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Selmaj K, Hartung HP, Mycko MP, Selmaj I, Cross AH. MS treatment de-escalation: review and commentary. J Neurol 2024:10.1007/s00415-024-12584-x. [PMID: 39093335 DOI: 10.1007/s00415-024-12584-x] [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: 06/03/2024] [Revised: 07/12/2024] [Accepted: 07/13/2024] [Indexed: 08/04/2024]
Abstract
Almost all currently licensed disease-modifying therapies (DMTs) for MS treatment require prolonged if not lifelong administration. Yet, as people age, the immune system has increasingly reduced responsiveness, known as immunosenescence. Many MS DMTs reduce the responsiveness of the immune system, increasing the risks for infections and possibly cancers. As people with MS (pwMS) age, it is recognized that inflammatory MS activity declines. Several studies have addressed de-escalation of DMTs for relapsing MS under special circumstances. Here, we review evidence for de-escalating DMTs as a strategy that is particularly relevant to pwMS of older age. Treatment de-escalation can involve various strategies, such as extended or reduced dosing, switching from high-efficacy DMTs having higher risks to moderately effective DMTs with lesser risks, or treatment discontinuation. Studies have suggested that for natalizumab extended dosing maintained clinical efficacy while reducing the risk of PML. Extended interval dosing of ocrelizumab mitigated the decline of Ig levels. Retrospective and observational discontinuation studies demonstrate that age is an essential modifier of drug efficacy. Discontinuation of MS treatment in older patients has been associated with a stable disease course, while younger patients who discontinued treatment were more likely to experience new clinical activity. A recently completed 2-year randomized-controlled discontinuation study in 260 stable pwMS > 55 years found stable clinical multiple sclerosis with only a small increased risk of new MRI activity upon discontinuation. DMT de-escalation or discontinuation in MS patients older than 55 years may be non-inferior to continued treatment with immunosuppressive agents having higher health risks. However, despite several small studies, a definite conclusion about treatment de-escalation in older pwMS will require larger and longer studies. Ideally, comparison of de-escalation versus continuation versus discontinuation of DMTs should be done by prospective randomized-controlled trials enrolling sufficient numbers of subjects to allow comparisons for MS patients of both sexes within age groups, such as 55-59, 60-65, 66-69, etc. Optimally, such studies should be 3 years or longer and should incorporate testing for specific markers of immunosenescence (such as T-cell receptor excision circles) to account for differential aging of individuals.
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Affiliation(s)
- Krzysztof Selmaj
- Department of Neurology, University of Warmia & Mazury, Olsztyn, Poland.
- Center of Neurology, Lodz, Poland.
| | - Hans-Peter Hartung
- Department of Neurology, Heinrich-Heine-University, Düsseldorf, Germany
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Department of Neurology, Palacky University, Olomouc, Czech Republic
- Brain and Mind Center, University of Sydney, Sydney, Australia
| | - Marcin P Mycko
- Department of Neurology, University of Warmia & Mazury, Olsztyn, Poland
| | | | - Anne H Cross
- Washington University School of Medicine, St. Louis, MO, USA
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Thiel S, Litvin N, Haben S, Gold R, Hellwig K. Disease activity and neonatal outcomes after exposure to natalizumab throughout pregnancy. J Neurol Neurosurg Psychiatry 2024; 95:561-570. [PMID: 38124108 PMCID: PMC11103322 DOI: 10.1136/jnnp-2023-332804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 12/01/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND After natalizumab discontinuation severe relapses can occur despite pregnancy, but third trimester exposure is associated with neonatal haematological abnormalities (HA). The best time point for stopping natalizumab during pregnancy is unclear. METHODS Prospective, observational cohort with 350 natalizumab exposed pregnancies from the German Multiple Sclerosis and Pregnancy Registry. Clinical disease activity and neonatal outcomes are compared between women with natalizumab discontinuation during (1st Trim-group) versus after the first trimester (maintaining-group) and for subgroup analysis before (<30-subgroup) or after (≥30-subgroup) the 30th gestational week (gw). RESULTS Baseline characteristics did not significantly differ between the 1st Trim-group (n=179; median exposure duration: 2.60 gw, IQR 1.30-3.60) and the maintaining-group (n=171; median exposure duration: 30.9 gw, IQR 26.9-33.3). Fewer relapses occurred during pregnancy and the postpartum year in the maintaining-group (25.7%) compared with the 1st Trim-group (62.6%; p<0.001). Women in ≥30-subgroup had a significantly lower relapse risk in the first 6 months postpartum (relapse rate ratio: 0.36, 95% CI: 0.15 to 0.84). In total, 7.5% retained meaningful disability 12 months postpartum. No significant effect on neonatal outcomes were observed, but anaemia (OR: 2.62, 95% CI: 1.12 to 6.52) and thrombocytopaenia (OR: 2.64, 95% CI: 1.15 to 6.46) were significantly more common in the ≥30-subgroup. 21.8% of all neonates were born small for gestational age, independent of the timing of natalizumab discontinuation. CONCLUSION Continuing natalizumab during pregnancy after gw 30 decreases the relapse risk postpartum going along with a higher risk for HA in the newborns. These results add relevant knowledge as a basis for informed risk-benefit discussion.
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Affiliation(s)
- Sandra Thiel
- Universitätsklinik für Neurologie der Ruhr-Universität Bochum, Katholisches Klinikum Bochum Sankt Josef-Hospital, Bochum, Nordrhein-Westfalen, Germany
| | - Nastassja Litvin
- Universitätsklinik für Neurologie der Ruhr-Universität Bochum, Katholisches Klinikum Bochum Sankt Josef-Hospital, Bochum, Nordrhein-Westfalen, Germany
| | - Sabrina Haben
- Universitätsklinik für Neurologie der Ruhr-Universität Bochum, Katholisches Klinikum Bochum Sankt Josef-Hospital, Bochum, Nordrhein-Westfalen, Germany
| | - Ralf Gold
- Universitätsklinik für Neurologie der Ruhr-Universität Bochum, Katholisches Klinikum Bochum Sankt Josef-Hospital, Bochum, Nordrhein-Westfalen, Germany
| | - Kerstin Hellwig
- Universitätsklinik für Neurologie der Ruhr-Universität Bochum, Katholisches Klinikum Bochum Sankt Josef-Hospital, Bochum, Nordrhein-Westfalen, Germany
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Ruggieri S, Ianniello A, Copetti M, Altieri M, Buscarinu MC, Centonze D, Cortese A, De Giglio L, Fantozzi R, Gasperini C, Grimaldi LME, Landi D, Marfia GA, Mirabella M, Nistri R, Nociti V, Oddo O, Romano S, Salemi G, Tortorella C, Pozzilli C, Petracca M. Treatment modifiers across different regimens of natalizumab treatment in MS: An Italian real-world experience. Neurotherapeutics 2024; 21:e00338. [PMID: 38413275 PMCID: PMC11070710 DOI: 10.1016/j.neurot.2024.e00338] [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: 09/25/2023] [Revised: 02/16/2024] [Accepted: 02/16/2024] [Indexed: 02/29/2024] Open
Abstract
Despite its widespread use in clinical practice, the effectiveness of natalizumab extended interval dosing (EID) adopted from treatment start across different treatment intervals and individual modifiers (body mass index - BMI) is still under-investigated. Here, seven-hundred and forty-five multiple sclerosis (MS) patients, exposed to natalizumab for 3.30 ± 1.34 years, were retrospectively enrolled in an observational multicenter study. After stratifying patients in EID or standard interval dosing (SID), we assessed differences in time to relapse, MRI activity and Expanded Disability Status Scale (EDSS) progression. The primary analysis was conducted on patients exposed to EID interval from 5 weeks and 1 day to 7 weeks, while a secondary analysis included also EID periods up to 8 weeks. An additional analysis explored the impact of BMI. No differences in time to first relapse, time to radiological activity, time to EDSS progression or time to EDA (evidence of disease activity) were detected between SID and EID group (EID interval from 5 weeks to 1 day to 7 weeks). When including EID periods from 7 weeks and 1 day to 8 weeks, the EID group showed a trend towards higher risk of experience clinical relapses than the SID group. A higher EDA risk was also identified in EID patients with BMI above median. In conclusion, a higher risk of relapses seems to occur for EID above 7 weeks. Independently from the EID scheme adopted, higher BMI increases the risk of EDA in these patients.
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Affiliation(s)
- Serena Ruggieri
- Department of Human Neurosciences, "Sapienza" University of Rome, Rome, Italy
| | - Antonio Ianniello
- Department of Human Neurosciences, "Sapienza" University of Rome, Rome, Italy
| | - Massimiliano Copetti
- Unit of Biostatistics, IRCCS - "Casa Sollievo della Sofferenza" - Hospital, San Giovanni Rotondo (FG), Italy
| | - Marta Altieri
- Department of Human Neurosciences, "Sapienza" University of Rome, Rome, Italy
| | - Maria Chiara Buscarinu
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), "Sapienza" University of Rome, Rome, Italy; Neurology Unit, S. Andrea University Hospital, Rome, Italy
| | - Diego Centonze
- IRCCS Neuromed, Pozzilli (IS), Italy; Department of Systems Medicine, Multiple Sclerosis Unit, University of Rome "Tor Vergata", Rome, Italy
| | - Antonio Cortese
- Multiple Sclerosis Center, Neurology Unit, San Filippo Neri Hospital, Rome, Italy
| | - Laura De Giglio
- Multiple Sclerosis Center, Neurology Unit, San Filippo Neri Hospital, Rome, Italy
| | | | - Claudio Gasperini
- Department of Neurosciences, San Camillo-Forlanini Hospital, Rome, Italy
| | - Luigi M E Grimaldi
- Neurology and Multiple Sclerosis Center, Fondazione Instituto "G. Giglio", Cefalù, Italy
| | - Doriana Landi
- Department of Systems Medicine, Multiple Sclerosis Unit, University of Rome "Tor Vergata", Rome, Italy
| | - Girolama A Marfia
- Multiple Sclerosis Center, Neurology Unit, San Filippo Neri Hospital, Rome, Italy
| | - Massimiliano Mirabella
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Riccardo Nistri
- Department of Human Neurosciences, "Sapienza" University of Rome, Rome, Italy
| | - Viviana Nociti
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Oscar Oddo
- Neurology and Multiple Sclerosis Center, Fondazione Instituto "G. Giglio", Cefalù, Italy
| | - Silvia Romano
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), "Sapienza" University of Rome, Rome, Italy; Neurology Unit, S. Andrea University Hospital, Rome, Italy
| | - Giuseppe Salemi
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
| | - Carla Tortorella
- Department of Neurosciences, San Camillo-Forlanini Hospital, Rome, Italy
| | - Carlo Pozzilli
- Department of Human Neurosciences, "Sapienza" University of Rome, Rome, Italy
| | - Maria Petracca
- Department of Human Neurosciences, "Sapienza" University of Rome, Rome, Italy.
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Soldati S, Bär A, Vladymyrov M, Glavin D, McGrath JL, Gosselet F, Nishihara H, Goelz S, Engelhardt B. High levels of endothelial ICAM-1 prohibit natalizumab mediated abrogation of CD4 + T cell arrest on the inflamed BBB under flow in vitro. J Neuroinflammation 2023; 20:123. [PMID: 37221552 DOI: 10.1186/s12974-023-02797-8] [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: 03/10/2023] [Accepted: 05/02/2023] [Indexed: 05/25/2023] Open
Abstract
INTRODUCTION The humanized anti-α4 integrin blocking antibody natalizumab (NTZ) is an effective treatment for relapsing-remitting multiple sclerosis (RRMS) that is associated with the risk of progressive multifocal leukoencephalopathy (PML). While extended interval dosing (EID) of NTZ reduces the risk for PML, the minimal dose of NTZ required to maintain its therapeutic efficacy remains unknown. OBJECTIVE Here we aimed to identify the minimal NTZ concentration required to inhibit the arrest of human effector/memory CD4+ T cell subsets or of PBMCs to the blood-brain barrier (BBB) under physiological flow in vitro. RESULTS Making use of three different human in vitro BBB models and in vitro live-cell imaging we observed that NTZ mediated inhibition of α4-integrins failed to abrogate T cell arrest to the inflamed BBB under physiological flow. Complete inhibition of shear resistant T cell arrest required additional inhibition of β2-integrins, which correlated with a strong upregulation of endothelial intercellular adhesion molecule (ICAM)-1 on the respective BBB models investigated. Indeed, NTZ mediated inhibition of shear resistant T cell arrest to combinations of immobilized recombinant vascular cell adhesion molecule (VCAM)-1 and ICAM-1 was abrogated in the presence of tenfold higher molar concentrations of ICAM-1 over VCAM-1. Also, monovalent NTZ was less potent than bivalent NTZ in inhibiting T cell arrest to VCAM-1 under physiological flow. In accordance with our previous observations ICAM-1 but not VCAM-1 mediated T cell crawling against the direction of flow. CONCLUSION Taken together, our in vitro observations show that high levels of endothelial ICAM-1 abrogate NTZ mediated inhibition of T cell interaction with the BBB. EID of NTZ in MS patients may thus require consideration of the inflammatory status of the BBB as high levels of ICAM-1 may provide an alternative molecular cue allowing for pathogenic T cell entry into the CNS in the presence of NTZ.
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Affiliation(s)
- Sasha Soldati
- Theodor Kocher Institute, University of Bern, Freiestrasse 1, 3012, Bern, Switzerland
| | - Alexander Bär
- Theodor Kocher Institute, University of Bern, Freiestrasse 1, 3012, Bern, Switzerland
| | - Mykhailo Vladymyrov
- Theodor Kocher Institute, University of Bern, Freiestrasse 1, 3012, Bern, Switzerland
| | - Dale Glavin
- Department of Biomedical Engineering, University of Rochester, Rochester, NY, USA
| | - James L McGrath
- Department of Biomedical Engineering, University of Rochester, Rochester, NY, USA
| | - Fabien Gosselet
- Blood-Brain Barrier Laboratory, University of Artois, Lens, France
| | - Hideaki Nishihara
- Theodor Kocher Institute, University of Bern, Freiestrasse 1, 3012, Bern, Switzerland
- Department of Neurotherapeutics, Yamaguchi University, Yamaguchi, Japan
| | | | - Britta Engelhardt
- Theodor Kocher Institute, University of Bern, Freiestrasse 1, 3012, Bern, Switzerland.
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Kaiserman J, O’Hara BA, Haley SA, Atwood WJ. An Elusive Target: Inhibitors of JC Polyomavirus Infection and Their Development as Therapeutics for the Treatment of Progressive Multifocal Leukoencephalopathy. Int J Mol Sci 2023; 24:8580. [PMID: 37239927 PMCID: PMC10218015 DOI: 10.3390/ijms24108580] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/08/2023] [Accepted: 05/09/2023] [Indexed: 05/28/2023] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare demyelinating disease caused by infection with JC Polyomavirus (JCPyV). Despite the identification of the disease and isolation of the causative pathogen over fifty years ago, no antiviral treatments or prophylactic vaccines exist. Disease onset is usually associated with immunosuppression, and current treatment guidelines are limited to restoring immune function. This review summarizes the drugs and small molecules that have been shown to inhibit JCPyV infection and spread. Paying attention to historical developments in the field, we discuss key steps of the virus lifecycle and antivirals known to inhibit each event. We review current obstacles in PML drug discovery, including the difficulties associated with compound penetrance into the central nervous system. We also summarize recent findings in our laboratory regarding the potent anti-JCPyV activity of a novel compound that antagonizes the virus-induced signaling events necessary to establish a productive infection. Understanding the current panel of antiviral compounds will help center the field for future drug discovery efforts.
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Affiliation(s)
| | | | | | - Walter J. Atwood
- Department of Molecular Biology, Cell Biology, and Biochemistry, Brown University, Providence, RI 02912, USA
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Pelle J, Briant AR, Branger P, Derache N, Arnaud C, Lebrun-Frenay C, Cohen M, Mondot L, De Seze J, Bigaut K, Collongues N, Kremer L, Ricard D, Bompaire F, Ohlmann C, Sallansonnet-Froment M, Ciron J, Biotti D, Pignolet B, Parienti JJ, Defer G. Real-World Effectiveness of Natalizumab Extended Interval Dosing in a French Cohort. Neurol Ther 2023; 12:529-542. [PMID: 36763307 PMCID: PMC10043118 DOI: 10.1007/s40120-023-00440-5] [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: 11/09/2022] [Accepted: 01/19/2023] [Indexed: 02/11/2023] Open
Abstract
INTRODUCTION Natalizumab, a therapy for relapsing-remitting multiple sclerosis (RRMS), is associated with a risk of progressive multifocal leukoencephalopathy (PML). Over the last several years, practitioners have used off-label extended interval dosing (EID) of natalizumab to reduce PML risk, despite the absence of a large-scale efficacy evaluation. METHODS We conducted a retrospective, multicenter cohort study among adults with RRMS receiving stable standard interval dosing (SID), defined as a ≥ 12-month consecutive period of ≥ 11 natalizumab infusions/year in France. We compared the 12-month risk difference of remaining relapse-free (primary endpoint) between patients who switched to EID (≤ 9 natalizumab infusions) and those who remained on SID, with a noninferiority margin of - 11%. We used propensity score methods such as inverse probability treatment weighting (IPTW) and 1:1 propensity score matching (PSM). Secondary endpoints were annualized relapse rate, disease progression, and safety. RESULTS Baseline characteristics were similar between patients receiving EID (n = 147) and SID (n = 156). The proportion of relapse-free patients 12 months postbaseline was 142/147 in the EID (96.6%) and 144/156 in the SID group (92.3%); risk difference (95% CI) 4.3% (- 1.3 to 9.8%); p < 0.001 for non-inferiority. There were no significant differences between relapse rates (0.043 vs. 0.083 per year, respectively; p = 0.14) or Expanded Disability Status Scale mean scores (2.43 vs. 2.72, respectively; p = 0.18); anti-JC virus index values were similar (p = 0.23); and no instances of PML were reported. The comparisons using IPTW (n = 306) and PSM (n = 204) were consistent. CONCLUSION These results support the pertinence of using an EID strategy for RRMS patients treated with natalizumab. CLINICAL TRIALS gov identifier (NCT04580381).
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Affiliation(s)
- Juliette Pelle
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP), Service de Neurologie, CHU de la Côte de Nacre, 14000, Caen, France
| | - Anais R Briant
- Unité de Biostatistiques et de Recherche Clinique, CHU de Caen-Cote de Nacre, Caen, France
| | - Pierre Branger
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP), Service de Neurologie, CHU de la Côte de Nacre, 14000, Caen, France
| | - Nathalie Derache
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP), Service de Neurologie, CHU de la Côte de Nacre, 14000, Caen, France
| | - Charlotte Arnaud
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP), Service de Neurologie, CHU de la Côte de Nacre, 14000, Caen, France
| | - Christine Lebrun-Frenay
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP), Unité de Recherche Clinique Côte d'azur (UR2CA), Équipe URRIS, CHU Pasteur 2, Nice, France
| | - Mikael Cohen
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP), Unité de Recherche Clinique Côte d'azur (UR2CA), Équipe URRIS, CHU Pasteur 2, Nice, France
| | - Lydiane Mondot
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP), Unité de Recherche Clinique Côte d'azur (UR2CA), Équipe URRIS, CHU Pasteur 2, Nice, France
| | - Jerome De Seze
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP), Département de Neurologie, CHRU de Strasbourg Hôpital de Hautepierre, Strasbourg, France
| | - Kevin Bigaut
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP), Département de Neurologie, CHRU de Strasbourg Hôpital de Hautepierre, Strasbourg, France
| | - Nicolas Collongues
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP), Département de Neurologie, CHRU de Strasbourg Hôpital de Hautepierre, Strasbourg, France
| | - Laurent Kremer
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP), Département de Neurologie, CHRU de Strasbourg Hôpital de Hautepierre, Strasbourg, France
| | - Damien Ricard
- Département de Neurologie, Hôpital d'Instruction des Armées Percy, Service de Santé des Armées, Clamart, France
| | - Flavie Bompaire
- Département de Neurologie, Hôpital d'Instruction des Armées Percy, Service de Santé des Armées, Clamart, France
| | - Charlotte Ohlmann
- Département de Radiologie, Hôpital d'Instruction des Armées Percy, Service de Santé des Armées, Clamart, France
| | - Magali Sallansonnet-Froment
- Département de Neurologie, Hôpital d'Instruction des Armées Percy, Service de Santé des Armées, Clamart, France
| | - Jonathan Ciron
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP)-Département des Neurosciences, CHU Toulouse-Purpan, and Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), University of Toulouse, CNRS, INSERM, UPS, Toulouse, France
| | - Damien Biotti
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP)-Département des Neurosciences, CHU Toulouse-Purpan, and Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), University of Toulouse, CNRS, INSERM, UPS, Toulouse, France
| | - Beatrice Pignolet
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP)-Département des Neurosciences, CHU Toulouse-Purpan, and Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), University of Toulouse, CNRS, INSERM, UPS, Toulouse, France
| | - Jean-Jacques Parienti
- Unité de Biostatistiques et de Recherche Clinique, CHU de Caen-Cote de Nacre, Caen, France
| | - Gilles Defer
- Centre de Ressources et Compétence Sclérose en Plaques (CRCSEP), Service de Neurologie, CHU de la Côte de Nacre, 14000, Caen, France.
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Perncezky J, Sellner J. Natalizumab extended-interval dosing in multiple sclerosis to mitigate progressive multifocal leukoencephalopathy risk: initial study evidence and real-world experience. J Cent Nerv Syst Dis 2022; 14:11795735221135485. [PMID: 36277271 PMCID: PMC9580073 DOI: 10.1177/11795735221135485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The high efficacy of natalizumab in the treatment of relapsing-remitting multiple sclerosis (MS) is without controversy. Indeed, effective disease control was not only demonstrated in the pivotal trials but has been corroborated impressively in real-world observations. This monoclonal IgG4 antibody blocks the α4β1 integrin-mediated leukocyte-endothelial interaction and thereby inhibits the migration of immune cells to the brain parenchyma. However, treatment with natalizumab carries the risk of progressive multifocal leukoencephalopathy (PML). This potentially lethal side effect is a significant limitation for treatment initiation and long-term therapy. Natalizumab is given intravenously or subcutaneously in the standard dose of 300 mg every 4 weeks, allowing drug concentrations at levels that ensure continuous α4β1 integrin receptor saturation on the surface of immune cells. Extended-interval dosing (EID) is an emerging treatment approach that aims to mitigate the natalizumab-related PML risk by prolonging the standard infusion intervals to 6 weeks or even more. This treatment approach may abrogate the PML risk due to improved immune surveillance within the central nervous system while maintaining clinical efficacy. Moreover, even an individual interval dosing can be envisioned based on the availability of a biomarker that is capable of monitoring both safety and efficacy aspects. This review summarizes the early and encouraging evidence for EID from observational and randomized-controlled trials and discusses current limitations and upcoming challenges for introducing a tailored treatment approach.
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Affiliation(s)
- Julian Perncezky
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria
| | - Johann Sellner
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria,Johann Sellner, Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Liechtensteinstr 67, Mistelbach 2130, Austria.
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8
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Foley JF, Defer G, Ryerson LZ, Cohen JA, Arnold DL, Butzkueven H, Cutter G, Giovannoni G, Killestein J, Wiendl H, Smirnakis K, Xiao S, Kong G, Kuhelj R, Campbell N, Dwyer C, Buzzard K, Spies J, Parratt J, van Pesch V, Willekens B, Perrotta G, Bartholomé E, Grand'Maison F, Jacques F, Giacomini P, Vosoughi R, Girard JM, de Seze J, Lebrun Frenay C, Ruet A, Laplaud DA, Reifschneider G, Wagner B, Rauer S, Pul R, Seipelt M, Berthele A, Klotz L, Kallmann BA, Paul F, Achiron A, Lus G, Centonze D, Patti F, Grimaldi L, Hupperts R, Frequin S, Fermont J, Madueno SE, Alonso Torres AM, Costa-Frossard França L, Meca-Lallana JE, Ruiz LB, Pearson O, Rog D, Evangelou N, Ismail A, Lathi E, Fox E, Leist T, Sloane J, Wu G, Khatri B, Steingo B, Thrower B, Gudesblatt M, Calkwood J, Bandari D, Scagnelli J, Laganke C, Robertson D, Kipp L, Belkin M, Cohan S, Goldstick L, Courtney A, Vargas W, Sylvester A, Srinivasan J, Kannan M, Picone M, English J, Napoli S, Balabanov R, Zaydan I, Nicholas J, Kaplan J, Lublin F, Riser E, Miller T, Alvarez E, Wray S, Gross J, Pawate S, Hersh C, McCarthy L, Crayton H, Graves J. Comparison of switching to 6-week dosing of natalizumab versus continuing with 4-week dosing in patients with relapsing-remitting multiple sclerosis (NOVA): a randomised, controlled, open-label, phase 3b trial. Lancet Neurol 2022; 21:608-619. [PMID: 35483387 DOI: 10.1016/s1474-4422(22)00143-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 02/28/2022] [Accepted: 03/31/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Treatment with natalizumab once every 4 weeks is approved for patients with relapsing-remitting multiple sclerosis, but is associated with a risk of progressive multifocal leukoencephalopathy. Switching to extended-interval dosing is associated with lower progressive multifocal leukoencephalopathy risk, but the efficacy of this approach is unclear. We aimed to assess the safety and efficacy of natalizumab once every 6 weeks compared with once every 4 weeks in patients with relapsing-remitting multiple sclerosis. METHODS We did a randomised, controlled, open-label, phase 3b trial (NOVA) at 89 multiple sclerosis centres across 11 countries in the Americas, Europe, and Western Pacific. Included participants were aged 18-60 years with relapsing-remitting multiple sclerosis and had been treated with intravenous natalizumab 300 mg once every 4 weeks with no relapses for at least 12 months before randomisation, with no missed doses in the previous 3 months. Participants were randomly assigned (1:1), using a randomisation sequence generated by the study funder and contract personnel with interactive response technology, to switch to natalizumab once every 6 weeks or continue with once every 4 weeks. The centralised MRI reader, independent neurology evaluation committee, site examining neurologists, site backup examining neurologists, and site examining technicians were masked to study group assignments. The primary endpoint was the number of new or newly enlarging T2 hyperintense lesions at week 72, assessed in all participants who received at least one dose of assigned treatment and had at least one postbaseline MRI, relapse, or neurological examination or efficacy assessment. Missing primary endpoint data were handled under prespecified primary and secondary estimands: the primary estimand included all data, regardless of whether participants remained on the assigned treatment; the secondary estimand classed all data obtained after treatment discontinuation or study withdrawal as missing. Safety was assessed in all participants who received at least one dose of study treatment. Study enrolment is closed and an open-label extension study is ongoing. This study is registered with EudraCT, 2018-002145-11, and ClinicalTrials.gov, NCT03689972. FINDINGS Between Dec 26, 2018, and Aug 30, 2019, 605 patients were assessed for eligibility and 499 were enrolled and assigned to receive natalizumab once every 6 weeks (n=251) or once every 4 weeks (n=248). After prespecified adjustments for missing data, mean numbers of new or newly enlarging T2 hyperintense lesions at week 72 were 0·20 (95% CI 0·07-0·63) in the once every 6 weeks group and 0·05 (0·01-0·22) in the once every 4 weeks group (mean lesion ratio 4·24 [95% CI 0·86-20·85]; p=0·076) under the primary estimand, and 0·31 (95% CI 0·12-0·82) and 0·06 (0·01-0·31; mean lesion ratio 4·93 [95% CI 1·05-23·20]; p=0·044) under the secondary estimand. Two participants in the once every 6 weeks group with extreme new or newly enlarging T2 hyperintense lesion numbers (≥25) contributed most of the excess lesions. Adverse events occurred in 194 (78%) of 250 participants in the once every 6 weeks group and 190 (77%) of 247 in the once every 4 weeks group, and serious adverse events occurred in 17 (7%) and 17 (7%), respectively. No deaths were reported. There was one case of asymptomatic progressive multifocal leukoencephalopathy (without clinical signs) in the once every 6 weeks group, and no cases in the once every 4 weeks group; 6 months after diagnosis, the participant was without increased disability and remained classified as asymptomatic. INTERPRETATION We found a numerical difference in the mean number of new or newly enlarging T2 hyperintense lesions at week 72 between the once every 6 weeks and once every 4 weeks groups, which reached significance under the secondary estimand, but interpretation of statistical differences (or absence thereof) is limited because disease activity in the once every 4 weeks group was lower than expected. The safety profiles of natalizumab once every 6 weeks and once every 4 weeks were similar. Although this trial was not powered to assess differences in risk of progressive multifocal leukoencephalopathy, the occurrence of the (asymptomatic) case underscores the importance of monitoring and risk factor consideration in all patients receiving natalizumab. FUNDING Biogen.
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Affiliation(s)
- John F Foley
- Rocky Mountain MS Clinic, Salt Lake City, UT, USA.
| | - Gilles Defer
- Department of Neurology, Centre Hospitalier Universitaire de Caen, Caen, France
| | | | - Jeffrey A Cohen
- Mellen MS Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Douglas L Arnold
- Montreal Neurological Institute, McGill University, Montréal, QC, Canada; NeuroRx Research, Montréal, QC, Canada
| | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Gary Cutter
- University of Alabama at Birmingham, School of Public Health, Birmingham, AL, USA
| | - Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK; Queen Mary University of London, London, UK
| | - Joep Killestein
- Department of Neurology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, Netherlands
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
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Morrow SA, Clift F, Devonshire V, Lapointe E, Schneider R, Stefanelli M, Vosoughi R. Use of natalizumab in persons with multiple sclerosis: 2022 update. Mult Scler Relat Disord 2022; 65:103995. [DOI: 10.1016/j.msard.2022.103995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/04/2022] [Accepted: 06/23/2022] [Indexed: 11/25/2022]
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Krajnc N, Bsteh G, Berger T, Mares J, Hartung HP. Monoclonal Antibodies in the Treatment of Relapsing Multiple Sclerosis: an Overview with Emphasis on Pregnancy, Vaccination, and Risk Management. Neurotherapeutics 2022; 19:753-773. [PMID: 35378683 PMCID: PMC8978776 DOI: 10.1007/s13311-022-01224-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 01/10/2023] Open
Abstract
Monoclonal antibodies have become a mainstay in the treatment of patients with relapsing multiple sclerosis (RMS) and provide some benefit to patients with primary progressive MS. They are highly precise by specifically targeting molecules displayed on cells involved in distinct immune mechanisms of MS pathophysiology. They not only differ in the target antigen they recognize but also by the mode of action that generates their therapeutic effect. Natalizumab, an [Formula: see text]4[Formula: see text]1 integrin antagonist, works via binding to cell surface receptors, blocking the interaction with their ligands and, in that way, preventing the migration of leukocytes across the blood-brain barrier. On the other hand, the anti-CD52 monoclonal antibody alemtuzumab and the anti-CD20 monoclonal antibodies rituximab, ocrelizumab, ofatumumab, and ublituximab work via eliminating selected pathogenic cell populations. However, potential adverse effects may be serious and can necessitate treatment discontinuation. Most importantly, those are the risk for (opportunistic) infections, but also secondary autoimmune diseases or malignancies. Monoclonal antibodies also carry the risk of infusion/injection-related reactions, primarily in early phases of treatment. By careful patient selection and monitoring during therapy, the occurrence of these potentially serious adverse effects can be minimized. Monoclonal antibodies are characterized by a relatively long pharmacologic half-life and pharmacodynamic effects, which provides advantages such as permitting infrequent dosing, but also creates disadvantages regarding vaccination and family planning. This review presents an overview of currently available monoclonal antibodies for the treatment of RMS, including their mechanism of action, efficacy and safety profile. Furthermore, we provide practical recommendations for risk management, vaccination, and family planning.
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Affiliation(s)
- Nik Krajnc
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Jan Mares
- Department of Neurology, Palacky University Olomouc, Olomouc, Czech Republic
| | - Hans-Peter Hartung
- Department of Neurology, Medical University of Vienna, Vienna, Austria.
- Department of Neurology, Palacky University Olomouc, Olomouc, Czech Republic.
- Department of Neurology, Medical Faculty, Heinrich-Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
- Brain and Mind Center, University of Sydney, Sydney, Australia.
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Butzkueven H, Kappos L, Spelman T, Trojano M, Wiendl H, Su R, Liao S, Hyde R, Licata S, Ho PR, Campbell N. No evidence for loss of natalizumab effectiveness with every-6-week dosing: a propensity score-matched comparison with every-4-week dosing in patients enrolled in the Tysabri Observational Program (TOP). Ther Adv Neurol Disord 2021; 14:17562864211042458. [PMID: 34603507 PMCID: PMC8481711 DOI: 10.1177/17562864211042458] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 08/10/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Extended interval dosing of natalizumab is associated with significantly lower progressive multifocal leukoencephalopathy risk compared with every-4-week (Q4W) dosing in patients with relapsing-remitting multiple sclerosis. Previous studies have suggested that natalizumab effectiveness is maintained in patients who switch from Q4W to extended interval dosing but have been limited by a lack of well-matched patient cohorts. Methods: Tysabri Observational Program (TOP) data as of November 2019 were used to identify patients with relapsing-remitting multiple sclerosis treated with natalizumab Q4W and those with a single physician-indicated dosing change from Q4W to every-6-week (Q6W) dosing after ⩾1 year of Q4W treatment. Patients were propensity score matched at the time of the switch from Q4W to Q6W dosing. Clinical outcomes (annualized relapse rate and probability of remaining relapse free or free of 24-week confirmed disability worsening) and safety outcomes were assessed for the two cohorts. Results: This study included 219 pairs of propensity score–matched Q6W and Q4W patients. Annualized relapse rates were similar for Q6W (0.150) and Q4W (0.157) patients. The probability of remaining relapse free [hazard ratio = 1.243 (95% confidence interval = 0.819–1.888); p = 0.307] and of remaining free of 24-week confirmed disability worsening [hazard ratio = 0.786 (95% confidence interval = 0.284–2.176); p = 0.644] did not differ significantly between Q6W and Q4W patients. Summarized safety results for the matched Q6W and Q4W patients are also presented. Conclusion: These real-world findings in well-matched patient cohorts from TOP demonstrate that natalizumab effectiveness is maintained in patients who switch to Q6W dosing after ⩾1 year of Q4W dosing. ClinicalTrials.gov identifier: NCT00493298
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Affiliation(s)
- Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Alfred Centre, Melbourne, VIC 3004, Australia. Department of Neurology, Box Hill Hospital, Monash University, Box Hill, VIC, Australia
| | - Ludwig Kappos
- Research Center for Clinical Neuroimmunology and Neuroscience Basel, Departments of Medicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital and University of Basel, Basel, Switzerland
| | - Tim Spelman
- Department of Medicine and Melbourne Brain Centre, Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Maria Trojano
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari, Bari, Italy
| | - Heinz Wiendl
- Department of Neurology, University of Münster, Münster, Germany
| | - Ray Su
- Biogen, Cambridge, MA, USA, at the time of this analysis
| | - Shirley Liao
- Biogen, Cambridge, MA, USA, at the time of this analysis
| | | | | | - Pei-Ran Ho
- Biogen, Cambridge, MA, USA, at the time of this analysis
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O’Hara BA, Gee GV, Haley SA, Morris-Love J, Nyblade C, Nieves C, Hanson BA, Dang X, Turner TJ, Chavin JM, Lublin A, Koralnik IJ, Atwood WJ. Teriflunomide Inhibits JCPyV Infection and Spread in Glial Cells and Choroid Plexus Epithelial Cells. Int J Mol Sci 2021; 22:ijms22189809. [PMID: 34575975 PMCID: PMC8468119 DOI: 10.3390/ijms22189809] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/18/2021] [Accepted: 08/24/2021] [Indexed: 11/16/2022] Open
Abstract
Several classes of immunomodulators are used for treating relapsing-remitting multiple sclerosis (RRMS). Most of these disease-modifying therapies, except teriflunomide, carry the risk of progressive multifocal leukoencephalopathy (PML), a severely debilitating, often fatal virus-induced demyelinating disease. Because teriflunomide has been shown to have antiviral activity against DNA viruses, we investigated whether treatment of cells with teriflunomide inhibits infection and spread of JC polyomavirus (JCPyV), the causative agent of PML. Treatment of choroid plexus epithelial cells and astrocytes with teriflunomide reduced JCPyV infection and spread. We also used droplet digital PCR to quantify JCPyV DNA associated with extracellular vesicles isolated from RRMS patients. We detected JCPyV DNA in all patients with confirmed PML diagnosis (n = 2), and in six natalizumab-treated (n = 12), two teriflunomide-treated (n = 7), and two nonimmunomodulated (n = 2) patients. Of the 21 patients, 12 (57%) had detectable JCPyV in either plasma or serum. CSF was uniformly negative for JCPyV. Isolation of extracellular vesicles did not increase the level of detection of JCPyV DNA versus bulk unprocessed biofluid. Overall, our study demonstrated an effect of teriflunomide inhibiting JCPyV infection and spread in glial and choroid plexus epithelial cells. Larger studies using patient samples are needed to correlate these in vitro findings with patient data.
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Affiliation(s)
- Bethany A. O’Hara
- Department of Molecular Biology, Cell Biology and Biochemistry, Brown University, Providence, RI 02903, USA; (B.A.O.); (S.A.H.); (J.M.-L.); (C.N.); (C.N.)
| | - Gretchen V. Gee
- MassBiologics, University of Massachusetts Medical School, Worcester, MA 01601, USA;
| | - Sheila A. Haley
- Department of Molecular Biology, Cell Biology and Biochemistry, Brown University, Providence, RI 02903, USA; (B.A.O.); (S.A.H.); (J.M.-L.); (C.N.); (C.N.)
| | - Jenna Morris-Love
- Department of Molecular Biology, Cell Biology and Biochemistry, Brown University, Providence, RI 02903, USA; (B.A.O.); (S.A.H.); (J.M.-L.); (C.N.); (C.N.)
| | - Charlotte Nyblade
- Department of Molecular Biology, Cell Biology and Biochemistry, Brown University, Providence, RI 02903, USA; (B.A.O.); (S.A.H.); (J.M.-L.); (C.N.); (C.N.)
| | - Chris Nieves
- Department of Molecular Biology, Cell Biology and Biochemistry, Brown University, Providence, RI 02903, USA; (B.A.O.); (S.A.H.); (J.M.-L.); (C.N.); (C.N.)
| | - Barbara A. Hanson
- Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60007, USA; (B.A.H.); (X.D.); (I.J.K.)
| | - Xin Dang
- Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60007, USA; (B.A.H.); (X.D.); (I.J.K.)
| | | | | | - Alex Lublin
- Sanofi, Cambridge, MA 02114, USA; (T.J.T.); (J.M.C.); (A.L.)
| | - Igor J. Koralnik
- Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60007, USA; (B.A.H.); (X.D.); (I.J.K.)
| | - Walter J. Atwood
- Department of Molecular Biology, Cell Biology and Biochemistry, Brown University, Providence, RI 02903, USA; (B.A.O.); (S.A.H.); (J.M.-L.); (C.N.); (C.N.)
- Correspondence: ; Tel.: +1-401-863-3116
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Bhise V, Dhib-Jalbut S. Potential Risks and Benefits of Multiple Sclerosis Immune Therapies in the COVID-19 Era: Clinical and Immunological Perspectives. Neurotherapeutics 2021; 18:244-251. [PMID: 33533012 PMCID: PMC7853164 DOI: 10.1007/s13311-021-01008-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2021] [Indexed: 02/07/2023] Open
Abstract
Coronavirus SARS-CoV2 has emerged as one of the greatest infectious disease health challenges in a century. Patients with multiple sclerosis (MS) have a particular vulnerability to infections through their use of immunosuppressive disease-modifying therapies (DMTs). Specific DMTs pose particular risk based on their mechanisms of action (MOA). As a result, patients require individualized approaches to starting new treatments and continuation of therapy. Additionally, vaccinations must be considered carefully, and individuals on long-term B cell-depleting therapies may have diminished immune responses to vaccination, based on preserved T cells and diminished but present antibody titers to influenza vaccines. We review the immunology behind these treatments and their impact on COVID-19, as well as the current recommendations for best practices for use of DMTs in patients with MS.
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Affiliation(s)
- Vikram Bhise
- Departments of Pediatrics, Rutgers Robert Wood Johnson Medical School, 89 French Street, Suite 2200, New Brunswick, NJ, 08901, USA.
| | - Suhayl Dhib-Jalbut
- Department of Neurology, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 65000, New Brunswick, NJ, 08901, USA
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