Sci 2020; 41:2939-2945. [PMID: 32350672 DOI: 10.1007/s10072-020-04434-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 04/16/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Multiple sclerosis (MS) is an autoimmune, neuroinflammatory, and neurodegenerative disease of the central nervous system. B cells have recently emerged as a promising target to significantly reduce inflammatory disease activity in MS, with successful trial studies using antiCD20 therapies. However, real-life data about safety and efficacy are limited. OBJECTIVES To analyze the clinical and radiological inflammatory activity, adherence to therapy, and safety of rituximab (RTX) in an MS patients' sample, treated from 2015 to 2018 in our center PATIENTS AND METHODS: Retrospective study on prospectively collected data about relapses, disability progression, and radiological activity (new T2 lesions and Gd-enhancing lesions) were recorded and used to assess no evidence of disease activity (NEDA) at 12 months. RTX-related adverse events were recorded. RTX was administered intravenously at a dosage of 1000 mg twice 2 weeks apart, then every 6 months. RESULTS Sixty-nine patients were included. Fifty-three (76.8%) had a relapsing-remitting, two a primary progressive course, and 14 a secondary progressive course. The mean follow-up period was 16 ± 9.7 months. Thirty-five (50.7%) patients had relapses in the year prior to RTX therapy, with a mean annualized relapse rate of 0.75, significantly reduced to 0.36 at 12 months (p < 0.001). Among the 36 patients included in the study who had an MRI available at 12 months, MRI activity was reduced from 88% (n = 32) to 8.3% (n = 3) at follow-up (p < 0.001). Twelve (17.4%) patients suspended RTX during the study. CONCLUSIONS Our real-life experience confirms that off-label therapy with RTX may represent a valid, cost-effective therapeutic option in MS.
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Affiliation(s)
- Angelo Bellinvia
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy
| | - Elio Prestipino
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy
| | - Emilio Portaccio
- SOC Neurologia, AUSL Toscana Centro, San Giovanni di Dio Hospital, Florence, Italy
| | - Lorenzo Razzolini
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy
| | - Mattia Fonderico
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy
| | - Roberto Fratangelo
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy
| | - Laura Tudisco
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy
| | - Luisa Pastò
- SOD Neurological Rehabilitation, Careggi University Hospital, Florence, Italy
| | - Maria P Amato
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy.
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy.
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Sotirchos ES, Gonzalez Caldito N, Filippatou A, Fitzgerald KC, Murphy OC, Lambe J, Nguyen J, Button J, Ogbuokiri E, Crainiceanu CM, Prince JL, Calabresi PA, Saidha S. Progressive Multiple Sclerosis Is Associated with Faster and Specific Retinal Layer Atrophy. Ann Neurol 2020; 87:885-896. [PMID: 32285484 DOI: 10.1002/ana.25738] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 03/30/2020] [Accepted: 04/01/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Therapeutic development in progressive multiple sclerosis (PMS) has been hampered by a lack of reliable biomarkers to monitor neurodegeneration. Optical coherence tomography (OCT)-derived retinal measures have been proposed as promising biomarkers to fulfill this role. However, it is unclear whether retinal atrophy persists in PMS, exceeds normal aging, or can be distinguished from relapsing-remitting multiple sclerosis (RRMS). METHODS 178 RRMS, 186 PMS, and 66 control participants were followed with serial OCT for a median follow-up of 3.7 years. RESULTS The estimated proportion of peripapillary retinal nerve fiber layer (pRNFL) and macular ganglion cell + inner plexiform layer (GCIPL) thinning in multiple sclerosis (MS) attributable to normal aging increased from 42.7% and 16.7% respectively at age 25 years, to 83.7% and 81.1% at age 65 years. However, independent of age, PMS was associated with faster pRNFL (-0.34 ± 0.09%/yr, p < 0.001) and GCIPL (-0.27 ± 0.07%/yr, p < 0.001) thinning, as compared to RRMS. In both MS and controls, higher baseline age was associated with faster inner nuclear layer (INL) and outer nuclear layer (ONL) thinning. INL and ONL thinning were independently faster in PMS, as compared to controls (INL:-0.09 ± 0.04%/yr, p = 0.03; ONL:-0.12 ± 0.06%/yr, p = 0.04), and RRMS (INL:-0.10 ± 0.04%/yr, p = 0.01; ONL:-0.13 ± 0.05%/yr, p = 0.01), whereas they were similar in RRMS and controls. Unlike RRMS, disease-modifying therapies (DMTs) did not impact rates of retinal layer atrophy in PMS. INTERPRETATION PMS is associated with faster retinal atrophy independent of age. INL and ONL measures may be novel biomarkers of neurodegeneration in PMS that appear to be unaffected by conventional DMTs. The effects of aging on rates of retinal layer atrophy should be considered in clinical trials incorporating OCT outcomes. ANN NEUROL 2020;87:885-896.
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Affiliation(s)
- Elias S Sotirchos
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Angeliki Filippatou
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kathryn C Fitzgerald
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Olwen C Murphy
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jeffrey Lambe
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - James Nguyen
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Julia Button
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Esther Ogbuokiri
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Jerry L Prince
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Peter A Calabresi
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shiv Saidha
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Ellwardt E, Rolfes L, Klein J, Pape K, Ruck T, Wiendl H, Schroeter M, Zipp F, Meuth SG, Warnke C, Bittner S. Ocrelizumab initiation in patients with MS: A multicenter observational study. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 7:7/4/e719. [PMID: 32273482 PMCID: PMC7176249 DOI: 10.1212/nxi.0000000000000719] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 03/11/2020] [Indexed: 02/06/2023]
Abstract
Objective To provide first real-world experience on patients with MS treated with the B cell–depleting antibody ocrelizumab. Methods We retrospectively collected data of patients who had received at least 1 treatment cycle (2 infusions) of ocrelizumab at 3 large neurology centers. Patients' characteristics including premedication, clinical disease course, and documented side effects were analyzed. Results We could identify 210 patients (125 women, mean age ± SD, 42.1 ± 11.4 years) who had received ocrelizumab with a mean disease duration of 7.3 years and a median Expanded Disability Status Scale score of 3.75 (interquartile range 2.5–5.5; range 0–8). Twenty-six percent of these patients had a primary progressive MS (PPMS), whereas 74% had a relapsing-remitting (RRMS) or active secondary progressive (aSPMS) disease course. Twenty-four percent of all patients were treatment naive, whereas 76% had received immune therapies before. After ocrelizumab initiation (median follow-up was 200 days, range 30–1,674 days), 13% of patients with RRMS/aSPMS experienced a relapse (accounting for an annualized relapse rate of 0.17, 95% CI 0.10–0.24), and 5% of all patients with MS experienced a 12-week confirmed disability progression. Treatment was generally well tolerated, albeit only short-term side effects were recorded, including direct infusion-related reactions and mild infections. Conclusions We provide class IV evidence that treatment with ocrelizumab can stabilize naive and pretreated patients, indicating that ocrelizumab is an option following potent MS drugs such as natalizumab and fingolimod. Further studies are warranted to confirm these findings and to reveal safety concerns in the longer-term follow-up. Classification of evidence This study provides Class IV evidence that for patients with MS, ocrelizumab can stabilize both treatment-naive and previously treated patients.
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Affiliation(s)
- Erik Ellwardt
- From the Focus Program Translational Neurosciences (FTN) and Immunology (FZI) (E.E., K.P., F.Z., S.B.), Rhine Main Neuroscience Network (rmn), Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (L.R., T.R., H.W.), University of Muenster; Department of Neurology (J.K., M.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; and Department of Neurology (S.G.M.), Institute of Translational Neurology, University of Muenster, Germany.
| | - Leoni Rolfes
- From the Focus Program Translational Neurosciences (FTN) and Immunology (FZI) (E.E., K.P., F.Z., S.B.), Rhine Main Neuroscience Network (rmn), Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (L.R., T.R., H.W.), University of Muenster; Department of Neurology (J.K., M.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; and Department of Neurology (S.G.M.), Institute of Translational Neurology, University of Muenster, Germany
| | - Julia Klein
- From the Focus Program Translational Neurosciences (FTN) and Immunology (FZI) (E.E., K.P., F.Z., S.B.), Rhine Main Neuroscience Network (rmn), Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (L.R., T.R., H.W.), University of Muenster; Department of Neurology (J.K., M.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; and Department of Neurology (S.G.M.), Institute of Translational Neurology, University of Muenster, Germany
| | - Katrin Pape
- From the Focus Program Translational Neurosciences (FTN) and Immunology (FZI) (E.E., K.P., F.Z., S.B.), Rhine Main Neuroscience Network (rmn), Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (L.R., T.R., H.W.), University of Muenster; Department of Neurology (J.K., M.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; and Department of Neurology (S.G.M.), Institute of Translational Neurology, University of Muenster, Germany
| | - Tobias Ruck
- From the Focus Program Translational Neurosciences (FTN) and Immunology (FZI) (E.E., K.P., F.Z., S.B.), Rhine Main Neuroscience Network (rmn), Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (L.R., T.R., H.W.), University of Muenster; Department of Neurology (J.K., M.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; and Department of Neurology (S.G.M.), Institute of Translational Neurology, University of Muenster, Germany
| | - Heinz Wiendl
- From the Focus Program Translational Neurosciences (FTN) and Immunology (FZI) (E.E., K.P., F.Z., S.B.), Rhine Main Neuroscience Network (rmn), Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (L.R., T.R., H.W.), University of Muenster; Department of Neurology (J.K., M.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; and Department of Neurology (S.G.M.), Institute of Translational Neurology, University of Muenster, Germany
| | - Michael Schroeter
- From the Focus Program Translational Neurosciences (FTN) and Immunology (FZI) (E.E., K.P., F.Z., S.B.), Rhine Main Neuroscience Network (rmn), Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (L.R., T.R., H.W.), University of Muenster; Department of Neurology (J.K., M.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; and Department of Neurology (S.G.M.), Institute of Translational Neurology, University of Muenster, Germany
| | - Frauke Zipp
- From the Focus Program Translational Neurosciences (FTN) and Immunology (FZI) (E.E., K.P., F.Z., S.B.), Rhine Main Neuroscience Network (rmn), Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (L.R., T.R., H.W.), University of Muenster; Department of Neurology (J.K., M.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; and Department of Neurology (S.G.M.), Institute of Translational Neurology, University of Muenster, Germany
| | - Sven G Meuth
- From the Focus Program Translational Neurosciences (FTN) and Immunology (FZI) (E.E., K.P., F.Z., S.B.), Rhine Main Neuroscience Network (rmn), Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (L.R., T.R., H.W.), University of Muenster; Department of Neurology (J.K., M.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; and Department of Neurology (S.G.M.), Institute of Translational Neurology, University of Muenster, Germany
| | - Clemens Warnke
- From the Focus Program Translational Neurosciences (FTN) and Immunology (FZI) (E.E., K.P., F.Z., S.B.), Rhine Main Neuroscience Network (rmn), Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (L.R., T.R., H.W.), University of Muenster; Department of Neurology (J.K., M.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; and Department of Neurology (S.G.M.), Institute of Translational Neurology, University of Muenster, Germany
| | - Stefan Bittner
- From the Focus Program Translational Neurosciences (FTN) and Immunology (FZI) (E.E., K.P., F.Z., S.B.), Rhine Main Neuroscience Network (rmn), Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz; Department of Neurology (L.R., T.R., H.W.), University of Muenster; Department of Neurology (J.K., M.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; and Department of Neurology (S.G.M.), Institute of Translational Neurology, University of Muenster, Germany
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Treatment Optimization in Multiple Sclerosis: Canadian MS Working Group Recommendations. Can J Neurol Sci 2020; 47:437-455. [DOI: 10.1017/cjn.2020.66] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Abstract:The Canadian Multiple Sclerosis Working Group has updated its treatment optimization recommendations (TORs) on the optimal use of disease-modifying therapies for patients with all forms of multiple sclerosis (MS). Recommendations provide guidance on initiating effective treatment early in the course of disease, monitoring response to therapy, and modifying or switching therapies to optimize disease control. The current TORs also address the treatment of pediatric MS, progressive MS and the identification and treatment of aggressive forms of the disease. Newer therapies offer improved efficacy, but also have potential safety concerns that must be adequately balanced, notably when treatment sequencing is considered. There are added discussions regarding the management of pregnancy, the future potential of biomarkers and consideration as to when it may be prudent to stop therapy. These TORs are meant to be used and interpreted by all neurologists with a special interest in the management of MS.
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231
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Grzegorski T, Losy J. Multiple sclerosis - the remarkable story of a baffling disease. Rev Neurosci 2020; 30:511-526. [PMID: 30645198 DOI: 10.1515/revneuro-2018-0074] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 10/18/2018] [Indexed: 11/15/2022]
Abstract
Multiple sclerosis has always been an enigma to its sufferers, their families, medical investigators, and clinicians. For many centuries, there have been attempts to understand its causes and nature, and to discover treatment methods. In the Middle Ages, the disease was claimed to be sent directly from God. A significant development in exploring multiple sclerosis took place in the 19th century, when Jean-Martin Charcot and his colleagues distinguished the disease, precisely described its symptoms, attempted to explain its pathophysiology, and introduced the first methods of symptomatic treatment. The 20th century was a period of discovery and development of diagnostic techniques, such as cerebrospinal fluid analysis, evoked potentials, and magnetic resonance imaging as well as an era of introducing steroid therapy for acute treatment. Currently, the dynamic development of disease modifying therapy and neuroimaging can be observed. The paper aims to delve into the remarkable history of multiple sclerosis by focusing on the earliest case reports and discovery of the disease and exploring its nature, diagnostic methods, and treatment.
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Affiliation(s)
- Tomasz Grzegorski
- Department of Clinical Neuroimmunology, Chair of Neurology, Poznan University of Medical Sciences, 49 Przybyszewskiego Street, 60-355 Poznan, Poland
| | - Jacek Losy
- Department of Clinical Neuroimmunology, Chair of Neurology, Poznan University of Medical Sciences, 49 Przybyszewskiego Street, 60-355 Poznan, Poland
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232
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Cancer Risk for Fingolimod, Natalizumab, and Rituximab in Multiple Sclerosis Patients. Ann Neurol 2020; 87:688-699. [DOI: 10.1002/ana.25701] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 02/11/2020] [Accepted: 02/11/2020] [Indexed: 01/02/2023]
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233
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Effect of Rituximab on Expanded Disability Status Scale and Relapse Rate in Multiple Sclerosis Patients. J Mol Neurosci 2020; 70:1165-1168. [PMID: 32144724 DOI: 10.1007/s12031-020-01523-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 02/28/2020] [Indexed: 10/24/2022]
Abstract
The aim of this study was to investigate the efficacy of rituximab, a monoclonal antibody that depletes circulating CD20+ B lymphocytes, in relapsing remitting multiple sclerosis (RRMS) patients with inadequate response to disease-modifying therapies. This single group quasi-experimental study recruited RRMS patients who were referred to Sina Farshchian Hospital, Hamadan, Iran, from March 2018 until August 2019. After getting informed consent from the patients, demographic data and duration of disease were recorded. Patients received 500 to 1000 mg of intravenous rituximab every 6 months until 18 months. Relapse rate per year and expanded disability status scale (EDSS) were obtained at baseline and throughout the post treatment follow-up. A total of 70 RRMS patients with the mean age 40.25 ± 8.17 were studied. At baseline, the mean of EDSS and relapse rate was 5.3 ± 1.08 and 0.95 ± 0.64, respectively. After 18 months treatment with rituximab, the relapse rates were significantly reduced (p < 0.000), but the mean EDSS almost remained unchanged (5.7 ± 1.4). Infusion-related adverse effects occurred in 60% of patients in first infusion, and most of them were mild. This study has indicated that rituximab can markedly reduce relapse rates in RRMS patients. The effect of rituximab on EDSS appears to be inappreciable. Also according to our results, administration of rituximab is safe and well tolerated.
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Abdel-Mannan O, Cortese R, Wassmer E, Hemingway C, Thompson A, Brownlee W, Ciccarelli O, Hacohen Y. Primary progressive multiple sclerosis presenting under the age of 18 years: Fact or fiction? Mult Scler 2020; 27:309-314. [PMID: 32124676 DOI: 10.1177/1352458520910361] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Previous cohort studies on paediatric multiple sclerosis (MS) have reported very low frequencies for a primary progressive MS (PPMS) course ranging from 0% to 7%. We identified six patients presenting prior to the age of 18 years and fulfilling the 2017 McDonald Criteria for PPMS. Presentation with progressive neurological symptoms and signs in young people should prompt evaluation for genetic causes such as leukodystrophies, hereditary spastic paraparesis and mitochondrial diseases given the rarity of primary progressive course in paediatric MS. In the absence of an alternative diagnosis, with new therapeutic options becoming available for PPMS, this diagnosis should then be considered.
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Affiliation(s)
- Omar Abdel-Mannan
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK/Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Rosa Cortese
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Evangeline Wassmer
- Department of Paediatric Neurology, Birmingham Children's Hospital, Birmingham, UK
| | - Cheryl Hemingway
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Alan Thompson
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK/Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK/NIHR UCLH Biomedical Research Centre, London, UK
| | - Wallace Brownlee
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Olga Ciccarelli
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK/NIHR UCLH Biomedical Research Centre, London, UK
| | - Yael Hacohen
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK/Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
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235
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Sellebjerg F, Blinkenberg M, Sorensen PS. Anti-CD20 Monoclonal Antibodies for Relapsing and Progressive Multiple Sclerosis. CNS Drugs 2020; 34:269-280. [PMID: 31994023 DOI: 10.1007/s40263-020-00704-w] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Multiple sclerosis (MS) was previously thought to be a T-cell-mediated, demyelinating disease of the central nervous system. Disease-modifying therapies targeting T cells have, indeed, shown remarkable efficacy in patients with relapsing-remitting MS. However, these therapies do also target B cells, and a B-cell-depleting monoclonal antibody (ocrelizumab) has recently been approved for MS therapy and is efficacious not only in relapsing forms of MS but also in some patients with primary progressive MS. This suggests that B cells may play a more important role in the pathogenesis of MS than previously appreciated. We review the potential roles of B cells, which are the precursors of antibody-secreting plasma cells in the pathogenesis of MS. Furthermore, we provide an overview of the characteristics and clinical data for the four monoclonal antibodies (ocrelizumab, ofatumumab, rituximab, and ublituximab) that have been approved, are currently been used off-label or are being investigated as treatments for MS. These antibodies all target the cluster of differentiation (CD)-20 molecule and bind to distinct or overlapping epitopes on B cells and a subset of T cells that express CD20. This leads to B-cell depletion and, possibly, to depletion of CD20-positive T cells. The net result is strong suppression of clinical and radiological disease activity as well as slowing of the development of persisting neurological impairment.
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Affiliation(s)
- Finn Sellebjerg
- Danish Multiple Sclerosis Clinic, Department of Neurology 2082, University of Copenhagen, Rigshospitalet, 9 Blegdamsvej, 2100, Copenhagen, Denmark
| | - Morten Blinkenberg
- Danish Multiple Sclerosis Clinic, Department of Neurology 2082, University of Copenhagen, Rigshospitalet, 9 Blegdamsvej, 2100, Copenhagen, Denmark
| | - Per Soelberg Sorensen
- Danish Multiple Sclerosis Clinic, Department of Neurology 2082, University of Copenhagen, Rigshospitalet, 9 Blegdamsvej, 2100, Copenhagen, Denmark.
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Abstract
PURPOSE OF REVIEW Recent years have seen the approval of more than 15 disease-modifying drugs for multiple sclerosis (MS), mainly for its relapsing-remitting form (RRMS). The focus of the MS clinical trials is moving toward clinical trials aimed at progressive patients or based on putatively neuroprotective compounds. Here we reviewed the challenges of this paradigm shift. RECENT FINDINGS Progressive MS and neuroprotective drugs trials will both need a change in patients' enrollment criteria, outcome selection, and clinical trials design. Published ocrelizumab Primary Progressive MS data, as well as translational neuroimaging and clinical research suggest that MRI markers of inflammation could be used to enrich progressive MS trials population, albeit with the risk of overestimating the relevance of antiinflammatory therapeutic effects in this population and that conventional MRI-based metrics need to be complemented with volumetric and multiparametric approaches to disease severity quantification. Lastly, regarding statistical design, Bayesian approaches are at last making their way from oncology to neurology improving our ability to evaluate multiple treatments in the same trials' population. SUMMARY Adequate clinical trials design was one of the key factors in the RRMS treatment success story. Multidisciplinary collaborations are needed to adequately plan the progressive MS and restorative therapies trials that lay ahead in the near future.
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237
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Naegelin Y, Naegelin P, von Felten S, Lorscheider J, Sonder J, Uitdehaag BMJ, Scotti B, Zecca C, Gobbi C, Kappos L, Derfuss T. Association of Rituximab Treatment With Disability Progression Among Patients With Secondary Progressive Multiple Sclerosis. JAMA Neurol 2020; 76:274-281. [PMID: 30615019 DOI: 10.1001/jamaneurol.2018.4239] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Importance Therapeutic options for patients with secondary progressive multiple sclerosis (SPMS) are limited. Objective To analyze disability progression in patients with SPMS treated with rituximab compared with matched control patients never treated with rituximab. Design, Setting, and Participants This retrospective cohort study analyzed data obtained from patients with SPMS at 3 multiple sclerosis centers located in Basel and Lugano, Switzerland, and Amsterdam, the Netherlands, from 2004 to 2017. Patients were included for analysis if they had received a diagnosis of SPMS, were treated (57 eligible; 54 included) or never treated (504 eligible; 59 included) with rituximab, and had at least 1 follow-up visit. The variables used for propensity score matching were sex, age, Expanded Disability Status Scale (EDSS) score, and disease duration. Follow-up duration was up to 10 years, with a mean (SD) of 3.5 (2.6) years for rituximab-treated patients and 5.4 (2.4) years for controls in the total cohort and a mean (SD) of 3.5 (2.7) years for rituximab-treated patients and 4.8 (2.2) years for controls in the matched cohort. Exposures Comparing EDSS score progression in patients with SPMS (treated with rituximab vs not treated with rituximab) using propensity score matching. Main Outcomes and Measures The primary end point was progression of EDSS score after baseline, and the secondary end point was time to confirmed disability progression. Results After 1:1 propensity score matching, 44 matched pairs (88 patients) were included in the analysis. At baseline, patients treated with rituximab had a mean (SD) age of 49.7 (10.0) years, mean (SD) disease duration of 18.2 (9.4) years, and mean (SD) EDSS score of 5.9 (1.4), and 26 (59%) were women, whereas controls had a mean (SD) age of 51.3 (7.4) years, mean (SD) disease duration of 19.4 (8.7) years, and mean (SD) EDSS score of 5.70 (1.29), and 27 (61%) were women. In the covariate-adjusted analysis of the matched set, patients with SPMS who were treated with rituximab had a significantly lower EDSS score during a mean (SD) follow-up of 3.5 (2.7) years (mean difference, -0.52; 95% CI, -0.79 to -0.26; P < .001). Time to confirmed disability progression was significantly delayed in the rituximab-treated group (hazard ratio, 0.49; 95% CI, 0.26-0.93; P = .03). Conclusions and Relevance In this study, patients with SPMS treated with rituximab had a significantly lower EDSS score for up to 10 years of follow-up and a significantly delayed confirmed progression compared with matched controls, suggesting that B-cell depletion by rituximab may be therapeutically beneficial in these patients. A prospective randomized clinical trial with a better level of evidence is needed to confirm the efficacy of rituximab in such patients.
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Affiliation(s)
- Yvonne Naegelin
- Neurologic Clinic and Policlinic, University Hospital and University of Basel, Basel, Switzerland
| | - Peter Naegelin
- Neurologic Clinic and Policlinic, University Hospital and University of Basel, Basel, Switzerland
| | - Stefanie von Felten
- Clinical Trial Unit, Department of Clinical Research, University of Basel, University Hospital Basel, Basel, Switzerland
| | - Johannes Lorscheider
- Neurologic Clinic and Policlinic, University Hospital and University of Basel, Basel, Switzerland
| | - Judith Sonder
- MS Center Amsterdam, Department of Neurology, VU University Medical Center, Amsterdam, the Netherlands
| | - Bernard M J Uitdehaag
- MS Center Amsterdam, Department of Neurology, VU University Medical Center, Amsterdam, the Netherlands
| | - Barbara Scotti
- Multiple Sclerosis Center, Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Chiara Zecca
- Multiple Sclerosis Center, Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Claudio Gobbi
- Multiple Sclerosis Center, Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Ludwig Kappos
- Neurologic Clinic and Policlinic, University Hospital and University of Basel, Basel, Switzerland
| | - Tobias Derfuss
- Neurologic Clinic and Policlinic, University Hospital and University of Basel, Basel, Switzerland
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Airas L, Nylund M, Mannonen I, Matilainen M, Sucksdorff M, Rissanen E. Rituximab in the treatment of multiple sclerosis in the Hospital District of Southwest Finland. Mult Scler Relat Disord 2020; 40:101980. [PMID: 32066031 DOI: 10.1016/j.msard.2020.101980] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/14/2020] [Accepted: 01/31/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND There are already numerous B-cell depleting monoclonal anti-CD20 antibodies which have been used to reduce the inflammatory burden associated with multiple sclerosis (MS). We describe here our experience of treating MS-patients with B-cell depleting rituximab. PATIENTS AND METHODS All MS-patients (n = 72) who had received rituximab treatment for at least six months by January 2019 were identified from the patient charts at the Turku University Hospital. Information about MS disease subtype, disease severity, MR-imaging outcomes and B-cell counts were collected from the charts. RESULTS Rituximab was well received and well tolerated by the patients. There were no serious infusion-related side effects. The most serious adverse event that led to treatment discontinuation was neutropenia. After rituximab initiation the annual number of relapses was decreased in the relapsing remitting and secondary progressive MS groups and the mean number of gadolinium-enhancing lesions was decreased in relapsing remitting MS. Our study confirms the usability of rituximab treatment for MS in the Finnish health care environment. CONCLUSIONS Off-label rituximab-treatment can be successfully used to reduce MS disease burden for the benefit of MS patients.
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Affiliation(s)
- Laura Airas
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland; Division of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland.
| | - Marjo Nylund
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland; Division of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland
| | - Iina Mannonen
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland; Division of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland
| | - Markus Matilainen
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Marcus Sucksdorff
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland; Division of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland
| | - Eero Rissanen
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland; Division of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland
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239
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Sharrack B, Saccardi R, Alexander T, Badoglio M, Burman J, Farge D, Greco R, Jessop H, Kazmi M, Kirgizov K, Labopin M, Mancardi G, Martin R, Moore J, Muraro PA, Rovira M, Sormani MP, Snowden JA. Autologous haematopoietic stem cell transplantation and other cellular therapy in multiple sclerosis and immune-mediated neurological diseases: updated guidelines and recommendations from the EBMT Autoimmune Diseases Working Party (ADWP) and the Joint Accreditation Committee of EBMT and ISCT (JACIE). Bone Marrow Transplant 2020; 55:283-306. [PMID: 31558790 PMCID: PMC6995781 DOI: 10.1038/s41409-019-0684-0] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 08/17/2019] [Indexed: 12/18/2022]
Abstract
These updated EBMT guidelines review the clinical evidence, registry activity and mechanisms of action of haematopoietic stem cell transplantation (HSCT) in multiple sclerosis (MS) and other immune-mediated neurological diseases and provide recommendations for patient selection, transplant technique, follow-up and future development. The major focus is on autologous HSCT (aHSCT), used in MS for over two decades and currently the fastest growing indication for this treatment in Europe, with increasing evidence to support its use in highly active relapsing remitting MS failing to respond to disease modifying therapies. aHSCT may have a potential role in the treatment of the progressive forms of MS with a significant inflammatory component and other immune-mediated neurological diseases, including chronic inflammatory demyelinating polyneuropathy, neuromyelitis optica, myasthenia gravis and stiff person syndrome. Allogeneic HSCT should only be considered where potential risks are justified. Compared with other immunomodulatory treatments, HSCT is associated with greater short-term risks and requires close interspeciality collaboration between transplant physicians and neurologists with a special interest in these neurological conditions before, during and after treatment in accredited HSCT centres. Other experimental cell therapies are developmental for these diseases and patients should only be treated on clinical trials.
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Affiliation(s)
- Basil Sharrack
- Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- NIHR Neurosciences Biomedical Research Centre, University of Sheffield, Sheffield, UK
| | - Riccardo Saccardi
- Cell Therapy and Transfusion Medicine Unit, Careggi University Hospital, Firenze, Italy
| | - Tobias Alexander
- Klinik fur Rheumatologie und Klinische Immunologie, Charite-Universitatsmedizin, Berlin, Germany
| | - Manuela Badoglio
- EBMT Paris study office, Department of Haematology, Saint Antoine Hospital, INSERM UMR 938, Sorbonne University, Paris, France
| | - Joachim Burman
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Dominique Farge
- Unité de Médecine Interne, Maladies Auto-immunes et Pathologie Vasculaire (UF 04), Hôpital St-Louis, AP-HP, Paris, France
- Centre de Référence des Maladies Auto-Immunes Systémiques Rares d'Ile-de-France, Filière, FAI2R, Paris, France
- EA 3518, Université Denis Diderot, Paris, France
- Department of Internal Medicine, McGill University, Montreal, QC, Canada
| | - Raffaella Greco
- Hematology and Bone Marrow Transplantation Unit, Istituto di Ricovero e Cura a Carattere Scientifico, San Raffaele Scientific Institute, Milan, Italy
| | - Helen Jessop
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Majid Kazmi
- Kings Health Partners, Department of Haematology, Guys Hospital, London, UK
| | - Kirill Kirgizov
- N.N. Blokhin National Medical Center of Oncology, Institute of Pediatric Oncology and Hematology, Moscow, Russia
| | - Myriam Labopin
- EBMT Paris study office, Department of Haematology, Saint Antoine Hospital, INSERM UMR 938, Sorbonne University, Paris, France
| | - Gianluigi Mancardi
- Department of Neuroscience, University of Genova and Clinical Scientific Institutes Maugeri, Genoa, Italy
| | - Roland Martin
- Neuroimmunology and MS Research, Neurology Clinic, University Hospital, Zurich, Switzerland
| | - John Moore
- Haematology Department, St. Vincent's Health Network, Darlinghurst, NSW, Australia
| | - Paolo A Muraro
- Department of Brain Sciences, Imperial College London, London, UK
| | - Montserrat Rovira
- BMT Unit, Department of Hematology, IDIBAPS, Hospital Clinic, Institut Josep Carreras, Barcelona, Spain
| | - Maria Pia Sormani
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
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Vural A, Derle E, Sayat-Gürel G, Karabudak R, Tuncer A. Predictors of progression in primary progressive multiple sclerosis in a large Turkish cohort. Mult Scler Relat Disord 2020; 38:101520. [DOI: 10.1016/j.msard.2019.101520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 11/07/2019] [Accepted: 11/10/2019] [Indexed: 10/25/2022]
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241
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Bose G, Freedman MS. Precision medicine in the multiple sclerosis clinic: Selecting the right patient for the right treatment. Mult Scler 2020; 26:540-547. [DOI: 10.1177/1352458519887324] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Multiple sclerosis (MS) is a chronic, inflammatory disease of the central nervous system (CNS), affecting patients of all ages, causing neurologic disability if inadequately treated. Some patients have a relatively benign disease course without significant disability after decades, while a more aggressive course ensues in others and disability progression occurs after only several years. Certain risk factors confer a higher chance of a patient having aggressive MS. Currently over 15 disease-modifying treatments (DMTs) are approved for MS with different efficacy and safety profiles. Deciding which DMT to use in a specific patient requires a careful analysis of a patient’s disease course for high-risk factors for early progression, consideration of the efficacy and safety profile for potential therapy, as well as understanding of a patient’s lifestyle and expectations. The integration of these factors is the art of precision medicine, a necessary practice in the treatment of patients with MS.
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Affiliation(s)
- Gauruv Bose
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada/Division of Neurology, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Mark S Freedman
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada/Division of Neurology, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
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242
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Evdoshenko EP, Neofidov NA, Bakhtiyarova KZ, Davydovskaya MV, Kairbekova EI, Kolontareva YM, Malkova NA, Odinak MM, Popova EV, Sazonov DV, Stolyarov ID, Smagina IV, Fedyanin AS, Habirov FA, Khaibullin TI, Khachanova NV, Shchukin IA, Boyko AN. [The efficacy and safety of siponimod in the Russian population of patients with secondary progressive multiple sclerosis]. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 119:110-119. [PMID: 31934996 DOI: 10.17116/jnevro201911910110] [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: 11/17/2022]
Abstract
AIM To study the efficacy and safety of siponimod in patients with secondary progressive multiple sclerosis (SPMS) in the Russian population of the EXPAND study. MATERIAL AND METHODS Ninety-four patients with SPMS from Russia were included in the analysis. Sixty-three patients received siponimod and 31 patients received placebo. The primary endpoint of the study was time to 3-month confirmed disability progression (3m-CDP) events, other clinical and radiological endpoints were also evaluated. RESULTS The siponimod group showed a 54% reduction in the risk of 3m-CDP compared with the placebo group (p=0.0334). Secondary endpoints also showed the advantage of the drug over placebo. In the siponimod group, mild adverse events associated with impaired liver function, as well as arterial hypertension, were more common. No patient left the study due to an adverse event. CONCLUSION The use of siponimod in patients with SPMS in the Russian population reduced the risk of disability progression. Siponimod showed a favorable safety profile.
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Affiliation(s)
- E P Evdoshenko
- SPb Centre of Multiple Sclerosis and AID (City Clinical Hospital №31); St. Petersburg, Russia
| | - N A Neofidov
- SPb Centre of Multiple Sclerosis and AID (City Clinical Hospital №31); St. Petersburg, Russia
| | | | - M V Davydovskaya
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - E I Kairbekova
- SPb Centre of Multiple Sclerosis and AID (City Clinical Hospital №31); St. Petersburg, Russia
| | | | - N A Malkova
- Regional Center of Multiple Sclerosis Novosibirsk Medical State University, Novosibirsk, Russia
| | - M M Odinak
- Kirov Military Medical Academy, St. Petersburg, Russia
| | - E V Popova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - D V Sazonov
- Siberian District Medical Centre of FMBA of Russia, Novosibirsk, Russia
| | - I D Stolyarov
- Bekhtereva Institute of the Human Brain, Russian Academy of Sciences, St. Petersburg, Russia
| | - I V Smagina
- Altay Medical State University, Barnaul, Russia ,Kazan State Medical Academy, Kazan, Russia
| | - A S Fedyanin
- Altay Medical State University, Barnaul, Russia ,Kazan State Medical Academy, Kazan, Russia
| | | | | | - N V Khachanova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - I A Shchukin
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A N Boyko
- Pirogov Russian National Research Medical University, Moscow, Russia
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243
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Bordet R, Camu W, De Seze J, Laplaud DA, Ouallet JC, Thouvenot E. Mechanism of action of s1p receptor modulators in multiple sclerosis: The double requirement. Rev Neurol (Paris) 2020; 176:100-112. [DOI: 10.1016/j.neurol.2019.02.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 01/31/2019] [Accepted: 02/20/2019] [Indexed: 01/22/2023]
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244
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Milo R. Ofatumumab – A Potential Subcutaneous B-cell Therapy for Relapsing Multiple Sclerosis. ACTA ACUST UNITED AC 2020. [DOI: 10.17925/enr.2020.15.1.27] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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245
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Kim W, Kim HJ. Monoclonal Antibody Therapies for Multiple Sclerosis and Neuromyelitis Optica Spectrum Disorder. J Clin Neurol 2020; 16:355-368. [PMID: 32657055 PMCID: PMC7354979 DOI: 10.3988/jcn.2020.16.3.355] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 12/01/2019] [Accepted: 12/02/2019] [Indexed: 12/21/2022] Open
Abstract
Considerable progress has been made in treatments for multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) over the last several decades. However, the present treatments do not show satisfactory efficacy or safety in a considerable proportion of patients, who experience relapse or disability progression despite receiving treatment and suffer from side effects, which can be severe. Improvements in the understanding of the pathophysiologies of MS and NMOSD have led to numerous therapeutic approaches being proposed and developed. Monoclonal antibodies (mAbs) are receiving increasing attention because of their specificity of action and likelihood of high efficacy with fewer side effects. Many mAbs have been evaluated, and some have been approved for MS or NMOSD treatment. This article reviews the use of mAbs for treating MS and NMOSD, including summarizing their mechanisms of action, efficacy, and safety profiles.
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Affiliation(s)
- Woojun Kim
- Department of Neurology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ho Jin Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, Korea.
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246
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Couloume L, Barbin L, Leray E, Wiertlewski S, Le Page E, Kerbrat A, Ory S, Le Port D, Edan G, Laplaud DA, Michel L. High-dose biotin in progressive multiple sclerosis: A prospective study of 178 patients in routine clinical practice. Mult Scler 2019; 26:1898-1906. [DOI: 10.1177/1352458519894713] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background: A recent controlled trial suggested that high-dose biotin supplementation reverses disability progression in patients with progressive multiple sclerosis. Objective: To analyze the impact of high-dose biotin in routine clinical practice on disability progression at 12 months. Methods: Progressive multiple sclerosis patients who started high-dose biotin at Nantes or Rennes Hospital between 3 June 2015 and 15 September 2017 were included in this prospective study. Disability outcome measures, patient-reported outcome measures, relapses, magnetic resonance imaging (MRI) data, and adverse events were collected at baseline, 6, and 12 months. Results: A total of 178 patients were included. At baseline, patients were 52.0 ± 9.4 years old, mean Expanded Disability Status Scale (EDSS) score was 6.1 ± 1.3, mean disease duration was 16.9 ± 9.5 years. At 12 months, 3.8% of the patients had an improved EDSS score. Regarding the other disability scales, scores either remained stable or increased significantly. In total, 47.4% of the patients described stability, 27.6% felt an improvement, and 25% described a worsening. Four patients (2.2%) had a relapse. Of the 74 patients (41.6%) who underwent an MRI, 20 (27.0%) had new T2 lesions, 8 (10.8%) had gadolinium-enhancing lesions. Twenty-five (14%) reported adverse event. Conclusion: In this study, high-dose biotin did not seem to be associated with a clear improvement in disability.
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Affiliation(s)
| | | | - Emmanuelle Leray
- Univ Rennes, EHESP, REPERES (Pharmacoepidemiology and health services research)—EA 7449, Rennes, France
| | - Sandrine Wiertlewski
- Service de Neurologie, CHU Nantes, Nantes, France/CIC0004 Inserm, Nantes, France
| | - Emmanuelle Le Page
- Univ Rennes, CHU Rennes, Neurology, Centre d’Investigation Clinique de Rennes (CIC Inserm 1414), Rennes, France
| | - Anne Kerbrat
- Univ Rennes, CHU Rennes, Neurology, Centre d’Investigation Clinique de Rennes (CIC Inserm 1414), Rennes, France
| | - Solenn Ory
- Univ Rennes, CHU Rennes, Neurology, Centre d’Investigation Clinique de Rennes (CIC Inserm 1414), Rennes, France
| | - Damien Le Port
- Univ Rennes, CHU Rennes, Neurology, Centre d’Investigation Clinique de Rennes (CIC Inserm 1414), Rennes, France
| | - Gilles Edan
- Univ Rennes, CHU Rennes, Neurology, Centre d’Investigation Clinique de Rennes (CIC Inserm 1414), Rennes, France
| | - David-Axel Laplaud
- Service de Neurologie, CHU Nantes, Nantes, France/CIC0004 Inserm, Nantes, France/Centre de Recherche en Transplantation et Immunologie (CRTI), Inserm U1064, Nantes, France/Université de Nantes, Nantes, France
| | - Laure Michel
- Service de Neurologie, CHU Pontchaillou, Rennes, France; Univ Rennes, CHU Rennes, Neurology, Centre d’Investigation Clinique de Rennes (CIC Inserm 1414), Rennes, France; Unité Mixte de Recherche (UMR) S1236, INSERM, University of Rennes, Etablissement Français du Sang, Rennes, France/Suivi Immunologique des Thérapeutiques Innovantes, Centre Hospitalier Universitaire de Rennes, Etablissement Français du Sang, Rennes, France
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247
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Stark JW, Josephs L, Dulak D, Clague M, Sadiq SA. Safety of long-term intrathecal methotrexate in progressive forms of MS. Ther Adv Neurol Disord 2019; 12:1756286419892360. [PMID: 31832101 PMCID: PMC6891004 DOI: 10.1177/1756286419892360] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 11/05/2019] [Indexed: 11/16/2022] Open
Abstract
Background There are few treatment options for multiple sclerosis (MS) patients with advanced disability [expanded disability status scale (EDSS) ⩾ 6.0]. In 2010, we reported initial results of using intrathecal methotrexate (ITMTX) in patients with progressive MS. We now report on long-term use of ITMTX. We performed a retrospective chart analysis of patients who have had 18 or more treatments to establish the ongoing safety and tolerability of ITMTX. Thus, the objective of this study was to establish the safety and tolerability of long-term therapy with (ITMTX) in patients with treatment-resistant, progressive forms of MS. Methods We studied 83 patients (67 secondary and 16 primary progressive) who received ITMTX 12.5 mg every 8-11 weeks for 3-10 years (range: 18-57 treatments). All patients were evaluated neurologically, and their EDSS was assessed at every treatment. In addition, all adverse events, frequency of infections, and any hospitalizations, were noted. Results There were no deaths, hospitalizations, or other serious adverse effects related to ITMTX. Headaches occurred at least once in 12% of patients, and transient fatigue occurred in 53% of patients. As determined by EDSS, there was no significant change from baseline status to post-treatment scores in both primary progressive MS (PPMS) and secondary progressive (SPMS) patients. Conclusions Pulsed ITMTX was well tolerated for up to 10 years in PPMS patients with no serious adverse effects. Although this was an open-label, retrospective analysis, and efficacy could not be studied, there was evidence of disease stabilization in many patients receiving ITMTX. It appears that long-term ITMTX is a safe therapeutic option in advanced progressive MS.
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Affiliation(s)
- James W Stark
- International Multiple Sclerosis Management Practice, New York, NY, USA
| | - Lena Josephs
- Tisch Multiple Sclerosis Research Center of New York, New York, NY, USA
| | - Deirdre Dulak
- Tisch Multiple Sclerosis Research Center of New York, New York, NY, USA
| | - Madison Clague
- Tisch Multiple Sclerosis Research Center of New York, New York, NY, USA
| | - Saud A Sadiq
- International Multiple Sclerosis Management Practice and Tisch Multiple Sclerosis Research Center of New York, 521 West 57th St., 4th floor, New York, NY 10019, USA
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248
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B cells in autoimmune and neurodegenerative central nervous system diseases. Nat Rev Neurosci 2019; 20:728-745. [DOI: 10.1038/s41583-019-0233-2] [Citation(s) in RCA: 128] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2019] [Indexed: 12/16/2022]
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249
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Migotto MA, Mardon K, Orian J, Weckbecker G, Kneuer R, Bhalla R, Reutens DC. Efficient Distribution of a Novel Zirconium-89 Labeled Anti-cd20 Antibody Following Subcutaneous and Intravenous Administration in Control and Experimental Autoimmune Encephalomyelitis-Variant Mice. Front Immunol 2019; 10:2437. [PMID: 31681317 PMCID: PMC6813232 DOI: 10.3389/fimmu.2019.02437] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 09/30/2019] [Indexed: 11/13/2022] Open
Abstract
Objective: To investigate the imaging and biodistribution of a novel zirconium-89 (89Zr)-labeled mouse anti-cd20 monoclonal antibody (mAb) in control and experimental autoimmune encephalomyelitis (EAE) mice following subcutaneous (s. c.) and intravenous (i.v.) administration. Background: Anti-cd20-mediated B-cell depletion using mAbs is a promising therapy for multiple sclerosis. Recombinant human myelin oligodendrocyte glycoprotein (rhMOG)-induced EAE involves B-cell-mediated inflammation and demyelination in mice. Design/Methods: C57BL/6J mice (n = 39) were EAE-induced using rhMOG. On Day 14 post EAE induction, 89Zr-labeled-anti-cd20 mAb was injected in control and EAE mice in the right lower flank (s.c.) or tail vein (i.v.). Positron emission tomography/computed tomography (PET/CT) imaging and gamma counting (ex vivo) were performed on Days 1, 3, and 7 to quantify tracer accumulation in the major organs, lymphatics, and central nervous system (CNS). A preliminary study was conducted in healthy mice to elucidate full and early kinetics of the tracer that were subsequently applied in the EAE and control mice study. Results:89Zr-labeled anti-cd20 mAb was effectively absorbed from s.c. and i.v. injection sites and distributed to all major organs in the EAE and control mice. There was a good correlation between in vivo PET/CT data and ex vivo quantification of biodistribution of the tracer. From gamma counting studies, initial tracer uptake within the lymphatic system was found to be higher in the draining lymph nodes (inguinal or subiliac and sciatic) following s.c. vs. i.v. administration; within the CNS a significantly higher tracer uptake was observed at 24 h in the cerebellum, cerebrum, and thoracic spinal cord (p < 0.05 for all) following s.c. vs. i.v. administration. Conclusions: The preclinical data suggest that initial tracer uptake was significantly higher in the draining lymph nodes (subiliac and sciatic) and parts of CNS (the cerebellum and cerebrum) when administered s.c. compared with i.v in EAE mice.
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Affiliation(s)
- Mary-Anne Migotto
- Centre for Advanced Imaging, The University of Queensland, Brisbane, QLD, Australia
| | - Karine Mardon
- Centre for Advanced Imaging, The University of Queensland, Brisbane, QLD, Australia.,National Imaging Facility, The University of Queensland, Brisbane, QLD, Australia
| | - Jacqueline Orian
- Department of Biochemistry and Genetics, La Trobe Institute for Molecular Science, La Trobe University, Melbourne, VIC, Australia
| | - Gisbert Weckbecker
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, Basel, Switzerland
| | - Rainer Kneuer
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, Basel, Switzerland
| | - Rajiv Bhalla
- Centre for Advanced Imaging, The University of Queensland, Brisbane, QLD, Australia.,ARC Training Centre for Innovation in Biomedical Imaging Technology, Brisbane, QLD, Australia
| | - David C Reutens
- Centre for Advanced Imaging, The University of Queensland, Brisbane, QLD, Australia.,ARC Training Centre for Innovation in Biomedical Imaging Technology, Brisbane, QLD, Australia
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250
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Goodman AD, Anadani N, Gerwitz L. Siponimod in the treatment of multiple sclerosis. Expert Opin Investig Drugs 2019; 28:1051-1057. [PMID: 31603362 DOI: 10.1080/13543784.2019.1676725] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Multiple sclerosis (MS) causes focal lesions of immune-mediated demyelinating events followed by slow progressive accumulation of disability. Over the past 2 decades, multiple medications have been studied and approved for use in MS. Most of these agents work by modulating or suppressing the peripheral immune system. Siponimod is a newer-generation sphingosine 1 phosphate (S1P) receptor modulator that internalizes S1P1 receptors, thereby inhibiting efflux of lymphocytes from lymph nodes and thymus. There are promising data suggesting that it may also have a direct neuroprotective property independent of peripheral lymphocytopenia.Areas covered: We reviewed the pharmacology and the clinical and radiological effects of siponimod.Expert opinion: The selective effect of siponimod on the S1P1 and S1P5 receptors offers a favorable side-effect profile and transient bradycardia can be avoided by dose titration. A phase-II study showed that siponomod has dose-dependent beneficial effects in patients with relapsing remitting disease. The results of a phase-III study suggest that siponimod may be beneficial in secondary progressive MS, at least in patients with disease activity.
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Affiliation(s)
- Andrew D Goodman
- Neuroimmunology Division, Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Nidhiben Anadani
- Department of Neurology, University of Oklahoma Medical Center, Oklahoma City, OK, USA
| | - Lee Gerwitz
- Neuroimmunology Division, Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
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