1
|
Hallberg S, Evertsson B, Lillvall E, Boremalm M, de Flon P, Wang Y, Salzer J, Lycke J, Fink K, Frisell T, Al Nimer F, Svenningsson A. Hypogammaglobulinaemia during rituximab treatment in multiple sclerosis: A Swedish cohort study. Eur J Neurol 2024; 31:e16331. [PMID: 38794973 DOI: 10.1111/ene.16331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/08/2024] [Accepted: 04/24/2024] [Indexed: 05/27/2024]
Abstract
BACKGROUND AND PURPOSE Mechanisms behind hypogammaglobulinaemia during rituximab treatment are poorly understood. METHODS In this register-based multi-centre retrospective cohort study of multiple sclerosis (MS) patients in Sweden, 2745 patients from six participating Swedish MS centres were identified via the Swedish MS registry and included between 14 March 2008 and 25 January 2021. The exposure was treatment with at least one dose of rituximab for MS or clinically isolated syndrome, including data on treatment duration and doses. The degree of yearly decrease in immunoglobulin G (IgG) and immunoglobulin M (IgM) levels was evaluated. RESULTS The mean decrease in IgG was 0.27 (95% confidence interval 0.17-0.36) g/L per year on rituximab treatment, slightly less in older patients, and without significant difference between sexes. IgG or IgM below the lower limit of normal (<6.7 or <0.27 g/L) was observed in 8.8% and 8.3% of patients, respectively, as nadir measurements. Six out of 2745 patients (0.2%) developed severe hypogammaglobulinaemia (IgG below 4.0 g/L) during the study period. Time on rituximab and accumulated dose were the main predictors for IgG decrease. Previous treatment with fingolimod and natalizumab, but not teriflunomide, dimethyl fumarate, interferons or glatiramer acetate, were significantly associated with lower baseline IgG levels by 0.80-1.03 g/L, compared with treatment-naïve patients. Switching from dimethyl fumarate or interferons was associated with an additional IgG decline of 0.14-0.19 g/L per year, compared to untreated. CONCLUSIONS Accumulated dose and time on rituximab treatment are associated with a modest but significant decline in immunoglobulin levels. Previous MS therapies may influence additional IgG decline.
Collapse
Affiliation(s)
- Susanna Hallberg
- Department of Clinical Sciences, Karolinska Institutet, Danderyds Sjukhus, Stockholm, Sweden
| | - Björn Evertsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Ellen Lillvall
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Malin Boremalm
- Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
| | - Pierre de Flon
- Department of Clinical Sciences, Neurosciences, Unit of Neurology, Östersund, Umeå University, Umeå, Sweden
| | - Yunzhang Wang
- Department of Clinical Sciences, Karolinska Institutet, Danderyds Sjukhus, Stockholm, Sweden
| | - Jonatan Salzer
- Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
| | - Jan Lycke
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Katharina Fink
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Frisell
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Faiez Al Nimer
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Anders Svenningsson
- Department of Clinical Sciences, Karolinska Institutet, Danderyds Sjukhus, Stockholm, Sweden
| |
Collapse
|
2
|
Kalincik T, Sharmin S, Roos I, Massey J, Sutton I, Withers B, Freedman MS, Atkins H, Krasulova E, Kubala Havrdova E, Trneny M, Kozak T, Burman J, Macdonell R, Torkildsen Ø, Bø L, Lehmann AK, Sharrack B, Snowden J. Effectiveness of autologous haematopoietic stem cell transplantation versus natalizumab in progressive multiple sclerosis. J Neurol Neurosurg Psychiatry 2024; 95:775-783. [PMID: 38538060 DOI: 10.1136/jnnp-2023-332790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 02/12/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Natalizumab was not shown to modify disability in progressive multiple sclerosis (MS). This matched observational study compared the effectiveness of autologous haematopoietic stem cell transplantation (AHSCT) with natalizumab in progressive MS. METHODS Patients with primary/secondary progressive MS from seven AHSCT MS centres and the MSBase registry, treated with AHSCT or natalizumab, were matched on a propensity score derived from sex, age, Expanded Disability Status Scale (EDSS), number of relapses 12/24 months before baseline, time from MS onset, the most effective prior therapy and country. The pairwise-censored groups were compared on hazards of 6-month confirmed EDSS worsening and improvement, relapses and annualised relapse rates (ARRs), using Andersen-Gill proportional hazards models and conditional negative binomial model. RESULTS 39 patients treated with AHSCT (37 with secondary progressive MS, mean age 37 years, EDSS 5.7, 28% with recent disability progression, ARR 0.54 during the preceding year) were matched with 65 patients treated with natalizumab. The study found no evidence for difference in hazards of confirmed EDSS worsening (HR 1.49, 95% CI 0.70 to 3.14) and improvement (HR 1.50, 95% CI 0.22 to 10.29) between AHSCT and natalizumab over up to 4 years. The relapse activity was also similar while treated with AHSCT and natalizumab (ARR: mean±SD 0.08±0.28 vs 0.08±0.25; HR 1.05, 95% CI 0.39 to 2.82). In the AHSCT group, 3 patients experienced febrile neutropenia during mobilisation, 9 patients experienced serum sickness, 6 patients required intensive care unit admission and 36 patients experienced complications after discharge. No treatment-related deaths were reported. CONCLUSION This study does not support the use of AHSCT to control disability in progressive MS with advanced disability and low relapse activity.
Collapse
Affiliation(s)
- Tomas Kalincik
- CORe, Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Sifat Sharmin
- CORe, Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Izanne Roos
- CORe, Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Jennifer Massey
- Department of Neurology, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Ian Sutton
- Department of Neurology, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- University of New South Wales, Sydney, New South Wales, Australia
- University of Syndey, Sydney, New South Wales, Australia
| | - Barbara Withers
- St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Haematology, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
| | - Mark S Freedman
- Department of Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Harold Atkins
- Department of Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Eva Krasulova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University, Prague, Czech Republic
- General University Hospital in Prague, Prague, Czech Republic
| | - Eva Kubala Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University, Prague, Czech Republic
- General University Hospital in Prague, Prague, Czech Republic
| | - Marek Trneny
- General University Hospital in Prague, Prague, Czech Republic
- Department of Haematology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Tomas Kozak
- Department of Haematology, Third Faculty of Medicine, Charles University, Prague, Czech Republic
- University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Joachim Burman
- Department of Medical Sciences, Neurology, Uppsala University, Uppsala, Sweden
| | - Richard Macdonell
- Department of Neurology, Austin Health, Melbourne, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | - Øivind Torkildsen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Lars Bø
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | | | - Basil Sharrack
- Department of Neuroscience and Sheffield NIHR Translational Neuroscience Biomedical Research Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - John Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Oncology and Metabolism, Medical School, The University of Sheffield, Sheffield, UK
| |
Collapse
|
3
|
Bava CI, Valentino P, Malucchi S, Bottero R, Martire S, Sapio AD, Bertolotto A. Prevalence of elevated sNFL in a real-world setting: Results on 908 patients with different multiple sclerosis types and treatment conditions. Mult Scler Relat Disord 2024; 88:105748. [PMID: 38959590 DOI: 10.1016/j.msard.2024.105748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 06/18/2024] [Accepted: 06/23/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND In the field of research for new validated surrogate biomarkers of treatment efficacy, disease activity and progression in Multiple Sclerosis (MS), serum neurofilament light-chain (sNFL) are actually the best candidate for MS patient monitoring. However, before they can be implemented in clinical practice, their usefulness as additional red flag routine measure must be demonstrated. To tackle the problem, this real-life cross-sectional study at the Regional Referring Center for Multiple Sclerosis (CRESM) aims to characterize sNFL levels and prevalence of elevated sNFL, according to our age-dependent cut-off values, in a large group of patients with different types of MS and treatment conditions. METHODS 908 serum samples from as many MS patients being admitted at CRESM for diagnostic definition and/or during routinary treatment monitoring were consecutively collected between January 2019 and January 2020. sNFL levels were measured by single molecule array (Simoa™) technology on SR-X instrument using NF-light assays (Quanterix); results were interpreted using previously published cut-off values. RESULTS Primary and Secondary Progressive MS (PPMS, SPMS) forms demonstrate higher levels and prevalence of elevated sNFL (PPMS= 32 %, SPMS= 21 %) compared to the Relapse and Remitting one (RRMS = 12 %). Besides, naïve samples of RRMS and PPMS subtypes showed higher prevalence of elevated sNFL (RRMS naïve= 31 %, PPMS naïve=67 %) compared to samples from patients treated for more than 12 months (RRMS treat>12m= 9 %, PPMS treat>12m= 19 %); treated SPMS patients demonstrated higher sNFL levels and a prevalence (22 %) of elevated sNFL compared to RRMS treated patients. Focusing on RRMS, no statistical difference was found between groups of patients treated for whatever time (up to or more than 60 months) and with either DMT type (high or low-efficacy DMT). Finally, RRMS patients treated with all DMTs for more than 12 months, with the exception of teriflunomide and alemtuzumab showed a prevalence of elevated sNFL in the range of 5-10 %. CONCLUSION in a real-world setting comprising about 1000 MS patients, sNFL quantification was elevated in 5-to-67 % of patients, in different MS forms and treatment conditions. Elevated levels of sNFL must be considered a red-flag suggesting the need of a further clinical monitoring in any circumstance, as it can be indicative of new inflammation, ongoing degeneration or co-morbidities. This study supports the introduction of sNFL quantification in everyday patient management.
Collapse
Affiliation(s)
- Cecilia Irene Bava
- NICO - Neuroscience Institute Cavalieri Ottolenghi, Orbassano, Italy; CRESM Biobank, University Hospital San Luigi Gonzaga, Orbassano, Italy; Department of Neurology and CRESM, University Hospital San Luigi Gonzaga, Orbassano, Italy.
| | - Paola Valentino
- NICO - Neuroscience Institute Cavalieri Ottolenghi, Orbassano, Italy
| | - Simona Malucchi
- Department of Neurology and CRESM, University Hospital San Luigi Gonzaga, Orbassano, Italy
| | - Rugiada Bottero
- Department of Neurology and CRESM, University Hospital San Luigi Gonzaga, Orbassano, Italy
| | - Serena Martire
- CRESM Biobank, University Hospital San Luigi Gonzaga, Orbassano, Italy; Department of Neuroscience "Rita Levi Montalcini", University of Turin, Italy
| | - Alessia Di Sapio
- CRESM Biobank, University Hospital San Luigi Gonzaga, Orbassano, Italy; Department of Neurology and CRESM, University Hospital San Luigi Gonzaga, Orbassano, Italy
| | | |
Collapse
|
4
|
Piehl F, Alping P, Virtanen S, Englund S, Burman J, Fink K, Fogdell-Hahn A, Gunnarsson M, Hillert J, Langer-Gould A, Lycke J, Mellergård J, Nilsson P, Olsson T, Salzer J, Svenningsson A, Frisell T. COMBAT-MS: A Population-Based Observational Cohort Study Addressing the Benefit-Risk Balance of Multiple Sclerosis Therapies Compared with Rituximab. Ann Neurol 2024. [PMID: 38923558 DOI: 10.1002/ana.27012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 05/28/2024] [Accepted: 06/04/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE To assess comparative effectiveness, safety, and tolerability of off-label rituximab, compared with frequently used therapies approved for multiple sclerosis (MS). METHODS A Swedish cohort study of persons with relapsing-remitting MS, age 18 to 75 years at inclusion and with a first therapy start or a first therapy switch between 2011 and 2018. Low-dose rituximab was compared with MS-approved therapies. Primary outcomes were proportions with 12 months confirmed disability worsening and change in MS Impact Scale-29 (MSIS-29) scores, respectively. Secondary endpoints included relapses, therapy discontinuation, and serious adverse events. Analyses used an intention-to-treat approach and were adjusted for demographics, MS features, and health characteristics. RESULTS We included 2,449 participants as first therapy start and 2,463 as first therapy switch. Proportions with disability worsening at 3 years were 9.1% for rituximab as first therapy and 5.1% after therapy switch, with no differences to MS-approved comparators. Worsening on rituximab was mostly independent of relapses. MSIS-29 with rituximab at 3 years improved by 1.3/8.4 points (physical/psychological) for first disease-modifying therapy (DMT) and 0.4/3.6 for DMT switch, and was mostly similar across therapies. Rituximab had lower relapse rates and higher therapy persistence in both groups. The rate of hospital-treated infections was higher with rituximab after a therapy switch, but not as a first therapy. INTERPRETATION This population-based real-world cohort study found low rates of disability progression, mostly independent of relapses, and without significant differences between rituximab and MS-approved comparators. Rituximab led to lower rates of inflammatory activity and higher treatment persistence, but was associated with an increased rate of serious infections. ANN NEUROL 2024.
Collapse
Affiliation(s)
- Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Academic Specialist Center, Stockholm Health Services, Stockholm, Sweden
| | - Peter Alping
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Suvi Virtanen
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Simon Englund
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Joachim Burman
- Department of Neurology, Uppsala University Hospital, and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Katharina Fink
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Fogdell-Hahn
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Martin Gunnarsson
- Department of Neurology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jan Hillert
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Annette Langer-Gould
- Clinical and Translational Neuroscience, Southern California Permanente Medical Group, Kaiser Permanente, Los Angeles, CA, USA
| | - Jan Lycke
- Department of Neurology, Sahlgrenska University Hospital, and Department of Clinical Neuroscience, University of Gothenburg, Gothenburg, Sweden
| | - Johan Mellergård
- Department of Neurology in Linköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Petra Nilsson
- Department of Neurology, Skåne University Hospital, and Department of Clinical Sciences/Neurology, Lund University, Lund, Sweden
| | - Tomas Olsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Jonatan Salzer
- Department of Neurology, Umeå University Hospital, and Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
| | - Anders Svenningsson
- Department of Neurology, Danderyd Hospital, and Department of Clinical Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Frisell
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
5
|
Alping P, Neovius M, Piehl F, Frisell T. Real-World Healthcare Cost Savings and Reduced Relapse Rate with Off-Label Rituximab versus Disease-Modifying Treatments Approved for Relapsing-Remitting Multiple Sclerosis: A Nationwide Cost-Effectiveness Study. Ann Neurol 2024; 95:1099-1111. [PMID: 38529711 DOI: 10.1002/ana.26914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 02/28/2024] [Accepted: 03/04/2024] [Indexed: 03/27/2024]
Abstract
OBJECTIVE Although off-label use of rituximab is a common alternative to disease-modifying therapies (DMTs) approved for multiple sclerosis (MS) in several countries, the impact of this on treatment cost-effectiveness is not well known. METHODS We evaluated the relative cost-effectiveness of rituximab and MS-approved DMTs in a register-based cohort study of Swedish residents with relapsing-remitting MS, aged 18-65 years, starting treatment with rituximab, natalizumab, fingolimod, or dimethyl fumarate between January 2010 and July 2016, and followed through July 2021 (n = 5,924). By linking the population-based Swedish MS register to several Swedish health care and demographic registers, we estimated health care costs in relation to number of relapses, over 5 years from treatment start. Differences between treatments were estimated in inverse probability of treatment-weighted regression models, adjusting for a broad range of potential confounders covering demographics, medical history, and MS-related clinical characteristics. RESULTS Off-label rituximab was associated with both lower total health care costs (mean cost savings ranged $35,000-$66,000 vs. each approved DMT), and fewer relapses (mean number of prevented relapses ranged 0.12-0.22), per started therapy over 5 years. Results were robust to variations in discounting and pricing of health care visits, with the main driver of cost-savings being the price of the index drug itself. INTERPRETATION The cost-effectiveness of rituximab dominated the MS-approved alternatives. Off-label, low-dose rituximab should be considered for persons with MS and could reduce barriers to treatment, especially in resource-limited settings. ANN NEUROL 2024;95:1099-1111.
Collapse
Affiliation(s)
- Peter Alping
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Martin Neovius
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Frisell
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
6
|
Graille-Avy L, Boutiere C, Rigollet C, Perriguey M, Rico A, Demortiere S, Durozard P, Hilezian F, Vely F, Bertault-Peres P, Pelletier J, Maarouf A, Audoin B. Effect of Prior Treatment With Fingolimod on Early and Late Response to Rituximab/Ocrelizumab in Patients With Multiple Sclerosis. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200231. [PMID: 38626360 PMCID: PMC11090020 DOI: 10.1212/nxi.0000000000200231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 02/02/2024] [Indexed: 04/18/2024]
Abstract
BACKGROUND AND OBJECTIVES Real-life studies noted that the risk of disease activity in multiple sclerosis (MS) after switching to rituximab (RTX) or ocrelizumab (OCR) may be unequal depending on prior disease-modifying therapy (DMT), with a higher risk associated with fingolimod (FING). METHODS We performed a retrospective analysis of a structured prospective data collection including all consecutive patients with relapsing MS who were prescribed RTX/OCR in the MS center of Marseille. Cox proportional hazards models were applied to clinical and MRI outcomes. RESULTS We included 321 patients with a median (interquartile range [IQR]) follow-up of 3.5 years (1.5-5) after RTX/OCR initiation. At the first RTX/OCR infusion, the mean (SD) age of patients was 37 (10) years, and the median (IQR) disease duration was 8 years (3-15): 68 patients did not receive treatment before RTX/OCR and 108 switched from FING, 47 from low efficacy therapy, and 98 from natalizumab. For statistical analysis, the group "FING" was divided into "short-FING" and "long-FING" groups according to the median value of the group's washout period (27 days). On Cox proportional hazards analysis, for only the "long-FING" group, the risk of relapse within the first 6 months of RTX/OCR was increased as compared with patients without previous DMT (hazard ratio [HR]: 8.78; 95% CI 1.72-44.86; p < 0.01). Previous DMT and washout period duration of FING had no effect on B-cell levels at 6 months. Beyond the first 6 months of RTX/OCR, age <40 years was associated with increased risk of relapse (HR: 3.93; 95% CI 1.30-11.89; p = 0.01), male sex with increased risk of new T2 lesions (HR: 2.26; 95% CI 1.08-4.74; p = 0.03), and EDSS ≥2 with increased risk of disability accumulation (HR: 3.01; 95% CI 1.34-6.74; p < 0.01). Previous DMT had no effect on the effectiveness of RTX/OCR beyond 6 months after initiation. DISCUSSION For patients switching from FING to RTX/OCR, the risk of disease reactivation within the first 6 months of treatment was increased as compared with patients with other DMT or no previous DMT only when the washout period exceeded 26 days. Neither FING nor other previous DMT reduced the effectiveness of RTX/OCR beyond the first 6 months of treatment.
Collapse
Affiliation(s)
- Lisa Graille-Avy
- From the APHM (L.G.-A., C.B., C.R., M.P., A.R., S.D., F.H., J.P., A.M., B.A.), Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie; Aix-Marseille University (A.R., J.P., A.M., B.A.), CNRS, CRMBM, Marseille; Centre hospitalier d'Ajaccio (P.D.), Service de Neurologie, Ajaccio; APHM (F.V.), Hôpital de la Timone, Service d'immunologie, Marseille Immunopôle; Aix Marseille University (F.V.), CNRS, INSERM, CIML; and APHM (P.B.-P.), Hôpital de la Timone, Service Pharmacie, Marseille, France
| | - Clemence Boutiere
- From the APHM (L.G.-A., C.B., C.R., M.P., A.R., S.D., F.H., J.P., A.M., B.A.), Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie; Aix-Marseille University (A.R., J.P., A.M., B.A.), CNRS, CRMBM, Marseille; Centre hospitalier d'Ajaccio (P.D.), Service de Neurologie, Ajaccio; APHM (F.V.), Hôpital de la Timone, Service d'immunologie, Marseille Immunopôle; Aix Marseille University (F.V.), CNRS, INSERM, CIML; and APHM (P.B.-P.), Hôpital de la Timone, Service Pharmacie, Marseille, France
| | - Camille Rigollet
- From the APHM (L.G.-A., C.B., C.R., M.P., A.R., S.D., F.H., J.P., A.M., B.A.), Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie; Aix-Marseille University (A.R., J.P., A.M., B.A.), CNRS, CRMBM, Marseille; Centre hospitalier d'Ajaccio (P.D.), Service de Neurologie, Ajaccio; APHM (F.V.), Hôpital de la Timone, Service d'immunologie, Marseille Immunopôle; Aix Marseille University (F.V.), CNRS, INSERM, CIML; and APHM (P.B.-P.), Hôpital de la Timone, Service Pharmacie, Marseille, France
| | - Marine Perriguey
- From the APHM (L.G.-A., C.B., C.R., M.P., A.R., S.D., F.H., J.P., A.M., B.A.), Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie; Aix-Marseille University (A.R., J.P., A.M., B.A.), CNRS, CRMBM, Marseille; Centre hospitalier d'Ajaccio (P.D.), Service de Neurologie, Ajaccio; APHM (F.V.), Hôpital de la Timone, Service d'immunologie, Marseille Immunopôle; Aix Marseille University (F.V.), CNRS, INSERM, CIML; and APHM (P.B.-P.), Hôpital de la Timone, Service Pharmacie, Marseille, France
| | - Audrey Rico
- From the APHM (L.G.-A., C.B., C.R., M.P., A.R., S.D., F.H., J.P., A.M., B.A.), Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie; Aix-Marseille University (A.R., J.P., A.M., B.A.), CNRS, CRMBM, Marseille; Centre hospitalier d'Ajaccio (P.D.), Service de Neurologie, Ajaccio; APHM (F.V.), Hôpital de la Timone, Service d'immunologie, Marseille Immunopôle; Aix Marseille University (F.V.), CNRS, INSERM, CIML; and APHM (P.B.-P.), Hôpital de la Timone, Service Pharmacie, Marseille, France
| | - Sarah Demortiere
- From the APHM (L.G.-A., C.B., C.R., M.P., A.R., S.D., F.H., J.P., A.M., B.A.), Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie; Aix-Marseille University (A.R., J.P., A.M., B.A.), CNRS, CRMBM, Marseille; Centre hospitalier d'Ajaccio (P.D.), Service de Neurologie, Ajaccio; APHM (F.V.), Hôpital de la Timone, Service d'immunologie, Marseille Immunopôle; Aix Marseille University (F.V.), CNRS, INSERM, CIML; and APHM (P.B.-P.), Hôpital de la Timone, Service Pharmacie, Marseille, France
| | - Pierre Durozard
- From the APHM (L.G.-A., C.B., C.R., M.P., A.R., S.D., F.H., J.P., A.M., B.A.), Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie; Aix-Marseille University (A.R., J.P., A.M., B.A.), CNRS, CRMBM, Marseille; Centre hospitalier d'Ajaccio (P.D.), Service de Neurologie, Ajaccio; APHM (F.V.), Hôpital de la Timone, Service d'immunologie, Marseille Immunopôle; Aix Marseille University (F.V.), CNRS, INSERM, CIML; and APHM (P.B.-P.), Hôpital de la Timone, Service Pharmacie, Marseille, France
| | - Frederic Hilezian
- From the APHM (L.G.-A., C.B., C.R., M.P., A.R., S.D., F.H., J.P., A.M., B.A.), Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie; Aix-Marseille University (A.R., J.P., A.M., B.A.), CNRS, CRMBM, Marseille; Centre hospitalier d'Ajaccio (P.D.), Service de Neurologie, Ajaccio; APHM (F.V.), Hôpital de la Timone, Service d'immunologie, Marseille Immunopôle; Aix Marseille University (F.V.), CNRS, INSERM, CIML; and APHM (P.B.-P.), Hôpital de la Timone, Service Pharmacie, Marseille, France
| | - Frederic Vely
- From the APHM (L.G.-A., C.B., C.R., M.P., A.R., S.D., F.H., J.P., A.M., B.A.), Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie; Aix-Marseille University (A.R., J.P., A.M., B.A.), CNRS, CRMBM, Marseille; Centre hospitalier d'Ajaccio (P.D.), Service de Neurologie, Ajaccio; APHM (F.V.), Hôpital de la Timone, Service d'immunologie, Marseille Immunopôle; Aix Marseille University (F.V.), CNRS, INSERM, CIML; and APHM (P.B.-P.), Hôpital de la Timone, Service Pharmacie, Marseille, France
| | - Pierre Bertault-Peres
- From the APHM (L.G.-A., C.B., C.R., M.P., A.R., S.D., F.H., J.P., A.M., B.A.), Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie; Aix-Marseille University (A.R., J.P., A.M., B.A.), CNRS, CRMBM, Marseille; Centre hospitalier d'Ajaccio (P.D.), Service de Neurologie, Ajaccio; APHM (F.V.), Hôpital de la Timone, Service d'immunologie, Marseille Immunopôle; Aix Marseille University (F.V.), CNRS, INSERM, CIML; and APHM (P.B.-P.), Hôpital de la Timone, Service Pharmacie, Marseille, France
| | - Jean Pelletier
- From the APHM (L.G.-A., C.B., C.R., M.P., A.R., S.D., F.H., J.P., A.M., B.A.), Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie; Aix-Marseille University (A.R., J.P., A.M., B.A.), CNRS, CRMBM, Marseille; Centre hospitalier d'Ajaccio (P.D.), Service de Neurologie, Ajaccio; APHM (F.V.), Hôpital de la Timone, Service d'immunologie, Marseille Immunopôle; Aix Marseille University (F.V.), CNRS, INSERM, CIML; and APHM (P.B.-P.), Hôpital de la Timone, Service Pharmacie, Marseille, France
| | - Adil Maarouf
- From the APHM (L.G.-A., C.B., C.R., M.P., A.R., S.D., F.H., J.P., A.M., B.A.), Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie; Aix-Marseille University (A.R., J.P., A.M., B.A.), CNRS, CRMBM, Marseille; Centre hospitalier d'Ajaccio (P.D.), Service de Neurologie, Ajaccio; APHM (F.V.), Hôpital de la Timone, Service d'immunologie, Marseille Immunopôle; Aix Marseille University (F.V.), CNRS, INSERM, CIML; and APHM (P.B.-P.), Hôpital de la Timone, Service Pharmacie, Marseille, France
| | - Bertrand Audoin
- From the APHM (L.G.-A., C.B., C.R., M.P., A.R., S.D., F.H., J.P., A.M., B.A.), Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie; Aix-Marseille University (A.R., J.P., A.M., B.A.), CNRS, CRMBM, Marseille; Centre hospitalier d'Ajaccio (P.D.), Service de Neurologie, Ajaccio; APHM (F.V.), Hôpital de la Timone, Service d'immunologie, Marseille Immunopôle; Aix Marseille University (F.V.), CNRS, INSERM, CIML; and APHM (P.B.-P.), Hôpital de la Timone, Service Pharmacie, Marseille, France
| |
Collapse
|
7
|
Tallantyre EC, Dobson R, Froud JLJ, St John FA, Anderson VM, Arun T, Buckley L, Evangelou N, Ford HL, Galea I, George S, Gray OM, Hibbert AM, Hu M, Hughes SE, Ingram G, Kalra S, Lim CHE, Mathews JTM, McDonnell GV, Mescall N, Norris S, Ramsay SJ, Rice CM, Russell MJ, Shawe-Taylor MJ, Williams TE, Harding KE, Robertson NP. Real-world persistence of multiple sclerosis disease-modifying therapies. Eur J Neurol 2024:e16289. [PMID: 38567516 DOI: 10.1111/ene.16289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 02/26/2024] [Accepted: 03/14/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND AND PURPOSE Treatment persistence is the continuation of therapy over time. It reflects a combination of treatment efficacy and tolerability. We aimed to describe real-world rates of persistence on disease-modifying therapies (DMTs) for people with multiple sclerosis (pwMS) and reasons for DMT discontinuation. METHODS Treatment data on 4366 consecutive people with relapse-onset multiple sclerosis (MS) were pooled from 13 UK specialist centres during 2021. Inclusion criteria were exposure to at least one MS DMT and a complete history of DMT prescribing. PwMS in blinded clinical trials were excluded. Data collected included sex, age at MS onset, age at DMT initiation, DMT treatment dates, and reasons for stopping or switching DMT. For pwMS who had received immune reconstituting therapies (cladribine/alemtuzumab), discontinuation date was defined as starting an alternative DMT. Kaplan-Meier survival analyses were used to express DMT persistence. RESULTS In 6997 treatment events (1.6 per person with MS), median time spent on any single maintenance DMT was 4.3 years (95% confidence interval = 4.1-4.5 years). The commonest overall reasons for DMT discontinuation were adverse events (35.0%) and lack of efficacy (30.3%). After 10 years, 20% of people treated with alemtuzumab had received another subsequent DMT, compared to 82% of people treated with interferon or glatiramer acetate. CONCLUSIONS Immune reconstituting DMTs may have the highest potential to offer a single treatment for relapsing MS. Comparative data on DMT persistence and reasons for discontinuation are valuable to inform treatment decisions and in personalizing treatment in MS.
Collapse
Affiliation(s)
- Emma C Tallantyre
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
- Department of Neurology, University Hospital of Wales, Cardiff, UK
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University London, London, UK
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Joseph L J Froud
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
- Postgraduate Department, St Thomas' Hospital, London, UK
| | - Frederika A St John
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
| | - Valerie M Anderson
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
| | - Tarunya Arun
- Department of Neuroscience, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Lauren Buckley
- Department of Neurology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Nikos Evangelou
- Nottingham Centre for Multiple Sclerosis and Neuroinflammation, Queen's Medical Centre, University Hospitals NHS Trust, Nottingham, UK
- University of Nottingham, Nottingham, UK
| | - Helen L Ford
- Centre for Neurosciences, Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds, UK
- Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Ian Galea
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Department of Neurology, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Sumi George
- Department of Neurology, Ulster Hospital, Dundonald, UK
| | - Orla M Gray
- Department of Neurology, Ulster Hospital, Dundonald, UK
| | - Aimee M Hibbert
- Nottingham Centre for Multiple Sclerosis and Neuroinflammation, Queen's Medical Centre, University Hospitals NHS Trust, Nottingham, UK
| | - Mo Hu
- Department of Neurology, Swansea University Health Board, Swansea, UK
| | | | - Gillian Ingram
- Department of Neurology, Swansea University Health Board, Swansea, UK
| | - Seema Kalra
- Neurology Department, University Hospital North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Chia-Hui E Lim
- Department of Neurology, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | | | - Naomi Mescall
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, University College London, London, UK
| | - Sam Norris
- Aneurin Bevan University Health Board, Department of Neurology, Royal Gwent Hospital, Newport, UK
| | | | - Claire M Rice
- Department of Neurology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
- Transplantation Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Melanie J Russell
- Centre for Neurosciences, Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds, UK
| | - Marianne J Shawe-Taylor
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, University College London, London, UK
| | - Thomas E Williams
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, University College London, London, UK
- Faculty of Brain Sciences, Queen Square Institute of Neurology, University College London, London, UK
| | - Katharine E Harding
- Aneurin Bevan University Health Board, Department of Neurology, Royal Gwent Hospital, Newport, UK
| | - Neil P Robertson
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
- Department of Neurology, University Hospital of Wales, Cardiff, UK
| |
Collapse
|
8
|
Mostkowska A, Rousseau G, Raynal NJM. Repurposing of rituximab biosimilars to treat B cell mediated autoimmune diseases. FASEB J 2024; 38:e23536. [PMID: 38470360 DOI: 10.1096/fj.202302259rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 02/12/2024] [Accepted: 02/21/2024] [Indexed: 03/13/2024]
Abstract
Rituximab, the first monoclonal antibody approved for the treatment of lymphoma, eventually became one of the most popular and versatile drugs ever in terms of clinical application and revenue. Since its patent expiration, and consequently, the loss of exclusivity of the original biologic, its repurposing as an off-label drug has increased dramatically, propelled by the development and commercialization of its many biosimilars. Currently, rituximab is prescribed worldwide to treat a vast range of autoimmune diseases mediated by B cells. Here, we present a comprehensive overview of rituximab repurposing in 115 autoimmune diseases across 17 medical specialties, sourced from over 1530 publications. Our work highlights the extent of its off-label use and clinical benefits, underlining the success of rituximab repurposing for both common and orphan immune-related diseases. We discuss the scientific mechanism associated with its clinical efficacy and provide additional indications for which rituximab could be investigated. Our study presents rituximab as a flagship example of drug repurposing owing to its central role in targeting cluster of differentiate 20 positive (CD20) B cells in 115 autoimmune diseases.
Collapse
Affiliation(s)
- Agata Mostkowska
- Department of Pharmacology and Physiology, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Guy Rousseau
- Department of Pharmacology and Physiology, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Noël J-M Raynal
- Department of Pharmacology and Physiology, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- Centre de recherche du CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| |
Collapse
|
9
|
Ongphichetmetha T, Jitprapaikulsan J, Siritho S, Rattanathamsakul N, Detweeratham T, Prayoonwiwat N. Efficacy and safety of rituximab in multiple sclerosis and neuromyelitis optica spectrum disorder. Sci Rep 2024; 14:3503. [PMID: 38347079 PMCID: PMC10861443 DOI: 10.1038/s41598-024-53838-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 02/06/2024] [Indexed: 02/15/2024] Open
Abstract
In Thailand, resource limitations lead many multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) patients to use off-label immunosuppressants. This study assesses the efficacy and safety of rituximab (RTX) with a CD19-based reinfusion regimen among Thai MS and NMOSD patients. A retrospective review of patients at the Faculty of Medicine Siriraj Hospital from January 1994 to April 2023 was conducted. The primary outcome assessed was the change in annualized relapse rate (ARR) for patients using RTX for over a year. Secondary outcomes included changes in the Expanded Disability Status Scale (EDSS) scores, time to the first relapse after RTX initiation for patients using RTX for over a year, and an evaluation of the safety of RTX. The study encompassed 36 MS and 39 NMOSD patients. A majority of patients (91.7% of MS and 79.5% of NMOSD) experienced no relapses during a median follow-up of 30 months (Interquartile range [IQR] 20-46) and 31 months (IQR 23-41), respectively. The median ARR significantly decreased in both MS (from 0.77 [IQR 0.42-1.83] to 0 [IQR 0-0], p < 0.001) and NMOSD (from 0.92 [IQR 0.68-1.78] to 0 [IQR 0-0.17], p < 0.001) patients after switching to RTX, with no difference between those following a fixed 6-month time point regimen and a CD19-based reinfusion regimen. Median EDSS scores improved significantly at the last follow-up visit in both groups. The mean time to the first subsequent relapse was 8.3 ± 3.0 months in MS and 6.8 ± 1.7 months in NMOSD. Mild adverse drug reactions occurred in 44% of patients. RTX effectively prevents relapses in Thai MS and NMOSD patients, with no observed serious adverse drug reactions.
Collapse
Affiliation(s)
- Tatchaporn Ongphichetmetha
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd, Siriraj, Bangkok noi, Bangkok, 10700, Thailand
- Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
- Division of Clinical Epidemiology, Department of Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
| | - Jiraporn Jitprapaikulsan
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd, Siriraj, Bangkok noi, Bangkok, 10700, Thailand
- Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
| | - Sasitorn Siritho
- Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
- Bumrungrad International Hospital, Bangkok, 10110, Thailand
| | - Natthapon Rattanathamsakul
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd, Siriraj, Bangkok noi, Bangkok, 10700, Thailand
- Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
| | - Thammachet Detweeratham
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd, Siriraj, Bangkok noi, Bangkok, 10700, Thailand
| | - Naraporn Prayoonwiwat
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd, Siriraj, Bangkok noi, Bangkok, 10700, Thailand.
- Siriraj Neuroimmunology Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand.
| |
Collapse
|
10
|
Aboseif A, Roos I, Krieger S, Kalincik T, Hersh CM. Leveraging Real-World Evidence and Observational Studies in Treating Multiple Sclerosis. Neurol Clin 2024; 42:203-227. [PMID: 37980116 DOI: 10.1016/j.ncl.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
Randomized controlled trials (RCTs) are essential for regulatory approval of disease-modifying therapies (DMTs), yet their strict selection criteria often lead to limited generalizability. Observational studies using real-world data (RWD) allow for more inclusive heterogeneous cohorts resulting in higher external validity to inform treatment practices. As reviewed in this article, well-designed comparative effectiveness studies are an important application of RWD. Although, like RCTs, observational studies have their own set of limitations, including various biases that may confound results, advanced statistical methods can mitigate many of these limitations. A focus on personalized treatment will continue to add value to individualize MS care.
Collapse
Affiliation(s)
- Albert Aboseif
- Department of Neurology, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue S10, Cleveland, OH 44195, USA
| | - Izanne Roos
- Department of Neurology, Neuroimmunology Centre, Royal Melbourne Hospital, L7 635 Elizabeth Street, Melbourne 3000, Australia; Department of Medicine, CORe, University of Melbourne, Melbourne, Australia
| | - Stephen Krieger
- Corinne Goldsmith Dickinson Center for MS Icahn School of Medicine at Mount Sinai, 5 East 98th Street, Box 1138, New York, NY 10029, USA
| | - Tomas Kalincik
- Department of Medicine, CORe, University of Melbourne, Melbourne, Australia; Department of Neurology, Neuroimmunology Centre, Royal Melbourne Hospital, L6 635 Elizabeth Street, Melbourne 3000, Australia
| | - Carrie M Hersh
- Lou Ruvo Center for Brain Health, Cleveland Clinic, 888 West Bonneville Avenue, Las Vegas, NV 89106, USA.
| |
Collapse
|
11
|
Langer-Gould A, Sotirchos ES, Bourdette D. Rituximab for Multiple Sclerosis: Hiding in Plain Sight. Neurology 2024; 102:e208063. [PMID: 38165314 PMCID: PMC10962910 DOI: 10.1212/wnl.0000000000208063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 10/13/2023] [Indexed: 01/03/2024] Open
Abstract
In February 2023, following extensive discussions with stakeholders and data review, the Institute for Clinical and Economic Review issued final policy recommendations for treatment of relapsing multiple sclerosis (RMS)1: "All stakeholders have a responsibility and an important role to play in ensuring that all effective treatment options for patients with RMS, including off-label use of rituximab, are utilized in ways to help improve affordability and access and reduce health inequities." The report calls on payers to remove barriers to rituximab coverage, the American Academy of Neurology and the National MS Society to publicly endorse rituximab for RMS, and clinicians to advocate for coverage of rituximab and its biosimilars. In July 2023, the World Health Organization listed rituximab as an essential medicine for MS.2 Yet not much has changed. Food and Drug Administration (FDA)-approved MS disease-modifying therapies continue to generate enormous profits for pharma, and rituximab remains hidden in plain sight.
Collapse
Affiliation(s)
- Annette Langer-Gould
- From the Department of Neurology (A.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group; Department of Clinical Science (A.L.-G.), Kaiser Permanente School of Medicine, Pasadena, CA; Department of Neurology (E.S.S.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (D.B.), Oregon Health & Science University, Portland
| | - Elias S Sotirchos
- From the Department of Neurology (A.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group; Department of Clinical Science (A.L.-G.), Kaiser Permanente School of Medicine, Pasadena, CA; Department of Neurology (E.S.S.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (D.B.), Oregon Health & Science University, Portland
| | - Dennis Bourdette
- From the Department of Neurology (A.L.-G.), Los Angeles Medical Center, Southern California Permanente Medical Group; Department of Clinical Science (A.L.-G.), Kaiser Permanente School of Medicine, Pasadena, CA; Department of Neurology (E.S.S.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Neurology (D.B.), Oregon Health & Science University, Portland
| |
Collapse
|
12
|
Lee CY, Chan KH. Personalized Use of Disease-Modifying Therapies in Multiple Sclerosis. Pharmaceutics 2024; 16:120. [PMID: 38258130 PMCID: PMC10820407 DOI: 10.3390/pharmaceutics16010120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/05/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Multiple sclerosis is an important neurological disease affecting millions of young patients globally. It is encouraging that more than ten disease-modifying drugs became available for use in the past two decades. These disease-modifying therapies (DMTs) have different levels of efficacy, routes of administration, adverse effect profiles and concerns for pregnancy. Much knowledge and caution are needed for their appropriate use in MS patients who are heterogeneous in clinical features and severity, lesion load on magnetic resonance imaging and response to DMT. We aim for an updated review of the concept of personalization in the use of DMT for relapsing MS patients. Shared decision making with consideration for the preference and expectation of patients who understand the potential efficacy/benefits and risks of DMT is advocated.
Collapse
Affiliation(s)
- Chi-Yan Lee
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, 405B, 4/F, Professorial Block, 102 Pokfulam Road, Hong Kong
- Neuroimmunology and Neuroinflammation Research Laboratory, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Koon-Ho Chan
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, 405B, 4/F, Professorial Block, 102 Pokfulam Road, Hong Kong
- Neuroimmunology and Neuroinflammation Research Laboratory, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong
- Research Center of Heart, Brain, Hormone and Healthy Aging, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong
| |
Collapse
|
13
|
Zhou X, Peng A, Li C, Li L, Yao D, Hao Y, Zhao C, Yan Q, Li Y, Liu J, Liu S, Zhu W, Du Y, Zhang W. Combined central and peripheral demyelination: a case report resembling encephalomyeloradiculoneuropathy. Front Neurol 2024; 14:1288546. [PMID: 38292033 PMCID: PMC10825037 DOI: 10.3389/fneur.2023.1288546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/27/2023] [Indexed: 02/01/2024] Open
Abstract
Combined central and peripheral demyelination (CCPD) is an extremely rare disease characterized by inflammatory demyelination in both the central and peripheral nervous systems. Herein, we reported case of a 14-year-old teenager who initially presented with the symptoms of acute myelitis (AM). Subsequently, the patient developed symptoms consistent with Guillain-Barré syndrome (GBS), which was supported by nerve conduction studies (NCV) and cerebrospinal fluid (CSF) analysis. Throughout the course of the disease, the patient experienced abdominal pain and abnormal liver function. After a comprehensive evaluation, we determined that the abnormal liver function was a result of hepatitis E virus (HEV) infection, which may have acted as a trigger for GBS. The patient was treated with corticosteroids, intravenous immunoglobulin and Rituximab, resulting in symptom relief and clinical improvement after therapy and follow-up. This case highlights the potential responsiveness and reversibility of CCPD. Given the heterogeneous nature of CCPD, there is currently no standardized diagnostic criteria or clear consensus on its treatment. Therefore, we recommend a thorough assessment of all possibilities and the development of consolidated management guidelines based on available data for this disorder.
Collapse
Affiliation(s)
- Xuan Zhou
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi’an, Shaanxi Province, China
| | - Ali Peng
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi’an, Shaanxi Province, China
| | - Chuan Li
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi’an, Shaanxi Province, China
| | - Lin Li
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi’an, Shaanxi Province, China
| | - Dan Yao
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi’an, Shaanxi Province, China
| | - Yunfeng Hao
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi’an, Shaanxi Province, China
| | - Chao Zhao
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi’an, Shaanxi Province, China
| | - Qi Yan
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi’an, Shaanxi Province, China
| | - Ying Li
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi’an, Shaanxi Province, China
| | - Juntong Liu
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi’an, Shaanxi Province, China
- Xi’an Medical University, Xi’an, Shaanxi Province, China
| | - Shuyu Liu
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi’an, Shaanxi Province, China
- Xi’an Medical University, Xi’an, Shaanxi Province, China
| | - Wenping Zhu
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi’an, Shaanxi Province, China
- Xi’an Medical University, Xi’an, Shaanxi Province, China
| | - Ying Du
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi’an, Shaanxi Province, China
| | - Wei Zhang
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi’an, Shaanxi Province, China
| |
Collapse
|
14
|
Nabizadeh F, Ahmadabad MA, Mohamadi M, Mirmosayyeb O, Maleki T, Kazemzadeh K, Seyedmirzaei H. Efficacy and safety of rituximab in multiple sclerosis: a systematic review and meta-analysis. Acta Neurol Belg 2023; 123:2115-2127. [PMID: 37428437 DOI: 10.1007/s13760-023-02329-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 06/28/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVE We aimed to synthesize all available observational studies and clinical trials of rituximab to estimate the safety and efficacy of this monoclonal antibody in people with multiple sclerosis (MS). METHODS The four databases including PubMed, Scopus, Embase, and Web of Science were comprehensively searched in April 2022. We defined PICO as follows. Problem or study population (P): patients with MS; intervention (I): Rituximab; comparison (C): none; outcome (O): efficacy and safety. RESULTS After two-step screening, a total of 27 studies entered into our qualitative and quantitative synthesis. Our analysis showed a significant decrease in EDSS score in all patients with MS after treatment (SMD: - 0.44, 95% CI - 0.85, - 0.03). In addition, the ARR was reduced after using rituximab compared to the pre-treatment period (SMD: - 0.65, 95% CI - 1.55, 0.24) but it was not significant. The most common side effect after rituximab with a pooled prevalence of 28.63% (95% CI 16.61%, 42.33%). Furthermore, the pooled prevalence of infection was 24% in patients with MS (95% CI 13%, 36%). In the end, the pooled prevalence of malignancies after rituximab treatment was 0.39% (95% CI 0.02%, 1.03%). CONCLUSION Our findings illustrated an acceptable safety for this treatment. However, further studies with randomized design, long follow-up, and large sample sizes are needed to confirm the safety and efficacy of rituximab in patients with MS.
Collapse
Affiliation(s)
- Fardin Nabizadeh
- Neuroscience Research Group (NRG), Universal Scientific Education and Research Network (USERN), Tehran, Iran.
- School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
| | - Mona Asghari Ahmadabad
- Neuroscience Research Center, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Mobin Mohamadi
- Neuroscience Research Group (NRG), Universal Scientific Education and Research Network (USERN), Tehran, Iran
- School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Omid Mirmosayyeb
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Tahereh Maleki
- School of Medicine, Tehran University of Medical Science, Tehran, Iran
| | - Kimia Kazemzadeh
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Homa Seyedmirzaei
- School of Medicine, Tehran University of Medical Science, Tehran, Iran
- Interdisciplinary Neuroscience Research Program (INRP), Tehran University of Medical Sciences, Tehran, Iran
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| |
Collapse
|
15
|
Alonso R, Casas M, Lazaro L, Liguori NF, Pita C, Cohen L, Rojas JI, Pappolla A, Patrucco L, Cristiano E, Burgos M, Vrech C, Piedrabuena R, Pablo L, Deri N, Luetic G, Miguez J, Cabrera M, Martinez A, Zanga G, Tkachuk V, Tizio S, Carnero Contentti E, Knorre E, Leguizamon F, Mainella C, Nofal P, Liwacki S, Hryb J, Menichini M, Pestchanker C, Garcea O, Silva B. Evaluation of the use of high-efficacy treatments (HETs) in patients with relapsing-remitting multiple sclerosis in Argentina. Mult Scler Relat Disord 2023; 79:104935. [PMID: 37634468 DOI: 10.1016/j.msard.2023.104935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/02/2023] [Accepted: 08/08/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Disease-modifying therapies (DMTs) in multiple sclerosis (MS) can be classified according to the efficacy in which they prevent inflammatory activity. To date, there are limited data regarding the use of high-efficacy treatments (HETs) in Latin America (LATAM). We aimed to analyze the use of HETs in Argentina, focusing on the clinical and sociodemographic characteristics of the patients who use these treatments and the changes in the trend of use over the years. METHODS A retrospective cohort study was done using the Argentina MS patient registry, RelevarEM. Patients diagnosed with relapsing-remitting MS (RRMS) according to validated diagnostic criteria and under treatment with natalizumab, alemtuzumab, cladribine, rituximab or ocrelizumab were included. RESULTS Out of 2450 RRMS patients under a DMT, 462 (19%) were on HETs. One third of those patients (35%) received HETs as the first treatment. The most frequent reason for switching to HETs was treatment failure to previous DMT (77%). The time from MS diagnosis to the first HET in treatment-naive patients was less than one year (IQR: 0-1 year) and in treatment-experienced patients it was 5 years (IQR: 3-9 years). Between 2015 and 2017 (P1), 729 patients included in RelevarEM started a new treatment, of which 85 (11.65%) were HETs. Between 2018 and 2020 (P2), 961 patients included in RelevarEM started a new treatment, of which 284 (29.55%) were HETs. When comparing P2 with P1, a significant increase in the use of HETs was observed (p < 0.01). The most frequently used HETs were alemtuzumab (50.59%) in P1, and cladribine (45.20%) in P2. CONCLUSION The demographic and clinical characteristics of patients under HET in Argentina were identified. Based on a real-world setting, we found a significant trend towards and a rapid increase in the use of HETs in clinical practice in patients with RRMS.
Collapse
Affiliation(s)
- Ricardo Alonso
- Centro Universitario de Esclerosis Múltiple, Hospital Ramos Mejía, Ciudad de Buenos Aires, Argentina; Servicio de Neurología, Sanatorio Güemes, Ciudad de Buenos Aires, Argentina
| | - Magdalena Casas
- Centro Universitario de Esclerosis Múltiple, Hospital Ramos Mejía, Ciudad de Buenos Aires, Argentina
| | - Luciana Lazaro
- Centro Universitario de Esclerosis Múltiple, Hospital Ramos Mejía, Ciudad de Buenos Aires, Argentina
| | - Nora Fernandez Liguori
- Servicio de Neurología, Sanatorio Güemes, Ciudad de Buenos Aires, Argentina; Servicio de Neurología, Hospital Tornú, Ciudad de Buenos Aires, Argentina
| | - Cecilia Pita
- Centro Universitario de Esclerosis Múltiple, Hospital Ramos Mejía, Ciudad de Buenos Aires, Argentina
| | - Leila Cohen
- Centro Universitario de Esclerosis Múltiple, Hospital Ramos Mejía, Ciudad de Buenos Aires, Argentina
| | - Juan Ignacio Rojas
- Centro de esclerosis Múltiple Buenos Aires, Ciudad de Buenos Aires, Argentina; Servicio de Neurología, CEMIC, Ciudad de Buenos Aires, Argentina
| | - Agustín Pappolla
- Centro de esclerosis Múltiple Buenos Aires, Ciudad de Buenos Aires, Argentina
| | - Liliana Patrucco
- Centro de esclerosis Múltiple Buenos Aires, Ciudad de Buenos Aires, Argentina
| | - Edgardo Cristiano
- Centro de esclerosis Múltiple Buenos Aires, Ciudad de Buenos Aires, Argentina
| | - Marcos Burgos
- Servicio de Neurología, Hospital San Bernardo, Salta, Argentina
| | - Carlos Vrech
- Servicio de Neurología, Sanatorio Allende, Córdoba, Spain
| | - Raul Piedrabuena
- Servicio de Neurología, Clínica Universitaria Reina Fabiola, Córdoba, Spain
| | - Lopez Pablo
- Sección de Neuroinmunología, Hospital Alemán, Ciudad de Buenos Aires, Argentina
| | | | | | - Jimena Miguez
- Servicio de neurología, Hospital Italiano, Argentina
| | - Mariela Cabrera
- Servicio de neurología, Hospital Militar, Campo de Mayo, Argentina
| | - Alejandra Martinez
- Servicio de neurología, Hospital Posadas, Ciudad de Buenos Aires, Argentina
| | - Gisela Zanga
- Servicio de neurología, Hospital Cesar Milstein, Ciudad de Buenos Aires, Argentina
| | - Verónica Tkachuk
- Servicio de neurología, Hospital de Clínica José de San Martín, Ciudad de Buenos Aires, Argentina
| | - Santiago Tizio
- Servicio de neurología, Hospital Español, La Plata, Argentina
| | | | - Eduardo Knorre
- Servicio de neurología, Hospital Álvarez, Ciudad de Buenos Aires, Argentina
| | - Felisa Leguizamon
- Servicio de neurología, Hospital Álvarez, Ciudad de Buenos Aires, Argentina
| | | | - Pedro Nofal
- Servicio de neurología, Hospital Nuestra Señora del Carmen, Tucumán, Argentina
| | - Susana Liwacki
- Servicio de neurología, Hospital Córdoba, Córdoba, Spain
| | - Javier Hryb
- Servicio de neurología, Hospital Durand, Ciudad de Buenos Aires, Argentina
| | | | | | - Orlando Garcea
- Centro Universitario de Esclerosis Múltiple, Hospital Ramos Mejía, Ciudad de Buenos Aires, Argentina
| | - Berenice Silva
- Centro Universitario de Esclerosis Múltiple, Hospital Ramos Mejía, Ciudad de Buenos Aires, Argentina; Servicio de neurología, Hospital Italiano, Argentina.
| |
Collapse
|
16
|
Alping P. Disease-modifying therapies in multiple sclerosis: A focused review of rituximab. Basic Clin Pharmacol Toxicol 2023; 133:550-564. [PMID: 37563891 DOI: 10.1111/bcpt.13932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 07/29/2023] [Accepted: 08/02/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Treatment for multiple sclerosis (MS), a chronic inflammatory disease of the central nervous system, has changed drastically in the last 30 years. Several different disease-modifying therapies are now available, with off-label use of the B-cell-depleting antibody rituximab becoming an increasingly popular choice, as more and more studies report on its effectiveness. OBJECTIVES The objective of this study was to summarize the current state of evidence for rituximab as a treatment for relapsing-remitting MS (RRMS). METHODS A structured literature search was conducted in PubMed, focusing on peer-reviewed studies of adult populations with RRMS. Ongoing trials with rituximab in MS were identified through Clinicaltrials.gov and additional references were identified through review articles. FINDINGS Despite promising results for rituximab as a treatment of MS, the market-authorization holder switched focus from rituximab and discontinued the industry-sponsored trials programme. However, several observational studies, smaller clinical trials and one large investigator-initiated randomized-controlled trial have continued to report fewer clinical relapses, fewer contrast-enhancing lesions on magnetic resonance imaging and better drug survival with rituximab, compared with MS-approved alternatives. CONCLUSIONS Rituximab should be considered as both a first- and second-line therapy option for most MS patients with active, non-progressive disease. However, as an off-label therapy for MS, regulatory approval remains a barrier for wider adoption in many countries.
Collapse
Affiliation(s)
- Peter Alping
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
17
|
Zeineddine M, Al-Hajje A, Salameh P, Helme A, Thor MG, Boumediene F, Yamout B. Barriers to accessing multiple sclerosis disease-modifying therapies in the Middle East and North Africa region: A regional survey-based study. Mult Scler Relat Disord 2023; 79:104959. [PMID: 37651815 DOI: 10.1016/j.msard.2023.104959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 08/20/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Multiple sclerosis (MS) management varies markedly between different countries of the Middle East and North Africa (MENA) region based on the availability and accessibility of disease-modifying therapies (DMTs). OBJECTIVE To evaluate the accessibility to DMTs in each MENA country, identify barriers to treatment and make recommendations for improved access to DMTs across the region. METHODS This is a descriptive, survey-based study whereby we extracted data collected, between October 2019 and April 2020, for countries in the MENA region by the Multiple Sclerosis International Federation (MSIF) through their Atlas of MS survey. RESULTS 16 out of 19 countries in the MENA region were included in this study. Sudan and Syria did not have any originator DMTs approved. Interferons were the most widely low-efficacy originator approved DMTs. Three countries did not have any high efficacy DMTs approved. Moreover, follow-on DMTs were approved in half (50%) of the countries. Cost of treatment was the most important barrier, reported in nearly half (47%) of the MENA countries. CONCLUSION Although most MENA countries have access to DMTs, more than half of countries report problems with treatment continuation, highlighting the need for a targeted regional strategy to address the variations in access to MS treatments.
Collapse
Affiliation(s)
- Maya Zeineddine
- Inserm U1094, IRD U270, University Limoges, CHU Limoges, EpiMaCT - Epidemiology of Chronic Diseases in Tropical Zone, Institute of Epidemiology and Tropical Neurology, Omega Health, Limoges, France; Neurology Institute, Harley Street Medical Center, Abu Dhabi, United Arab Emirates.
| | - Amal Al-Hajje
- Faculty of Pharmacy, Lebanese University, Beirut, Lebanon; National Institute of Public Health, Clinical Epidemiology and Toxicology (INSPECT-LB), Beirut, Lebanon
| | - Pascale Salameh
- Faculty of Pharmacy, Lebanese University, Beirut, Lebanon; National Institute of Public Health, Clinical Epidemiology and Toxicology (INSPECT-LB), Beirut, Lebanon; School of Medicine, Lebanese American University, Byblos, Lebanon; Department of Primary Care and Population Health, University of Nicosia Medical School, Nicosia 2417, Cyprus
| | - Anne Helme
- Multiple Sclerosis International Federation, London, United Kingdom
| | | | - Farid Boumediene
- Inserm U1094, IRD U270, University Limoges, CHU Limoges, EpiMaCT - Epidemiology of Chronic Diseases in Tropical Zone, Institute of Epidemiology and Tropical Neurology, Omega Health, Limoges, France
| | - Bassem Yamout
- Neurology Institute, Harley Street Medical Center, Abu Dhabi, United Arab Emirates
| |
Collapse
|
18
|
Rød BE, Wergeland S, Bjørnevik K, Holmøy T, Ulvestad E, Njølstad G, Myhr KM, Torkildsen Ø. Humoral response to Epstein-Barr virus in patients with multiple sclerosis treated with B cell depletion therapy. Mult Scler Relat Disord 2023; 79:105037. [PMID: 37804765 DOI: 10.1016/j.msard.2023.105037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/25/2023] [Accepted: 09/24/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND B cell depletion therapy is highly effective in relapsing-remitting multiple sclerosis (RRMS). However, the precise underlying mechanisms of action for its biological effects in MS have still not been clarified. Epstein-Barr virus (EBV) is a known risk factor for MS and seems to be a prerequisite for disease development. EBV resides latently in the memory B cells, and may not only increase the risk of developing MS, but also contribute to disease activity and disability progression. Therefore, the effects of B cell depletion in MS could be associated with the depletion of EBV-infected cells and the altered immune response to the virus. In this study, we investigate the impact of B cell depletion on the humoral immune response specific to EBV in patients with MS. METHODS Newly diagnosed, treatment-naïve patients with RRMS were followed up to 18 months after initiation of B-cell depletion therapy in the Overlord-MS study, a phase III trial (NCT04578639). We analyzed serum sampled before treatment and after 3, 6, 12 and 18 months for immunoglobulin γ (IgG) against Epstein-Barr nuclear antigen 1 (EBNA1) and Epstein-Barr viral capsid antigen (VCA). We analyzed antibodies to cytomegalovirus (CMV) and total IgG in serum, as controls for viral and overall humoral immunity. The risk allele, HLA-DRB1*15:01, and the protective allele, HLA-A*02:01, were determined in all participants. In addition, polymerase chain reaction (PCR) for circulating EBV-DNA was performed in the first 156 samples drawn. The associations between time on B cell-depletion therapy and serum anti-EBV antibody levels were estimated using linear mixed-effects models. RESULTS A total of 290 serum samples from 99 patients were available for analysis. After 6, 12 and 18 months, the EBNA1 IgG levels decreased by 12.7 % (95 % CI -18.8 to -6.60, p < 0.001), 12.1 % (95 % CI -19.8 to -3.7, p = 0.006) and 14.6 % (95 % CI to -25.3 to -2.4, p = 0.02) respectively, compared to baseline level. Carriers of the HLA-DRB1*15:01 allele had higher EBNA1 IgG levels at baseline (p = 0.02). The VCA IgG levels significantly increased by 13.7 % (95 % CI 9.4 to 18.1, p < 0.001) after 3 months, compared to baseline, and persisted at this level throughout the follow-up. CMV IgG levels decreased, but to a lesser extent than the decrease of EBNA1 IgG, and total IgG levels decreased during therapy. Circulating EBV-DNA was found in only three of 156 samples from 64 patients. CONCLUSIONS EBNA1 IgG levels decreased, while VCA IgG levels increased, during B cell depletion therapy. This supports the hypothesis that the mechanism of action for B cell depletion therapy might be mediated by effects on EBV infection, which, in turn, mitigate immune cross-reactivity and disease perpetuation.
Collapse
Affiliation(s)
- Brit Ellen Rød
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Stig Wergeland
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway; The Norwegian Multiple Sclerosis Registry and Biobank, Haukeland University Hospital, Bergen, Norway
| | - Kjetil Bjørnevik
- Departments of Epidemiology and Nutrition, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Trygve Holmøy
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Elling Ulvestad
- Department of Microbiology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Sciences, University of Bergen, Bergen, Norway
| | - Gro Njølstad
- Department of Microbiology, Haukeland University Hospital, Bergen, Norway
| | - Kjell-Morten Myhr
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Øivind Torkildsen
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| |
Collapse
|
19
|
Roos I, Hughes S, McDonnell G, Malpas CB, Sharmin S, Boz C, Alroughani R, Ozakbas S, Buzzard K, Skibina O, van der Walt A, Butzkueven H, Lechner-Scott J, Kuhle J, Terzi M, Laureys G, Van Hijfte L, John N, Grammond P, Grand’Maison F, Soysal A, Jensen AV, Rasmussen PV, Svendsen KB, Barzinji I, Nielsen HH, Sejbæk T, Prakash S, Stilund MLM, Weglewski A, Issa NM, Kant M, Sellebjerg F, Gray O, Magyari M, Kalincik T. Rituximab vs Ocrelizumab in Relapsing-Remitting Multiple Sclerosis. JAMA Neurol 2023; 80:789-797. [PMID: 37307006 PMCID: PMC10262062 DOI: 10.1001/jamaneurol.2023.1625] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 02/23/2023] [Indexed: 06/13/2023]
Abstract
Importance Ocrelizumab, a humanized monoclonal antibody targeted against CD20+ B cells, reduces the frequency of relapses by 46% and disability worsening by 40% compared with interferon beta 1a in relapsing-remitting multiple sclerosis (MS). Rituximab, a chimeric monoclonal anti-CD20 agent, is often prescribed as an off-label alternative to ocrelizumab. Objective To evaluate whether the effectiveness of rituximab is noninferior to ocrelizumab in relapsing-remitting MS. Design, Setting, and Participants This was an observational cohort study conducted between January 2015 and March 2021. Patients were included in the treatment group for the duration of study therapy and were recruited from the MSBase registry and Danish MS Registry (DMSR). Included patients had a history of relapsing-remitting MS treated with ocrelizumab or rituximab, a minimum 6 months of follow-up, and sufficient data to calculate the propensity score. Patients with comparable baseline characteristics were 1:6 matched with propensity score on age, sex, MS duration, disability (Expanded Disability Status Scale), prior relapse rate, prior therapy, disease activity (relapses, disability accumulation, or both), magnetic resonance imaging lesion burden (missing values imputed), and country. Exposure Treatment with ocrelizumab or rituximab after 2015. Main outcomes and Measures Noninferiority comparison of annualized rate of relapses (ARRs), with a prespecified noninferiority margin of 1.63 rate ratio. Secondary end points were relapse and 6-month confirmed disability accumulation in pairwise-censored groups. Results Of the 6027 patients with MS who were treated with ocrelizumab or rituximab, a total of 1613 (mean [SD] age; 42.0 [10.8] years; 1089 female [68%]) fulfilled the inclusion criteria and were included in the analysis (898 MSBase, 715 DMSR). A total of 710 patients treated with ocrelizumab (414 MSBase, 296 DMSR) were matched with 186 patients treated with rituximab (110 MSBase, 76 DMSR). Over a pairwise censored mean (SD) follow-up of 1.4 (0.7) years, the ARR ratio was higher in patients treated with rituximab than in those treated with ocrelizumab (rate ratio, 1.8; 95% CI, 1.4-2.4; ARR, 0.20 vs 0.09; P < .001). The cumulative hazard of relapses was higher among patients treated with rituximab than those treated with ocrelizumab (hazard ratio, 2.1; 95% CI, 1.5-3.0). No difference in the risk of disability accumulation was observed between groups. Results were confirmed in sensitivity analyses. Conclusion In this noninferiority comparative effectiveness observational cohort study, results did not show noninferiority of treatment with rituximab compared with ocrelizumab. As administered in everyday practice, rituximab was associated with a higher risk of relapses than ocrelizumab. The efficacy of rituximab and ocrelizumab administered at uniform doses and intervals is being further evaluated in randomized noninferiority clinical trials.
Collapse
Affiliation(s)
- Izanne Roos
- Neuroimmunology Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- CORe, Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | | | | | - Charles B. Malpas
- Neuroimmunology Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- CORe, Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Sifat Sharmin
- CORe, Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Cavit Boz
- KTU Medical Faculty Farabi Hospital, Trabzon, Turkey
| | - Raed Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Sharq, Kuwait
| | | | - Katherine Buzzard
- Neuroimmunology Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Neurology, Box Hill Hospital, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - Olga Skibina
- Department of Neurology, Box Hill Hospital, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
- Department of Neurology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Anneke van der Walt
- Department of Neurology, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Helmut Butzkueven
- Department of Neurology, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Jeannette Lechner-Scott
- School of Medicine and Public Health, University Newcastle, Newcastle, New South Wales, Australia
- Department of Neurology, John Hunter Hospital, Hunter New England Health, Newcastle, New South Wales, Australia
| | - Jens Kuhle
- Departments of Medicine, Biomedicine, and Clinical Research, Neurologic Clinic and Policlinic, University Hospital and University of Basel, Basel, Switzerland
| | - Murat Terzi
- Medical Faculty, 19 Mayis University, Samsun, Turkey
| | - Guy Laureys
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | | | - Nevin John
- Department of Neurology, Monash Health, Melbourne, Victoria, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | | | | | - Aysun Soysal
- Bakirkoy Education and Research Hospital for Psychiatric and Neurological Diseases, Istanbul, Turkey
| | - Ana Voldsgaard Jensen
- Danish Multiple Sclerosis Center, Rigshospitalet Glostrup, Copenhagen University Hospital, Denmark
| | | | | | | | - Helle Hvilsted Nielsen
- The Multiple Sclerosis Clinic, Department of Neurology, Odense University Hospital, Odense C, Denmark
| | - Tobias Sejbæk
- Department of Neurology, Esbjerg Hospital, University Hospital of Southern Denmark, Esbjerg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Esbjerg, Denmark
| | | | | | - Arkadiusz Weglewski
- Neurology Department Herlev Hospital, Denmark
- Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Matthias Kant
- Hospital of Southern Jutland, University of Southern Denmark, Aabenraa, Denmark
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, Rigshospitalet Glostrup, Copenhagen University Hospital, Denmark
| | - Orla Gray
- South Eastern HSC Trust, Belfast, United Kingdom
| | - Melinda Magyari
- Danish Multiple Sclerosis Center, Rigshospitalet Glostrup, Copenhagen University Hospital, Denmark
| | - Tomas Kalincik
- Neuroimmunology Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- CORe, Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
20
|
Park J, Wu Y, Li Q, Choi J, Ju H, Cai Y, Lee J, Oh YK. Nanomaterials for antigen-specific immune tolerance therapy. Drug Deliv Transl Res 2023; 13:1859-1881. [PMID: 36094655 DOI: 10.1007/s13346-022-01233-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2022] [Indexed: 11/26/2022]
Abstract
Impairment of immune tolerance might cause autologous tissue damage or overactive immune response against non-pathogenic molecules. Although autoimmune disease and allergy have complicated pathologies, the current strategies have mainly focused on symptom amelioration or systemic immunosuppression which can lead to fatal adverse events. The induction of antigen-specific immune tolerance may provide therapeutic benefits to autoimmune disease and allergic response, while reducing nonspecific immune adverse responses. Diverse nanomaterials have been studied to induce antigen-specific immune tolerance therapy. This review will cover the immunological background of antigen-specific tolerance, clinical importance of antigen-specific immune tolerance, and nanomaterials designed for autoimmune and allergic diseases. As nanomaterials for modulating immune tolerances, lipid-based nanoparticles, polymeric nanoparticles, and biological carriers have been covered. Strategies to provide antigen-specific immune tolerance have been addressed. Finally, current challenges and perspectives of nanomaterials for antigen-specific immune tolerance therapy will be discussed.
Collapse
Affiliation(s)
- Jinwon Park
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, 08826, Republic of Korea
| | - Yina Wu
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, 08826, Republic of Korea
| | - Qiaoyun Li
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, 08826, Republic of Korea
| | - Jaehyun Choi
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, 08826, Republic of Korea
| | - Hyemin Ju
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, 08826, Republic of Korea
| | - Yu Cai
- College of Pharmacy, Jinan University, Guangzhou, 510632, China
| | - Jaiwoo Lee
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, 08826, Republic of Korea
| | - Yu-Kyoung Oh
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, 08826, Republic of Korea.
| |
Collapse
|
21
|
Kalincik T, Sharmin S, Roos I, Freedman MS, Atkins H, Burman J, Massey J, Sutton I, Withers B, Macdonell R, Grigg A, Torkildsen Ø, Bo L, Lehmann AK, Havrdova EK, Krasulova E, Trněný M, Kozak T, van der Walt A, Butzkueven H, McCombe P, Skibina O, Lechner-Scott J, Willekens B, Cartechini E, Ozakbas S, Alroughani R, Kuhle J, Patti F, Duquette P, Lugaresi A, Khoury SJ, Slee M, Turkoglu R, Hodgkinson S, John N, Maimone D, Sa MJ, van Pesch V, Gerlach O, Laureys G, Van Hijfte L, Karabudak R, Spitaleri D, Csepany T, Gouider R, Castillo-Triviño T, Taylor B, Sharrack B, Snowden JA. Comparative Effectiveness of Autologous Hematopoietic Stem Cell Transplant vs Fingolimod, Natalizumab, and Ocrelizumab in Highly Active Relapsing-Remitting Multiple Sclerosis. JAMA Neurol 2023; 80:702-713. [PMID: 37437240 PMCID: PMC10186210 DOI: 10.1001/jamaneurol.2023.1184] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 02/12/2023] [Indexed: 07/14/2023]
Abstract
Importance Autologous hematopoietic stem cell transplant (AHSCT) is available for treatment of highly active multiple sclerosis (MS). Objective To compare the effectiveness of AHSCT vs fingolimod, natalizumab, and ocrelizumab in relapsing-remitting MS by emulating pairwise trials. Design, Setting, and Participants This comparative treatment effectiveness study included 6 specialist MS centers with AHSCT programs and international MSBase registry between 2006 and 2021. The study included patients with relapsing-remitting MS treated with AHSCT, fingolimod, natalizumab, or ocrelizumab with 2 or more years study follow-up including 2 or more disability assessments. Patients were matched on a propensity score derived from clinical and demographic characteristics. Exposure AHSCT vs fingolimod, natalizumab, or ocrelizumab. Main outcomes Pairwise-censored groups were compared on annualized relapse rates (ARR) and freedom from relapses and 6-month confirmed Expanded Disability Status Scale (EDSS) score worsening and improvement. Results Of 4915 individuals, 167 were treated with AHSCT; 2558, fingolimod; 1490, natalizumab; and 700, ocrelizumab. The prematch AHSCT cohort was younger and with greater disability than the fingolimod, natalizumab, and ocrelizumab cohorts; the matched groups were closely aligned. The proportion of women ranged from 65% to 70%, and the mean (SD) age ranged from 35.3 (9.4) to 37.1 (10.6) years. The mean (SD) disease duration ranged from 7.9 (5.6) to 8.7 (5.4) years, EDSS score ranged from 3.5 (1.6) to 3.9 (1.9), and frequency of relapses ranged from 0.77 (0.94) to 0.86 (0.89) in the preceding year. Compared with the fingolimod group (769 [30.0%]), AHSCT (144 [86.2%]) was associated with fewer relapses (ARR: mean [SD], 0.09 [0.30] vs 0.20 [0.44]), similar risk of disability worsening (hazard ratio [HR], 1.70; 95% CI, 0.91-3.17), and higher chance of disability improvement (HR, 2.70; 95% CI, 1.71-4.26) over 5 years. Compared with natalizumab (730 [49.0%]), AHSCT (146 [87.4%]) was associated with marginally lower ARR (mean [SD], 0.08 [0.31] vs 0.10 [0.34]), similar risk of disability worsening (HR, 1.06; 95% CI, 0.54-2.09), and higher chance of disability improvement (HR, 2.68; 95% CI, 1.72-4.18) over 5 years. AHSCT (110 [65.9%]) and ocrelizumab (343 [49.0%]) were associated with similar ARR (mean [SD], 0.09 [0.34] vs 0.06 [0.32]), disability worsening (HR, 1.77; 95% CI, 0.61-5.08), and disability improvement (HR, 1.37; 95% CI, 0.66-2.82) over 3 years. AHSCT-related mortality occurred in 1 of 159 patients (0.6%). Conclusion In this study, the association of AHSCT with preventing relapses and facilitating recovery from disability was considerably superior to fingolimod and marginally superior to natalizumab. This study did not find evidence for difference in the effectiveness of AHSCT and ocrelizumab over a shorter available follow-up time.
Collapse
Affiliation(s)
- Tomas Kalincik
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- CORe, Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Sifat Sharmin
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- CORe, Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Izanne Roos
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- CORe, Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Mark S. Freedman
- University of Ottawa, Department of Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Harold Atkins
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Joachim Burman
- Department of Medical Sciences, Neurology, Uppsala University, Uppsala, Sweden
| | - Jennifer Massey
- Department of Neurology, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
- St Vincent’s Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Ian Sutton
- Department of Neurology, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Barbara Withers
- St Vincent’s Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Haematology, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
| | - Richard Macdonell
- Department of Neurology, Austin Health, Melbourne, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew Grigg
- University of Melbourne, Melbourne, Victoria, Australia
- Department of Haematology, Austin Health, Melbourne, Victoria, Australia
| | - Øivind Torkildsen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Lars Bo
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | | | - Eva Kubala Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Eva Krasulova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Marek Trněný
- Department of Haematology, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Tomas Kozak
- Department of Haematology, 3rd Faculty of Medicine, Charles University in Prague, and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Anneke van der Walt
- Department of Neurology, The Alfred Hospital, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Helmut Butzkueven
- Department of Neurology, The Alfred Hospital, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Pamela McCombe
- University of Queensland, Brisbane, Queensland, Australia
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Olga Skibina
- Department of Neurology, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Neurology, Box Hill Hospital, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - Jeannette Lechner-Scott
- School of Medicine and Public Health, University Newcastle, Newcastle, New South Wales, Australia
- Department of Neurology, John Hunter Hospital, Hunter New England Health, Newcastle, New South Wales, Australia
| | - Barbara Willekens
- Department of Neurology, Antwerp University Hospital, Edegem, Belgium
- Translational Neurosciences Research Group, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | | | | | - Raed Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Sharq, Kuwait
| | - Jens Kuhle
- Neurologic Clinic and Policlinic, Departments of Medicine and Clinical Research, University Hospital and University of Basel, Basel, Switzerland
| | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies, GF Ingrassia, Catania, Italy
- Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Pierre Duquette
- CHUM MS Center and Universite de Montreal, Montreal, Quebec, Canada
| | - Alessandra Lugaresi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Samia J. Khoury
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mark Slee
- Flinders University, Adelaide, South Australia, Australia
| | - Recai Turkoglu
- Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | | | - Nevin John
- Monash Medical Centre, Melbourne, Victoria, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | | | - Maria Jose Sa
- Department of Neurology, Centro Hospitalar Universitario de Sao Joao, Porto, Portugal
| | - Vincent van Pesch
- Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Université Catholique de Louvain, Ottignies-Louvain-la-Neuve, Belgium
| | - Oliver Gerlach
- Academic MS Center Zuyderland, Department of Neurology, Zuyderland Medical Center, Sittard-Geleen, the Netherlands
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Guy Laureys
- Department of Neurology, University Hospital Ghent, Ghent, Belgium
| | | | - Rana Karabudak
- Department of Neurology, Hacettepe University Hospitals, Ankara, Turkey
| | - Daniele Spitaleri
- Azienda Ospedaliera di Rilievo Nazionale San Giuseppe Moscati Avellino, Avellino, Italy
| | - Tunde Csepany
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Riadh Gouider
- Department of Neurology, Razi University Hospital, Manouba, Tunis, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | | | - Bruce Taylor
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
- Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Basil Sharrack
- Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - John A. Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | | |
Collapse
|
22
|
Techa-Angkoon P, Siritho S, Tisavipat N, Suansanae T. Current evidence of rituximab in the treatment of multiple sclerosis. Mult Scler Relat Disord 2023; 75:104729. [PMID: 37148577 DOI: 10.1016/j.msard.2023.104729] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 04/15/2023] [Accepted: 04/22/2023] [Indexed: 05/08/2023]
Abstract
Multiple sclerosis (MS) is a chronic inflammatory demyelinating disorder of the central nervous system. The immunopathology of MS involves both T and B lymphocytes. Rituximab is one of the anti-CD20 monoclonal antibody therapies which deplete B-cells. Although some anti-CD20 therapies have been approved by the Food and Drug Administration for treatment of MS, rituximab is used off-label. Several studies have shown that rituximab has a good efficacy and safety in MS, including certain specific patient conditions such as treatment-naïve patients, treatment-switching patients, and the Asian population. However, there are still questions about the optimal dose and duration of rituximab in MS due to the different dosing regimens used in each study. Moreover, many biosimilars have become available at a lower cost with comparable physicochemical properties, pharmacokinetics, pharmacodynamics, efficacy, safety, and immunogenicity. Thus, rituximab may be considered as a potential therapeutic option for patients without access to standard treatment. This narrative review summarized the evidence of both original and biosimilars of rituximab in MS treatment including pharmacokinetics, pharmacodynamics, clinical efficacy, safety, and dosing regimen.
Collapse
Affiliation(s)
- Phanutgorn Techa-Angkoon
- Division of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Ubon Ratchathani University, Ubon Ratchathani, Thailand
| | - Sasitorn Siritho
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand; Siriraj Neuroimmunology Center, Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand; Bumrungrad International Hospital, Bangkok, Thailand
| | | | - Thanarat Suansanae
- Division of Clinical Pharmacy, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, 447 Sri Ayutthaya Road, Ratchathewi, Bangkok 10400, Thailand.
| |
Collapse
|
23
|
Navarro CE, Betancur JE. Cost-Utility Analysis Comparing Ocrelizumab vs Rituximab in the Treatment of Relapsing-Remitting Multiple Sclerosis: The Colombian Perspective. Value Health Reg Issues 2023; 36:83-91. [PMID: 37058870 DOI: 10.1016/j.vhri.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 12/14/2022] [Accepted: 02/28/2023] [Indexed: 04/16/2023]
Abstract
OBJECTIVES This study aimed to determine the cost-utility of ocrelizumab versus rituximab in patients with RRMS, from the perspective of the Colombian healthcare system. METHODOLOGY Cost-utility study based on a Markov model, with a 50-year horizon and payer perspective. The currency was the US dollar for the year 2019, with a cost-effectiveness threshold of $5180 defined for Colombian health system. The model used annual cycles according to the health status determined by the disability scale. Direct costs were considered, and the incremental cost-effectiveness ratio per 1 quality-adjusted life-year (QALY) gained was used as the outcome measure. A discount rate of 5% was applied to costs and outcomes. Multiple one-way deterministic sensitivity analyses and 10 000 Monte Carlo simulation were conducted. RESULTS For the treatment of patients with RRMS, ocrelizumab versus rituximab had an incremental cost-effectiveness ratio of $73 652 for each QALY gained. After 50 years, 1 subject treated with ocrelizumab earns 4.8 QALYs >1 subject treated with rituximab, but at a higher cost of $521 759 versus $168 752, respectively. Ocrelizumab becomes a cost-effective therapy if its price is discounted > 86% or if there is a high willingness to pay. CONCLUSIONS Ocrelizumab was not a cost-effective drug as compared with rituximab in treating patients with RRMS in Colombia.
Collapse
Affiliation(s)
- Cristian E Navarro
- Health Economic Evaluation program. School of Economic Sciences and School of Medicine, Universidad de Antioquia, Medellín, Colombia.
| | - John E Betancur
- Health Economic Evaluation program. School of Economic Sciences and School of Medicine, Universidad de Antioquia, Medellín, Colombia
| |
Collapse
|
24
|
Pivovarova-Ramich O, Zimmermann HG, Paul F. Multiple sclerosis and circadian rhythms: Can diet act as a treatment? Acta Physiol (Oxf) 2023; 237:e13939. [PMID: 36700353 DOI: 10.1111/apha.13939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 12/15/2022] [Accepted: 01/24/2023] [Indexed: 01/27/2023]
Abstract
Multiple sclerosis (MS) is an autoimmune inflammatory and neurodegenerative disease of the central nervous system (CNS) with increasing incidence and prevalence. MS is associated with inflammatory and metabolic disturbances that, as preliminary human and animal data suggest, might be mediated by disruption of circadian rhythmicity. Nutrition habits can influence the risk for MS, and dietary interventions may be effective in modulating MS disease course. Chronotherapeutic approaches such as time-restricted eating (TRE) may benefit people with MS by stabilizing the circadian clock and restoring immunological and metabolic rhythms, thus potentially counteracting disease progression. This review provides a summary of selected studies on dietary intervention in MS, circadian rhythms, and their disruption in MS, including clock gene variations, circadian hormones, and retino-hypothalamic tract changes. Furthermore, we present studies that reported diurnal variations in MS, which might result from circadian disruption. And lastly, we suggest how chrononutritive approaches like TRE might counteract MS disease activity.
Collapse
Affiliation(s)
- Olga Pivovarova-Ramich
- Research Group Molecular Nutritional Medicine, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
- Department of Endocrinology, Diabetes and Nutrition, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - Hanna Gwendolyn Zimmermann
- Experimental and Clinical Research Center, Max-Delbrück Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Einstein Center Digital Future, Berlin, Germany
| | - Friedemann Paul
- Experimental and Clinical Research Center, Max-Delbrück Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| |
Collapse
|
25
|
Koprulu M, Carrasco-Zanini J, Wheeler E, Lockhart S, Kerrison ND, Wareham NJ, Pietzner M, Langenberg C. Proteogenomic links to human metabolic diseases. Nat Metab 2023; 5:516-528. [PMID: 36823471 PMCID: PMC7614946 DOI: 10.1038/s42255-023-00753-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/01/2023] [Indexed: 02/25/2023]
Abstract
Studying the plasma proteome as the intermediate layer between the genome and the phenome has the potential to identify new disease processes. Here, we conducted a cis-focused proteogenomic analysis of 2,923 plasma proteins measured in 1,180 individuals using antibody-based assays. We (1) identify 256 unreported protein quantitative trait loci (pQTL); (2) demonstrate shared genetic regulation of 224 cis-pQTLs with 575 specific health outcomes, revealing examples for notable metabolic diseases (such as gastrin-releasing peptide as a potential therapeutic target for type 2 diabetes); (3) improve causal gene assignment at 40% (n = 192) of overlapping risk loci; and (4) observe convergence of phenotypic consequences of cis-pQTLs and rare loss-of-function gene burden for 12 proteins, such as TIMD4 for lipoprotein metabolism. Our findings demonstrate the value of integrating complementary proteomic technologies with genomics even at moderate scale to identify new mediators of metabolic diseases with the potential for therapeutic interventions.
Collapse
Affiliation(s)
- Mine Koprulu
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge, UK
| | - Julia Carrasco-Zanini
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge, UK
| | - Eleanor Wheeler
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge, UK
| | - Sam Lockhart
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge, UK
- MRC Metabolic Diseases Unit, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Nicola D Kerrison
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge, UK
| | - Nicholas J Wareham
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge, UK
| | - Maik Pietzner
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge, UK
- Computational Medicine, Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany
- Precision Healthcare University Research Institute, Queen Mary University of London, London, UK
| | - Claudia Langenberg
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge, UK.
- Computational Medicine, Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany.
- Precision Healthcare University Research Institute, Queen Mary University of London, London, UK.
| |
Collapse
|
26
|
Ma X, Ma R, Zhang M, Qian B, Wang B, Yang W. Recent Progress in Multiple Sclerosis Treatment Using Immune Cells as Targets. Pharmaceutics 2023; 15:pharmaceutics15030728. [PMID: 36986586 PMCID: PMC10057470 DOI: 10.3390/pharmaceutics15030728] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 02/02/2023] [Accepted: 02/16/2023] [Indexed: 02/24/2023] Open
Abstract
Multiple sclerosis (MS) is an autoimmune-mediated demyelinating disease of the central nervous system. The main pathological features are inflammatory reaction, demyelination, axonal disintegration, reactive gliosis, etc. The etiology and pathogenesis of the disease have not been clarified. The initial studies believed that T cell-mediated cellular immunity is the key to the pathogenesis of MS. In recent years, more and more evidence has shown that B cells and their mediated humoral immune and innate immune cells (such as microglia, dendritic cells, macrophages, etc.) also play an important role in the pathogenesis of MS. This article mainly reviews the research progress of MS by targeting different immune cells and analyzes the action pathways of drugs. The types and mechanisms of immune cells related to the pathogenesis are introduced in detail, and the mechanisms of drugs targeting different immune cells are discussed in depth. This article aims to clarify the pathogenesis and immunotherapy pathway of MS, hoping to find new targets and strategies for the development of therapeutic drugs for MS.
Collapse
Affiliation(s)
- Xiaohong Ma
- Department of Neuroscience, The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou 450000, China
- The First Clinical Medical School, Henan University of Chinese Medicine, Zhengzhou 450046, China
| | - Rong Ma
- School of Pharmaceutical Sciences, Henan Key Laboratory of Targeting Therapy and Diagnosis for Critical Diseases, Zhengzhou University, Zhengzhou 450001, China
| | - Mengzhe Zhang
- School of Pharmaceutical Sciences, Henan Key Laboratory of Targeting Therapy and Diagnosis for Critical Diseases, Zhengzhou University, Zhengzhou 450001, China
| | - Baicheng Qian
- Department of Neuroscience, The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou 450000, China
| | - Baoliang Wang
- Department of Neuroscience, The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou 450000, China
- Correspondence: (B.W.); (W.Y.)
| | - Weijing Yang
- School of Pharmaceutical Sciences, Henan Key Laboratory of Targeting Therapy and Diagnosis for Critical Diseases, Zhengzhou University, Zhengzhou 450001, China
- Correspondence: (B.W.); (W.Y.)
| |
Collapse
|
27
|
Garcia A, Dugast E, Shah S, Morille J, Lebrun-Frenay C, Thouvenot E, De Sèze J, Le Page E, Vukusic S, Maurousset A, Berger E, Casez O, Labauge P, Ruet A, Raposo C, Bakdache F, Buffels R, Le Frère F, Nicot A, Wiertlewski S, Gourraud PA, Berthelot L, Laplaud D. Immune Profiling Reveals the T-Cell Effect of Ocrelizumab in Early Relapsing-Remitting Multiple Sclerosis. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:10/3/e200091. [PMID: 36810163 PMCID: PMC9944617 DOI: 10.1212/nxi.0000000000200091] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 12/12/2022] [Indexed: 02/23/2023]
Abstract
BACKGROUND AND OBJECTIVES Ocrelizumab (OCR), a humanized anti-CD20 monoclonal antibody, is highly efficient in patients with relapsing-remitting multiple sclerosis (RR-MS). We assessed early cellular immune profiles and their association with disease activity at treatment start and under therapy, which may provide new clues on the mechanisms of action of OCR and on the disease pathophysiology. METHODS A first group of 42 patients with an early RR-MS, never exposed to disease-modifying therapy, was included in 11 centers participating to an ancillary study of the ENSEMBLE trial (NCT03085810) to evaluate the effectiveness and safety of OCR. The phenotypic immune profile was comprehensively assessed by multiparametric spectral flow cytometry at baseline and after 24 and 48 weeks of OCR treatment on cryopreserved peripheral blood mononuclear cells and analyzed in relation to disease clinical activity. A second group of 13 untreated patients with RR-MS was included for comparative analysis of peripheral blood and CSF. The transcriptomic profile was assessed by single-cell qPCRs of 96 genes of immunologic interest. RESULTS Using an unbiased analysis, we found that OCR as an effect on 4 clusters of CD4+ T cells: one corresponding to naive CD4+ T cells was increased, the other clusters corresponded to effector memory (EM) CD4+CCR6- T cells expressing homing and migration markers, 2 of them also expressing CCR5 and were decreased by the treatment. Of interest, one CD8+ T-cell cluster was decreased by OCR corresponding to EM CCR5-expressing T cells with high expression of the brain homing markers CD49d and CD11a and correlated with the time elapsed since the last relapse. These EM CD8+CCR5+ T cells were enriched in the CSF of patients with RR-MS and corresponded to activated and cytotoxic cells. DISCUSSION Our study provides novel insights into the mode of action of anti-CD20, pointing toward the role of EM T cells, particularly a subset of CD8 T cells expressing CCR5.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - David Laplaud
- From the CHU Nantes (A.G., E.D., S.S., J.M., A.N., S.W., P.-A.G., L.B., D.L.), Nantes Université, INSERM UMR1064, Center for Research in Transplantation and Translational Immunology (CR2TI); CRCSEP (C.L.-F.), CHU de Nice Pasteur 2, Université Nice Côte d'Azur UR2CA URRIS; Service de Neurologie (E.T.), CHU de Nîmes, Institut de Génomique Fonctionnelle, Université de Montpellier, CNRS, INSERM; Service de Neurologie et Centre d'Investigation Clinique (J.D.S.), CHU de Strasbourg; Service de Neurologie (E.L.P.), CHU Pontchaillou, Rennes; Université de Lyon (S.V.), Université Claude Bernard Lyon 1; Service de Neurologie (S.V.), sclérose en plaques, pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron; Observatoire Français de la Sclérose en Plaques (S.V.), Centre de Recherche en Neurosciences de Lyon; EUGENE DEVIC EDMUS Foundation Against Multiple sclerosis (S.V.), state-approved Foundation, Bron; Service de Neurologie (A.M.), CHU Bretonneau, Tours; Service de Neurologie (E.B.), CHU de Besançon; Service de Neurologie (O.C.), CHU de Grenoble; Service de Neurologie (P.L.), CHU de Montpellier, Montpellier; Service de Neurologie (A.R.), CHU de Bordeaux; Université de Bordeaux (A.R.), INSERM, Neurocentre Magendie; F. Hoffmann-La Roche Ltd (C.R., F.B., R.B.) CIC INSERM 1413 (F.L.F., S.W., D.L.), Nantes; CHU Nantes (S.W., D.L.), Nantes Université, Service de Neurologie; and CHU Nantes (P.-A.G.), Nantes Université, Clinique des données, France.
| |
Collapse
|
28
|
Karlowicz JR, Klakegg M, Aarseth JH, Bø L, Myhr KM, Torgauten HM, Torkildsen Ø, Wergeland S. Predictors of hospitalization due to infection in rituximab-treated MS patients. Mult Scler Relat Disord 2023; 71:104556. [PMID: 36842313 DOI: 10.1016/j.msard.2023.104556] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 12/30/2022] [Accepted: 02/07/2023] [Indexed: 02/13/2023]
Abstract
BACKGROUND Rituximab is extensively used off-label to treat multiple sclerosis (MS), and long-term vigilance for adverse events is needed. This study was conducted to determine frequencies and predictors of hematological adverse events, including hypogammaglobulinemia, severe lymphopenia, neutropenia, and infections leading to hospitalization. METHODS This retrospective cohort study included all patients with MS initiating rituximab treatment at Haukeland University Hospital between January 1st, 2017, and July 1st, 2021. Patients were followed by clinical monitoring and repeated blood sampling every six months. Clinical outcomes and laboratory results were retrieved from the Norwegian MS Registry and Biobank and the patient administrative system at Haukeland University Hospital. RESULTS Five hundred and fifty-six patients were included, 515 with relapsing-remitting MS (RRMS) and 41 with progressive MS. Overall, 33 patients (5.9%) experienced 56 episodes of infections requiring hospital admission. Sixty patients (10.8%) had confirmed hypogammaglobulinemia, 17 (3.1%) had confirmed severe lymphopenia, and 10 (1.8%) had confirmed severe neutropenia. Predictors of infection requiring hospital admission were progressive MS (adjusted OR (aOR): 4.81; 95%CI: 1.25-18.48), duration of treatment with rituximab (aOR: 1.52; 95%CI: 1.11-2.09) and confirmed severe lymphopenia (aOR: 13.58; 95%CI: 3.41-54.06) and neutropenia (aOR: 13.40; 95%CI: 2.93-61.25). Of the hematological abnormalities, only hypogammaglobulinemia was associated with treatment duration (aOR: 1.35; 95%CI: 1.09-1.69). CONCLUSION The risk of hospitalization due to infection is associated with time on rituximab treatment, in patients with lympho- or neutropenia, and in patients with primary progressive MS. We observed a time-dependent decline in IgG values, in contrast to neutrophil and lymphocyte count, suggesting a cumulative dose-dependent response. These predictors can assist clinicians in assessing and monitoring MS patients receiving rituximab.
Collapse
Affiliation(s)
| | - Mattias Klakegg
- Department of clinical medicine, University of Bergen, Norway
| | - Jan Harald Aarseth
- Norwegian MS-registry and biobank, Dept of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Lars Bø
- Department of clinical medicine, University of Bergen, Norway; Neuro-SysMed, Haukeland University Hospital, Bergen, Norway
| | - Kjell-Morten Myhr
- Department of clinical medicine, University of Bergen, Norway; Neuro-SysMed, Haukeland University Hospital, Bergen, Norway
| | - Hilde Marie Torgauten
- Department of clinical medicine, University of Bergen, Norway; Neuro-SysMed, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- Department of clinical medicine, University of Bergen, Norway; Neuro-SysMed, Haukeland University Hospital, Bergen, Norway
| | - Stig Wergeland
- Department of clinical medicine, University of Bergen, Norway; Norwegian MS-registry and biobank, Dept of Neurology, Haukeland University Hospital, Bergen, Norway; Neuro-SysMed, Haukeland University Hospital, Bergen, Norway.
| |
Collapse
|
29
|
Rual C, Biotti D, Lepine Z, Delourme A, Berre JL, Treiner E, Ciron J. 2 grams versus 1 gram rituximab as maintenance schedule in multiple sclerosis, neuromyelitis optica spectrum disorders and related diseases: What B-cell repopulation data tell us. Mult Scler Relat Disord 2023; 71:104563. [PMID: 36791624 DOI: 10.1016/j.msard.2023.104563] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/31/2023] [Accepted: 02/09/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND Rituximab (RTX) is largely used as a long-term maintenance therapy in various inflammatory neurological diseases. Reducing the dose of maintenance therapy of RTX from 2 grams every 6 months (traditional regimen) to 1 gram every 6 months (reduced regimen) is a widely applied practice, with the assumption that it decreases the risk of side effects while maintaining efficacy. METHODS In order to better describe the biological consequences of this strategy, we retrospectively compared, in a single center, the B-cell count after the traditional regimen and after the reduced regimen in patients who underwent both (n = 161). RESULTS The rate of patients with B-cell repopulation was not significantly different between traditional and reduced regimens (9.9% vs 15.6%, p = 0.18). Among the 145 patients who did not have B-cell repopulation following the traditional regimen, B-cell repopulation following the reduced regimen occurred in only 16 cases (11.0%) and was usually slight: 11/16 patients had only 1% of CD19+ cells. CONCLUSION These data emphasize the relevance of 1 g of RTX as maintenance therapy and the fact that 2 g of RTX is generally an overtreatment in inflammatory neurological diseases.
Collapse
Affiliation(s)
- Celso Rual
- CRC-SEP, Department of Neurology, University Hospital of Toulouse, Toulouse Cedex 9, F-31059, France
| | - Damien Biotti
- CRC-SEP, Department of Neurology, University Hospital of Toulouse, Toulouse Cedex 9, F-31059, France; Infinity, INSERM UMR1291 - CNRS UMR5051, University Toulouse III, Toulouse Cedex 3, F-31024, France
| | - Zoe Lepine
- CRC-SEP, Department of Neurology, University Hospital of Toulouse, Toulouse Cedex 9, F-31059, France
| | - Adrien Delourme
- CRC-SEP, Department of Neurology, University Hospital of Toulouse, Toulouse Cedex 9, F-31059, France
| | - Juliette Le Berre
- CRC-SEP, Department of Neurology, University Hospital of Toulouse, Toulouse Cedex 9, F-31059, France
| | - Emmanuel Treiner
- Laboratory of Immunology, University Hospital of Toulouse, Toulouse Cedex 9, F-31059, France; Infinity, INSERM UMR1251, University Toulouse III, Toulouse Cedex 3, F-31024, France
| | - Jonathan Ciron
- CRC-SEP, Department of Neurology, University Hospital of Toulouse, Toulouse Cedex 9, F-31059, France; Infinity, INSERM UMR1291 - CNRS UMR5051, University Toulouse III, Toulouse Cedex 3, F-31024, France.
| |
Collapse
|
30
|
Boz C, Ozakbas S, Terzi M, Karabudak R, Sevim S, Turkoglu R, Soysal A, Balcı BP, Efendi H, Turan ÖF, Yüceyar N, Yetkin MF, Karahan SZ, Demirkıran M, Guler S, Agan K, Kıylıoğlu N, Baba C, Tuncer A, Köseoğlu M. The comparative effectiveness of fingolimod, natalizumab, and ocrelizumab in relapsing-remitting multiple sclerosis. Neurol Sci 2023; 44:2121-2129. [PMID: 36689010 DOI: 10.1007/s10072-023-06608-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 01/08/2023] [Indexed: 01/24/2023]
Abstract
BACKGROUND Fingolimod, natalizumab, and ocrelizumab are commonly used in the second-line treatment of relapsing-remitting multiple sclerosis (RRMS). However, these have only been compared in observational studies, not in controlled trials, with limited and inconclusive results being reported. A comparison of their effect on relapse and disability in a real-world setting is therefore needed. OBJECTIVES The objective of this study was to compare the efficacy of fingolimod, natalizumab, and ocrelizumab in reducing disease activity in RRMS. METHODS This multicenter, retrospective observational study was carried out with prospectively collected data from 16 centers. All consecutive RRMS patients treated with fingolimod, natalizumab, and ocrelizumab were included. Data for relapses, Expanded Disability Status Scale (EDSS) scores, and brain magnetic resonance imaging (MRI) scans were collected. Patients were matched using propensity scores. Annualized relapse rates (ARR), time to first relapse, and disability accumulation were compared. RESULTS Propensity score matching retained 736 patients in the fingolimod versus 370 in the natalizumab groups, 762 in the fingolimod versus 434 in the ocrelizumab groups, and 310 in the natalizumab versus 310 in the ocrelizumab groups for final analyses. Mean ARR decreased markedly from baseline after treatment in all three treatment groups. Mean on-treatment ARR was lower in natalizumab-treated patients (0.09, 95% confidence interval (CI), 0.07-0.12) than in those treated with fingolimod (0.17, 0.15-0.19, p<0.001), ocrelizumab (0.08, 0.06-0.11), and fingolimod (0.14, 0.12-0.16, p=0.001). No significant difference was observed in mean on-treatment ARR between patients treated with natalizumab (0.08, 0.06-0.11) and ocrelizumab (0.09, 0.07-0.12, p=0.54). Compared to fingolimod, the natalizumab and ocrelizumab groups exhibited a higher percentage of relapse-free patients and a lower percentage of MRI-active patients at year 1. No significance differences in disability accumulation were determined between the therapies. CONCLUSION Natalizumab and ocrelizumab exhibited similar effects on relapse control, and both were associated with better relapse control than fingolimod. The effects of the three therapies on disability outcomes were similar.
Collapse
Affiliation(s)
- Cavit Boz
- Department of Neurology, Karadeniz Technical University Medical Faculty, 61080, Trabzon, Turkey.
| | - Serkan Ozakbas
- Department of Neurology, Dokuz Eylul University, Izmir, Turkey
| | - Murat Terzi
- Department of Neurology, Ondokuz Mayis University, Samsun, Turkey
| | - Rana Karabudak
- Department of Neurology, Hacettepe University, Ankara, Turkey
| | - Serhan Sevim
- Department of Neurology, Mersin University, Mersin, Turkey
| | - Recai Turkoglu
- Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - Aysun Soysal
- Bakirkoy Education and Research Hospital for Psychiatric and Neurological Diseases, Istanbul, Turkey
| | - Belgin Petek Balcı
- Department of Neurology, Haseki Educational and Research Center, Istanbul, Turkey
| | - Hüsnü Efendi
- Department of Neurology, Kocaeli University, Izmit, Turkey
| | | | - Nur Yüceyar
- Department of Neurology, Ege University, Izmir, Turkey
| | | | - Serap Zengin Karahan
- Department of Neurology, Karadeniz Technical University Medical Faculty, 61080, Trabzon, Turkey
| | | | - Sibel Guler
- Department of Neurology, Trakya University, Edirne, Turkey
| | - Kadriye Agan
- Department of Neurology, Marmara University, Istanbul, Turkey
| | - Nefati Kıylıoğlu
- Department of Neurology, Aydın Adnan Menderes University, Aydin, Turkey
| | - Cavid Baba
- Department of Neurology, Dokuz Eylul University, Izmir, Turkey
| | - Asli Tuncer
- Department of Neurology, Hacettepe University, Ankara, Turkey
| | - Mesrure Köseoğlu
- Bakirkoy Education and Research Hospital for Psychiatric and Neurological Diseases, Istanbul, Turkey
| |
Collapse
|
31
|
de Sèze J, Maillart E, Gueguen A, Laplaud DA, Michel L, Thouvenot E, Zephir H, Zimmer L, Biotti D, Liblau R. Anti-CD20 therapies in multiple sclerosis: From pathology to the clinic. Front Immunol 2023; 14:1004795. [PMID: 37033984 PMCID: PMC10076836 DOI: 10.3389/fimmu.2023.1004795] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 02/13/2023] [Indexed: 04/11/2023] Open
Abstract
The immune system plays a significant role in multiple sclerosis. While MS was historically thought to be T cell-mediated, multiple pieces of evidence now support the view that B cells are essential players in multiple sclerosis pathogenic processes. High-efficacy disease-modifying therapies that target the immune system have emerged over the past two decades. Anti-CD20 monoclonal antibodies selectively deplete CD20+ B and CD20+ T cells and efficiently suppress inflammatory disease activity. These monotherapies prevent relapses, reduce new or active magnetic resonance imaging brain lesions, and lessen disability progression in patients with relapsing multiple sclerosis. Rituximab, ocrelizumab, and ofatumumab are currently used in clinical practice, while phase III clinical trials for ublituximab have been recently completed. In this review, we compare the four anti-CD20 antibodies in terms of their mechanisms of action, routes of administration, immunological targets, and pharmacokinetic properties. A deeper understanding of the individual properties of these molecules in relation to their efficacy and safety profiles is critical for their use in clinical practice.
Collapse
Affiliation(s)
- Jérôme de Sèze
- Department of Neurology, Hôpital de Hautepierre, Clinical Investigation Center, Institut National de la Santé et de la Recherche Médicale (INSERM), Strasbourg, France
- Fédération de Médecine Translationelle, Institut National de la Santé et de la Recherche Médicale (INSERM), Strasbourg, France
- *Correspondence: Jérôme de Sèze,
| | - Elisabeth Maillart
- Department of Neurology, Pitié Salpêtrière Hospital, Paris, France
- Centre de Ressources et de Compétences Sclérose en Plaques, Paris, France
| | - Antoine Gueguen
- Department of Neurology, Rothschild Ophthalmologic Foundation, Paris, France
| | - David A. Laplaud
- Department of Neurology, Centre Hospitalier Universitaire (CHU) Nantes, Nantes Université, Institut National de la Santé et de la Recherche Médicale (INSERM), Centre d’Investigation Clinique (CIC), Center for Research in Transplantation and Translational Immunology, UMR, UMR1064, Nantes, France
| | - Laure Michel
- Clinical Neuroscience Centre, CIC_P1414 Institut National de la Santé et de la Recherche Médicale (INSERM), Rennes University Hospital, Rennes University, Rennes, France
- Microenvironment, Cell Differentiation, Immunology and Cancer Unit, Institut National de la Santé et de la Recherche Médicale (INSERM), Rennes I University, French Blood Agency, Rennes, France
- Neurology Department, Rennes University Hospital, Rennes, France
| | - Eric Thouvenot
- Department of Neurology, Centre Hospitalier Universitaire (CHU) Nîmes, University of Montpellier, Nîmes, France
- Institut de Génomique Fonctionnelle, UMR, Institut National de la Santé et de la Recherche Médicale (INSERM), University of Montpellier, Montpellier, France
| | - Hélène Zephir
- University of Lille, Institut National de la Santé et de la Recherche Médicale (INSERM) U1172, Centre Hospitalier Universitaire (CHU), Lille, France
| | - Luc Zimmer
- Université Claude Bernard Lyon 1, Hospices Civils de Lyon, Institut National de la Santé et de la Recherche Médicale (INSERM), CNRS, Lyon Neuroscience Research Center, Lyon, France
| | - Damien Biotti
- Centre Ressources et Compétences Sclérose En Plaques (CRC-SEP) and Department of Neurology, Centre Hospitalier Universitaire (CHU) Toulouse Purpan – Hôpital Pierre-Paul Riquet, Toulouse, France
| | - Roland Liblau
- Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), University of Toulouse, CNRS, Institut National de la Santé et de la Recherche Médicale (INSERM), UPS, Toulouse, France
- Department of Immunology, Toulouse University Hospital, Toulouse, France
| |
Collapse
|
32
|
Gascón-Giménez F, Alcalá C, Ramió-Torrentà L, Montero P, Matías-Guiu J, Gómez-Esteve I, Oreja-Guevara C, Gil-Perotín S, Blanco Y, Carcelén M, Quintanilla-Bordás C, Costa L, Villar LM, Martínez-Rodriguez JE, Domínguez JA, Calles C, González I, Sotoca J, Oterino A, Lucas-Jimenez C, Pérez-Miralles F, Casanova B. Treatment of multiple sclerosis with rituximab: A Spanish multicenter experience. Front Neurol 2023; 14:1060696. [PMID: 36959824 PMCID: PMC10027934 DOI: 10.3389/fneur.2023.1060696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/09/2023] [Indexed: 03/09/2023] Open
Abstract
Introduction Rituximab (RTX) is considered a potential therapeutic option for relapsing-remitting (RRMS) and progressive forms (PMS) of multiple sclerosis (MS). The main objective of this work was to investigate the effectiveness and safety of rituximab in MS. Patients and methods Observational multicenter study of clinical and radiological effectiveness and safety of rituximab in RRMS and PMS. Results A total of 479 rituximab-treated patients were included in 12 Spanish centers, 188 RRMS (39.3%) and 291 (60.7%) PMS. Despite standard treatment, the annualized relapse rate (ARR) the year before RTX was 0.63 (SD: 0.8) and 156 patients (41%) had at least one gadolinium-enhanced lesion (GEL) on baseline MRI. Mean EDSS had increased from 4.3 (SD: 1.9) to 4.8 (SD: 1.7) and almost half of the patients (41%) had worsened at least one point. After a median follow-up of 14.2 months (IQR: 6.5-27.2), ARR decreased by 85.7% (p < 0.001) and GEL by 82.9%, from 0.41 to 0.07 (p < 0.001). A significant decrease in EDSS to 4.7 (p = 0.046) was observed after 1 year of treatment and this variable remained stable during the second year of therapy. There was no evidence of disease activity in 68% of patients. Infusion-related symptoms were the most frequent side effect (19.6%) and most were mild. Relevant infections were reported only in 18 patients (including one case of probable progressive multifocal leukoencephalopathy). Conclusion Rituximab could be an effective and safe treatment in RRMS, including aggressive forms of the disease. Some selected PMS patients could also benefit from this treatment.
Collapse
Affiliation(s)
- Francisco Gascón-Giménez
- Neuroimmunology Unit, Neurology Department, Hospital Clinico Universitario, Valencia, Spain
- *Correspondence: Francisco Gascón-Giménez
| | - Carmen Alcalá
- Neuroimmunology Unit, La Fe University and Polytechnic Hospital, Valencia, Spain
| | | | - Paloma Montero
- Department of Neurology, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - Jorge Matías-Guiu
- Department of Neurology, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - Irene Gómez-Esteve
- Department of Neurology, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | | | - Sara Gil-Perotín
- Neuroimmunology Unit, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Yolanda Blanco
- Neurology Department, Clinical Hospital of Barcelona, Barcelona, Spain
| | - María Carcelén
- Neurology Department, General University Hospital of Valencia, Valencia, Spain
| | | | - Lucienne Costa
- Neurology Department, Ramón y Cajal University Hospital, Madrid, Spain
| | | | | | - José Andrés Domínguez
- Neuroimmunology Unit, Neurology Department, Hospital Clinico Universitario, Valencia, Spain
| | - Carmen Calles
- Neurology Department, Son Espases University Hospital, Palma de Mallorca, Spain
| | - Inés González
- Neurology Department, Álvaro Cunqueiro Hospital, Vigo, Spain
| | - Javier Sotoca
- Neurology Department, Mutua de Terrasssa University Hospital, Barcelona, Spain
| | - Agustin Oterino
- Neurology Department, Marqués de Valdecilla University Hospital, Santander, Spain
| | - Celia Lucas-Jimenez
- Systems and Applications Engineer Department, Subdirectorate of Information Systems Hospital La Fe, Valencia, Spain
| | | | - Bonaventura Casanova
- Neuroimmunology Unit, La Fe University and Polytechnic Hospital, Valencia, Spain
| |
Collapse
|
33
|
Pape K, Rolfes L, Steffen F, Muthuraman M, Korsen M, Meuth SG, Zipp F, Bittner S. Comparative effectiveness of natalizumab versus ocrelizumab in multiple sclerosis: a real-world propensity score-matched study. Ther Adv Neurol Disord 2022; 15:17562864221142924. [PMID: 36568489 PMCID: PMC9772974 DOI: 10.1177/17562864221142924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 11/16/2022] [Indexed: 12/23/2022] Open
Abstract
Background For treatment of relapsing-remitting multiple sclerosis (RRMS), a broad range of disease-modifying therapies (DMT) is available. However, few comparative effectiveness studies between different drugs have been performed. Objectives This study aimed to compare the efficacy and treatment continuation of natalizumab and ocrelizumab in a real-world cohort of patients with relapsing-remitting multiple sclerosis (RRMS) from two German university hospitals. Methods We performed a retrospective analysis of RRMS patients who initiated treatment with natalizumab or ocrelizumab between January 2016 and April 2019 at the German university hospitals of Mainz and Düsseldorf. Bayesian propensity score matching was conducted to correct for differences in baseline characteristics. Our primary outcome was no evidence of disease activity [NEDA-3: no relapses, no confirmed disability progression, and no magnetic resonance imaging (MRI) activity] and its subcomponents. Secondary outcomes included measurement of neurofilament light chain (NfL) in serum, analysis of premature discontinuation, and evidence of rebound activity in patients switching from natalizumab to ocrelizumab. Results We identified 63 patients starting treatment with natalizumab and 76 patients starting with ocrelizumab. Binary logistic regression showed that treatment with natalizumab or a higher number of relapses in the previous year were independently associated with a higher risk for relapses. Patients receiving natalizumab had a higher probability of premature discontinuation of therapy (p = 0.002). After propensity score matching of the two treatment arms, 55 patients remained per group. NEDA-3 after 30 months of follow-up was reached by 53.1% in the ocrelizumab group and 36.1% in the natalizumab group (p = 0.177). Ocrelizumab was superior to natalizumab concerning the occurrence of relapses in log-rank test (p = 0.019). NfL levels in serum were low under both treatments. Patients who switched from natalizumab to ocrelizumab showed no increased rebound activity. Discussion This study provides class IV evidence that treatment of RRMS patients with ocrelizumab and natalizumab show comparable effectiveness in combined endpoints, while ocrelizumab might be more effective in preventing the occurrence of relapses.
Collapse
Affiliation(s)
- Katrin Pape
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Leoni Rolfes
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Falk Steffen
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Muthuraman Muthuraman
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Melanie Korsen
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Sven G. Meuth
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Frauke Zipp
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | | |
Collapse
|
34
|
Chico-García JL, Rodríguez-Jorge F, Sainz-Amo R, Monreal E, Walo-Delgado P, Roldán E, Rodríguez-Martín E, Masjuan J, Costa-Frossard L, Sainz de la Maza S, Villar LM. B-lymphocyte-guided retreatment contributes to establish good effectiveness and safety profile in MS patients treated with rituximab. Mult Scler Relat Disord 2022; 68:104218. [PMID: 36270253 DOI: 10.1016/j.msard.2022.104218] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 09/28/2022] [Accepted: 10/04/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Rituximab is extensively used for multiple sclerosis (MS) treatment. However, the best dosage remains to be established. It has been proposed that retreatment could be guided by B lymphocyte (BL) percentages. OBJECTIVE To establish the best BL value for retreatment with rituximab in MS and to confirm the safety and efficacy of this approach. METHODS A prospective study was done with an exploratory cohort and a confirmatory cohort of MS patients treated with rituximab between 2017 and 2021. The first one comprised 10 MS patients with BL assessed every 3 months after rituximab infusion and retreatment done when BL values were ≥0.5%. The confirmatory cohort included 41 MS patients (41.5% women, 87.8% with secondary progressive MS, median age = 46.3 (interquartile range: 41.3-52.1) years, disease duration = 14.1 (9-19.6) years, EDSS score = 5.5 (4.0-6.5)). The confirmatory cohort was treated with rituximab following the pattern established in the exploratory cohort. RESULTS In the exploratory cohort, ≥0.2% BL was established as the best value for retreatment because in most cases, a substantial increase of BL counts was preceded by initial values of 0.2-0.3%. In the confirmatory cohort, rituximab reduced the annualized relapse rate (ARR 0.56 vs. 0.125, p < 0.001), proportion of patients with appearance of new/enlarged T2 lesions (63.4% vs. 12.2%, p < 0.001), gadolinium-enhancing lesions (39% vs. 0%, p < 0.001), and confirmed disability progression (55% vs. 27.5%, p = 0.037). There were 22 patients (53.7%) who achieved NEDA-3. No patients had severe infections, and 10.7% cases had reduced IgG levels. CONCLUSION Rituximab treatment guided by BL showed high effectiveness and a good safety profile for MS patients after one year of treatment.
Collapse
Affiliation(s)
- Juan Luis Chico-García
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitario Ramón y Cajal, IRYCIS, M-607, 9, 100, Madrid 28034, Spain.
| | - Fernando Rodríguez-Jorge
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitario Ramón y Cajal, IRYCIS, M-607, 9, 100, Madrid 28034, Spain
| | - Raquel Sainz-Amo
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitario Ramón y Cajal, IRYCIS, M-607, 9, 100, Madrid 28034, Spain
| | - Enric Monreal
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitario Ramón y Cajal, IRYCIS, M-607, 9, 100, Madrid 28034, Spain; Universidad de Alcalá, Alcalá de Henares, Spain
| | - Paulette Walo-Delgado
- Department of Immunology, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Ernesto Roldán
- Department of Immunology, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | | | - Jaime Masjuan
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitario Ramón y Cajal, IRYCIS, M-607, 9, 100, Madrid 28034, Spain; Universidad de Alcalá, Alcalá de Henares, Spain
| | - Lucienne Costa-Frossard
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitario Ramón y Cajal, IRYCIS, M-607, 9, 100, Madrid 28034, Spain
| | - Susana Sainz de la Maza
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitario Ramón y Cajal, IRYCIS, M-607, 9, 100, Madrid 28034, Spain; Universidad de Alcalá, Alcalá de Henares, Spain
| | - Luisa Maria Villar
- Department of Immunology, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| |
Collapse
|
35
|
Zhu C, Zhou Z, Roos I, Merlo D, Kalincik T, Ozakbas S, Skibina O, Kuhle J, Hodgkinson S, Boz C, Alroughani R, Lechner-Scott J, Barnett M, Izquierdo G, Prat A, Horakova D, Kubala Havrdova E, Macdonell R, Patti F, Khoury SJ, Slee M, Karabudak R, Onofrj M, Van Pesch V, Prevost J, Monif M, Jokubaitis V, van der Walt A, Butzkueven H. Comparing switch to ocrelizumab, cladribine or natalizumab after fingolimod treatment cessation in multiple sclerosis. J Neurol Neurosurg Psychiatry 2022; 93:1330-1337. [PMID: 36261289 DOI: 10.1136/jnnp-2022-330104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/26/2022] [Indexed: 03/16/2023]
Abstract
BACKGROUND To compare the effectiveness and treatment persistence of ocrelizumab, cladribine and natalizumab in patients with relapsing-remitting multiple sclerosis switching from fingolimod. METHODS Using data from MSBase registry, this multicentre cohort study included subjects who had used fingolimod for ≥6 months and then switched to ocrelizumab, cladribine or natalizumab within 3 months after fingolimod discontinuation. We analysed relapse and disability outcomes after balancing covariates using an inverse-probability-treatment-weighting method. Propensity scores for the three treatments were obtained using multinomial-logistic regression. Due to the smaller number of cladribine users, comparisons of disability outcomes were limited to natalizumab and ocrelizumab. RESULTS Overall, 1045 patients switched to ocrelizumab (n=445), cladribine (n=76) or natalizumab (n=524) after fingolimod. The annualised relapse rate (ARR) for ocrelizumab was 0.07, natalizumab 0.11 and cladribine 0.25. Compared with natalizumab, the ARR ratio (95% confidence interval [CI]) was 0.67 (0.47 to 0.96) for ocrelizumab and 2.31 (1.30 to 4.10) for cladribine; the hazard ratio (95% CI) for time to first relapse was 0.57 (0.40 to 0.83) for ocrelizumab and 1.18 (0.47 to 2.93) for cladribine. Ocrelizumab users had an 89% lower discontinuation rate (95% CI, 0.07 to 0.20) than natalizumab, but also a 51% lower probability of confirmed disability improvement (95% CI, 0.32 to 0.73). There was no difference in disability accumulation. CONCLUSION After fingolimod cessation, ocrelizumab and natalizumab were more effective in reducing relapses than cladribine. Due to the low ARRs in all three treatment groups, additional observation time is required to determine if statistical difference in ARRs results in long-term disability differences.
Collapse
Affiliation(s)
- Chao Zhu
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Zhen Zhou
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Izanne Roos
- Clinical Outcomes Research Unit, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Daniel Merlo
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Tomas Kalincik
- Clinical Outcomes Research Unit, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | | | - Olga Skibina
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Jens Kuhle
- Neurologic Clinic and Policlinic, Departments of Medicine and Clinical Research, University Hospital and University of Basel, Basel, Switzerland
| | - Suzanne Hodgkinson
- Departments of Nephrology and Neurology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Cavit Boz
- KTU Medical Faculty Farabi Hospital, Trabzon, Turkey
| | | | - Jeannette Lechner-Scott
- Department of Neurology, John Hunter Hospital, Newcastle, New South Wales, Australia.,School of Medicine and Public Health, University Newcastle, Newcastle, New South Wales, Australia
| | - Michael Barnett
- Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
| | | | - Alexandre Prat
- Hôpital Notre Dame, CHUM and Universite de Montreal, Montreal, Québec, Canada
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Eva Kubala Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | | | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies, GF Ingrassia, Catania, Italy.,Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Samia Joseph Khoury
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mark Slee
- Flinders University, Adelaide, South Australia, Australia
| | - Rana Karabudak
- Department of Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Marco Onofrj
- Department of Neuroscience, Imaging, and Clinical Sciences, University G. d'Annunzio, Chieti, Italy
| | | | - Julie Prevost
- Centre integre de sante et de services sociaux des Laurentides point de service de Saint-Jerome, Saint-Jerome, Quebec, Canada
| | - Mastura Monif
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Vilija Jokubaitis
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Anneke van der Walt
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | | |
Collapse
|
36
|
Mohebbi N, Taghizadeh-Ghehi M, Savar SM, Abdi S, Kouhsari R, Gholami K, Nafissi S. Adverse drug reactions of Rituximab in patients suffering from autoimmune neurological diseases. Daru 2022; 30:323-329. [PMID: 36152270 PMCID: PMC9715899 DOI: 10.1007/s40199-022-00452-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 09/16/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Rituximab, a chimeric human/mouse monoclonal antibody targeting CD-20 antigens, has been used recently for various rheumatological and autoimmune diseases, including autoimmune neurological disorders. OBJECTIVES We aimed to study the frequency, seriousness, causality, and preventability of adverse drug reactions (ADRs) of rituximab in Iranian patients with autoimmune neurological diseases. METHODS In this cross-sectional observational study, patients with autoimmune neurological diseases who had an indication for rituximab treatment were enrolled. Naranjo adverse drug reaction probability scale was used to assess the causality of ADRs, and the preventability of the ADRs was determined by P-Method. The seriousness of ADRs was also determined. RESULTS A total of 264 ADRs were recorded from 97 patients. The Median (min-max) number of ADRs experienced by patients was 3 (1-7) events. 11.3% of patients experienced serious ADRs. 18.2% and 26.9% of ADRs were Definite and Probable, respectively. Only 5% of the ADRs were ''preventable". The most frequent ADRs were rituximab infusion-related reactions. CONCLUSION Rituximab had an acceptable safety profile in our study patients. However, there must be certain cautions regarding the use of the medication for the elderly or patients with a compromised immune system. Timely detection and management of ADRs would also be crucial to prevent severe and permanent damages. Moreover, considering that rituximab is used as an off-label treatment for autoimmune neurological diseases, a risk-benefit assessment would be necessary before deciding on the treatment choice.
Collapse
Affiliation(s)
- Niayesh Mohebbi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Taghizadeh-Ghehi
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mehrdad Savar
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| | - Siamak Abdi
- Department of Neurology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Romina Kouhsari
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Kheirollah Gholami
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahriar Nafissi
- Department of Neurology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
- Iranian Neuromuscular Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| |
Collapse
|
37
|
The Efficacy and Safety of Anti-CD20 Antibody Treatments in Relapsing Multiple Sclerosis: A Systematic Review and Network Meta-analysis. CNS Drugs 2022; 36:1155-1170. [PMID: 36245023 DOI: 10.1007/s40263-022-00961-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Several large randomized controlled trials of anti-CD20 antibodies have been successfully conducted for the treatment of relapsing multiple sclerosis. Despite this, there are few systematic comparisons of different anti-CD20 antibodies and a comprehensive evaluation of their efficacy and safety is yet to be carried out. OBJECTIVE The objective of this systematic review and network meta-analysis was to evaluate the efficacy and safety of the three approved anti-CD20 antibodies for the treatment of relapsing multiple sclerosis and to aid clinicians in choosing medications. METHODS MEDLINE, EMBASE, Cochrane Library, and clinicaltrials.gov were all searched for randomized controlled trials conducted to evaluate anti-CD20 antibodies (rituximab, ocrelizumab, ofatumumab) and corresponding controls up to 31 May, 2022. Review Manager 5.3 and R 3.5.2 software were used to assess the data. The risk ratio and mean difference were analyzed and calculated with a random-effects model. RESULTS We pooled 4181 patients from ten randomized controlled trials. Without increasing the risk of adverse events and serious adverse events, anti-CD20 antibodies were superior to the active control group in all efficacy outcomes (both p < 0.005, certainty of evidence, very low to high). For the comparison between anti-CD20 groups, rituximab was found to be able to significantly increase the number of patients free of relapse more effectively than the other two interventions; however, the surface under curve ranking area values for serious adverse events were also the highest (84.8%). At the same time, ocrelizumab and ofatumumab exhibited satisfactory efficacy without showing a worse safety than any other interventions. CONCLUSIONS Overall, anti-CD20 antibody treatment is superior to a corresponding control in efficacy and safety measures and ocrelizumab and ofatumumab may be the most suitable anti-CD20 antibodies for treating relapsing multiple sclerosis. Additional large-scale and high-quality studies are still needed to further explore the safety of these therapies.
Collapse
|
38
|
Cree BA. All anti-CD20 monoclonal antibodies have similar efficacy and safety risks: Yes. Mult Scler 2022; 28:1843-1844. [PMID: 36124839 PMCID: PMC9493405 DOI: 10.1177/13524585221108294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Bruce Ac Cree
- Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA 94158, USA
| |
Collapse
|
39
|
Saad MA, Eissa NM, Ahmed MA, ElMeshad AN, Laible G, Attia AS, Al-Ghobashy MA, Abdelsalam RM, Al-Shorbagy MY. Nanoformulated Recombinant Human Myelin Basic Protein and Rituximab Modulate Neuronal Perturbations in Experimental Autoimmune Encephalomyelitis in Mice. Int J Nanomedicine 2022; 17:3967-3987. [PMID: 36105617 PMCID: PMC9464642 DOI: 10.2147/ijn.s359114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 07/24/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Rituximab (RTX) and recombinant human myelin basic protein (rhMBP) were proven to be effective in ameliorating the symptoms of multiple sclerosis (MS). In this study, a nanoformulation containing rhMBP with RTX on its surface (Nano-rhMBP-RTX) was prepared and investigated in comparison with other treatment groups to determine its potential neuro-protective effects on C57BL/6 mice after inducing experimental autoimmune encephalomyelitis (EAE). Methods EAE was induced in the corresponding mice by injecting 100 μL of an emulsion containing complete Freund's adjuvant (CFA) and myelin oligodendrocyte glycoprotein (MOG). The subjects were weighed, scored and subjected to behavioural tests. After reaching a clinical score of 3, various treatments were given to corresponding EAE-induced and non-induced groups including rhMBP, RTX, empty nanoparticle prepared by poly (lactide-co-glycolide) (PLGA) or the prepared nanoformulation (Nano-rhMBP-RTX). At the end of the study, biochemical parameters were also determined as interferon-γ (IFN-γ), myeloperoxidase (MPO), interleukin-10 (IL-10), interleukin-4 (IL-4), tumor necrosis factor alpha (TNF-α), nuclear factor kappa B (NF-kB), brain derived neurotrophic factor (BDNF), 2', 3' cyclic nucleotide 3' phosphodiesterase (CNP) and transforming growth factor beta (TGF-β) along with some histopathological analyses. Results The results of the Nano-rhMBP-RTX group showed promising outcomes in terms of reducing the clinical scores, improving the behavioural responses associated with improved histopathological findings. Elevation in the levels of IL-4, CNP and TGF-β was also noticed along with marked decline in the levels of NF-kB and TNF-α. Conclusion Nano-rhMBP-RTX treated group ameliorated the adverse effects induced in the EAE model. The effectiveness of this formulation was demonstrated by the normalization of EAE-induced behavioral changes and aberrant levels of specific biochemical markers as well as reduced damage of hippocampal tissues and retaining higher levels of myelination.
Collapse
Affiliation(s)
- Muhammed A Saad
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Cairo University, Cairo, Egypt.,School of Pharmacy, Newgiza University, Giza, Egypt
| | - Noha M Eissa
- School of Pharmacy, Newgiza University, Giza, Egypt
| | - Mohammed A Ahmed
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - Aliaa N ElMeshad
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Cairo University, Cairo, Egypt.,Faculty of Nanotechnology for Postgraduate Studies, Cairo University, Giza, Egypt
| | - Götz Laible
- AgResearch, Ruakura Research Centre, Hamilton, New Zealand.,School of Medical Sciences, University of Auckland, Auckland, New Zealand.,Maurice Wilkins Centre for Molecular Biodiscovery, Auckland, New Zealand
| | - Ahmed S Attia
- Department of Microbiology and Immunology, Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - Medhat A Al-Ghobashy
- Analytical Chemistry Department, Faculty of Pharmacy, Cairo University, Cairo, Egypt.,Bioanalysis Research Group, School of Pharmacy, Newgiza University, Giza, Egypt
| | - Rania M Abdelsalam
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Cairo University, Cairo, Egypt.,School of Pharmacy, Newgiza University, Giza, Egypt
| | - Muhammad Y Al-Shorbagy
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Cairo University, Cairo, Egypt.,Department of Pharmaceutical Sciences, College of Pharmacy, Gulf Medical University, Ajman, United Arab Emirates
| |
Collapse
|
40
|
Kvistad SAS, Burman J, Lehmann AK, Tolf A, Zjukovskaja C, Melve GK, Bø L, Torkildsen Ø. Impact of previous disease-modifying treatment on safety and efficacy in patients with MS treated with AHSCT. J Neurol Neurosurg Psychiatry 2022; 93:844-848. [PMID: 35508373 PMCID: PMC9304086 DOI: 10.1136/jnnp-2022-328797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/18/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND Autologous haematopoietic stem cell transplantation (AHSCT) is a highly effective treatment for multiple sclerosis (MS). The impact of previous long-lasting disease-modifying treatments (DMT) for safety and efficacy of AHSCT is unknown. OBJECTIVE To explore whether previous DMTs with long-lasting effects on the immune system (anti-CD20 therapy, alemtuzumab and cladribine) affect treatment-related complications, long-term outcome and risk of new MS disease activity in patients treated with AHSCT. METHODS Retrospective observational study of 104 relapsing remitting patients with MS treated by AHSCT in Sweden and Norway from 2011 to 2021, grouped according to the last DMT used ≤6 months prior to AHSCT. The primary outcomes were early AHSCT-related complications (mortality, neutropenic fever and hospitalisation length), long-term complications (secondary autoimmunity) and proportion of patients with No Evidence of Disease Activity (NEDA-3 status): no new relapses, no MRI activity and no disease progression during the follow-up. RESULTS The mean follow-up time was 39.5 months (range 1-95). Neutropenic fever was a common AHSCT-related complication affecting 69 (66%) patients. There was no treatment-related mortality. During the follow-up period, 20 patients (19%) were diagnosed with autoimmunity. Occurrence of neutropenic fever, hospitalisation length or secondary autoimmunity did not vary dependent on the last DMT used prior to AHSCT. A total of 84 patients (81%) achieved NEDA-3 status, including all patients (100%) using rituximab, alemtuzumab or cladribine before AHSCT. CONCLUSION This study provides level 4 evidence that AHSCT in patients previously treated with alemtuzumab, cladribine or rituximab is safe and efficacious.
Collapse
Affiliation(s)
- Silje Agnethe Stokke Kvistad
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway .,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Joachim Burman
- Department of Neuroscience, Uppsala Universitet, Uppsala, Sweden
| | - Anne Kristine Lehmann
- Department of Medicine, Section of Hematology, Haukeland University Hospital, Bergen, Norway
| | - Andreas Tolf
- Department of Neuroscience, Uppsala Universitet, Uppsala, Sweden.,Department of Neurology, Akademiska sjukhuset, Uppsala, Sweden
| | | | - Guro Kristin Melve
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Lars Bø
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Norwegian Multiple Sclerosis Competence Centre, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Neurology, Norwegian Multiple Sclerosis Competence Centre, Bergen, Norway
| |
Collapse
|
41
|
Naismith RT, Cross AH. Further support for rituximab in relapsing multiple sclerosis. Lancet Neurol 2022; 21:672-673. [DOI: 10.1016/s1474-4422(21)00180-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 05/28/2021] [Indexed: 11/29/2022]
|
42
|
Safety and efficacy of rituximab versus dimethyl fumarate in patients with relapsing-remitting multiple sclerosis or clinically isolated syndrome in Sweden: a rater-blinded, phase 3, randomised controlled trial. Lancet Neurol 2022; 21:693-703. [DOI: 10.1016/s1474-4422(22)00209-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/24/2022] [Accepted: 05/03/2022] [Indexed: 12/15/2022]
|
43
|
Rød BE, Torkildsen Ø, Myhr KM, Bø L, Wergeland S. Safety of breast feeding during rituximab treatment in multiple sclerosis. J Neurol Neurosurg Psychiatry 2022; 94:jnnp-2022-329545. [PMID: 35879056 PMCID: PMC9763193 DOI: 10.1136/jnnp-2022-329545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/29/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND There are limited data on the safety of breast feeding during rituximab therapy. Our objective is to determine exposure from breast feeding and biological effects of rituximab in breastfed infants. METHODS In our case series of six mother-infant pairs, the nursing mothers with relapsing-remitting multiple sclerosis received rituximab during breast feeding. As part of clinical follow-up, six serial breast milk samples, and blood samples from both mothers and infants, were collected and analysed. RESULTS The median average rituximab concentration (Cavg) in breast milk was 0.04 µg/mL and the estimated relative infant dose (RID) was 0.07%. The highest measured concentration of rituximab in the breast milk samples was 0.25 µg/mL, giving an estimated RID of 0.26%.All infant serum rituximab concentrations were below 0.01 µg/mL. The CD19 +B cell count values were within the 10th- 90th percentiles of reported normal ranges in healthy infants. CONCLUSIONS We found minimal transfer of rituximab into breast milk and could not reliably detect levels of rituximab in infant serum. B cell counts in infants were unaffected.
Collapse
Affiliation(s)
- Brit Ellen Rød
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Øivind Torkildsen
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Kjell-Morten Myhr
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Lars Bø
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Norwegian Multiple Sclerosis Competence Centre, Haukeland University Hospital, Bergen, Norway
| | - Stig Wergeland
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Norwegian MS-Registry and Biobank, Haukeland University Hospital, Bergen, Norway
| |
Collapse
|
44
|
Lycke J, Svenningsson A. Long-term treatment with anti-CD20 monoclonal antibodies is untenable because of risk: Commentary. Mult Scler 2022; 28:1177-1178. [PMID: 35678609 PMCID: PMC9189590 DOI: 10.1177/13524585221101138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Jan Lycke
- J Lycke Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Blå stråket 7, Sahlgrenska University Hospital, Gothenburg 415 45, Sweden.
| | - Anders Svenningsson
- Department of Clinical Sciences and Department of Neurology, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
45
|
Hernández-Preciado MR, Marquez-Pedroza J, Sánchez-Rosales NA, García-Rivera JDJ, Kobayashi-Gutiérrez A, Torres-Mendoza BM, Chavarría-Avila E, Montaño-Serrano RA, Cortes-Enriquez F, Mireles-Ramírez MA. Effect of Rituximab Compared with Natalizumab and Fingolimod in Patients with Relapsing-Remitting Multiple Sclerosis: A Cohort Study. J Clin Med 2022; 11:jcm11133584. [PMID: 35806869 PMCID: PMC9267823 DOI: 10.3390/jcm11133584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/16/2022] [Accepted: 06/20/2022] [Indexed: 02/01/2023] Open
Abstract
The objective of this study was to evaluate the clinical files of patients with RRMS who started rituximab (RTX) compared with a second-line treatment (natalizumab (NTZ) or fingolimod (FTY)). This was a historical cohort study. We compared the effect according to the Expanded Disability Status Scale (EDSS) and the number of relapses in RRMS patients receiving these treatments after a mean period of 12 months. We found a statistically significant difference (p < 0.001) when comparing the EDSS scores and the annual relapse rates of patients receiving RTX with those receiving NTZ or FTY. This study is essential for our clinical practice, since patients with limited treatment options represent a challenge with regard to the management of their medical care. However, clinical trials and prospective studies with long follow-up periods are necessary to provide sufficient evidence on the efficacy of RTX and thus include this treatment in the therapeutic profile of patients with MS.
Collapse
Affiliation(s)
- Martha Rocio Hernández-Preciado
- High Specialty Medical Unit, Western National Medical Center of the Mexican Institute of Social Security, Guadalajara 44340, Mexico
- Neurosciences Division, Western Biomedical Research Center (IMSS), Guadalajara 44340, Mexico
| | - Jazmin Marquez-Pedroza
- High Specialty Medical Unit, Western National Medical Center of the Mexican Institute of Social Security, Guadalajara 44340, Mexico
| | - Nayeli Alejandra Sánchez-Rosales
- High Specialty Medical Unit, Western National Medical Center of the Mexican Institute of Social Security, Guadalajara 44340, Mexico
| | - José de Jesús García-Rivera
- High Specialty Medical Unit, Western National Medical Center of the Mexican Institute of Social Security, Guadalajara 44340, Mexico
| | - Antonio Kobayashi-Gutiérrez
- High Specialty Medical Unit, Western National Medical Center of the Mexican Institute of Social Security, Guadalajara 44340, Mexico
| | - Blanca Miriam Torres-Mendoza
- Neurosciences Division, Western Biomedical Research Center (IMSS), Guadalajara 44340, Mexico
- Department of Philosophical and Methodological Disciplines, University Health Sciences Center, University of Guadalajara, Guadalajara 44340, Mexico
| | - Efraín Chavarría-Avila
- Department of Philosophical and Methodological Disciplines, University Health Sciences Center, University of Guadalajara, Guadalajara 44340, Mexico
| | | | - Fernando Cortes-Enriquez
- Department of Neurology, Hospital General Regional No 45 of the Mexican Institute of Social Security, Guadalajara 44910, Mexico
| | - Mario Alberto Mireles-Ramírez
- High Specialty Medical Unit, Western National Medical Center of the Mexican Institute of Social Security, Guadalajara 44340, Mexico
| |
Collapse
|
46
|
Yang JH, Rempe T, Whitmire N, Dunn-Pirio A, Graves JS. Therapeutic Advances in Multiple Sclerosis. Front Neurol 2022; 13:824926. [PMID: 35720070 PMCID: PMC9205455 DOI: 10.3389/fneur.2022.824926] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
Multiple sclerosis (MS) is an autoimmune disease affecting the central nervous system that causes significant disability and healthcare burden. The treatment of MS has evolved over the past three decades with development of new, high efficacy disease modifying therapies targeting various mechanisms including immune modulation, immune cell suppression or depletion and enhanced immune cell sequestration. Emerging therapies include CNS-penetrant Bruton's tyrosine kinase inhibitors and autologous hematopoietic stem cell transplantation as well as therapies aimed at remyelination or neuroprotection. Therapy development for progressive MS has been more challenging with limited efficacy of current approved agents for inactive disease and older patients with MS. The aim of this review is to provide a broad overview of the current therapeutic landscape for MS.
Collapse
Affiliation(s)
- Jennifer H. Yang
- Department of Neurosciences, University of California San Diego, San Diego, CA, United States
- *Correspondence: Jennifer H. Yang
| | - Torge Rempe
- Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Natalie Whitmire
- Department of Neurosciences, University of California San Diego, San Diego, CA, United States
| | - Anastasie Dunn-Pirio
- Department of Neurosciences, University of California San Diego, San Diego, CA, United States
| | - Jennifer S. Graves
- Department of Neurosciences, University of California San Diego, San Diego, CA, United States
| |
Collapse
|
47
|
Mirabella M, Annovazzi P, Brownlee W, Cohen JA, Kleinschnitz C, Wolf C. Treatment Challenges in Multiple Sclerosis – A Continued Role for Glatiramer Acetate? Front Neurol 2022; 13:844873. [PMID: 35493825 PMCID: PMC9051342 DOI: 10.3389/fneur.2022.844873] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/09/2022] [Indexed: 12/14/2022] Open
Abstract
Earlier diagnosis, access to disease-modifying therapies (DMTs), and improved supportive care have favorably altered the disease course of multiple sclerosis (MS), leading to an improvement in long-term outcomes for people with MS (PwMS). This success has changed the medical characteristics of the population seen in MS clinics. Comorbidities and the accompanying polypharmacy, immune senescence, and the growing number of approved DMTs make selecting the optimal agent for an individual patient more challenging. Glatiramer acetate (GA), a moderately effective DMT, interacts only minimally with comorbidities, other medications, or immune senescence. We describe here several populations in which GA may represent a useful treatment option to overcome challenges due to advanced age or comorbidities (e.g., hepatic or renal disease, cancer). Further, we weigh GA's potential merits in other settings where PwMS and their neurologists must base treatment decisions on factors other than selecting the most effective DMT, e.g., family planning, conception and pregnancy, or the need for vaccination.
Collapse
Affiliation(s)
- Massimiliano Mirabella
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
- Centro di Ricerca Sclerosi Multipla (CERSM), Università Cattolica, Rome, Italy
- *Correspondence: Massimiliano Mirabella ; orcid.org/0000-0002-7783-114X
| | - Pietro Annovazzi
- MS Center, ASST Valle Olona, Gallarate Hospital, Gallarate, Italy
| | - Wallace Brownlee
- Queen Square MS Centre, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Jeffrey A. Cohen
- Department of Neurology, Mellen Center, Neurologic Institute, Cleveland Clinic, Cleveland, OH, United States
| | | | | |
Collapse
|
48
|
Almatrafi YM, Babakkor MA, Irfan M, Samkari ET, Alzahrani WM, Mohorjy DK, Zahoor S, Farooq MT, Sajid Jehangir HM. Efficacy and safety of rituximab in patients with multiple sclerosis: An observational study at a tertiary center in Makkah, Saudi Arabia. NEUROSCIENCES (RIYADH, SAUDI ARABIA) 2022; 27:65-70. [PMID: 35477910 PMCID: PMC9257910 DOI: 10.17712/nsj.2022.2.20210122] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 03/15/2022] [Indexed: 04/15/2023]
Abstract
OBJECTIVES To assess the efficacy and safety of rituximab for multiple sclerosis (MS) treatment in terms of reduction in clinical relapses, magnetic resonance imaging (MRI) activity, Expanded Disability Status Scale (EDSS) score and adverse events. METHODS This is a retrospective cross-sectional study conducted at King Abdullah Medical City, from January 2017 to August 2021, involving patients with MS given rituximab, with 1-year follow-up. Clinical parameters were noted pre- and post-treatment to determine efficacy; adverse events were noted to analyze safety. A paired samples t-test was used to compare responses pre- and post-treatment. A p-value<0.05 was considered significant. RESULTS Among 31 patients, 6 (19.4%) had progressive MS, and 25 (80.6%) had relapsing-remitting MS (mean disease duration=8.12±5.65 years). The annual relapse rate reduced from 1.67±0.97 to 0.06±0.25 (p<0.001), the EDSS score from 3.16±2.14 to 2.80±2.28 (p=0.141) and the MRI activity score from 1.84±1.03 to 1.03±0.18 (p<0.001). Only one patient had enhancing lesion activity post-treatment. The commonest side effect was urinary tract infection (25.8%). Only 2 patients discontinued the drug. CONCLUSION Rituximab is an efficient drug in reducing the annual relapse rate and MRI activity of patients with MS, with few tolerable side effects not leading to drug discontinuation or any lethal outcome.
Collapse
Affiliation(s)
- Yassir M. Almatrafi
- From the Department of Neurology (Almatrafi, Babakkor, Irfan, Samkari, Alzahrani), from Research centre (Mohorjy), King Abdullah Medical City, Makkah, from Punjab Institute of Cardiology (Zahoor), Lahore, Pakistan
| | - Mohammed A. Babakkor
- From the Department of Neurology (Almatrafi, Babakkor, Irfan, Samkari, Alzahrani), from Research centre (Mohorjy), King Abdullah Medical City, Makkah, from Punjab Institute of Cardiology (Zahoor), Lahore, Pakistan
| | - Muhammed Irfan
- From the Department of Neurology (Almatrafi, Babakkor, Irfan, Samkari, Alzahrani), from Research centre (Mohorjy), King Abdullah Medical City, Makkah, from Punjab Institute of Cardiology (Zahoor), Lahore, Pakistan
| | - Ebaa T. Samkari
- From the Department of Neurology (Almatrafi, Babakkor, Irfan, Samkari, Alzahrani), from Research centre (Mohorjy), King Abdullah Medical City, Makkah, from Punjab Institute of Cardiology (Zahoor), Lahore, Pakistan
| | - Waleed M. Alzahrani
- From the Department of Neurology (Almatrafi, Babakkor, Irfan, Samkari, Alzahrani), from Research centre (Mohorjy), King Abdullah Medical City, Makkah, from Punjab Institute of Cardiology (Zahoor), Lahore, Pakistan
| | - Doaa K. Mohorjy
- From the Department of Neurology (Almatrafi, Babakkor, Irfan, Samkari, Alzahrani), from Research centre (Mohorjy), King Abdullah Medical City, Makkah, from Punjab Institute of Cardiology (Zahoor), Lahore, Pakistan
| | - Sarmad Zahoor
- From the Department of Neurology (Almatrafi, Babakkor, Irfan, Samkari, Alzahrani), from Research centre (Mohorjy), King Abdullah Medical City, Makkah, from Punjab Institute of Cardiology (Zahoor), Lahore, Pakistan
- Address correspondence and reprint request to: Dr. Sarmad Zahoor, Punjab Institute of Cardiology, Lahore, Pakistan. E-mail: ORCID ID: https://orcid.org/0000-0003-1964-2655
| | - Muhammad T. Farooq
- From the Department of Neurology (Almatrafi, Babakkor, Irfan, Samkari, Alzahrani), from Research centre (Mohorjy), King Abdullah Medical City, Makkah, from Punjab Institute of Cardiology (Zahoor), Lahore, Pakistan
| | - Hafiz M. Sajid Jehangir
- From the Department of Neurology (Almatrafi, Babakkor, Irfan, Samkari, Alzahrani), from Research centre (Mohorjy), King Abdullah Medical City, Makkah, from Punjab Institute of Cardiology (Zahoor), Lahore, Pakistan
| |
Collapse
|
49
|
Moreira A, Munteis E, Vera A, Macías Gómez A, Bertrán Recasens B, Rubio Pérez MÁ, Llop M, Martínez-Rodríguez JE. Delayed B cell repopulation after rituximab treatment in multiple sclerosis patients with expanded adaptive NK cells. Eur J Neurol 2022; 29:2015-2023. [PMID: 35247022 PMCID: PMC9310749 DOI: 10.1111/ene.15312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/23/2022] [Accepted: 02/25/2022] [Indexed: 11/29/2022]
Abstract
Background and purpose The aim was to evaluate whether adaptive NKG2C+ natural killer (NK) cells, characterized by enhanced antibody‐dependent cell cytotoxicity (ADCC), may influence time to B cell repopulation after rituximab treatment in multiple sclerosis (MS) patients. Methods This was a prospective observational study of MS patients treated with rituximab monitoring peripheral B cells for repeated doses. B cell repopulation was defined as CD19+ cells above 2% of total lymphocytes, classifying cases according to the median time of B cell repopulation as early or late (≤9 months, >9 months, respectively). Basal NK cell immunophenotype and in vitro ADCC responses induced by rituximab were assessed by flow cytometry. Results B cell repopulation in 38 patients (24 relapsing–remitting MS [RRMS]; 14 progressive MS) was classified as early (≤9 months, n = 19) or late (>9 months, n = 19). RRMS patients with late B cell repopulation had higher proportions of NKG2C+ NK cells compared to those with early repopulation (24.7% ± 16.2% vs. 11.3% ± 10.4%, p < 0.05), and a direct correlation between time to B cell repopulation and percentage of NKG2C+ NK cells (R 0.45, p < 0.05) was observed. RRMS cases with late repopulation compared with early repopulation had a higher secretion of tumor necrosis factor α and interferon γ by NK cells after rituximab‐dependent NK cell activation. The NK cell immunophenotype appeared unrelated to B cell repopulation in progressive MS patients. Conclusions Adaptive NKG2C+ NK cells in RRMS may be associated with delayed B cell repopulation after rituximab, a finding probably related to enhanced depletion of B cells exerted by NK‐cell‐mediated ADCC, pointing to the use of personalized regimens with anti‐CD20 monoclonal antibody therapy in some patients.
Collapse
Affiliation(s)
- Antía Moreira
- Neurology Department, Neuroimmunology Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain.,Hospital Universitari d'Igualada, Barcelona, Spain
| | - Elvira Munteis
- Neurology Department, Neuroimmunology Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain.,Departament de Medicina, Universitat de Barcelona, Spain
| | - Andrea Vera
- Neurology Department, Neuroimmunology Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Adrián Macías Gómez
- Neurology Department, Neuroimmunology Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Bernat Bertrán Recasens
- Neurology Department, Neuroimmunology Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Miguel Ángel Rubio Pérez
- Neurology Department, Neuroimmunology Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Mireia Llop
- Neurology Department, Neuroimmunology Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Jose E Martínez-Rodríguez
- Neurology Department, Neuroimmunology Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| |
Collapse
|
50
|
Rollot F, Couturier J, Casey R, Wiertlewski S, Debouverie M, Pelletier J, De Sèze J, Labauge P, Ruet A, Thouvenot E, Ciron J, Berger E, Gout O, Clavelou P, Stankoff B, Casez O, Bourre B, Zephir H, Moreau T, Lebrun-Frenay C, Maillart E, Edan G, Neau JP, Montcuquet A, Cabre P, Camdessanché JP, Defer G, Nasr HB, Maurousset A, Hankiewicz K, Pottier C, Leray E, Vukusic S, Laplaud DA. Comparative Effectiveness of Natalizumab Versus Anti-CD20 in Highly Active Relapsing-Remitting Multiple Sclerosis After Fingolimod Withdrawal. Neurotherapeutics 2022; 19:476-490. [PMID: 35217934 PMCID: PMC9226262 DOI: 10.1007/s13311-022-01202-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2022] [Indexed: 10/19/2022] Open
Abstract
In France, two therapeutic strategies can be offered after fingolimod (FNG) withdrawal to highly active relapsing-remitting multiple sclerosis (RRMS) patients: natalizumab (NTZ) or anti-CD20. We compared the effectiveness of these two strategies as a switch for FNG within the OFSEP database. The primary endpoint was the time to first relapse. Other outcomes were the relapse rates over 3-month periods, time to worsening the EDSS score, proportion of patients with worsened 24-month MRI, time to treatment discontinuation, and incidence rates of serious adverse events. The dynamics of event rates over time were modeled using multidimensional penalized splines, allowing the possibility to model the effects of covariates in a flexible way, considering non-linearity and interactions. A total of 740 patients were included (337 under anti-CD20 and 403 under NTZ). There was no difference between the two treatments regarding the dynamic of the first occurrence of relapse, with a monthly probability of 5.0% at initiation and 1.0% after 6 months. The rate of EDSS worsening increased in both groups until 6 months and then decreased. No difference in the proportion of patients with new T2 lesions at 24 months was observed. After 18 months of follow-up, a greater risk of NTZ discontinuation was found compared to anti-CD20. This study showed no difference between NTZ and anti-CD20 after the FNG switch regarding the clinical and radiological activity. The effect of these treatments was optimal after 6 months and there was more frequent discontinuation of NTZ after 18 months, probably mainly related to JC virus seroconversions.
Collapse
Affiliation(s)
- Fabien Rollot
- Université de Lyon, Université Claude Bernard, Lyon 1, Lyon, France.
- Service de Neurologie, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, sclérose en plaques, pathologies de la myéline et neuro-inflammation, Bron, France.
- Centre de Recherche en Neurosciences de Lyon, Observatoire Français de La Sclérose en Plaques, INSERM 1028 et CNRS UMR 5292, Lyon, France.
- EUGENE DEVIC EDMUS Foundation Against Multiple Sclerosis, State-Approved Foundation, Bron, France.
| | | | - Romain Casey
- Université de Lyon, Université Claude Bernard, Lyon 1, Lyon, France
- Service de Neurologie, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, sclérose en plaques, pathologies de la myéline et neuro-inflammation, Bron, France
- Centre de Recherche en Neurosciences de Lyon, Observatoire Français de La Sclérose en Plaques, INSERM 1028 et CNRS UMR 5292, Lyon, France
- EUGENE DEVIC EDMUS Foundation Against Multiple Sclerosis, State-Approved Foundation, Bron, France
| | - Sandrine Wiertlewski
- Service de Neurologie, CHU Nantes, Nantes, France
- INSERM, CIC 0004, CRTI-INSERM UMR U1064, Nantes, France
| | - Marc Debouverie
- Service de Neurologie, Centre Hospitalier Régional Et Universitaire de Nancy, Université de Lorraine, 4360 APEMAC, Vandoeuvre-Lès-Nancy, EA, France
| | - Jean Pelletier
- Aix Marseille University, APHM, Hôpital de La Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, CEMEREM, 13005, Marseille, France
| | - Jérôme De Sèze
- Service de Neurologie Et Centre d'Investigation Clinique, CHU de Strasbourg, INSERM 1434, Strasbourg, France
| | - Pierre Labauge
- Service de Neurologie, CHU de Montpellier, Montpellier, France
| | - Aurélie Ruet
- Service de Neurologie, CHU de Bordeaux, Bordeaux, France
- Université de Bordeaux, INSERM, Neurocentre Magendie, U1215, Bordeaux, France
| | - Eric Thouvenot
- Service de Neurologie, CHU de Nîmes, Nîmes, France
- Institut de Génomique Fonctionnelle, Université de Montpellier, CNRS, INSERM, Montpellier, France
| | - Jonathan Ciron
- Service de Neurologie, CHU de Toulouse, Hôpital Pierre-Paul Riquet, CRC-SEP, Toulouse, France
- Institut Toulousain Des Maladies Infectieuses Et Inflammatoires (Infinity), INSERM UMR 1291, CNRS UMR 5051, Université Toulouse III, Toulouse, France
| | - Eric Berger
- Service de Neurologie, CHU de Besançon, Besançon, France
| | - Olivier Gout
- Service de Neurologie, Hôpital Fondation A de Rothschild, Paris, France
| | - Pierre Clavelou
- Service de Neurologie, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Olivier Casez
- Service de Neurologie, CHU de Grenoble, Grenoble, France
| | | | - Hélène Zephir
- Pôle Des Neurosciences Et de L'appareil Locomoteur, CRC-SEP, Hôpital Roger Salengro, Université de Lille, Inserm U1172, Lille, France
| | | | - Christine Lebrun-Frenay
- Service de Neurologie, Neurologie Pasteur 2, CHU de Nice, Université Nice Cote d'Azur UR2CA-URRIS, Nice, France
| | - Elisabeth Maillart
- Département de Neurologie, APHP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Gilles Edan
- Service de Neurologie, CHU Pontchaillou, Rennes, France
| | | | | | - Philippe Cabre
- Service de Neurologie, CHU de Fort de France, Fort de France, France
| | | | - Gilles Defer
- Service de Neurologie, Centre Expert SEP, CHU de Caen, Université Normandie, Caen, France
| | - Haifa Ben Nasr
- Service de Neurologie, Hôpital Sud Francilien, Corbeil Essonnes, France
| | | | | | | | - Emmanuelle Leray
- Université de Rennes/EHESP, REPERES - EA, 7449, Rennes, France
- CHU Rennes, CIC-P 1414, Rennes, France
| | - Sandra Vukusic
- Université de Lyon, Université Claude Bernard, Lyon 1, Lyon, France
- Service de Neurologie, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, sclérose en plaques, pathologies de la myéline et neuro-inflammation, Bron, France
- Centre de Recherche en Neurosciences de Lyon, Observatoire Français de La Sclérose en Plaques, INSERM 1028 et CNRS UMR 5292, Lyon, France
- EUGENE DEVIC EDMUS Foundation Against Multiple Sclerosis, State-Approved Foundation, Bron, France
| | - David-Axel Laplaud
- Service de Neurologie, CHU Nantes, Nantes, France.
- INSERM, CIC 0004, CRTI-INSERM UMR U1064, Nantes, France.
| |
Collapse
|