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Ito S, Wang D, Purcell A, Chetlapalli K, Lee AI, Cuker A, Goshua G. Cost-effectiveness of sutimlimab in cold agglutinin disease. Am J Hematol 2024; 99:1475-1484. [PMID: 38733355 DOI: 10.1002/ajh.27358] [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: 04/14/2024] [Revised: 04/22/2024] [Accepted: 04/26/2024] [Indexed: 05/13/2024]
Abstract
Primary cold agglutinin disease (CAD) is a rare autoimmune hemolytic anemia caused by cold-reactive antibodies that bind to red blood cells and lead to complement-mediated hemolysis. Patients with primary CAD experience the burden of increased health resource utilization and reduced quality of life. The standard-of-care (SOC) in patients with primary CAD has included cold avoidance, transfusion support, and chemoimmunotherapy. The use of sutimlimab, a humanized monoclonal antibody that selectively inhibits C1-mediated hemolysis, was shown to reduce transfusion-dependence and improve quality of life across two pivotal phase 3 studies, further supported by 2-year extension data. Using data from the transfusion-dependent patient population that led to sutimlimab's initial FDA approval, we performed the first-ever cost-effectiveness analysis in primary CAD. The projected incremental cost-effectiveness ratio (ICER) in our Markov model was $2 340 000/QALY, significantly above an upper-end conventional US willingness-to-pay threshold of $150 000/QALY. These results are consistent across scenarios of higher body weight and a pan-refractory SOC patient phenotype (i.e., treated sequentially with bendamustine-rituximab, bortezomib, ibrutinib, and eculizumab). No parameter variations in deterministic sensitivity analyses changed our conclusion. In probabilistic sensitivity analysis, SOC was favored over sutimlimab in 100% of 10 000 iterations. Exploratory threshold analyses showed that significant price reduction (>80%) or time-limited treatment (<18 months) followed by lifelong clinical remission off sutimlimab would allow sutimlimab to become cost-effective. The impact of sutimlimab on health system costs with longer term follow-up data merits future study and consideration through a distributional cost-effectiveness framework.
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MESH Headings
- Humans
- Anemia, Hemolytic, Autoimmune/therapy
- Anemia, Hemolytic, Autoimmune/drug therapy
- Anemia, Hemolytic, Autoimmune/economics
- Cost-Benefit Analysis
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antibodies, Monoclonal, Humanized/economics
- Female
- Male
- Middle Aged
- Markov Chains
- Quality-Adjusted Life Years
- Aged
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Affiliation(s)
- Satoko Ito
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Daniel Wang
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | - Alfred I Lee
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - George Goshua
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA
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2
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Shah SA, Oakes RS, Jewell CM. Advancing immunotherapy using biomaterials to control tissue, cellular, and molecular level immune signaling in skin. Adv Drug Deliv Rev 2024; 209:115315. [PMID: 38670230 PMCID: PMC11111363 DOI: 10.1016/j.addr.2024.115315] [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: 11/14/2023] [Revised: 03/20/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024]
Abstract
Immunotherapies have been transformative in many areas, including cancer treatments, allergies, and autoimmune diseases. However, significant challenges persist in extending the reach of these technologies to new indications and patients. Some of the major hurdles include narrow applicability to patient groups, transient efficacy, high cost burdens, poor immunogenicity, and side effects or off-target toxicity that results from lack of disease-specificity and inefficient delivery. Thus, there is a significant need for strategies that control immune responses generated by immunotherapies while targeting infection, cancer, allergy, and autoimmunity. Being the outermost barrier of the body and the first line of host defense, the skin presents a unique immunological interface to achieve these goals. The skin contains a high concentration of specialized immune cells, such as antigen-presenting cells and tissue-resident memory T cells. These cells feature diverse and potent combinations of immune receptors, providing access to cellular and molecular level control to modulate immune responses. Thus, skin provides accessible tissue, cellular, and molecular level controls that can be harnessed to improve immunotherapies. Biomaterial platforms - microneedles, nano- and micro-particles, scaffolds, and other technologies - are uniquely capable of modulating the specialized immunological niche in skin by targeting these distinct biological levels of control. This review highlights recent pre-clinical and clinical advances in biomaterial-based approaches to target and modulate immune signaling in the skin at the tissue, cellular, and molecular levels for immunotherapeutic applications. We begin by discussing skin cytoarchitecture and resident immune cells to establish the biological rationale for skin-targeting immunotherapies. This is followed by a critical presentation of biomaterial-based pre-clinical and clinical studies aimed at controlling the immune response in the skin for immunotherapy and therapeutic vaccine applications in cancer, allergy, and autoimmunity.
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Affiliation(s)
- Shrey A Shah
- Fischell Department of Bioengineering, University of Maryland, College Park, 8278 Paint Branch Drive, College Park, MD 20742, USA
| | - Robert S Oakes
- Fischell Department of Bioengineering, University of Maryland, College Park, 8278 Paint Branch Drive, College Park, MD 20742, USA; Department of Veterans Affairs, VA Maryland Health Care System, 10. N Green Street, Baltimore, MD 21201, USA
| | - Christopher M Jewell
- Fischell Department of Bioengineering, University of Maryland, College Park, 8278 Paint Branch Drive, College Park, MD 20742, USA; Department of Veterans Affairs, VA Maryland Health Care System, 10. N Green Street, Baltimore, MD 21201, USA; Robert E. Fischell Institute for Biomedical Devices, 8278 Paint Branch Drive, College Park, MD 20742, USA; Department of Microbiology and Immunology, University of Maryland Medical School, Baltimore, MD, 21201, USA; Marlene and Stewart Greenebaum Cancer Center, 22 S. Greene Street, Suite N9E17, Baltimore, MD, 21201, USA.
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3
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Shirani A, Stuve O, Cross AH. Role of B Cells in Relapsing-Remitting and Progressive Multiple Sclerosis and Long-Term Effects of B Cell Depletion. Neurol Clin 2024; 42:137-153. [PMID: 37980111 DOI: 10.1016/j.ncl.2023.06.001] [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
Depletion of circulating B lymphocytes using anti-CD20 monoclonal antibodies (mAbs) greatly reduces inflammatory activity in relapsing multiple sclerosis (RMS); it reduces progression to a lesser extent in nonrelapsing progressive MS. Mechanisms whereby anti-CD20 mAbs reduce MRI and clinical relapse activity in people with RMS are still being elucidated. Anti-CD20 agents do not fully protect from nonrelapsing disease progression, possibly due to their inability to cross the blood-brain barrier and inability to ameliorate the full extent of biology of MS progression. Anti-CD20 mAbs have a relatively favorable safety profile, at least in the short-term. Long-term safety studies are still needed.
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Affiliation(s)
- Afsaneh Shirani
- Division of Multiple Sclerosis, Department of Neurological Sciences, University of Nebraska Medical Center, 988440 Nebraska Medical Center, Omaha, NE 68198-8440, USA
| | - Olaf Stuve
- Department of Neurology, University of Texas Southwestern Medical Center, 6000 Harry Hines Boulevard, Dallas, TX 75390-8813, USA
| | - Anne H Cross
- Department of Neurology, Washington University School of Medicine in St. Louis, 660 South Euclid Avenue, CB 8111, St Louis, MO 63110, USA.
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4
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Alhamadh MS, Alhowaish TS, Mathkour A, Altamimi B, Alheijani S, Alrashid A. Infection Risk, Mortality, and Hypogammaglobulinemia Prevalence and Associated Factors in Adults Treated with Rituximab: A Tertiary Care Center Experience. Clin Pract 2023; 13:1286-1302. [PMID: 37987416 PMCID: PMC10660466 DOI: 10.3390/clinpract13060115] [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: 09/13/2023] [Revised: 10/09/2023] [Accepted: 10/18/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Rituximab is a human monoclonal antibody directed against the B-cell transmembrane protein CD20. Although well-tolerated, given its mechanism of action, rituximab can induce a state of severe immunosuppression, increasing the risk of opportunistic and fulminant infection and mortality. AIM To evaluate the risk of infection, mortality, and hypogammaglobulinemia and their associated factors among rituximab receivers. METHOD This was a single-center retrospective cohort study of adults treated with rituximab for various indications. Hypogammaglobulinemia was defined by a cut-off value below the normal limit (an IgG level of <7.51 g/L, an IgM level of <0.46 g/L, and/or an IgA level of <0.82 g/L). Patients who met the definition of hypogammaglobinemia solely based on IgA were excluded. Severe infection was defined as any infection that required intensive care unit admission. RESULTS A total of 137 adults with a mean age of 47.69 ± 18.86 years and an average BMI of 28.57 ± 6.55 kg/m2 were included. Hematological malignancies and connective tissue diseases were the most common primary diagnoses for which rituximab was used. More than half of the patients received the 375 mg/m2 dose. Rituximab's mean cumulative dose was 3216 ± 2282 mg, and the overall mortality rate was 22.6%. Hypogammaglobulinemia was diagnosed in 43.8% of the patients, and it was significantly more prevalent among males and the 375 mg/m2 and 500 mg doses. Hematological malignancy was the only predictor for infection. Patients with blood type AB or B, hematological malignancies, and corticosteroids had a significantly higher mortality rate. Receiving the 1000 mg dose and having a low CD19 were associated with a significantly lower risk of infection and mortality, respectively. CONCLUSIONS Hypogammaglobulinemia was diagnosed in 43.8% of the patients, and it was significantly more common among males and the 375 mg/m2 and 500 mg doses. Hematological malignancies were significantly associated with higher infection and mortality rates, while corticosteroids were significantly associated with a higher mortality. Since the culprit of mortality was infection, these findings highlight the critical need for more frequent immunological monitoring during rituximab treatment period to mitigate the burden of infection and identify candidates for immunoglobulin replacement.
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Affiliation(s)
- Moustafa S. Alhamadh
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Ministry of the National Guard-Health Affairs, Riyadh 14611, Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of the National Guard-Health Affairs, Riyadh 11481, Saudi Arabia; (T.S.A.)
| | - Thamer S. Alhowaish
- King Abdullah International Medical Research Center, Ministry of the National Guard-Health Affairs, Riyadh 11481, Saudi Arabia; (T.S.A.)
- Department of Neurology, King Abdulaziz Medical City, Ministry of the National Guard-Health Affairs, Riyadh 11426, Saudi Arabia
| | | | - Bayan Altamimi
- King Abdullah International Medical Research Center, Ministry of the National Guard-Health Affairs, Riyadh 11481, Saudi Arabia; (T.S.A.)
- Department of Medicine, Division of Rheumatology, King Abdulaziz Medical City, Ministry of the National Guard-Health Affairs, Riyadh 11426, Saudi Arabia
| | - Shahd Alheijani
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
| | - Abdulrahman Alrashid
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Ministry of the National Guard-Health Affairs, Riyadh 14611, Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of the National Guard-Health Affairs, Riyadh 11481, Saudi Arabia; (T.S.A.)
- Department of Medicine, Division of Rheumatology, King Abdulaziz Medical City, Ministry of the National Guard-Health Affairs, Riyadh 11426, Saudi Arabia
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5
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Hoff FW, Rolwes J, Hardeman PA, Perkins M, Major EO, Douek D, Collins RH, Greenberg BM. Long-term outcome of progressive multifocal leukoencephalopathy with recombinant interleukin-2 treatment and an associated increase in the number of HPyV-2-specific T-cells: a case report. Ther Adv Hematol 2023; 14:20406207231201721. [PMID: 37822572 PMCID: PMC10563476 DOI: 10.1177/20406207231201721] [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: 02/07/2023] [Accepted: 08/31/2023] [Indexed: 10/13/2023] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease caused by reactivation of the human polyomavirus 2 (HPyV-2). PML is associated with a high morbidity and mortality rate and there is currently no standard curative therapy. We report short-term immunologic response and long-term clinical outcomes in a patient diagnosed with follicular lymphoma (FL) who developed PML. Diagnosis of PML was established conclusively based on findings from a brain biopsy. The patient was treated with recombinant interleukin 2 (IL-2) and showed rapid clinical improvement. HPyV-2-specific T-cells were tracked longitudinally and correlation with clinical status, viral load, and radiographic imaging was documented. After the progression of the patient's FL, which required an allogeneic bone marrow transplant, the patient prophylactically received human leukocyte antigen-matched donor-derived HPyV-2 T-cells to prevent the recurrence of the PML as part of a clinical trial. Twelve years after the initial diagnosis of PML, he did not develop a relapse of his PML, supporting data that therapies that increase HPyV-2-specific T-cells, including IL-2, may be effective in the management of PML.
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Affiliation(s)
- Fieke W Hoff
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
| | - John Rolwes
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
| | - Paula A Hardeman
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Molly Perkins
- Human Immunology Section, Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Eugene O Major
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Daniel Douek
- Human Immunology Section, Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Robert H Collins
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8806, USA
| | - Benjamin M Greenberg
- Department of Neurology, O'Donnell Brain Institute, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8806, USA
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6
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Li X, Armon C, Barkhaus P, Barnes B, Benatar M, Bertorini T, Bromberg M, Carter GT, Crayle J, Cudkowicz M, Dimachkie M, Feldman EL, Glass J, Goslinga J, Heiman-Patterson T, Jhooty S, Lichtenstein R, Lund I, Mcdermott C, Pattee G, Pierce K, Ratner D, Salmon K, Wicks P, Bedlack R. ALSUntangled #67: rituximab. Amyotroph Lateral Scler Frontotemporal Degener 2023; 24:544-547. [PMID: 36106861 DOI: 10.1080/21678421.2022.2122845] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 09/04/2022] [Indexed: 11/01/2022]
Abstract
ALSUntangled reviews alternative and off-label treatments on behalf of people with ALS who ask about them. Here we review rituximab, a drug which specifically depletes B lymphocytes. We show a current lack of evidence for a role of these cells in ALS progression. The one patient we found who described using Rituximab for their ALS found no benefit. Given all this, and the known serious risks of rituximab, we advise against its use as an ALS treatment.
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Affiliation(s)
- Xiaoyan Li
- Department of Neurology, Duke University, Durham, NC, USA
| | - Carmel Armon
- Department of Neurology, Loma Linda University, Loma Linda, CA, USA
| | - Paul Barkhaus
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Benjamin Barnes
- Department of Neurology, Medical College of Georgia, Augusta, GA, USA
| | - Michael Benatar
- Department of Neurology, University of Miami, Miami, FL, USA
| | - Tulio Bertorini
- Neurology Department, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Mark Bromberg
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Gregory T Carter
- Department of Rehabilitation, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Jesse Crayle
- Neurology Department, Washington University, St. Louis, MO, USA
| | - Merit Cudkowicz
- Department of Neurology, Harvard Medical School, Boston, MA, USA
| | - Mazen Dimachkie
- Department of Neurology, University of Kansas, Kansas City, KS, USA
| | - Eva L Feldman
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Jonathan Glass
- Department of Neurology, Emory University, Atlanta, GA, USA
| | - Jill Goslinga
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | | | - Sartaj Jhooty
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rachel Lichtenstein
- Avram and Stella Goren-Goldstein Biotechnology Engineering Department, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Isaac Lund
- Undergraduate, Green Hope High School, Cary, NC, USA
| | | | - Gary Pattee
- Department of Neurology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Kaitlyn Pierce
- Department of Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Dylan Ratner
- Undergraduate, Longmeadow High School, Longmeadow, MA, USA
| | - Kristiana Salmon
- Department of Neurology, Montreal Neurological Institute, Montreal, CA and
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Hosea R, Hillary S, Wu S, Kasim V. Targeting Transcription Factor YY1 for Cancer Treatment: Current Strategies and Future Directions. Cancers (Basel) 2023; 15:3506. [PMID: 37444616 DOI: 10.3390/cancers15133506] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 06/28/2023] [Accepted: 07/03/2023] [Indexed: 07/15/2023] Open
Abstract
Cancer represents a significant and persistent global health burden, with its impact underscored by its prevalence and devastating consequences. Whereas numerous oncogenes could contribute to cancer development, a group of transcription factors (TFs) are overactive in the majority of tumors. Targeting these TFs may also combat the downstream oncogenes activated by the TFs, making them attractive potential targets for effective antitumor therapeutic strategy. One such TF is yin yang 1 (YY1), which plays crucial roles in the development and progression of various tumors. In preclinical studies, YY1 inhibition has shown efficacy in inhibiting tumor growth, promoting apoptosis, and sensitizing tumor cells to chemotherapy. Recent studies have also revealed the potential of combining YY1 inhibition with immunotherapy for enhanced antitumor effects. However, clinical translation of YY1-targeted therapy still faces challenges in drug specificity and delivery. This review provides an overview of YY1 biology, its role in tumor development and progression, as well as the strategies explored for YY1-targeted therapy, with a focus on their clinical implications, including those using small molecule inhibitors, RNA interference, and gene editing techniques. Finally, we discuss the challenges and current limitations of targeting YY1 and the need for further research in this area.
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Affiliation(s)
- Rendy Hosea
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, College of Bioengineering, Chongqing University, Chongqing 400044, China
- The 111 Project Laboratory of Biomechanics and Tissue Repair, College of Bioengineering, Chongqing University, Chongqing 400044, China
| | - Sharon Hillary
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, College of Bioengineering, Chongqing University, Chongqing 400044, China
- The 111 Project Laboratory of Biomechanics and Tissue Repair, College of Bioengineering, Chongqing University, Chongqing 400044, China
| | - Shourong Wu
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, College of Bioengineering, Chongqing University, Chongqing 400044, China
- The 111 Project Laboratory of Biomechanics and Tissue Repair, College of Bioengineering, Chongqing University, Chongqing 400044, China
- Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital, Chongqing University, Chongqing 400030, China
| | - Vivi Kasim
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, College of Bioengineering, Chongqing University, Chongqing 400044, China
- The 111 Project Laboratory of Biomechanics and Tissue Repair, College of Bioengineering, Chongqing University, Chongqing 400044, China
- Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital, Chongqing University, Chongqing 400030, China
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8
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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.
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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.)
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9
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Bridges JM, Chatham WW. Biologic Response Modifiers. Clin Immunol 2023. [DOI: 10.1016/b978-0-7020-8165-1.00086-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
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10
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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.
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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
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Sharma K, Tolaymat S, Yu H, Elkhooly M, Jaiswal S, Jena A, Kakara M, Sriwastava S. Progressive multifocal leukoencephalopathy in anti-CD20 and other monoclonal antibody (mAb) therapies used in multiple sclerosis: A review. J Neurol Sci 2022; 443:120459. [PMID: 36283150 DOI: 10.1016/j.jns.2022.120459] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 09/08/2022] [Accepted: 10/11/2022] [Indexed: 11/27/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a subacute CNS inflammatory disease seen primarily among immunocompromised patients. It is caused by the JC virus (JCV), a polyomavirus that otherwise induces an insidious, latent infection in the general population. This reactivated disease is characterized by cognitive and behavioral changes, language disturbances, motor weakness, or visual deficits. Median survival in patients with AIDS is approximately 2-4 months, and mortality is high (around 4% in untreated AIDS). Recent scientific developments indicate that PML can also be associated with the increased utilization of monoclonal antibody (mAb) immunotherapy. In fact, PML has been witnessed with several mAbs, including natalizumab in multiple sclerosis, rituximab for lymphoma or lupus, efalizumab for psoriasis, and ofatumumab in leukemia; this leads us to the risk reassessment of PML due to treatment-induced immunosuppression. The range of clinical presentations of JCV-related disease has transformed over time and can pose significant challenges to the current diagnostic criteria. Most cases with PML suffer from persistent and irreversible neurological conditions, and some with chronic, low-level viral replication in the CNS. With the expanded use of mAbs for various autoimmune and lymphoproliferative disorders, we are now seeing this infection in non-HIV patients on drugs such as natalizumab, rituximab, and other recently approved therapies. This article aims to review the relationship between the incidence of PML and all four mAbs used in the treatment of MS. Currently, at least 18 FDA-approved medications carry label warnings for PML;to this date, no treatment has been convincingly effective.
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Affiliation(s)
- Kanika Sharma
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States of America
| | - Sarah Tolaymat
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States of America
| | - Hongxuyang Yu
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States of America
| | | | - Shruti Jaiswal
- West Virginia Clinical and Translational Science Institute, Morgantown, WV, United States of America
| | - Anek Jena
- Calcutta Medical College, Calcutta, India
| | - Mihir Kakara
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, PA, United States of America
| | - Shitiz Sriwastava
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States of America; West Virginia Clinical and Translational Science Institute, Morgantown, WV, United States of America; School of Medicine, West Virginia University, Morgantown, WV, United States of America; Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX, United States of America.
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12
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Cardani‐Boulton A, Boylan BT, Stetsenko V, Bergmann CC. B cells going viral in the CNS: Dynamics, complexities, and functions of B cells responding to viral encephalitis. Immunol Rev 2022; 311:75-89. [PMID: 35984298 PMCID: PMC9804320 DOI: 10.1111/imr.13124] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
A diverse number of DNA and RNA viruses have the potential to invade the central nervous system (CNS), causing inflammation and injury to cells that have a limited capacity for repair and regeneration. While rare, viral encephalitis in humans is often fatal and survivors commonly suffer from permanent neurological sequelae including seizures. Established treatment options are extremely limited, predominantly relying on vaccines, antivirals, or supportive care. Many viral CNS infections are characterized by the presence of antiviral antibodies in the cerebral spinal fluid (CSF), indicating local maintenance of protective antibody secreting cells. However, the mechanisms maintaining these humoral responses are poorly characterized. Furthermore, while both viral and autoimmune encephalitis are associated with the recruitment of diverse B cell subsets to the CNS, their protective and pathogenic roles aside from antibody production are just beginning to be understood. This review will focus on the relevance of B cell responses to viral CNS infections, with an emphasis on the importance of intrathecal immunity and the potential contribution to autoimmunity. Specifically, it will summarize the newest data characterizing B cell activation, differentiation, migration, and localization in clinical samples as well as experimental models of acute and persistent viral encephalitis.
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Affiliation(s)
| | - Brendan T. Boylan
- Cleveland Clinic Lerner Research Institute, NeuroscienceClevelandOhioUSA,Case Western Reserve University School of Medicine, PathologyClevelandOhioUSA
| | - Volodymyr Stetsenko
- Cleveland Clinic Lerner Research Institute, NeuroscienceClevelandOhioUSA,Kent State University, School of Biomedical SciencesKentOhioUSA
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13
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Chen TX, Fan YT, Peng BW. Distinct mechanisms underlying therapeutic potentials of CD20 in neurological and neuromuscular disease. Pharmacol Ther 2022; 238:108180. [DOI: 10.1016/j.pharmthera.2022.108180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/16/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
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14
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Sgarlata E, Chisari CG, Toscano S, Finocchiaro C, Lo Fermo S, Millefiorini E, Patti F. Changes in John Cunningham Virus Index in Multiple Sclerosis Patients Treated with Different Disease-Modifying Therapies. Curr Neuropharmacol 2022; 20:1978-1987. [PMID: 34766895 PMCID: PMC9886813 DOI: 10.2174/1570159x19666211111123202] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/17/2021] [Accepted: 09/20/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Progressive Multifocal Leukoencephalopathy (PML) is an opportunistic infection caused by John Cunningham virus (JCV) reactivation, potentially associated with natalizumab (NTZ) treatment for Multiple Sclerosis (MS). The anti-JCV antibodies titre (JCV index) increases during NTZ treatment; however, the effects of other disease-modifying therapies (DMTs) on the JCV index have not been fully explored. OBJECTIVE The aim of the study was to evaluate changes in the JCV index during treatment with several DMTs. METHODS This longitudinal study evaluated the JCV index before starting DMT (T0) and during treatment with DMT (T1). RESULTS A total of 260 participants (65.4 % females, mean age 43 ± 11.3 ) were enrolled: 68 (26.2 %) treated with fingolimod (FTY), 65 (25 %) rituximab or ocrelizumab (RTX/OCR), 37 (14.2 %) dimethyl-fumarate (DMF), 29 (11.2 %) cladribine (CLD), 23 (8.8 %) teriflunomide (TFM), 20 (7.7 %) interferon or glatiramer acetate (IFN/GA), and 18 (6.9 %) alemtuzumab (ALM). At T1, the percentage of patients with JCV index <0.90 was found to be significantly increased in the ALM group (16.7 % versus 66.7 %, p = 0.05), while the percentage of patients with JCV index >1.51 was found to be significantly reduced in the RTX/OCR group (51.6 % versus 37.5 %, p = 0.04). In the FTY group, a significant reduction in the percentage of patients with JCV index <0.90 was also found (23.5 % versus 1.4 %, p = 0.0006). The mean JCV index was reduced in the RTX/OCR and ALM groups, while a significant increase was observed in the FTY group. CONCLUSION DMTs with a T and/or B depleting mechanism of action induced a significant reduction in the JCV index. These results may suggest new possible sequencing strategies potentially maximizing disease control while reducing the PML risk.
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Affiliation(s)
| | | | | | | | | | | | - Francesco Patti
- Address correspondence to this author at the Department of Medical and Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, Section of Neurosciences, University of Catania, Catania, Italy; Tel: 0953782783; E-mail:
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15
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Cauchi M, Willis M, Andrews A, Backx M, Brownlee W, Ford HL, Gran B, Jolles S, Price S, Rashid W, Schmierer K, Tallantyre EC. Multiple sclerosis and the risk of infection: Association of British Neurologists consensus guideline. Pract Neurol 2022; 22:practneurol-2022-003370. [PMID: 35863879 DOI: 10.1136/practneurol-2022-003370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 11/03/2022]
Abstract
Infection in people with multiple sclerosis (MS) is of major concern, particularly for those receiving disease-modifying therapies. This article explores the risk of infection in people with MS and provides guidance-developed by Delphi consensus by specialists involved in their management-on how to screen for, prevent and manage infection in this population.
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Affiliation(s)
- Marija Cauchi
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, University Hospital of Wales, Cardiff, UK
| | - Mark Willis
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, University Hospital of Wales, Cardiff, UK
| | - Angela Andrews
- Pharmacy Neurosciences Directorate, University Hospital of Wales, Cardiff, UK
| | - Matthijs Backx
- Infectious Diseases, University Hospital of Wales and Department of Microbiology, Public Health Wales, Cardiff, UK
| | - Wallace Brownlee
- Queen Square MS Centre, University College London Institute of Neurology, Queen Square Multiple Sclerosis Centre, London, UK
| | - Helen L Ford
- Centre for Neurosciences, Leeds Teaching Hospitals NHS Trust, Leeds, UK, Leeds, UK
| | - Bruno Gran
- Department of Neurology, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Mental Health and Clinical Neuroscience Academic Unit, University of Nottingham School of Medicine, Nottingham, UK
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Sian Price
- Department of Neuroscience, University of Sheffield, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Waqar Rashid
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Klaus Schmierer
- The Blizard Institute (Neuroscience, Surgery & Trauma), Queen Mary University of London Faculty of Medicine and Dentistry, London, UK
- Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Emma C Tallantyre
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, University Hospital of Wales, Cardiff, UK
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16
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Kougkas N, Dara A, Pagkopoulou E, Dimitriadou A, Papadimitriou E, Avdelidou E, Garyfallos A, Dimitroulas T. Methotrexate induced neurotoxicity in a patient with rheumatoid arthritis on rituximab therapy: a case-based review. Rheumatol Int 2022; 42:1849-1854. [PMID: 35849191 DOI: 10.1007/s00296-022-05166-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 06/11/2022] [Indexed: 11/28/2022]
Abstract
Rheumatoid arthritis (RA) is a systemic inflammatory disease treated with conventional and biologic disease-modifying drugs. Methotrexate is the anchor drug for the treatment of RA and is also frequently used for various autoimmune diseases. Adverse events are common and generally easy to manage, involving mainly the gastrointestinal tract and the liver function. However, neurotoxicity is very uncommon in adults with rheumatic diseases. B cell depletion with rituximab is another therapy approach particularly in patients with refractory RA. Whistle leukoencephalopathy - namely progressive multifocal leukoencephalopathy-is an infrequent but well-described side effect of rituximab. In contrast, central nervous system toxicity due to methotrexate is extremely rare especially in RA individuals under oral or subcutaneous low dose on weekly basis. We present a challenging case of a RA patient on treatment with methotrexate and rituximab presenting with leukoencephalopathy. The patient was diagnosed with methotrexate-induced leukoencephalopathy which reversed after treatment discontinuation. We comment on the symptoms and diagnostic workout and we review the available literature on this issue based on recommendations for narrative reviews.
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Affiliation(s)
- Nikolaos Kougkas
- Fourth Department of Internal Medicine, Medical School, Hippokration University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Athanasia Dara
- Fourth Department of Internal Medicine, Medical School, Hippokration University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Pagkopoulou
- Fourth Department of Internal Medicine, Medical School, Hippokration University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Evdokia Papadimitriou
- Fourth Department of Internal Medicine, Medical School, Hippokration University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eugenia Avdelidou
- Department of Neurology, Hippokration University Hospital, Thessaloniki, Greece
| | - Alexandros Garyfallos
- Fourth Department of Internal Medicine, Medical School, Hippokration University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodoros Dimitroulas
- Fourth Department of Internal Medicine, Medical School, Hippokration University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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17
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Ovchinnikov A, Findling O. An overview of pivotal trials and real-world evidence for CD20-depleting therapy in multiple sclerosis : Immunotherapy with rituximab, ocrelizumab, and ofatumumab. Wien Med Wochenschr 2022; 172:359-364. [PMID: 35723820 PMCID: PMC9208251 DOI: 10.1007/s10354-022-00939-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 05/04/2022] [Indexed: 11/28/2022]
Abstract
Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system leading to demyelination and neurodegeneration of brain tissue. For a long time, research focused on T cells as the primary mechanism of disease. Driven by reports on the clinical results of B cell-depleting therapies, this therapeutic approach has come into focus in the last decade, and new highly effective treatments have been developed and are now complementing the therapeutic landscape. This review provides an overview of the development of B cell-depleting therapies and shows the advantages and disadvantages of current developments. In addition, we discuss basic considerations for CD20-depleted MS patients in the face of the COVID-19 pandemic.
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Affiliation(s)
- Arkady Ovchinnikov
- Department of Neurology, Kantonsspital Aarau, Tellstr. 25, 5001, Aarau, Switzerland
| | - Oliver Findling
- Department of Neurology, Kantonsspital Aarau, Tellstr. 25, 5001, Aarau, Switzerland.
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18
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Molnár A, Studinger P, Ledó N. Diagnostic and Therapeutic Approach in ANCA-Associated Glomerulonephritis: A Review on Management Strategies. Front Med (Lausanne) 2022; 9:884188. [PMID: 35721093 PMCID: PMC9205443 DOI: 10.3389/fmed.2022.884188] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 05/18/2022] [Indexed: 11/24/2022] Open
Abstract
Anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis is a destructive small vessel vasculitis affecting multiple organs. Renal involvement often leads to end-stage renal disease and increases mortality. Prompt diagnosis and initiation of adequate immunosuppressive therapy are critical for the best patient and kidney outcomes. However, considerable heterogeneity in symptoms and severity across the patients frequently hinder the diagnosis and management. The objective of this review is to emphasize the heterogeneity of the ANCA-associated vasculitis, facilitate the recognition and give guidance to the therapeutical possibilities. We present epidemiologic and risk factors, pathogenesis, and provide comprehensive clinical features of the disease. This article also focuses on the currently available therapeutic options and emerging cellular and molecular targets for the management of systemic and especially renal disease. We conducted extensive literature research published on PubMed and Google Scholar. We systematically reviewed, analyzed, and assembled databases, covering a broad spectrum of aspects of the disease. We compared and summarized the recommendations of two recent guidelines on ANCA-associated vasculitis. The incidence of ANCA-associated vasculitis, hence glomerulonephritis shows a steady increase. Familiarity with the presenting symptoms and laboratory abnormalities are necessary for rapid diagnosis. Early initiation of treatment is the key aspect for favorable patient and renal outcomes. A better understanding of the pathogenesis constantly leads to more targeted and therefore more efficient and less toxic treatment.
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Affiliation(s)
| | | | - Nóra Ledó
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
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19
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Progressive Multifocal Leukoencephalopathy in B-CLL Successfully Treated With Venetoclax and Pembrolizumab. Hemasphere 2022; 6:e723. [PMID: 35747841 PMCID: PMC9208891 DOI: 10.1097/hs9.0000000000000723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 04/15/2022] [Indexed: 11/27/2022] Open
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Chatterjee T, Roy M, Lin RC, Almoujahed MO, Ahmad S. Pembrolizumab for the treatment of Progressive Multifocal Leukoencephalopathy (PML) in a patient with AIDS: A Case Report and Literature Review. IDCases 2022; 28:e01514. [PMID: 35637642 PMCID: PMC9144385 DOI: 10.1016/j.idcr.2022.e01514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/16/2022] [Indexed: 11/25/2022] Open
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21
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Diamantopoulos PT, Kalopisis K, Tsatsou A, Efthymiou A, Giannakopoulou N, Hatzidavid S, Viniou NA. Progressive multifocal leukoencephalopathy in the context of newer therapies in hematology and review of new treatment strategies. Eur J Haematol 2022; 108:359-368. [PMID: 35100451 DOI: 10.1111/ejh.13751] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/25/2022] [Accepted: 01/27/2022] [Indexed: 02/07/2023]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare, often fatal demyelinating disease of the central nervous system (CNS) caused by the reactivation of JC polyomavirus in the CNS. We present a case of a 54-year-old man with follicular lymphoma diagnosed with PML after being treated with anti-CD20 monoclonal antibody-based regimens for several years. Due to the lack of effective treatment choices for PML, the patient was treated with nivolumab, based on recent reports, but succumbed to his disease a few months after diagnosis. In this paper, we focus on reviewing the literature of PML cases correlated with newer agents used in hematology, possible factors affecting disease prognosis, as well as the available data on upcoming therapeutic options for patients with PML. Though newer promising treatments such as anti-PD1 monoclonal antibodies arise, a definitive treatment option is yet to be found. Vigilance, early detection, and prompt intervention play a crucial role in the prognosis of PML in patients with hematological malignancies.
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Affiliation(s)
- Panagiotis T Diamantopoulos
- First Department of Internal Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Kalopisis
- First Department of Internal Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Athina Efthymiou
- Department of Neurology, Laikon General Hospital, Athens, Greece
| | - Nefeli Giannakopoulou
- First Department of Internal Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Sevastianos Hatzidavid
- First Department of Internal Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Nora-Athina Viniou
- First Department of Internal Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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22
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Dalla-Pozza P, Hentzien M, Allavena C, Doe de Maindreville A, Bouiller K, Valantin MA, Lafont E, Zaegel-Faucher O, Cheret A, Martin-Blondel G, Cotte L, Bani-Sadr F. Progressive multifocal leukoencephalopathy in patients with immunovirological control and at least 6 months of combination antiretroviral therapy. AIDS 2022; 36:539-549. [PMID: 34873087 DOI: 10.1097/qad.0000000000003145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES AND METHODS : Progressive multifocal leukoencephalopathy (PML) has rarely been reported in people with HIV (PWH) with long-term HIV immune-virological control. We describe the clinical and biological characteristics of patients with confirmed PML among PWH with a CD4+ cell count more than 200 cells/μl and an undetectable HIV RNA viral load after at least 6 months of combined antiretroviral therapy (cART) at the time of PML diagnosis, in the large French multicenter Dat'AIDS cohort. RESULTS : Among 571 diagnoses of PML reported in the Dat'AIDS cohort between 2000 and 2019, 10 cases (1.75%) occurred in PWH with a CD4+ cell count greater than 200 cells/μl and an undetectable HIV RNA viral load after at least 6 months of cART. Median CD4+ cell count at PML diagnosis was 395 cells/μl (IQR 310-477). The median duration between the last detectable HIV viral load and the PML diagnosis was 41.1 months (IQR 8.2-67.4). Only one patient treated with rituximab-based chemotherapy for a large B-cell lymphoma had an established risk factor for PML. Among the nine other patients with no apparent severe immunodeficiency, multiple factors of impaired immunity could have led to the development of PML: hepatitis C virus (HCV) co-infection (n = 6), cirrhosis (n = 4), HHV-8 co-infection (n = 3) with Kaposi's sarcoma (n = 2) in association with Castleman's disease (n = 1) and indolent IgA multiple myeloma (n = 1). CONCLUSION : This study highlights that factors other than low CD4+ cell count and high HIV viral load may be associated with the occurrence of PML. Further studies are warranted to investigate in greater detail the immunologic characteristics of PWH with immune-virological control who develop PML.
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Affiliation(s)
- Paul Dalla-Pozza
- Department of Internal Medicine, Clinical Immunology and Infectious Diseases, Robert Debré Hospital, University Hospital of Reims
| | - Maxime Hentzien
- Department of Internal Medicine, Clinical Immunology and Infectious Diseases, Robert Debré Hospital, University Hospital of Reims
| | - Clotilde Allavena
- Department of Infectious Diseases, University Hospital of Nantes, Nantes
| | | | - Kévin Bouiller
- Department of Infectious Diseases, University Hospital of Besancon
| | - Marc-Antoine Valantin
- Department of Infectious Diseases, Pitié-Salpêtrière Hospital, Assistance Publique des Hôpitaux de Paris
| | - Emmanuel Lafont
- Department of Infectious Diseases, Necker Hospital, Assistance Publique des Hôpitaux de Paris, Paris
| | - Olivia Zaegel-Faucher
- Department of Immunology and Hematology, Sainte-Marguerite Hospital, Assistance Publique des Hôpitaux de Marseille, Marseille
| | - Antoine Cheret
- Department of Internal Medicine, Kremlin Bicêtre Hospital, Assistance Publique des Hôpitaux de Paris, Bicêtre
| | - Guillaume Martin-Blondel
- Department of Infectious Diseases, University Hospital of Toulouse, Toulouse, France and Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), INSERM UMR1291 - CNRS UMR5051 - Université Toulouse III, Toulouse
| | - Laurent Cotte
- Department of Infectious Diseases, Croix-Rousse Hospital, Hospices Civils de Lyon, and INSERM U1052, Lyon
| | - Firouzé Bani-Sadr
- Department of Internal Medicine, Clinical Immunology and Infectious Diseases, Robert Debré Hospital, University Hospital of Reims
- University of Reims Champagne-Ardenne, EA-4684/SFR CAP-SANTE, Reims, F-51095, France
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23
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Lim YL, Bohelay G, Hanakawa S, Musette P, Janela B. Autoimmune Pemphigus: Latest Advances and Emerging Therapies. Front Mol Biosci 2022; 8:808536. [PMID: 35187073 PMCID: PMC8855930 DOI: 10.3389/fmolb.2021.808536] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/20/2021] [Indexed: 12/31/2022] Open
Abstract
Pemphigus represents a group of rare and severe autoimmune intra-epidermal blistering diseases affecting the skin and mucous membranes. These painful and debilitating diseases are driven by the production of autoantibodies that are mainly directed against the desmosomal adhesion proteins, desmoglein 3 (Dsg3) and desmoglein 1 (Dsg1). The search to define underlying triggers for anti-Dsg-antibody production has revealed genetic, environmental, and possible vaccine-driven factors, but our knowledge of the processes underlying disease initiation and pathology remains incomplete. Recent studies point to an important role of T cells in supporting auto-antibody production; yet the involvement of the myeloid compartment remains unexplored. Clinical management of pemphigus is beginning to move away from broad-spectrum immunosuppression and towards B-cell-targeted therapies, which reduce many patients’ symptoms but can have significant side effects. Here, we review the latest developments in our understanding of the predisposing factors/conditions of pemphigus, the underlying pathogenic mechanisms, and new and emerging therapies to treat these devastating diseases.
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Affiliation(s)
- Yen Loo Lim
- Department of Dermatology, National Skin Centre, Singapore
| | - Gerome Bohelay
- Department of Dermatology and INSERM U1125, Avicenne Hospital, Bobigny, France
| | - Sho Hanakawa
- A*STAR Skin Research Labs (ASRL), Agency for Science, Technology and Research (A*STAR), Singapore
| | - Philippe Musette
- Department of Dermatology and INSERM U1125, Avicenne Hospital, Bobigny, France
| | - Baptiste Janela
- A*STAR Skin Research Labs (ASRL), Agency for Science, Technology and Research (A*STAR), Singapore
- Skin Research Institute of Singapore (SRIS), Agency for Science, Technology and Research (A*STAR), Singapore
- A*STAR Infectious Diseases Labs, Agency for Science, Technology and Research (A*STAR), Singapore
- Singapore Immunology network, Agency for Science, Technology and Research (A*STAR), Singapore
- *Correspondence: Baptiste Janela,
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24
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Diagnostic Value of JC Polyomavirus Viruria, Viremia, Serostatus and microRNA Expression in Multiple Sclerosis Patients Undergoing Immunosuppressive Treatment. J Clin Med 2022; 11:jcm11020347. [PMID: 35054041 PMCID: PMC8781243 DOI: 10.3390/jcm11020347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/07/2022] [Accepted: 01/10/2022] [Indexed: 12/04/2022] Open
Abstract
Markers of JC polyomavirus (JCPyV) activity can be used to evaluate the risk of progressive multifocal leukoencephalopathy (PML) in treated multiple sclerosis (MS) patients. The presence of JCPyV DNA and microRNA (miR-J1-5p), the anti-JCV index and the sequence of the non-coding control region (NCCR) in urine and plasma were determined in 42 MS subjects before treatment (T0), 6 months (T6) and 12 months (T12) after natalizumab, ocrelizumab, fingolimod or dimethyl-fumarate administration and in 25 healthy controls (HC). The number of MS patients with viruria increased from 43% at T0 to 100% at T12, whereas it remained similar for the HC group (35–40%). Viremia first occurred 6 months after treatment in MS patients and increased after 12 months, whereas it was absent in HC. The viral load in urine and plasma from the MS cohort increased over time, mostly pronounced in natalizumab-treated patients, whereas it persisted in HC. The archetypal NCCR was detected in all positive urine, whereas mutations were observed in plasma-derived NCCRs resulting in a more neurotropic variant. The prevalence and miR-J1-5p copy number in MS urine and plasma dropped after treatment, whereas they remained similar in HC specimens. Viruria and miR-J1-5p expression did not correlate with anti-JCV index. In conclusion, analyzing JCPyV DNA and miR-J1-5p levels may allow monitoring JCPyV activity and predicting MS patients at risk of developing PML.
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Flanagan EP, Levy M, Katz E, Cimbora D, Drappa J, Mealy MA, She D, Cree BAC. Inebilizumab for treatment of neuromyelitis optica spectrum disorder in patients with prior rituximab use from the N-MOmentum Study. Mult Scler Relat Disord 2022; 57:103352. [PMID: 35158461 DOI: 10.1016/j.msard.2021.103352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 09/24/2021] [Accepted: 10/24/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND The B-cell-depleting agent rituximab (anti-CD20) was historically used to prevent attacks in neuromyelitis optica spectrum disorder (NMOSD). Inebilizumab, which targets and depletes CD19-expressing B cells, plasmablasts, and some plasma cells, received approval from the US Food and Drug Administration for treatment of NMOSD based on results from the randomized, placebo-controlled, phase 2/3 N-MOmentum trial. Because of their closely related mechanisms of action, consideration as to whether inebilizumab may be a suitable treatment option for patients with prior rituximab experience is important. This post hoc analysis of data from N-MOmentum assessed inebilizumab efficacy and tolerability in participants previously treated with rituximab. METHODS Adjudicated attacks, secondary efficacy outcomes, and treatment-emergent adverse events were assessed by prior rituximab use during a 6-month randomized control period and open-label period. RESULTS Seventeen participants in N-MOmentum had prior rituximab use, of whom 13 were randomly assigned to the inebilizumab treatment group. Seven of these participants had breakthrough attacks prior to enrollment (annualized attack rate, 0.78 attacks/person-year) despite rituximab use. While they were receiving inebilizumab in the randomized control period, 1 of 13 participants with prior rituximab use had an attack (hazard ratio vs all placebo, 0.16; 95% confidence interval: 0.02 1.20; p = 0.07). Two additional participants with prior rituximab use experienced attacks on inebilizumab during the open-label period, with an overall annualized attack rate of 0.08 (95% confidence interval: 0.02 0.34) attacks/person-year. This annualized attack rate was similar to that of participants without prior rituximab use (0.10 [95% confidence interval: 0.07 0.15]). None of the 7 participants who experienced attacks while taking rituximab experienced an attack while receiving inebilizumab. Two (12%) participants with prior rituximab use experienced serious treatment-emergent adverse events related to inebilizumab, with serious or grade ≥3 infections occurring in 3 (18%) participants each. No deaths or opportunistic infections were reported in this cohort. CONCLUSIONS These findings support the efficacy of inebilizumab in participants with NMOSD who had previously been treated with rituximab. Infections occurred in nearly all study participants with prior rituximab exposure, highlighting a need for clinical vigilance in such individuals. Further studies are necessary to determine potential safety concerns of inebilizumab, including risk of infection, in rituximab-experienced patients. ClinicalTrials.gov identifier: NCT02200770.
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Affiliation(s)
- Eoin P Flanagan
- Departments of Neurology and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Michael Levy
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Eliezer Katz
- Horizon Therapeutics (formerly Viela Bio) plc, Deerfield, IL, USA
| | - Daniel Cimbora
- Horizon Therapeutics (formerly Viela Bio) plc, Deerfield, IL, USA
| | - Jorn Drappa
- Horizon Therapeutics (formerly Viela Bio) plc, Deerfield, IL, USA
| | - Maureen A Mealy
- Horizon Therapeutics (formerly Viela Bio) plc, Deerfield, IL, USA
| | - Dewei She
- Horizon Therapeutics (formerly Viela Bio) plc, Deerfield, IL, USA
| | - Bruce A C Cree
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California San Francisco, 675 Nelson Rising Lane, Box 3206, San Francisco, CA, USA
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Deveci B, Saba R. Prolonged viral positivity induced recurrent coronavirus disease 2019 (COVID-19) pneumonia in patients receiving anti-CD20 monoclonal antibody treatment: Case reports. Medicine (Baltimore) 2021; 100:e28470. [PMID: 34967391 PMCID: PMC8718200 DOI: 10.1097/md.0000000000028470] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/15/2021] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION The outbreak of novel coronavirus (severe acute respiratory syndrome coronavirus 2), which causes the coronavirus disease 2019 (COVID-19), is the most important current health problem. The number of patients is increasing worldwide. Pneumonia is the most life-threatening complication of the disease. Prolonged viral shedding in hematological patients with COVID-19 has been demonstrated; however, data on COVID-19 patients receiving anti-CD20 monoclonal antibody therapy are limited. Accordingly, focusing on humoral immunity, herein, we present 4 COVID-19 patients who were on anti-CD20 monoclonal antibody treatment and had prolonged pneumonia. PATIENT CONCERNS Two of 4 patients were on rituximab and the other 2 were on obinutuzumab therapy. DIAGNOSIS The polymerase chain reaction test results for severe acute respiratory syndrome coronavirus 2 were positive for all 4 patients and their COVID pneumonia lasted for >50 days. INTERVENTIONS Although all patients were treated with an adequate amount of convalescent plasma, prolonged polymerase chain reaction positivity and prolonged pneumonia were possibly due to the lack of ability of the immune system to initiate its antibody response. OUTCOMES Despite the administration of standard therapies, recurrent pneumonia observed in the present case series of non-neutropenic patients, in whom primary malignancies were under control. CONCLUSIONS It is suggested that further investigations should be performed to understand the underlying pathophysiology.
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Affiliation(s)
- Burak Deveci
- Medstar Antalya Hospital, Hematology and Stem Cell Transplantation Unit, Antalya, Turkey
| | - Rabin Saba
- Medstar Antalya Hospital, Infectious Disease Unit, Antalya, Turkey
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Maissa T, Amira A, Neila F, Ahmed G, Wissal BY, Bouraoui O, Neirouz G. Rituximab-induced mild encephalopathy with a reversible splanial lesion syndrome (MERS): an adverse effect to add to the list. Br J Clin Pharmacol 2021; 88:2969-2972. [PMID: 34921445 DOI: 10.1111/bcp.15189] [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: 06/30/2021] [Revised: 10/26/2021] [Accepted: 11/29/2021] [Indexed: 11/28/2022] Open
Abstract
Mild encephalopathy with a reversible splenial lesion syndrome (MERS) is a rare clinico-radiological entity. Rituximab (RTX)-induced MERS has never been described before. Herein, we report the case of a 33-year-old patient diagnosed since 2017, with an IgG4-RD. This diagnosis was retained in front of a prolonged fever, sicca syndrome, hepatic damage and renal pseudotumor associated to a high level of IGg4 at 2.8 g/l with suggestive renal histology. The patient was treated with corticosteroid therapy with persistence of renal impairment and nephrotic syndrome indicating RTX therapy. The patient received his first dose of RTX and presented few hours after, neurological and respiratory impairments. An infectious investigation comprising a SARS CoV-2 PCR and viral PCRs (VZV, Herpes and CMV) on cerebrospinal fluid (CSF) were negative. The HBV, HCV, HIV, Parvo B19, CMV, EBV, Herpes, Mycoplasma and syphilis serologies as well as Legionella antigenuria were also negative. The patient had received intravenous immunoglobulins (IVIG) and methylprednisone, associated with sodium valproate with favourable outcome. The diagnosis of MERS induced by RTX was retained in our patient according to clinical and radiological features. We herein report the first case of MERS following RTX in a patient treated for IgG4 related disease (IgG4-RD).
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Affiliation(s)
- Thabet Maissa
- Internal Medicine Department, Farhat Hached University Hospital
| | - Atig Amira
- Internal Medicine Department, Farhat Hached University Hospital
| | | | - Guiga Ahmed
- Internal Medicine Department, Farhat Hached University Hospital
| | | | - Ouni Bouraoui
- Department of Pharmacology, Faculty of Medicine of Sousse
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Darcy S, Alexander M, McCarthy A, O'Dowd S. Pembrolizumab treatment of inflammatory progressive multifocal leukoencephalopathy: a report of two cases. J Neurovirol 2021; 28:145-150. [PMID: 34874539 DOI: 10.1007/s13365-021-01028-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 04/03/2021] [Accepted: 11/02/2021] [Indexed: 11/25/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare but devastating neurological disease caused by reactivation of the JC virus in susceptible individuals. The illness has classically been associated with the human immunodeficiency virus (HIV) and multiple sclerosis (MS) patients who are treated with natalizumab. It is also associated with haematological malignancies, organ transplantation, autoimmune disease and immunodeficiency. Aside from natalizumab, a range of other immunomodulators including obinutuzumab and rituximab have been associated with PML. The nature of these associations is unclear due to the overall low incidence of PML associated with these drugs and the fact that most patients will have other confounding risk factors for developing the disease. There is no known effective treatment available for PML in the non-HIV, non-MS cohort. Recent case studies and series have proposed that pembrolizumab, an anti-PD-1 immune checkpoint inhibitor, may be a potentially efficacious option for these patients. We present two cases of non-HIV, non-MS patients with PML who were treated with pembrolizumab with little clinical benefit. The literature surrounding pembrolizumab use in PML is discussed, with a focus on potential indicators of successful outcomes for patients who receive this therapy.
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Affiliation(s)
- Sarah Darcy
- Department of Neurology, Tallaght University Hospital, Dublin 24, Ireland.
| | - Michael Alexander
- Department of Neurophysiology, Tallaght University Hospital, Dublin 24, Ireland
| | - Allan McCarthy
- Department of Neurology, Tallaght University Hospital, Dublin 24, Ireland
| | - Seán O'Dowd
- Department of Neurology, Tallaght University Hospital, Dublin 24, Ireland
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Quirant-Sánchez B, Mansilla MJ, Navarro-Barriuso J, Presas-Rodríguez S, Teniente-Serra A, Fondelli F, Ramo-Tello C, Martínez-Cáceres E. Combined Therapy of Vitamin D3-Tolerogenic Dendritic Cells and Interferon-β in a Preclinical Model of Multiple Sclerosis. Biomedicines 2021; 9:biomedicines9121758. [PMID: 34944573 PMCID: PMC8698295 DOI: 10.3390/biomedicines9121758] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/18/2021] [Accepted: 11/20/2021] [Indexed: 12/17/2022] Open
Abstract
Autologous antigen-specific therapies based on tolerogenic dendritic cells (tolDC) offer the possibility to treat autoimmune diseases by restoring homeostasis and targeting specifically autoreactive responses. Here, we explore the hypothesis that systemic inflammation occurring in autoimmune diseases, such as multiple sclerosis (MS), can generate a disease-specific environment able to alter the functionality of tolDC. In this context in fact, a combined therapy of tolDC with an immunomodulatory treatment could potentiate the beneficial effect of this antigen-specific cell therapy. For this purpose, we analyzed the efficacy of a combined therapy based on the use of vitamin D3 (VitD3)-tolDC plus interferon beta (IFN-beta) in MS. VitD3-tolDC were generated from healthy donors and MS patients and co-cultured with allogeneic peripheral blood mononuclear cells, in the presence or absence of IFN-beta. In vitro, VitD3-tolDC treatment reduced the percentage of activated T cells and allogeneic proliferation, whereas VitD3-tolDC+IFN-beta treatment enhanced the suppressive ability of VitD3-tolDC and, additionally, induced a shift towards a Th2 profile. To determine the clinical benefit of the combined therapy, C57BL/6-experimental autoimmune encephalomyelitis (EAE)-induced mice were treated with antigen-specific VitD3-tolDC and/or IFN-beta. Treatment of EAE mice with combined therapy ameliorated the disease course compared to each monotherapy. These results suggest that a combined therapy based on antigen-specific VitD3-tolDC and IFN-beta may represent a promising strategy for MS patients.
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Affiliation(s)
- Bibiana Quirant-Sánchez
- Immunology Division, LCMN, Germans Trias i Pujol University Hospital and Research Institute, Campus Can Ruti, 08916 Badalona, Spain; (B.Q.-S.); (M.J.M.); (J.N.-B.); (A.T.-S.); (F.F.)
- Department of Cellular Biology, Physiology and Immunology, Campus Bellaterra, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain
| | - María José Mansilla
- Immunology Division, LCMN, Germans Trias i Pujol University Hospital and Research Institute, Campus Can Ruti, 08916 Badalona, Spain; (B.Q.-S.); (M.J.M.); (J.N.-B.); (A.T.-S.); (F.F.)
- Department of Cellular Biology, Physiology and Immunology, Campus Bellaterra, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain
| | - Juan Navarro-Barriuso
- Immunology Division, LCMN, Germans Trias i Pujol University Hospital and Research Institute, Campus Can Ruti, 08916 Badalona, Spain; (B.Q.-S.); (M.J.M.); (J.N.-B.); (A.T.-S.); (F.F.)
- Department of Cellular Biology, Physiology and Immunology, Campus Bellaterra, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain
| | - Silvia Presas-Rodríguez
- Multiple Sclerosis Unit, Department of Neurosciences, Germans Trias i Pujol University Hospital, 08916 Badalona, Spain;
- Department of Medicine, Campus Bellaterra, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain
| | - Aina Teniente-Serra
- Immunology Division, LCMN, Germans Trias i Pujol University Hospital and Research Institute, Campus Can Ruti, 08916 Badalona, Spain; (B.Q.-S.); (M.J.M.); (J.N.-B.); (A.T.-S.); (F.F.)
- Department of Cellular Biology, Physiology and Immunology, Campus Bellaterra, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain
| | - Federico Fondelli
- Immunology Division, LCMN, Germans Trias i Pujol University Hospital and Research Institute, Campus Can Ruti, 08916 Badalona, Spain; (B.Q.-S.); (M.J.M.); (J.N.-B.); (A.T.-S.); (F.F.)
- Department of Cellular Biology, Physiology and Immunology, Campus Bellaterra, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain
| | - Cristina Ramo-Tello
- Multiple Sclerosis Unit, Department of Neurosciences, Germans Trias i Pujol University Hospital, 08916 Badalona, Spain;
- Department of Medicine, Campus Bellaterra, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain
- Correspondence: or (C.R.-T.); (E.M.-C.); Tel.: +34-93-497-8433 (C.R.-T.); +34-93-497-8666 (E.M.-C.)
| | - Eva Martínez-Cáceres
- Immunology Division, LCMN, Germans Trias i Pujol University Hospital and Research Institute, Campus Can Ruti, 08916 Badalona, Spain; (B.Q.-S.); (M.J.M.); (J.N.-B.); (A.T.-S.); (F.F.)
- Department of Cellular Biology, Physiology and Immunology, Campus Bellaterra, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain
- Correspondence: or (C.R.-T.); (E.M.-C.); Tel.: +34-93-497-8433 (C.R.-T.); +34-93-497-8666 (E.M.-C.)
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Ahrendsen JT, Sehgal K, Sarangi S, Uhlmann EJ, Varma H, Arnason J, Avigan D. Progressive Multifocal Leukoencephalopathy After Chimeric Antigen Receptor T-Cell Therapy for Recurrent Non-Hodgkin Lymphoma. J Hematol 2021; 10:212-216. [PMID: 34804310 PMCID: PMC8577592 DOI: 10.14740/jh903] [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: 07/26/2021] [Accepted: 09/01/2021] [Indexed: 11/25/2022] Open
Abstract
Chimeric antigen receptor (CAR) T-cell therapy targeting cluster of differentiation (CD)19 has had a transformative impact on patient outcomes in a subset of patients with relapsed/refractory non-Hodgkin lymphoma. We present a patient with refractory large B-cell lymphoma in complete remission for 2 years following treatment with CD19-targeted CAR T-cell therapy, who presented with 2 weeks of progressive aphasia. Imaging revealed a left occipital brain lesion and biopsy demonstrated features diagnostic of progressive multifocal leukoencephalopathy. Further evaluation revealed severe hypogammaglobulinemia and a low CD4 count. She was treated with pembrolizumab and intravenous immunoglobulin resulting in decreased cerebrospinal fluid viral load without clinical improvement and died 8 weeks after presentation. This case highlights that there is potential for severe opportunistic infections after CAR T-cell therapy, including fatal progressive multifocal leukoencephalopathy. Strategies to enhance post-treatment immune reconstitution are essential to further harness the unique potency of CAR T-cell therapy.
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Affiliation(s)
- Jared T Ahrendsen
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Kartik Sehgal
- Division of Hematology and Medical Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Sasmit Sarangi
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Erik J Uhlmann
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Hemant Varma
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Jon Arnason
- Division of Hematology and Medical Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - David Avigan
- Division of Hematology and Medical Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
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Pogna EA, Middleton S, Nazir J, Ralph L, Wilson K, Jurczak W. Characterization and treatment of immune thrombocytopenia in Europe: a qualitative observational study. ACTA ACUST UNITED AC 2021; 26:860-869. [PMID: 34719349 DOI: 10.1080/16078454.2021.1992945] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Immune thrombocytopenia (ITP) is a rare disease, characterized by increased platelet destruction/suboptimal platelet production, leading to thrombocytopenia and risk of severe bleeding events. METHODS Interviews with 23 physicians and 12 payors, a survey with 113 physicians and validation using published data were used to define the current treatment paradigm and healthcare resource utilization and to determine the costs associated with managing acute bleeds in six European countries (Germany, Spain, France, Italy, Netherlands, UK). The study estimated a prevalence of 9 to 10 per 100,000 adults in 2020 across all six countries (disease severity split: 34% mild, 32% moderate, 33% severe (due to rounding up some values might not sum up to 100%). RESULTS Physician feedback showed that most patients with ITP (60%) received first-line treatment or were monitored by their physician; ∼75% of patients relapsed within 3-4 months. Thrombopoietin-receptor agonists (TPO-RAs) and rituximab were used to achieve disease stabilization in patients who relapse; patients could switch to an alternative TPO-RA to control symptoms, manage side-effects or improve adherence. The costs of rescue therapies and hospital services (e.g. surgery and admissions) accounted for the majority of healthcare resources to manage bleeding events. CONCLUSION Physicians would welcome earlier use of TPO-RAs to help maintain long-term control of ITP bleeds and potentially reduce both hospitalization and therapy costs.
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Affiliation(s)
| | | | - Jameel Nazir
- Swedish Orphan Biovitrum (Sobi™), Stockholm, Sweden
| | | | - Koo Wilson
- Swedish Orphan Biovitrum (Sobi™), Stockholm, Sweden
| | - Wojciech Jurczak
- Maria Sklodowska-Curie National Research Institute of Oncology, Kraków, Poland
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32
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Handley G, Hand J. Adverse Effects of Immunosuppression: Infections. Handb Exp Pharmacol 2021; 272:287-314. [PMID: 34671868 DOI: 10.1007/164_2021_550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Immunosuppressive therapies are currently indicated for a wide range of diseases. As new agents emerge and indications evolve the landscape grows increasingly complex. Therapies can target pathologic immune system over-activation in rheumatologic or autoimmune disease, or conditioning and graft versus host disease (GVHD) prophylactic regimens may eliminate or inhibit host immune function to improve graft survival and risk of complication in solid organ transplantation (SOT) or hematopoietic stem cell transplantation (HSCT). With immunosuppressive therapy, infections occur. Complex disease states, host factors, and concomitant therapies contribute to a "net state" of immunosuppression that must be considered and may confound perceived increased infection risks in patients receiving treatment.
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Affiliation(s)
- Guy Handley
- Division of Infectious Disease and International Medicine, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Jonathan Hand
- Department of Infectious Diseases, Ochsner Health, The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA, USA.
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Rensel M, Zabeti A, Mealy MA, Cimbora D, She D, Drappa J, Katz E. Long-term efficacy and safety of inebilizumab in neuromyelitis optica spectrum disorder: Analysis of aquaporin-4-immunoglobulin G-seropositive participants taking inebilizumab for ⩾4 years in the N-MOmentum trial. Mult Scler 2021; 28:925-932. [PMID: 34595983 PMCID: PMC9024030 DOI: 10.1177/13524585211047223] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background: Efficacy and safety of inebilizumab for treatment of neuromyelitis optica spectrum disorder in adults seropositive for aquaporin-4 (AQP4)–immunoglobulin (Ig) G were demonstrated in the 28-week randomized controlled period of the N-MOmentum study. Objective: To assess efficacy and safety of long-term inebilizumab treatment. Methods: Post hoc analysis was performed in 75 AQP4–IgG–seropositive participants receiving inebilizumab for ⩾4 years in the randomized controlled period and open-label extension of the N-MOmentum study. Results: Eighteen attacks occurred in 13 participants during inebilizumab treatment (annualized attack rate, 0.052 attacks/person-year). Twelve attacks occurred during the first year of treatment, and two each occurred in years 2–4. Disability scores remained stable throughout ⩾4 years of treatment. Inebilizumab was well tolerated, with two (2.7%) serious treatment-emergent adverse events related to inebilizumab and no deaths. Immunoglobulin G levels decreased over time; however, correlation between severe infections and low IgG levels could not be determined because of their small numbers. Conclusion: These results from the N-MOmentum study continue to support use of inebilizumab for treatment of neuromyelitis optica spectrum disorder. Furthermore, the findings suggest that efficacy of inebilizumab may be enhanced after the first year of treatment, warranting additional long-term investigation.
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Affiliation(s)
- Mary Rensel
- Mellen Center for Multiple Sclerosis, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.,Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, USA
| | - Aram Zabeti
- University of Cincinnati, Cincinnati, OH, USA
| | - Maureen A Mealy
- Horizon Therapeutics plc, Deerfield, IL, USA; (known as Viela Bio at the time of study conduct)
| | - Daniel Cimbora
- Horizon Therapeutics plc, Deerfield, IL, USA; (known as Viela Bio at the time of study conduct)
| | - Dewei She
- Horizon Therapeutics plc, Deerfield, IL, USA; (known as Viela Bio at the time of study conduct)
| | - Jorn Drappa
- Horizon Therapeutics plc, Deerfield, IL, USA; (known as Viela Bio at the time of study conduct)
| | - Eliezer Katz
- Horizon Therapeutics plc, Deerfield, IL, USA; (known as Viela Bio at the time of study conduct)
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Prezioso C, Grimaldi A, Landi D, Nicoletti CG, Brazzini G, Piacentini F, Passerini S, Limongi D, Ciotti M, Palamara AT, Marfia GA, Pietropaolo V. Risk Assessment of Progressive Multifocal Leukoencephalopathy in Multiple Sclerosis Patients during 1 Year of Ocrelizumab Treatment. Viruses 2021; 13:v13091684. [PMID: 34578264 PMCID: PMC8473394 DOI: 10.3390/v13091684] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 08/20/2021] [Accepted: 08/23/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Progressive multifocal leukoencephalopathy (PML) caused by the JC virus is the main limitation to the use of disease modifying therapies for treatment of multiple sclerosis (MS). Methods: To assess the PML risk in course of ocrelizumab, urine and blood samples were collected from 42 MS patients at baseline (T0), at 6 (T2) and 12 months (T4) from the beginning of therapy. After JCPyV-DNA extraction, a quantitative-PCR (Q-PCR) was performed. Moreover, assessment of JCV-serostatus was obtained and arrangements’ analysis of non-coding control region (NCCR) and of viral capsid protein 1 (VP1) was carried out. Results: Q-PCR revealed JCPyV-DNA in urine at all selected time points, while JCPyV-DNA was detected in plasma at T4. From T0 to T4, JC viral load in urine was detected, increased in two logarithms and, significantly higher, compared to viremia. NCCR from urine was archetypal. Plasmatic NCCR displayed deletion, duplication, and point mutations. VP1 showed the S269F substitution involving the receptor-binding region. Anti-JCV index and IgM titer were found to statistically decrease during ocrelizumab treatment. Conclusions: Ocrelizumab in JCPyV-DNA positive patients is safe and did not determine PML cases. Combined monitoring of ocrelizumab’s effects on JCPyV pathogenicity and on host immunity might offer a complete insight towards predicting PML risk.
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Affiliation(s)
- Carla Prezioso
- IRCSS San Raffaele Roma, Microbiology of Chronic Neuro-Degenerative Pathologies, 00163 Rome, Italy
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, 00185 Rome, Italy; (G.B.); (F.P.); (S.P.)
- Correspondence: (C.P.); (V.P.)
| | - Alfonso Grimaldi
- Multiple Sclerosis Clinical and Research Unit, Fondazione Policlinico di Tor Vergata, 00133 Rome, Italy; (A.G.); (D.L.); (C.G.N.); (G.A.M.)
| | - Doriana Landi
- Multiple Sclerosis Clinical and Research Unit, Fondazione Policlinico di Tor Vergata, 00133 Rome, Italy; (A.G.); (D.L.); (C.G.N.); (G.A.M.)
- Department of Systems Medicine, Tor Vergata University, 00133 Rome, Italy
| | - Carolina Gabri Nicoletti
- Multiple Sclerosis Clinical and Research Unit, Fondazione Policlinico di Tor Vergata, 00133 Rome, Italy; (A.G.); (D.L.); (C.G.N.); (G.A.M.)
- Department of Systems Medicine, Tor Vergata University, 00133 Rome, Italy
| | - Gabriele Brazzini
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, 00185 Rome, Italy; (G.B.); (F.P.); (S.P.)
| | - Francesca Piacentini
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, 00185 Rome, Italy; (G.B.); (F.P.); (S.P.)
| | - Sara Passerini
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, 00185 Rome, Italy; (G.B.); (F.P.); (S.P.)
| | - Dolores Limongi
- IRCCS San Raffaele Roma, Telematic University, 00163 Rome, Italy;
| | - Marco Ciotti
- Laboratory of Virology, Polyclinic Tor Vergata Foundation, 00133 Rome, Italy;
| | - Anna Teresa Palamara
- Department of Infectious Diseases, Istituto Superiore di Sanità, 00161 Rome, Italy;
- Laboratory Affiliated to Institute Pasteur Italia-Cenci Bolognetti Foundation, Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, 00185 Rome, Italy
| | - Girolama Alessandra Marfia
- Multiple Sclerosis Clinical and Research Unit, Fondazione Policlinico di Tor Vergata, 00133 Rome, Italy; (A.G.); (D.L.); (C.G.N.); (G.A.M.)
- Department of Systems Medicine, Tor Vergata University, 00133 Rome, Italy
- Unit of Neurology, IRCCS Istituto Neurologico Mediterraneo NEUROMED, 86077 Pozzilli, Italy
| | - Valeria Pietropaolo
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, 00185 Rome, Italy; (G.B.); (F.P.); (S.P.)
- Correspondence: (C.P.); (V.P.)
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Abstract
Since the initial observation of increased immunoglobulin concentrations in the cerebrospinal fluid of multiple sclerosis (MS) patients in the 1940s, B cells have been considered to participate in the pathology of MS through the production of autoantibodies reactive against central nervous system antigens. However, it is now recognized that B cells contribute to MS relapses via antibody-independent activities, including the presentation of antigens to T cells and the release of pro-inflammatory cytokines. In addition, the recent identification of B cell-rich follicle-like structures in the meninges of progressive MS patients suggests that the pathogenic roles of B cells also exist at the progressive phase of this disease. Recently, large-scale clinical trials have demonstrated the efficacy of B-cell depletion therapy using anti-CD20 antibodies in relapsing as well as primary progressive MS. B-cell depletion therapy has become an essential treatment option for MS based on its unique benefit to risk balance in relapsing MS, and because it is the only drug that has been shown to be effective in primary progressive MS to date.
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Affiliation(s)
- Yusei Miyazaki
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Sapporo, Japan
| | - Masaaki Niino
- Department of Clinical Research, National Hospital Organization Hokkaido Medical Center, Sapporo, Japan
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36
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Hartung HP, Mares J, Meuth SG, Berger T. Multiple Sclerosis: Switching from Natalizumab to Other High-Efficacy Treatments to Mitigate Progressive Multifocal Leukoencephalopathy Risk. Neurotherapeutics 2021; 18:1654-1656. [PMID: 34480292 PMCID: PMC8609079 DOI: 10.1007/s13311-021-01102-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2021] [Indexed: 02/04/2023] Open
Affiliation(s)
- Hans-Peter Hartung
- Department of Neurology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.
- Brain and Mind Centre, University of Sydney, Sydney, Australia.
- Department of Neurology, Palacky University, Olomouc, Olomouc, Czech Republic.
- Department of Neurology, Medical University of Vienna, Vienna, Austria.
| | - Jan Mares
- Department of Neurology, Palacky University, Olomouc, Olomouc, Czech Republic
| | - Sven G Meuth
- Department of Neurology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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Schweitzer F, Laurent S, Fink GR, Barnett MH, Hartung HP, Warnke C. Effects of disease-modifying therapy on peripheral leukocytes in patients with multiple sclerosis. J Neurol 2021; 268:2379-2389. [PMID: 32036423 PMCID: PMC8217029 DOI: 10.1007/s00415-019-09690-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 12/24/2019] [Indexed: 12/11/2022]
Abstract
Modern disease-modifying therapies (DMTs) in multiple sclerosis (MS) have variable modes of action and selectively suppress or modulate the immune system. In this review, we summarize the predicted and intended as well as unwanted adverse effects on leukocytes in peripheral blood as a result of treatment with DMTs for MS. We link changes in laboratory tests to the possible therapeutic risks that include secondary autoimmunity, infections, and impaired response to vaccinations. Profound knowledge of the intended effects on leukocyte counts, in particular lymphocytes, explained by the mode of action, and adverse effects which may require additional laboratory and clinical vigilance or even drug discontinuation, is needed when prescribing DMTs to treat patients with MS.
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Affiliation(s)
- F Schweitzer
- Department of Neurology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - S Laurent
- Department of Neurology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - G R Fink
- Department of Neurology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
- Cognitive Neuroscience, Institute of Neuroscience and Medicine (INM-3), Research Center Jülich, Jülich, Germany
| | - Michael H Barnett
- Department of Neurology, Royal Prince Alfred Hospital, and Brain and Mind Centre, University of Sydney, Sydney, Australia
| | - H P Hartung
- Department of Neurology, Medical Faculty, and Center for Neurology and Neuropsychiatry, LVR Klinikum, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - C Warnke
- Department of Neurology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany.
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38
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Turine G, London F. Obinutuzumab use complicated by progressive multifocal leukoencephalopathy in a patient with chronic lymphocytic leukemia: a case report. Acta Neurol Belg 2021; 121:781-783. [PMID: 33063195 DOI: 10.1007/s13760-020-01520-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/05/2020] [Indexed: 11/24/2022]
MESH Headings
- Aged
- Antibodies, Monoclonal, Humanized/adverse effects
- Antineoplastic Agents, Immunological/adverse effects
- Female
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnostic imaging
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukoencephalopathy, Progressive Multifocal/chemically induced
- Leukoencephalopathy, Progressive Multifocal/diagnostic imaging
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Affiliation(s)
| | - Frédéric London
- Department of Neurology, CHU UCL Namur, 1 avenue G. Thérasse, 5530, Yvoir, Belgium.
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39
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Sun C, Wiestner A. Can Immunocompetence Be Restored in Chronic Lymphocytic Leukemia? Hematol Oncol Clin North Am 2021; 35:827-845. [PMID: 34174988 DOI: 10.1016/j.hoc.2021.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Reversing or preventing immunodeficiency in patients with chronic lymphocytic leukemia (CLL) is of the highest priority. The past decade of research has met the challenge of treating CLL for most patients. Patients continue to struggle, however, with infections and second primary malignancies related to immunodeficiency. Strategies addressing this need currently are limited to vaccinations, with suboptimal efficacy, and immunoglobulin replacement. Correlative studies have provided insights into immunologic alterations on treatment. Understanding vulnerabilities in the immune system may help identify potential interventions to boost immunity. An emphasis on systematically testing such interventions is required to restore immunocompetence in patients with CLL.
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Affiliation(s)
- Clare Sun
- Hematology Branch, NHLBI, NIH, Building 10-CRC, Room 3-5132, 10 Center Drive, Bethesda, MD 20892-0004, USA.
| | - Adrian Wiestner
- Hematology Branch, NHLBI, NIH, Building 10-CRC, Room 3-5140, 10 Center Drive, Bethesda, MD 20892-0004, USA
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40
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Gauckler P, Shin JI, Alberici F, Audard V, Bruchfeld A, Busch M, Cheung CK, Crnogorac M, Delbarba E, Eller K, Faguer S, Galesic K, Griffin S, van den Hoogen MW, Hrušková Z, Jeyabalan A, Karras A, King C, Kohli HS, Mayer G, Maas R, Muto M, Moiseev S, Odler B, Pepper RJ, Quintana LF, Radhakrishnan J, Ramachandran R, Salama AD, Schönermarck U, Segelmark M, Smith L, Tesař V, Wetzels J, Willcocks L, Windpessl M, Zand L, Zonozi R, Kronbichler A. Rituximab in Membranous Nephropathy. Kidney Int Rep 2021; 6:881-893. [PMID: 33912740 PMCID: PMC8071613 DOI: 10.1016/j.ekir.2020.12.035] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 12/28/2020] [Accepted: 12/29/2020] [Indexed: 12/14/2022] Open
Abstract
Membranous nephropathy (MN) is the most common cause of primary nephrotic syndrome among adults. The identification of phospholipase A2 receptor (PLA2R) as target antigen in most patients changed the management of MN dramatically, and provided a rationale for B-cell depleting agents such as rituximab. The efficacy of rituximab in inducing remission has been investigated in several studies, including 3 randomized controlled trials, in which complete and partial remission of proteinuria was achieved in approximately two-thirds of treated patients. Due to its favorable safety profile, rituximab is now considered a first-line treatment option for MN, especially in patients at moderate and high risk of deterioration in kidney function. However, questions remain about how to best use rituximab, including the optimal dosing regimen, a potential need for maintenance therapy, and assessment of long-term safety and efficacy outcomes. In this review, we provide an overview of the current literature and discuss both strengths and limitations of "the new standard."
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Affiliation(s)
- Philipp Gauckler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
- Division of Pediatric Nephrology, Severance Children's Hospital, Seoul, Korea
- Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Korea
| | - Federico Alberici
- Nephrology Unit, ASST Spedali Civili di Brescia, Brescia, Italy
- Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Vincent Audard
- Department of Nephrology and Transplantation, Rare French Disease Centre "Idiopathic Nephrotic syndrome", Henri-Mondor/Albert-Chenevier Hospital Assistance Publique-Hôpitaux de Paris, Inserm U955, Team 21, Paris-East University, Créteil, France
| | - Annette Bruchfeld
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Renal Medicine, CLINTEC, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Martin Busch
- Department of Internal Medicine III, University Hospital Jena, Friedrich-Schiller-University, Jena, Germany
| | - Chee Kay Cheung
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Matija Crnogorac
- Department of Nephrology and Dialysis, Dubrava University Hospital, Zagreb, Croatia
| | - Elisa Delbarba
- Nephrology Unit, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Kathrin Eller
- Clinical Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Stanislas Faguer
- Département de Néphrologie et Transplantation d'Organes, Centre de Référence des Maladies Rénales Rares, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Institut National de la Santé et de la Recherche Médicale, U1048 (Institut des Maladies Cardiovasculaires et Métaboliques-équipe 12), Toulouse, France
| | - Kresimir Galesic
- Department of Nephrology and Dialysis, Dubrava University Hospital, Zagreb, Croatia
| | - Siân Griffin
- Department of Nephrology and Transplantation, University Hospital of Wales, Cardiff, UK
| | | | - Zdenka Hrušková
- Department of Nephrology, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Anushya Jeyabalan
- Division of Nephrology, Columbia University Medical Center, New York, New York, USA
| | - Alexandre Karras
- Service de Néphrologie, Hôpital Européen-Georges Pompidou, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Catherine King
- Department of Renal Medicine, Queen Elizabeth Hospital, University Hospitals Birmingham, Edgbaston, Birmingham, UK
| | - Harbir Singh Kohli
- Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Gert Mayer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Rutger Maas
- Department of Nephrology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Masahiro Muto
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Sergey Moiseev
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Balazs Odler
- Clinical Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Ruth J. Pepper
- University College London Department of Renal Medicine, Royal Free Hospital, London, UK
| | - Luis F. Quintana
- Department of Nephrology and Renal Transplantation, Hospital Clínic, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR), Department of Medicine, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Jai Radhakrishnan
- Division of Nephrology, Columbia University Medical Center, New York, New York, USA
| | - Raja Ramachandran
- Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Alan D. Salama
- University College London Department of Renal Medicine, Royal Free Hospital, London, UK
| | - Ulf Schönermarck
- Division of Nephrology, Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | - Mårten Segelmark
- Department of Clinical Sciences Lund, University, Skane University Hospital, Nephrology Lund, Lund, Sweden
| | - Lee Smith
- The Cambridge Centre for Sport and Exercise Science, Anglia Ruskin University, Cambridge, UK
| | - Vladimír Tesař
- Department of Nephrology, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jack Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Lisa Willcocks
- Department of Renal Medicine, Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Martin Windpessl
- Department of Internal Medicine IV, Section of Nephrology, Klinikum Wels-Grieskirchen, Wels, Austria
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Ladan Zand
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Reza Zonozi
- Division of Nephrology, Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
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41
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Sandal R, Mishra K, Jandial A, Sahu KK, Siddiqui AD. Update on diagnosis and treatment of immune thrombocytopenia. Expert Rev Clin Pharmacol 2021; 14:553-568. [PMID: 33724124 DOI: 10.1080/17512433.2021.1903315] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Immune thrombocytopenia (ITP) is a heterogeneous acquired disorder characterized by isolated thrombocytopenia whose exact pathogenesis is not yet clear. Depending upon the presence or absence of an underlying treatable cause, ITP can be categorized as primary or secondary. Primary ITP is a diagnosis of exclusion and there is no gold standard test for its confirmation. Recent drug intake, infections, lymphoproliferative disorders, and connective tissue disorders should be ruled out before labeling a patient as primary ITP. AREA COVERED This review summarizes a comprehensive update on the diagnostic and therapeutic modalities for ITP. We reviewed the literature using GOOGLE SCHOLAR, PUBMED and ClinicalTrial.gov databases as needed to support the evidence. We searched the literature using the following keywords: 'immune thrombocytopenia,' 'idiopathic thrombocytopenic purpura,' 'thrombocytopenia,' 'immune thrombocytopenic purpura,' and 'isolated thrombocytopenia'. EXPERT OPINION We believe that more detailed studies are required to understand the exact pathophysiology behind ITP. The first-line drugs like corticosteroids have both short-term and long-term adverse effects. This brings the need to explore effective alternative medications and to reconsider their role in ITP treatment algorithm if guidelines can be modified based on new studies.
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Affiliation(s)
- Rajeev Sandal
- Dept of Clinical Hematology, IGMC, Shimla, Himachal Pradesh, India
| | - Kundan Mishra
- Department of Internal Medicine (Adult Clinical Hematology Division), Postgraduate Institute of Medical Education and Research, Chandigarh (Union Territory), India
| | - Aditya Jandial
- Dept of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral), Delhi, India
| | - Kamal Kant Sahu
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, Massachusetts, USA
| | - Ahmad Daniyal Siddiqui
- Division of Hematology and Oncology, Department of Internal Medicine, Saint Vincent Hospital, Worcester, Massachusetts, USA
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42
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Diavati S, Asimakopoulos JV, Galopoulos D, Konstantinou I, Argyrakos T, Toulas P, Vassilakopoulos TP, Konstantopoulos K, Angelopoulou MK. Progressive Multifocal Leukoencephalopathy Following Treatment With Obinutuzumab in a Patient With Non-Hodgkin Follicular Lymphoma: A Case Report. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:e601-e605. [PMID: 33814337 DOI: 10.1016/j.clml.2021.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 02/27/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Stavrianna Diavati
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - John V Asimakopoulos
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Galopoulos
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Iliana Konstantinou
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Panagiotis Toulas
- Department of Radiology, Biiatrics Group Diagnostic Centers, Athens, Greece
| | - Theodoros P Vassilakopoulos
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Kostas Konstantopoulos
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria K Angelopoulou
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece.
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43
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Abstract
Glucocorticoids are the first-line drug for the remission induction therapy of immunoglobulin (Ig) G4-related disease. Achieving drug-free remission using glucocorticoids alone is difficult, however, and many patients require maintenance therapy with glucocorticoids and immunosuppressants. Studies have recently found that the number of peripheral memory B cells and plasmablasts is increased in IgG4-related disease and have indicated the efficacy of rituximab, which, in remission induction therapy, rapidly reduces serum IgG4 levels and has the tapering effect of glucocorticoids. Rituximab has been shown to reduce the risk of relapse more than oral immunosuppressants such as azathioprine. However, maintaining drug-free remission is difficult with a single course of rituximab alone, and many cases require maintenance therapy with rituximab. This article outlines the potential of B-cell targeted therapy, focusing on the efficacy, and safety of rituximab for IgG4-related disease.
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Affiliation(s)
- Motohisa Yamamoto
- Department of Rheumatology and Allergy, IMSUT Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
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44
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Riley TR, George MD. Risk for infections with glucocorticoids and DMARDs in patients with rheumatoid arthritis. RMD Open 2021; 7:e001235. [PMID: 33597206 PMCID: PMC7893655 DOI: 10.1136/rmdopen-2020-001235] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/02/2021] [Accepted: 02/06/2021] [Indexed: 12/15/2022] Open
Abstract
Immunomodulatory therapy for rheumatoid arthritis (RA) carries risk for infectious complications. Understanding the risks of different therapeutic options is essential for making treatment decisions and appropriately monitoring patients. This review examines data on the risks for serious infections and other key infections of interest for the major classes of agents in use for RA: glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (DMARDs), biologics and Janus kinase (JAK) inhibitors. Conventional synthetic DMARDs have an excellent safety profile with recent data available supporting the relative safety of methotrexate. Tumour necrosis factor (TNF) inhibitors are associated with an increase in the risk of serious infections. Risk with other biological agents and with JAK inhibitors varies somewhat but overall appears similar to that of TNF inhibitors, with JAK inhibitors also associated with a greater risk of herpes zoster. Glucocorticoids have a dose-dependent effect on serious infection risk-at higher doses risk of infection with glucocorticoids is substantially greater than with other immunomodulatory therapies, and even low-dose therapy carries a risk of infection that appears to be similar to that of biological therapies.
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Affiliation(s)
- Thomas R Riley
- Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael D George
- Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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45
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Gklinos P, Papadopoulou M, Stanulovic V, Mitsikostas DD, Papadopoulos D. Monoclonal Antibodies as Neurological Therapeutics. Pharmaceuticals (Basel) 2021; 14:ph14020092. [PMID: 33530460 PMCID: PMC7912592 DOI: 10.3390/ph14020092] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/20/2021] [Accepted: 01/22/2021] [Indexed: 02/08/2023] Open
Abstract
Over the last 30 years the role of monoclonal antibodies in therapeutics has increased enormously, revolutionizing treatment in most medical specialties, including neurology. Monoclonal antibodies are key therapeutic agents for several neurological conditions with diverse pathophysiological mechanisms, including multiple sclerosis, migraines and neuromuscular disease. In addition, a great number of monoclonal antibodies against several targets are being investigated for many more neurological diseases, which reflects our advances in understanding the pathogenesis of these diseases. Untangling the molecular mechanisms of disease allows monoclonal antibodies to block disease pathways accurately and efficiently with exceptional target specificity, minimizing non-specific effects. On the other hand, accumulating experience shows that monoclonal antibodies may carry class-specific and target-associated risks. This article provides an overview of different types of monoclonal antibodies and their characteristics and reviews monoclonal antibodies currently in use or under development for neurological disease.
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Affiliation(s)
- Panagiotis Gklinos
- Department of Neurology, KAT General Hospital of Attica, 14561 Athens, Greece;
| | - Miranta Papadopoulou
- Center for Clinical, Experimental Surgery & Translational Research, Biomedical Research Foundation of the Academy of Athens (BRFAA), 11527 Athens, Greece;
| | - Vid Stanulovic
- Global Pharmacovigilance, R&D Sanofi, 91385 Chilly-Mazarin, France;
| | - Dimos D. Mitsikostas
- 1st Neurology Department, Aeginition Hospital, National and Kapodistrian University of Athens, 11521 Athens, Greece;
| | - Dimitrios Papadopoulos
- Laboratory of Molecular Genetics, Hellenic Pasteur Institute, 129 Vasilissis Sophias Avenue, 11521 Athens, Greece
- Salpetriere Neuropsychiatric Clinic, 149 Papandreou Street, Metamorphosi, 14452 Athens, Greece
- Correspondence:
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46
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Progressive multifocal leukoencephalopathy in the era of new disease-modifying treatments for multiple sclerosis. Med Clin (Barc) 2021; 156:509-514. [PMID: 33431183 DOI: 10.1016/j.medcli.2020.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/21/2020] [Accepted: 10/21/2020] [Indexed: 11/22/2022]
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47
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Bohelay G, Caux F, Musette P. Clinical and biological activity of rituximab in the treatment of pemphigus. Immunotherapy 2021; 13:35-53. [PMID: 33045883 DOI: 10.2217/imt-2020-0189] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
B-cells are major effector cells in autoimmunity since they differentiate into plasmocytes that produce pathogenic auto-antibody such as anti-desmoglein antibodies in pemphigus patients. Major advances were obtained using whole B-cell depleting therapies including anti-CD20 antibodies in refractory pemphigus patients that lead to rituximab approval in pemphigus patients in EU and USA. This review summarizes the data supporting the efficacy of rituximab in pemphigus and provides an overview of the reported immunological changes underlying its therapeutic action. Short and long-term remission in pemphigus is explained by the removal of autoreactive B-cells involved in the production of pathogenic IgG auto-antibodies and by enhancement of the appearance of regulatory B-cells that could maintain long term immune tolerance.
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Affiliation(s)
- Gérôme Bohelay
- Department of Dermatology, Groupe Hospitalier Paris Seine-Saint-Denis, AP-HP & INSERM UMR1125, Bobigny, France
| | - Frédéric Caux
- Department of Dermatology, Groupe Hospitalier Paris Seine-Saint-Denis, AP-HP & INSERM UMR1125, Bobigny, France
| | - Philippe Musette
- Department of Dermatology, Groupe Hospitalier Paris Seine-Saint-Denis, AP-HP & INSERM UMR1125, Bobigny, France
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48
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Rituximab Use in Warm and Cold Autoimmune Hemolytic Anemia. J Clin Med 2020; 9:jcm9124034. [PMID: 33322221 PMCID: PMC7763062 DOI: 10.3390/jcm9124034] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/06/2020] [Accepted: 12/09/2020] [Indexed: 01/22/2023] Open
Abstract
Autoimmune hemolytic anemia is a rare condition characterized by destruction of red blood cells with and without involvement of complement. It is associated with significant morbidity and mortality. In warm autoimmune hemolytic anemia, less than 50% of patients remain in long-term remission following initial steroid therapy and subsequent therapies are required. Cold agglutinin disease is a clonal hematologic disorder that requires therapy in the majority of patients and responds poorly to steroids and alkylators. Rituximab has a favorable toxicity profile and has demonstrated efficacy in autoimmune hemolytic anemia in first-line as well as relapsed settings. Rituximab is the preferred therapy for steroid refractory warm autoimmune hemolytic anemia (wAIHA) and as part of the first- and second-line treatment of cold agglutinin disease. This article reviews the mechanism of action of rituximab and the current literature on its role in the management of primary and secondary warm autoimmune hemolytic anemia and cold agglutinin disease.
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49
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Amitai I, Gafter-Gvili A, Shargian-Alon L, Raanani P, Gurion R. Obinutuzumab-related adverse events: A systematic review and meta-analysis. Hematol Oncol 2020; 39:215-221. [PMID: 33252145 DOI: 10.1002/hon.2828] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 11/11/2022]
Abstract
Rituximab, the first anti-CD20 monoclonal antibody, has dramatically improved outcomes for patients with B-cell lymphoproliferative disorders. Obinutuzumab was developed to potentiate activity and overcome resistance to rituximab. Clinical data suggest that obinutuzumab is superior to rituximab in follicular lymphoma (FL) and chronic lymphocytic leukemia (CLL). Yet, it has increased toxicity. This systematic review and meta-analysis compiled all randomized controlled trials (RCTs) comparing obinutuzumab-based regimens with rituximab-based regimens to better assess their toxicity profile. Primary outcome was grade 3-4 infections; secondary outcomes included any adverse events (AE), grade 3-4 AE, drug discontinuation rate, and 3-years mortality. Relative risks (RRs) were estimated and pooled using a fixed-effect model, unless there was significant heterogeneity, in which case a random-effects model was used. Our comprehensive search yielded five RCTs conducted between 2009 and 2014, including 4247 patients. The trials included FL patients, CLL and diffuse large B cell lymphoma. Monoclonal antibodies were given with different chemotherapy regimens (in four trials) or as monotherapy (in one trial). The point estimate favored increase in both grade 3-4 infections rate (RR 1.17 [95% CI, 1.0-1.36]) and any AE rate (RR 1.05 [95% 1-1.1]) with obinutuzumab, although this was not statistically significant. There was a significantly increased rate of grade 3-4 AE (RR 1.15 [95% CI, 1.09-1.2]), as well as grade 3-4 toxicities including thrombocytopenia (RR 2.8 [95% CI, 1.92-4.06]), infusion related reactions (RR 2.8 [95% CI, 2.16-3.64]) and cardiac events (RR 1.65 [95% CI, 1.11-2.46]). There was no significant difference in grade 3-4 anemia and neutropenia nor in the 3-year mortality rate. The point estimate favored increase in discontinuation rate due to AE with obinutuzumab, although without statistical significance (RR 1.24 [95% CI, 1.0-1.54]). In conclusion, physicians need to weigh the clinical benefits of this agent against higher toxicity.
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Affiliation(s)
- Irina Amitai
- Odette Cancer Center, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Gafter-Gvili
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel.,Department of Internal Medicine A, Rabin Medical Center, Petah Tikva, Israel
| | - Liat Shargian-Alon
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Pia Raanani
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Ronit Gurion
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
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50
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Bonek R, Guenter W, Jałowiński R, Karbicka A, Litwin A, Maciejowski M, Zajdel R, Petit V, Rejdak K. JC Virus Seroprevalence and JCVAb Index in Polish Multiple Sclerosis Treatment-Naïve Patients. J Clin Med 2020; 9:E3867. [PMID: 33261210 PMCID: PMC7759948 DOI: 10.3390/jcm9123867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/21/2020] [Accepted: 11/24/2020] [Indexed: 11/17/2022] Open
Abstract
Multiple sclerosis (MS) treatment with new agents is associated with the risk of the development of progressive multifocal leukoencephalopathy (PML). The seropositivity and a high index of anti-John Cunningham virus (JCV) antibodies are some of the risk factors for PML development. The aim of this study was to assess the seroprevalence of anti-JCVAb and JCVAb index (AI), as well as its correlations with demographic and clinical characteristics in treatment-naïve Polish MS patients. This is a multicenter, prospective, and cross-sectional study involving 665 MS patients. The overall prevalence of anti-JCVAb was 65.3%, while 63.1% of seropositive patients had an index level of >1.5. The seroprevalence was shown to increase along with the patient's age. Except for age, the prevalence of anti-JCVAb was not associated with demographic or clinical data. No correlations between the index levels and the demographic or clinical data were observed. In Poland, the seroprevalence of anti-JCVAb in treatment-naïve MS patients is one of the highest in Europe. The majority of seropositive patients had an anti-JCV antibody level denoting a high-risk category. This means that we need further studies to be conducted on the individualization of MS treatment in order to provide patients with an appropriate therapeutic safety level.
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Affiliation(s)
- Robert Bonek
- Department of Neurology and Clinical Neuroimmunology, Regional Specialist Hospital, 86-300 Grudziadz, Poland
- Foundation Supporting Development of Neurology and Clinical Neuroimmunology MoA, 85-654 Bydgoszcz, Poland
| | - Wojciech Guenter
- Department of Clinical Neuropsychology, Nicolaus Copernicus University, 87-100 Torun, Poland, and Collegium Medicum, 85-094 Bydgoszcz, Poland;
| | - Robert Jałowiński
- Department of Neurology, Regional Hospital, 71-455 Szczecin, Poland; (R.J.); (A.K.)
| | - Anna Karbicka
- Department of Neurology, Regional Hospital, 71-455 Szczecin, Poland; (R.J.); (A.K.)
| | - Anna Litwin
- Department of Neurology, Regional Hospital, 10-561 Olsztyn, Poland;
| | | | - Radosław Zajdel
- Chair of Business Informatics, University of Lodz, 90-214 Lodz, Poland;
| | - Veronique Petit
- Department of Neurology, Medical University of Lublin, 20-090 Lublin, Poland; (V.P.); (K.R.)
| | - Konrad Rejdak
- Department of Neurology, Medical University of Lublin, 20-090 Lublin, Poland; (V.P.); (K.R.)
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